Assessing Care: Progress Towards The Measurement Of Selected Childcare And Feeding Practices, And Implications For Programs

The role of care as a critical influence on child nutrition, health, and development has received increasing attention in the last decade. While the role of care has been well elaborated at a conceptual level, we still lack simple, valid, and reliable tools to measure many aspects of care. In this review, experience with the measurement of selected childcare and feeding practices is summarized and implications for programs are discussed. Hygiene practices The use of interviews and recall methods is discouraged for the measurement of hygiene practices because research has shown that responses tend to be biased towards overreporting of “good” practices. Observational methods are therefore the method of choice, but they are subject to problems of reactivity—that is, that people behave differently in the presence of an observer—and normal day-to-day variability. Spot-check observations are an increasingly popular alternative, as they are less time consuming and costly and appear to be less reactive. However, like structured observations, they are subject to problems of day-to-day variability. Approaches to minimize biases and errors due to reactivity and day-to-day variability are discussed. Feeding practices Most feeding practice research has focused on the dietary aspects of feeding, and primarily on breastfeeding and complementary feeding. These practices are usually measured by maternal recall, but little evidence exists to document the reliability and validity of maternal recall of these practices. Recall errors may be particularly problematic when long recall periods are involved and when recall periods vary widely between respondents (e.g., when mothers of all children under 5 years of age are asked to recall early breastfeeding practices). Recall bias also may occur, especially following education interventions, when individuals are aware of what the “correct” answer is. Suggestions for reducing recall errors and biases in research and program contexts are discussed. Caregiver-child interactions during feeding The new focus on care in nutrition research has led to recognition of the importance of additional, nondietary aspects of child feeding, which include a variety of caregiver-child interactions. The importance of the role of poor appetite has also been highlighted. Interactions include responsive feeding, encouragement to eat, response to poor appetite, and adaptation of feeding to the child’s developmental stage. Structured observations have been the method of choice for measuring these interactions, and various measurement scales have been developed, though most of them have not yet been validated. There is very limited experience with survey approaches, and it is probable that many aspects of these interactions will never be amenable to survey approaches. Attempts to operationalize and measure child appetite have been successful, and the use of a simple visual appetite analogue scale appears promising. Additional considerations for programming and research ! There is evidence that good (or bad) practices tend to cluster, both within dimensions of care such as hygiene or feeding, and across dimensions. Also, it may be that a minimum number of good practices is necessary for health benefits to be obtained. For these reasons, composite indices or summary measures that combine various practices in one index may be useful. Additional research is needed to validate these indices. ! Program planning and design should be preceded by qualitative work in order to provide well-grounded and specific knowledge of practices, relevant norms, and potential constraints to adoption of optimal practices. In addition to guiding program design, this information should be used to inform selection of indicators and methods for monitoring and evaluation. ! Mixed methods, including both qualitative and quantitative approaches, are recommended at the planning stage, as well as in monitoring and evaluation stages, in order to maximize opportunities for triangulation of findings.