![[Feedback]](/icons/banner/feedbackACT.gif){kind=icon}
![[For Subscribers]](/icons/banner/subscriberACT.gif){kind=icon}
![[Archive]](/icons/banner/archiveACT.gif){kind=icon}
![[Search]](/icons/banner/searchACT.gif){kind=icon}
![[Contents]](/icons/banner/tocACT.gif){kind=icon}
|
|
|
|
|
||
,3
The Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana;
*
International Food Policy Research Institute (IFPRI), Washington, DC 20006; and
CARE-International, East Africa/Middle East Regional Management Unit, Nairobi, Kenya
2To whom correspondence and reprint requests should be addressed.
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
KEY WORDS: • child care practices • child feeding practices • Ghana • hygiene • female education • urban nutrition
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
). Commensurate with this increasing
urbanization is an increase in poverty and a decline in living
standards, which stands in contrast to a general decrease in the level
of poverty nationwide (World Bank 1995
). Between 1987
and 1993, the absolute number of poor households and undernourished
children in urban areas of Ghana has increased and is accounting for a
growing share of the overall burden of poverty and malnutrition in this
country (Haddad et al. 1999
). Registered unemployment
increased by 20% from 1987 to 1993, and those otherwise unable to find
employment continued to crowd into marginal self-employment, mostly
petty trade, in the city’s informal sector (ISSER 1995
). At the same time, women continue to be heavily involved
in work outside the home, particularly in the low paying occupational
categories of petty trading and street food vending (Levin et al. 1999
).
The conditions of urban poverty, most importantly the high proportion
of women working away from home, the dependence on cash income and the
deteriorating environmental conditions pose special challenges to the
care of children. The nutrition, growth and development of infants and
young children depend not only on sufficient food, but also on adequate
health services and appropriate care behaviors (UNICEF 1990
). A household’s capacity to provide care is dependent on
the availability of resources (or the absence of constraints) within
the household and the wider community. Engle and Lhotska (1999)
describe various maternal and household resources for
care and group them into three main categories, i.e., human, economic
and organizational resources. This paper addresses the first two
categories of care resources as follows: 1) the human
resources, particularly the caregivers’ characteristics such as
nutrition, education, ethnic group, employment characteristics and time
constraints; and 2) the household economic resources
including household income, food availability, demographics,
availability of water, hygiene and sanitation services, and
availability of child care substitutes.
The main purpose of this research was to examine specifically within
the context of an urban African center (Accra) which of the maternal
and household characteristics were more severe constraints to the
provision of good child care in this environment. The care practices
studied were child feeding, preventive health seeking behaviors and
hygiene practices. We showed previously that these care practices were
strong determinants of child nutritional status in this population,
particularly among children from poorer families and children whose
mothers had less than secondary schooling (Ruel et al. 1999
). A crucial question then, which is addressed here, is the
following: what are the main constraints to optimal child care
practices in this population? Answers to this question can provide
useful insights for the design of interventions to improve care
practices because the success of education interventions depends not
only on targeting the right practices, but also on addressing the
constraints to their adoption.
|
SUBJECTS AND METHODS |
|---|
|
TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
The data were from a representative survey of households with
children 
3 y of age in Accra, Ghana. The overall objective of the
study was to understand the nature of urban poverty and the
relationships among urban poverty, food insecurity and malnutrition in
a major urban center in Africa. The study combined qualitative and
quantitative methods. Most of the data presented here are drawn from
the quantitative survey carried out between January and March 1997.
Information on the design and the major findings of the overall study
have been published (Maxwell et al. 2000)
.
Survey sampling strategy and data collection methodology
The basic sampling units for the survey were households with children <3 y of age. A two-stage sampling strategy was adopted, with "enumeration areas" mapped out by the Ghana Statistical Service as the primary sampling units. Sample size calculations were made on the basis of ±3% precision in prevalence estimates of low anthropometric status, and to detect significant differences of 0.5 Z-scores among groups with 90% power. The required sample size was 36 households in 16 enumeration areas, for a total of 576 households. The achieved sample size was 556 households, distributed among 16 enumeration areas.
The survey included the following questionnaire modules: household
roster, employment and self-employment, adaptive strategies,
credit, transfers and other income, urban agriculture, livestock and
fishing, food habits and coping strategies, meals roster, household
consumption and expenditure, maternal sociodemographic and employment
characteristics, child feeding practices and the use of preventive
health services, child morbidity, a hygiene spot check, and maternal
and child anthropometry. All modules were based on an interview
(self-reporting), except anthropometry (measurements were taken) and
the hygiene spot check, which was done by observation. Field workers
were hired locally and trained for 8 wk by the project principal
investigators (DGM, MAK and CEL). All questionnaires were field checked
by the immediate supervisor as well as the principal investigators, and
supervisors made random checks on all enumerators every week. All data
were double entered to minimize data entry errors. Systematic data
cleaning was conducted and discrepancies were corrected by reference to
the questionnaire. Additional information on the study methodology is
available elsewhere (Accra Study Team 1998
).
All households gave their verbal consent to participate after the study objectives and methodology were read to them. Ethical clearance was obtained from the Health Research Unit of the Ministry of Health of Ghana.
Variables used and index creation
The maternal characteristics examined as potential constraints
(or resources) to care giving included age, body mass index (BMI,
kg/m2)4
and schooling, which were hypothesized to be positively associated with
child care practices. The direction of the association with other
characteristics such as marital status, head of householdship, maternal
employment and use of alternative child care was more difficult to
predict because the literature on these topics is largely inconclusive.
For example, there is no general consensus about whether maternal
employment is beneficial or detrimental for young children in
developing countries. The controversy stands because this is a complex
issue that must be examined in the context of all other factors that
may have conflicting influences on the final outcomes, care practices
and children’s well-being (Engle et al. 1997
,
Leslie and Paolisso 1989
). We also did not have any
specific hypothesis about ethnicity, but it was assumed that some
ethnic groups may have specific traditional or cultural beliefs that
would affect their caring practices, either positively or negatively.
The use of prelacteal teas and liquids as a ritual or to cure or
prevent specific ailments is an example of such practices that have
strong cultural roots.
The household level constraints to care that were examined were the
following: household size; crowding (number of rooms/person); household
income (proxied by household consumption expenditure for food and
nonfood items); food budget share (percentage of household expenditure
spent on food); household food availability (energy) per adult
equivalent [derived from the food consumption expenditure module in
which adult equivalent units are based on standards for the United
Kingdom (Gibson 1990
)]; type of dwelling, availability
of water, sanitation and garbage disposal services, and ownership of
assets. Except for crowding and household size, all household
characteristics were hypothesized to be positively associated with care
practices, with the view that household resources may facilitate the
provision of care and the maintenance of a safe and healthy
environment.
Three care indices were created, i.e., a child feeding index, a preventive health seeking index and a hygiene index. A household socioeconomic index was also created using information on assets, housing quality and availability of services. The methodology used to derive these indices is summarized below.
Child feeding index.
The list of variables used to create the child feeding index is
presented in Table 1
, as well as the scoring system used to grade each question. The index
was created only for children 
4 mo old (n = 512)
because only two variables were available to construct the index for
infants below this age. These two variables are the first ones
presented in Table 1
, i.e., whether the mother reported having used
prelacteal feeds before initiating breast-feeding and whether the
mother reported currently breast-feeding the child. Because the
number of variables for this age group was so small and because there
was very little variability in breast-feeding (98% of children in
this age group were breast-feeding), it was decided to exclude this age
group from the child feeding index.
|
. When a practice was particularly good, such as using fortified
cereals for complementary feeding, a score of +1 was given. Practices
were considered positive or negative on the basis of current child
feeding recommendations (WHO 1995
) and available
scientific evidence about their benefits or risks. For example, not
breast-feeding a child 4–9 mo of age was given a score of -1
because it is known to be potentially harmful for the child, and
breast-feeding is a recommended practice for this age group. For
older children, however, not breast-feeding was given a score of 0
because it is not clear whether failure to breast-feed at this age
really has a negative effect on children’s health and growth.
Scientific evidence on this issue is controversial (Brown et al. 1995
). The other practice that was used differently in the
index depending on the age of the child was whether anyone helped the
child to eat. Before 9 mo of age, all children were receiving help, and
therefore the variable was excluded from the index because it had no
variability. The index was created for each age group by adding up the
scores obtained for the different practices. The maximum possible score
was +2 and the minimum was -9 for each age group. The variable was
normally distributed and had a mean and a SD of -2.24 and
1.81, respectively.
Preventive health seeking index.
This index included only three variables, i.e., whether the child had
been taken to growth monitoring in the previous month, and whether the
child had received diphtheria, pertussis and tetanus (DPT) and measles
immunizations (Table 2). A score of -1 was given for children who had not received the
immunization or had not attended growth monitoring in the previous
month, and 0 for those who have done so. Because immunizations are
expected to occur when the child reaches a certain age, these variables
were included in the index only for the relevant age groups.
Information was gathered on other preventive health seeking behaviors
such as giving multivitamins and minerals to the child or using malaria
prophylaxis drugs. Findings from our qualitative research, however,
revealed that these products were not used for prevention, but rather
they were used when the child had no appetite or was sickly (in the
case of vitamins) or when the child actually had malaria (as opposed to
using it to prevent malaria). Thus, these behaviors were not included
in the preventive health seeking index. The index scores ranged from
-3 to 0. Because few cases scored -3, the values of -3 and -2 were
grouped to form the "poor health seeking" group (18% of the
sample); values of -1 formed the "average health seeking" group
(40% of the sample); and values of 0 constituted the "good health
seeking" group (42% of the sample).
|
. Field workers were carefully trained and standardized on each aspect
to be observed, in making subjective, yet consistent, judgements.
Standardization was carried out until perfect concordance between pairs
of field workers, and with their supervisor, was obtained.
|
), and for which
there was sufficient variability in the data (the variable "presence
of human feces in compound" was excluded from the index because up to
98% of the sample had a positive behavior, and hence the variable did
not discriminate). Each positive behavior received a value of 1 and a
negative behavior, a value of 0. Thus, the index was the sum of six
variables, and scores ranged between 0 and 6. On the basis of the
frequency distribution of the index, we created the following three
categories of hygiene practices: 1) poor: scores 0–3
(30.5% of the sample); 2) average: scores 4–5 (39% of
the sample); and 3) good: score of 6 (30.5% of the
sample). Quality of housing and assets index. This index was created using principal components analysis. First, a "possession" index was created by summing up ownership of four assets: refrigerator, electric stove, tape deck and television set (owned = 1; not owned = 0). Then, factor analysis was used to derive one factor that would summarize variables related to the quality of housing (construction material for roof, walls and floor), the "possession" index, the source of drinking water, and the availability of sanitary facilities and garbage disposal. The principal components factor extraction method was used. Loadings smaller than 0.5 were excluded from the initial model. The final model had five variables (floor, walls, water source, possession index and sanitary facilities) and explained 46% of the total variance in the constituent variables.
Analytical methodology
Means and SD are reported for continuous variables, and frequency distributions for categorical variables. Associations between care resources (maternal and household characteristics) and care practices were tested using ANOVA for the child feeding index, which was a continuous and normally distributed variable. The chi-square test was used for the health and hygiene indices, which were both categorical variables. Differences among groups as well as linear trends were tested for significance.
Principal components analysis was used to create the quality of housing and asset index as described in the previous section. Socioeconomic quintiles were created from this variable for use in bivariate analyses. Expenditure quintiles were also created from the household per capita annual expenditures.
Multivariate analysis was used to confirm the results of the bivariate analyses. The main objective was to determine whether the factors identified as potential constraints to child care remained significant after controlling for potentially confounding factors. Ordinary least squares (OLS) regression analysis was used to model the child feeding index as a dependent variable because it was a continuous variable with a normal distribution. For the health seeking and hygiene indices, which were categorical and nonnormally distributed variables, maximum likelihood ordered probit estimation was used. For both multivariate approaches, all covariates were tested for nonlinearity in their association with the outcomes and none was found. For categorical variables, joint F-tests were used to test the significance of differences among categories.
In the regression analysis, a number of the explanatory variables were potentially endogenous; that is, they may be correlated with the error term of the regression model, which would bias the OLS regression coefficients. One can avoid this potential problem by using only exogenous explanatory variables, or by using instrumental variable regression techniques such as two-stage least-squares regression. We rejected the first strategy because we were interested in the association of our selected explanatory variables with our care indices. We rejected the second strategy because of the difficulty in identifying the large number of instruments necessary to generate the unbiased instrumental variables required to estimate our potentially endogenous variables. Future research in this area is warranted.
The probability level considered significant was < 0.05 for all analyses; the statistical programs used were SPSS, version 8 (Chicago, IL) and Stata, version 6 (College Station, TX).
The data presented in this paper are based on a final sample size of 479 for the child feeding index, 509 for the preventive health seeking index and 468 for the hygiene index. These numbers result from the exclusion of children 0–4 mo old (n = 44) for the child feeding index (see previous description) and some missing values in the variables included in the respective indices.
|
RESULTS |
|---|
|
TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
The second column of Table 1
presents basic descriptive statistics for
the child feeding variables included in the index. Approximately half
of the sample of 4- to 36-mo-old children were being breast-fed at
the time of the survey. Although breast-feeding is almost universal
in this population, very little exclusive breastfeeding was observed.
Up to 33% of mothers reported using prelacteal feeds before full
breast-feeding was established, and extensive use of water, infant
formula and other liquids during the first 4 mo was reported. Even
solid foods were given to more than half of the children before they
had reached 4 mo of age. The most popular complementary food for
infants was "koko," a traditional, thin porridge of low energy and
low nutrient density, which is prepared from fermented maize dough.
Sixty percent of the mothers reported using it as opposed to other
fortified products, even the locally formulated cereal-legume
mixture called "weanimix." The median age of inclusion of
complementary foods in the children’s diet was 5.2 mo, earlier than
the recommended 6 mo. The median age of inclusion of family food was
9.2 mo and the median duration of breast-feeding was 18.2 mo
(median ages were adjusted for truncated data by survival analysis)
(results not shown).
Children were usually fed by their primary caregivers in 66% of the
cases, whereas 28% fed themselves and 6% were fed by an alternate
caregiver. When asked what they did when their child refused to eat,
24% of mothers claimed that they did not have this problem, but among
those who did, 14% reported trying to force their child to eat, 25%
coaxed or played with their children, 16% changed the food and 20%
did not do anything. Helping feed and stimulate the child during meals
is recognized as an important component of psychosocial care, which has
been associated with improved nutrient intake and growth
(Bentley et al. 1995
).
Table 2
shows that immunization rates were high (>85%), as is typical
of urban areas in developing countries (Ruel et al. 1998
). Growth monitoring, on the other hand, was attended by
only 63% of children in the previous month.
Hygiene practices, as measured by the spot-check observations,
showed that for all 11 aspects observed, at least 50% (and often 70%
or more) had good hygiene scores (Table 3)
. This suggests that families
achieved a relatively good level of hygiene, in spite of the generally
precarious conditions in which they lived.
Care resources.
Maternal sociodemographic and employment characteristics are presented
in Table 4
. Women in our sample were relatively young (the majority were between
20 and 35 y of age) mainly because of our sampling criteria that
excluded households who did not have a child 3 y old. In terms of
nutritional status, the majority were in the normal BMI range, but as
many as 25% were either overweight or obese (BMI 27
kg/m2). Only 6% of the women were underweight
(BMI < 18.5 kg/m2). The majority of mothers
(63%) had some form of basic education; 26% had high school or higher
education and 12% had no schooling at all. Ethnic origin showed a fair
split between ethnic groups. A large proportion of women in our sample
were married, but up to 35% were head of household. Most mothers
reported receiving some financial support from the child’s father.
|
) at the time of the survey. Of those working, 49% were selling in the
markets or on the streets, 34% were working from home and only 17%
were in salaried employment as office, factory or shop workers; almost
all worked at least 4 h, and more than half worked 8 h or
more. Up to 56% of mothers worked and looked after their child at the
same time, and only one third used alternate child care. Of these, 28%
used creches and 61% used single-person alternate care. Although
the majority of alternate caregivers were older than 15 y of age,
15% were between 6 and 15 y of age.
|
. The statistics generally reflect a low socioeconomic status and poor
living conditions. The majority of households lived in rooms (90%)
rather than houses or apartments. More than half of the households
bought their drinking water from vendors (54%), used public latrines
(54%) and used public dumping bins for waste disposal (67%). In terms
of ownership of assets, only a few households owned a car (8%).
Ownership of television, tape deck, radio and refrigerator was common
in spite of the generally precarious living conditions. Median
household size was 5 persons and families had on average approximately
one third of a room available per person. Median expenditure per capita
per year was equivalent to $394 and household-level energy
availability was 2585 kcal (10.8 MJ) per adult equivalent unit.
Households spent 55% of their resources on food, an indication of
limited resources.
|
Table 7
summarizes the results of the bivariate analysis of the association
between selected care resources on the one hand, and the child feeding,
health seeking and hygiene indices, on the other hand. None of the
resources studied was significantly associated with all three care
indices. Maternal education was significantly associated with both the
child feeding and the hygiene index, and household income was
associated with both the health and the hygiene index. The associations
were in the expected direction, i.e., more educated mothers and
households with greater income had higher care practices scores.
Maternal education was the only care resource associated with the child
feeding index. Child feeding practices were not associated with
household food availability, income or wealth, nor with any other
maternal or household characteristics.
|
Because many of the bivariate associations were likely to be confounded by socioeconomic factors or other characteristics, multivariate models were used to confirm these findings.
Ordinary least-squares regression was carried out to model the
determinants of the child feeding index. All maternal and household
characteristics hypothesized to be potential constraints to child
feeding practices were included in the regression model (Table 8
). The results confirm that none of the household characteristics was
associated with the child feeding index scores. As documented in the
bivariate analysis, maternal schooling was the only factor associated
with child feeding, aside from age of the child, which was negatively
associated with child feeding. The adjusted
R2 of the model was only 0.10, which
suggests that the model had a poor prediction power. Thus, except for
maternal schooling, the maternal and household characteristics that
were hypothesized to be resources or constraints to appropriate child
feeding practices were not found to be associated with child feeding
practices in this population.
|
As found in the bivariate analysis, maternal schooling and household socioeconomic status (quality of housing and asset index) were positively associated with hygiene, and being a female head of household was negatively associated with the hygiene index scores. Working women who worked <4 h/d also had significantly lower hygiene index scores. It may be that women who were head of households had more severe time constraints, which impeded their ability to maintain a clean environment. Mothers who worked only a few hours per day may not have been as well organized as those who worked full time, or may not have had the resources necessary to afford household help and thus had poorer hygiene scores.
The general lack of association between maternal working patterns and
child caregiving practices in both the bivariate and multivariate
analyses was somewhat unexpected considering the young age of our
sample of children. In an effort to understand this finding, we did
additional exploratory analysis of the characteristics of mothers’
employment by age of their child. The results, presented in
Figure 1
, indicate a strong association between children’s age and mothers’
employment patterns and the use of child care alternatives. For
example, mothers of young infants (0–4 mo of age) were much less
likely to work (only 23% worked, compared with 76% among mothers of
children 18 mo of age); they were less likely to work full time, and
they were more likely to take their child to work with them if they
worked (100% among the 0- to 4-mo-old group compared with 46% among
the oldest age group). The use of child care substitutes was much more
popular among mothers of older children (53% compared with only 9% of
mothers of young infants) (not shown). Even the type of substitute
child care selected varied by child age, i.e., the use of multiple
caretakers and of day care centers increased gradually with child age,
from 0% among mothers of young infants to 47% among mothers of
children 18 mo of age (not shown). These findings suggest that
mothers understood the need to, and were able to modify their working
patterns and their use of child care substitute gradually as their
child became older. This allowed them to respond to the special caring
needs of their young children.
|
|
DISCUSSION |
|---|
|
TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
Our study confirms that in Accra, maternal education is a crucial asset
for good caregiving practices related to child feeding, the use of
preventive health services and hygiene practices. Limited household
resources such as low income, poor housing quality, few assets, and
limited access to water, sanitation and garbage collection services, on
the other hand, were constraints only for preventive health care use
and hygiene practices. These and other household-level
characteristics such as food availability did not appear to limit
mothers’ ability to feed their children appropriately. Thus, in this
population, child feeding practices were more dependent on mothers’
education than on household food availability and economic resources.
The "obese mother/malnourished child" phenomenon commonly observed
in this sample supports this hypothesis and suggests that inequitable
use of resources rather than severe poverty or absolute lack of
resources are main constraints to adequate nutrition among preschoolers
in Accra (Maxwell et al. 2000
).
Maternal education has been shown consistently to be critically
important for child health, nutrition and survival (Alderman 1990
, Caldwell and McDonald 1982
, Cebu Study Team 1991
, Cleland and van Ginneken 1988
).
Although the precise mechanisms by which maternal education affects
child outcomes are not fully understood, evidence from various
countries indicates that knowledge and practices are key pathways. Our
findings from Accra show that, keeping income and other child, maternal
and household characteristics constant, maternal education is strongly
and positively associated with better child feeding, health seeking
(P < 0.10) and hygiene practices. These good care
practices, in turn, have a large positive effect on children’s
nutritional status (Ruel et al. 1999
), particularly
among children from poorer families and among children whose mothers
have less than secondary schooling. Thus, in this population, it
appears that the positive effect of maternal education on child
outcomes is mediated largely by improved care practices.
Household income did not appear to be a major constraint to adequate child feeding practices among the age group studied (0–36 mo). This may not be so surprising, considering that at least up to 6 mo of age, adopting the recommended practice of exclusive breast-feeding is less expensive than buying baby bottles and breast-milk substitutes. In Ghana, the cost of feeding infant formula in 1997 was estimated to be almost five times the cost of providing the additional maternal diet required to produce the equivalent amount of breast milk through lactation (PROFILES estimates; J. Ross, Academy for Educational Development, personal communication). These estimates did not even take into account the time cost of buying and preparing the substitutes, the fuel to boil the water, the time and water to clean the bottles and, even more importantly, the time and cost required to handle the health consequences of using substitutes. Thus these estimates grossly underestimate the real cost of using breast-milk substitutes. Even after 6 mo of age, when special foods have to be purchased, the proportion of the family budget that is required to provide the child with an adequate diet is likely to be relatively small; thus one would not expect household income to be a major limiting factor in providing an adequate diet to children at this age. What seems to be of utmost importance for the choices that mothers make regarding child feeding in this population is their level of education.
With respect to health seeking and hygiene behaviors, household
socioeconomic factors were important resources. As could be expected,
higher income and better housing quality, which are closely linked to
greater availability of water, sanitation and waste disposal services,
all contributed to improved hygiene. As documented in other
environments, maternal education, even when controlling for
socioeconomic factors, was also a strong determinant of good hygiene
practices (Gorter et al. 1998
). Women-headed
households and families in which mothers worked only a few hours per
day had poorer hygiene. Women heads of households are likely to have
more severe time constraints if they have to work to generate income.
For those women who worked only a few hours per day, it may be that
their income was insufficient to allow them to hire help and that they
had difficulties balancing their work, household and child care
responsibilities.
The specific issue of maternal work was not the main focus of this
study and will be explored in future analyses of the data. Our
preliminary findings, however, showed that maternal employment was not
a major constraint to child care or hygiene practices, apparently
because mothers modified their work patterns to attend to their young
infant’s special caring needs. These "adaptive strategies," by
which mothers stop working, or work fewer hours, or even take their
infant to work if they do work, may be successful in protecting their
infant, but may seriously jeopardize the mothers’ ability to generate
income for the family. In the informal work environment, characteristic
of our Accra sample, women had to create their own unpaid maternity
leave. The qualitative work carried out as part of the overall study
also highlighted the acute trade-offs that mothers had to face
between their productive and reproductive roles, particularly around
the time of birth. Mothers in focus groups and qualitative case studies
clearly indicated that the two major factors that determined when they
returned to their income-generating activities after delivery were
how rested they felt and how strongly they felt the imperative to earn
income (Maxwell et al. 2000
). Programs and policies are
urgently needed for women working in the informal sector to assist them
during the early postnatal period, to relieve some of the burden of
their dual role of income earner and principal caretaker. Some
countries are experimenting currently with subsidized community day
care center programs, particularly in Latin America, but these programs
often limit enrollment of young infants because of their need for
intense care during the 1st y.
Strengths and weaknesses of the study.
This study is the first one to our knowledge that has measured and quantified care practices into three indices, using cross-sectional survey data. We are also unaware of any other studies that have used appropriate statistical modeling to examine the associations between a variety of maternal and household care resources and the actual care behaviors.
It is important to highlight that the care indices constructed for this
study reflect only three of a large number of aspects related to the
overall concept of care (Engle et al. 1997
). The indices
also capture only a few practices related to child feeding, preventive
health seeking and proxies for hygiene behaviors, largely because of
the limitations of interview and recall techniques. Care is better
measured through observations in households and through longitudinal
studies that allow the timing and the nature of changes and transitions
to be captured (Engle and Ricciuti 1995
). This was not
possible in the context of our survey, which had a wide range of other
objectives and for which care was only one of many components. Another
limitation, which applies mainly to the child feeding index, was the
fact that the recall period varied with the age of the child. This was
particularly true for the questions about feeding practices during the
period soon after birth and during the first 4 mo of the child’s life.
There is no reason to believe, however, that this would introduce any
systematic bias. For example, it is unlikely that poor memory would
result in systematically more "No" or "Yes" answers among
mothers of older children to questions such as whether they used
prelacteal liquids. Thus, the type of bias likely to be introduced by
the unequal recall period is a random, nonsystematic type of error,
which does not affect the internal validity of the results but tends to
reduce the power to detect differences.
In spite of these limitations, this study showed that it is possible to measure at least some dimensions of care through large, cross-sectional surveys, with relatively simple interview instruments and using maternal recall information. Much more research is required to refine the methodologies to measure and quantify care appropriately, but this study was a first attempt in that direction.
Implications of programs.
Our study identified two main elements that can assist in the design of effective programs and interventions to improve caregiving practices in Accra, particularly with regard to feeding practices. First, it highlighted which specific feeding practices are deficient in this population; second, it identified the main constraints to the adoption of optimal feeding practices. This section reviews and builds on these findings, and discusses ways to address both the problems and constraints to child feeding in Accra. It also suggests potential vehicles for effective delivery of interventions to improve care in this setting.
Our study identified various child feeding practices during the 1st y
that could be improved. First, use of prelacteal feeds and
complementary liquids and foods during the first 4 mo of life was
widespread, although breastfeeding was the norm. Second, most mothers
used nonfortified, traditional complementary foods and up to 10%
introduced family foods directly into the child’s diet without using
any type of transitional foods. Finally, a large proportion of children
were not helped or encouraged to eat, even those who refused to eat.
These nonoptimal feeding practices, when combined into a care index,
were found to be strongly associated with poor nutritional status,
after controlling for a variety of maternal and household
characteristics (Ruel et al. 1999
). The prevalence of
stunting among children whose mothers were in the lowest care practices
tercile was >3 times higher than among children whose mothers were in
the highest care terciles (7% stunting prevalence compared with 24%).
Thus, efforts to improve child feeding practices and to relieve the
constraints to the adoption of optimal practices could have a
significant effect on child nutritional status in this population.
Carefully designed intervention studies should be implemented to
confirm this hypothesis using a probability approach that would allow
inferences of causality to be made.
Maternal education was the most consistent constraint to child care
identified in this urban population. Maternal education is both
amenable to change in the long term and, in the short term, nutrition
education interventions can be used as an alternative, although an
imperfect one. Promotion of girls’ schooling must be high on the
priority list of policy makers in Accra, particularly because it will
have long-term benefits that go far beyond the effect on child
care. In our study, maternal schooling was associated with a range of
positive outcomes in addition to good care practices, namely, higher
household income, food availability, diet quality, better paid
employment and lower child malnutrition and morbidity (Maxwell et al. 2000
). Education of girls is a long-term strategy
but, fortunately, some of the benefits of maternal schooling can be
simulated by effective nutrition education and behavior change
strategies (Caulfield et al. 1999
). The success of these
interventions depends largely on a clear understanding of which
practices should be modified and what are the main constraints to the
adoption of the recommended practices. This study developed a
methodology to carry out this type of analysis.
Another key aspect to the success of nutrition education efforts is
timeliness. Mothers need to receive the education before the child is
born to ensure that they will be motivated to initiate
breast-feeding at birth, avoid prelacteal feeds during the first
few weeks and maintain exclusive breastfeeding for 4–6 mo. In Accra,
attendance at prenatal clinics was extremely high (97%), even in the
first trimester of pregnancy (44%) (Maxwell et al. 2000
). Thus, prenatal clinics could be used as a vehicle to
establish a first contact with mothers and to start discussing issues
related to child feeding and care. Childhood immunization was also high
as is common in urban areas, and the education strategy should build on
this contact with the health services as well in order to strengthen
the messages about early infant feeding. The DPT immunizations, which
require three visits during the first 3 mo of the child’s life, could
be an excellent opportunity to promote continued exclusive
breast-feeding and to establish a support system for mothers who
experience difficulties with breast-feeding. Additional contacts
with the mother should be planned such that mothers could be trained on
the use of complementary foods before the child reaches 6 mo of age.
Measles immunization, which is due at 9 mo of age, could be yet another
opportunity to strengthen mothers’ knowledge about appropriate
complementary feeding practices at the end of the 1st y.
Finally, an additional key question is who should be the target of the
education and behavior change strategy. In Accra, we have seen that
mothers largely take on the responsibility for child care particularly
in the 1st y of their child’s life. After that period, however,
substitute caretakers gradually start taking a more important role in
feeding and caring for children, and education strategies should
consider ways to reach them as well. Additional information is needed
on who the substitute caretakers are and where and how they can be
reached. We know that many of them are older siblings, grandmothers and
other female relatives. This again highlights the importance of girls’
schooling and suggests that specific nutrition training at school could
be useful for young girls who are currently taking care of their
younger siblings, but even more importantly, it would prepare them for
their future role as mothers and even grandmothers. Recent experiences
with nutrition education and behavior change programs targeted to
school girls show promising results [see for example Smitasiri and Dhanamitta (1999)
in Thailand), but no evidence is
available yet of the long-term effect of these programs on adult
women’s nutrition knowledge and practices.
The potential for nutrition education and behavior change interventions
to have a major effect on child care in Accra is great. This is mainly
because socioeconomic factors are not such overwhelming constraints in
this population. Evidence shows that in contexts in which resources are
too limited, maternal education and knowledge are simply not enough
(Bairagi 1980
, Doan 1988
, Reed et al. 1996
, Ruel et al. 1992
). In these
circumstances, nutrition education and behavior change interventions
must be accompanied by poverty reduction strategies so that the
recommended practices can be adopted (Ruel et al. 1992
).
This is not to say that income generation and poverty reduction
activities are not also needed in Accra, but rather that the success of
nutrition education and behavior change strategies in this context is
not contingent on the synergism between the two approaches.
|
ACKNOWLEDGMENTS |
|---|
|
FOOTNOTES |
|---|
4 Abbreviations used: BMI, body mass index; DPT, diphtheria, pertussis and tetanus; OLS, ordinary least squares.
Manuscript received July 28, 1999. Initial review completed October 25, 1999. Revision accepted January 25, 2000.
|
REFERENCES |
|---|
|
TOPABSTRACTINTRODUCTIONSUBJECTS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
1. Accra Study Team Promoting Urban Food and Nutrition Security for the Vulnerable in the Greater Accra Metropolitan Area: Technical Report to the World Health Organization 1998 IFPRI and Noguchi Memorial Institute for Medical Research Washington, DC and Legon, Ghana.
2. Alderman H. Nutritional Status in Ghana and Its Determinants. Working Paper No. 3, Policy Analysis 1990 The World Bank Washington, DC.
3. Bairagi R. Is income the only constraint on child nutrition in rural Bangladesh?. Bull. WHO 1980;58:767-772[Medline]
4. Bentley M. E., Black M. M., Hurtado E. Child-feeding and appetite: what can programmes do?. Food Nutr. Bull. 1995;16:340-348
5. Brown K. H., Creed-Kanashiro H., Dewey K. G. Optimal complementary feeding practices to prevent childhood malnutrition in developing countries. Food Nutr. Bull. 1995;16:320-339
6. Caldwell J. C., McDonald P. Influence of maternal education on infant and child mortality: levels and causes. Health Policy Educ. 1982;2:251-267[Medline]
7. Caulfield L. E., Huffman S. L., Piwoz E. G. Interventions to improve intake of complementary foods by infants 6 to 12 mo of age in developing countries: impact on growth and on the prevalence of malnutrition and potential contribution to child survival. Food Nutr. Bull. 1999;20:183-200
8.
Cebu Study Team Underlying and proximate determinants of child health: The Cebu Longitudinal Health and Nutrition Study. Am. J. Epidemiol. 1991;133:185-201
9. Cleland J. G., van Ginneken J. K. Maternal education and child survival in developing countries: the search for pathways of influence. Soc. Sci. Med. 1988;27:1357-1368
10. Doan R. Class and Family Structure: A Study of Child Nutritional Status in Four Urban Settlements in Amman, Jordan 1988 Doctoral thesis Cornell University, Ithaca, NY.
11. Engle P., L & Lhotska L. The role of care in programmatic actions for nutrition: designing programmes involving care. Food Nutr. Bull. 1999;20:121-135
12. Engle P. L., Menon P., Haddad L. Care and Nutrition: Concepts and Measurement 1997 IFPRI Occasional Paper. International Food Policy Research Institute Washington, DC.
13. Engle P. L., Ricciuti H. N. Psychosocial aspects of care and nutrition. Food Nutr. Bull. 1995;16:356-377
14. Ghana-MLG (Ministry of Local Government) Strategic Plan for the Greater Accra Metropolitan Area. Volume 1: Context Report 1992 Department of Town and Country Planning, Ministry of Local Government Accra, Ghana.
15. Gibson R. Principles of Nutritional Assessment 1990 Oxford University Press New York, NY.
16.
Gorter A. C., Sandiford P., Pauw J., Morales P., Pérez R. M., Alberts H. Hygiene behavior in rural Nicaragua in relation to diarrhoea. Int. J. Epidemiol. 1998;27:1090-1100
17. Haddad L., Ruel M. T., Garrett J. L. Are urban poverty and undernutrition growing? Some newly assembled evidence. World Dev 1999;27:1891-1904[Also available as Food Consumption and Nutrition Division Discussion Paper # 63, which can be downloaded from IFPRI’s web site (www.cgiar.org/ifpri/)]
18. ISSER (Institute of Statistical, Social and Economic Research) The State of the Ghanaian Economy. 1994 1995 ISSER Legon, Ghana.
19. Leslie J., Paolisso M. Women, Work and Child Welfare in the Third World 1989 Westview Press for the American Association for the Advancement of Science Boulder, CO.
20. Levin C. E., Maxwell D. G., Armar-Klemesu M., Ruel M. T., Morris S. S., Ahiadeke C. Working women in an urban setting: traders, vendors, and food security in Accra. World Dev. 1999;27:1977-1992[Also available as Food Consumption and Nutrition Division Discussion Paper # 66, which can be downloaded from IFPRI’s web site (www.cgiar.org/ifpri/)].
21. Maxwell D., Levin C. E., Armar-Klemesu M., Ruel M. T., Morris S. S., Ahideke C. Urban livelihoods, food and nutrition security in Greater Accra. Research Report 2000 International Food Policy Research Institute Washington, DC (in press).
22.
Reed B. A., Habicht J.-P., Niameogo C. The effects of maternal education on child nutritional status depend on socio-environmental conditions. Int. J. Epidemiol. 1996;25:585-592
23. Ruel M. T., Garrett J. L., Morris S. S., Maxwell D., Oshaug A., Engle P., Menon P., Slack A., Haddad L. Urban challenges to nutrition security: a review of food security, health and care in the cities 1998 Food Consumption and Nutrition Division Discussion Paper # 51, International Food Policy Research Institute Washington, DC.
24.
Ruel M. T., Habicht J.-P., Pinstrup-Andersen P., Gröhn Y. The mediating effect of maternal nutrition knowledge on the association between maternal schooling and child nutritional status in Lesotho. Am. J. Epidemiol. 1992;135:904-914
25. Ruel M. T., Levin C. E., Armar-Klemesu M., Maxwell D., Morris S. S. Good care practices can mitigate the negative effects of poverty and low maternal schooling on children’s nutritional status: evidence from Accra. World Dev. 1999;27:1993-2009[Also available as Food Consumption and Nutrition Division Discussion Paper # 62, which can be downloaded from IFPRI’s web site (www.cgiar.org/ifpri/)].
26. Smitasiri S., Dhanamitta S. Sustaining behavior change to enhance micronutrient status: community- and women-based interventions in Thailand. ICRW/OMNI Research Program. Research Report Series 2 1999 International Center for Research on Women Washington, DC.
27. UNICEF Strategy for Improved Nutrition of Children and Women in Developing Countries 1990 UNICEF Policy Review Paper UNICEF, New York.
28. World Bank Ghana Poverty Past, Present and Future 1995 World Bank Washington, DC. Report No. 14504-GH
29. World Health Organization The World Health Organization’s infant-feeding recommendations. Bull. WHO 1995;73:165-174[Medline]
This article has been cited by other articles:
|
|
 |
|
  M. M Moursi, Y. Martin-Prevel, S. Eymard-Duvernay, G. Capon, S. Treche, B. Maire, and F. Delpeuch Assessment of child feeding practices using a summary index: stability over time and association with child growth in urban Madagascar Am. J. Clinical Nutrition, May 1, 2008; 87(5): 1472 - 1479. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. L Webb, A. D Stein, U. Ramakrishnan, V. S Hertzberg, M. Urizar, and R. Martorell A simple index to measure hygiene behaviours Int. J. Epidemiol., December 1, 2006; 35(6): 1469 - 1477. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. A. Levandowski, P. Sharma, S. D. Lane, N. Webster, A. M. Nestor, D. A. Cibula, and S. Huntington Parental Literacy and Infant Health: An Evidence-Based Healthy Start Intervention Health Promot Pract, January 1, 2006; 7(1): 95 - 102. [Abstract] [PDF]
|
|
|
|
 |
|
 B. Ntab, K. B. Simondon, J. Milet, B. Cisse, C. Sokhna, D. Boulanger, and F. Simondon A Young Child Feeding Index Is Not Associated with Either Height-for-Age or Height Velocity in Rural Senegalese Children J. Nutr., March 1, 2005; 135(3): 457 - 464. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. T. Ruel and P. Menon Child Feeding Practices Are Associated with Child Nutritional Status in Latin America: Innovative Uses of the Demographic and Health Surveys J. Nutr., June 1, 2002; 132(6): 1180 - 1187. [Abstract] [Full Text] [PDF]
|
|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
