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How does programming change if care is involved? Three changes can be identified, which reflect many recommendations currently being made to increase the effectiveness and sustainability of projects: assess and change care behaviours in addition to distal factors such as food or health care; evaluate care practices and resources from the household or integrated perspective; and plan for additive or combined effects on care practices and care resources through programming that considers multiple routes to change.

First, in addition to distal strategies such as increasing education or providing better services, actual care practices or behaviours should be assessed and targeted for change, if inappropriate, or reinforcement, if appropriate. The provision of care is a critical link between food and health resources and the child's physical and psychosocial development. For example, a new health-delivery system might not only provide a new strategy for diagnosing illnesses, but also adapt that information to the caregivers' beliefs and knowledge about illness and illness terms used in home treatment. A programme to improve complementary feeding should assess, analyse, and take action to improve not only foods but also feeding practices, such as frequency of feeding, responsiveness to children's cues of hunger, or the feeding situation.

Second, the "care" focus requires the programme planner to evaluate household practices in support of children as an integrated whole. The same individuals perform multiple tasks to support child health and development. An intervention might affect several care practices or resources for care, since it could result in multiple demands on time, energy, and knowledge. The costs of a programme should be evaluated in terms of care. For example, a programme that provides additional income-generation opportunities for women should evaluate consequences of changed behaviours for care practices, such as food preparation, home health care, or care for women. The benefits of a programme can also be evaluated in terms of care. A family-planning programme that results in longer birth spacing may provide mothers with increased available time. Teaching a caregiver to be more responsive to her child's indications of hunger may also increase her tendency to respond to a child's attempts to communicate and therefore increase the speed of language development. Increasing resources for care, such as increasing the help provided by fathers, may have positive effects on several aspects of care.

Third, there may be additive or interactive effects on child outcomes of changes in care practices that programmes can capitalize on. Improving several aspects of care at the same time will have greater effects on child growth and development than improving only one aspect of care. Interventions to improve child nutrition or child health as well as child development may have additional impacts on child development. A child who is healthy may be more responsive to improved environmental inputs and therefore may develop more rapidly. A more active and verbal child may also stimulate more care from busy caregivers. There is an intimate relationship between physical and psychological growth, particularly in the first years of life [44,45]. Programming that includes several of these care needs simultaneously maybe more able to reach families and provide the impetus for significant change in child outcomes than single-focus programmes.

Examples of programmes that involve care

To illustrate how programmes change when care is taken into account, examples of four kinds of programmes for children under three years of age that involve care are presented: a nutrition education project, interventions for low-birthweight infants, a parent education programme including both early child development and nutrition, and a child-care/day-care programme. In each case, programme effectiveness and which component might be labeled "care" are described. These programme models and others are summarized in table 1.

Nutrition education project

The Nutrition Communication Project of the Academy for Educational Development used the principles of nutrition education and social marketing to create, implement, and evaluate strategies to improve maternal and child nutrition without increasing income [48]. Over an eight-year period, projects took place in Mali, Niger, Burkina Faso, and Honduras. In each country, the strategy involved a five-step process of assessment through formative evaluation and surveys, planning, preparation of materials, implementation of the intervention, and evaluation. These projects are defined as involving care, because specific feeding practices in the home and resources for care were included in assessment, intervention, and evaluation. Other components of the project focused on increasing the supply of vitamin A (e.g., by making sauces with green leafy vegetables), and these did not involve care.

The Mali project provides a good example of how care can be part of a nutrition education project [48]. The nutrition problems identified in the region were wasting (11%), stunting (25%), low birthweight (15%), and night blindness. Formative evaluation and surveys led to the identification of problems, some of which were caring practices: the introduction of complementary foods was delayed to nine months of age; 80% of young children's meals were not supervised; and 66% of children were given pre-lacteal feeds. Some problems identified fell under the category of care for women within the family. A family should be sure that women are allocated sufficient supplies of the family food and that they have the autonomy and decision-making power to obtain it. In Mali neither men nor women were aware of children's and women's dietary needs, and men were responsible for many food purchases.

Based on the assessment phase, behavioural messages and targets were defined. In addition to food messages, some messages involved the process of feeding, a care practice: "Promote more appropriate active feeding behaviours: specifically, three supervised meals a day; use a separate bowl for children 6 to 24 months of age; make sure the child finishes the bowl, and give more if the child is still hungry."

One involved resources for care and care for women "Emphasize men's responsibility for women's and children's nutrition; men can keep children happy by buying healthful food at the market."

These messages were communicated through community mobilization. Some of the techniques were the use of story pictures showing local women succeeding at tasks, interpersonal communication (mother's card, counselling cards), placing stickers on the mother's card to reinforce the counselling message, and showing men in the pictures on the mother's card (health record card). An evaluation of the programme from 1991 through 1994 indicated significant changes from pre-test to post-test in the trial villages. The percentage of children with low weight-for-height dropped from 38% to 28% in trial villages, whereas in a comparison group of villages it increased by 1%. The percentage of stunted children was reduced from 46% to 31% without an increase in household income. Some behavioural changes were also noted. Fathers were more likely to bring food home to the families, and mothers were more likely to eat what the men brought.

In Burkina Faso, similar key target behaviours were defined. However, the results were less impressive in Burkina Faso than in Mali, probably because the intensity of the programme was lower. In Mali non-governmental organizations and local workers presented the message in the communities and the homes, whereas in Burkina Paso the health-care workers communicated the message during health-care visits.

Among the lessons learned were the following: one needs workers dedicated to the project in order for it to be effective; specific messages need to be given to specific audiences; social support for women needs to be strengthened; and different behaviour changes require different methods. The authors concluded that of the problems they identified, complementary feeding was the most difficult to change and required intensive interpersonal communication to change. On the other hand, increasing the intake of vitamin A required a media-based approach focused on increasing intake of specific foods.

High-risk infants: Low-birthweight children

A second type of programme that incorporates care into a medical facility is the treatment of low-birthweight infants. A number of carefully controlled efficacy studies showed that the care practice of tactile stimulation or gentle massage will result in greater weight gain in low-birthweight or very low-birthweight babies [60, 61]. The authors suggested that the mechanism for the observed effects may be that the massage increases catecholamine and vagal activity, which leads to increased food absorption. More rapid initiation of breastfeeding when combined with rooming-in was also found for low-birthweight babies who received tactile stimulation [51]. One study even reported higher levels of cognitive functioning at 18 months as a result of tactile stimulation postnatally [50]. Infant massage is a traditional care practice in a number of societies and has been shown to have positive effects on growth by observational studies [28].

TABLE 1. Incorporating care into health, nutrition, and integrated programmes: the care component and research evidence for its effectiveness according to type of programme

Abbreviations: AED, Academy for Educational Development; HIV, human immunodeficiency virus; LBW, low-birthweight.
^a. + indicates that the intervention had a positive effect; 0 indicates that no effect was found.
^b. Satoto. Care and child feeding, growth, and development. Paper prepared for the Indonesian Conference on Complementary Feeding, Surabaya, Indonesia, January 1996.
^c. Early Childhood Enrichment Program-Parent Effectiveness Service Evaluation Study. Final Report, Manila, 1989.

In the United States, a large effectiveness trial to assess the possibility of avoiding long-term deficits among low-birthweight and very low-birthweight infants was conducted. This programme, the Infant Health and Development Program for low-birthweight infants, combined home-based activities for the first year, then intensive centre-based activities for the next two years, plus parent support groups. In a randomized trial, children receiving the home visits and centre-based programme showed a significant increase in IQ [52]. The intervention was conducted to improve the quality of psychosocial care that parents could provide and enhance their human resources for care through home visits and support groups. The greatest impact was observed with families who were most involved, although this relationship was not necessarily causal.

Among the lessons learned from this and other programmes was that these home-visiting programmes were most effective when the families perceived the need for the visits, which tended to be the case for families with low-birthweight infants. Visits to low-income families with term infants had more mixed results, perhaps because the families felt less need for the intervention.

Integrated programmes: Increasing parental knowledge and skills in health, nutrition, and early childhood development

The previous two examples illustrate how specific care practices either can be the main focus of a project or can complement other interventions. The third example combines interventions to improve several care practices into an integrated programme for increased effectiveness.

In the Philippines, the parent effectiveness service provides low-income and disadvantaged families with an opportunity to increase their knowledge and skills in 13 areas, including health and nutrition, child growth and development, and responsible parenthood [57]. Families are recommended to the neighbourhood parent effectiveness assembly for the sessions. The members of about 10 families (almost entirely women) meet weekly with a social worker, the implementer, or a parent volunteer to discuss the material and use role playing and activities to learn the concepts.

Two evaluations were reported in 1989 and 1993 [57].* Both were one-time surveys of parents in the programme and the programme leaders (post-test only, no control groups). These evaluations suggested that parents were generally pleased with the programme. They reported positive changes in their own behaviour and in their interactions with their children. Parents felt that the sessions on husband-wife relationships and responsible parenthood were most useful. There was slightly less interest in the sessions on child development and very little interest in games and children with disabilities. In both evaluations, most parents did not attend all of the sessions. No objective measure of impact was taken.

(* Early Childhood Enrichment Program - Parent Effectiveness Service Evaluation Study. Final Report, Manila 1989.)

A number of lessons were learned. When the evaluation sample of parents were asked to identify their child-care activities, 81% mentioned feeding and 56% mentioned grooming. Very few mentioned psychosocial care for child development. Evidently psychosocial care was a less salient care practice than feeding and cleaning. Not surprisingly, parents found the sessions on child development less useful than those on health and nutrition. The most valuable sessions from the perspective of the parents and the social workers were those on husband-wife relationships and the responsibilities and duties of parents, including rules of the household and child management techniques. As in the previous programme model, perception of, the need for the programme seemed to be an important component of success.

The group leaders, who were social workers and volunteers, had only five days of training on the methods and no follow-up training. Some felt that they had not mastered the technical information in the health and family-planning sessions; they recommended asking representatives from the Ministry of Health or Family Planning to present these sessions. Lessons learned included a need for a reduced workload for the implementers and increased training.

Day-care centres, crèches, and alternative child-care strategies

Child care for working mothers, particularly for children under three years of age, is an increasing need in many parts of the world, particularly in the growing megacities of the South. A variety of alternative care systems are used: institutional day care, home day care (care of several children in her home by a non-relative for pay), informal arrangements with family members, and paid workers in the home. Each of these arrangements involves food, health, and care of several types.

Mehra et al. [58] evaluated nine well-known day-care centre projects for children under three in developing countries. They examined the effects of these child-care programmes on children's nutritional status. The programmes reviewed included mobile crèches in India, seasonal day-care centres in Senegal, and the Accra Market Women's Association in Ghana. All programmes were closely connected to the women's workplace.

According to the reports from these institutions, significant increases in nutritional status as a function of the interventions were found in over half of the projects. Children in home day care or pre-schools had lower rates of mortality and morbidity than those not receiving intervention. The authors concluded that these effects were due to the amount of food served, the cleanliness of the locations, and the protection of the space.

The psychoeducational component of these programmes was not specifically evaluated in the report. However, Mehra et al. concluded that this component of the institutional programmes was not nearly as strong as the health and nutrition component. The ratio of caregiver to child was about 1 to 15 or 20 in both institutional and home day care. This ratio contrasts with the recommendation in the United States of 1 to 3 for children under three years of age. Kits for educational instruction were sometimes available but were not always used because of lack of knowledge of how to use them or fear that the children would damage the materials.

The lessons from this review were that easy access to these centres was a key determinant in the use of the day-care programme; there is a need for quality control and training of caregivers in child development, nutrition, health, and hygiene; and nutrition can be improved with these programmes. Finally, since less is known about providing psychosocial care to children, there is a need for research on the best models or techniques for care.

Perhaps this work can be informed by work in the West. An extensive investigation of the quality of day care for children under three years of age in the United States concluded that only three factors consistently influenced children's development: the ratio of caregivers to children, small group size, and absence of authoritarian or rule-based attitudes among the child-care providers [62].

The number of children in these care programmes was very small compared with those in informal alternative care. These alternative care arrangements may be less than optimal, and the caregivers may be too young or untrained to be capable of providing care. To help clarify the extent of the problem, an assessment of where children are cared for when the primary caregiver is out of the home for an extended period and who is providing the care should be an essential part of demographic and census reports. This question has been included in several of the Demographic and Health Surveys, such as that in Zimbabwe [63]