|SCN News, Number 12 (ACC/SCN, 1995, 60 p.)|
The causes of poor child nutrition are undergoing a substantial reassessment with recent understanding of the importance of care. Richard Longhurst and Andrew Tomkins of the Institute of Child Health summarize current thinking.
by Richard Longhurst and Andrew Tomkins, Centre for International Child Health, Institute of Child Health, 30 Guilford St (University of London), London WC1N 1EH, UK
The causes of poor child nutrition, all reflected in child survival, growth and development are undergoing a substantial re-assessment. For a long time nutrition outcomes have been equated primarily as being dependent on availability of food, in which the term household food security is used, and the presence of infection which influences the intake, absorption and utilisation of food. There has been some recognition that 'other factors', never properly defined, were important. People with knowledge of nutrition at all levels: family members, village workers, government officials, international civil servants and academics, have often recognised other determinants in the process, usually referring to issues such as 'social factors', 'ignorance' and, in some cases, 'love and support'.
A problem in identifying these other 'social' factors, was that they were often seen as too closely inter-twined with 'food' and 'health' as to be separated. Now these non-food, non-health factors are being brought together in a coherent and practical manner within an understanding of the role of care in nutrition outcomes. Care consists of the actions necessary to promote survival, growth and development, involving actions at the household level parallel with household food security and health promoting behaviour. Resources for improving care exist at the household level: income, food, time, attitudes, relationships and knowledge.
Care for children is recognised within the Declaration on the Rights of the Child as follows: "the child... needs special safeguards and care, including appropriate legal protection, before as well as after birth" and in the UN Convention on the Rights of the Child in Article 3: "to ensure the child such protection and care as is necessary for his or her well-being" and elsewhere in Article 6 and in Articles related to protection from abuse and in especially difficult circumstances such as war and when deprived of the family environment.
The principal drive for promoting and clarifying the concept of care in child nutrition outcomes, within the context of food and health has come from UNICEF. Within its nutrition strategy, adopted in 1990, and in work leading to it, especially in the Iringa Nutrition Programme in Tanzania, care of women and children was recognised, with household food security and the nature of the health environment and health services as one of three conditions, each necessary but not sufficient, for the fulfillment of child survival, growth and development. The actions of food, health and care were the foundation of the work of the ACC/SCN group meeting of November 1990 which reviewed actions that had been undertaken to address the major problems of underconsumption and malnutrition especially among the poorest, to point the way for renewed efforts in the 1990s.
At the International Conference on Nutrition, held in Rome in December 1992, food, health and care were recognised as the three fundamental components for nutritional well being. The theme paper on care for the ICN drew on empirical work world-wide and on consultative meetings with nutritionists, medical doctors and child psychologists. The role of NGOs and religious groups has been invaluable.
Care within maternal and child health has been strongly promoted within WHO and more recently, economists have begun to delve within households as the basic decision-making unit in their efforts to understanding the allocation of resources (or 'household economies'), work that had been carried out among others by the International Food Policy Research Institute (IFPRI). Most recently, papers on topics relating to care and nutrition of the very young child (from birth to 3 years of age) were presented at a UNICEF-funded meeting at Cornell University, New York, in October 1994. At the Institute of Child Health in London, work has been performed on methods for assessing and analysing care situations, developing guidelines and designing workable interventions, particularly for children in especially difficult circumstances.
Research from three areas - 'positive deviance', 'failure to thrive' and fieldwork on care in Central America - has confirmed what many field workers have understood: that care in terms of affection, emotional support, and effective allocation of resources with an atmosphere of stability and security has a direct influence on child nutrition as defined in terms of survival, growth and development. This research has shown that even in situations of poverty involving household food insecurity and an unhealthy environment, enhanced care giving can promote good nutrition outcomes in young children.
Care means different things to different professions and people. "Care" in general refers to the provision in the household and the community, of time, attention and support to meet the physical, emotional, intellectual and social needs of the growing child and other family members. It leads to the optimal use of human, economic and organisational resources. At an extreme, lack of "care" is neglect. Care in terms of child nutrition refers to facilitating the optimal use of household food resources for child feeding, and the optimal use of parental (or other) resources to protect from infection and care for the sick child, or other vulnerable members (e.g. the disabled, elderly). Care in the form of stimulation, affection and support can have a direct effect on growth in the young child, by affecting the timing of release of growth hormones and matching of nutrient intake with requirements.
Among groups of people regarded as nutritionally vulnerable, attention is often devoted to the very young child. However, there are other vulnerable groups for whom care is important such as mothers, refugees, the elderly, the disabled, the school age child and those suffering the shock of an emergency. Children in especially difficult circumstances who have dropped through the safety net of family and community support require special care interventions. Positive care behaviours allocate the household food supply to household members according to need (it should be recognised that this may conflict with cultures where males feed first) and promote the dietary intake of family members who are unwell. Loss of appetite from infection or emotional stress is thus not accepted as an obligatory event. Care involves encouragement, coaxing, keeping food safe and even provision of alternative more expensive, appetizing food sources. Care behaviours also encourage health promoting behaviour such as the use of latrines and appropriate water supplies and support health seeking behaviour through regular visits to preventive and curative medical services. All of these behaviours can be promoted and supported by government ministries of health, agriculture, education and community development, together with NGOs. Programme planners who find it difficult to understand why children are not fed when adequate food appears to be available in the household, nor wash their hands when water and soap are already used may look to care behaviours for some of the reasons.
Development programmes aiming to improve nutrition outcomes need to recognise Care as a crucial ingredient along with 'food' and 'health'. Programme managers should start with a situation-specific appraisal. This involves finding out who are the caregivers involved and how existing child care practices can be protected and supported. This appraisal also involves a dynamic understanding of trends and how the pressure on child care practices are changing. Through a process of assessment, analysis and action, then re-assessment, re-analysis and so on - a recurring Triple-A cycle - resources available at household and community level can be activated by different forms of communication to improve care, and hence nutrition.
Care, Nutrition and the Young Child
Care is vital in the nutrition of the young child. According to Professor Engle of CalPoly in California care giving behaviours include "breastfeeding, diagnosing illnesses, determining when a child is ready for supplementary feeding, stimulating language and other cognitive capacities, and providing emotional support". Thus, the use of bottle feeding breaks down the most effective way of caring for the very young child, which is via breast feeding. The role of the caregiver is obviously very important and although it is generally assumed that mothers are the primary caregivers, in many societies care is shared by older siblings, older relatives and possibly by other families in community-organised arrangements. The role of fathers is very important as they have specific care-giving behaviours to impart but often their care giving role is limited because of employment, personal leisure or attitudes.
Engle has also drawn attention to an important concept for analysing the need for, and impact of care, especially for the young child. This is the division of care behaviours into those which bring a child up to a minimally healthy level (compensatory behaviours) and those designed to increase the child's capabilities, growth or development (enhancement behaviours). She has pointed out that if parents do not value enhancement child care, extra time (an important resource) may be spent on other activities thought to be more important for the family such as income generation or leisure, rather than child care.
Research by psychologists has shown that the characteristics of a child strongly affect the nature of care that s/he receives. The two-way feedback between child and carer is very important: a non responsive child reduces the care s/he gets while a responsive and active child elicits more care from the care giver. Nutritionists have not given much attention to this, but it is acknowledged that characteristics such as appetite, temperament, responsiveness, health status and gender all influence caring behaviours. The need for care is often greatest with cases of severe protein-energy malnutrition. Inadequate levels of Care may well have been the reason for the cause of the nutrition problem in the first place. Therefore a re-inforcing cycle is set up.
Dr Urban Jonsson of UNICEF suggests that care behaviours for the young child can be grouped into four: i) feeding behaviours including breastfeeding, and complementary feeding especially those relating to frequency, amount and density; ii) hygiene behaviours related to food, personal and home, iii) psychosocial behaviours including responsiveness, warmth, involvement and opportunities for learning and iv) health behaviours such as service utilisation, oral rehydration therapy and home care. Feeding behaviours may be as important as food availability for child nutrition. Care factors provide specific lessons for supplementary feeding. The areas of appetite and complementary feeding are very important and only now are being properly understood.
Promoting care in the context of breast feeding involves several supporters. Employers need to provide adequate maternity support and facilitation of breast feeding in the workplace, governments must provide adequate control of the media and agreement by the food industry to ensure responsible activities regarding advertising of infant and child feeding commodities. Free or low cost supplies of breast-milk substitutes must not be provided to maternity services. Hospital personnel must be trained in the physical and psychological elements of breast feeding, with changes in hospital practices regarding births and stronger support for breast feeding. The lactating mother also needs support by other family members.
For severely malnourished children there is increasing consensus on the best regimes for treatment with regard to content of energy, protein, mineral, electrolytes and vitamins. There is also agreement, in general, on effective, affordable regimes of infection control. However, with few exceptions, there has been rather little attention to care issues that are necessary for the effective delivery of these interventions, including protecting and promoting traditional and effective child care practices. This obviously involves support for the carers; in some programmes this has been neglected such that the carers become demotivated, frustrated and ineffective. Such issues need attention within the family and organisations such as primary health care projects to prevent and manage organisational and personal stress.
A lot of the work on care has been directed at the child under three years of age and at pregnant and lactating women within the context of breast feeding. But care remains equally important for the nutrition of other groups and is equally neglected as a means of understanding how efforts to improve their welfare can be improved. Care has an important role in increasing nutrient intake and decreasing episodes of infection in high risk groups. Also, despite the considerable attention given to micronutrients over the last few years, for example, care as a factor in enabling their intake has been little examined.
Care, Nutrition and the School Age Child
The nutrition of the school age child has often been neglected, compared to the preschooler. But care and nutrition are vital for child development and health. Many school feeding programmes, for example, ignore care completely, their objective is often to make sure that a child consumes a specific amount of nutrients. The timing and nature of meals and the related social interaction are important opportunities to combine with knowledge of nutrition which might usefully be incorporated into the curriculum with practical experience of preparation and consumption of nutritious food prepared and eaten in hygienic environments. In such instances, care can be seen as the driving force which stimulates education ministries, schools and communities to ensure that resource provision accompanies theoretical learning. Care of individuals within schools who are 'not coping' because of malnutrition requires the incorporation of recognition and appropriate response within "teacher training". This is particularly important for children who do not receive breakfast or are micronutrient deficient. Similarly the special needs of children from particularly disadvantaged families require sensitive, informed and effective treatment.
In many countries the number of school age children attending school has remained constant; in some countries they are falling. The costs of primary school education, the need for the child as a worker in poor communities, decreasing opportunities for employment, civil disruption, and orphanhood from various causes including AIDs means that even in harmonious families and communities, school attendance may be limited. Add to this the burden of street children, those involved in exploited labour and the generally unattached, there is now increasing need to consider the care of school aged children who do not attend school. There is urgent need to promote appropriate interventions from the voluntary, religious and governmental sectors which involve unconditional care for individuals and the unattached. While these activities are normally considered the responsibility of social welfare services, the scale of the problem is so great that all avenues of response should be considered. Care may well involve avoidance of over-nutrition. With the one child policy in China for instance, there is likely to be increasing emphasis on essential micronutrient supplementation, by parents, in order to achieve scholastic and physical success. Similarly, foods that promote dental caries should be avoided.
Care, Nutrition and the Disabled Child
Many reports suggest that in both developed and developing countries about 7% of children have some form of disability. However, most studies show that, on average only 2-3% of children are considered disabled by the community and needy of special attention. Many causes of disability relate to poverty and care and nutrition can do much to prevent disabilities and ensure that the disabled child is not at a disadvantage.
The nutritional status of the disabled child is often poor; in many cases the disability has been caused by previous nutritional insults such as vitamin A deficiency leading to blindness, cerebral palsy as a result of premature birth or low birth weight caused by poor maternal nutrition or iodine deficiency causing varying degrees of mental retardation. Malnutrition among the physically or mentally handicapped child is a common reason for marginalisation. In addition severe malnutrition due to insufficient energy intake is also a major disabling factor. Malnourished children get infections more seriously: diarrhoea for example can lead to serious dehydration, high fever and sometimes brain damage. Many disabilities can be prevented with improved care practices, protecting against infections and household and community accidents, making a strong case for care at community and national level to prevent energy and micronutrient deficiency induced disabilities. Communities need to have the resources to ensure iodised salt can be purchased and that, for example, vitamin A capsules can be distributed effectively and equitably.
As mentioned earlier, the obverse of care is neglect; many handicapped children may be neglected, but not because of any uncaring attitude on behalf of the family. In the scramble for scarce resources within a poor family there is a negative outcome for those who require more compensatory care, and may never even begin to receive the desperately needed enhancement care, especially in societies where the period of 'being cared for' is very short. For example, children who are disabled from birth with cerebral palsy may have feeding difficulties such that their families will continue to have to do everything for them long after other children have developed self-feeding skills. Extra attention paid at this stage will avoid future malnutrition and compounding of the disablement. Furthermore, the potential for improved function among disabled children and adults as a result of improved nutrition, is considerable. The problems of disabled children need more attention and advocacy with the introduction of programmes that recognise their special circumstances. They often 'fall between the cracks' of bureaucratically-defined programmes.
Care, Nutrition and the Urban Child
What are the principle differences between an 'urban' child compared to a 'rural' child and how does this affect care? There are increasing concentrations of people in urban areas depending on a higher level of economic diversification than an agriculturally based society. There is crowding, more of a cash economy, a lower level of physical activity in certain occupations, predominance of manufacturing, bureaucratic and service activities and some degree of organised public services. In addition it is believed that family ties may be weak especially for those who have entered an urban community recently. However, urban populations enjoy greater political clout. About twenty years ago the data showed that malnutrition was higher in rural areas but since then the differences have narrowed.
The urban economy and economic constraints resulting from recession and adjustment have caused an increase in the numbers of women working outside the home. The impact of women's work in terms of child nutrition appears to vary depending on the type of work undertaken, its intensity and location and level of income received. Women may not work longer than in rural areas but may have to travel further for that work. Employers may discourage accompanying children. Women may face confusion from health professionals and advertising with extra messages for child care and feeding. In many cases the time for child care is reduced. Fathers are often absent. Urban social systems are seen to differ from rural ones with important often destructive social consequences for child care. There is debate as to whether urbanisation results in a lack of community or different forms of community.
Social conditions are certainly different with additional stresses and dangers such as violence, drug addiction and prostitution. The urban environment is probably more unhealthy in terms of sanitary conditions: the disposal of both industrial and domestic waste are health hazards. Differing patterns of infection are seen both to cause and result from malnutrition. Breastfeeding is seen to have declined in many urban areas in terms of duration, if not of incidence, and thus emerges as a further cause of urban malnutrition.
It is in urban areas that especially disadvantaged children will exist. Children from the age of six upwards will be vulnerable to shocks from lack of supervision and discipline/nurture, prostitution, drugs and poisoning. Care programmes for urban children have to take account of the tact that they may not be located in a family, and that this care structure has to be provided in some form through other community institutions. Indigent children and orphans need to be considered as a special group for care and be included in nutrition programmes such as community kitchens.
Care, Nutrition and Refugees and People in Emergencies
The importance of care, within the context of food and health, is also leading to a different way in which we understand emergencies. Emergencies have grown in number and intensity over the last ten years, and many, especially in Africa, but also in the former Yugoslavia and Soviet Union, are also associated with conflict. As a result of these crises, the number of internally displaced people and refugees has grown; in Africa refugees and displaced now number 20 million, the size of a fair-sized nation. Many emergencies, including those of the sudden onset nature, have been seen as crises of food: people have nothing to eat and this has to be provided for them from outside as rapidly as possible. Famine relief has become common especially in the Horn of Africa and food aid operations have taken a lot of the resources of multilateral and bilateral agencies.
However, over the last ten years, the notion that food alone meets the short term needs of populations in an emergency has been re-assessed. For children there is now a clear understanding that food and infection control alone are not enough. The major reason for this reformulation is that not enough attention has been devoted to understanding how those affected by an emergency behave. In most cases, they are not 'helpless victims' but cope and adapt to a crisis whether unexpected or not. These coping mechanisms are now beginning to be understood within the operational context of many agencies: strategies involve a number of insurance mechanisms, disposal of productive assets, income diversification, leading to distress activities such as splitting of families and communities and migrating to relief camps. Several of these will have important implications for children.
Families often decide to protect livelihoods rather than lives, which suggests that food intake is reduced early in the crisis (rather than later as is often assumed) and that the wage earners and their assets (e.g. livestock) are also protected. This will have negative implications for child care. With income diversification and longer searches for water, food and work, the amount of time devoted to children is also likely to decrease. Distress and destitution activities include migration by entire family units, prostitution and in extremes, selling off and abandonment of children.
When families migrate and join other destitute families in camps then a food crisis becomes compounded by a health crisis'. Congregations of large numbers of weak people with poor sanitation often cause outbreaks of infectious diseases such as cholera and measles. It is for this reason that health care, including widespread immunisations of children and provision of clean water, is now a component of relief aid. (Recent analysis of data from some famines in India in the nineteenth century has shown that malaria (in the irrigated areas) was the greatest cause of mortality, not lack of food by itself.) Refugees suffer from the same types of nutritional deficiencies as other groups, but often more so due to their increased destitution. Mental and emotional illnesses are also common among the displaced. Recently the importance of micronutrient deficiencies among refugees and the displaced has been extensively documented. Apart from vitamin A and iron deficiencies, scurvy and pellagra deficiencies have been seen in refugee populations.
However there had been little attention paid to components of care in relief interventions, until the effects of conflict on children became better understood. Care interventions involve maintaining intellectual and cognitive development, psycho-social care relating to the direct traumatic effects on child emotional development related to loss of personal security, and broader aspects relating to a child's wider social needs. In several emergencies involving conflict (popularly known as "complex" emergencies), children have suffered traumatic experiences including the sight of parents and others being killed. Therefore compensatory care related interventions have been needed for psychological rehabilitation. Emotional stress as a result of recent traumatic experiences may be very severe, affecting care of self and children. Withdrawal, depression, anxiety and despair have profound impact on appetite. Thus improved management of such problems should become an integral part of nutritional care. It is particularly important that teachers recognise that post traumatic disaster disorders may be an explanation for the "difficult" child, refusing to pay attention or eat.
More recently care has been broadened as an important emergency intervention to mitigate the disruption that occurs to a child's environment: loss of schooling, normal patterns of social life, separation from the family and protection during conflict from abduction, conscription, rape, imprisonment, abuse wounding and murder, all in contravention of the Geneva Convention. Care in the form of maintaining school education is increasingly being recognised as essential during a crisis, although it remains a low priority for donors after feeding and health care. A school binds a community together maintaining an air of normality, keeping children's minds off the shocks that the emergency may be causing.
In refugee camps, activities are designed to be very service delivery oriented to mechanistically deliver food, immunisations and water. Care interventions are not usually included. Breast feeding is not encouraged and organising social activities for children happens only in rare cases. Child play is not usually encouraged. More can be done to ensure that family and social units stay together and maintain some cohesiveness so that young children do not become cut off from their families. Informal schooling could be organised in the camps. All of these have positive effects on nutrition and child development.
Care for improving nutrition, it has been emphasised, revolves around the allocation of resources and appropriate behaviours. Resources for the poor are always scarce; when resources are constrained, allocation always has negative implications for someone. So the whole issue of care has to revolve around the rights of children. Actions for improved child care has to be driven by an ethical position that the child has first call on resources. The fact that improving care also improves nutrition and function is therefore a helpful, but not necessary, imperative for improving nutrition.
Many interventions can have an impact on care, directly or indirectly. Actions taken by governments and other bodies at international and national or regional level can affect care at household level. It is not a closed family matter for the mother and child. At all levels care has to be recognised as an important factor in nutrition. Much is already known about food intake and health as inputs for nutrition; emphasis on care does not weaken their importance. In fact it does the opposite: understanding care issues will enable a more effective understanding of first, food as a commodity to be consumed and be used as a resource for improving livelihoods and family welfare and second, the health environment and health services in the context of available family practices and resources. Most importantly basing nutritional improvement on care, as well as food and health means that communities can take power into their own hands to improve the welfare of their children and not be solely directed by service delivery options from outside their community.
At national level many economic activities can have an impact on care in terms of improving the resources available at community level, including income generation and credit programmes that improve women's control over income, literacy and nutrition education that reflects resource scarcity at the household level, technology devices for workload reduction and legislation for rights for women and children. Whether these can be translated into improved care depends on whether care is seen as a responsibility for all, not just the primary care giver. Protection against harmful trends including necessary legislation and enforcement is another measure that can be taken nationally. Breast feeding should be protected and encouraged. In the community, care can be legitimised as an activity for the responsibility of all. Informal young child care networks can be strengthened with resources to expand beyond custodial services to provide enhancement care in terms of nutrition supplementation and cognitive and psycho-social stimulation. There are good models for this in several countries, notably Nepal. Within formal and informal employment relations, child care facilities could be instituted and strengthened. The importance of care in the promotion of nutrition is too important to be neglected any longer.
Engle, P. (1992) Care and Child Nutrition Paper for the International Conference on Nutrition. UNICEF, New York.
Gillespie, S. & Mason, J. (1991) Nutrition Relevant Actions: Some Experiences from the Eighties and Lessons for the Nineties. ACC/SCN State-of-the Art Series Nutrition Policy Discussion Paper No 10. ACC/SCN, Geneva.
Hanbury, C. (1992) Child-to-Child and Children Living in Camps Child-to-Child Trust, Institute of Education, University of London.
ICN (1992) Caring for the Socio-Economically Deprived and Nutritionally Vulnerable. Theme Paper No 3. FAO/WHO, Rome.
Myers, R. (1992) The Twelve Who Survive: Strengthening Programmes of Early Childhood Development in the Third World. Routledge/UNESCO, London. (See especially Chapter 9).
Ressler, E., Tortorici J., & Marcelino, A. (1993) Children in War: A Guide to the Provision of Services. UNICEF, New York.
Richman, N. (1993) Children in Situations of Political Violence. J. Child Psychol. Psychiat., 34(8), 1286-1302.
Werner, D. (1987) Disabled Village Children: A Guide for Community Health Workers, Rehabilitation Workers, and Families. Hesperian Foundation, Palo Alto
Zeitlin. M., Gassemi, H. & Mansour, M. (1990) Positive Deviance in Child Nutrition. UNU, Tokyo.