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The need to develop appropriate knowledge-based strategies to promote better care was the basis for the UNICEF-Cornell University Colloquium on care and nutrition of the young child. The first step was to develop a conceptual model that described the various factors that influenced the quality of care and the pathways through which care influenced the nutrition status of young children below three years of age. The direct care-related behaviours included breastfeeding, complementation, feeding during illness, health related behaviours, and psychosocial care. Several underlying factors at the household, community, and national level and the interactive process of care were also considered. The resource constraints and trends were child characteristics; caregiver factors, including time availability; psychological, health, and nutrition status; organizational resources; and modernization and urbanization. The triple-A process of assessment, analysis, and action was followed to identify, understand, and prioritize the key areas while planning for the Colloquium. Besides the focus and theme papers, case-studies from developing countries and working group sessions were also included.
UNICEF nutrition strategy recognizes care as an important determinant of nutrition status as part of its conceptual framework . Care was first identified as a missing ingredient in the Joint Nutrition Support Program in Iringa, Tanzania, and has since been articulated in positive deviance studies in various developing countries [2-4]. These studies have demonstrated that in spite of adverse conditions, e.g., poverty, food insecurity, and limited health care, enhanced caregiving could optimize existing resources to promote good health and nutrition in young children. The concept of care is broad and has different meanings across disciplines.
The need to identify current knowledge in this area and consequently develop appropriate strategies to promote good care has been recognized. A detailed review of the literature analysing the role of care in nutrition was prepared as a theme paper for the International Conference on Nutrition held in Rome in 1992 . A draft strategy on care and nutrition has been evolving primarily through the efforts of UNICEF . An understanding of the dynamics of caregiving in different settings is needed to identify strategies to promote better care as well as improve food security and health. This formed the basis of the planning for the UNICEF-Cornell University Colloquium on care and nutrition.
Cornell conceptual model for care and nutrition
A conceptual model describing the various factors that influence quality of care and how care itself influences nutrition status was developed at Cornell University (fig. 1). Since care is such a broad area, this framework focused specifically on the care of children below the age of three years and its implication for improving nutrition status. It evolved from the UNICEF nutrition strategy , which defines household food security, care of women and children, and access to health services, along with a healthy environment, as the necessary ingredients to promote good nutrition. Adequate dietary intake and health status are the immediate determinants of good nutrition, but caregiving ultimately determines the delivery of adequate food and health to the child. Although closely linked to household food security, the actual amount of food ingested by the young child is determined by care-related feeding behaviours such as breastfeeding, complementation, food preparation, and overseeing the progression of the child from complete dependence to partaking of adult family food. Similarly, care-related behaviours determine how available health services, for both preventive and curative purposes, are utilized to optimize child health and thereby influence nutrition. Finally, factors such as affection, psychosocial stimulation, emotional stability, predictability, and patterning are important to the overall development of the child [7, 8].
In addition to these direct care-related behaviours, it is important to recognize that care is a highly interactive process between child and caregiver, with inputs by and rewards for both. It is vital to regard care in the context of a dyed while planning strategies. Although mothers are generally assumed to be the primary caregivers, it should not be overlooked that in many societies caregiving is shared by siblings, other relatives, fathers, neighbours, and caregivers in day-care centres and family day-care homes. Planning strategies must consider several factors relating to both the caregiver and child that determine caregiving behaviour. These relate to the time demands, cultural attitudes, beliefs, and knowledge of the caregiver as well as several characteristics of the child including gender, age, birth order, appetite, and level of intellectual and motor development. The immediate environment of this interactive behaviour is in turn influenced by various other factors operating at the household, community, and national level. A planning document  describing this framework, combined with an update of the literature and suggestions for the workshop, was presented by Cornell University to UNICEF in December 1993.
FIG. 1. Conceptual framework for care and nutrition of the young child
A meeting to finalize the plans for the UNICEF-Cornell workshop on care and nutrition was held at the Institute of Child Health, London University on 6-7 January 1994. This meeting was attended by Drs. U. Jonsson, M. Kyenkya-Isabirye, D. Alnwick, and J. Csete from UNICEF (Nutrition Cluster, New York); M. C. Latham, H. Ricciuti, and U. Ramakrishnan from Cornell University; T. Greiner (Uppsala University-SIDA, Sweden); P. Engle (California Polytechnic University, San Luis Obispo, California, USA); and A. Tompkins and R. Longhurst from the Institute of Child Health, London University. Most of the above comprised the Organizing Committee for the Colloquium.
At the outset it was recognized that care is a very broad area, and that although other areas, such as education, women's development, and social welfare, are important, the focus of the workshop would be limited to nutrition-related aspects. It was also agreed by the group that present efforts would be limited to children under three years of age in developing countries with large numbers of malnourished children (mainly in Africa and Asia). The importance of care of older children and women was recognized but not included in order to limit the topic. The objectives for the workshop were defined to summarize present knowledge of inadequate care and nutrition as well as to identify gaps in knowledge. Our understanding of care and nutrition can be classified as resolved issues, unresolved issues, need for further research, and application.
The triple-A process of assessment, analysis, and action  was followed to help identify, understand, and prioritize key areas to be included in the conference. The first step of assessment was identifying issues specifically related to inadequate care practices influencing nutrition. Based on our present understanding and conceptual framework of care and nutrition, a list of issues (table 1) was identified.
It was clear that all the topics in the list could not be addressed in a single workshop and that simplification to narrow down the key issues was required. This was done systematically for each category, and the process is summarized in the following section. The topics selected for the final list are highlighted in bold type in the table, and the areas of concern to be addressed for the colloquium are described below.
TABLE 1. List of care practices that might influence the nutrition status of the young child
|Cessation of breastfeeding
|Replacement of breastmilk
|Energy density/nutrient quality
|Feeding frequency (in 24 hours)
|Prevention of illness
|personal bathing, handwashing
|household water, sanitation, domestic animals, food
|Prevention of accidents
|Utilization of health service
|Care during illness
|Feeding (at home and in service settings)
|Care giver involvement and affection/love
|Sensitivity and regularity of response
|Mutually rewarding reciprocal interaction
|Providing opportunities for play, exploration, and learning
|Socialization and mom training
|Safety and stability of the home environment
|Continuity and number of caregivers over time
|Protection from cold
Breastfeeding is the only activity that satisfies the needs of food, health, and care at the same time. Although breastfeeding was acknowledged as an extremely important component of care, it was agreed that issues such as breastfeeding initiation, exclusive breastfeeding, and so on would not be addressed, since they have already been considered in detail by the breastfeeding promotion efforts of UNICEF. Yet the relevance of the overlap between breastfeeding and care (nearly 85%) was nominated as a special topic for the workshop. The need to address issues beyond the Innocenti Declaration was raised, especially within the protect, support, and promote framework. Evaluation of present strategies used to protect, support, and promote breastfeeding, combined with the need to balance community versus health care resources, was to be included in this general paper.
Although originally disregarded, the issue of sustained breastfeeding was raised in the discussions on complementary feeding. Two areas of concern warranted special attention: the dangers of promoting exclusive breastfeeding while simultaneously supporting sustained breastfeeding, and the benefits of sustained breastfeeding in the second year of life [11,12] within the nutrition and care perspective.
Introducing foods in addition to breast milk signals the beginning of one of the most vulnerable phases in the life of young children in developing countries. This period may begin from as early as 2 months to as late as 18 months of age in different cultures. Decisions related to when to introduce other supplementary foods, choice of food, and quantity and frequency of feeding are inherently linked with caregiving practices in different cultures. Complementary feeding was regarded as a high-priority area where inadequate care practices would affect the nutrition status of the child, and three major themes emerged.
1. Timing of complementation and replacement of breastmilk. There is considerable debate about the timing of complementary foods, especially their effect on children's eating behaviour and growth [13, 14]. It was agreed that the transition from exclusive breastfeeding to introducing appropriate amounts of other foods merits high priority. Clarification of how much to replace breastmilk with other foods is intrinsic to the discussion of timing and quantity of complementary foods. It is important to understand the factors influencing total energy intake and the relative contributions from breastmilk and complementary foods when forming strategies that influence care.
2. Nutrient density and frequent feeding. Infrequent feeding and low nutrient and energy density of complementary foods have been recognized as major problems contributing to malnutrition [15,16]. However, although caloric and nutrient density of complementary foods and feeding frequency can be regarded as two separate topics, they need to be addressed together. When the intake of bulky foods is coupled with infrequent feeding, it is difficult for the young child to obtain adequate nutrients. Limitations to frequent feeding could be addressed by promoting foods with higher nutrient density. Although the relationship between eating frequency and caloric density seems obvious, few studies have documented this under home conditions . Current scientific knowledge about the relationship between feeding frequency and nutrient density (not only calories but also micronutrients such as vitamin A and iron) should be used to plan strategies.
3. Appetite and feeding style. Palatability of foods, feeding style, and appetite were identified as extremely important and interrelated factors where inadequate care determines the actual food intake of the child [18, 19].
4. Contamination. This topic was included in the broader topic relating to hygiene.
Prevention of illness
Hygiene was recognized as the most important aspect of inadequate care to be included in the Colloquium. Although utilization of health services was also considered important, it was excluded as it is being addressed by other groups. Hygiene operates at the personal, household, and community levels. Household hygiene was given particular priority and included issues related to water and sanitation, i.e., disposal of faeces, especially among young children, quality of play area, relevance of handwashing, contamination of weaning foods, and the presence of domestic animals in living areas.
Care during illness
Although health-seeking behaviours and the role of health professionals and traditional practices were recognized as important areas, only the nutritional management of illnesses was to be addressed at this meeting. The efforts of the Sick Child Initiative promoted by the health section of UNICEF were mentioned as well as the need to integrate the efforts of health and nutrition groups. Feeding during illness was assigned high priority for this Colloquium . In particular, nutritional management of symptoms such as pain, fever, ulcers, and breathlessness was addressed. The increasing privatization of primary health care and the need to establish standards for care were also regarded as important. The role of the service settings such as clinics and hospitals in determining the care that a child receives during illness, especially in relation to feeding, warranted special attention. Finally, the evaluation of public health messages, such as the promotion of oral rehydration salts in the management of diarrhoea, can also be addressed when considering care during illness within the protect, support, and promote framework.
Research literature in developmental psychology and child development allows us to identify several characteristics of early child care or child rearing that are positively associated with socio-emotional, intellectual, and motor development in young children. These include maternal involvement and affection, sensitivity and regularity in responding to the child's needs, engaging in mutually rewarding interactions with the child, and providing opportunities for play, exploration, and learning [7, 21]. Given the focus of the Colloquium on linkages between inadequate care and nutrition status, it is important to note that these same characteristics also tend to be positively associated with nutritional care, and thus with positive nutritional and growth outcomes. Although these four dimensions of good care tend to be interrelated, there was some discussion of the possibility that the fourth characteristic (providing opportunities for play, exploration, and learning) should be given separate consideration, since it may be more closely linked to cognitive development.
Issues related to socialization and discipline were assigned lower priority, since considerably less is known about their impact on early behavioural development, and the issues are highly culture specific. However, this area may be addressed by examining the role of moral training in different cultures, as it is extremely important in determining the amount of food that the child may receive. Also, socialization and discipline practices that are clearly neglectful or abusive would be considered instances of poor care according to the four characteristics already mentioned.
Safety and stability of the home environment
The nature of the physical environment in the home was regarded as important, especially in view of the fact that care is multidimensional and should not be restricted to feeding and psychosocial care. Factors related to the stability and safety of the child's environment, including the prevention of accidents and the availability and consistency of caregivers over time, cannot be ignored. However, limitations in time and budget resulted in the assignment of a lower priority for this topic.
The next stage was analysis, i.e., to understand the underlying and basic causes that contribute to observed inadequacies in care leading to impaired nutrition status. This stage can be closely linked to action, where strategies evolve to deal with care and nutrition. Underlying causes were identified for the specific examples outlined earlier to determine common themes. The following generic factors influencing the triple-A cycle  were used to aid this process: perception and understanding, effective demand, capabilities, and resources. The common underlying and basic factors related to resource constraints at various levels, as well as trends based on the conceptual model, were child characteristics, caregiver factors, organizational resources, and the impact of modernization, urbanization, and societies in change.
Child care is a highly interactive process in which the caregiver and the child operate as a dyed. Conventional approaches to care have tended to concentrate on the caregiver. There is increasing evidence that several child characteristics elicit different responses from different caregivers, for example, temperament (irritability, crying), birth order, gender, the stage of motor and intellectual development (activity patterns, attention-seeking behaviours), and appetite. Infants differ in adaptability, activity level, irritability, exploratory behaviour, and response to new situations. A child who is more active and explores more might increase his or her ability to locate caregivers and evoke caregiving, in contrast to the severely malnourished child who is listless, passive, and apathetic about his or her surroundings. The child's development stage also plays a key role in determining the nature of care-related behaviours elicited and consequently directly influences both the food intake and the health status of the young child. For example, the degree of vocalization can determine the ability of the child to demand food and consequently the amount of food he or she will receive. Similarly, the level of motor development is closely linked to exploratory behaviour and may influence child characteristics such as assertiveness and demand for attention. Very little is known about mechanisms that characterize caregiver-child behaviour in developing and responding to cues for hunger, satiety, and food preferences during these vulnerable stages. Other special groups include children with physical handicaps or mental disorders and those subject to social discrimination because of their gender, parity, twin status, uncertain parentage, or membership in socially disadvantaged groups. Refugee children are a growing group whose needs are unique. Children who are of high birth order or who are female have been reported to receive less attention in parts of South Asia.
The importance of the quality of the home environment and the mother-infant interaction in the psychological development of the young child has been widely studied and recognized. These same factors could influence child growth through care. Inadequate child care in developing countries is often assumed to be due to mothers' limited knowledge. Although this may be partly true, the competing demands on poor mothers' time that prevent appropriate child care need to be recognized. The interaction between the time, knowledge, and income constraints of the caregiver needs high priority in planning strategies to improve child growth and development. The following areas were recognized as high priority for the Colloquium.
Studies conducted throughout the developing world reveal that women commonly work longer hours than men and that women do more than their fair share of work in agricultural activities, as well as in household chores [22, 23]. They are largely responsible for maintaining household continuity through reproduction and nurturing children, and perform most of the key and energy-demanding tasks for the households. Heavy demands on women's time due to income-producing and home production activities limit the time available for child care. Yet social science research reveals that mothers resort to various compensatory mechanisms that might buffer the negative effects of time constraints [24-27]. An understanding of these mechanisms is useful in planning strategies to promote better child care. In particular, the role of factors such as family structure, control of household income, the time required for certain basic home production activities (food processing and preparation, obtaining fuel and water), and participation in and implementation of four key child survival activities (breastfeeding, immunization, growth monitoring, and oral rehydration) needs to be evaluated.
Psychological and emotional state of the caregiver
Studies have shown that mothers of severely malnourished children are often those with low self-esteem, low confidence, and less education. In contrast, positive deviance studies have shown that mothers of children who grow well despite adverse socio-economic constraints are highly motivated and spend more time on quality care [3, 4]. A review of strategies that have been used to improve maternal self-esteem and confidence in both developing and developed countries is recommended. Consideration should be given to various maternal or caregiver personality characteristics, attitudes, and beliefs that may have a positive or negative influence on quality of child care. These might include a sense of empowerment or personal efficacy; self-esteem; knowledge, attitudes, and beliefs supportive of good child-care practices; and positive attitudes towards health care and education. Negative influences might result from maternal depression, passivity, low self-esteem, lack of basic knowledge regarding good care, and attitudes and beliefs likely to lead to poor child-care practices.
Health and nutrition status of the caregiver
The health and nutrition status of the primary caregiver, often the mother, was recognized as important in determining the quality of care that the child receives. High priority was assigned to reviewing the evidence demonstrating how the overall health and nutrition status of the mother or caregiver affects the amount and quality of care, specifically the impact of competing risks of both reproductive and productive demands on the woman of child-bearing age in most developing countries. Practical suggestions for action were also emphasized.
Organizational resources are available at the community, district, and national levels that may be utilized to improve the quality of care. In particular, the role of out-of-home care, including informal child-care arrangements in different settings and cultures; the role of the health professional; and, finally, the role of both government and non-government organizations from the community to the national level need to be considered. In most societies, especially in developing countries, child care is not the sole responsibility of a single caregiver, but is shared by alternative caregivers. It is important to understand the role of alternative caregivers, especially fathers. Specific concerns included identification of the alternative caregivers and strategies available to make them more effective, evaluation of the proportion of time the child spends with the mother or other primary caregiver and the alternative caregiver, as well as time spent alone, and how these influence programmes aimed at improving nutrition and care. Also recommended was an evaluation of the different types of out-of-home care common in various settings, including both formal and informal arrangements, particularly arrangements having potential or actual nutritional benefits.
Modernization and urbanization
Trends in society such as modernization, urbanization, and westernization proceed rapidly. Their impact on traditional structures and patterns needs to be examined, particularly those affecting child-rearing practices.
There was considerable discussion of how to deal with the issues described above. The possibility of addressing these issues with the topics identified in the assessment phase was considered. Different options were considered in relation to this outcome. It was decided that although suggestions for action, namely what to do, were regarded as a major outcome of this workshop, aspects related to implementation, such as empowerment and communication, i.e., how to do it, would not be addressed. The need to include developing country perspectives in care and nutrition was also acknowledged. It was finally decided that the underlying issues affecting the quality of care would be addressed as individual theme papers in the broad context of care and nutrition. Similar consideration of these issues was also to be included in the earlier-described focus papers. The importance of using the protect, support, and promote framework for all topics was stressed, especially in identifying good caring practices that need to be protected, as well as the threats to these practices as a result of modernization and urbanization, and methods to develop culture-specific indicators.
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