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Care during complementary feeding
The research and development process for care
Incorporating care in the design of programmes
Current work on care
Conclusions and recommendations
Patrice L. Engle and Lida Lhotska
Patrice Engle is affiliated with the Department of Psychology and Human Development at Cal Poly State University in San Luis Obispo, California, USA. Lida Lhotska is affiliated with the Nutrition Section, UNICEF, New York.
Incorporating care practices and resources for care into existing health, nutrition, and integrated programmes can have significant positive effects on childrens growth and development. Correlational studies and a few efficacy trials suggest the promise of this approach for improving the survival, growth, and development of children, particularly those under three years of age. This paper defines the concept of care, clarifies characteristics of nutrition programmes that include care, and describes four intervention strategies for health and nutrition that incorporated care. It summarizes lessons learned from these and other experiences and current actions that UNICEF and others are taking regarding care, and suggests further steps.
Care can have powerful effects on childrens growth and development. In the 1950s and 1960s, John Bowlby . described the significance of a childs attachment to a single caregiver for normal emotional, cognitive, and physical development. About the same time, Wayne Dennis  observed infants at two years of age in orphanages who could barely sit up and could not speak. They had little contact with the child-care workers in the facility. As an experiment, he selected a group of infants for special treatment; he assigned each child to one particular caregiver who was asked to pick up, hug, and talk to the child on a daily basis. Children with this treatment changed radically; they began to talk, developed rapidly in terms of their motor behaviour, and grew well. The treatment was care. Since these early studies, much research has illustrated the importance of attachment between child and caregiver, a unique and enduring bond, and of psychosocial care in general for all aspects of a childs development. Yet despite this knowledge, in 1991 the world witnessed the deprived conditions under which Romanian orphans were being raised .
Cruezinger  describes conditions in an orphanage in Russia that was probably similar to the Romanian institutions. Each caregiver was responsible for 20 children under three years of age and worked for 24 hours at a time. The caregivers felt overwhelmed by the work and the childrens needs. They believed that they had to train the children to be able to survive in the institution that they would move into at age four (the Childrens House), and had to make the children tough. Also, caregivers and administrators felt that orphans or abandoned children were different emotionally, since they came from a poor heritage. Children were rarely held, for fear that they would demand more than the caregivers could provide. If children cried from a fall, they were told to shut up and stop crying. They were continually hurried to the next activity of the day. As a result, the children soon became silent and non-verbal, and they grew up totally unprepared for life beyond the institution. One mother who traveled to Romania to adopt an 18-month-old child reported that he could not sit up and one side of his head was flattened from curling up next to the bottle that had been attached to his crib as if he were a hamster .
The opportunity to replicate some aspects of Denniss classic experiment occurred as these infants, many of whom were at least moderately malnourished, were adopted into Canadian families. Could they show as much progress as Denniss Iranian orphans? In this case, not only was care improved, but also health services and nutritional intake.
Morison et al.  asked adoptive parents to estimate the childrens developmental levels before adoption, when they were first observed in the facility. Children were assessed a year after they had been adopted into Canadian homes. Two groups of children were identified: those who were adopted before they had spent 4 months in the orphanage and those who had spent at least 8 months in the orphanage, usually closer to 18 months. In both groups, almost all of the children were rated as delayed in language, social development, and fine and gross motor development. Both groups improved dramatically in the subsequent year. At that assessment, over half of the children were reported as normal; their progress was marked.
The comparison between the early and later adoptees (approximately 45 per group) on the one-year assessment was revealing. Both groups had improved dramatically, but the children adopted before spending four months in the orphanage were indistinguishable from comparison children born in Canada. The children adopted later still lagged far behind their compatriots, particularly in language and social development. Moreover, these children as a group showed a series of behaviours that tested the patience of their caregivers; they had difficulty with food, often eating far more than needed. They formed only weak attachments to their new parents, and some were indiscriminately friendly to strangers. Their most difficult, but most common, characteristic was poor control over attention-seeking behaviours and frequent episodes of anger and irritability. The longer the children had been institutionalized, the more persistent the problems [3, 6]. It appears that care as well as health and food inputs during the first year of life were crucial for the childrens development.
This paper describes four intervention strategies for health and nutrition that incorporated care. It discusses lessons learned from these and other experiences, reviews briefly current actions that UNICEF and others are taking regarding care, and suggests the next steps that we need to take. The first step is to define the concept of care and what characterizes a programme that involves care.
Care as it has been defined in the past 10 years refers to the behaviours and practices of caregivers (mothers, siblings, fathers, and child-care providers) to provide the food, health care, stimulation, and emotional support necessary for childrens healthy growth and development. These practices translate food security and health-care resources into a childs well-being. Not only the practices themselves, but also the ways they are performed - with affection and with responsive-ness to children - are critical to childrens growth and development .
Food, health, and care are all necessary, but none alone is sufficient for healthy growth and development, according to the UNICEF conceptual framework . All three elements must be satisfactory for good nutrition. Even when poverty causes food insecurity and limited health care, enhanced caregiving can optimize the use of existing resources to promote good health and nutrition in women and children. Breastfeeding is an example of a practice that provides food, health, and care simultaneously.
One way to categorize influences on children is to divide the environment into a continuum ranging from proximal (close) to distal (distant) aspects of the environment . Aspects of the environment directly experienced by the child are labeled proximal and include both physical and social dimensions. Care practices or behaviours are proximal aspects of the environment that are primarily social and influence childrens growth and their development. This is a wide net that captures many behaviours that have long been recognized as important for child nutrition, such as breastfeeding, home health care, and hygiene practices, and brings in less recognized behaviours, such as a familys care for women and psychosocial care. Using a single term to encompass these behaviours has the advantage of highlighting their interrelationship within the locus of the household. Using a single term has the possible disadvantage of including so many behaviours that the term becomes meaningless. In order to avoid the latter problem, care behaviours defined here are those relevant to nutrition and growth, and six kinds of behaviour have been specified as most important for child growth and development.
Distal aspects of the environment, such as the availability of a water source within the house, the amount of food available on a daily basis, or the energy and knowledge of a primary caregiver, affect child nutrition indirectly. The distal aspects of the environment of interest here provide resources for care, which may be human, economic, or organizational. Human resources at the family level include the caregivers knowledge, beliefs, and education and enough physical health and mental health and confidence to put the knowledge into practice. Economic resources include the caregivers control of resources and time in order to provide care. Organizational resources include alternative caregivers and community care arrangements, and emotional support from family members and community networks . These same three kinds of resources also occur at the community, district, national, and international levels.
Caring practices and resources vary tremendously by culture and perhaps even more among families within cultures. Childrens basic needs for food, health care, protection, shelter, and love are the same in all cultures. Differences may be seen in how each culture and each family attempts to meet these needs. Widespread changes in families due to urbanization, the increased economic role of women, expansion of primary education, and population increase require changes and adaptations in care practices for which families may be ill prepared.
Care practices include care for women, including care for pregnant and lactating women; breastfeeding and complementary feeding; psychosocial care; food preparation and food hygiene; hygiene practices; and home health practices . Some care practices, such as breast-feeding and hygiene practices, have been investigated extensively, whereas others, such as family support for young women to delay childbearing, have rarely been studied. This paper will focus on two care practices - care during complementary feeding and psychosocial care - since these are two areas that have received relatively less attention.
Adaptation to psychomotor abilities for self-feeding
The feeding situation
High-quality complementary food, which is provided from about the sixth month onward, is a key component of good nutrition. Previously food quantity and, to some extent, food quality were the major topics considered. However, behaviours or practices related to how food is provided to children and fed to them have been found to influence nutrient intake in studies such as those in Nepal .
Four aspects of the proximal behaviours of complementary feeding that affect intake can be defined: adapting the feeding method to the childs psychomotor abilities (e.g., spoon handling); feeding responsively, including encouraging a child to eat, attending to possible low appetite, balancing child versus caregiver control of eating, and using an affectionate or warm style of relating to the child during feeding; creating a satisfactory feeding situation by reducing distractions, developing a consistent feeding schedule, and supervising and protecting children during eating; and feeding frequently and when children are hungry.
Adapting to childrens changing motor skills can require close attention by the caregiver, since these abilities change rapidly during the first two years of life. For example, by seven months of age the gag reflex moves to the posterior third of the tongue, permitting the child to ingest solids more easily than earlier . The time required for a child to eat a certain amount decreases with age for solid and viscous foods, but not for thinner purees. Childrens abilities to hold a spoon, handle a cup, or grasp a piece of solid food increase with age and practice . Self-feeding with a spoon requires a number of steps from putting the spoon in the plate, filling it with food, taking it to the mouth, and emptying it. Children practice these components separately at first, putting the spoon in the dish over and over, often banging the spoon and handling it to gain skills. Only several months later are the sequences concatenated .
Feeding responsively can be particularly important for young children. Caregivers encourage, cajole, offer more helpings, talk to children while eating, and monitor how much the child eats. Mothers and other caregivers who show or model for children how to eat healthful foods will encourage childrens eating, especially when food quality is low. The amount of food that a child consumes may depend as much on the caregivers active encouragement of eating as on the amount offered [11, 14,15].
The caregivers understanding of and response to the childs hunger cues may be critical for adequate food intake. For example, if the caregiver perceives a childs typical mouthing actions in response to new food sensations as a food refusal and ceases to feed, the child will receive less food.* When children are fed from a common pot, the amount eaten is not easy to determine. Having a separate bowl for each child can help determine quantities eaten and protect the slow eater, although the person with whom the food is shared makes a difference .
(* Kotchabhakdi NJ, Winichagoon P, Smitasiri S, Dhanamitta S, Valyasevi A. The integration of psychosocial components of early childhood development in a nutrition education programme of Northeast Thailand. Paper prepared for the Third Inter-Agency Meeting of the Consultative Group on Early Childhood Care and Development, Washington DC, January 1987.)
Cultures vary along a dimension of control of eating. At one extreme, the caregiver has all of the control and children are force-fed, whereas at the other extreme, control is given entirely to the child. Neither extreme is good for children. When too much control is in the hands of the caregiver, forced feeding or continued and even intrusive pressure on children to eat is seen, which may lead eventually to inability to monitor food intake and to obesity [17, 18]. Passive feeding, particularly if a child has anorexia or poor appetite, may result in inadequate intake . Caregivers have been observed to encourage feeding only after seeing that the child is refusing to eat, which may simply result in fruitless battles .
The feeding situation may also influence the food intake of young children. Some children are fed on a regular basis each day, sitting in a prescribed place with food easily accessible, whereas others are fed while wandering around or at the time the caregiver finds convenient . If the main meal is prepared late at night, children may fall asleep before it is completed. Children can be easily distracted, particularly if food is difficult to eat (e.g., soup with a spoon the child is unable to use) or not particularly tasty. If supervision of feeding is not adequate, other siblings or even animals may take advantage of a young childs vulnerability and take food away, or food may be spilled on the ground.
Responsiveness to developmental milestones and cues
Attention, affection, and involvement
Encouragement of autonomy, exploration, and learning
A second set of care practices that influence both growth and development of children consists of social, emotional, and cognitive interactions between caregivers and children. Four major kinds of practices have been defined [7,21].
Responsiveness to developmental milestones and cues affects childrens growth and development. This includes the extent to which caregivers are aware of their childrens signals and needs, interpret them accurately, and respond to them promptly, appropriately, and consistently . Responsiveness maybe illustrated by the caregivers behaviour when a child cries or fusses. If the caregiver does not have time to respond or misinterprets the reason for the crying, the caregiver may miss an opportunity to feed the child when the child is hungry. Responsiveness is also important for developing language. Even before they can talk, children understand simple adult speech and can learn the give and take of conversation. Caregivers who talk to their children in simple language and respond to childrens verbal play will help their children learn language earlier.
Responsivity also varies according to the age of the child; the most appropriate response changes with the childs developmental stage. For a very young child, the response to fussing may be touching and holding, whereas at an older age, it could involve talking or demonstrating appropriate behaviours.
Vygotskys theory explains the importance of responsiveness for cognitive development and language . Vygotsky suggests that learning is most likely to occur when information is appropriate to the childs developmental status or is in the childs zone of proximal development. The extent to which a caregiver can adapt information and interaction to the childs emerging structures will determine the effectiveness of the learning . This process has been labeled scaffolding, since a scaffold is an extra structure or support needed to construct a building and is perfectly adapted to that particular building. As applied here, the caregiver provides the support or scaffold for the childs developing cognition. The caregivers ability to be responsive or sensitive to the childs emerging abilities facilitates the childs development. Sensitivity is the ability to accurately perceive and interpret the infants attachment signals, and to respond to them promptly and adequately .
Sensitivity or responsivity improves childrens learning and cognitive development . For example, maternal sensitivity coded during mother - child interactions at 9 months uniquely predicted the childs language comprehension at 13 months - more than the childs comprehension at 9 months . The mothers excessive directiveness or intrusiveness was unrelated to language development, a result also found in other studies .
Meins  asked mothers to construct a box with their 36-month-old children. Mothers who had a close relationship with their children (securely attached) were more likely to use feedback from their childrens performance in gauging the level of specificity of their succeeding instructions than mothers with a more distant relationship. Closely connected mothers may be more able to pitch their instructions at an appropriate level. Meins described these findings in terms of the zone of proximal development; mothers had the ability to tutor their children within the region of sensitivity to instruction.
Parents expectations of the age at which children learn important skills like walking or speaking their first word (developmental milestones) also affect their childrens development; parents who expect earlier development are likely to have children who develop earlier. Helping parents to be aware of developmental stages can have positive effects on childrens development and can help the parents identify slow development.
The attention, affection, and involvement that caregivers show to children influence their growth and development. The most important factor in a childs healthy development is to have at least one strong relationship (attachment) with a caring adult who values the well-being of the child. Lack of a consistent caregiver can create additional risks for children. The child needs frequent positive interactions. To the extent possible, valuable traditional practices should be identified and sustained. Examples are infant massage in India , postpartum rest of mother and child in many Muslim countries, and responsiveness to childrens desires in Bali. These customs maybe undermined by an encroachment of Western values and urbanization.
Encouragement of autonomy, exploration, and learning by caregivers can improve childrens intellectual development and nutritional status. Young children are born with the ability to learn, but they need the encouragement and freedom to be able to develop that ability. In developing countries, malnourished children who have been given verbal and cognitive stimulation have higher growth rates that those who have not . Caregivers need to provide safe conditions for play, encourage exploration, and provide learning opportunities in addition to good nutrition.
Evidence for the effectiveness of care in interventions
Effects of care on child growth and development: correlational studies
Effects of care on child development: experimental studies or efficacy studies
Effects of care on child growth: experimental studies or efficacy studies
Occasionally a concept will be recognized as logically necessary and critical to understand long before the details of definition, conceptual mapping, indicators, and even evidence for effectiveness are well established. This is true for care; the concept was recognized by a number of researchers during the Iringa experiment of the 1980s , explored further in Zeitlins positive deviance work , and reinforced by the success of using communication strategies for positive behaviour change via social marketing. It was also supported by new research indicating that factors other than income, such as maternal education, were important predictors of undernutrition. The process of defining care as an integrated construct and having it become part of our planning and programming has been the work of the 1990s.
Care is an overarching concept that includes a number of discrete care behaviours, such as breastfeeding or care seeking, that have been investigated intensively and that provide good models for the research and development process. As with breastfeeding, the process should follow a logical progression from literature review to research suggesting that care plays a significant role in child growth and nutrition, research delineating the kinds of problems that result in poor care, development of possible care interventions, efficacy trials to test the interventions, and finally scaling the interventions up to national or international levels and evaluating the results. The development of indicators occurs during this process.
The research efforts indicate quite clearly the importance of care for growth and development, and the kinds of problems that lead to poor care. Interventions have been developed and tested for some care behaviours, but not others, and we do not yet have universally accepted agreements on the measurement of care practices in all areas. The number of studies that address more than one care practice is limited. Because the concept is complex and behavioural, it may take some time and effort to move through these steps. The recent appearance of research examining behavioural factors related to growth and development suggests that the process is under way.
Although one can envision an investigation that would compare the effects of a distal intervention, such as household water taps, with and without an intervention to change care practices, such as hygiene, studies of that type were not located. However, there were a number of studies demonstrating that changed care practices resulted in improved child growth or child development. Incorporating care practices and resources for care into existing health, nutrition, and integrated programmes can have significant positive effects on childrens growth and development.
A number of studies found correlations between care practices and child growth and development, even with controls for household economic resources. For example, in a study in Barbados, feeding practices, such as breast-feeding preference and feeding intensity, predicted later growth . Several recent reviews have summarized the correlational data showing effects of these variables on growth and development [21, 33, 34].
Several recent reviews of the experimental literature on the effects of various forms of early intervention on childrens cognitive development provide evidence that a psychosocial intervention can have significant effects on childrens development. Small-scale experimental designs that manipulate parental behaviour have shown effects on childrens language and cognitive development .
Programmes to improve psychosocial care through parent education about parent-child interaction have been effective. In the United States, programmes promoting improved parenting skills through home visits have shown modest effects on cognitive outcome . Home visiting has been found to be an effective component of programmes targeting low-birthweight and premature infants , non-organic failure-to-thrive children , and undernourished children in developing countries [39,40]. Olds and Kitzman  reviewed four randomized trials of home-visiting interventions that were designed to work with parents to improve the cognitive development of pre-term and low-birthweight newborns. All of the trials found consistent evidence of increased mental test performance. In programmes that are aimed at parents and children who are at social and economic risk, the results are more mixed than for those interventions directed to families of pre-term and low-birthweight infants.
A mother-training intervention was also found to be effective in Turkey . A training programme for mothers that was designed to help them to foster cognitive development using the home-intervention programme for pre-school children and to become sensitized to their childrens needs was assessed in combination with three different child-care arrangements in a 2 x 3 research design. They compared the effects of attending pre-school programmes with educational aims versus custodial day-care programmes versus staying at home. Mothers participation in the home-training programme was associated with higher scores on cognitive tests and school performance, particularly when combined with an educationally oriented programme.
Another approach to improving psychosocial care is through day-care centres or child-care programmes, with the care provided by child-care workers in a group environment. When high-quality child development activities in child-care centres are implemented with acceptable fidelity, they have consistently had a positive impact on cognitive function and IQ scores in the United States and in other developed [42,43] and developing  countries.
There is considerable evidence that growth is affected by some care practices, such as exclusive breastfeeding and appropriate disposal of waste and excreta. More surprisingly, there is some evidence that changes in psychosocial care can have effects on physical growth. In an controlled efficacy trial in Bogota, Colombia, malnourished children who were provided with maternal education visits twice weekly from six months through three years of age were significantly taller at three years  and maintained that difference three years after completion of the programme . The presumed mechanism was that the parents were more aware of their childrens food needs and were more likely to direct food towards them. It is possible that parents who were alerted to childrens cognitive needs were also more responsive to nutritional needs.
Relatively few programmes have investigated whether and how specific care practices have changed as a result of intervention. These assessments could be useful for process evaluation. For example, in two studies, changes in parental behaviour, such as responsiveness, teaching behaviour, and encouragement, were found even when the child outcomes did not change .
Examples of programmes that involve care
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 childs 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 childrens 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 childs indications of hunger may also increase her tendency to respond to a childs 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.
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 . 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 . 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 childrens 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 childrens and womens 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 mens responsibility for womens and childrens 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 (mothers card, counselling cards), placing stickers on the mothers card to reinforce the counselling message, and showing men in the pictures on the mothers 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 . One study even reported higher levels of cognitive functioning at 18 months as a result of tactile stimulation postnatally . 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 .
TABLE 1. Incorporating care into health, nutrition, and integrated programmes: the care component and research evidence for its effectiveness according to type of programme
Type of programme
Care component (practice or resource)
Primary health care
Curative: Encourage active feeding & stimulation of sick children
Several studies under way
Preventive & promotive: Screened for delays, provided information
on care for development
Provided social support during pregnancy to reduce stress
Randomized controlled trial of prenatal home visits resulted in decreased
incidence of abuse & more positive child-rearing attitudes (+)
Provided information on caregiving skills prenatally & immediately
Multicentric trial of social support during pregnancy showed no effects
on birthweight or complications  (0)
Education: Included messages on supervision of eating, need for a separate
bowl, increased monitoring of child intake, offering additional foods
AED project in Mali showed significant increases in child nutritional
status & feeding behaviours as a result of the communication strategy
Education: Increased resources for food by increasing the value of feeding
of women & children by men
AED project in Mali increased fathers role in food purchasing (+)
Iringa project in Tanzania increased mens labour to free womens
labour  (+)
Education: Combined teaching about parenting skills & interactions
regarding food with food recommendations for toddlers in low-income families
Building blocks for toddlers programme (Cornell University Extension)
combined home visits & small groups enrolled in WIC programmes
Growth monitoring & promotion: Taught caregivers about developmental
norms as well as improved diets for young children in regular assessments
& counselled parents with problems
Significant differences in nutrition knowledge, food variety, & self-reported
parenting strategies were found (+)
Breastfeeding promotion: Included information on specific aspects of
development during the postnatal counselling visit & in support groups
LBW infants: Increased opportunities for tactile stimulation
Early skin-to-skin contact & rooming: more rapid feeding initiation,
higher cognitive development at 18 mo 
LBW: Home visiting for parent instruction
Infant health & development programme for LBW infants combined home-based
activities for the 1st yr, then centre-based activities: significant
increase in IQ 
HIV-infected children: Increased cognitive stimulation & caregivers
awareness of feeding problems
Behavioural consequences of HIV may affect care. Correlational studies
reported language deficit  & feeding difficulties 
Malnutrition: Increased maternal motivation to change feeding practices
by seeing change in children over the 2-wk period
Hearth Model of 2-wk feeding & group sessions resulted in significant
changes in proportion of moderately & severely malnourished children
in Viet Nam & Haiti (+)
Home-visiting programmes for low- income families: Included direct services
for children, help for parents with literacy, jobs, etc.
Results of randomized trials in US showed only short-term effects on
cognitive development, few effects on parents  (0)
Community development &/or income-generation projects: Day-care programmes
or feeding centres may be included; community mobilization for improved
growth & development of children
Parenting programmes with health &nutrition component: Provided information
on growth & development of children as well as role plays & materials
on responsible parenting (husband - wife relationship, rights, & obligations)
Participants in the Parent Effectiveness System Programme in the Philippines
who met weekly in groups to learn & role play on 13 topics, including
child growth & development, health & nutrition, & husband-wife
relationships, reported significant changes in their & their childrens
behaviour c(+? - no other impact data)
Child-care programmes for working mothers: Strong components of both
nutrition & early child stimulation are needed
Some of the centres reviewed by the International Center for Research
on Women also showed positive effects on growth(+)
Models include pre-school centres & family- based care
Colombia home day care programme (ICBF) has shown some positive effects,
particularly on psychosocial development, less on nutrition  (+)
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 . 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 . 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 .* 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.  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 childrens nutritional status. The programmes reviewed included mobile crèches in India, seasonal day-care centres in Senegal, and the Accra Market Womens Association in Ghana. All programmes were closely connected to the womens 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 childrens development: the ratio of caregivers to children, small group size, and absence of authoritarian or rule-based attitudes among the child-care providers .
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 
Interest in combined nutrition, health, and child development or psychosocial care programmes has increased dramatically recently. Several major efforts by the Child Health and Development Division of the World Health Organization (WHO) , the Pan American Health Organization , and the World Bank  to compile research and define best practices provide a basis for building programmes for care.
UNICEF has made considerable efforts to incorporate care into its programming. In a review of the annual reports from 1996,40 countries mentioned projects involving care, most of which involved psychosocial care to improve early child development. Many mentioned training materials and courses. Collecting and evaluating these materials could be an important role for UNICEF. The Nutrition Section provided training and workshops for policy makers and planners in a number of countries and regions during the 1997-1998 period: India, Pakistan, Viet Nam, Lesotho Regional office, Brazil, Central and Eastern Europe, Jamaica and Latin America, West Africa, and the Philippines. In each country, efforts are being made to incorporate care into programs, using models such as those described in table 1. The Care Initiative  has been translated into a number of languages.
Because the interest in the integrated approach to care has been relatively recent, programming has had to rely on accumulated wisdom rather than research findings. Experts with long experience, such as Myers , have written on the costs and benefits of integrated programs, although without using the term care.
Within the next five years, we should have much more information on the effectiveness of incorporating care into health and nutrition programmes, particularly psychosocial care. In Bangladesh a large nutrition programme is under way that was designed to include care in two ways: focusing on feeding behaviours and practices and increasing resources for care. The latter included a womens support group and specific counselling for couples when they get married. In Bolivia, Uganda, the Philippines, and Indonesia, the World Bank and the Asian Development Bank are sponsoring integrated programmes that include nutrition, health, and psychosocial development. Programmes are also being designed by non-governmental organizations such as Save the Children in Nicaragua.
These efforts should help us move from research studies to programmatic efforts. At this point, however, there is a need for more research to provide specific guidelines for programmes, particularly those that focus on psychosocial care and active complementary feeding behaviours. Do we have the appropriate materials to guide these efforts? How can the psychosocial component be most effectively integrated? Who has the resources to present this information? What should the delivery mechanism be? Currently a highly controlled efficacy study is being planned to test the hypothesis that increasing active feeding will result in greater nutrient intake, apart from increasing food availability.
Four different approaches to improving psychosocial care for young children have been developed but have not been systematically compared:
» the milestones approach: providing caregivers with milestones of development and assessing their progress using a growth monitoring and promotion model, as occurred in Indonesia with the developmental milestones card known as the KKA (Kartu Kembang Anak) ;Probably each of these approaches is effective in a particular context, and each has its limitations. The first may help parents identify and focus on their childrens achievement of norms. However, it may also result in anxiety over the childrens failure if the children are not able to reach the norms and if counselling is not provided. If the tests are administered in a group session, as in Indonesia, parents and children may feel ashamed or unwilling to attend future sessions, as described by Coletta et al. . A key aspect of a milestones approach is to have relevant information and recommendations for improving psychosocial care. Otherwise, the child is assessed but there is no counselling for improvement, as in a growth-monitoring programme without promotion.
» the information approach: providing information on the stages of child development and factors that influence that development, as in UNICEFs Better Parenting initiative and materials ;
» the parenting skills approach: teaching caregivers skills for interacting with their children, such as the parent effectiveness service in the Philippines or the Eight Guidelines for Interaction of the WHO Programme on Mental Health ;
» the parental resources approach: strengthening the resources for care through improving parents abilities to provide economic and human resources to their children (e.g., two-generation programmes ).
The second approach maybe of most interest to parents who understand and value child development; it has been well accepted in the Middle East and Northern Africa region and in the United States but has not been as widely used in other areas. If many parents think of care as feeding and cleaning their children rather than psychosocial care, as was reported in the Philippines sample , parents may need additional orientation and awareness to understand and value child development before this educational approach becomes more popular.
The third model appeared to be of interest in the Philippines, where the concept of psychosocial care was still new. It is consistent with current psychological theory, which stresses the importance of the quality of the interaction between child and caregiver for learning and development, particularly the sensitivity or responsivity of the caregiver to the child (e.g., in Valenzuela ). A pilot programme in South Africa is using the Eight Guidelines for Interaction developed by the WHO Programme on Mental Health as a family support programme . Feeding behaviours could also be taught using this skill-based approach. This model seems to be promising but requires considerable training for the trainers.
The fourth model of resource enhancement was effective in the nutrition communication projects of the Academy for Educational Development  and probably should be a part of all studies. However, research suggests that resource enhancement will be more effective for child outcomes when combined with direct services for children .
The delivery mechanism was also a concern in a number of programmes. Projects that relied on health-care workers incorporating care messages into their daily work were much less effective than those that took the message into the homes through home visits, community actions such as dramas, or parent support groups. Frequency of contact seems to be a key element in programme effectiveness . As we move towards integrated programmes, there is a concern that training a single person to be capable in child development and family functioning as well as health and nutrition issues may be difficult. In the Philippines Parent Effectiveness Service, the social workers felt that they could not handle all of the information . The Indian Child Development Services workers found it difficult to provide home visits for the younger children, both because of time constraints and because of their perception of limitations in their knowledge regarding health and nutrition .
Resolving these delivery issues will require carefully evaluated studies. In the World Bank project in the Philippines, a new position of child development worker is being created. A similar approach was followed in the community-based nutrition centres in Indonesia. The Philippines Parent Effectiveness Service programme trained parents to be group facilitators who were as effective as the paid implementers. As experience with the integrated projects grows, strategies to maximize the benefits of this approach will be developed.
The importance of care practices and resources, particularly the linkages among health, nutrition, psycho-social care, and psychosocial development, seems to justify its inclusion into programming. The following conclusions are now evident from the literature:
» Programmes that include care are likely to be effective in increasing nutrient intake and improving growth and development of children from birth to three years of age.Other issues are much less clear. What contextual factors should be taken into account to determine which of the four methods (testing milestones, providing knowledge about child growth and development, facilitating skill development, or strengthening resources in these programmes) would be most effective in improving growth or development? To what extent will changes in one care practice have effects on other practices? For example, will training mothers to be more responsive to childrens cues in feeding result in improvements in caring for sick children or providing responsive stimulation? Will an integrated approach to care be more effective than single-focus programmes?
» A key element in psychosocial care is the sensitivity or responsivity of the caregiver to the childs emerging abilities.
» Effects on children are most likely to be seen from high-intensity interventions directly with children or with both parents and children, rather than solely with parents.
» Effective delivery of messages or support for care may be more likely to occur in a home setting than a health-care setting.
» In order for families to provide effective care, resources for care must be available and under the control of the caregivers.
» The potential contribution of men in families to the well-being of their children needs to be developed.
There is much work yet to be done. Particular concern should be accorded to the urban context and the special caregiving challenges that occur under those conditions, including day-care and informal care arrangements. Delivery mechanisms also will require further investigation. Training of workers for care in general, and for psychosocial care and complementary feeding practices in particular, is urgently needed. The training should be based on efficacy research and programme evaluation. Using ongoing programmes to build a research base will be an essential element of this process. The definition of indicators for evaluating care has been discussed elsewhere  and is the next challenge.
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