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Abstract
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.