Understanding the influence of Caregivers’ Health Belief Model of
‘Child Undernutrition’ on their Health-Seeking Behaviour
Beyond the numbers; Systematic Review of Qualitative Data
By
Jiyeoun Bae
August 2020
Nadine Voelkner / University of Groningen
Sulagna Maitra / University College Dublin
This thesis is submitted for obtaining the Master’s Degree in International Humanitarian Action. By submitting the thesis, the author certifies that the text is from his/her hand, does
not include the work of someone else unless clearly indicated, and that the thesis has been produced in accordance with proper academic practices.
Acknowledgement
I believe that this thesis is the fruit of cumulative conversations, observations, and inspirations that I was privileged to have over the past two years.
I would like to express my gratitude to my research supervisor, Dr Nadine Voelkner, for guiding me and supporting me throughout this research, particularly in this unprecedented time of COVID 19.
The NOHA master course has brought the world closer to me. It opened my eyes to the world that I did not know before. I owe the most beautiful time for my colleagues who have been my friends and family throughout the years.
Lastly, but certainly not the least, I would like to extend my gratitude and appreciation to my family and friends across the world for their love, prayers, understanding, and continuing support throughout my life.
I wish to continue questioning inequity and injustice around the world and keep taking my responsibilities for equity and justice.
This paper was supported by The KOICA/WFK Scholarship funded by the Korea International Cooperation Agency. (제2018-163호)
Abstract
Despite the continuous effort of fighting against hunger, far too many people are affected by an inadequate food environment. Particularly infants and young children are at high risk of not surviving and further to not fulfilling their full developmental potential. In a context where access to health service, availability of quality food and information is limited, the role of caregivers is more significant than any other setting. Therefore, this study aims to build a deep understanding of caregivers’ Health Belief Model on child nutrition to create a comprehensive knowledge of their health-seeking behaviours. The study is analysing three Sub-Saharan Africa Countries, namely, Ethiopia, Malawi, and Tanzania. Pre-existing qualitative data is drawn for a systematic synthesis. Deeply rooted cultural practices and conceptualisation around infant and young child feeding practices hinder caregivers from taking optimal care-seeking behaviours. Among others, postpartum sexual abstinence rule is perceived as a critical way to keep infants healthy. Therefore caregivers’ of malnourished infants are stigmatised by the community members as are they sexually misbehaving. Moreover, caregivers tend to consult the traditional healers instead of health professionals when they perceive the cause of child illness and malnourishment as cultural factors. Concept of stunting, short stature, is considered as inherited rather than related to a child’s growth and nutrition. The knowledge gap in the early initiation of breastfeeding and exclusive breastfeeding are identified in this study. It is critical to evaluate the languages that are being used in nutrition interventions in order to minimise the knowledge gap among caregivers. Lastly, socio-ecological factors from extended family members, neighbours, to accessibility and quality of health services influence caregivers’ health belief model and eventually their health-seeking behaviours. Contextual knowledge and information that address the root causes of child malnutrition shall be translated into comprehensive and sustainable programme designing and implementation.
TABLE OF CONTENTS TABLE OF CONTENTS 3 CHAPTER 1. Introduction 7 1.1 Background 7 1.2 Problem Statement 8 1.3 Research Question 10 1.4 Research Objectives 11
1.5 Research Design and Methodology 12
1.6 Utility 12
CHAPTER 2. Literature review 13
Introduction 13
2.1 Childhood Malnutrition definition and the health implication 13
2.1.1 Global Statistics 15
2.2 Global Nutritional Policy Chronology 16
2.3 Global nutrition report 2020: Nutrition through inequity lens 18 2.4 UNICEF Maternal and Child Malnutrition Conceptual Framework 20
2.5 Nurturing Care Framework; linkage to nutrition 21
2.6 Child Nutrition in Ethiopia 24
2.7 Child Nutrition in Malawi 26
2.8 Child Nutrition in Tanzania 28
CHAPTER 3: Methodology 31
Introduction 31
3.1 Theoretical framework 31
3.1.1 Socio-Ecological Model 31
3.1.2 The Health Belief Model 32
3.2 Research Approach and design 35
3.3 Research method 35
3.4 Search strategy 36
3.5 Inclusion and exclusion criteria 36
3.6 Analysis 38
3.7 Ethics 39
3.8 Limitation 39
Introduction 40
4.1 Infant and Young Child Feeding 40
4.1.1 Breastfeeding 40
4.1.2 Complementary feeding 46
4.2 Health Belief Model of childhood undernutrition 50
4.2.1 Concept of childhood undernutrition 50
4.2.2 Perceived cause of child malnutrition 53
4.2.3 Health seeking behaviour 55
4.3 Postpartum Sexual Abstinence 59
4.4 Parenthood 67
CHAPTER 5. Discussion and Conclusion 70
5.1 Discussion 70
5.1.1 Cultural practice that generates stigmatisation 70
5.1.2 ‘Are we talking the same language?’ 71
5.1.3 ‘It takes a village to raise a child’ 72
5.2 Conclusion 73
LIST OF ACRONYMS
AARR Average Annual Rate of Reduction
ASF Animal Source Food
COVID 19 CoronaVirus Disease 2019
CMAM Community-based Management of Acute Malnutrition
ECD Early Childhood Development
EMDHS 2019 Ethiopia’s Mini Demographic and Health Survey 2019
EOTC Ethiopian Orthodox Tewahedo Church
FGD Focus Group Discussion
GAM Global Acute Malnutrition
GMP Growth Monitoring Programme
GNR Global Nutrition Report
HBM Health Belief Model
HEW Health Extension Worker
HIV/AIDS Human Immunodeficiency Virus
/Acquired Immune Deficiency Syndrome
IDI In-Depth Interview
IMAM Integrated Management of Acute Malnutrition
IYCF Infant and Young Child Feeding
KII Key Informant Interview
LBW Low Birth Weight
DHS Malawi Demographic Health Surveys 2004-2015
MUAC Middle-Upper Arm Circumferences
MAM Moderate Acute Malnutrition
NGOs Non Governmental Organizations
NCF Nurturing Care Framework
NCDs Non-Communicable Diseases
RUTF Ready to Use Therapeutic Food
SUN Scaling Up Nutrition
NNP2 Second National Nutrition Programme (2016/2020)
SAM Severe Acute Malnutrition
SBCC Social Behaviour Change Communication
SEM Socio-Ecological Model
SSA Sub-Saharan Africa
SDGs Sustainable Development Goals
UNICEF United Nations International Children’s Emergency Fund
SCN United Nation Standing Committee on Nutrition
UHC Universal Health Coverage
WASH Water, Sanitation and Hygiene
CHAPTER 1. Introduction
1.1 Background
In 2016, the United Nations General Assembly declared ‘2016-2025; Decade of Action on Nutrition’, as part of the UN Sustainable Development Goals (SDGs) (Baker et al., 2018; Agegnehu et al., 2019). It is a commitment by the UN Member States to take responsibilities of tackling all forms of malnutrition through coherent and sustainable policy, interventions and investments (Ibid). The World Health Organization (WHO) defines ‘Malnutrition’ as deficiencies, excesses, or imbalance of an individual’s intake of
the nutrient and energy (WHO:
https://www.who.int/news-room/fact-sheets/detail/malnutrition). It includes the conditions of undernutrition; wasting, stunting, underweight, obesity, diet-related non-communicable diseases (NCDs) and micronutrient deficiencies (Ibid). Due to the rapid transition of food consumption, supply, food and health policy, and lifestyle for the recent years, the global agenda of malnutrition has become more complexed to address the ‘Triple burden of Malnutrition; Undernutrition, Obesity and NCDs, Micronutrient deficiencies’ (Development Initiatives Poverty Research Ltd, 2020a, p.51).
Persistently, malnutrition is one of the leading causes of global death and disability (Verhagen et al., 2005; Baker et al., 2018). Lately published Global Nutrition Report (GNR) highlights the inequity as a root-cause of malnutrition and its consequence at the same time, calling for collective action towards ‘Nutritional Well-being for all’, ensuring the nutritional health of the most vulnerable communities especially where the poverty and conflict are chronic (Development Initiatives Poverty Research Ltd, 2020a, p.10).
Childhood undernutrition, among other nutritional challenges, continues to impact child growth, cognitive and physical development and survival. It is accountable for at least 35% of global child mortality (Abeway et al., 2018). The GNR stated, in the year 2018, 149 million children under five were stunted, 49.5 million (7.3%) of them were wasted, and 40.1 million (5.9%) of children under five were overweight. Especially in Low Middle-Income Countries, around 43% of children under five are at risk of not reaching
their full developmental potential due to childhood undernutrition (Richter et al., 2018; Bernard Van Leer Foundation, 2019). Childhood undernutrition is precipitated from intersectoral and multilevel factors that perpetuate a vicious circle of inequity (Ibid). In 1990, UNICEF developed a conceptual framework of the determinants of childhood and maternal malnutrition, categorising the contributing factors of malnutrition into immediate, underlying and basic causes (Black et al., 2020). The Conceptual Framework amplifies the complexity of the intersectoral nature of childhood undernutrition, and therefore, the importance of multi-sectoral intervention approach in addressing childhood undernutrition has been emphasised (Ibid). Over the past 30 years, the framework has been a driving force of policies, programmes and researches that were contributing to the reduction of all forms of childhood malnutrition (Ibid) which led to Integrated programmes of Nutrition-Specific interventions, that are addressing the availability, accessibility and acceptability of nutrient and food, andNutrition-Sensitive interventions, that aims to tackle extended societal factors that affect nutritional statuses such as access to sanitation and water, hygiene practice, income and livelihood, gender inequity in a household (Ruel et al., 2013, cited in Black and Dewey., 2014). Acknowledging the fact that nutrition plays a critical role in Early Childhood Development (ECD), especially the first 1,000 days; from conception to the first two years after birth, WHO introduced the Nurturing Care Framework (NCF) that comprises five components of Good Health, Adequate Nutrition, Safety and Security, Responsive Caregiving and Opportunity for Early Learnings (WHO et al., 2018). Furthermore, it is shown that effective interventions early in life can contribute to reducing inequities hence increasing the chance to reach their full developmental potential (Black et al., 2014).
1.2 Problem Statement
Robust researches were conducted to identify determinants and contributing factors of childhood undernutrition for effective interventions. While many of the investigations are focused on quantitative data collection and analysis, there are minimal numbers of researches conducted for qualitative data (Development Initiatives Poverty Research Ltd,
2020a). However, in recent studies, there is increasing recognition of the importance of understanding the childhood undernutrition context to achieve sustainable nutritional impact (Abubaker et al., 2011; Bazzano et al. 2016; de Groot et al., 2017; Development Initiatives Poverty Research Ltd, 2020a). Bazzano et al. (2016) argue that context-appropriate behavioural and psychosocial information is essential for a successful and effective nutrition programme. Furthermore, qualitative research provides information on the childhood undernutrition root causes, and it brings the voice of affected people to the front of nutrition policy and interventions (OCHA, 2019; Development Initiatives Poverty Research Ltd, 2020a).
Among other elements that a child interacts throughout his or her life course, family, especially the caregivers, plays the central role that impacts child development and early experience as they are the immediate and primary environment of child development (Black and Dewey, 2014). Caregivers’ beliefs and local culture of childhood nutrition shape children’s food acceptance and feeding practice (Ibid). In a resource-scarce setting where access to quality health service is limited, caregivers’ role in childhood development and child illness management becomes more critical than in a context where health service is easily accessible. A recent study shows that parental perception of child obesity and nutrition has changed among the refugee families who have migrated to the United States from Sub Saharan African (SSA) countries due to the consistent nutritional advice from the health professionals (Dawson-Hahn E et al., 2020).
Majority of the current literature studying caregivers’ perception of child nutrition is focused on childhood obesity, and it lacks in childhood undernutrition studies. Despite the significant reduction in childhood undernutrition prevalence, stunting and wasting, in recent years, Ethiopia is still accountable for the most substantial burden of childhood malnutrition in the Africa continent ( Ministry of Finance and UNICEF Ethiopia, 2019). In 2019, the prevalence rate of chronic malnutrition, stunting, among children aged under five was 37%, and the wasting rate was 7% (Ibid). The Ministry of Health has launched an inter-ministerial National Food and Nutrition Policy, highlighting nutrition-specific and
nutrition-sensitive interventions. Yet the progress is considerably slow to meet the Nutrition target 2030.
Malawi has significantly improved compared to other countries, although the burden of childhood undernutrition is still a challenge ( Development Initiatives Poverty Research Ltd, 2020a). Nearly 1.1 million (37.1 per cent) children in Malawi are stunted as of 2015. Wasting prevalence is 2.8 per cent, which is relatively low compared to other developing countries. Challenges around optimal child feeding practice are prevalent in Malawi, where only 7.8 per cent of children aged 6 -23 months are fed to meet the minimum acceptable dietary requirements.
Similarly, in Tanzania, stunting prevalence is higher than the average of developing countries, as it is 34.5 per cent. The GNR examines the progress of nutritional statues in Tanzania as inadequate to meet the 2030 nutrition targets. Child feeding practice is also identified as one of the significant causes of childhood undernourishment, and therefore the state is establishing community grounded structure that can oversee nutritional progress, endorsing Integrated Community based Management of Acute Malnutrition (CMAM).
1.3 Research Question
The guiding question of this research is :
What is the caregivers’ health belief model of Child Nutrition, and how does it influence their health-seeking behaviour in Subsaharan Countries; Ethiopia, Malawi, and Tanzania?
The sub-questions are:
1) What is the caregivers’ health belief model (HBM) of childhood nutrition and feeding practice: exclusive breastfeeding, complementary feeding
2) What is the caregivers’ perception and attitude of childhood undernutrition, particularly wasting, stunting, and kwashiorkor
3) What are the caregivers’ health-seeking behaviour in childhood nutrition
4) What are the underlying factors that shape the caregivers’ perception of child nutrition: cultural element, religious practice
5) What is the implication of nutrition interventions correlated to the context of childhood undernutrition particularly in relation to the caregivers’ HBM
6) How caregivers’ HBM and health-seeking behaviour in child nutrition and growth differ or similar in Ethiopia, Malawi and Tanzania
1.4 Research Objectives
The overall objective of the research is to understand the parental, and caregivers’, HBM of child nutrition and its impact on their health-seeking behaviour of child undernutrition in addition to the following:
1) To understand the caregivers’ HBM of child nutrition in Ethiopia, Malawi and Tanzania.
2) To explore how caregivers’ HBM of child nutrition influences their health-seeking behaviour in child undernutrition.
3) To examine the implication of the NCF in relation to the context of child nutrition and growth.
4) To develop a set of qualitative evidence of the childhood undernutrition context. The specific objectives are:
a. Analyse caregivers’ perception of child nutrition in HBM: perceived susceptibility, severity, benefits and barriers.
b. Explore socio-ecological factors that structure caregivers’ perception, attitude, and practice of child nutrition and growth.
c. Understand the underlying reasoning of caregivers’ HBM and their health-seeking behaviour in child nutrition and growth
d. Identify similarities and differences of caregivers’ HBM of child nutrition among three different contexts; Ethiopia, Malawi and Tanzania.
1.5 Research Design and Methodology
The qualitative research approach is applied to ensure in-depth and contextual understanding of child undernutrition. It is comparative research that questions the caregivers' HBM of childhood nutrition in three different contexts of Ethiopia, Malawi, and Tanzania. The synthesis is carried out without a specific hypothesis. Data is extracted from existing qualitative studies in the topic regarded, then systematically synthesised based on the themes arising during the analysis. The socio-ecological framework and the HBM are the grounded theory of the research approach. Therefore, the focus is given to understanding the caregiver’s HBM, how it is translated into particular health-seeking behaviour, and what are the socio-ecological factors that influence caregivers’ HBM. Contextual analysis is applied to have a thorough understanding of the dynamic environmental factors that construct and influence the caregivers’ HBM and their health-seeking behaviours.
1.6 Utility
Studies highlight that caregiver’s capacity in identifying a child’s undernourishment and illness for timely response is critical, that is directly affecting childhood morbidity and mortality, particularly in resource-limited settings (Development Initiatives Poverty Research Ltd, 2020a). Therefore, it is crucial to understand how caregivers perceive child feeding, caring and illness management. The role of contextual, cultural, environmental, and structural factors that influence, particularly in dietary behaviours, is increasingly recognised (Powell et al., 2017). Thus analysing contextual factors of caregivers’ health belief model will provide qualitative evidence that can guide a practical approach to empower the caregivers to increase the demands on better health and nutrition services. Furthermore, the findings from this research can inform policymakers in developing contextualised nutritional interventions and policies that tackle the root causes of childhood undernutrition context and therefore seeking for sustainable social behaviour change.
CHAPTER 2. Literature review
Introduction
In this chapter, the definition of childhood malnutrition, health and the developmental implication that it has is elaborated. Global statistics to have a glance at the current nutritional status of children, and the policy trends are described. The significant global nutrition agendas are further analysed by looking into the GNR, UNICEF Maternal and Childhood Malnutrition Conceptual Framework and the emerging trend of Nurturing Care Framework in the nutrition sector. Lastly, the national statistics and policy implementation of each country, Ethiopia, Malawi and Tanzania, is researched.
2.1 Childhood Malnutrition definition and the health implication
The WHO definition of malnutrition is an atypical physical condition that is caused by insufficient, unbalanced, inadequate and excessive nutrition intake (Baker et al., 2018). The concept covers two groups of terms; first is undernutrition that consists of chronic malnutrition, stunting, acute and severe undernutrition, wasting, underweight, and micronutrient deficiencies. Another group is conditions that are caused by overnutrition, such as for overweight, obesity, diet-related NCDs including heart diseases, diabetes, strokes and cancers (Development Initiatives Poverty Research Ltd, 2020a). The WHO characterises malnutrition as it takes many different forms as mentioned above, and it is ubiquitous since it is well known that malnutrition exists everywhere, and in all case, more than one type of malnutrition coexists, so-called ‘double and triple burden of malnutrition’, and it has immediate, lifelong and intergenerational consequences affecting individuals, families, communities and the nations to the further extent (WHO, 2019). Particularly childhood malnutrition, compared to the malnutrition among adults, is associated with early mortality (Flax et al., 2016), accounting for 35 per cent of child mortality (Desalegn et al., 2016; cited in Abeway, 2018). Furthermore, childhood malnourishment can result in disabilities, poverty in later life, delayed or impaired development (Baker et al., 2018). The chronic undernutrition or malnutrition during the early years in life when development and
growth are rapid hence adequate nutrition intake is critical leads to stunting, that is short stature, below minus two standard deviations (-2SD) height-for-age z-score from the median of the WHO’s child growth standard, children who are below minus three standard deviations (-3SD) are considered as severely stunted (Abeway et al., 2018). Oftentimes, stunting is referring to those children who are too short for their age. However, recent studies argue that ‘stunting’ is the best indicator that reflects childhood well being in general. Moreover, it is acknowledged that linear growth indicator marks social inequities at a certain level (Onis and Branca, 2016; UNICEF, 2019). Stunting, in particular, has a long term impact than acute malnutrition, including delayed physical and cognitive development, fewer years in school, reduced performance at school and work, lower-income and therefore higher risk of poverty, greater risk of chronic disease in adulthood (Black and Dewey, 2014; Flax et al., 2016; Onis and Branca, 2016; Baker et al., 2018). Furthermore, a study suggests that stunted children are less likely to interact with caregivers than those who are nourished well (Onis and Branca, 2016). It is also associated with more significant morbidity and mortality risk due to infectious disease such as diarrhoea and malaria (Ibid).
Wasting is a form of acute malnutrition that refers to a child who is too thin for his or her stature when a child is below minus two standard deviations (-2SD) from median weight-for-height z-score according to the WHO reference population. When a child is below minus three standard deviations (-3SD), she or he is regarded as severely wasted. Wasting is a consequence of acute and recent loss of weight, often due to the severely inadequate nutritional intake and, or because of frequent incidence of disease or prolonged child illness (UNICEF, 2019; Islam et al., 2020). Wasting prevalence can be varying, reflecting the seasonal availability of food and nutrition, in addition to malaria, diarrhoea disease patterns (Ibid). Acute malnutrition is further categorised into Moderate Acute Malnutrition (MAM), Severe Acute Malnutrition (SAM), and Global Acute Malnutrition (GAM). It is measured by weight-for-height z-score but also by the middle-upper arm circumferences (MUAC) (Tashome, 2019). A child with MAM can be identified when his or her MUAC is below 125mm, above 115mm or when his or her weight-for-height z-score
is between minus two standard deviations (-2SD) and minus three standard deviations (-3SD). When MUAC is below 110mm, either first or second-degree two-sided pitting oedema is observed, or a child’s weight-for-height z-score is below minus three standard deviations (-3SD), a child is identified as suffering from SAM, known as Marasmus. On the other hand, when a child's weight-for-height z-score is above minus three standard deviations (-3SD) and MUAC is higher than 115mm, but symptoms of oedema are detected, a child is identified as Kwashiorkor (Ndozo and Jackson, 2018). GAM is often referred to as wasting, although its technical term indicates children with symptoms of wasting and bilateral pitting oedema (Development Initiatives Poverty Research Ltd, 2020a). Wasting and severe acute malnutrition can lead to suboptimal brain development. Furthermore, it contributes to child mortality. A study shows that wasted children can have five to twenty times higher risk of child death and mortality compared to those who are in good health (Black et al., 2013; Teshome et al., 2019). Furthermore, lack of timely and adequate interventions and treatment of SAM can result in impaired brain and physical development or often developmental delay of the child that impacts throughout the life course of the affected child (Development Initiatives Poverty Research Ltd, 2020a). Therefore, proper management of SAM cases can contribute to reducing child mortality, hence improving SAM case treatment and management is recognised as one of the top 10 most effective nutritional interventions (Ibid).
2.1.1 Global Statistics
Persistently malnutrition is one of the major issues that threatens far too many people’s lives. According to the 2020 GNR ( Development Initiatives Poverty Research Ltd, 2020a), one in every nine people, 820 million, are living in hunger in the world. Conversely, one in every three, is either obsessed or overweight. In most of the places, the double burden of malnutrition prevails where undernutrition and overnutrition coexist, and a recent study argues that malnutrition affects every country in the world (Baker et al., 2018) which is in line with the fact that at least one form of malnutrition is found in all 143 countries where data was collected (Development Initiatives Poverty Research Ltd, 2020a). However, the number of people who are undernourished is increasing since 2015, particularly in Africa,
West Asia and Latin America (Ibid). Among them, 113 million people are experiencing acute hunger due to climate shocks, conflict, and food insecurities, while others are suffering from chronic hunger, and food shortage (Ibid).
Globally, less than a quarter of children under five are stunted in the year 2018, 149 million children (21.9%), 49.5 million (7.3%) children are wasted, and 40.1 million (5.9%) of children under five are overweight. Particularly in Low Middle-Income Countries, around 43% of children under five are at risk of not reaching their full developmental potential due to childhood undernutrition (Black et al. 2017; cited in Richter et al., 2018, Bernard Van Leer Foundation, 2019; Development Initiatives Poverty Research Ltd, 2020a). Affordable and accessible health care is vital to address developmental inequities, as only one in four children aged under five with severe acute malnutrition received proper medical support in 2017 (Development Initiatives Poverty Research Ltd, 2020a). It reflects that most childhood malnutrition disproportionately affects low and middle-income countries, including fragile, conflict-prone nations (Richter et al., 2018). Moreover, the report highlights that nutritional inequality within countries and therefore understanding the context of malnutrition is essential for effective nutritional interventions ( Development Initiatives Poverty Research Ltd, 2020a).
In SSA, 33 per cent of children under five-year-old are stunted, and the figure is higher in Eastern and Southern Africa as it is 34 per cent. Wasting prevalence among under-five-year-old children is 8 per cent in SSA, and 6 per cent in Eastern and Southern Africa region (UNICEF, 2019).
2.2 Global Nutritional Policy Chronology
Malnutrition affects every one person in three across all countries, leaving no nation untouched (Baker et al., 2018). The nutritional challenges have become more complex as people’s lifestyle and food system changes rapidly over the last few decades (WHO, 2019). In response to that, the global nutrition agenda has been broadened to address the altering nutritional needs. The United Nation Standing Committee on Nutrition (SCN) was inaugurated in 1977, expanded from the United Nation’s Protein Advisory Group, which was leading the discussion around reducing the undernutrition (Guled et al., 2016). Since
the establishment, the SCN plays a role of the focal point of the global nutrition agenda throughout the UN system, coordinating the nutrition policies and strategies (Mokoro, 2015). In the 1980s to the ’90s, nutrition agendas focusing on micronutrient deficiency and breastfeeding were dominantly promoted (Nisbett et al., 2014). In 1992, the First International Conference on Nutrition was held, adopting the World Declaration on Nutrition. The declaration articulates the elimination of hunger and reduction of all forms of malnutrition (Ibid). In 1996, the Rome Declaration was adopted during the World Food Summit which sets the aim of food security for all, and the member states pledged in halving the number of undernourished population by 2015 (Ibid). At this time, nutrition issues that are not particularly medical were put on the table for discussion, with the emergence of the community-led nutrition interventions (Ibid). In 2008, the Lancet Series on Maternal and Child Nutrition published the systematic evidence of the longstanding impact of undernutrition on infancy, including child mortality. It demonstrates the critical period of child development and survival from the conception to the first 24 months of life, the first 1,000 days (Britto et al., 2017). The World Summit on Food Security in the following year introduced the Five Rome Principles for the Sustainable Global Food Security; (1) country-led intervention support; (2) endeavour comprehensive approaches; (3) effective coordination of programmes; (4) enhance multilateral cooperation; (5) and encourage more investment on food and agriculture security. In 2010, April, The Scaling Up Nutrition (SUN) Framework was endorsed by more than 100 international institutions across diverse sectors and a month later at the Rome Nutrition Forum, and it was further conceptualised, assembled thematic groups of five; capacity building; advocacy; civil society; donors; business. Currently, the SUN movement covers sixty-one countries across Asia, Middle-East, Africa and Latine America (Mokoro, 2015). At the sixty-fourth, World Health Assembly, in 2012, global nutrition target of; 40% childhood stunting reduction; 50% reduction of anaemia among reproductive-aged women; 30% reduction of low birth weight; 0% increase in childhood overweight; 50% increase of exclusive breastfeeding; reduction of child wasting rate to less than 5% were set (Ibid). At the Rio conference on Sustainable Development, the ‘Zero Hunger Challenge’ was launched upholding the food
security for all, and to build the resilient food system. In 2014, at the Second International Conference on Nutrition, the Rome Declaration was revised, incorporating the emerging challenges of diet-related NCDs and obesity, therefore, to tackle the double burden of malnutrition (Nisbett et al., 2014). The declaration of the UN Decade of nutrition 2016-2025 reaffirms the global commitment to tackle malnutrition in its all forms, accelerating the multi-sectoral, multi-level approach in nutrition interventions (Baker et al., 2018).
Figure 1. Nutritional Global Agenda Chronology (Adapted from Gillespie et al., 2003) Protein focused
to Multi-sectoral approach
Back to Nutrition Focus
Micronutrient Global Priority 1,000 days Momentum 1970 1980 1990 2000 2010- Standing Committee on Nutrition (SCN) Breastfeeding campaign Rome Declaration MDG1 Lancet Nutrition Series(2008) SUN Movement Lancet Nutrition Series(2013) Zero Hunger
2.3 Global nutrition report 2020: Nutrition through inequity lens
Amid COVID 19 pandemic, The GNR 2020, released on May 12th 2020. The GNR has been published since 2014 after the 2013 Nutrition for Growth Summit, in order to follow up the global movement of improving nutrition status. Since then, the report is one of the world’s leading high quality and comprehensive nutrition data sets overseeing the progress of nutrition agenda, that aims to meet the nutrition target of ending all forms of malnutrition by 2025 (Development Initiatives Poverty Research Ltd., 2020a). The GNR 2020 elaborates the current nutrition status of the world, analysing the progress made by regions to meet the 2025 targets, and examining major nutrition agendas. In 2020 report, it is highlighted that nutrition agenda has been put on the front amid world pandemic of COVID 19 circumstances, since the virus disproportionately affected the most vulnerable communities where nutritional status is poor, and so does other social factors such as
income, education, access to health service, safe water and sanitation facilities. In particular, food security ‘hot-spots’ such as conflict-affected regions, fragile states, countries that are affected by climate change crisis are at higher risk of marginalisation (Johnsen et al., 2020). Therefore, the nutrition agenda should be further prioritised to achieve ‘nutrition well being for all’ with consideration on the most vulnerable communities. The report is emphasising the ethical dimension of malnutrition, focusing on analysing food systems and structures that are not adequately functioning to provide universal and equal access to adequate food and nutrition for all. This underpins the ground principle of universality and nutrition security for all as human rights (de Castro, 2019). It reflects the shifting nutrition agenda from focusing on understanding the different nutrition outcomes as inequality to recognising the food system that encompasses production, distribution and consumption, further extending to social factors that influence those elements (or process) that generates an uneven distribution of food and nutrition (Nisbett, 2019). It mirrors the new analysis of different nutrition status within the country as stunting and wasting are more prevalent among the poorest while the overweight rate is higher among the richest (Development Initiatives Poverty Research Ltd, 2020a). The report advocates for the further investment in nutrition, especially places where the double burden of undernutrition and overnutrition are prevalent, to establish equitable, resilient and durable food and health system, to enhance collaborative efforts across sectors and fields to overcome barriers in ending malnutrition and lastly, to leverage crucial moments for strengthening nutrition commitments and accountability (Johnsen et al., 2020).
The report encourages nutrition actors to see the nutritional status through ‘equity’ lens, promoting ‘equity-sensitive’ nutrition actions, including collecting and analysing qualitative data to understand the root causes of inequalities ( Development Initiatives Poverty Research Ltd, 2020a). Furthermore, the multisectoral approach where nutrition agenda is mainstreamed especially in health sectors by integrating nutrition interventions into Universal Health Coverage (UHC) is suggested as an efficient and cost-effective way to have synergies to reach better health outcomes for all (Ibid).
Emphasis on understanding and reducing inequity that includes health and nutrition is based on the core value of a human rights-based approach that the humanitarian aid field should pursue. To quote the 2020 GNR (Development Initiatives Poverty Research Ltd, 2020a), ‘Optimal health and wellbeing is a human right not the privilege of only those who can afford to pay.’ stresses the altering paradigm of realising the global malnutrition agendas.
2.4 UNICEF Maternal and Child Malnutrition Conceptual Framework
In 1990, when lack of shared understanding about what causes childhood undernutrition was a great challenge among nutrition partners and communities (Levitt et al., 2009), UNICEF introduced the conceptual framework of the determinants of childhood and maternal undernutrition, to enhance systematic understanding of the causes of undernutrition (Ibid). The Conceptual Framework categorises undernutrition causes into three levels; (1) Societal level: basic determinants such as poverty and nutrition policy; (2) Household and Community level: underlying determinants including access to health service and WASH facilities, food security and care practices; and (3) Individual level: immediate causes of nutrient intake and immunity (Haisma et al., 2018; Nisbett, 2019). Over the past 30 years, the framework has played its role as a critical reference of researches and policy development as well as programmes implementation that are contributing to the reduction of all forms of childhood malnutrition (Nisbett, 2019; Black et al., 2020), for instance, a conceptual framework of childhood stunting that is developed by WHO is also based on UNICEF's childhood undernutrition framework. Furthermore, Levitt et al. (2009) argue that the framework can be adapted to diverse contexts to address more than 250 issues around food and nutrition (Ibid). The framework outlines the complexity of the interrelated nature of childhood undernutrition causes, and therefore the importance of a comprehensive multi-sectoral intervention approach in addressing childhood undernutrition is recognised as critical (Nisbett et al., 2014). It led to the emergence of Integrated programmes of Nutrition-Specific interventions, that are addressing the availability, accessibility and acceptability of nutrient and food, and Nutrition-Sensitive interventions, that aims to tackle extended societal factors that affect nutritional statuses such as access to
sanitation and water, hygiene practice, income and livelihood, gender inequity in a household (Ruel et al., 2013, cited in Black and Dewey, 2014).
As the framework has served a key role in understanding and guiding childhood nutrition interventions for the last few decades, there are various perspectives that suggest to rethink and re-form the framework, translating contemporary nutrition agendas and knowledge, and therefore enhance its relevance up to date. Haisma et al. (2018) argue that the current approach of nutritional interventions, including the framework, need to be revisited. The study emphasises the importance of taking the contextual diversities into account, recognising the societal, structural inequities. Furthermore, it underlines the constructive approach of how the socio-cultural context influences on defining the notion of ‘child growth’ and ‘child care behaviours’ (Ibid). In 2019, UNICEF published the State of the World’s Children report introducing a revised version of the framework (Annex 2). The new version of the framework uses positive narrative, articulating enabling factors of proper nutrition, including adequate diet and care for children, equity in the food environment and access to health services, and the political commitment towards good governance and positive social norms (Ibid). It emphasises that each of the determinants of proper childhood nutrition are the windows of opportunities to improve childhood nutrition. In the latest journal of Black et al. (2020), the authors argue for a revision of the framework reflecting the current knowledge and priorities in childhood health and development. As the SDGs has broadened the agenda of children surviving into children surviving and thriving, more attention is required to not only health and nutrition but also security and safety, responsive caregiving, and learning opportunities (Ibid). The journal is echoing the recent development and introduction of the NCF, which represents a comprehensive, multisectoral system for childhood thriving beyond the agenda of a childhood surviving.
2.5 Nurturing Care Framework; linkage to nutrition
It is widely recognised that investment in early childhood is one of the best ways to promote economic development and an inclusive society. The NCF builds on the state of the art groundwork about how ECD can be improved through appropriate policies and interventions in place (Smith et al., 2018; WHO et al., 2018). The ‘Nurturing Care’ is
defined as a balanced environment that is responsive to children’s needs on nutrition and health while protecting them from threats and providing early learning opportunities, responsive interactions, emotional support and age and developmentally appropriate stimulations (Britto et al., 2017). The concept of NCF drew attention from global society through the 2017 Lancet series,Advancing Early Childhood Development: From Science to Scale (Richter et al., 2018; Black et al., 2020). In the series, it is promoted as an essential initiative that reinforces the multidimensional ECD corporations across sectors that can assist families and young children from low-and middle-income countries (Black et al., 2017; Britto et al., 2017; Richer et al., 2018). Later in 2018 May, at the 71st World Health Assembly, UNICEF, WHO, and the World Bank officially launched the framework. The framework outlines its core components and principles through a whole-of-government and a whole-of-society approach that encompass multi-level, and multi-sectoral interventions offering a holistic perspective of understanding dynamic factors around ECD (Richter et al., 2018; WHO et al., 2018). The NCF consists of interrelated core components, which are Good Health, Adequate Nutrition, Responsive caregiving, Security and Safety, and Opportunity for Early Learning which are essential factors for the children to develop to their full potential (Britto et al., 2017; WHO et al., 2018). Although most of the time ECD refers to children aged from 0 to 8 years old, in the Nurturing Care context, it emphasises the period from conception to the first three years of child’s life as it is scientifically proven time of active brain development hence it is one of the most critical developmental stages throughout the life course (Black and Dewey, 2014; Smith et al., 2018). During this period of time, nutrition is a significant factor that influences children's development, since the nutritional need is high due to the rapid neurodevelopment that requires a lot of energy to consume (Ibid). Black and Dewey (2014) argue that ensuring health, nutrition and development during infanthood and early childhood can significantly promote equity. Furthermore, they suggest that ECD integrated into nutrition interventions offer an effective reduction in inequities later in life (WHO, 2012; Engle and Tamburlini, 2013 cited in Black and Dewey, 2014). In the framework, the core concept of nurturing care integrates into health and nutrition sector through five major activities, a) to ensure affordable quality
health and nutrition service for women and young children inline with the UHC, b) disseminate messages of responsive caregiving, the importance of caregiver’s mental health, early learning opportunities and stimulation throughout maternal child health systems including antenatal visits, postnatal cares, and child visits. c) Enhance home visits for the most vulnerable households that the risk of suboptimal child care, maltreatment and malnutrition is greater, d) introduce specialised services for families with special needs of disabilities or developmental difficulties, e) collaborate across sectors to provide comprehensive nurturing care environments (Britto et al., 2017).
The caregiving context has a significant role in the early life of children for their protection and socialisation (Black and Dewey, 2014). As the framework focuses on the first years of childhood, the immediate home environment is acknowledged as the primary care setting that is the most critical context to understand (Britto et al., 2017; Black et al., 2020). The framework also highlights creating an enabling environment to enhance capabilities of the caregivers is important, since early age children’s health and development is critically dependent on caregiver’s health and capacity to provide adequate and responsive care (WHO et al., 2018; Britto et al., 2017). Family-centred, community-based approaches are suggested in the framework which enhances social accountability and awareness of ECD (Ibid). In addition, it is explicitly critical to support caregivers in fragile contexts such as in humanitarian settings, to improve parental mental health, responsive care practice, knowledge of child-rearing, attitude and belief (Britto et al., 2017; Richter et al., 2018; WHO et al., 2018). Britto et al. (2017) elaborate the framework as a ‘two-generation package’ since emphasis goes to the promoting caregivers’ well being and health at the same time empowering their capability to provide nurturing care to their child (WHO et al., 2018).
The NCF has gained its momentum, and the country profile data set under the framework has expanded from addressing 91 countries to 138 countries (Longhurst, 2010). Operationalising the framework, putting the health, child well being and development at the core to strengthen the integration of critical components requires strong commitment and cooperation throughout diverse communities, sectors and different levels of government.
2.6 Child Nutrition in Ethiopia
Despite rapid economic growth and the significant reduction of poverty rate from 45.5% in 1995/1996 to 23.5% in 2015/2016, nearly 24 million people are still living in absolute poverty of below $1.90 (Ministry of Finance and UNICEF Ethiopia, 2019). Furthermore, it is alarming that almost 9 out of every ten children are suffering from multidimensional deprivation (Ibid). While the agenda of child survival has improved considerably as1 under-five child mortality rate has been decreased from 123 per 1,000 live births in 2005 to 55 per 1,000 live births in 2019 (Ibid), child undernutrition persistently affects far too many children in Ethiopia. According to Ethiopia’s Mini Demographic and Health Survey 2019 (Ethiopian Public Health Institute and ICF, 2019), the national chronic malnutrition, stunting, prevalence rate among under-five-year-old children is 37 per cent, accounting for 5.6 million, which is the biggest burden of stunting in the world (Ibid). It is more significant than both of the average prevalence of African continent, 33 per cent, and 34 per cent of East Africa regional prevalence rate (USAID, 2018a; UNICEF, 2019). The progress of reduction has been stagnated, considering the fact that stunting prevalence rate was 38 per cent in 2016 (Ibid). Childhood wasting rate was 7 per cent in 2019 (Ethiopian Public Health Institute and ICF, 2019), declined from 10 per cent in 2016, yet, it is greater than the East Africa average wasting rate of 6 per cent. As analysed in the GNR 2020, the country is off-track to meet the 2025 nutrition targets since the current average annual rate of reduction (AARR) in stunting is 1.89 per cent while required AARR is 4.84 per cent to meet the goal of 22.6 per cent of stunted children (Development Initiatives Poverty Research Ltd, 2020b).
Vigorous researches were carried out to investigate the determinants of childhood undernutrition, therefore, to inform the policymakers and programme designers to implement effective nutrition interventions. In overall, researches conducted in Ethiopia found that children with less diversified dietary intake, who were not exclusively breastfed
1 Multidimensional Child Deprivation(MCD): Childhood deprivation in three out of six major domains for
children’s basic right and need for development; (1)Development/Stunting;(2)Nutrition; (3)Health; (4)Water;(5)Sanitation and (6)Housing_UNICEF 2018 Multi-dimensional Child Deprivation in Ethiopia
for the first six months are at a greater risk of stunted growth (Abate and Belachew, 2017). Moreover, among children residing in rural areas, whose mothers did not have formal education, boys, who are fed less than optimal meal frequency, and children in the two lowest wealth quintiles show higher stunting and wasting prevalence rate compared to their counterparts (Abate and Belachew, 2017; Abeway et al., 2018; Ministry of Finance and UNICEF Ethiopia, 2019). On the other hand, the wasting rate is higher among children aged 0 to 24 months old, while the stunting rate is higher between 24 to 59 months old (Development Initiatives Poverty Research Ltd, 2020). Abate and Belachew (2017) argue that the primary cause of childhood undernutrition in Ethiopia is related to suboptimal caring practices which are reflected in the EMDHS 2016 as only 58 per cent of under six months old children are exclusively breastfed and 7 per cent of children aged between 6 to 23 months meet minimum acceptable dietary requirements. As a result, childhood malnutrition, especially undernutrition in this context, is responsible for 57 per cent of child death in Ethiopia (Abeway et al. 2018).
Ethiopia has consistently experienced cycles of drought, famine through its history, and therefore undernutrition remains as a persistent challenge (Walls et al., 2019). Consequently, the national nutrition policy has been much focused on acute and emergency nutritional response. However, in recent years the national nutrition policy agenda has shifted to not only addressing emergency food insecurities but also to address chronic undernutrition issues by emphasising multi-sectoral approaches (Ibid). In 2015, the Ethiopia government launched a nation-wide commitment to end child undernutrition by 2030 known as the Seqota Declaration (Abate and Belachew 2019). Through the Declaration, the government established the National Nutrition Coordination Body that oversees multi-sectoral integrated nutrition policy and strategies, and the National Nutrition Technical Committee to direct technical decision making (USAID, 2018a). The country is also a member state of the SUN Movement that is a global coalition of 55 countries leading the well-being of childhood development and growth (Ibid). Currently, in Ethiopia, The Second National Nutrition Programme (NNP2 2016/2020) plays a significant role in guiding cohesive nutrition interventions across the nation. It highlights strategies of
focusing on the first 1,000 days, as it is the most crucial period of human development, and promoting multi-sectoral coordination of nutrition interventions, reflecting the multifaceted nature of the nutrition issues (Federal Democratic Republic of Ethiopia, 2016). The recent UNICEF report on situation analysis of women and children in Ethiopia suggests that ‘the whole-system’ approach in addressing determinants and contributing factors of undernutrition is necessary and to adapt the approach into current nutrition policies, it is critical to understand deeply-rooted socio-cultural belief, norms and practices of child-caring practices (Ministry of Finance and UNICEF Ethiopia, 2019). This is echoing the NNP2 where identifying cultural and social barriers to the optimal child feeding practices is prioritised in a context of promoting optimal child-rearing practices including feeding practices is being recognised as a crucial element of tackling childhood undernutrition in Ethiopia (Abate and Belachew 2019).
2.7 Child Nutrition in Malawi
Malawi is highly dependent on agriculture as 80 per cent of the population are small-scale farmers, and it remains as one of the poorest nations in the world (USAID, 2018b). According to the statistics, over 66 per cent of the population live under the poverty line of below US$ 1.90 a day, and one in every four people live in extreme poverty (Ibid).
The GNR shows that the childhood nutrition and survival outcome indicators of Malawi has significantly improved compared to the other countries. However, the burden of childhood undernutrition is still a challenge ( Development Initiatives Poverty Research Ltd, 2020c). The under-five mortality rate has improved notably as in 2004, 133 children died per 1,000 live births, while 64 deaths per 1,000 live births were recorded in 2015 (National Statistics Office and ICF, 2016). As of 2015, the national stunting prevalence rate among under-five children is 37.1 per cent which has fallen from 53 per cent compared to 2004 (Ibid). It is still higher than the average stunting prevalence of a developing country, 22 per cent. In other words, chronic malnutrition is affecting 1.1milions of children’s development in Malawi (UNICEF Malawi, 2018). Wasting prevalence is considerably low as it is 2.8 per cent compared to the average of developing countries, 8.9 per cent ( Development Initiatives Poverty Research Ltd, 2020d). The GNR 2020 examines the reduction trend of Malawi as
promising to meet two nutritional targets of under-five wasting and overweight reduction while stunting reduction and IYCF needs more attention (Ibid). It reflects the reality of poor feeding practice in Malawi, where only 7.8 per cent of children aged 6 to 23 months are fed to minimum acceptable dietary requirements as of 2016 (UNICEF Malawi, 2018; USAID, 2018). Furthermore, only 61 per cent of children aged 0 to 5 months old are exclusively breastfed, and the figure goes down to 34 per cent among children aged 4 to 5 months old (USAID, 2018). Overall, both, stunting and wasting prevalence rates are higher among boys than to the girls. Wasting is more prevalent among children residing in urban areas, while children in rural areas are more likely to be stunted. The stunting prevalence rate is higher among children from two lowest income quintiles while wasted children are mainly from the highest either middle-income quintiles. Secondary or higher maternal education level is correlated with higher wasting prevalence when stunting prevalence is related to none or primary maternal education level. Children aged 0 to 23 months old are more likely to be wasted while 24 to 35 months old children are more at risk to be stunted (Development Initiatives Poverty Research Ltd, 2020c).
Nutrition is positioned high on the national development agenda in Malawi. In 2011, Malawi joined the SUN Movement. Furthermore, eliminating stunting and other forms of malnutrition is recognised as a national priority in the Malawi Growth and Development Strategy3 (UNICEF Malawi, 2018; UNICEF, 2019). The National Multi-Sector Nutrition Policy set eight priorities in nutrition interventions, a) Prevention of undernutrition; b) Gender equity, protection and empowerment for improved nutrition; c) Treatment of acute malnutrition; d) Prevention and management of nutrition-related NCDs and overweight; e) Nutrition education and positive behaviour change; f) Emergency nutrition response; g) Enabling environment for nutrition; h) Monitoring and surveillance (Department of Nutrition, HIV and AIDS, 2018). The socio-Cultural barrier of deeply rooted gender inequity is widely recognised in both Non-governmental and governmental policy brief as it put women in place to compromise her nutritional status and health and further extend to her children’s health and nutrition (Department of Nutrition, HIV and AIDS, 2018; UNICEF Malawi, 2018). Moreover, it encourages early motherhood which is a significant
driver of intergenerational malnutrition (USAID, 2018). Similar to Ethiopia, the core of the national nutrition policy and policy is reinforcing the multi-sectoral approaches of nutrition-sensitive and nutrition-specific interventions. The government has established a National Nutrition Committee, Nutrition Technical Working Group and District Nutrition Coordination Committees (Department of Nutrition, HIV and AIDS, 2018). Nutrition agenda has become a cross-cutting issue throughout national health, child protection, education, gender, and agriculture policies. Among other strategies, decentralisation policy which aims to roll-out nutrition interventions and empowers district and community level leadership reflects the nature of Malawi’s political system that is deeply intertwined with sociocultural practices of Traditional Authorities, a customary structure of leadership that manages several villages (Mkandawire and Hendriks, 2018). Notably, Malawi is one of the countries where ECD Centres are extensively established in Africa ( MunthalI et al., 2014). Although the national strategy of nutrition integration intervention into ECD frameworks is comprehensive and well structured, it is recommended that to review them at an operational level in practice (Black and Dewey, 2014). In addition to that, UNICEF Malawi suggests the national and local structure of nutrition management needs to be engaged in integrated policy planning, budgeting and service delivery in order to tackle prolonged undernutrition issues and to attain sustainable improvement of nutrition status in the country (UNICEF Malawi, 2018).
2.8 Child Nutrition in Tanzania
Tanzania places 131st out of 157 countries to meet the SDGs (USAID, 2018c). The country's economic growth on average has been between 6 to 7 per cent a year over the last decade. The poverty rate had dropped from 60 per cent in 2007 to 47 per cent in 2016. However, the absolute number of people living in poverty, below US$1.90 a day has not declined due to the high population growth and estimated 12 million people are living in extreme poverty of below US$0.60 a day (Ibid). As of 2015, under-five stunting prevalence in Taniza is 34.5 per cent that is greater than 22 per cent of developing countries average prevalence. On the other hand, under five wasting prevalence rate of Tanzania is close to half of the developing nation’s average, as it is 4.5 per cent while the latter figure is 8.9 per
cent. Stunting reduction rate equates to 4 per cent a year which meets the World Health Assembly target, although the recently published GNR 2020 assesses that the stunting reduction in Tanzania needs to be accelerated in order to meet the 2030 nutrition target, while under-five wasting reduction is on track to meet the target ( Development Initiatives Poverty Research Ltd, 2020d). Both stunting and wasting prevalence rates are greater among boys than girls, and among those children residing in rural areas compared to those inhabiting urban areas. Wasting is more prevalent in households with the lowest and middle-income quintiles when children from the lowest income quintile households are more prone to be stunted. Both wasting and stunting affect more children with mothers who do not have education or only with primary education compared to those with secondary or higher maternal education levels. Wasting prevalence is significantly greater among children aged 0 to 23 months old, whilst stunting is predominantly widespread among older children aged 24 to 47 months old (Ibid). Less than 60 per cent of children are exclusively breastfed during their first six months of life (Ibid). The cause of under-five malnutrition in Tanzania is multifaceted and according to UNICEF Tanzania, inadequate care and feeding practice particularly during the first 1,000 days from pregnancy to child’s early years of life are recognised as the primary cause of childhood undernutrition ( Government of the United Republic of Tanzania and UNICEF, 2017 ). The government of Tanzania is committed to SUN interventions. Tanzania joined the SUN movement in 2011 and has launched the Nation Multi-Sectoral Nutrition Action Plan (NMNAP) in 2016 (USAID, 2018c) with the political leadership of Kikwete Presidency (2005-2015)(te Lintelo et al., 2020). High-Level Steering Committee on Nutrition, Tanzania Food and Nutrition Centre, and a Multi-Sectoral Nutrition Technical Working Group are mandated to provide nutrition strategies and frameworks for comprehensive nutrition interventions (Ibid). The National Nutrition Policy and the structure of it put weight on decentralising the management of nutrition interventions as it is a critical factor for sustainability. There is a Nutrition officer in each region and district of the country who is in charge of coordinating multidisciplinary nutrition programmes, although Katherine et al. (2020) mention that their activities are hindered by the lack of authorities (Dickin et al., 2019). The NMNAP priorities seven
significant issues; a) Scaling up Maternal, Infant, Young Child and Adolescents Nutrition; b) Scaling up prevention and management of micronutrient deficiency; c) Scaling up Integrated Management of Acute Malnutrition (IMAM); d) Scaling up prevention and management of diet-related NCDs; e) Promoting multi-sectoral nutrition-sensitive interventions; f) Strengthening multi-sectoral nutrition governance; g) Establishing multi-sectoral nutrition information system (United Republic of Tanzania, 2016). Overall, the NMNAP2 aims to establish community-centred multi-sectoral nutrition system that engages multiple sectors of Agriculture, WASH, Health and Education, at multiple levels of national, regional/district, Local Government Authorities and communities, with various partners from Government, NGOs, UN, academia and private sectors (Ibid). A recent study evaluates the national policy implementation in the past years, improvement of the data management and use of data for evidence-informed policymaking has enhanced nutritional achievement for the last decades (te Lintelo et al., 2020). Furthermore, facilitation of Annual Joint Multi-Sectoral Nutrition Review encourages accurate monitoring and evaluation of nutrition-sensitive, nutrition-specific programme implementations (Ibid). UNICEF Tanzania and recent studies suggest putting emphasis on promotion of optimal IYCF practice as it is widely known as a cost-effective and durable way to improve nutrition (Government of the United Republic of Tanzania and UNICEF, 2017). Promoting optimal nutrition practice through social behaviour change communication is one of the ten critical strategies of the NMNAP 2, followed by social mobilisation and advocacy demanding political commitment for better nutrition and health services in the country. Focusing on community-level capacity building for efficient and effective integrated nutrition approach is also listed as a significant strategy of NMNAP 2 (Ibid). Vigorous activities for Social Behaviour Change Communication (SBCC) has been implemented as it achieved nearly 50 per cent of budget utilisation while other activities such as Monitoring and Evaluation, quality nutrition service provision, technical capacity buildings are below 30 per cent of budget execution (Ibid).
CHAPTER 3: Methodology
Introduction
This chapter introduces the structure of the research including its philosophy, approach, design, methodology, theoretical framework and analysis and limitations of the study. The qualitative approach can provide in-depth, contextual data that allows having insight on the components of the research topic ( Verhagen et al., 2005; Seers 2012; Bazzano et al., 2016), in this case, the perceptual, behavioural and cultural context of child nutrition. Therefore the study is following the qualitative approach in order to answer the research question of What are the caregivers’ health belief model of Child Nutrition and how does it influence their health-seeking behaviour in Subsaharan Countries; Ethiopia, Malawi, and Tanzania?.
3.1 Theoretical framework
This section outlines the theoretical framework that this study is based on. In the study, The Health Belief Model (HBM) and Socio-Ecological Model(SEM) provide a theoretical framework for the analysis underlying the context of child feeding, caring and illness management perceptions of caregivers.
3.1.1 Socio-Ecological Model
For a deeper understanding of individuals, societies and cultural resources in promoting health, it is essential to analyse the context through the ecological lens (Im, 2018; Kodish et al., 2019). Bronfenbrenner (1979) developed the Developmental Ecology Model, underlining a multi-layered environment that influences a child’s development, later the term expanded to the Socio-Ecological Model (SEM). The SEM is constructed of five layers of environment that interact with each other. The Microsystem is where an individual lives. It is the primary environment of the person that most of the immediate interaction takes place. This includes caregivers, parents, family, siblings, peers, neighbours, and schools. The Mesosystem refers to the interactions and relationships amongst the elements
of Microsystem. For instance, a relationship between caregivers and teachers, or neighbourhood is categorised as Mesosystem. The Exosystem involves a social setting that the individual is not an actor and its the interplay with the primary context of the individual. For example, an increased price of health service can hinder caregivers in seeking health service, which then will affect a child's accessibility to health service. The Macrosystem is the overall cultural context where the individual lives in. It directs to socio-cultural practices, beliefs, and ideology. Lastly, the Chronosystem refers to the time component that includes patterns of experience or a personal transition throughout the life course (Christensen, 2016; Richter et al., 2018). The SEM enables a holistic analysis of a general context (Ibid).
A nutritional anthropologist, claims that the nutrition strategies need to consider multifaceted spheres of interactions that are internal and external to family influencing attitudes and practice of nutritional behaviour affecting children (Aubel, 2012). Therefore, taking account of the intrahousehold dynamics into the basis of childhood nutrition intervention is imperative (Aubel, 2012; Reifsnider et al., 2020). Caregivers as a primary environment and social component that a child directly and immediately interacts with, play the essential role in healthy childhood development and growth (Pulakka et al., 2015; Britto et al., 2017; Richter et al., 2018). Especially in the resource-scarce context, where caregivers’ capacity of early identification of child undernourishment, illness, and seeking for health service, plays a crucial role affecting child morbidity and mortality ( Abubakar et al., 2013). Fundamentally, caregivers’ decision making in health-seeking behaviour is grounded on cultural, social and economic context (Flax, 2015; Flax et al., 2016).
3.1.2 The Health Belief Model
The Health Belief Model (HBM) was developed in the early 1950s by social psychologists to understand the low level of participation in asymptomatic disease screening and preventive measures (Janz and Becker, 1984; Cook, 2018). It is proven that HBM is a critical tool to examine personal health perceptions( Iranagh, 2016). And therefore, it is one of the most widely used theories that allow a systematic understanding of health behaviours (Mulualem et al., 2016). The core of HBM is that individuals' health behaviours are based
