J HEALTH POPUL NUTR 2010 Apr;28(2):167-172
ISSN 1606-0997 | $ 5.00+0.20
©INTERNATIONAL CENTRE FOR DIARRHOEAL
DISEASE RESEARCH, BANGLADESH
Determinants of Appropriate Child Health and
Nutrition Practices among Women in Rural Gambia
Martha Mwangome1, Andrew Prentice2, Emma Plugge3, and Chidi Nweneka2
1
Kenya Medical Research Institute–Wellcome Trust Collaborative Research Programme, Centre for Geographic Medicine
Research, PO Box 230, Kilifi, Kenya,2Medical Research Council Laboratories, Keneba Field Station, PO Box 273, Banjul,
The Gambia, West Africa, and 3Department of Public Health and Primary Health Care, University of Oxford,
OX3 7LZ Headington, Oxford, UK
ABSTRACT
Health education and awareness involves providing knowledge about causes of illness and choices to promote a change in individual behaviour and, thus, improves survival of individuals. Studies have, however,
shown that improved knowledge and awareness is not always translated into appropriate actions. This
study aimed at exploring the factors determining mothers’ choices of appropriate child health and nutrition practices in the Gambia. Eight focus-group discussions (FGDs) were held with 63 women whose
children had been seen at the Keneba MRC Clinic within the 12 months preceding the study. The FGDs
were analyzed using a thematic framework. Gender inequality, presence or absence of support networks,
alternative explanatory models of malnutrition, and poverty were identified as the main factors that would
determine the ability of a mother to practise what she knows about child health and nutrition. The findings highlight the need to consider the broader social, cultural and economic factors, including the value
of involving men in childcare, when designing nutritional interventions.
Key words: Child health; Child nutrition; Child nutrition disorders; Gender; Health education; Interventions; Knowledge, attitudes, practices; The Gambia
INTRODUCTION
Malnutrition remains a factor in 60% of 11 million
deaths of children aged less than five years globally each year. It is the most important risk factor
for the burden of disease in developing countries
(1), causing long-term detrimental consequences,
such as impaired cognitive development, growth
impairment, and poor academic performance (2).
Children most at risk are those aged less than five
years living in developing countries (3).
Recently, there has been an increase in the prevalence of malnutrition in Africa, which means that
the goal set to reduce the levels of undernutrition
by 50% between 1990 and 2015 may not be met.
The number of underweight children in Africa inCorrespondence and reprint requests should be
addressed to:
Miss Martha Mwangome
Kenya Medical Research Institute–Wellcome Trust
Collaborative Research Programme
Centre for Geographic Medicine Research
PO Box 230, Kilifi
Kenya
Email: mmwangome@kilifi.kemri-wellcome.org
creased from 26 million in 1990 to 32 million in
2000 (4). Other studies have predicted that the contribution to the global prevalence of childhood undernutrition from Africa will increase from 24.0%
in 1990 to 26.8% in 2015 (5,6).
To date, various interventions for targeting malnutrition have been proposed and implemented
in different parts of the world. The use of health
education as a component of child health and nutrition programmes is a common practice and is
based on the premise that health-education messages promote specific behavioural changes, which
should yield benefit in child survival. Studies have
shown that nutritional knowledge of a mother is
positively associated with the nutritional status of
her children (7). Studies have also shown that the
use of health education as a component is rarely
sufficient on its own (8) and that adequate knowledge is not always translated into appropriate actions (9). Understanding the factors that determine
the translation of adequate child health and nutrition knowledge into appropriate action might help
design more effective interventions against malnutrition.
Mwangome M et al.
Child health and nutrition practices among Gambian women
This paper presents the findings of a pilot study
among women in a rural community in The Gambia. Detailed descriptions of the participating villages have been published elsewhere (10-12). These
villages experience a seasonal agricultural system
that revolves around an annual rainy season from
July to November and a dry season from November to May (13). Data on maternal pregnancies,
birth anthropometric measures, and gestational
ages have been collected since 1978 (11,13). Records of morbidity and anthropometric data on all
children, aged less than three years, from the three
villages, presenting at the field station’s clinics, are
also available in a database.
The Keneba MRC Nutrition Supplementation Centre, established approximately 20 years ago, is an
example of both community-based management
and nutrition/health-education approaches for the
rehabilitation of severely-malnourished children.
The activities at the Keneba field station, including
those of the supplementation centre, have directly
or indirectly exposed the community to a substantial amount of child health and nutrition knowledge and awareness. Some of these activities include
provision of clinical care and nutritional supplementation to severely-malnourished children,
education of carers on child-nutrition practices, basic
hygiene, and food-preparation methods. Other
activities include various nutrition-related research and intervention programmes the station has
supported since its founding (14-16). These interventions have been thought to contribute to the reduction of the risk of dying by as much as three times
in infants aged 0-1 years and up to seven times in
all children aged less than five years in rural Gambia
(15,16), although this improvement in mortality rate
was not necessarily associated with improvements in
the nutritional status of children (11).
The aim of this pilot study was to explore the factors determining mothers’ choices of appropriate
child health and nutrition practices in this community. The term ‘appropriate’ practice is used in
the title and text to mean practices that enable the
child to grow and develop normally, additionally,
those that are not detrimental to the well-being of
the child.
MATERIALS AND METHODS
Study site
The study was undertaken among mothers in three
villages near the Keneba field station of the Medical
Research Council (MRC) in the Gambia. The three
villages—Keneba, Manduar, and Kantong Kunda—
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are commonly referred to as the core villages because they were the original sites of research activities of the Keneba field station.
Participants
The study involved mothers of children, aged less
than three years, residing in any one of the three
core villages and had been seen at the MRC clinic
in the 12 months before the commencement of
the study (March 2005–February 2006). The MRC
surveillance database was used for identifying these
children and their mothers.
Purposive sampling was used for identifying and
selecting a homogenous group of participants for
the FGDs. It was assumed that this group of women
would give up-to-date information of the situation
in question since they would be going through
the process of making feeding choices at the time
of the study. They were also preferred because the
available dataset at the MRC could easily be used
for identifying them.
Verbal informed consent was obtained individually
for participation. The MRC Gambia Scientific Coordinating Committee and the Gambian Government/MRC Joint Ethics Committee approved the
study.
Focus-group discussions
An FGD guide was developed in line with the main
research question: “why is it that the mothers in
this community cannot practise what they know
about child health and nutrition?” The discussion was guided by the existing literature on the
subject “Does adequate knowledge lead to appropriate action?” and through conducting informal
discussions with the local health workers around
the Keneba field station. It contained unstructured
open-ended questions with non-directive prompts
used for generating and directing the discussion.
Informed consent was obtained from the mothers
for tape-recording the discussions. Two trained, experienced nurses fluent in Mandinka—one as the
facilitator and the other as a note-taker—conducted all discussions in this local language. One of the
authors (MM) observed all the sessions.
Analysis of data on focus-group discussions
The transcripts from the eight FGDs were prepared
by the facilitators, translated into English and entered separately as Microsoft word documents.
Thematic framework approach (17) was used for
analyzing the transcripts. This involved reading
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Child health and nutrition practices among Gambian women
through the transcripts and identifying emerging
themes which were grouped into main themes
(concepts) and sub-themes as other new themes
emerged.
RESULTS
Study participants
Of the 70 mothers invited for the FGDs, 63 participated in the discussions. Each focus group involved
7-8 mothers. The mean age and parity of the women was 32 years and five children respectively. The
level of education among the participants was generally low. Eleven of the mothers had formal education while 34 had attended Arabic school at some
point in their life. The rest had non-formal education. Further information on individual social economic status was not sought; however, detailed description, including general social economic status
of the inhabitants of the three research villages, has
been published elsewhere (10-12).
Themes emerging from focus-group discussion
The study explored the factors determining mothers’ choices to appropriate child health and nutrition practices in this rural community. Several factors emerging as themes are described below.
Gender role inequality
The role of men and women in this society as described by the participants indicates that women
are the sole caretakers of their children with little or
no assistance from their male counterparts. They
(women) engage in laborious work under harsh
conditions sometimes at the expense of the child’s
welfare.
Women are expected to do both farm work and
household chores, thus, infringing on the time allocated for the health and nutritional needs of the
child as one mother reported:
They (our husbands) should be helping us but unfortunately they are not doing it. What can one do
when a man says no!
Women also reported that men receive the largest,
best, and first share of the meals and that the women only eat after the men and children are satisfied.
This practice was attributed to their respect for their
husbands:
The men are our husbands, and we respect them
and so give them a larger share. They are the leaders, and so, we give them the best parts.
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Mwangome M et al.
This cultural practice may have severe consequences on the health and nutrition of pregnant mothers
and consequently the child they bear.
The women also reported that decision-making
on issues of marriage, child-bearing, and childspacing were out of their domain, although these
affect them. Such decisions in many households
in this community are either strongly influenced
or are made solely by men. They further reported
incidences where men would have the last word on
issues without necessarily consulting or considering the women’s opinions. Thus, the knowledge
acquired by women during clinical visits would not
necessarily lead to the intended response if it were
in conflict with the views of men.
Poverty
The impact of poverty on malnutrition in these
communities was highlighted in various ways: (a)
poverty leading to lack of food, or lack of variety of
foods; (b) poverty aggravating the inequalities and
desperation already experienced by women in the
community; (c) lack of alternative means of livelihood making the women vulnerable to harsh environmental conditions, which further aggravate
their food situation. Such conditions may include
insects and wild animals attacking and destroying
farm crops. One women stated:
It is beyond us. Each of us would want to stay
at home with our children but we have to
survive. The only way for us to survive without
begging is to farm. We do not like it that way
but we have no choice.
Alternative explanatory models of malnutrition
The study women identified alternative explanations to causes of nutrition-related ailments among
children in this community. These alternative explanations are closely related to cultural beliefs and
perceptions about the origin and treatment of malnutrition. The theory of the ‘devil child’ is one such
explanation that blames malnutrition for an evil
spirit. The characteristics, causes, and treatment
of the devil child were described in detail by the
women during the discussions. It was noted that
the characteristics of the devil child included:
A child usually born with a big head and a
small wrinkled body resembling features of a
small-for-gestational age baby or a low-birthweight baby.
The women described the causes and treatment of
this syndrome. They described how, if the disease is
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Child health and nutrition practices among Gambian women
perceived to be caused by the devil, the treatment
would be to test the infant for its humane nature
and prove that the child is not a devil:
… mothers will take such a child to the
bush, place the child somewhere, and then
leave for a few hours. If the mother returns
and does not find the child, she will know
that the child was really the devil but if the
mother finds the child where she left him,
she will know that it is a human being,
she will take the child home, and continue
treating it.
Other than the devil child, the women discussed
other conditions with physical resemblance to
those of a malnourished child. Such conditions are
locally known by the names—montoo, tiyoo, and
fonoo. Montoo was described as a disease causing
a child to have high fever, a big pot-shaped abdomen, and brown hair while tiyoo was a disease associated with the rainy season while fonoo was associated with bad wind, blown by evil spirit. Treatment
for these ailments was reported to occur at the local
herbalist and, according to the mothers, would depend on the perceived cause of the disease.
If a child has tiyoo or montoo, you go to the herbalist
for treatment, for fonoo,—a dry bone from a dead
crocodile is soaked in water, and then the child is
washed with that water.
Role of support networks
Social support in this context is used for referring
to the degree to which the physical and emotional
needs of women are satisfied through their interaction with organizations and societies (formal) and
relatives, friends, and others (informal).
The women identified their husbands, older siblings to the index child, and in-laws (grandmothers
to the child) as part of child health and nutritionsupport networks. They identified circumstances
where both presence and absence of the support
networks in child health and nutrition might be
experienced. For example, it was explained that:
When mothers go to the field, the child is
left with other children, or at times, we will
leave them at home under the care of an elderly person.
The mothers felt supported in childcare by the presence and the working system of the MRC clinic in
Keneba village:
The nurses have shown us how weights are
plotted on the charts. If the child is loosing
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Mwangome M et al.
weight, they will advise you on diet.
Economic support was reported in areas of farming
and farm-products through friends and relatives
and also in the activities of non-governmental organizations through providing farm-equipment:
… There was a time that the wife of an MRC’s
doctor sent a group to us that brought some
farm-equipment ….
In this regard, the presence or absence of the support network has direct or indirect influences in
ensuring proper care for the child.
Public-health implications of study results
We explored the factors that determine mothers’
choices of appropriate child health and nutrition
practices. Our findings suggest that the key determinants include gender relations within the family,
presence and types of support networks available
to the mother, alternative explanatory models of
malnutrition within a particular community, and
the availability of food in the communities. These
findings have public-health implications.
Gender relations with respect to decisions on child
health and nutrition as found in this study are consistent with reports from other parts of the world
(18). First, in a setting where a husband makes the
key decisions, claims top priority in household resource allocation, including food, and is in total
control of household finances, the mother has limited choices when deciding on appropriate childhealth and nutrition practices (18).
In such settings, giving mothers adequate knowledge on proper childcare practices has a little impact on consequent actions without the involvement of the partner.
Second, men mediate on access of women to economic resources, which has implications on the
nutritional status of women, especially during
pregnancy and nursing periods. This means that
the health of both child and mother depends heavily on the decisions of the dominant male figure in
their life (19).
Third, men were reported to dictate decisions on
child-spacing and family size, which may ultimately affect the health and nutrition of children (20). The rigidity and ignorance of men on
issues of family planning hinders the fertility decline in four ways: (a) by dominating in reproductive decisions for which they are ignorant; (b) by
refusing to provide economic resources required to
access contraception; (c) by displaying inflexibility
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Child health and nutrition practices among Gambian women
towards family-planning initiatives as reported in
other studies (19,21); and (d) men were found to
dictate on the timing and choice of the marriage
partner for women. This makes it impossible for the
woman to negotiate her own child-bearing practices and discuss other child-upbringing choices with
the man.
Poverty is a complex multi-dimensional phenomenon characterized by deprivation, exclusion, and
vulnerability. The results showed a number of aspects of poverty in the context of their children’s
health and nutrition practices. First, poverty as lack
of food demonstrates the direct link to under-nutrition in most communities around the world. In
fact, malnutrition is a legitimate indicator of poverty in society (22). Second, poverty as powerlessness
is aggravated by the role of gender bias within the
community. The results showed that women lacked
a sense of social power and financial control over
their households and were, therefore, unable to negotiate for proper food choices for their children
(1). Lastly, poverty as vulnerability is seen in the
susceptibility of the community’s food situation
to environmental conditions. This community’s
survival is completely dependent on production of
crops, which, in turn, is reliant on environmental
conditions, making them highly vulnerable to climate change and other adverse environmental circumstances. This finding is consistent with those
of other reports (23).
Although the traditional beliefs and practices as
discussed in the present study may not be in current practice among members of this community,
of importance is that the participants felt the need
to point them out as factors that may determine
their choices of proper child-nutrition practice. This
shows that the factors may still have an influence
on the way of thinking and, thus, on the decisionmaking process among the community members.
The traditional beliefs and practices could affect
child health and nutrition in different ways: (a)
they could interrupt and or complicate the disease
status of children to the point of death or disability;
(b) they could deplete or limit the available family
resources, thereby limiting the capacity of families
to pay for proper biomedical interventions; (c) they
could breed social stigma, in this case ‘the devil
child’ which could lead to negligence and improper
treatment of an otherwise malnourished child.
We also identified the cultural beliefs and practices
that encourage good hygiene and childcare practices, such as protecting children from extreme
wetness. “Tiyoo is a condition that occurs during the
rainy season when a child is put to sit on the floor or
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Mwangome M et al.
wet ground.” The need to identify and address the
cultural rationales that underlie negative practices
and to reinforce and protect the beliefs that support
positive practices has been highlighted in other
studies (24).
Poor social support networks as reported in this
study and the huge domestic and agricultural demand on the mother expose the child to maternal
deprivation, which, in turn, impacts negatively on
the child’s health. As part of the support networks
in rural Africa, elderly women, especially grandmothers and even siblings, are often called upon to
baby-sit when the mother needs to be away. Grandmothers are trusted to be skilled in child upbringing, irrespective of the existence of the generation
gaps (21). They are preferred for their perceived
child-upbringing skills and know-how. Studies have
shown that having a living maternal grandmother
has a significant effect on the survival of the child
(25,26). In rural communities, grandmothers command respect from their sons (women’s husbands).
This changes the dynamics of the decision-making
process in a household. This is true in scenarios
where the man (father to the index child) is mostly
away. In such settings, the mother might have adequate knowledge to inform proper action but her
actions are highly influenced by the grandmother’s
opinion (22,25).
Limitations
Qualitative research was undoubtedly the most appropriate method of gaining an understanding of
the child health and nutrition practices of mothers.
However, the investigators were not fluent in the
local language by whom most data were collected
and, therefore, required the use of trained local staff
for the translation of the transcripts. The complexity of translating non-English focus-group data may
have introduced unidentified bias (27).
Conclusions
Malnutrition is an important global public-health
problem, and it is important to understand the factors that determine the translation of child health
and nutrition knowledge into appropriate actions
to develop more effective interventions against
malnutrition. This study has shown the potential
positive impact of considering gender equity and
poverty-reduction initiatives as interventions to
improve child health and nutrition. Our findings
also concur with those of earlier reports that malnutrition is a product of complex interplay between
many different factors, some of which are social
factors such that any successful interventions will
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Child health and nutrition practices among Gambian women
benefit from considering the broad cultural and socioeconomic context in which the intervention is
to be delivered.
ACKNOWLEDGEMENTS
The authors acknowledge the support of Bakare
Kante, Fatumata Sanyang, Fatumata Sidibeh, Sira
Bah, all the staff at MRC Keneba and the community mothers, children, and families who willingly
participated in the study.
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