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Characteristics of the caregiver
Most non-psychological studies examining the effects of care on nutrition limit themselves to evaluating the time availability of the principal caregiver. This variable is important; however, more detailed studies have been able to conceptualize "time" as the "quality" or responsiveness of the caregiver-child interaction, using the four dimensions outlined above, generally a better predictor of early experience. Caregiver time is necessary but not sufficient in determining whether the child has received adequate care. Beliefs and attitudes about caregiving, emotional state, sense of personal efficacy and self esteem, and physical and mental health are other characteristics that influence a caregiver's quality of care.
These variables are related to the nutrition status of children because at each developmental stage they depend on caregiver behaviour and caregiver responsiveness to receive adequately prepared food in a timely manner (principally in response to the child's hunger signals). The caregiver's motivation and physical abilities can be as important as providing food. Thus these characteristics have important nutritional consequences for children.
Beliefs about parenting
Frequently, development projects attempt to provide women with labour-saving devices (piped water, fuel substitutes) in order to free up their time for more child care. However, we examined the consequences of these devices and found that women will replace the time with additional domestic chores or income earning schemes rather than child care . Unless parents perceive that additional time with children will benefit themselves or their children, strategies to increase their available time will probably have minimal effects on actual child care time or quality. Therefore, it is essential to understand how a parent perceives the needs children have, particularly for psychosocial care. Both maternal and paternal views should be examined, since the father's opinion may greatly influence his wife, even if he spends little time in child care. Similarly, the child-rearing attitudes of the maternal or paternal grandmother need to be considered.
Beliefs about parenting that may influence child nutrition and development include the goals that parents have for children, their beliefs about developmental milestones (the age at which a child should be able to perform certain actions), beliefs about parental efficacy, and theories about how a parent can encourage development and growth.
It has been suggested that parents in all cultures have three general goals for their children: ensuring their health and survival, teaching them the skills for eventual attainment of economic security, and developing within them those traits that are consistent with local perceptions of virtue . Levine argues that the specific goal that the family finds most important will depend on the ecological context of the family . In agricultural families, when children are valued for their work and are expected to remain as loyal family members, but risks to survival are high, the first goal is predominant. On the other hand, urban families may not need the children's work, and infant mortality may be lower. When survival is not in question, and children are valued for the affection that they bring to the family rather than their work, the second or third goal will predominate. In this case, parents may be more likely to encourage children's independence and assertiveness rather than obedience to expected patterns of behaviour.
These goals are similar to a dichotomy observed by others . Some caregivers may focus on the child's survival (as in agricultural families), whereas others may hope the child will develop according to a series of milestones (as in urban families). These can be called compensatory and enhancement goal orientations. Some behaviours are intended to return a child to a previously accepted state of health or development (compensatory care), and others serve to enhance further development (enhancement care). Examples of compensatory care are taking an ill child to a health centre to restore his or her health, or encouraging an anorexic child to eat until he or she achieves a normal appetite. Enhancement care includes stimulating a child in play and language, encouraging a welleating child to finish the last bite, or taking a child to the health centre for preventative care or vaccinations.
The general orientation for psychosocial development is toward enhancement; given the care and the development of an appropriate relationship (attachment) with a caregiver, the child will be able to develop positively. Health care often appears to have a compensatory orientation. Thus we introduce the concept of enhancement care and propose that caregivers be encouraged to develop different goal orientations for their children.
Parenting. efficacy and self-efficacy
Parenting efficacy refers to the parent's belief that the way the child turns out has something to do with the parent's behaviour. A parent low in efficacy tends to believe that the child will develop according to genetic factors or the child's own efforts, whereas the parent with high efficacy believes that the child's development depends on the way the parent acts toward the child. This concept differs from self-efficacy, or a person's belief that he or she can perform well compared with others in a particular situation . A person might feel he or she was a very competent parent, for example, but feel that most of his or her child's behaviour was a function of the child's genetic background (low parental efficacy). Someone could have high parental efficacy and low self-efficacy beliefs, and vice versa.
Parents' beliefs or attributions about the causes of their children's behaviour may significantly influence feeding behaviours where undernutrition is endemic. In one study, low-income Nicaraguan mothers who reported that they would take some action to help an anorexic child eat (higher parental efficacy) had better-nourished children than mothers who felt that the child who refused food should be left alone . Malian mothers who left eating decisions to their children may also have had a low sense of parental efficacy; they believed that what the child ate depended on the child's desires rather than on the parent [73, 74]. These beliefs may be particularly important when appetite is a limiting factor, as is often the case in conditions of poverty .
Higher self-efficacy, and the related concept of self-esteem, have been associated with improved caring behaviours. Mothers with greater self-confidence have been observed to be more willing to try to feed anorexic children [76, 77]. Other researchers found that women with higher maternal self-efficacy were significantly more likely to be observed holding their 12- to 18-month-old children, even controlling for other possible explanatory variables . In the United States, significant associations were found between Bayley scores at 18 and 30 months and maternal self-efficacy (assessed at 5 months), which were higher than associations with more distal measures such as parent education. All the foregoing studies are correlational, so causal links and pathways can only be hypothesized in the absence of experimental investigations.
Beliefs about children's developmental milestones
Beliefs about the ages at which children should reach developmental milestones influence parental expectations for children's behaviour, and may result in too little stimulation on the one hand or excessive demands for mature behaviour on the other. One of the reasons cited for the poor performance of children of adolescent mothers in the United States is the inaccurate beliefs about developmental milestones the mothers hold . Expectations about milestones also vary by culture and may reflect values of that culture. For example, Japanese mothers expected their four-year-old children to be emotionally mature, obedient, and courteous earlier than US mothers. The latter group expected children to be verbally assertive and proficient in social skills with peers earlier . In both cases, mothers' expectations were reflected in the child's behaviour.
Similarly, parents' behaviour may be influenced by their theories of cognitive competence . Some parents believe that children learn from manipulating objects, constructing their reality, whereas others think that children learn from being told or from being shown. The way parents interact with their children reflects those beliefs.
The relationship of beliefs to behaviour is not strong; however, a number of studies suggesting low but significant associations between the two have been cited . Since so much effort is spent in changing parental beliefs, confirming the relationship between belief and behaviour, particularly in non-US settings, should be a high research priority.
The role of schools in changing beliefs about child-rearing is another area needing further investigation. Many studies find relatively proximal changes in behaviour as a function of education; in Bangladesh, educated mothers were more responsive and attentive to their children in the feeding situation, even controlling for SES of the family (only 25% of the mothers had attended school) . How this effect might operate needs to be investigated; it is unlikely that the actual content matter of school increased the mothers' knowledge.
Caregiver stress, depression, and anxiety
Estimates worldwide of the incidence of depression suggest that it is widespread , that women report greater emotional distress than men , and that rates are higher (up to 40%) for women in the lower socio-economic strata  and in conditions of powerlessness.
Maternal depression has been associated with deficiency in caring behaviour. A recent review of 20 years of research in the United States linked maternal depression with lack of adequate care and supervision of children, more medical problems and accidents among children, and more time spent in mutual child-caregiver negative states . Many studies show impaired patterns of synchrony in interactions between mother and child that seem to be related to the depression itself rather than to associated family risk factors.
Given the effects of maternal depression on caregiving in the United States, and its prevalence in developing countries, depression could be a factor in some cases of preschool undernutrition, including failure to thrive. We found an association between higher somatic symptoms of stress and preschool children's lower height-for-age in 300 women in a peri-urban area of Guatemala. Zeitlin et al.  reported significant associations in Bangladesh between the nutrition status and growth rate of children and the mothers' happy mood state, rated according to operationally defined criteria and observed over several visits. Although the direction of causality is unclear, the results are provocative.
Many women live in conditions of extreme stress related to poverty and civil strife. A psychosomatic symptom frequency scale  was used to measure stress in poor Guatemalan and Nicaraguan urban mothers. High rates of stress were found in both groups. Approximately half of each group reported a history of nervios, a psychosomatic illness. In both Guatemala and Nicaragua, the poorest women were under significantly more stress than the slightly better-off women living in the same neighbourhoods. The women under most stress were those who were working but had inadequate child-care arrangements (child watched by a sibling less than 11 years old) and those who were having problems with their husbands. Despite the need for further research, particularly in developing countries, it is reasonable to assume that high levels of maternal stress will have adverse effects on the quality of caregiving.
Characteristics of the support system
The support system refers to three kinds of support: informational, emotional, and physical. Informational support refers to sources of information available to the caregiver, either from family or from local or regional institutions. Emotional support refers to the attitudes of family members toward the caregiver. Physical support, as used here, refers to actual assistance with child care and support for the family. The concept of the care/support niche has been used to describe the various combinations of this physical support that a child may experience . The dimensions are the person who provides major financial support in the family, and the type of caregiving environment (person and location).
The support system influences nutritional care and psychosocial care in several ways. The emotional support system will influence the "motivational variables" that determine whether a caregiver uses her or his skills and knowledge for appropriate nutrition, health, and psychosocial care. Informational support can help the caregiver determine appropriate foods, and the care/support niche will affect the resources available for food and the time available for feeding.
Social support: Family and community
Social support refers to the help of the community and family, and includes emotional support, knowledge support, and actual assistance, which can reduce workloads and increase the amount or quality of caregiving available. Community support can be critical for solving problems of alternative child care, credit, or agricultural productivity through the formation of work groups, cooperatives, or informal sharing of tasks.
Support from other family members in child care may influence the quality and amount of care provided, both directly through freeing up the mother's time, and indirectly through influences on the mother, such as reducing her stress. Whether freed time is actually spent on child care may depend on a culture's beliefs about child care .
Fathers are rarely included in discussions of care, but they can substantially improve the welfare of their children . This can occur through a number of different avenues, such as contributing a higher proportion of their income to their children's welfare, performing more caregiving, or valuing and providing support to the mother for her caregiving. It is important to understand local conceptions of fathering roles and responsibilities, since there are significant cultural differences in the role fathers play in their children's upbringing, ranging from "finding a good mother" to highly involved child-rearing . Strategies for increasing the role of the father in caregiving are beginning to be discussed, and represent an important area for future development.
Alternative child care in the home
It is sometimes assumed that when a mother is not working for income, she is the primary caregiver. However, there is evidence that caregiving is shared by other family members in many societies. A common pattern is for the mother to provide a higher percentage of care to the child through the first year of age and then to share more care of the child with other family members, especially the older girl child. In fact, sibling care, or multiple caregivers, is probably the most common arrangement worldwide [61, 89]. At the same time, women's income earning has major implications for the care/support environment of the child, with the effects of maternal employment being determined to some extent by the quality of the alternative care available.
In general, research from developing countries as well as the United States suggests that early child care in the home by adults other than the mother need not have negative effects if the quality of care is good [90, 91]. A small percentage of children in developing countries are cared for in formal day care centres or in family "day-care" group homes. The effects of these and of less formal non-maternal care arrangements on children's growth, morbidity, or psychosocial development have received relatively little study. However, research in the United States and also in developing countries suggests that high-quality day-care centres can have beneficial effects on children, particularly those from the poorest socio-economic backgrounds .
The ecological setting for these care behaviours will dramatically affect the kinds of care required and the difficulty in providing that care. The poorer the conditions of the environment for health maintenance and disease prevention, the more limited or more unstable the food supply, the more the health and development of the child will depend on the caring behaviours of the caregiver and family. Unfortunately, as is so often true, the more one needs, the less one gets. Thus behaviour that might seem maladaptive in one setting (not encouraging feeding) may make sense when children have to learn to deal with periodic food shortages.
Autonomy and income control
The low status of women in many cultures means that often they do not have much control over family resources, nor do they have much decision-making power in the household. They may have responsibility for child-rearing without control over the resources to carry out that responsibility. Control of resources may be greater if the woman earns the income, although this is not always the case . A few studies have shown that women who earn an income have more household decision-making power than those who do not [94, 95].
The person who earns (and therefore presumably controls) the income has increasingly been seen as a factor in the nutrition status of the child. A number of correlational studies  have shown that income in the control of women is more likely to be allocated for the immediate benefit of children, such as the purchase of food, than is income earned by men [96-98].
Two studies have linked women's perception of autonomy in the household with better nutrition status of children. In Amman, Jordan, the lower the mother's autonomy in the household, the more poorly nourished the children, even controlling for other possible explanatory factors . Another study examining correlates of child nutrition in Chad reported that the single most predictive factor associated with child nutrition was the mother's statement that she made some decisions about food allocations .
It is important to recognize that increasing women's control of income is not sufficient to ensure good nutrition for mother or child. Without adequate resources, no amount of caregiving or resource control is sufficient. We must not blame the victim. For example, women in Guatemala who worked long hours with very low earnings had children who were poorly nourished , and women in Chile  and Indonesia (Soekiman, personal communication, 1985) who earned reasonable wages had well-nourished children despite alternative care arrangements. Projects that have increased the workload of the mother, without increasing the amount of income under her control, have had only limited or no effect on children's nutrition status .
Action strategies for protecting, supporting, and promoting good psychosocial care
Four intervention approaches can be distinguished: working directly with the child, improving the care giver-child relationship, increasing the resources available to the caregiver, and altering the social support available for the caregiving system. These categories are similar to those developed by Hines, Landers, and Leslie  and reproduced in table 1. The authors do not list the nature of the child-caregiver relationship as a separate level. On the other hand, they distinguish community, national, and advocacy roles, which we have not done here. Several recent publications provide valuable reviews of this literature [3, 39,104-107].
All four types of intervention show promise, but probably the first will be least effective for its cost. Some of these approaches have been tested, whereas others are in need of evaluation. In general, psychosocial interventions should not be separate from health and nutrition interventions; psychosocial variables should be included in all projects in order to increase the possibility of positive change. However, this is more easily said than done. The many barriers to integrating the elements discussed in this article into a single programme have been discussed elsewhere . Such a programme would include health, nutrition, education, psychosocial stimulation, and possibly work with mothers on parenting or employment or income-generating schemes, and work with fathers to increase family involvement.
Issues of territoriality, competition for scarce resources, and even the sense of the word "integration" probably make these combined programmes difficult. "The word integration is accompanied by false expectations ... it suggests a relationship that is interdependent and much more permanent than can be achieved by simply setting parts, or programmes, side by side" [105, p. 156]. Yet the simple process of including several components in a single programme can be valuable. Myers  outlines various forms of integration, including that at the level of ideas, of planning, or of organization and implementation. Integration can occur in the content of programmes, and finally, in the actions of caregivers, families, and communities. He suggests a number of strategies to assist programmes in integration.
Interventions with children alone (not caregivers) have often been successful but expensive. These programmes often focus on cognitive development as an outcome. Strategies include intensive intervention in hospital or rehabilitation settings with malnourished children , programmes to increase the health or nutrition status of children in order to improve psychosocial functioning , and programmes that combine health, nutrition, and psychosocial stimulation . In general, the earlier the programme starts, the longer it continues, and the more facets of development it includes, the greater is its long-term impact . It appears that the mechanism through which successful health and nutrition interventions work may be in part psychosocial; as the child's behaviour changes, the child's interaction with the environment begins to change. Such intervention efforts may be particularly effective for high-risk children, as one might suspect from the transactional model; when the child is less able to stimulate caregiving, teaching a caregiver to provide more input may be particularly valuable.
Although model child-care programmes appear to have beneficial effects on overall development, institutional day care (not community-based programmes) in developing countries rarely provides this kind of benefit, and it is very costly. Systematic evaluations of the effects of these programmes on children are lacking. We evaluated 35 Guatemalan day-care programmes and found low coverage due to cultural inappropriateness, lack of funding, inexperience with methods of handling children in groups, and an absence of parental involvement in many of the programmes. The vast majority of children without maternal care were cared for in informal settings, not day-care centres. The Integrated Centres for Child Development in south India represent an early attempt to provide integrated nutrition, health, and psychosocial stimulation to children, but they have not had the success expected . Although they are ostensibly community based, the centres' teachers are community workers selected by a central administration, and there is relatively little community input into the programme. The teachers are considered volunteers and receive little pay. However, most community-based pre-school programmes were found to be more cost-effective than formal day care.
TABLE 1. Programming for child development: Complementary approaches and models
|Deliver a service||The child
Improvement of child care
|Home day care
Integrated child development
|Educate caregivers||Parent, family
|Promote community development||Community
|Strengthen national resources and capacities||Programme personnel
Experimental demonstration projects
|Advocate to increase demand||Policy makers
Build political will
Excerpted from ref. 104 p. 41.
Interventions to enhance child-caregiver interactions
A more efficient strategy for improving outcomes for children is to modify the nature of the child-caregiver interaction. Programmes that work with families not only provide needed care for the child, but also serve as a vehicle for helping the mother or caregiver understand the nature of the child's development and how she can enhance that development.
Two main strategies have been used: home visiting programmes, in which a trained educator (often a paraprofessional) visits the caregiver on a regular basis and provides modeling, materials, and instruction about psychosocial care of the young child; and preschool programmes, in which mothers or caregivers take a more active role than the ones described earlier, either by sharing the teaching role with other parents, planning, and making decisions about the centre, or by becoming involved in parent education programmes with the centre.
Interventions that have attempted to improve children's cognitive development by improving the mother's caregiving skills have been shown to result in improved levels of cognitive development and even long-term nutritional effects. Home visiting programmes have been found to be effective in increasing children's cognitive development [28, 29] and even in having long-term effects on children's nutrition status, as previously noted.
Home visiting programmes can address feeding as well as non-feeding behaviours, reinforce indigenous positive caregiving behaviours, and model positive interactions with the infant and toddler. They attempt to sensitize the caregiver to the child's developmental progress, the importance of verbal and social interactions with the infant, and the usefulness of play materials. The aim is not simply to ensure adequate stimulation of the child, but to promote responsive, positive interactions between the caregiver and the child that will not only promote behavioural development but enhance nutritional care as well. One of the benefits of the home visitor approach is that the caregiver has the opportunity to observe someone else interacting with her child, and can develop skills by observation, a valid way of learning in most parts of the world.
It is essential to avoid simply "teaching" caregivers how to care for their children; rather, their own successful strategies should be recognized and built on. "Home visiting programmes should avoid the image of a visitor temporarily substituting for a parent who, rather, must be viewed as an expert in her own home" [105, p. 123]. Myers  notes that these programmes work best when they are combined with group meetings, involve all family members, and focus on concrete problems and actions, and when solutions are worked out jointly.
Pre-school-type programmes can incorporate the caregiver in a number of ways. He or she can take turns with other mothers or caregivers to work with her child and their children, a model employed in Nepal  and Senegal . Parents can be included in the planning and development of the programme, and sometimes a parent volunteer is hired to lead the programme, as has occurred in the Puno area of Peru . For parents who do not have time during the day, active parent involvement and education programmes can be a part of a pre-school programme, as in the Hogares del Bienestar in Colombia (A. Sanz de Santamaria, personal communication, 1989). Some countries have even included an experiential element in the parent-child programme in which the parent receives information on child development and how to play with a child, then has the opportunity to interact with her or his child to apply these principles .
Interventions to enhance the caregiver's resources
Targeting the caregiver can lead to different types of interventions. If initial descriptive work suggests that many of the mothers are depressed or physically ill, an intervention could involve support groups for women, skill training, health improvement, or self-esteem building. If the primary caregivers are siblings, approaches that target their needs can be developed.
Although a number of recommendations for strategies to support the caregiver or to reduce workloads have been made based on correlational evidence (e.g., formal education, labour force participation), the number of careful intervention studies in developing countries based on this hypothesis is limited. A study in the United States found that enrolling poor black women in support groups was equally or more effective for changing children's cognitive levels as specific skill training in a home visiting programme . Whether social support groups or other alterations in women's health (physical or mental) would have similar effects on children's cognitive or nutritional development in a developing country is open for investigation. Empowerment of women appears to have positive effects on children, although research documenting this is lacking.
Increasing parental resources can have long-term effects. A programme was developed to provide resources to a small sample of high-risk mothers . The resources included medical care, day care, and a home visitor who offered "whatever psychological and social services were needed." Not only were significant differences seen in the children when they entered school, these effects apparently carried over to the next youngest sibling when she or he entered school. The authors concluded that the mothers had learned more competent parenting.
Belief systems about child-rearing should be the subject of both investigations and interventions. Until parents perceive that there is a need for more extensive work with children, it is unlikely that psychosocial care will increase significantly. These beliefs can be the target of educational and mass media messages, which have shown effects on psychosocial behaviours. Zeitlin et al.  observed that weaning food programmes that focused on behavioural change, using social marketing methods, such as the Nutrition Education and Behavioral Change Component of the Indonesian Nutritional Improvement Program and the Applied Nutrition Program in the Dominican Republic, tended to have a more measurable impact on anthropometric status than supplementary feeding programmes that focused on food distribution. Reductions in gender differences in weight following a nutrition education programme in India have been reported . However, it is essential to build on existing beliefs, rather than present a new set of "correct" beliefs, thereby undermining caregivers' confidence in their existing methods .
Increasing social support In family and community
Strategies to enhance interactions between parents and children need not be limited to the mother; since children are the major caregivers of young children, they should be involved in these programmes. The Child to Child programme , which has extended to 60 countries, teaches school children about nutrition and health care and empowers them to work with peers and their younger siblings. There is some evidence that it has resulted in changes in siblings' behaviour [115, 116]. This programme has developed a number of materials on health and nutrition for school-age children; materials could be added on psychosocial care. An evaluation of the effects of these programmes on children is needed.
Fathers are often the unseen alternative caregivers. Fathers and men in families need to be included in the social support network for children. The dependency burden of children is too great for women alone to be able to support ; men must take an active role if the next generation is to be healthy. Programmes to enhance fathers' interactions with their children have appeared in the United States in low-income areas, where they have resulted in significant changes in fathers' investment in children [109,118].
A number of intervention strategies to enhance the role of men as caregivers in families have been summarized elsewhere . These include research on the role of fathers and father substitutes in decision-making and informational support, on documenting the kinds of contributions they make, and on locating men who are supporting their children. Intervention programmes can operate at the level of direct services to men, strategies to improve the interaction patterns of fathers and children through experiential learning, and, finally, changing institutions, including the media, healthcare systems, educational systems, and employment, to be more responsive to the role of men in families as responsible nurturers.
Community-based early stimulation programmes for children from impoverished environments, using paraprofessionals, can result in significant changes in children's cognitive development, particularly if they are begun when the child is under three years of age and when the mother or primary caregiver is involved . An approach involving parents was described earlier; similar approaches can be developed if parents are not directly involved. What is unique about community-based approaches is that they respond to community concerns and are under the direction of the community rather than the government. Community-based programmes can include support groups for mothers, credit- and income-generating projects for women, or non-formal education interventions. Projects have been developed in six areas, which include credit for women, savings, and health and nutrition education through the Freedom from Hunger organization . Data from the Thailand project showed significantly more dry season cultivation, use of oral rehydration therapy, and providing colostrum to newborns. The project relies on a poverty-lending technique that makes small working capital loans available to groups of poor women in rural communities to increase their incomes and acquire more and better food.
The joint UNICEF/JNSP project located in Iringa, Tanzania, in four years reduced the incidence of severe and moderate malnutrition in 168 villages, compared with control villages, through a combination of improvements in health care, water and sanitation, agricultural development, and child care and development . Initial assessments of the factors associated with high rates of malnutrition suggested that children were being fed only two times a day, and that mothers' time was too limited by heavy workloads to increase the frequency.
One of the interventions was the establishment of community-level day-care projects to provide frequent and regular feeding of children. Rather than supplying them with supplementary foods, mothers were taught how to use existing foods to meet the children's nutrient needs. Because the project operated through community participation, it was possible to develop culturally acceptable child-caretaker organizations. Finally, the project identified the need for women to control the income generated from their labours in order to meet household food and nutritional needs. This project is an excellent example of incorporating a within-household perspective into a larger effort. However, it was a demonstration study, and one cannot tease out the causal effects of any one intervention for child nutrition status.
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