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Development of indicators: A note of caution
Various quantitative methods have been developed and employed successfully to assess relevant features of psychosocial care. These include questionnaires or interviews asking the parents or caregivers to describe their care practices and/or their children's typical experiences; "qualitative" rating scales with behaviourally defined scale points to assess broadly stated characteristics of care, following observations in naturalistic or experimental settings; systematic observations of the caregiver and the child in the natural setting, focusing on particular behaviours whose frequencies are reflected in summary scores; and detailed observational coding of ongoing sequences of caregiver-child interaction, aimed at characterizing relevant features of the dyadic relationship.
Many of these strategies and techniques for assessing quality of care in the various research studies require extensive observations and technical methodologies. For the most part, therefore, they are not feasible for practical use in the field as screening procedures. However, some of these approaches to the measurement of care have been, or may be, adapted for more practical field use in assessing breakdowns in, or threats to, psychosocial care. The relevance of these measures in different cultures should always be of concern to investigators. It is important in all such approaches to develop indicators that have meaning and validity across a variety of cultures, although this is a daunting task. A behaviour that may appear to be maladaptive to an outside observer may be the norm within a particular culture. Therefore, it is essential to approach indicators with a healthy skepticism, and to attempt to use a within-culture yardstick-to compare a caregiver with others within her or his own cultural group.
The Caring Analysis Tool
Before planning or developing an intervention, it is essential to assess the current status of psychosocial care. If the time of the caregiver is extremely limited, the approach may require identifying alternatives. If food or health is severely limited, care alone is unlikely to make a difference. A possible analytic strategy for dealing with this general problem is outlined in the Caring Analysis Tool shown in table 2 [39]. This technique incorporates a series of questions that can be adapted by local programme planners in thinking through the implications of women and children's care for policies, strategies, and programmes. The questions are shown in table 2 in an expanded form. Brief forms for regular use and for quick scanning are also included.
The Caring Analysis Tool is intended to be used in addition to other strategies to increase programme effectiveness. Successful nutrition programmes are flexible, give priority to high-risk environments, use a multifaceted and integrated approach, and are community based and participatory [105].
Summary
There is considerable evidence that poor psychosocial care is associated with unfavourable cognitive development and poorer nutrition and growth outcomes in young children in both industrialized and developing countries. Mothers or other primary caregivers of malnourished children have been reported to be less sensitive to the child's needs, less involved and emotionally responsive, and less engaged in reciprocal interaction with their children than mothers or other primary caregivers of adequately or well-nourished children. They have also been described as somewhat passive, lacking in selfesteem, and socially isolated. Although these associations seem somewhat more marked and consistent in the case of children experiencing clinical or severe malnutrition, they have been observed in children with chronic undernutrition as well.
How can these reported associations best be interpreted? It is important not to view the relatively unfavourable childcare and maternal characteristics associated with malnutrition as being personal flaws or deficiencies of the mother or other primary caregiver. One needs to be aware of the major economic, social, and resource constraints that exert their pressures on poor families and make it difficult for them to provide high-quality child care. Some of the factors that influence the availability of psychosocial care are the caregivers' beliefs in their self efficacy or developmental norms; the caregivers' stress, anxiety, or depression; the caregivers' income control and autonomy; the presence of social support from family and community; and the availability of alternative child care.
With regard to the important question of directions of influence, it is apparent that the features of psychosocial care just summarized may be viewed either as responses to the phenotypic or behavioural characteristics of a sickly or malnourished child, or as an indicator of poor quality of overall child care contributing to the child's malnutrition, or both. It is probably best to view these associations as representing bidirectional or transactional pathways of influence, which may be self-sustaining in the absence of some form of preventive intervention. Perhaps enhancement of the young child's motor, mental, and social development through improved psychosocial care makes the child a more efficient "elicitor" of good nutritional care from parent or caregiver, thus increasing the likelihood of improved nutritional outcomes. Alternatively, such a psychosocial intervention may lead to a general improvement in the quality of nutritional as well as psychosocial care provided by the mother or primary caregiver. Likewise, findings suggest that enhancing the very young child's motor and behavioural competencies through improved health and nutrition may, in turn, render the child a more effective elicitor of good nutritional care.
Additional research is needed to clarify the nature of these bidirectional and transactional pathways of influence. There is a need to move beyond correlational studies to experimental designs. In the meantime, it is very apparent that intervention or preventive educational programmes to improve nutrition should include systematic efforts to support positive caregiver-child interactions and to optimize the quality of overall care infants and young children receive, in both the psychosocial and the nutritional, health, and physical care arenas. Such integrative efforts are needed not only to reduce the risk of early malnutrition's occurring in the first place, but also to promote the growth and behavioural development of children whose nutrition status may already have been compromised.
TABLE 2. Caring analysis tool
Part I. Assessment of existing situation
Describe the current caregiving situation.
1. What are the relative roles of inadequate household food security, lack of health services or an unhealthy environment, or lack of care in generating malnutrition in the current situation?
2. What are the most common care and support environments in which caregiving occurs? Who takes care of the children, where are they cared for, and who is supporting the family? Are care and support resources adequate? Are there untapped care and support resources?
3. In what age or developmental period (prenatal, newborn, infant, one- to two-year-old, pre-schooler) are the children who are the most in need?
4. Are there good caregiving beliefs or behaviours already in existence that could be built upon?
5. Are there basic societal reasons for the lack of availability of care?
Part II. Programme actions: effects of care on nutrition
As the programme develops, what kinds of changes in caregiving behaviours, beliefs, or knowledge will result?
1. What are the behaviours and the cultural beliefs underlying these behaviours that the programme is encouraging, and who is likely to perform these behaviours?
2. What other activities or belief systems will the primary caregiver forego in order to perform these new caring behaviours?
3. Did the programme consider the influence of psychological and social factors on the mother or child? Was there a concern for these factors in prenatal care, birth procedures, or breastfeeding promotion? Was there a concern for the social and emotional aspects of the weaning and feeding process?
Part III. Programme actions: effect of the child on care
Did the programme consider ways in which characteristics of the child might influence the kinds of caregiving received? Are there parental beliefs that might mean that certain kinds of children are more likely to benefit from the programme than others?
1. Will girl children be affected more or less than boy children?
2. Will the child's anorexia or appetite, energy level, or health or nutrition status influence his or her programme participation?
3. Are there other conditions, such as physical handicaps, that might influence programme participation?
4. Does the programme consider developmental changes in the child's needs for care? Is the programme addressing the appropriate age group?
Part IV. Programme actions: constraints to care
Describe the availability of care at either the household or the community level, and identify possible constraints to that care. Are any of the following factors constraints to care? If so, how can the constraint be ameliorated?
1. Physical ill health of the mother or other caregiver.
2. Lack of self-confidence, depression, or stress.
3. Beliefs about child-rearing and feeding, about who should control the amount of food young children eat, and lack of education or information about child-rearing practices that would achieve parents' goals for children.
4. Excessive workload of mother or other caregiver to achieve household food security; excessive workload for home production and child care or inequitable division of labour; lack of responsibility of other family members (e.g., father).
5. Lack of social support: emotional support, instrumental support (assistance), or informational support from family, community, or services.
6. Absence of resources or lack of control of resources by caregiver.
Part V. Programme actions: basic causes of constraints to care
Has the programme attempted to address any of the basic societal causes of constraints to care observed initially?
1. Technical or material conditions of production.
2. Social conditions of production.
3. Political factors.
4. Ideological or cultural factors.
Part Vl. Evaluation
What indicators of changes in caring behaviours could be used to assess the effectiveness of the programme? Are there measures to assess changes in the caregiver's behaviour, in the child's behaviour, and in developmental outcomes for children?
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