2. Determinants of the Nutritional Status of Children

The conceptual framework underlying this study (Figure 1) is adapted from the United Nations Children’s Fund’s framework for the causes of child malnutrition (UNICEF 1990, 1998) and the subsequent extended model of care as presented in Engle, Menon, and Haddad (1999). The framework is comprehensive, incorporating both biological and socioeconomic causes, and encompasses causes at both micro and macro levels. It breaks the determinants of child nutritional status into three levels of causality: immediate determinants (the most proximate level), underlying determinants, and basic determinants (the deepest level).

The immediate determinants of child nutritional status manifest themselves at the level of the individual human being. They are dietary intake (energy, protein, fat, and micronutrients) and health status. These factors themselves are interdependent. A child with inadequate dietary intake is more susceptible to disease. In turn, disease depresses appetite, inhibits the absorption of nutrients in food, and competes for a child’s energy. Dietary intake must be adequate in quantity and in quality, and nutrients must be consumed in appropriate combinations for the human body to be able to absorb them.

The immediate determinants of child nutritional status are, in turn, influenced by three underlying determinants manifesting themselves at the household level. These are food security, adequate care for mothers and children, and a proper health environment, including access to health services. Associated with each is a set of resources necessary for their achievement.

Food security is achieved when a person has access to enough food for an active and healthy life (World Bank 1986). The resources necessary for gaining access to food are food production, income for food purchases, or in-kind transfers of food (whether from other private citizens, national or foreign governments, or international institutions). No child grows without nurturing from other human beings: this aspect of child nutrition is captured in the concept of care for children and their mothers, who give birth to children and who are commonly their main caretakers after they are born. Care, the second underlying determinant, is the provision in households and communities of “time, attention, and support to meet the physical, mental, and social needs of the growing child and other household members” (ICN 1992). Examples of caring practices are child feeding, health-seeking behaviors, support and cognitive stimulation for children, and care and support for mothers during pregnancy and lactation. The adequacy of such care is determined by the caregiver’s control of economic resources, autonomy in decisionmaking, and physical and mental status. All of these resources for care are influenced by the caregiver’s status relative to other household members. A final resource for care is the caregiver’s knowledge and beliefs. The third underlying determinant of child nutritional status, health environment and services, rests on the availability of safe water, sanitation, health care, and environmental safety, including shelter.

A key factor affecting all underlying determinants is poverty. A person is considered to be in absolute poverty when he or she is unable to satisfy basic needs - for example, to obtain adequate food, health care, water, shelter, primary education, and community participation (Frankenberger 1996). The effects of poverty on child malnutrition are pervasive. Poor households and individuals are unable to achieve food security, have inadequate resources for care, and are not able to make use of (or contribute to the creation of) resources for health on a sustainable basis.

Figure 1 - Conceptual framework guiding empirical analysis

Sources: Adapted from UNICEF 1990, 1998; and Engle, Menon, and Haddad 1999.

Finally, the underlying determinants of child nutrition (and poverty) are, in turn, influenced by basic determinants, which include the potential resources available to a country or community, limited by the natural environment, access to technology, and the quality of human resources. Political, economical, cultural, and social factors affect the utilization of these potential resources and how they are translated into resources far food security, care, and environments and services.