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In order to provide continuous high-quality care for the first two to four years of the infant's life, the mother or other primary caretaker must have adequate ability and motivation.
Figure 10 represents a conceptual framework illustrating maternal characteristics that contribute to the ability and motivation that are required to sustain the favourable interactions described earlier and to carry out appropriate child-feeding and health care practices. These characteristics apply not only to the mother but to the infant's entire immediate care environment.
We will use the term mother here as an abbreviation for: mother, other primary caretaker, or caretaking group. In practice, several people often care for an infant jointly. In a recently conducted survey in the United States, the writer found that mothers frequently respond to the question, "Who is taking care of the baby?" with the reply, "His father and I together."
These characteristics intimately affect the changeable proximate determinates discussed in the section on mother-child interactions. They may be relatively uniform in stable societies and may therefore be taken for granted. Yet their importance becomes evident if social structure is destabilized either for the group or for the individual household. When rapid changes occur, these factors are seen to be linked to anomalies in mother-child interaction and in child growth and development.
In the diagram, a circle has been drawn around the term socio-economic level to indicate that research on positive deviance assumes that this level is both low and controlled with regard to macro-indicators such as type of neighbourhood, housing, and approximate household income. In fact, within the same low socio-economic level, parents of well-nourished infants tend to have more positive maternal and paternal employment histories and greater material resources than those of the malnourished (Auba and Alvarez, 1983; Alvarez and Wurgaft, 1982). In general, the reproductive history and domestic work burden of the mother, and her productive work burden at an income-generating job or in farm labour, both affect her ability to care for her infant through time and energy constraints.
Her psychological characteristics, including mental health and personal developmental history, influence the quality of care she is able to provide and the amount of initiative that she applies to problem-solving. Her attitudes and behaviour - either helpless and fatalistic or responsible and enterprising - affect her ability to cope with adversity. These attitudes interact with her motivation to care for the infant. The more formal education, nutrition and health education, and exposure to modernizing influences she receives, the more likely she is to be enterprising and responsible and vice versa.
The mother's education, both formal and specific to child care, and her exposure to modernization affect her ability and her motivation. These variables also influence her strategy of investing in childbearing. The perceived value of the child and the child's role in the mother's expectations for her own life-course are interrelated. Both affect the strength and quality of her motivations to care for it. Finally, the urgency of other agendas that compete with care of the child affect her day-to-day motivation to sustain care. Conceptually, ability and motivation both are conceived as having innate components - i.e. some individuals are inherently more competent in parenting and more highly motivated to engage in infant care than others.
Fig. 10. Conceptual framework illustrating maternal characteristics that influence positive deviance in nutrition.
This section will briefly review the literature relating the characteristics in Figure 10 to positive-deviant outcomes, in order of presentation from left to right.
Reproductive History and Domestic Work Burden
The number and spacing of children born to the mother are closely related to her domestic work burden and also affect the physiological ability of her body to provide nutrients to the foetus and the nursing infant. Yoder and Berggren (1987), looking specifically for causes of positive deviance, found well-nourished children in Haiti more commonly in families with four or fewer children and with mothers below the age of 35 years. A substantial body of research linking nutritional status to fertility (see Zeitlin et al., 1982, chap. 4, pp. 46-53, for a review of this literature) confirms that infants with fewer siblings are better nourished than those with many siblings. Infants born so late that their mothers have many older children to help with the domestic workload sometimes are exceptions to this rule.
Moreover, differences in nutritional status between children in small versus large families are greater than differences usually achieved through nutrition interventions. Chavez and associates (1974), in their positive-deviance study in Solis, Mexico, found a higher ratio of adults to children in the homes of the well-nourished. The fact that height of children consistently declines with increasing birth order in all but the most affluent groups (Wray, 1971) suggests that at the same economic level (within the same household) infants with fewer siblings are more likely to be positive deviants as defined here.
Goodall (1979), reporting on a Ugandan study, notes that the urban child starts to displace the next older sibling before his birth, increasing the risk of kwashiorkor. In China, on the other hand, Dr. Zhi-Chien }lo reported, in response to a mail survey (results of which are presented in part 2, table 9) that the "only one child" policy had improved parents' receptivity to the nutrition and health education advice provided by the health services.
Chavez and associates (1974) also found that mothers of positive-deviant children themselves had better-quality diets than mothers of malnourished children. A good maternal diet may obviously mitigate the nutritional cost of frequent births but may not eliminate these costs. Favourable household structure and child-care arrangements mitigate the negative impact of maternal time constraints.
Mothers who start childbearing in their teens are in some societies at a greater disadvantage since they may be still growing physically, their formal education may be incomplete, their socialsupport systems may be inadequate, and they may tend to be psychologically unready for motherhood. Jones and associates ( 1980) found that mothers below the age of 19 were significantly less responsive to their newborns than older mothers, suggesting there is a critical age at which mothers may develop "maternal readiness" contributing to a strong maternal-infant bond.
Although child malnutrition is often associated with the overburdened mother (Hepner and Maiden, 1971), no generalizations can be made concerning the effects of the mother's incomegenerating employment or her participation in farming. These effects depend entirely on the quality and costs of child care available to her and on her income and the ways in which she spends it. In nineteenth-century England, women's work in factories was associated with appalling levels of infant mortality (Hewitt, 1958). Throughout nineteenth- and early twentieth-century reports, the height of rural children was greater than that of urban children. a situation which has now been reversed, but that probably reflected women's and children's roles in the rapid industrialization of the earlier period.
The fact that some studies in rural areas of developing countries (e.g. Engle, 1982, in Guatemala) find maternal employment positively associated with child survival indicates that poverty and under development per se do not preclude the existence of social-support systems that permit the mother to work without harming her child. Women's unemployment is so consistently associated with large family size that unless women are increasingly engaged in the labour force the prospects for achieving population goals are low. Recent studies in the United States (Zeitlin et al., 1984) and in Thailand and Indonesia (Latham et al., 1984) indicate that women of high educational levels and high socio-economic status are leading a trend towards early re-entry into the labour force following childbirth.
A study by Scrimshaw and Scrimshaw (1980) rated plantation wage-earning mothers on the basis of the health and growth status and survival of all their children. They found that mothers who were most successful were entrepreneurial and that they also contributed family income from petty trading, marketing, animal husbandry, kitchen gardening, etc., whereas those with poorer child outcomes were not earning comparable additional income.
An excessive work burden may negatively affect the nutritional status of children whose mothers work at home. Repeated spot observations conducted in the homes of 185 4- to 27month-old children in the Bangladesh positive-deviance study (Zeitlin et al., 1989) show that well-nourished infants have less income-generating work going on around them and are more likely to be in the care of adult women who are available to help the mother.
Psychological State of the Mother
Failure-to-thrive is associated with poor mental health of the mother. Positive deviance may, by contrast, be a result of excellent psychological adjustment and functioning. The psychological conditions most clearly linked to infant malnutrition are character disorders, depression, stress, and abnormal parenting responses attributed to poor parenting experience during the mother's own childhood (Wurgaft et al., 1984).
The term character disorder implies rigidity and inflexibility of mental mechanisms, and less overall effectiveness in maintaining an adjustment and assuring development (Fischoff et al., 1971). The mother's capacity for successful adaptation to changing environmental circumstances or stresses is limited by an inflexible personality and inability to assess the stresses or changes in her environment, her internal needs, or the needs of her children. The American mothers in Fischoff's study had: "literal, concrete thinking patterns, with limited capacity for abstraction or planning for the future; the use of denial, isolation, and projection as major mechanisms of defence, and a predisposition toward acting out as opposed to thought."
A study by Kerr and associates (197X) in Jamaica found similar characteristics among mothers of severely malnourished children. Their "relationships were more stereotyped, transient, and focused on material aspects. The mothers' narcissistic concerns took precedence over the needs of their children. " Fischoff and associates ( 1971 ) and Greenspan (1981) describe such mothers as need-oriented, competing with their children for concrete as well as psychological and social supports, and attempting to reverse the dependency relationship that should exist during early childhood. Kerr and co-workers (1978) described these mothers as falling into two types: apathetic and dependent or manipulative and evasive.
The "multiple-risk-factor families ' to which such mothers tend to belong, as described by Greenspan (1981), require expensive intervention in the form of infant mental-health programmes. Given the fact, however, that families such as these are self-perpetuating and very costly to any health-care system, such expenditure may be cost-saving in the long run. Greenspan, citing the report of the congressionally author rized Joint Commission on the Mental Health of Children (1965), estimates that 6 per cent of the US population use approximately 70 per cent of all public expenditures for health, social, and auxiliary services. In traditional societies with high infant mortality, such families were less likely to perpetuate themselves from generation to generation. To the extent that PHC strategies succeed in reducing mortality, the number of "multi-risk-factor families" might be expected to increase. Their presence increases the need to link health and nutrition with psychological and social services.
Depression and Stress
Table 6 (Longfellow et al., 1982) shows correlations between maternal behaviour, three measures of stress, and one measure of depression. The definition of the word "mand," used in this table, is: "The attempt by one individual (the subject) to change the behaviour of another (the object) in order to realize a goal." The scales of stress and depression measured the mother's subjective state - feeling stressed or depressed. Objective measures of stress did not show correlations with maternal behaviour. The table shows clearly the mothers experiencing depression or stress were more hostile towards their children and less nurturing. This study was conducted on pre-schoolers rather than on infants. Breznitz and Sherman (1987) reported that depressed mothers engaged in less conversation with their three-year-olds, particularly when eating lunch with them.
Table 6. Correlations of maternal life-conditions stressor score, life-conditions stress and depression
|Events stress||Conditions stressor score||Conditions stress||Depression|
|Dominant mends||- 24b||-.16||.04||.19|
|Compliance to child's dependent mends||.04||-.30b||-.45c||-.52d|
|Hostile and dominating mend styles||-.04||.03||.12||.44c|
|Friendly-affiliative mend styles||.13||-.06||-.05||.00|
|Positive-response styles||.10||-.11||-.19||_ 35b|
|Negative -response styles||-.24 a||.08||.32b||.37b|
Source: Longfellow et. al., 1982.
Cohn and Tronick (1983) found that three-month-old infants reacted with negative facial expressions, crying and arching backs, or with wary expressions to their mothers' simulation of depressed behaviour. Crnic and colleagues (1983) present data confirming the negative effects of stress on maternal-infant interactions. According to Bithoney and Rathbun (1983), loss, stress, poverty, and marital strain can be causal factors in the genesis of HTT. Stress can come from any source that might influence family functioning.
Most studies of failure-to-thrive (Leonard et al., 1966; Pollitt et al., 1975; Kerr et al., 1978; Wurgaft et al., 1984) have found that mothers of FTT children experienced less adequate parenting themselves than mothers of the well-nourished.
If the above forms of psychological condition are used to derive opposite descriptors that might characterize the mothers of positive deviants, they would have:
Helpless/Hopeless versus Enterprising Attitudes
Guthrie and associates (1982) concluded that mothers in their rural Philippines sample of malnourished children "showed many features of learned helplessness" that prevented or delayed them from adopting improved child-care and feeding practices taught by an intervention programme. Seligman (1975) explains that when outcomes are not contingent on efforts, subjects develop an inability to learn new and more effective actions. He reports: "Our mothers usually see little relationship between what they feed their babies and the babies' growth because growth is delayed, and they see illness and death which bear no apparent relationship to diet or care. . ."
Hepner and Maiden (1971) quote Cecily Williams's characterization of mothers of kwashiorkor children in Ghana as hopeless and apathetic. Fischoff and colleagues (1971) characterize the mothers of FTT children as having "fantasies that reflect no hope." Kerr and co-workers (1978) describe mothers of the severely malnourished as behaving towards their infants as if they were helpless to improve their situation. They "were often aware of poor treatment in day-care or other homes but did nothing about it. Three malnourished babies were hospitalized after such experiences and on recovery were returned to the same situations. Seven mothers of malnourished children described encountering malnutrition in other offspring and apparently had not been able to change feeding patterns."
Positive deviance defined as type 4 adaptation, by which individuals and households succeed in '`beating the system" of poverty and deprivation that surrounds them, would seem to depend heavily on the ability to take effective contingent actions in response to new information and new challenges. It is no surprise to find enterprising, non-fatalistic attitudes associated with positive deviance. Not all problem-solving needs to be, however, the result of conscious effort. Chance discoveries may also lead to beneficial behaviours and social structures.
Formal Education, Nutrition and Health Education, and Modernization
Formal education, and nutrition and health education, as well as modernization, are considered together in this section as the channels through which populations learn to stop practicing the first three types of adaptation described on pages 10-34. If internalized, family-planning education relieves the necessity for adapation type 1, nutrition education, concerning weaning in particular, removes the mechanism holding adaptation type 2 in place. Formal education greatly increases receptivity to health/nutrition/family-planning education. Moreover, formal education and other modernizing opportunities together introduce new child-rearing practices more adapted to individual expression and mobility, and in so doing remove the need for adaptation type 3.
Caldwell (1981) explains mechanisms through which schooling releases the African mother from a relatively helpless, passive role in child care, in which she depends on decisions made by grandparents within a traditional belief system. 'The education of a female is likely to convert her maternal indulgence into maternal protective action' and she feels that the school and the larger community expect this of her even if the older people do not. She is more likely than her uneducated counterparts to feel personal responsibility." Caldwell also mentions that education changes intra-household food distribution. Under the rules of adaptation type 3, the father, who is head of the family's agricultural production unit, gets the best food, and the youngest children the left-overs. With changing aspirations for employment, mothers perceive they must prepare their children to compete for higher education and modern sector jobs. Better food must be invested in the child to prepare him for this competition (Zeitlin et al., 1982).
LeVine ( 1980) states that education is "assertiveness training" for girls in traditional societies, and discusses other mechanisms by which women's education leads to smaller family size and reduced mortality. He and his research team also find that mothers with more education give their children more psychosocial stimulation. The great majority of traditional nutrition surveys looking for determinants of malnutrition in developing countries do find that maternal education is a significant correlate of good nutrition. Bairagi (1980) found in Bangladesh an interaction between education and income, indicating that more educated women were better able to use incremental income to improve the nutritional status of their children.
Spot and event observations conducted on 185 4- to 21-month-old rural infants, as part of a Bangladesh positive-deviance study (Guldan, 1988), found that education had a significant effect on child-care and feeding behaviours after controlling for family wealth. As fewer than 20 per cent of the mothers had attended school, a measure of the highest level of education in the immediate family was constructed. On this scale only 30 per cent of households had no exposure to schooling. With increasing education, infants were less likely to be found playing in the dirt, men were more likely to hold and feed the babies, the babies were more likely to eat foods specially prepared for them and less likely to eat food that had been cooked more than eight hours earlier. With more education, infants were also fed more times per hour of observation, were better nourished, more active, and more developmentally advanced.
Education promotes modern beliefs. Most formal education systems in developing countries make fun of the superstitious health benefits purveyed by "witch doctors," etc., as being old fashioned and erroneous, and therefore train their pupils to be receptive to modern health education. Chavez and co-workers (1971) found that mothers of malnourished children had more 'market magic" concepts of health and nutrition, while mothers of the well-nourished had more modern ideas regarding child illness and corresponding treatment.
As noted by Zeitlin and Formacion (1981), educated mothers are likely to feel more comfortable with nutrition and health workers and vice versa. Nevertheless, the effectiveness of nutrition and health education in improving young-child nutritional status does not necessarily depend on the formal education of the mother. Zeitlin and coworkers (1981) found in an evaluation of the pre-school clinic programme in Ghana that mothers' educational level was no longer significantly related to nutritional status of 6- to 24-month-olds after adjusting for the mother's knowledge of nutrition and health education messages taught by clinic nurses. Zeitlin and associates (1984) found that the pilot programme run by the Nutrition Education and Behavioural Change Component of the World-Bank-supported Indonesian Nutrition Improvement Programme appeared to be of most benefit to the infants of mothers with 1 to 5 years of formal schooling, bringing their nutritional status up to the level of children of more highly educated mothers. Zeitlin and Formacion (1981) and Chulankarangka and Onate (1980) both found in the Philippines that mothers' nutritional knowledge was related to the growth status of their children.
Other manifestations of a psychological predisposition to modernize are also associated with positive deviance. Cravioto and colleagues (1967) found in Guatemala that Cakchiquel Indian mothers who spoke some Spanish when talking to their child had infants with better weight gains than those who spoke to the child in Cakchiquel only. Zeitlin (unpublished) found in surveys in rural areas of the Philippines, Burkina Faso, and Bangladesh that mothers who wanted their infants to have more formal education and more modern occupations had significantly better nourished children than those who expected the child to remain uneducated or to continue in a traditional occupation.
The term modernization is used here generally to refer to the attitudes and practices of segments of the population who are attuned to more advanced technologies and who tend to be oriented towards urban life-styles. Further study on this topic (see Bernard and Pelto, 1987; Poggie and Lynch, 1974) should be incorporated into positive-deviance research.
The configuration of psychosocial characteristics found by Rogers and Shoemaker (1971) to typify early adoption of innovation may also characterize households of positive deviants. Early adopters typically are more enterprising, more cosmopolitan, and of relatively higher socioeconomic status than their later adopting neighbours. What is being adopted with modernization may in fact be a new outlook concerning the role and value of children, as explained in the next section.
Investment in Childbearing
Modernization, as noted earlier, affects the mother's strategy of investing in her children (see Zeitlin et al., 1982, for a discussion of demographic transition theory as it relates to nutrition). As families see options for supporting themselves outside of traditional subsistence agriculture, they tend to have fewer children and to invest more in each child, in order to prepare them to compete for modern-sector occupations. A common and very ancient strategy of investing in childbearing changes with the demographic transition (as child death-rates and birth-rates decline). In subsistence agricultural communities, where the demographic transition process has not yet begun, each child provides a material return to his or her parents from an early age, and the direction of intergenerational investment flow is from child to parent. In general. the less efficient the agricultural technology, the more heavily the children need to be involved in agricultural work in order to produce enough food for the family.
As the demographic transition occurs, the direction of the intergenerational investment flow is reversed. Children become very costly to their parents. In economic terms, the child changes from being an "investment good" to being a "consumer good." The stage of the family in this transition influences child care and feeding. The mother's own investment strategy - whether she plans to hear many children who will farm for the family, or few children who will attend school and compete for civil service or other modern jobs - affects her level of motivation to provide care for each individual child.
Satisfaction with Life-course
Self-esteem and overall satisfaction with life may affect maternal behaviour. Alvarez and associates (1982) in Chile found that mothers of 20 malnourished infants were more dissatisfied with their family life than the mothers of 20 well-nourished controls. In this study, the only variable in the past history of the mothers of well-nourished and malnourished children that differed significantly was the jobs held by the mothers prior to the infant's birth: 65 per cent of mothers of well-nourished children had held jobs, compared to 35 per cent of the malnourished. This job experience may have contributed to their higher self-esteem. Kerr and associates (1978) found in Jamaica and Leonard and associates (1966) in the United States that mothers of HTT children lacked self-esteem.
While lack of satisfaction with life may often be difficult to distinguish from depression, lack of satisfaction with life-course may be worth distinguishing from other sources of depression because it helps to explain mothers' reactions to individual children and may help in designing programme approaches. Mothers in all societies have been found to have a vision or plan for the course they would like their lives to take (Neugarten, 1964, 1969; Neugarten and Danton, 1973; Neugarten and Hagestad, 1976). This plan may include time of marriage, type of employment, number of children, sex of children, level of wealth, types of possessions, etc. Individuals develop a mental map of the life-cycle. By such and such an age one should marry; by another age one should have a certain number of children, be a grandparent, and so on. It is likely that people everywhere internalize a social ''clock" by which they determine if they are "on time" or "off time."
Women who perceive themselves "on course" generally express satisfaction with their lives. Those who fail to approximate their course because of adverse circum stances experience dissatisfaction, depression, and low self-esteem. In particular, a badly timed pregnancy, a child of the unwanted sex, or a sickly or difficult child may deflect the mother from her desired course and have negative effects on the care that she is able to give this individual infant. Graves (1976) found, for example, in West Bengal, that 78 per cent of the mothers of the malnourished versus 33 per cent of the well-nourished had a negative attitude toward their pregnancy with the study child. Maginnis and associates (1967) found, among mothers of 50 FTT children, that 30 stated that they wanted a child of the other sex and 32 claimed that they did not want a child at all.
The mother's motivation to care for an unwanted child, whose presence is inconsistent with her life-course agenda or overburdens her resources, may be very low. Nag (1983), in a review of the ways in which modernization affects fertility, explained that unwanted children are born when the physical, psychic, and monetary costs of practising family planning are perceived by the couple to be higher than the benefits of small family size. He cites Johnson-Ascadi and Weinberger (1982), who noted that, in 17 out of 20 countries where the World Fertility Survey was conducted, at least 40 per cent of "exposed" women (currently married, non-pregnant, and fecund) who said they did not want more children were not using any contraceptives.
Scrimshaw (1982) shows that unwanted children in previous eras frequently were eliminated via culturally sanctioned infanticide. She questions whether the current situation, where they more frequently die slowly from malnutrition and ill-health caused by lack of maternal attention, is more humane than rapid neo-natal death.
Traditional life-course agendas are rapidly becoming obsolete in developing countries such as Mexico and Indonesia. Life-course agendas for women are also in rapid transition in industrialized countries, such as the United States (Schlossman and Zeitlin, 1988). It would seem important to determine the topographical features of the life-cycle "map" for women and men in positive-deviance study populations, since such a map would provide insight into the ways in which members of a given group monitor and evaluate their own and other people's performance, progress, and status in the community. Differences in perceived agendas between positive-deviant families and those having malnourished children should be instructive. Unrealistic goals might yield to change through communications strategies or counseling. The writer knows, for example, of a little girl brought for speech therapy, named "Killjoy." The child started to talk soon after the mother had been persuaded to rename her "Joy."
Urgency of Agendas Competing with Care of Child and the Ability to be SeJfsacrificing
Not all mothers are mature enough to put aside their own interests sufficiently to care for a helpless infant. The personal developmental agendas of very young mothers in particular sometimes appear to be too urgent to permit them to care for the child consistently. Mothers who have been severely deprived socio-economically - who have never in their lives owned a nice dress, for example - may not be able developmentally to put the child's needs before their own. Lady Health Visitors in Peshawar, Pakistan, complained to the writer that the low-income mothers of malnourished children attending their clinic were more concerned with their own aches and pains than with the growth or illness of their babies.
In many non-Western societies "good mothers" are perceived to be self-sacrificing.
The concept of good motherhood includes the ability of the mother to give her child's needs higher priority than her own. Responses on the mail survey from China, Japan, and Turkey, published reports from Bangladesh (Rizvi et al., 1984), and personal observations from India, Pakistan, Tunisia, and Mexico support the concept that a good mother is self-sacrificing. Dr. Ayse Baysal of Hacettepe University in Ankara wrote the following Turkish proverb on her response to the positive-deviance mail survey: "It is said of the mother: She does not eat, but feed; she does not wear, but clothe; and she makes her hair a broom for her children." Western society has exchanged this value for the belief that sacrifice should be avoided if possible and certainly shared by both parents if needed.
Findings Applicable to Programme Design
Many of the maternal characteristics discussed above fall into the category of known malnutrition correlates. Programme approaches developed for dealing with the problems identified in this section include family planning, female education, women's income-generating projects, provision of child care, and community development along Freierian lines to combat fatalism and attitudes of helplessness.
Additional outreach components, taking existing health/nutrition and other programmes into the homes of mothers who do not voluntarily participate, should greatly improve their effectiveness in combating malnutrition. The mothers of malnourished infants typically are more psychologically passive, socially isolated, and suffer from more hopeless/helpless attitudes and behaviour patterns than mothers of the well nourished. Since those at greatest risk are least likely to participate spontaneously, the programmes must seek them out.
In existing programmes that include components such as primary health care, growth monitoring, family planning, female education, women's income-generating activities, etc., the psychological quality of the interaction between the programme staff and the participant mothers should be of primary concern. To the extent that the interaction between the provider and the mother is psychologically supportive for the mother, this support, per se, should significantly enhance her maternal competence. These benefits will not occur if the worker fails to involve the mother emotionally in working together with her to achieve a favourable outcome.
Where traditional practitioners provide psychologically supportive care, they should be incorporated into the formal primary health-care system, if possible.
Growth-monitoring programmes are a powerful means of combating child neglect and teaching mothers to invest more in each infant. The unspoken message of growth monitoring is that each and every infant is important to the community and that mothers are publicly accountable for each infant's growth and development. Dr. Harold Rice (personal communication, 1987) observed a growth-monitoring programme in Thailand which appeared to be effective in motivating mothers to invest more in their infants. The worker in this programme specifically sought out the mothers of the malnourished and the mothers who did not spontaneously attend the weighing and spent most of her time counselling them.
Programmes using community-level lay workers to reach the malnourished should use the good nutritional status of the children of the proposed candidates as one criterion for the selection. The attempt to enlist mothers of the malnourished in reaching out to each other is less likely to succeed because they are less likely to have the necessary social skills. Mothers whose own children are well-nourished also have a greater likelihood of transmitting skills and attitudes that contribute to a favourable growth outcome.
Prevention of teenage pregnancy prevents adverse child outcomes because in most societies teenage mothers are psychologically as well as physiologically immature and have less stable social networks supporting themselves and their infants.
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