The impact of the AFDC and Food Stamp programs on child nutrition: empirical evidence from New Orleans.

This study tests the hypotheses that the participation in the Aid to Families with Dependent Children (AFDC) and Food Stamp programs has a positive impact on children's nutritional status, after controlling for other potentially important household- and individual-level characteristics. The analysis is based on the responses of a health facility survey of 246 pairs of low-income mothers and children in New Orleans. The results indicate that participation in the AFDC and Food Stamp programs is associated with increased anthropometric status of children, but the foods consumed by children in families receiving welfare benefits were of significantly lower nutritional value than foods consumed by other children. Among the study's conclusions are the following: (1) in this low-income setting, AFDC and Food Stamp benefits are associated with higher food expenditures, higher anthropometric levels, but inferior diets, and (2) female-headed households spend more on food expenditures than other households, after controlling for other individual- and household-level characteristics.

The impact of primary health care services on under-five mortality in rural Niger.

BACKGROUND: Despite large investments in basic primary health care in sub-Saharan Africa over the past two decades, quantifying the contribution of national programme efforts to the reduction of infant/child mortality in the region has proven difficult. This study takes advantage of the phased implementation of the national Rural Health Improvement Program in Niger and conveniently timed survey data to reassess programme impact on under-five mortality during the 1980-1985 period. METHODS: Health service use and under-five mortality rates for children born in the 5 years prior to the 1985 survey are compared for three groups of villages: villages served by a dispensary, villages served by village health teams (VHT), and villages without access to modern primary care services. Multi-level regression analyses using both household- and community-level variables are undertaken in estimating the magnitude of effects. RESULTS: Children residing in villages proximate to health dispensaries were approximately 32% less likely to have died during the study period than children without access to modern health services. Village health teams were not, however, associated with significantly lower mortality probabilities. Formal test for endogeneity indicated that these effects were not the result of non-uniform/non-random allocation of resources. CONCLUSIONS: The findings are largely supportive of the key premise underlying selective primary health care interventions - that packages of basic services can be effectively mounted nationally in poor countries and have a significant impact over a short time period. In Niger, less than optimal implementation of VHT appears to have reduced the magnitude of the impact achieved.

PIP: The phased implementation of Niger's Rural Health Improvement Program, in conjunction with a 1985 Ministry of Health survey, facilitated quantification of the contribution of primary health care interventions to the reduction of infant and child mortality. During 1978-84, over 8000 health workers were trained and deployed to unserved villages; in addition, 45% of rural villages were provided with primary care services through dispensaries or village health teams. The 35 rural clusters covered in the survey were grouped into three categories: 1) villages located 5 km or less from a dispensary; 2) those located over 5 km from a dispensary, but with a village health team; and 3) villages located more than 5 km from a dispensary and with no health team. Mothers residing near a dispensary were two to five times more likely than their counterparts in the other two groups to have received prenatal care for the most recent birth, had the delivery attended by trained health personnel, received nutrition and health education, and know how to prepare oral rehydration solution. Children in the dispensary-proximate villages were three times more likely to have been at least partially immunized and to have a health card and twice as likely to have had their most recent diarrhea episode treated by a health worker. The unadjusted proportions of infants and children who died in the five years preceding the survey were 0.191 in villages served by a dispensary, 0.203 in villages served by a health team, and 0.267 in villages with neither resource. Multivariate analyses indicated that significantly lower mortality was associated with the presence of a dispensary, maternal literacy, and the existence in the community of farm machinery or access to seeds to plant the next crop. Overall, these findings confirm the significance of primary health care services, especially treatment of infantile diarrhea and tetanus, to reducing under-five mortality in sub-Saharan Africa.

Prevalence and differentials of low birth weight in Niamey, Niger.

This study provides population representative data on live births occurring in Niamey, Niger during the period 1980 to 1985. A total of 5097 live births were systematically sampled from maternity registers over the study period. Due to legislation and incentives to register all live births, between 90 and 95 per cent of all live births are represented in this study. The data here suggest that low birth weight (LBW) prevalence may be lower in this urban area than it is in the region as a whole; and that the demographic risk factors are similar to those found in other developing countries. Finally, in many developing countries, maternity coverage of attended births may be quite high, suggesting that record or prospective studies examining trends in LBW and risk factors for perinatal outcomes might be convenient and implemented at very low cost.

Intra-household correlations in maternal-child nutritional status in rural Guinea: implications for programme-screening strategies.

It is commonly assumed in public health practice that households in developing country settings are relatively homogeneous with respect to nutritional status. To the extent that this assumption is valid, nutritional assessments of mothers or individual children would provide an effective screening mechanism for household-level maternal-child nutritional risk. However, there has been no confirmation of the strength of intra-household correlations in nutritional status among women and children. Using data from a cross-sectional survey undertaken in 1990 in rural central Guinea, the present study investigates the nature of within-household relationships in maternal and child nutritional status and considers the implications for programme screening strategies. Mothers and their surviving children under 5 years of age are the focus of the analysis. Correlations between maternal and child nutritional levels are assessed and the performance of maternal-child nutritional indicators as screening tools for household nutritional risk are formally evaluated by analysing the sensitivity, specificity, and positive-negative predictive values of various indicators.

PIP: The authors explore to what extent households may be identified as being at risk of maternal-childhood malnutrition on the basis of a nutritional assessment of one household member. Cross-sectional survey data collected in 1990 from the central Guinean provinces of Labe, Tougue, Lelouma, Dolaba, and Pita, on 780 mothers and their 1118 surviving children under 5 years of age are the focus of the analysis. The survey had been conducted to obtain baseline data on nutrition and health problems in the region. Investigators assessed correlations between maternal and child nutrition, and formally evaluated the performance of maternal-child nutritional indicators as screening tools for household nutrition risk. Although significant intra-households correlations were found with regard to nutritional status among women and children, the data clearly indicate the inefficiency of screening for household-level maternal-child nutritional risk on the basis of anthropometric indicators for mothers and/or individual children under age five years.

Breast-feeding, water and sanitation, and childhood malnutrition in the Philippines.

This study examines effects and interactions of socioeconomic status, access to water supply and sanitation, and breast-feeding practices in relation to child growth in two provincial cities in the Philippines. Multivariate analysis identified food expenditure per head, education of the household head and gender of the child as significant predictors of nutritional status. The duration of partial and full breast-feeding was negatively (though non-significantly) associated with growth. Sanitation facilities and breast-feeding are, however, important determinants during the first year of life. Among children over 1 year of age, socioeconomic variables and gender are the most important predictors. Breast-feeding is shown to provide more important health benefits for children in lower income households. The need for further studies on the causes of gender differences in nutritional status was apparent.

Socioeconomic, environmental, demographic and behavioral factors associated with occurrence of diarrhea in young children in the Republic of Congo.

This study is the result of a cross-sectional survey undertaken in five regions of the Republic of Congo. A sample of 612 women having children under 3 years of age was interviewed to determine the socioeconomic, environmental, demographic and behavioral factors associated with the occurrence of diarrhea in young children. Logistic regression analysis was used to determine which variables predict the occurrence of diarrhea in a multivariable context. Most of the statistically significant variables were those suggesting behaviorally mediated modes of transmission. These include: type of weaning food fed to the child, maternal age, sex of the child, maternal sickness and method of refuse disposal. Male children had a more than two-fold odds of experiencing recent diarrhea than did female children among those greater than 1 year of age. Although breastfeeding status was not statistically significantly associated with diarrheal disease, children under 1 year of age who were already weaned had a greater odds of disease than those who were still breasted. Due to the pattern of extended breastfeeding in this population, this relationship was difficult to assess. Urban residence also was highly associated with diarrheal disease occurrence. Urban residence is likely to reflect a host of socioeconomic, environmental and behavioral factors. These findings underscore the potential impact of educational interventions on the occurrence of diarrheal disease among young children.

Costs of rearing children in agricultural economies: an alternative estimation approach and findings from rural Bangladesh.

PIP: There are changes in child costs during demographic transition. This study examines household time allocation from 66 agricultural households in 3 villages in Tangail District in rural north central Bangladesh in 1984-85 (371 days). Component and total child-rearing costs are estimated in alternative ways. Conventional "opportunity wage" measures are considered overestimated. The methodological shortcomings of direct cost accounting procedures and consumer demand methods in computing time cost and monetary cost of child rearing are pointed out. In this study's alternative computation, age standardized equivalent costs are generated. Child food consumption costs were generated from a large national survey conducted in 1983. Nonfood expenditures were estimated by food to nonfood expenditure ratios taken from the aforementioned survey. For estimating breast-feeding costs, an estimate was produced based on the assumption that costs for infant food consumption were a fixed proportion of food costs for older children. Land ownership groups were set up to reflect socioeconomic status: 1) landless households, 2) marginal farm households with 1 acre or .4 hectares of land, 3) middle income households with 1-2 acres of land, 4) upper middle income households with 2-4 acres of land, and 5) upper income or rich households with over 4 acres of land. The nonmarket wage rate for hired household help was used to determine the value of cooking, fetching water, and household cleaning and repairing. The results confirm the low costs of child rearing in high fertility societies. Productive nonmarket activities are effective in subsidizing the costs of children. The addition of a child into households already with children has a low impact on time costs of children; "this economies of scale effect is estimated ... at 20%." The highest relative costs were found in the lowest income households, and the lowest costs were in the highest income households. 5% of total household income is devoted to child rearing in the lowest income households compared to 1% of income in the highest income households. The implications are that fertility decline is more directly related to structural changes in the economy, satisfaction of existing demand for family planning, and the producing additional demand for fertility control.^ieng

Conceptual framework for nutrition surveillance systems.

This article describes the evolution of nutrition surveillance as an intervention strategy and presents a framework for improving the usefulness of nutrition surveillance programs. It seems clear that such programs' impact on nutritional well-being will depend increasingly on their ability to reach and influence decision-makers. Therefore, it is important to consider political and social forces, and also to realize that if a program is too decentralized or too far removed from key decision-makers, its ability to influence resource flows may be limited. It is of course important that the surveillance information provided be appropriate and of good quality. Therefore, the data collected should be analyzed to ensure they are accurate and representative. Once that has been done, relevant findings should be presented in a readily understandable form designed to meet the intended recipients' information needs. Such findings should also be disseminated to all important decision-maker constituencies, including external donors of nutrition assistance and the general public.

PIP: Latin America has been able since the mid-1970s to establish nutritional surveillance systems in a sustainable and operational manner. The status of activities in the region is displayed graphically to show the types and extent of surveillance. A unique feature is the extent of professional networks, regional training, and technical support programs. The history of nutrition surveillance is traced from its inception at about the time of computer driven information systems. Also presented is a general discussion of the conceptual framework involved in social sector decision making: accountability factors (political forces, social values, organization, legislation, media); resource control; and effective information characteristics (content, presentation, and timeliness). Recommendations are made to perform an assessment of the nutrition situation among the population (the types and magnitudes of existing problems) before designing a nutrition surveillance system. A decision-making process assessment is also many times neglected, but nonetheless still essential for future planning. An information-decision audit can be performed to identify the key decision-making individuals, the information used for decision, and when and how decision are made. Microcomputers and software for analysis, such as the Geographic Information Systems, must be included within programs. The central program office should be organized in such a way as to be close to major decision makers, to provide nutritional status data in an interpretable form for nonexperts, and to select a program director with senior manager experience. Nutritional surveillance programs should focus on specific issues consistent with priorities, which were revealed through nutrition situation analysis and information audits. Flexibility in program implementation allows for dealing with emerging problems. The best nutrition surveillance programs are linked to decision makers who determine the nutritional well being of the national population. The Latin American models can provide a useful basis for applying these recommendations and in providing leadership in developing more advanced nutritional surveillance.

Composite indicators for famine early warning systems.

Traditional famine early warning systems use a host of indicators to predict food crisis situations, from rainfall and increased rate of marketing of household durables to the behavior of birds and animals. Although many of these indicators are valid in general, limited understanding of the sensitivity and specificity of the distress signals makes food crisis prediction a highly subjective exercise. In order to make the system more effective and credible, we need to identify a limited number of 'composite' indicators, which naturally summarize most relevant food-related information contained in the specific predictors of food crisis. Considering the chronology of the food production and consumption chain, three composite indicators specific to three different stages of the chain have been identified. The satellite data based Normalized Deviation of Vegetative Index (NDVI), prices of major food grains, and malnutrition rates are found to be correlated not only with the quality and quantity of inputs of this process but also with the final outcome. Both NDVI and price data are widely used as important predictors of food crisis by famine warning systems. What we have demonstrated is that improved sensitivity of the indicators is likely to be due to their inherent capability of summarizing information from various specific measures. Child malnutrition rates also summarize inputs and outputs of the food consumption process very effectively, and therefore should be able to predict community level food crisis in an efficient manner. The empirical results confirm this conjecture by showing that malnutrition rates can predict food crisis probability three months into the future with a high degree of specificity. The use of 'composite' indicators not only simplifies the problem of aggregation, but is also likely to yield forecasts that are highly specific and sensitive.

Differential correlates of nutritional status in Kinshasa, Zaire.

In an effort to search for causes of malnutrition in the urban environment to guide intervention efforts, a study of more than 2000 mother/child pairs was conducted in Kinshasa, Zaire. Under the auspices of the Zairian National Nutrition Planning Center a representative sample of a large lower class urban population was interviewed at two points in time. One phase covered morbidity and nutritional status measurements for all children under five years of age. A second phase examined a complex set of socioeconomic and behavioural variables possibly linked to nutritional outcomes for a 20% sample of the households. After merging the data sets bivariate and multivariate regression analyses were performed twice, using the youngest child and the household as the unit of analysis respectively. Results showed that different complexes of variables predicted malnutrition as measured by three separate anthropometric measures. For so-called acute malnutrition (weight-for-height) morbidity, migration, and diarrhoeal knowledge, all emerged as significant predictors. Chronic malnutrition (height-for-age), however, was only significantly predicted by zone of residence, a level of living score, and recent morbidity when all major variables were considered in the regression model. Factors that were significant predictors of each of these two indices also were predictors of the third nutritional indicator, weight-for-age. Birth interval also was associated with this index. The findings here suggest more careful scrutiny of the nature, causes, interpretation and use of these widely accepted measures of nutritional status.

Long term effect of gynecologic age on somatic growth of children.

A sample of New Orleans black primiparous women under 25 years of age, participants in the national collaborative perinatal study, and their singleton children were studied to determine the relationship of maternal gestational age (GeA), gynecologic age (GyA) and size for GeA (S/GeA) on the child's growth over seven years observation. Early childbearers (less than 4 years GyA) had a somewhat higher proportion of preterm births than the late group (greater than or equal to 4 yrs GyA). A repeated measures analysis of variance after correction for maternal prepregnant weight and weight gain, demonstrated the early group remained smaller throughout the seven years in weight, length and head circumference. Preterm infants showed catch up by one year in height and weight in both Early and Late Groups, though the Early Preterm infants failed to catch up with the other groups in head circumference. In this lower socio economic group, the legacy of early childbearing appears to be smaller child body dimensions which are likely permanent.

Correlates and implications of breast-feeding practices in Bas Zaire.

PIP: A sample of 1871 women having a child under 3 years old in Bas Zaire was studied to determine the correlates of breastfeeding practices and to examine the interrelationships among breastfeeding, contraceptive practices and desire for pregnancy. The methods of analysis applied were life table analysis and its multivariate extensions. Most of the findings in this analysis are consistent with current literature on the correlates of the duration of breastfeeding. Maternal education, economic status, age, parity, urban residence, pregnancy, and sex of the index child were significantly related to the length of breastfeeding. Among non-pregnant women, current desire for pregnancy was also related to breastfeeding status when the length of time since birth of the last child was taken into consideration. Rural women were reportedly ready for another pregnancy sooner after the birth of their last child than were urban women. Breastfeeding appears to be the most important means of contraceptive protection in the study population. The effective traditional method of extended postpartum abstinence is not widely prevalent, particularly among the urban sample, and indeed seems to be on the decline. The data presented here also suggest that breastfeeding pratices are changing in this area of Africa where little economic development has occurred in the past 20 years. This research suggests that if current trends continue, fertility levels are likely to increase significantly. The findings also indicate that Bas Zairian mothers want to space their births and for this reason may be receptive to family planning programs that use appropriate strategies.^ieng