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Socio-cultural support

Price (1977) found in a study of mother-infant reciprocity that the relationship between mother and infant deteriorated significantly in reciprocity from one to five weeks of age in families in which the father was rated low on availability. Fathers who had low ratings had either just lost their jobs, were "seldom around," or appeared to compete with the infant for the mother's time and attention. She cites an example in which the mother of a five-week-old infant began to play a somewhat sadistic game with her baby a week after she became seriously estranged from her husband. In this game the mother "brushed the nipple over the infant's mouth several times quickly, then drew it out of reach, stating, 'It's no fun when he doesn't snap for it'."

A number of studies provide evidence that the social network or support system available to the mother is important in determining the quality of care she is able to give her infant. Figure 11 outlines a conceptual framework for the relationships involved. In this diagram, the socialsupport network is shown to affect the quality of the maternal-child relationship both directly and through maternal characteristics. The type of society and the rate of social change influence social networks.

There is a large and recent literature linking social support to health in industrialized countries (Cohen and Syme, 1985). Social support may be instrumental, providing cash loans, food, or other goods and services, such as child care and job referrals. Social networks providing instrumental support are particularly relevant for low income persons (Pelton, 1982; Wills, 1985). The traditional extended family, particularly in Africa, is a primary channel for instrumental support, according to conventions that tend to conflict with the demands of urban life. Social support also provides esteem, status, motivation, information, companionship, emotional empathy and understanding (Wills, 1982; Crnic et al., 1983).

It is useful to divide social support into intimate versus community and structural versus functional support. Intimate support comes from members of the immediate household while community support may come from neighbourhood or workplace associations. Social structures such as marriage, the church, and the health centre are sources of support. However, they may or may not function in a supportive manner for individuals (Cohen and Syme, 1985). The distinction between intimate and community support is taken from an article by Crnic and associates (1983), which reviews a number of studies showing that social support tends to buffer mothers against the effects of stress and depression, in addition to presenting original findings relating social support to maternal attitudes and mother-child interactions.

Structural support is more or less enforceable, legally or through social pressures, exerted by an intact community. The literature describing the effects of rapid social change on traditional communities is full of examples of the disintegration of traditional social and legal support structures. Emecheta's (1979) novel The Joys of Mother hood describes the decomposition of women's traditional childbearing role and the disintegration of the support built into customary tribal law that protected the welfare of mothers and young children in traditional Ibo culture in Nigeria.

Some of this literature is in the formal scientific domain and describes the effects of loss of previous support structures on mother-child interactions and child health and nutrition. Such social change is a feature of almost all developing-country societies, occurring most acutely with rapid urbanization. Contractual support may be strengthened by social policies and programmes but requires an understanding of the nature of the contracts involved. Nonstructural support is more a matter of individual enterprise and personality.

Fig. 11. Conceptual framework illustrating socio-cultural support systems that influence positive deviance in nutrition.

Intimate Structural Support

The husband, other immediate and extended family members, and hired help all may be sources of intimate structural support for the mother, depending on the particular social structures involved. Expectations of what the structure should provide within a given culture are partially susceptible to individual negotiation and may vary by social class. Zeitlin and co-workers (1983, 1984) and Schlossman and Zeitlin (1983) found that more educated, higher-income, breast-feeding mothers both expected and received more help with housework and child care from their husbands than lower income, less educated, bottlefeeders.

Mothers with malnourished children have often been found to lack the consistent support of a husband or partner (Kerr et al., 1978; Dixon et al., 1982; Goodall, 1979). Morley and coworkers (1968) found in a positive-deviance study in Nigeria that the mothers of malnourished children received less support from both their husbands and from their families than mothers of the well-nourished. In this setting where polygamy was common, more marriages among the well-nourished group were monogamous.

Where support is present, it may compensate for high-risk characteristics of the mother. The Jamaica study by Kerr and associates (1978), for example, notes that three of the control mothers had "personalities similar to those of the MMC (mothers of malnourished children found to have problems that could be classified as character disorders). Each was receiving, however, considerable structural support."

The functional quality of structural support, as well as its presence or absence, conditions its effects on the mother-child relationship. The "unavailable" fathers in Price's study were living with their wives and infants, but were psychologically remote or unsupportive. Social support is generally considered to have a number of dimensions, including instrumental assistance, information provision, and emotional empathy and understanding (Crnic et al., 1983). There is a voluminous literature that cannot be reviewed here covering ways of measuring these dimensions and the effects that they have on an individual's psychological and physical health. The Crnic study found that a measure of mothers" intimate support, received primarily from their husbands, was directly related to their affect in interactions with their infants at the age of four months. The affect scores for the infants of these well-supported mothers also were higher.

The quality of intimate support may be drastically eroded by social change. As an extreme example, Schaeffer and Metayer (1976) discuss the disastrous effects of exposure to modernization on family relationships among the Eskimo. Table 7 presents the contrasts they found between the past versus the present. They note specifically that "intimate infant-mother interaction and understanding (are) lost."

The extended family is an important part of the intimate structural support system in many societies. The part the grandmother plays in most Mexican households is critical to the quality of child care, according to work in progress by Sarah LeVine (personal communication, 1984). Once her own childbearing is over, she devotes herself to her grandchildren. Without her help the task of raising families of 8, 10, or 12, which is still the rule in many rural and working-class urban Mexican households, might be an impossibility.

The bond between a Mexican mother and daughter is extremely strong, and whether or not a woman is geographically separated from her natal family is likely to have considerable bearing on her psychological adjustment and sense of well-being. Mestizo villages in central Mexico are primarily endogamous, which means that after marriage a young woman continues to live very close to her own parents. Although the wife usually lives with her husband's family, if they have insufficient land she may bring him to live with her own parents.

When the move to the city occurs, the husband's parents are much more likely to accompany the young couple than are the wife's, since sons rather than daughters are expected to be responsible for their aging parents. In the city, a woman then faces not only a totally new environment but also the loss of her own mother's constant practical and emotional support. By the second generation, the city-dweller may very well have re-instituted the rural pattern of husband, wife, and husband's parents in a three generational household, but with the wife's parents now living nearby. This example illustrates the complicated manner in which social change, such as urbanization, may affect a mother's intimate contractual support system.

Table 7 Contrast between past and present roles and functions of Eskimo family members

In the past Now
Father Father
Highly respected. The provider of food, on whose hunting skill the life of every member of the family depended. To be known as a good food provider for his own family, the elderly, and neighbours in need was a source of pride and satisfaction Feels useless and worthless. Eskimo men have lost the independence of the traditional hunter. Work is often for and under a non Eskimo agent, doing menial, despised, and degrading jobs or, even worse, the Eskimo may be shamed into the status of a welfare recipient. He finds transient emotional redress from feelings of frustration, idleness, dependence, and hurt pride in drinking. Alcohol unmasks pent-up hostility feelings leading to violence. The hangover is accompanied by remorse and suicidal behaviour
Mother Mother
Loved and needed. Preparer of shelter, food and clothing. Indispensible centre of family, always busy making and repairing fur clothing, tents, and utensils, tending seal-oil lamps day and night, nursing, training, and playing with children. Giving and receiving stimulation and satisfaction in intense interaction with child carried skin-to-skin for three years on her back or breast Has lost central family role, feeling dispersible and idle. Clothing and food bought in store.

Infants bottle-fed and deposited with siblings, grandparents or left unattended in corner of bed. Idleness whiled away in movies, dances, bars, and "friends." Becoming impatient and punitive, with less well understood and less well trained children

Children Children
Loved and cared for, feeling secure and satisfied, with ideal parent figures to imitate.

Grew up on mother's back, first three years in intimate contact, receiving response and satisfaction to every urge, motion. and demand in sheltered and secure position, allowing participation in mother's and family's activities and progressing from playful imitation to useful participation in parent's chores

Intimate infant-mother interaction and understanding lost. Less secure shelter, inferior nourishment. Emotional and sensory deprivation when left to stare listless at empty ceiling or screaming frustrated in soggy diapers. Later, loss of parents' ideal image and respect. Feeling useless and frustrated, having lost functional role in Eskimo world while unable to realize desires awakened by school and movies. Becomes confused and rebellious
Interaction in family Interaction in family
Very close. Complete and unquestioned interdependence but with extreme personal tolerance Drifting apart. Not needing each other so much. Expressions of anger and intolerance: wife and child beatings. Children rebelling against elders

Source: Schaeffer and Metayer, 1976.

Its importance for nutrition is borne out by the finding in a Mexican periurban squatter settlement (Zeitlin and Johnson, in progress) that 80 per cent of well nourished, versus 40 per cent of malnourished. infants had maternal grandmothers available.

Community Structural Support

This term refers to the social services and group activities within the community that the individual is entitled to, either through formal legal rights or by social convention. Health and nutrition services, church activities, clubs, adult education, recreational facilities, day-care assistance, political youth groups, traditional work parties, block associations, women's cooperatives, the advice of elders, etc., may be available. Societies differ vastly in the presence or absence of such community support mechanisms. At one extreme, in Central Tunisia, isolated homesteads are located so far apart that a mother may never interact with individuals outside her family. At the other, socialist countries and particularly East Asian societies have highly structured communities- so highly structured in China, for example, that each woman's menstrual period is monitored by a neighbourhood "granny." Western countries now have large numbers of voluntary associations by problem area, e.g. single parents' group, Alcoholics Anonymous, etc., that to some extent simulate "natural" family arangements.

A study in Toronto (Dellcrest Children's Center, 1985) found that low-income mothers with sparse social networks were more likely to use and receive emotional support from formal support services, such as health-care professionals. There is ample evidence that inadvertent social support, as provided by projects that do not wish to change the social environment, create a beneficial Hawthorne effect. The Hawthorne effect occurs when subjects respond not to treatments but to the excitement or prestige of participation (Grosof and Sardy, 1985). In creating programmes that provide such support, however, health workers should be aware that individuals with very deficient social skills may not be greatly helped. Their lack of support may be more a consequence of their own inability to interact positively with others and may not indicate that their environments are non-supportive (Kiesler, 1985).

Intervention programmes designed to provide more support for mothers can either build on existing support structures or create new ones. As mentioned on page 54, the Ford Foundation in New York City and Boston, for example, runs a programme under the name Alliance for Young Families, which pairs high-risk teenage mothers with mature volunteer mothers. The mature mothers provide the young mothers with intimate support on a voluntary but contractual basis. This is an example of a "buddy system. "

There may be a time lag before traditional groups learn to use the modern services that are made available to them. Dugdale (1980) reports on a 20-year study of an Australian Aboriginal community in which infant mortality dropped from 280 to about 40 per 1,000. Growth, infant-feeding method, and health facilities remained almost the same over this period. The author proposes that ability and willingness to use existing community health facilities, as well as other attitudinal factors characterizing the Aboriginal group, changed over this period. As a result, the Aboriginal families were much better able to take advantage of the contractual support structures within their neighbourhoods.

Functional Social Support

Individuals vary in their ability to obtain functional benefits from social-support structures and to generate functional support for themselves where social structures have broken down or do not exist. Kotelchuck and Newberger (1983) found American families with FTT children were more isolated from their neighbours. Bithoney and Newberger (1982) found them to be characterized by social isolation. Chavez and associates (1974) in Mexico observed that mothers of malnourished children had less contact with the external world. Similarly, Kerr and colleagues (1978) found the mothers of their malnourished group had fewer social contacts except with extended families. A passive, depressed, not particularly competent individual is less likely to be effective in establishing friendships and personal loyalties, and less likely to obtain social approval from the community. Similarly, a newcomer to an established come munity may suffer the psychological effects of isolation, although this individual is socially competent.

The Crnic study found that a measure of friendship support (non-structural) was related to a measure of satisfaction in parenting but not directly to mother-child interaction. Community support (a measure of perceived informal support by the community) was directly related to a social-emotional-growth fostering dimension of the mother-child interaction. Moreover, this sense of community support reduced the effects of stress on the mother-child relationship.

One of the interactions between structural and functional support is probably worth noting. Where structural support systems have failed to develop. have broken down or are nonenforceable, the mother tends to be thrown back on ad hoc functional arrangements, which need to be constantly renegotiated. Her life-style tends to become incompatible with consistent child care. Gussler (1975), writing on the adaptive strategies and social networks of women in St. Kitts7 describes a defective social structure in which young men are not contractually obliged to support the children they father. Therefore, the young mothers tend to need to expend large amounts of energy recruiting boyfriends and bearing children by a series of men in the hope that one or more of the relationships will pay off either in remittances or in a long-term alliance later in life.

It is also worth noting that for reasons related to adaptation types 1 to 3, the come munity may psychologically support its members to pursue practices that do not favour the growth and development of the child. The writer recalls a Dinka primary-school teacher in the Sudan who had resisted persistent pressures to place her children in the homes of extended family members. By keeping them with her she became overworked and the same time lacked sympathy from the community.

Importance of Intact Normative Reference Groups for Maintaining Moral Behaviour

Encompassing both the structural and functional aspects of social support is the concept of a normative reference group. This is the set of other people from whom one takes social values and ideas of what is good and bad, right and wrong. The degree to which individuals behave morally in such matters as responsibly caring for their children is in part determined by the strength of their normative reference groups (Naroll, 1983). Common examples of such reference groups are the extended family, religious groups, and intellectual schools of thought. Where social change and urbanization proceed rapidly, such reference groups may be destroyed or may lose their influence on individuals.

Findings Applicable to Programme Design

The strongest implications for intervention in this section lie in the area of social legislation. Almost all pre-industrial cultures enforce laws or customs requiring men to provide continuing material support for the children they father. In matriarchal systems, as among the Akan in Ghana, the support may go the the sister's children. Other variations in role may occur, but the mother in almost all intact traditional groups receives both material and social support for the child.

Legislation in modern industrialized societies also encompasses child support both by the father and by the state if no paternal support is forthcoming. It is primarily in newly urbanized cultures and among populations who were formerly slaves that customary law and formal legislation protecting mothers and children has broken down or is non-existent.

In many locations positive deviants appear to be children with intact social-support systems because their mothers and fathers happen to be congenial enough to stay together in spite of divisive social pressures. Changes in social legislation and stricter reinforcement of existing formal and customary laws obviously are needed.

Legislation for working mothers regarding maternity and health benefits and the provision of day care is also important.

In the attempt to improve social legislation it is important not to propose unenforceable laws that will backfire against the groups they are trying to protect. A law requiring all companies to provide maternity benefits to women who have been in their employment for more than 90 days, for example, could:

  1. Influence companies not to hire women.
  2. Lead to the practice of firing and rehiring new employees every 90 days.

With regard to programme design it was noted earlier in this paper that it is sometimes possible to induce groups of individuals with similar problems to work together on a voluntary basis, in their own interest. This is not an ideal approach to take with the mothers of malnourished children. As the literature indicates, these mothers are characterized by social isolation, passive helpless attitudes, and poor interpersonal skills. It is unlikely that they can carry the burden of organizing and conducting an outreach programme.

The Indonesian growth-monitoring projects implemented by mothers' clubs or women's associations such as the UPGK (National Women's Association) may have succeeded so well because they are not targeted to the malnourished. Rather, these programmes enlist positive-deviant mothers in the communities to be trained in nutrition and to conduct monthly weighing sessions for the entire community. Although attempts are made by the Indonesian Growth Monitoring Programmes to reach all mothers, particularly those of the malnourished, there still tends to be a 15 to 40 per cent non-participation rate. Those who participate less have children who are less well-nourished (Zeitlin et al., 1984).

Churches and other community organizations that are strong and altruistic in orientation should be encouraged to extend outreach to unenrolled community members and to provide health and nutrition services. There are individuals at great risk for whom the church is much less intimidating than the hospital. The writer had a Yoruba friend in Nigeria whose two infant sons died of measles. On both occasions the mother had taken the child to the church instead of the hospital. The church could also serve as a liaison between community members and the health services.

The Government of Indonesia has strengthened organized religion in a nonsectarian manner by urging all citizens to worship God in the religion of their choice, whether Islam, Hinduism, Buddhism, or Christianity. Strengthening religious institutions increases the moral authority of normative reference groups.

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