Contents - Previous - Next

This is the old United Nations University website. Visit the new site at http://unu.edu

Income Generation and Control

There is no doubt that education would provide women with personal and social benefits that could result in improvements in their own well-being and the health and well-being of their families. It is of limited benefit to promote the education of women if women cannot realize basic improvements from this education. If education operates through employment to increase a woman's status and power within the home, we must:
- identify what types of employment will result in the greatest increase;
- identify the constraints (child care, for example) on women's employment in jobs that will enhance their social and economic status;
- take measures to overcome these constraints and ensure that these employment opportunities exist and are considered socially acceptable for women;
- ensure that household production, consumption and socialization incorporate considerations about women's employment opportunities. Our concern is with improving both the perceived economic and social value of women, so that changes in household power bases are prolonged and multi-generational.

Women's Income-generating Activities-A Review

There is evidence that participation in income-generating activities improves a woman's control over household resource allocation, perhaps because having her own income establishes an economic base for the woman within the household. The degree of control or strength of this base depends on: the type of employment (agricultural, marketing, informal sector work, formal sector employment); its location (inside or outside the home); the salary or wage paid; and control or direct access to income earned.

For example, Acharya and Bennett found that women working in subsistence farming in Nepal had little control of resource distribution in the home [2]. When women participated in market work outside the household, their decision-making power in all household activities increased. Economic participation, it was theorized, enhanced the perception that they are contributing partners. Subsistence work was not perceived as an economic or household contribution regardless of its income-saving value.

The importance of a woman's access to her earned income to improve household decision-making powers was reported by Roldan among home-based female piece-workers in Mexico City [137] . This held true both in households where husbands and wives pooled family earnings and in those where they did not. In both groups a woman's access to her own income improved her decision-making power and her self-esteem, regardless of how this income was spent. Her decision-making power, however, was directly proportional to the percentage of her income contribution. Men reported being opposed to having their wives work because they feared loss of respect and control over them.

The effects of a woman's employment on the health and nutrition of her family is an area that has received increasing attention. Most emphasis has been placed on studying the effects of a mother's employment outside the home on: the initiation and duration of breast-feeding; the time spent on child care; the nutritional status of her children; and fertility, contraceptive use, and child spacing [41, 45, 53, 69, 70, 125, 150].

The results of these studies have been mixed, but have none the less led policy-makers to advocate employment programmes and activities compatible with child-care. Compatibility is usually equated with flexible hours, freedom to breast-feed, and the ability to carry children to the workplace [40, 114] . Unfortunately, due to limitations on education and job skills, and to a lack of enforceable government policies to provide child care in the formal sector, women participating in such employment programmes have been relegated to low-paying, informal, or home-based employment.

Although home-based or informal-sector activities may be more compatible with women's availability to feed their infants, a welfare approach to women's employment is unlikely to enhance their perceived social and economic value. Dixon advocates employment outside the home because it gives women greater exposure and opportunities for social interaction, and it ensures that they are paid directly for their work, enhancing their control over income earned [35] .

A complete discussion of the effects of development programmes on women's employment, and of women's employment on family health, is beyond the scope of this article. Much work is now being carried out in this area. However, it is important to point out that most programmes and policies that promote women's income-generating and employment activities do so out of a concern for improving child welfare. This orientation has in part been based on the popular belief that women, rather than men, are more likely to spend their income on food and other basic necessities for their families [46,111,148], and that women's earnings are associated with a better standard of living for their families [17].

The different spending patterns of men and women have been well documented for many sub-Saharan African countries where women have full responsibility for household food production and family expenses [34, 62, 78, 127] . Though internal economies are common in African households where the division of labour and spheres of activity are welle-stablished, it is unknown to what extent they exist in other parts of the world [23] . The influence of women's work on household spending and family health may be greatest when women enter the wage labour force out of economic necessity. Under these circumstances, their earnings are more likely to be spent on basic needs for family survival. Men, as demonstrated in Belize [143], Yemen [109], and the Gambia [34], were more likely to spend their earnings on alcohol, tobacco, radios, and other personal items.

Given this situation, however, interventions should not be restricted only to improving women's income generating and child-providing abilities. Health and nutrition should not be considered only the woman's responsibility-it is a family concern. When women are sole providers for their children, as in the case of female household heads, opportunities to improve their employment status should be provided. When other wage-earners are present, the importance of their contributions to family health and well-being should be stressed.

More research is needed to identify how improving women's perceived social and economic value can improve decisionmaking on household resource use and, ultimately, family health. Decision-making power appears to be influenced by dichotomies in spheres of activity and the sexually based division of labour. This division is known to change over time with changes in economic exposure to mass media, marketing, and other forms of communication [91, 92].

Health and nutrition practices are determined not by one but by several factors influencing behaviour, and the household is considered the appropriate context for analysing these factors. Decision-making will be represented through the study of intra-household resource distribution. Educational interventions are proposed as a means of promoting the more equitable and efficient use of all household resources, and also of advocating the social acceptability of such practices as the education of girls and the contribution of men's time and income to individual and household maintenance. Additional research, however, is needed to identify whether education - provided face-to-face or through a social marketing approach
-can precipitate social changes which, when carried out in combination with other interventions, can result in improvements in family health, nutrition, and economic well-being.

Human resource development and training requirements must be considered in order to carry out both research and the proposed educational interventions. In-service training of personnel should include emphasis on how decisionmaking and resource distribution in the home (and their possible modifications) could result in improvements in health, feeding, and nutrition.

The following sections of this article will include a discussion of specific methods for the study of IHHRD, an analysis of current knowledge on intra-household food distribution and its importance to the study of nutritional behaviour, and a discussion of how household behaviour can form the basis for a new approach to nutrition and health education.

INTRA-HOUSEHOLD RESOURCE DISTRIBUTION (IHHRD): A COMMUNITY-LEVEL STUDY

The study of IHHRD can be carried out initially as a community-level assessment to determine whether existing health and nutrition problems are caused or perpetuated by critically inadequate resource supply, the inequitable distribution of available resources, or some combination of both conditions. In order to find out if there is a distribution problem within a community at large, one should look for basic indicators. Community-wide indicators include household and sex specific differences in: (i) literacy and schooling, (ii) employment opportunities and salaries, (iii) infant and under-five mortality, (iv) nutritional status and undernutrition, (v) health-care service utilization, and (vi) legal rights (in employment, marriage, and politics, for example).

Sex-specific differences are emphasized because they reflect differences in resource distribution based on present social and economic values and perceived future roles. These differences may result in health and nutrition problems being perpetuated through generations, but demographic, sociological, and economic studies often overlook their importance. Other important differences not related to sex, such as birth order, are omitted from this document since they have been the object of attention in various studies. Not all of the above indicators are necessary for a community assessment and some may be difficult to measure, as well as being less significant. A list of additional community-level indicators is shown in table 3.

The major purpose of a community-level assessment is to determine whether there is an intra-household resource distribution problem and to identify elements of household production, consumption, and socialization which may perpetuate it. Within a community it is also important to pinpoint, using differences in the identified indicators, households at risk from poor health and nutrition, and to compare them with low-risk households in the same setting.

The community-level indicators listed in table 3 independently reflect different conditions, but together provide a composite of community behaviour. If sex-specific data is not available, investigators or programme planners are advised to carry out rapid surveys. Indicators such as literacy and schooling, employment opportunities and salaries, and legal rights may be relatively easy to uncover. Indicators such as infant and under five mortality, nutritional status and undernutrition, and the utilization of health-care services may require more systematic study. Data concerning the utilization of health-care services should be sought if there are marked differences in mortality by sex for specific causes. This information, however, may be limited and misleading because the decision to attend a health centre may reflect factors such as time, cost, distance to the nearest health facility, and availability and utilization of other health resources.

Differences in literacy, education, and employment opportunities should be analysed together. If there is a local literacy programme, or mandatory and enforceable primary education, this must also be considered. Education itself is a long-term investment. As an indicator, it is not sensitive to short-term or seasonal variations. For this reason, it may be relevant to ask the questions listed in table 3.

TABLE 3. Community-level indicators for the study of IHHRD

Investments in the education of children represent decisions made about the trade-off between present utility in household production and the long-term benefits of education for future performance and the fulfillment of future roles [43]. If women are more likely to work inside the home only, girl children, it is hypothesized, will be less likely to receive a formal education. As training programmes and industries emerge, the benefits of future employment may outweigh the costs of sending children to school or employment training.

Economists have found that the benefits of children begin to outweigh their costs by the time they reach eight years of age and are assisting in home and market production activities [ 156] . The decision to forgo or delay this "balance of payment" may be made when (a) parents perceive that education will benefit the child in such a way that the benefit will outweigh the cost, or (b) parents perceive their own limited education as a liability and see the education of their children as a means of improving their lives.

The employment indicators listed in table 3 help us understand existing attitudes towards different types of work and may reflect the relative decision-making power of men versus women in the home. Informal versus formal sector employment should be considered, as a woman working long hours as a domestic servant, for example, is less likely to gain in household decision-making status [114]. Differences in unemployment rates and employment rights shed light on prejudice outside the home and may also be a relevant indicator; they should be considered in view of the age of first marriage, community-level fertility rates, education, and the increased status of women in household and society.

SEX-SPECIFIC DIFFERENCES IN NUTRITIONAL STATUS

Differences in nutritional status among children may be attributed to a variety of causes, including infection, environment, food consumption, activity, and, to a lesser degree, genetics [63]. When there is a difference in undernutrition that is sex-specific and occurs throughout a community, intra-household food-distribution practices should be studied very closely. Of particular relevance to such a study are the intra-household variables associated with proper versus inadequate nutrition.

The subject of intra-household food distribution (IHFD) has received increasing attention, but unfortunately there is little information to document the contribution of intra-household feeding practices to the perpetuation of undernutrition within households and the community as a whole. Of the social, cultural and economic influences on IHFD, of particular importance is the transmission of knowledge and beliefs about the perceived nutritional needs of different household members based on age, sex, and household role. In the presence of measurable differences in nutritional status between household members, differences in food intake can be sensitive indicators of household decision-making.

INTRA-HOUSEHOLD FOOD DISTRIBUTION (IHFD)

Intra-household food distribution, also known as intrafamilial food distribution, refers to patterns of eating and feeding that take place in the home. It does not include, but may be influenced by, feeding which takes place outside the household. IHFD patterns are the result of a complex of factors including:
1. Environment: seasonality; variety of available foods; distance to markets; availability of fuel for cooking availability of appropriate technology.
2. Economics: total income; food availability and purchasing power; source, periodicity, and stability of income.
3. Culture: taboos; special properties of food; prevailing attitudes towards food; food avoidances; health, disease, and convalescentcare feeding.
4. Perceived biological need: perceptions about the food needs of certain population groups according to age, phase in lifecycle, health status, size.
5. Individual preference: specific likes and dislikes; cravings; anorexia; disease.
6. Social organization: division of labour; household budget control; the role and status of women time available for food preparation; household eating patterns.

Much has been written in recent years about the determinants of intra-household food distribution [22, 32, 117], and the policy implications such practices have for the design and implementation of nutrition programmes [80,86, 122, 134, 149] . Some of the models proposed for examining intra-household food allocation behaviour are presented in figures 2, 3, and 4.

Though the theoretical bases for the study of IHFD are well defined, there is little information currently available on the functional consequences of household food distribution processes. That is, while prevailing nutritional beliefs and feeding practices have been well documented for many cultures, few studies have systematically analysed and evaluated the effects these practices have on the nutritional status of individual family members over time. Specifically, the following questions remain unanswered:

- What is the impact of reported beliefs, taboos and food restrictions on food distribution and nutritional status? How does adherence to these customs change with age, family member's role, or change in economic circumstances?
- What is the contribution of IHFD practices to the perpetuation of undernutrition in conditions of relative food availability or of chronic shortage?
- Are distribution practices different in times of food scarcity than in times of greater availability? How does food scarcity affect the distribution of food within the home?
- To what extent are decisions about household food distribution made in the absence of adequate nutritional knowledge?
- How do the characteristics of the person distributing the food affect the share each family member receives?
- How are decisions about food allocation made?
- What are the gender and/or generational determinants of food production, preparation, and distribution processes?
- What are the bases for perceptions about individual need?

To what degree is nutritional knowledge determined by household/family tradition and socialization, and to what degree by formal education on nutritional properties and food preparation? What is the input of other members in household food activities, and the role of the husband and the motherin-law? How do traditional meal patterns (and infant feeding habits) affect food intake? To what degree is this affected by snacking and meals obtained outside the home? What do distribution practices reflect or reveal about prevailing beliefs regarding the relative social and economic value of males versus females, or of adults versus children?

FIG. 2. Proposed model of food flow in the household (after Katona-Apte [80] )

FIG. 3. Factors and processes influencing food availability, acquisition, and allocation (after Pinstrup-Andersen [122] )

Although previous works have provided much insight into the factors which influence household behaviour, few studies have directly examined household decision-making processes and the impact changes in environmental, economic, cultural and other variables have on intra-household resource allocation behaviour. Specific studies are needed to examine directly household decision-making processes in relation to food and other resource allocations, so that we can understand better how social, economic and political factors interact to determine behaviour.

IHFD AND NUTRITION EDUCATION

Findings suggest that improvements in nutrition cannot be achieved only by increasing the supply of food available to the household. Efforts must be made to improve the utilization and distribution of that food once it enters the home. Nutrition education has commonly been proposed as the most direct means for influencing such behaviour. As the above models indicate, however, the factors underlying and motivating nutrition behaviour are complex and numerous. Most programmes limit their approach to improving the preparation and utilization of food in the home. While socio-cultural beliefs, taboos and restrictions are often identified, few programmers have considered the household dynamics that influence transmission of knowledge and adherence to these customs.

Planners must evaluate the degree to which household characteristics and individual beliefs, goals, values and psychobiological perceptions influence decision-making behaviour. Educational interventions must be directed at all identified conditions that affect behavioural choices. They must address the limiting factors and necessary circumstances for behavioural improvement, as well as variables that act as points of resistance to change.

FIG. 4. A conceptual framework for the study of intrahousehold food distribution (after Van Esterik [149] )

The theory underlying our assessment of the importance of IHFD and household decision-making processes is based on the following assumptions:
1. Although there has been a call for health and nutrition education programmes to be culturally appropriate, most planners and educators have little idea of what this means in functional terms. 2. Culture, for the purposes of health and nutrition programme design, should not be viewed in the normative sense. Culture is shaped by the changing processes of production, consumption, and socialization.
3. Nutrition behaviour is determined by a complex of factors mediated through the household, as the household is the primary unit of production, consumption, and socialization in society.
4. Nutrition education activities that aim to influence behaviour must address both observed nutritional practices and those factors underlying and conditioning behaviour (the co variants of behaviour).
5. The design of nutrition interventions must consider other household processes such as the division of labour and time, internal economies, chains of information transmission, and decisionmaking powers to identify the most effective means of producing holistic improvements.

A REVIEW OF THE LITERATURE ON INTRA-HOUSEHOLD FOOD DISTRIBUTION

Literature on intra-household food distribution is of two major kinds: (i) works that document observed feeding practices, and (ii) studies that provide frameworks for analysing intra-household processes affecting food distribution. The first kind of information is provided in anthropologic or ethnographic literature, and also in dietary and nutrition surveys. The second kind of information has been almost exclusively the domain of agricultural and development economics.

Anthropological Literature

Studies carried out by anthropologists alone [7, 130, 145], or in conjunction with nutrition specialists [75,132], have provided comprehensive and detailed information about beliefs concerning food and feeding behaviour. These studies have traditionally focused on normative descriptions of idealized behaviours and have given insight into societal attitudes about foods, the identification of prestige and super-foods, systems of food commensuality, and the connection people make between food and various conditions of health and disease [79, 112, 142, 152, 154] .

Few studies have examined the association of stated beliefs with actual practice and the impact that adherence to these beliefs has on nutritional status through time [119, 120] . The ethnographic literature has emphasized the "typical" diet, giving an impression of homogeneity. Recent attention to the intra-cultural diversity of feeding behaviour and the influence of changing household economic and social structure on reported beliefs and observed practices has produced interesting results.

A recent study carried out by CARE [151] of rural food habits in six developing countries-Peru, Guatemala, Colombia, Jordan, Tunisia and Bangladesh-collected data on five qualities commonly associated with food and believed to influence consumption. These were: hot and cold qualities, assumed beneficial qualities, medicinal qualities, prestige value, and other qualities (strength-giving or blood giving, for example). The degree to which these qualities were reported to influence feeding behaviour varied from country to country, but adherence to the beliefs was stated to depend on factors such as strength of the belief, availability of foods with the desired qualities, and the cost of the desired food.

The CARE report identified beliefs and practices associated with feeding. Some commonly held beliefs identified in this study are outlined in table 4.

Dewalt and Pelto [33], in an analysis of social status and beliefs in a Mexican community, attempted to understand patterns of intragroup diversity in household food intake. They found that the level of nutritional knowledge was not strongly correlated with adequate consumption. Important determinants of household consumption and nutritional adequacy were: material life-style (size and construction of house, ownership of appliances, furnishings); household composition (including the number of wage earners); ownership of animals; and occupation of household head.

Munoz de Chavez carried out another study in Mexico [108], comparing the dietary practices of families with malnourished and well-nourished children. In an economically homogeneous population, the variables associated with differences in nutritional status were: differences in the ratio of children to adults within a household; sex differences (68 per cent of the malnourished children were girls while 62 per cent of the well nourished were boys); diet of the mother; and weaning history of the child.

In Costa Rica, Rawson and Valverde [129] found good nutritional status to be associated with: stability of income; land ownership and inheritance; and resource-sharing among family members.

TABLE 4. Food beliefs and practices during pregnancy, peritinal period, breast feeding, and early childhood
I. Pregnancy
Belief in eating less or only "normally" during pregnancy (a desire for small babies) Practice of decreasing food intake when ill Belief in beneficial vs. harmful foods for the pregnant woman
II. Postpartum
Practice of withholding food from mother after childbirth Belief in harmful vs. beneficial foods
III. Lactation
Belief that a nursing woman's milk is altered by diet Practices aimed at increasing the quantity of breast-milk Belief that a mother should not nurse a child when she or the child is ill Belief that a pregnant woman should not breast-feed her other young, not yet weaned child ("sevrage"
IV. Infants and pre-school children
Practice of introducing food to child at birth to "cleanse" system
Belief that infants should not breast-feed immediately; should not be fed colostrum
Beliefs about the duration of breast-feeding, when to introduce solid foods, weaning food recipes
Practice of sudden weaning
Practice of purging
Belief that a child eating solid foods no longer needs to be nursed
Practice of preferential feeding of males

Care must be taken in extrapolating the results of the Costa Rica study to other locations due to the small sample sizes; and the methods of data analysis employed in the Munoz de Chavez study in Mexico limit its usefulness. The implications of both studies, however, are significant. Surveys of reported beliefs alone are not sufficient to understand nutritional behaviour and the undernutrition problem. Although food intake is in part influenced by food availability and nutritional knowledge, household nutritional behaviour and individual nutritional status are associated with a number of factors tied to social (including health), economic, and political structures. Further research on IHFD would help us to understand better the relationship between food availability, household structure and composition, and differences in nutrition and health status among household members. Of particular importance is an understanding of how changes in household structure (household heads, nuclear versus extended families) and source and stability of income and food affect nutritional behaviour over time.

Nutritional Studies

Dietary and nutrition surveys characteristically include a description of foods available within a community, socioeconomic data, and information obtained from observation and 24-hour recall surveys. Nutritional surveys may also include anthropometric and biochemical status information. Information on household food distribution usually includes observed feeding, reported beliefs, and a comparison between calculated intakes and standardized requiremeets [ 117 ] .

The methodological and field limitations of these types of studies have been well documented [18] . Individual intake is difficult to measure when household members eat from a common bowl or when feeding is frequently supplemented with snacks obtained outside the home. Conclusions drawn about household distribution practices and preferential feeding when they are not substantiated by the actual evaluation of nutritional status may reflect imprecise estimation of all food intake, or an inadequate comparison between intake, nutritional need, the nutrient content of recipes and foods, and other factors (such as physical activity or infection) that influence nutrient utilization.

Several authors [22, 32, 72, 117] have attempted to understand patterns and determinants of intra household distributtion of food on the basis of information obtained from dietary and nutrition studies. Den Hartog [32] analysed results of nutrition surveys from Ghana 130], Nigeria [101, 103], India [100], Indonesia [126], and Guatemala [49]. From these he concluded that IHFD had both physiological and socio-cultural bases. The physiologic basis, he postulated, reflected perceived needs associated with age, sex, and physical activity. The socio-cultural factors influencing food distribution included:
- the social and economic position of members in their own household and society;
- the prevailing concepts about food and the relationship of food to growth, health, and illness; - the social function of food in the household and society, including the giving of food as a form of hospitality, prestige foods, and the perceived value of staples versus other foods. Den Hartog's conclusions were based on subjective reports from different types of studies. The degree to which these socio-cultural variables actually influence behaviour is unknown and as yet untested.

A similar analysis of dietary and nutrition studies was carried out by the USDA Nutrition Economics Group [117]. The authors of this report analysed surveys from Chile [66], indict [89, 146, 147], Ethiopia [141], Liberia [57], Colombia [144], Nigeria [61, 101, 113], and the Philippines [45].

Their analysis was geared toward an understanding of the food policy implications of observed patterns of intrahousehold food distribution. From the results of the surveys, the authors observed the following patterns of IHFD: equitable distribution; age dominant distribution; sex-dominant distribution; and complex distribution pasterns.

It is important to note that conclusions could not be drawn about the determinants of these types of distribution patterns, as all studies were carried out independently, utilizing a wide variety of research methodologies to collect and analyse the data. None of the studies was carried out specifically to examine household distribution and feeding, and some studies did not disaggregate information by sex or by income. The USDA Nutrition Economics Group suggested that the following list of questions be answered when attempting to analyse household behaviour: - Is there preferential distribution by age?
- Is there preferential distribution by sex?
- What is the knowledge level of nutritional needs?
- To what extent and for whom are cultural beliefs followed within the household?
- How is food allocated at meal times?
- How is individual physical need considered?
- by size, by activity level, by social or economic importance, or by cultural and/or religious norms?

Van Esterik [149] has carried out the most recent review of the literature on IHFD. Her analysis focused on the effects of IHFD on maternal and child nutrition. She concluded [p 10]:

On the basis of past research, it appears that neither economists nor nutritionists have examined the operating dynamics of food distribution within the household; yet both disciplines have replicable and quantifiable methods for measuring the distribution of food to individuals in the household, and of other resources such as time and income which influence food selection and preparation. On the other hand, anthropologists provide insights into cultural mechanisms operating in households and communities, but often fail to measure differences in food consumption within and between households. Much past research provided indirect evidence for inequality without providing reasonable explanations for underlying causes.

There is the need for frameworks for the study of IHFD and for studies to identify variables associated with household decisionmaking and distribution behaviour. The following section will set forth a framework that can be used both for designing such studies and for creating interventions effective in modifying food distribution patterns.

1. Food acquisition: food production; food purchase (whose income is used to purchase food, including what, when and how much money is spent on food); food gifts.
2. Food processing, storage, and preparation.
3. Actual distribution: family meal patterns; monitoring of food distribution.

An example of how resource flows or channels affect IHFD is shown in figure 5. Table 5 illustrates how decision-making can be analysed by the study of household resource flow.

Once the responsibilities that individual household members have in steps 1 and 2 have been identified, then the decision-making processes in step 3, distribution, must be studied. It is important to identify beliefs regarding food, health, nutrition and disease, and ascertain to whom they apply and what possible effects they might have on nutrition and health status. Questions 1 to 7 in table 6 are relevant in this context.

In addition to reported beliefs that may reflect or perpetuate perceived status [73, 79], it is equally important to identify actual practice. Behaviour regarding food production and acquisition can easily be verified. The assessment of actual food distribution processes will require direct observation. Relevant guiding questions posed by the NEG [117] were listed earlier in this article. Questions 8 to 14 in table 6 are also important in considering actual practice.

RESOURCE SUPPLY

The supply of food is a critical determinant of household feeding behaviour. When resource supply is stable (either adequate or chronically limited), distribution practices, though not always nutritionally optimum, may be in balance with perceived needs. Undernutrition may still prevail because perception may not equal the true biological needs for growth, maturation, pregnancy, lactation, physical activity, and recovery from illness.

When food supply is adequate, yet undernutrition persists, it is important to identify those aspects of household health and nutrition behaviour which contribute to the existence of this problem. Measurement of intra-household food consumption may reveal inequities in distribution based on age-more commonly adults receive a more than adequate diet, but children do not-or on sex-girls and women are systematically disfavoured.

FIG. 5. Resource flows affecting IHFD (after Nutrition Economics Group [117] )

TABLE 5. Household food path

Source: Carloni [23,p.8]

Age

When food supply is adequate, yet distribution and intake favour adults, the undernutrition problem in children is believed to be the result of inadequate knowledge or inappropriate feeding practices. The following causes are frequently cited:

1. Low level of knowledge about the nutritional bases of food and nutritional needs of children (including inadequate perceptions about appropriate growth and adequate state of health)
2 Specific feeding patterns that limit the food intake of infants and children (including portion sizes, frequency of feeding, eating from a common bowl and competition, late introduction of solid foods).
3. Specific beliefs regarding available foods that limit total intake (for example, children should eat only staples, and intake should be restricted during diarrhoea or illness).
4. Low demand by children because of illness-induced anorexia.
5. Unavailable "home" technologies to improve child feeding (including strainers and food blenders).

When this distribution condition prevails, it is important to identify the co-variants of household feeding behaviour, or those aspects of household and community provisioning that sustain present practices. In addition to these key factors, it is necessary to identify responsible decisionmakers as well as persons and processes that may act as points of resistance to behavioural change, including time, money, decision-making power, and the objections of an extended family member.

Several educational objectives are commonly proposed to modify child feeding practices. The utility or anticipated success of these objectives should be evaluated in terms of the co-variants and points of resistance identified. Consideration should also be given to a comparison between conditions and intra-household practices in households with well-nourished children and in those with poorly nourished children. The decision whether to design and implement any specific educational intervention alone or in conjunction with other activities will depend on the priority assigned to the causes of undernutrition and the availability of resources to carry out such a programme.

TABLE 6. Guiding questions for the assessment of IHFD
1. What foods (and their characteristics) are appropriate for breast-feeding children?
2. When and how are children weaned (boys vs. girls)?
3. When are solid foods introduced in the diet? What are they?
4. What food qualities are desired or considered appropriate for: (a) children (boys vs. girls) (b) adults (working men, working women) (c) pregnant women (d) lactating women (e) the elderly
5. What foods are restricted during illness? In the face of anorexia what is fed, and by whom? After illness, is appetite satisfied (more food intake)? Is food "measured"?
6. What are prevailing beliefs about ideal body size? What are the associations between health and diet, and between diet and growth?
7. Are there foods abundant in the community that are not consumed? What are the restrictions concerning these foods? Are most food restrictions for foods which are uncommon in the area?
8. What are patterns of snacking? Who obtains meals outside the home?
9. Which persons make the decisions in the steps of the food pathway?
10. How is food distributed within the household at meals? Is this process overseen by someone? Who monitors adherence to food restrictions and taboos?
11. How do time restrictions affect food preparation and distribution? Are feeding responsibilities shared?
12. Do household members eat together? Do children eat from a common bowl? Are infants fed separately?
13. Do food preparers have access to food during the preparation process? Do they nibble?
14. Is food preparation different for "special groups"?
(a) Do children eat the same foods as adults? the same spices?
(b) Do time or restrictions in "appropriate technology" limit the consumption of available foods by infants and children?
(c) Do women eat the same foods while pregnant? lactating? in greater or lesser amounts? Why does diet change during these times?

Nutrition education is believed to be most effective when the supply of food is not the limiting factor [ 163] . There fore, the following educational approaches to rectify poor food distribution practices are suggested:

1. Providing direct education on health and the varying nutritional needs of children for growth and development, during illness, etc.
2. Aiming efforts at modifying feeding patterns: to encourage giving children food on separate plates; to give less bulky, smaller, more nutrient-dense portions and more frequent feedings; to have household members eat together to promote more equitable servings.
3. Proposing growth monitoring as a means for mothers or child caretakers to identify the relationship between a child's nutritional needs and growth; also educating the child's caretakers to recognize the characteristics of a healthy child (and, therefore, those of a child who is not healthy).
4. Directing education at the family as a whole, so that it is understood that not only do adults need to receive minimum requirements for work, but children also need to receive them in order to grow.
5. Making efforts to guard against the purchase of advertised "prestige" foods (for example, soft drinks, unnecessary uses of infant formula)
6. Local testing and community demonstration of alternative methods of food preparation with the involvement of families of well and poorly nourished or sick children (with focus on the differences in the distribution of all resources in each type of home).

Additional educational messages should address all the identified elements of household dynamics that impede innovation and change. The targets of these messages will be the mother herself, the household as a whole, and the relevant household decision-maker.

continue

Contents - Previous - Next