|Care and Nutrition - Concepts and Measurement (IFPRI, 1997, 56 p.)|
Meeting the needs of the hungry and addressing the problems of malnutrition requires an understanding of each step in the process from seed in the ground to food in the mouth. The first steps in this process have received the most attention. This paper, however, is concerned with conceptual developments in the last stage of the process: how the various aspects of care of young children affect their nutrient intake and their nutritional status. As it becomes increasingly accepted that many activities in child care - feeding practices, food preparation and storage, hygiene, access to health care, and psychosocial stimulation - contribute to good nutrition for the child, ways to measure the adequacy of care must be developed. This report has reviewed the care model and the implications for measurement of resources for caregivers and of the care provided, with a special focus on feeding and psychosocial development.
In the past 10 years, much progress has been made in understanding the complex interactions of the biological and behavioral factors that determine nutritional status (Alien et al. 1992; Neumann, Bwibo, and Sigman 1992; Pollitt et al. 1993; Cebu Study Team 1991; Haddad, Hoddinott, and Alderman 1997). These studies and others like them have provided a clearer idea of the linkages between quality of nutrient intake, growth, patterns of interaction between child and care-giver, and cognitive development.
The UNICEF model of nutrition and care has been expanded in this paper to include consideration of the resources that caregivers require in order to provide effective caregiving. Further research is needed to clarify the effects of these resources, but some general observations can be made here, based on the review of the literature.
· Education, knowledge, and beliefs. Education of the mother is often associated with a greater commitment to care of the child. Educated women tend to provide better home health care and hygiene, and they are more likely to seek help when a child is ill. But, on the negative side, better-educated women in developing countries tend to terminate breast-feeding earlier.
· Health and nutritional status of the caregiver. Many women in developing countries are chronically ill or undernourished. Studies show that lack of iron decreases productivity, and 60 percent of women in South Asia have iron-deficiency anemia. Although a direct link between caregiver nutritional status and quality of care has not been studied extensively, patterns indicate that women care for their children less during periods of food shortages, perhaps because they must spend more time looking for food and because their energy levels are low.
· Mental health, lack of stress, and self-confidence of the caregiver. A large body of literature links maternal depression and stress with poor care-giving in the developed countries, but few studies to establish this connection have been done in developing countries. Measures of depression and stress should be developed that are tailored to the developing countries, since the methods that have been used may not be appropriate across cultures.
· Autonomy, control of resources, and intrahousehold allocation. Studies have shown that when women control household resources, they tend to allocate larger amounts of resources such as food to children than when men are in control. Working for income does not always mean that a woman has control of income.
· Workload and time constraints. According to the literature, women spend more time than men in all work activities. In addition to child care, women often must gather wood, carry water, prepare food, and do farmwork or other productive work. The effects on child nutrition are not straightforward: some studies suggest that when women work outside the home, even on their own farms, their children are more likely to be malnourished, especially if they do not control income or if a child is under one year old. Other studies have found no negative effects from mothers' working, and some have found positive effects when mothers' work was well paid.
· Social support received by the caregiver. Provision of competent alternate child care is one important type of social support. Institutional care is seldom available in developing countries. The increased entry of women into the labor force without adequate child care support is cause for concern. Surprisingly little is known about alternate caregivers - who they are, their capacity for providing care, and how caregiving instructions are transmitted from the primary caregiver to the alternate. Provision of care to young children comes at a high cost if it means that older girls are kept out of school to act as alternate caregivers. The role of fathers as decisionmakers and as possible alternate caregivers has seldom received attention in developing-country studies and may be a potential that has been overlooked.
Interactions between Caregiver and Child
The UNICEF model of child care is a useful framework for assessing the capacity and ability of the caregiver to provide care. However, the model should not only assess the caregiver's behavior but also the behavior of the child and the environment in which the child is being raised. All three of these factors play a significant role in the eventual nutritional status of the child.
Responsiveness of the caregiver to the child's signals is a critical part of caregiving, and the unresponsive child may have a difficult time eliciting a response from the caregiver. Studies have shown that children who are larger and better nourished may receive more care than low-birth-weight children. Poorly nourished children may be more lethargic and may therefore not encourage caregivers to respond to them. The child who refuses food or is difficult to feed may discourage caregivers from persisting in feeding long enough for the child to consume an adequate amount of food. Inadequate interaction between caregiver and child often lies behind the problem of a child who fails to thrive. In sum, a positive relationship between caregiver and child may lead to increased dietary intake. It may also affect the health of the child.
This paper seeks a progression from theoretical definitions (here called constructs) to the development of valid measurements to help determine the indicators of risk. For example, the construct for nutritional status is growth, a measurement tool is anthropometric measures of height and weight, and a risk indicator is -2 below the standard deviation for height-for-age.
Time spent on child care alone is not an adequate indicator of care. Time estimates should be complemented by measurements of the quality of child care. Quality determinations are not easy to make, however, because cultural differences in care practices and resources are immense. Some constraints to care are easy to measure and others are difficult. For example, it is easy to determine the nutritional status of a caregiver but hard to measure the caregiver's self-esteem. It may be easier to identify inappropriate or even harmful practices in different cultures than to catalog all of the positive ways of interacting.
Measurement tools for assessing care include questionnaires or interviews, qualitative feeding scales, systematic observations in the care setting, experimental procedures followed by observation, and detailed coding of ongoing sequences of interactions. A behavior that may appear strange to an outsider may be the norm in a particular culture; therefore, it is important to compare a caregiver with others in his or her own culture.
Methods for evaluating feeding behaviors of caregivers and children quantitatively and qualitatively might include observation of a feeding session and rating of behavior based on a list of items, or rating of the overall quality of interaction between the caregiver and child. They might entail observation of frequency of feeding over a period of time. Or a new food or feeding practice might be introduced, and observers may note how the caregiver and child handle the situation.
In measuring the psychosocial elements of care provision, it is crucial to keep in mind that affection and responsiveness can be shown through physical, visual, and verbal contact: the patterns of expression vary from one culture to another.
There is not enough evidence at this point to suggest specific indicators that should be used for risk assessment, particularly across cultures and contexts. Much work needs to be done to clarify these measures and to develop a body of research on caregivers' resources in a wide range of cultures. Studies on maternal education and beliefs and mothers' use of time in developing countries are plentiful. Little has been done, however, on the effects of mothers' nutritional status on the nutrition of the child, nor on the effects of mothers' self-esteem and confidence, stress, and possible depression on child care, although these factors are probably significant constraints to care provision. The potential for improving the provision of care through more research and intervention in these two areas seems promising.