Grandmothers - a cultural resource for women and children's health and well-being across the life cycle.

Grandmothers exist in all societies. Especially in the non-western Majority World, where Elders are both highly respected and responsible for transmitting their knowledge to younger generations, there is extensive anecdotal evidence of Grandmothers' role in health promotion and healing. However, due to Eurocentric and reductionist views of families and communities, in the extensive past research on maternal, child and adolescent health issues across Africa, Asia, Latin America and the Middle East, and in Indigenous societies in North America, Australia and New Zealand, scant attention has been given to the role of Grandmothers. This paper addresses this oversight and supports the imperative to decolonize health promotion in the non-western world by building on non-western worldviews, roles and values. Based on an eclectic body of both published and gray literature, this review presents extensive evidence of Grandmothers' involvement across the life cycle of women and children and of the similar core roles that they play across cultures. While in some cases Grandmothers have a negative influence, in most cases their involvement and support to younger women and children is beneficial in terms of both their advisory and their caregiving roles. For future research and interventions addressing maternal, child and adolescent health, the conclusions of this review provide strong support for: adoption of a family systems framework to identify both gender-specific and generation-specific roles and influence; and the inclusion of Grandmothers in community health promotion programs dealing with different phases of the life cycle of women and children.

Transforming social norms to improve girl-child health and well-being: a realist evaluation of the Girls' Holistic Development program in rural Senegal.

BACKGROUND: Early adolescence is a critical period where social norms, attitudes, and behaviors around gender equality form. Social norms influence adolescent choices and behaviors and are reinforced by caregivers and community members, affecting girls' reproductive health and educational opportunities. Understanding how to shift these often-interconnected norms to delay child marriage, pregnancy and keep girls in school requires understanding of the structure and dynamics of family and community systems. The Senegalese and American non-governmental organization, the Grandmothers Project-Change through Culture, seeks to address these intertwined factors through innovative community change strategies that build on the specific structure and values of West African collectivist cultures. METHODS: The Girls' Holistic Development approach in rural Vélingara, Senegal posits that by increasing recognition, knowledge and empowerment of elder community women and reinforcing intergenerational communication and decision-making, community members including girls will support and advocate on behalf of girls' interests and desires. We assessed the Girls Holistic Development approach using Realist Evaluation with a mixed-method, quasi-experimental design with a comparison population. We examined differences in intergenerational communication, decision-making and descriptive and injunctive norms related to early marriage, pregnancy and schooling. RESULTS: After 18 months, intergenerational communication was more likely, grandmothers felt more valued in their communities, adolescent girls felt more supported with improved agency, and norms were shifting to support delayed marriage and pregnancy and keeping girls in school. Grandmothers in intervention villages were statistically significantly more likely to be perceived as influential decision-makers by both VYA girls and caregivers for marriage and schooling decisions compared to girls and caregivers in comparison villages. CONCLUSIONS: This realist evaluation demonstrated shift in social norms, particularly for VYA girls, in intervention villages favoring delaying girls' marriage, preventing early pregnancy and keeping girls in school along with increased support for and action by grandmothers to support girls and their well-being related to these same outcomes. These shifts represent greater community social cohesion on girl-child issues. This research helps explain the linkage between social norms and girls' reproductive health and education outcomes and demonstrates that normative shifts can lead to behavior change via collective community action mechanisms.

During adolescence in Senegal, as elsewhere, decisions on whether to keep girls in school and at what age to marry girls are made by their caregivers and influenced by family and community members. Early pregnancy occurs at these ages, either before or during marriage. These social influences, called social norms, set expectations for parents and girls.The Grandmothers Project­Change through Culture developed an intervention to shift social norms and change these three outcomes­early pregnancy, early marriage and keeping girls in school. The project, called Girls Holistic Development (GHD), builds on local relationships between girls, grandmothers, parents and community leaders and local values to facilitate discussion, reflection, collaboration and advocacy.This study used realist evaluation methods, including qualitative and quantitative interview and focus group discussions, to understand whether these shifts in norms and behaviors took place. Research took place with girls, grandmothers and male and female caregivers 18 months after GHD started. Quantitative survey included 7 intervention and 7 comparison villages.Results supported GHDs' expectations and strategy. In intervention villages, grandmothers and girls reported closer relationships; parents considered grandmothers important sources of advice. Girls, grandmothers and caregivers described social expectations as favoring girl's education, marriage at older ages and development of strategies to prevent girl's pregnancy in intervention villages.This evaluation provided strong support for GHDs' ability to shift social norms to improve girls' outcomes. By working with local relationships and values, GHD created more communication between community and family members and facilitated increased social bonds within the community.

Introduction: A family systems approach to promote maternal, child and adolescent nutrition.

In all cultures, women and children are embedded in family systems that determine roles, relationships, patterns of communication and authority between family members. Especially in non-western societies, maternal and child nutrition practices are determined not only by the biological parents but also by other influential family members. Most maternal and child nutrition research and interventions do not consider the constellation of family roles and influence on women and children and continue to focus on the mother-child dyad and individual knowledge, attitudes and practices. There is growing agreement on the need to adopt an ecological framework to address public health issues, including those dealing with maternal and child nutrition. This special issue presents examples of research from a variety of settings that employed an ecological, family systems approach either to investigate maternal, child or adolescent nutrition issues or to design interventions that engaged various actors within family settings. These 11 articles contribute to a growing body of evidence supporting the relevance of a wider family systems perspective for nutrition research and interventions. Key themes across studies include the limitations of using a nuclear family model for research and intervention design, the need for formative research that comprehensively explores family systems, increasing recognition of the extensive involvement and support provided by grandmothers, and the importance of engaging men in culturally appropriate ways based on community dialogue and women's perspectives. Future maternal and child nutrition research and interventions can be strengthened by systems thinking that acknowledges that individuals are situated within family and community systems.

Grandmothers - a neglected family resource for saving newborn lives.

Across the globe, the well-being of newborns is significantly influenced by the knowledge and practices of family members, yet global health policies and interventions primarily focus on strengthening health services to save newborn lives. Predominant approaches to promote newborn survival in non-western cultures across the Global South are based on a western, nuclear family model and ignore the roles of caregivers within wider family systems, whose attitudes and practices are determined by culturally prescribed strategies. In this paper, I review evidence of a neglected facet of newborn care, the role and influence of senior women or grandmothers.Based on a family systems frame, I reviewed research from numerous settings in Africa, Asia and Latin America that provides insight into family roles related to newborn care, specifically of grandmothers. I identified primarily published studies which provide evidence of grandmothers' role as culturally designated and influential newborn advisors to young mothers and direct caregivers. Research from all three continents reveals that grandmothers play similar core roles in newborn care while their culturally specific practices vary. This review supports two main conclusions. First, future newborn research should be conceptualised within a family systems framework that reflects the structure and dynamics of non-western collectivist cultures. Second, newborn interventions should aim not only to strengthen health services but also influential family caregivers, particularly grandmothers and the indigenous social support networks of which they are a part, in order to improve family-level newborn practices and save newborn lives.

Grandmothers as Change Agents: Developing a Culturally Appropriate Program to Improve Maternal and Child Nutrition in Sierra Leone.

BACKGROUND: Global recommendations on optimal maternal and child nutrition (MCN) practices are clear; however, there is limited literature 1) exploring how roles of family members influence those practices and on 2) designing programs accordingly. Researchers using a family-systems approach in the Global South find that grandmothers often play a vital role in MCN, yet most nutrition programs narrowly target mothers, thereby potentially limiting effectiveness. OBJECTIVES: This article reports on the results of qualitative research exploring the roles and influence of family members on MCN in southern Sierra Leone, the local MCN beliefs and practices, and how those findings informed the design of a culturally appropriate program. METHODS: Focus group discussions (FGDs) were conducted with mothers, fathers, and grandmothers in 9 communities in Bonthe District, Sierra Leone. We used participatory tools to explore family members' roles and local MCN beliefs and practices. Interviews were recorded by notetakers and coded and analyzed using a content analysis approach. RESULTS: A total of 88 mothers, 125 grandmothers, and 79 fathers participated in the FGDs. All groups indicated that 1) grandmothers are the culturally designated advisors and supervisors of women on MCN issues and 2) mothers are not autonomous decision makers and are greatly influenced by grandmothers. The research identified both beneficial MCN practices and gaps between optimal and existing MCN practices-particularly related to maternal diet during pregnancy and exclusive breastfeeding for 6 mo. Research findings were used to design a grandmother-inclusive program. CONCLUSIONS: Our research showed that mothers are embedded in a family system of caring and supervision where grandmothers have primary influence on MCN practices, clearly supporting the need for grandmothers to have a central role in community MCN programs. It also points to the need for increased use of a family-systems approach in designing public health nutrition programs.

An Innovative Grandmother-Inclusive Approach for Addressing Suboptimal Infant and Young Child Feeding Practices in Sierra Leone.

BACKGROUND: Suboptimal infant and young child feeding (IYCF) practices contribute to child undernutrition. Sierra Leone Demographic and Health Survey data show that IYCF practices remain poor despite modest improvements. Recent studies have identified the role of grandmothers as critical to child nutrition; however, in Sierra Leone to date, the potential for grandmothers to influence IYCF practices has not been investigated. OBJECTIVES: We examined how an innovative grandmother-inclusive approach (GMIA) can be used to address suboptimal IYCF practices. METHODS: Using a quasi-experimental design, we compared IYCF beliefs and practices between GMIA intervention communities (receiving monthly dialogue sessions on nutrition, quarterly community praise sessions, and intergenerational forums) and comparison communities (receiving standard nutrition education) in Bum chiefdom from 2013 and 2016. The quantitative endline survey targeted 101 pregnant women, 291 women with children aged <2 y, and 219 grandmothers. Statistical analyses utilized t tests and χ2 tests to examine differences between intervention and comparison communities at endline. Multivariate regression was used to determine the intervention's effect on IYCF outcomes of interest. RESULTS: Awareness of and participation in the GMIA was high among mothers and grandmothers in intervention communities. The percentage of infants and young children aged 0-23 mo (n = 291) exclusively breastfed during the first week of life was significantly higher in the intervention group (90.2% compared with 79.4%, P = 0.01). Among infants aged 6-23 mo (n = 219), the percentage achieving minimum dietary diversity and minimum acceptable diet was significantly higher in the intervention group (77.2% compared with 51.8%, P < 0.001; and 53.8% compared with 22.6%, P < 0.001, respectively). Differences in percentages achieving minimum meal frequency (MMF) were only significant for infants aged 9-23 mo, with the intervention group achieving a higher MMF (54.6% compared with 36.9%, P = 0.02). CONCLUSIONS: Results suggest that a GMIA that recognizes grandmothers' roles and strengthens their knowledge can contribute to improved IYCF practices.

The role and influence of grandmothers on child nutrition: culturally designated advisors and caregivers.

Improving the nutritional status of infants and young children in developing countries depends to a significant extent on adoption of optimal nutrition-related practices within the context of the household. Most policies, research and programmes on child nutrition in non-Western societies focus narrowly on the mother-child dyad and fail to consider the wider household and community environments in which other actors, hierarchical patterns of authority and informal communication networks operate and influence such practices. In particular, the role and influence of senior women, or grandmothers, has received limited attention. Research dealing with child nutrition from numerous socio-cultural settings in Africa, Asia and Latin America reveals three common patterns related to the social dynamics and decision-making within households and communities. First, grandmothers play a central role as advisers to younger women and as caregivers of both women and children on nutrition and health issues. Second, grandmother social networks exercise collective influence on maternal and child nutrition-related practices, specifically regarding pregnancy, feeding and care of infants, young children and sick children. Third, men play a relatively limited role in day-to-day child nutrition within family systems. The research reviewed supports the need to re-conceptualize the parameters considered in nutritional policies and programmes by expanding the focus beyond the mother-child dyad to include grandmothers given their role as culturally designated advisers and caregivers.

Senegalese grandmothers promote improved maternal and child nutrition practices: the guardians of tradition are not averse to change.

The vast majority of community nutrition/health programs in developing countries focus on women of reproductive age (WRA) and a few explicitly involve senior women, or grandmothers. In Senegal, as in many other places, older, experienced women play an influential role in household maternal and child health (MCH) matters. Formative research in Serer villages revealed their importance and this was taken into account in an action research nutrition education (NE) project in which grandmothers were encouraged to promote improved nutritional practices related to pregnancy (e.g. decreased work and improved diet) and infant feeding (e.g. breastfeeding and complementary feeding). A participatory communication/empowerment education approach was used involving songs, stories and group discussion. Quantitative and qualitative data were collected to both document and evaluate the intervention. Triangulation of the evaluation data suggests that 12 months after the intervention was initiated there were significant improvements in grandmothers' nutritional knowledge, in their advice to WRA, and in the nutrition-related practices of these younger women associated both with pregnancy and infant feeding. For example, in the pre-test only 20% of grandmothers stated that they advise pregnant women to decrease their workload whereas in the post-test 87% reported giving this advice. At the same time, 91% of WRA in villages with the grandmother strategy reported having decreased their workload during their last pregnancy whereas in villages with NE activities for WRA but not with grandmothers, only 34% of younger women reported having done so. These findings provide evidence of grandmothers' ability to learn, to integrate new information into their practices and to positively influence the practices of WRA. These results support the need for future MCH programs, in different cultural contexts, to involve grandmothers and in so doing to build on their intrinsic commitment to family well-being.