The influence of male care givers on child health in rural Haiti

Soc. Sci. Med. Vol. 43, No. 4, pp. 479-488, 1996

Pergamon

0277-9536(95)00426-2

Copyright © 1996ElsevierScienceLtd Printed in Great Britain.All rights reserved 0277-9636/96$15.00+ 0.00

THE INFLUENCE OF MALE CARE GIVERS ON CHILD HEALTH IN RURAL HAITI ROBIN B. DEVIN l and PAMELA I. ERICKSON 2 ~Universityof Rhode Island Library, 15 Lippitt Road, Kingston, RI 02881, U.S.A. and 2Department of Anthropology, Beach Hall Box U-176, University of Connecticut, Storrs, CT 06269, U.S.A. Abstract--This study examines the relationship between a woman's workload and the health of her pre-school children aged 24-59 months. The role of gender of alternate care givers when the woman is away from home is the specific focus of the research. Interviews were conducted with 106 women in rural Haiti, 44% of whom had malnourished children. Factors which significantly discriminated between normal and malnourished nutritional status were birth space between the index child and its next oldest sibling, number of children in the home, roof type (a proxy for socioeconomicstatus), and having a male substitute care giver. Further multivariate analysis produced a model which demonstrated that having a male care giver exacerbated the effect of birth space on nutrition status. Further research is necessary to determine characteristics of substitute care givers and their impact on nutritional status and child health in less developed countries. This is particularly important in light of the increased economic pressure on Third World rural women to work outside the home in order to meet the basic needs of their families. Copyright © 1996 Elsevier Science Ltd Key words--women's work, child nutrition, child care, rural Haiti

INTRODUCTION The impact of a woman's work on the health of her young children has been the subject of numerous research studies conducted throughout the less developed world. This research has indicated that the inc~ased income resulting from a woman's employment may translate into an improved nutritional status for her children. On the other hand, a decrease in the time available for child care may result in a decline in her children's health status. Leslie provides an excellent summary of the literature in her article "Women's work and child nutrition in the Third World" [1]. Other more recent articles such as Lado's review of the agricultural workload of African women and its effect on the health of their families [2], Wandal and Holmboe-Ottesen's research on maternal work and child nutrition in Tanzania [3], and Rabiee and Geissler's study in rural Iran [4] continue this research. Although researchers have become acutely aware of the relationships between women's domestic and non-domestic work routines and their caretaking activities in relation to small children [5-9] and maternal time allocation has been included as a factor in recent models of the household production of health [10], few studies have specifically focused on the child care arrangements of the working women of the Third World. In 1977 Weisner and Gallimore provided cross-cultural data on child caretaking and reported that the great majority (80%) of young children are not cared for principally by their mothers [11]. Yet in a recent review of the literature on child care arrangements of working

mothers in the Third World, Joekes reports that the "surprising finding of this survey of the literature is that empirical information is scarce and scattered concerning how young children are cared for in Third World countries. . . . There is no coherent body of research to be assessed . . . . The topic has not been considered in depth within any of the relevant social science or biomedical disciplines" [12] (p. 59). The few studies that Joekes is able to cite in her review of the role of substitute care givers seem to indicate that child care appears to be more or less exclusively a female activity. Research has indicated that adult male household members play a minimal role, although pre-adolescent male siblings may take on some child care tasks. The most frequent substitute care givers in less developed countries are grandmothers, older female siblings and other female relatives [12]. Little is known about the male role in child care in the developing world. The influence of the father on child development is currently a focus of numerous studies in the United States as evidenced in Biller's recent review of research findings [13]. This research has noted the positive impact of increased male parental involvement, particularly on psychological and social development. But few studies have examined the role of the father in relation to child care in non-industrial societies. Notable exceptions are Katz and Konner's review of the role of the father [14] and Hewlett's recent compilation of fieldwork on father-child relations [15]. These studies examine either male parental investment in children from a biosocial perspective or focus on cultural factors

479

480

Robin B. Devin and Pamela I. Erickson

influencing the father's role. While these studies indicate that fathers make important contributions to the welfare of their children, none of the studies specifically address the impact of male vs female care giving on child survival. This paper will examine the impact of male alternate care givers on child health in rural Haiti. The study examines women's workloads and their effect on time available for child care and specifically focuses on the child care arrangements made by mothers when they have to leave their young children in the care of others for extended parts of the day. The research focuses on the impact of these factors on the health status of young children in the context of rural Haitian life. METHODS

The research for this study was conducted in the rural areas surrounding Jeremie, Haiti. Jeremie is located on the northwest tip of the southern peninsula of Haiti in an area known as the Grand Anse. The rural population consists primarily of subsistence farmers who work plots of land no larger than three acres, many of which are located on steep mountainous slopes [16]. The principal crops grown are beans, corn, manioc and sweet potatoes.

Sample selection The sample for this research was a subgroup selected from a larger population which is part of a study examining the variables affecting nutritional status among pre-schoolers in this area of Haiti. The sample was drawn from the population served by the Primary Health Care Outreach Program of the Haitian Health Foundation (HHF) clinic in Jeremie. This clinic is a non-governmental organization operated by HHF. H H F is a private Connecticut-based non-profit organization founded by Dr Jeremiah Lowney in the mid 1980s to provide medical, dental and other assistance programs to the poor of Haiti. The Primary Health Care Outreach Program provides primary health care services to 39 villages in the rural area surrounding Jeremie. The sample for this study included the population of three of these villages which contained a total of 742 households. The villages selected for this study fell within the mid-range of the villages on their overall nutritional status. The sites were chosen as villages representative of the general population in the area with nutritional statuses representing neither the best nor worst case. Thus, although the research findings may not be

applicable to the 'worst' villages in rural Haiti, the demographic indicators from the H H F database demonstrated that these villages were typical of those in the area. The villages were located in three different cardinal directions from Jeremie and all were 30--40 minutes distance by car. The logistics of repeat interviews with the participants required that the villages be accessible by motor vehicle throughout most of the year. The outreach program maintains a database which provides census information and health data on the household members within the villages it serves. Health data for children under the age of five include weight for age measurements which are taken every few months. Nutrition status is calculated as a Z score indicating the number of standard deviations below the mean weight-for-age based on the Normalized NCHS/CDC Anthropometric Reference. The variable weight-for-age was used as the sole indicator of nutrition status because it was the only variable available in the H H F database. Although weightfor-age does not distinguish between current and past malnutrition, it has shown to be a better indicator of mortality than either height-for-age or weight-for-height indicators [17]. There is also evidence that since malnutrition or growth faltering is due to many factors, the weight-for-age index may appropriately be considered a nonspecific indicator of child health [18]. In each of the three villages selected for this study all children, aged 24-59 months, were identified from this H H F database. The sample design called for two groups, one consisting of all children with normal nutrition status and one consisting of all children whose nutrition status was two standard deviations or more below the norm. In order to create these two distinct groups for comparison, children aged 24-59 months whose nutrition status was one standard deviation below the mean were excluded from the study. The first group, the children with normal nutrition status, comprised all children with normal weight for age as of March 1993, and whose weight for age measurements during the previous year were all normal or no more than one standard deviation below the mean. The comparison group, the severely malnourished children, comprised all children whose weight-for-age was at least two standard deviations below the mean as of March 1993, and whose weight-for-age measurements during the preceding year were all below the mean. If more than one child in a household was identified in the sample selection, only the youngest was included in

Table I. Sample size

Village A B C Total

Total HH

HH W/ 2-4 yr old

Nutrition normal

Nutrition SD = 1

Nutrition SD > 1

276 275 191 742

67 83 40 190

25 (37%) 26 (31%) 16 (40%) 67 (35%)

26 (39%) 29 (35%) 14 (35%0) 69 (36%)

16 (24%) 28 (34%) 10 (25%) 54 (28%)

Male care givers and child health the study. Table 1 shows the number of households included in each category in each of the three villages. The age group 24-59 months was selected as the target group for children because H H F data indicated that this was the age group with the highest levels of malnutrition. In Haiti, as is common in other areas of the Third World, children begin to show increased signs of malnutrition during the period of weaning which typically occurs at 18-24 months of age [19]. Once these two groups of children were identified in each village, interviews were conducted with the female primarily responsible for the care of each child. In almost all cases the mother of the child was the primary caretaker. The initial sample selection of children identified a total of 121 female primary caretakers who were to be interviewed for this study. Of the 121 women selected 15 were excluded from the final sample: two had died, nine had moved to other locations (usually Port-au-Prince), and four women were found not to fit the original selection criteria. The remaining 106 were located and all agreed to participate in the study. This remarkable response rate of 100% in each village was due to the excellent census data available in the H H F database and the high level of trust which H H F has developed in the communities in which they work.

481

sponsible for the tasks performed within the household, in farming activities and in marketing or other income-producing activities. This checklist was accompanied by a 24-hour recall interview of each woman's activities during the previous day. This method of assessing time allocation was demonstrated to provide reliable and accurate results by Johnson [20]. During this section of the interview particular attention was paid to recording all food that was prepared during the preceding day. The interview information was supplemented from the Haitian Health Foundation database, which provided the exact birth date of the index child plus the exact birth date of the next sibling (both younger and older). This database also provided ages for those mothers who did not remember how old they were, as well as information on the ages of other significant household members. These interviews yielded 106 usable questionnaires, 60 from the mothers of children with normal nutritional status (57%) and 46 from mothers of malnourished children (43%). Data from the interviews were entered into Epi Info version 5, a software program developed by the Centers for Disease Control for use in community-based studies conducted by public health researchers and analyzed using EPI Info, SAS and SYSTAT.

Data collection

Since H H F has been operating in Haiti for over seven years, a great deal of ethnographic data about the communities in the area had been collected by that project and were made available for the purposes of this study. In addition the principal author conducted more than two months of participant observation in the communities working with the Primary Health Care Outreach Project of the H H F clinic prior to beginning data collection. The research instrument was developed based on the knowledge gained from this experience. The structured interview instrument that was developed was pilot tested in other similar communities within the H H F service area in order to ensure that all the items were understandable to the respondents and that the questions elicited adequate information about the variables being investigated. All questions were translated into Haitian Creole by a bilingual Haitian translator. The interviews were conducted in Creole by one of two Haitian research assistants. The interviewers were blind to the nutritional status of the child of the woman being interviewed. The interviewers gathered information on household composition; age, occupation, educational level, religion and birth place of the primary female caretaker; and socio-economic indicators. The interviews included specific questions on the work activities of the women being interviewed, including questions on who provided assistance with child care during the woman's work-related absences. A checklist of tasks/activities was used to determine who was re-

SAMPLE DESCRIPTION

Among the 106 children aged 24-59 months, about half were female and half male (see Table 2). Both the average age and median age of the children was 40 months. The average number of children under 15 years of age was 4.3 per household. Among children who had an older sibling living in the household (87%), the average spacing between the index child and its next older sibling was 39 months. Among those who had a younger sibling living in the home (74%), the average spacing between the younger sibling and the index child was 30 months. In all but two cases the primary female care givers of these children were their biological mothers. The two exceptions were grandmothers taking care of their grandchildren while their daughters worked in Port-au-Prince. The women ranged from 19 to 54 years of age with a mean age of 35. More than three quarters of the women were living in the same general locality in which they were born. Over half of the women had never attended school. Of those who had attended school none had gone beyond the equivalent of 7th grade. Only slightly more than a third of the women (36%) had had sufficient education to be able to sign their own signature on the consent to participate form used for the interviews. Household size varied greatly (range 3-16) with an average household size of about eight. The majority of the women (81%) were living with a male partner. In over half of the households (58%) the primary

Robin B. Devin and Pamela I. Erickson

482

Table 2. Population sample profile Variable

N

Total

Norm. group

Main. group

Characteristics of child Mean age in months Child is female Mean birth space older in months Mean birth space younger in months

106 106 93 78

40.3 + 9.2 45.3% 38.7 + 20.3 30.0 ± 7.3

40.5 40.0% 43.9 30.8

40.0 52.2% 32.3 29.2

Characteristics of mother Mean age in years Living at birth locale Religion Catholic Never attended school Works in garden Sells in market

105 105 105 106 106 106

34.8 + 7.1 79.0% 61.9% 54.7% 71.2% 83.8%

34.0 81.7% 54.2% 54.0% 69.5% 76.7%

35.8 75.6% 71.1% 56.5% 73.3% 93.3%

0.05

Household characteristics Mean household size Male partner in home Mean children under 15 in home Child/adult ratio Child/female over 14 ratio

106 106 106 106 106

7.5 ± 2.4 81.1% 4.3 ± 1.7 1.6 3.3

7.3 80.0% 3.9 1.4 2.9

7.9 82.6% 4.8 1.8 3.8

0.01 0.01 0.01

Socio-economic characteristics Mean number of rooms in house House has tin roof House has cement floor House has radio House has latrine Mean SES score

106 106 106 106 106 106

2.5 +_0.9 34.0% 21.7% 21.7% 8.5% 1.83 ± 0.8

2.6 43.3% 23.3% 28.3% 10.0% 1.95

2.4 21.7% 19.6% 13.0% 6.5% 1.67

82 82 99 99 99

26.8% 32.6 + 22.3 45.6% 37.2 :[: 20.2 4.6

17.8% 35.0 33.3% 37.2 4.7

'37.8% 29.8 61.9% 37.0 4.6

Care giver characteristics Male care giver for gardening Mean age of garden care giver Male care giver for marketing Mean age of marketing care giver Days/wk mother is away from child

female care giver was the only female over the age of 14 living in the house. RESULTS

In rural Haiti, as in other areas of the Third World, the typical woman is engaged in work activities from sunrise to well after sunset. The full range of these activities typically includes domestic household tasks, agricultural labor, and income-producing marketing activities. The women are responsible for all domestic tasks such as cooking, cleaning, washing and carrying water. Most women also spend a considerable amount of time on agricultural tasks such as planting, weeding and harvesting crops. In addition Haitian women have primary responsibility for all marketing activity. This activity includes both the purchasing of food and other goods and selling of merchandise at the markets. The sale of excess produce, as well as small household supplies such as soap and matches, are the principal sources of cash income for most rural households. These duties demand that the typical Haitian woman be away from the house for a large part of most days and for a majority of the daylight hours during a typical week. As the Haitian mother goes about her daily activities such as washing, marketing and agricultural work in the gardens, which take her away from the household for substantial periods of time, she is never accompanied by her young children. Unlike many cultures in other parts of the Third

P value

0.01

0.05

0.05 0.01

World, Haitian mothers are never seen with their babies strapped to their backs on the way to market nor do their young children accompany them to the fields. Haitian infants and young children remain at home in the care of substitute care givers during their mothers' absences. What is unusual about this arrangement is that a very high percentage of the substitute care givers are male, primarily fathers and older brothers. The effect that these substitute care givers have on the health of young children is the focus of the results presented here. Before turning to the influence of type of care giver on child health as measured by nutritional status of children aged 24-59 months, we looked at a number of variables that have been demonstrated by other researchers to be related to the nutritional status of young children including birth spacing, socioeconomic status and maternal education. Using EPI Info version 5 simple correlations were computed to test for significant differences between the group who had normal weight-for-age children and the group whose children were malnourished (see Table 2).

Birth spacing and number of siblings Birth spacing between the index child and its next oldest sibling was negatively related to nutritional status (i.e. the child was more likely to be malnourished if its next oldest sibling was closer in age; H ffi 6.902, df-- 1, P < 0.01). The mean birth spacing between the index child and its next oldest sibling for

Male care givers and child health the normal weight-for-age group was 43.9 ( + 24) months compared to 32.2 ( + 12) months for the malnourished grouly--a difference of almost a year. The number of children under 15 was also positively related to malnourished status (i.e. the more young children in the household, the more likely the index child was to be malnourished; F = 7.526, d f = 1, P < 0.01). In households with a malnourished child the average number of young children in the home was 4.8 (___ 1.6) compared to 3.9 ( + 1.7) in the normal weight-for-age grouly--an average difference of about one child. In addition, it was found that the child to adult and the child to female adult ratios were also associated with nutritional status. The higher both ratios (i.e. the more children per adult), the more likely the index child was to be malnourished (child: adult H = 7.874, df = 1, P < 0 . 0 1 ; child:female adult F = 7 . 0 5 2 , d f = l , P < 0.01).

Socio-economic status as reflected in housing characteristics The physical characteristics of the houses provided some indication of the socio-economic conditions. The typical house had three rooms with a floor consisting of packed dirt covered by a thatch roof (mean number of rooms 2.5 + 0.9, range 1-5), and a cook house which was always a separate structure. Less than 10% had latrines, and most (78%) did not have radios. N o house was equipped with electricity or running water. Water was obtained from a spring or river located an average of 45 minutes roundtrip from the house. An overall indicator of socio-economic status was constructed by summing the presence/absence of the housing variables listed in Table 2. In bivariate analysis, although the trends of all housing characteristic indicators were in the expected direction, only roof type was associated with child nutritional status (i.e. children who lived in homes with tin roofs were less likely to be malnourished than children whose homes had thatch roofs (chi square = 5.41, d f = 1, P < 0.05). Thus, the presence or absence of a tin roof was used as a proxy for socio-economic status in this study. It is recognized that within the rural population of Haiti, differences in socio-economic status could perhaps be demonstrated by using other indicators such as annual income, amount of land owned, or number and type of animals owned. However previous research had indicated that such information is virtually impossible to obtain with any degree of accuracy since this type of information is not readily shared even among the population itself [21]. In any case it must be recognized that any demonstrated difference in socio-economic status within this population would only differentiate between relative degrees of absolute poverty.

483

Maternal education Throughout the developing world a strong relationship has been found between child survival and maternal education [22]. In this sample, however, female education was not associated with child nutrition. Neither school attendance nor the level of grades completed was significantly different among the two groups of women. It is probable that the homogeneity of the sample of women with respect to education is responsible for this lack of statistically significant association. Cleland and van Ginneken do note that Haiti was one of the few countries where World Fertility Survey data did not find net effects of maternal education on child survival [22]. Other characteristics of the sample of women such as age, place of birth and religion also showed no association with child nutrition.

Maternal economic activities Analysis of the current economic activities of the women interviewed revealed a population in which women are highly active in economic activity. Almost half of the women (48%) listed their principal occupation as merchant, but almost all of the women (83%) were engaged in marketing activity. The majority of the women (83%) sold at least some of the produce which was grown in their gardens. Only a small percentage of the sample (13%) listed their principal occupation as farmer, but almost three quarters of the women (71%) usually engaged in work in the gardens. Principal activities included harvesting, raking and clearing weeds and debris (ranmase), planting and weeding. Nearly half of the women (43%) also reported working in gardens other than their own. By using a checklist of activities, it was found that the mother performs the majority of the tasks involved in running a household herself. The vast majority of these women carry water and make an average of two trips a day to the water source. They cook and prepare an average of two meals a day and wash the dishes afterwards. They clean their houses an average of twice a day, sweeping the floor and straightening-up. Twice a week they carry their laundry to the river to wash clothes for the family. They also sew or mend clothing for the family. Most of the women report that they care for children other than those who live in their household. Almost all of them report that they share in the task of taking care of animals such as chickens or goats. This is a task which is performed an average of two or three times per day. In addition to the activities described above almost a quarter of the women reported that they occasionally make food to sell at the market. The following is a typical day in the life of one of the women interviewed. I woke up around five o'clock because I had to go to Jeremie. I left at 5:30 a.m. I was going to resell coconuts and sweet oranges. I was walking. It took me 3 hours to make

484

Robin B. Dcvin

and

it. I arrived around 8:30 a.m. The selling was very good and quick. I finished selling around noon. I had bought coconuts for 2 gourdes and sold them for 3 gourdes. (1 Haitian gourde = $0.08 U.S.). I made a profit of 1 gourde. I bought the sweet oranges for 13 gourdes and sold them for 20 gourdes. I made a profit of 7 gourdes. With the money I bought provisions. I bought fuel, spices, oil, and salt . . . . . I left town around 1:00 p.m. I arrived home around 3:30 p.m. I took a little rest. I drank water, after that I breastfed my baby. I cleaned up the greens, after that I cooked corn meal with beans and greens. I put red herring in it. When the food was cooked, I separated it and gave some to everybody in the house. It was about 7:00 p.m. When they finished eating we sat down. Around 8:00 p.m. I bathed the children and I fixed the bed for them to sleep. We went to sleep at 9:30 p.m. Before we slept we told old stories. In a review of the women's typical weekly activity patterns it was found that the women go to the market an average of 2.4 ( + 1.7) days per week. Almost a quarter of the women go to the market four or more times per week. On the average the women are at home 2.36 ( _+ 1.8) days per week. Less than a quarter of them are home more than three days a week. On the days when they are not at the market, the women are usually washing clothes at the river, or participating in church or community activities. Although the church and community activities usually do not involve a full day, they do consume at least half a day's time and were counted in this analysis as a day not at home. Looking at the impact of maternal economic activities on child health we see that a higher percentage of the women with malnourished than with normal weight-for-age children sold commodities in the market. A m o n g women who had a malnourished child, 93% said they sold at market compared to 77% of those who had normal weight-for-age children (chi square = 5.26, d f = 1, P < 0.05). There was no relationship with gardening activities. In summary, these bivariate analyses of variables associated with malnutrition in other studies suggest that households with malnourished children are more

Relationship to mother Female Older daughter Mother Female neighbor Mother-in-law Sister-in-law Aunt

Niece Sister Female servant Female total

Pamela I. Erickson likely to be relatively more economically stressed than households without malnourished children due to a greater n u m b e r of young children in the household, more closely spaced births between children, fewer adults per child to contribute to child care and income, and less material wealth (as measured by roof type). There is no difference in child nutrition status by maternal gardening activities. However, maternal market activities appear to be important to child nutritional status, perhaps due to the fact that marketing activities take the women away from the house for more extended periods of time. A greater proportion of households with a malnourished child than those without have mothers who sell commodities in the market. While the majority of women with nutritionally normal children also sell in the market (77%), almost all (93%) of the women with malnourished children do so. Thus, selling in the market may be a further indicator of strained economic circumstances in the household and marketing may be more of an economic necessity for those households with malnourished children.

Care giver when mother is away As described above, the majority of women in this sample were away from their children for a considerable proportion of the week and relied on substitute care givers while they engaged in activities away from home. On the average these mothers were away from home 4.6 days per week. Contrary to expectations based on a review of the literature which indicated that the majority of alternate child care givers in developing countries are women, a surprisingly high proportion of regular alternate care givers in this sample (45%) were males, usually husbands or older brothers (see Table 3). Female care givers included older daughters, mothers and other adult female relatives. Data were collected on the characteristics of the

Table 3. Market care givers (P = 0.016) Total Normal

Malnourish.

20 17 5

13 12 3

7 5 2

4 3 2

2 2 2

2 1 --

2 1 1 55 (55%)

2 -1 37 (66%)

--

28

11

17

5 1 1 1

8 ---

1

-18 (42%)

Male Husband

Older son Father Father-in-law Younger brother Male total

13 1 1 1 44 (45%)

19 (34%)

25 (58%)

Totals

99

56

43

--

Male care givers and child health persons who took care of the children while the mother was working in the garden or at the market. In a small number of cases the garden was loc/~ted in the yard so a substitute care giver was not needed. Of the women who needed child care while they worked in their gardens (N = 82), 27% relied on a male care giver. The average age of these care givers was 33 ( + 22.3) with a median of 20 years of age. More than a quarter of these care givers (29%) were under the age of 15. Most of the mothers (93 %) went to the market and relied on substitute care givers to care for their children while they were selling or buying at the market. Among those who needed a care giver while they were away at the market (N -- 99), almost half (45%) relied on male relatives. The average age was 37 ( _+ 20.2) years with a median of 39. Care givers under the age of 15 represented 17% of this group. Age of the alternate care giver was not related to child nutritional status, but sex of care giver was. A greater proportion of households with a malnourished child had a male care giver during female gardening activities (38%) than among households with a normal weight-for-age child (18%; chi square=4.16, df= 1, P <0.05). This relationship was even more dramatic for marketing activities where 62% of households with a malnourished child used a male care giver when the woman was away at the market compared to only 33% of households with a normal weight-for-age child (chi square--7.96, df = 1, P < 0.01). When a woman reported that she used a male care giver for gardening she always used a male care giver for marketing as well. Thus, a significant proportion of children were cared for by male care givers for a substantial portion of the week, and only a small percent of the mothers (16%) prepared food for their children before leaving, the remainder expected someone else, usually the care giver, to prepare the children's food while they were away. IMPACT OF GENDER OF CARE GIVER ON CHILD NUTRITION

Stepwise discriminant analysis was performed to see whether the variables known to be associated with compromised nutritional status in children predicted normal weight-for-age and malnourished children in this sample. Independent variables included number of children in the household (range, 1-9); birth spacing (in years, range 1-3) between the index child and its next oldest sibling (children with no older sibling were assigned the maximum interval); education level of the mother (0 = never attended school, 1 -- Ist to 4th grade, 2 = 5th to 7th grade); presence of a tin roof (0 = no, 1 = yes); ratio of adult females to children under the age of 15 in the household (range, 0.4-7); and sex of care giver while the woman markets (0 = male, 1 = female). The analysis included the 95 cases of the 99 households for women who SSM 43/4--("

485

Table 4. Stepwisediscriminantanalysisfor child nutritionalstatus (iv = 95)

Variable

Partial R 2

F

Probability > F

Number of children 0.0464 4.627 Roof type 0.0615 6.226 Sex of care giver 0.0530 5.322 Wilks' lambda~ 0.828 6.559 Average canonicalsquared correlation= 0.1716

0.0340 0.0143 0.0232 0.0004

market which had information on all variables of interest. The final model included number of children, roof type and sex of care giver (see Table 4). In this analysis roof type is the most important contributing variable followed closely by sex of care giver and number of children, and the model explains 17% of the variance in child nutritional status. Thus, having a greater number of children in the househol d, a male care giver when the woman markets, and being relatively more economically deprived (as indicated by roof type) discriminate child nutritional status relatively well in this sample. When stepwise discriminant analysis is run separately by sex of care giver while the woman markets, further corroboration of the impact of economic deprivation is revealed. Among women who market and use a female care taker while they are away, only the economic variable, roof type, enters the final model, predicting 7% of the variance in child nutrition. When a male cares for the child when the woman is away at the market the economic variable and birth spacing remain in the final equation, and birth spacing is the more important variable. The model for male care givers discriminates nutritional status better than that for female alternative care givers explaining 18% of the variance in nutritional status (see Table 5). Thus, it appears that, overall, relative economic deprivation, and number and spacing of children are important discriminating variables for child nutritional status in this sample. This effect is exacerbated by birth spacing between children and the sex of the alternative care giver when the woman goes to the market. Short birth intervals have their greatest effect on nutritional status when the alternative care giver is a male. This relationship is shown graphically in the model produced by SYSTAT's LOGIT analysis (see Fig. 1.). Table5. Stepwisediscriminantanalysisfor childnutritionalstatusby sex of care giver (N = 95)

Variable

Partial R2

F

Probability> F

Female care giver (N = 52) Roof type

0.0719

4.026

0.0500

Male care giver (N = 43) Birth spacing Roof type

0.1215 0.0611

5.945 2.734

0.0190 0.1057

4.459

0.0175

Wilks' lambda = 0.825

Average canonical squared correlation = 0.1751

486

Robin B. Devin and Pamela I. Erickson

o

O.

= O.

c

O.

,.D

o.

O0

Fig. 1. LOGIT model. Parameter 1 Constant 2 Woman 3 Month

Estimate - 1.852 1.189 0.043

S.E. 0.649 0.481 0.017

T-ratio - 2.853 2.473 2.554

P -Value 0.004 0.013 0.011

95.0% Bounds Parameter 2 Woman 3 Month

Odds ratio 3.285 1.044

Upper 8.432 1.079

Lower 1.280 1.010

Log likelihood of constants only model = LL(O) = 59.607. 2*[LL(N)- LL(0)] = 17.508 with 2 df Chi-sq P-value = 0.000.

The probability of normal weight-for-age is three times higher if the alternate care giver is a woman and the probability of normal weight-for-age rises 4.4% for each month separating the index child from its next oldest sibling. Since having a male rather than a female as an alternate care giver had a significant effect on child nutrition net of other variables such as child spacing and relative SES, we performed further analysis to determine whether males were used in situations of 'last resort' since the literature on other less developed areas of the world indicate that it is typically females who care for children. The child to adult female ratio was significantly related to gender of care giver. Those households with a higher child to female ratio (i.e. more children per adult women) were more likely to utilize males as alternate care givers than households with lower child to female ratios, indicating a lack of available adult females in households

using male care givers ( F - 16.457, d f = 1, P < 0.001). The children cared for by males had an average of 4.0 ( _+2.5) children per female over age 14 compared to 2.6 ( + 2.5) for households using female alternate care givers, and this relationship persisted when stratified by nutritional status of the index child. Thus, it appears that males are used as alternate care givers primarily when women are not available to take on these roles. This suggests that households that do not have access to grandmothers, older daughters or other female relatives for child care are at a disadvantage when the mother must go to market and indicates the importance of the contribution of female labor to child well-being. DISCUSSION

Since the statistical analysis showed that males are typically used more often as substitute care givers in

Male care givers and child health households that have a higher child/female ratio this suggests that male substitute care givers are used only when a female is not available. They also may be caring for children who are more at risk for malnutrition to begin with due to the smaller birth interval between children in the male care giver group. In an attempt to more fully understand the association between the gender of the substitute care giver and child health status, follow-up interviews were conducted with several women who had reported that the father of their children cared for the sample child on market days. These women were questioned in some detail about the tasks performed by the male care giver during her absence. Additional interviews were also conducted with several fathers whose wives had reported their participation in child care. From these data a picture emerged of fathers who do prepare meals for their children when the mother is not there and who may also wash and dress them in the mother's absence. However men are not with the children throughout the entire day. They, too, leave the house to tend for animals which must be moved two or three times a day to other grazing areas or to work in their fields. The children in most cases are left in the care of the oldest sibling who may be as young as five years of age. In fact, in travelling throughout these villages during the interview period we often found children home alone in the care of a young sibling. In one case we arrived at the home of one of the research participants to find seven children (the youngest being one year of age) left in the care of a young girl about eleven years old. Thus, the mother's report that her children are cared for by their father or an older brother in her absence may in fact mean that the children are left by themselves a large part of the day. One example from our study included a family of five consisting of a mother, father and three young girls aged five, three and two years. During our interviews the mother reported that she left the children in the care of their father when she went to the market. A follow-up interview with the father revealed that he left the girls alone while he tended his animals or did necessary work in his fields during the day. On the other hand if mothers report that grandmothers or older female siblings care for the children in her absence this may mean that the female care giver is physically present during the majority of the day. An alternative explanation for the correlation between male care givers and poorer child health status may be due to the relative lack of knowledge that men have of nutrition. Interviewing revealed that most females, even those who do not participate in mothers' groups which provide information on nutrition, have absorbed the messages about what constitutes a healthy diet. When asked what foods they would give their children if they could choose any of the foods available in the Haitian diet, women choose some variation of a balanced meal. The men who were asked this question, however, either responded

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that all foods are equally beneficial or selected a food that may be filling, such as plantain, but which is lacking in protein and vitamins. Other men expressed the opinion that a meal is not complete unless it includes meat, a food that most Haitian families cannot afford. This difference in the understanding of adequate nutrition may be one of the major factors which contributes to better care giving by females as opposed to males. As a result of these research findings, the H H F Primary Health Care Outreach Program in Jcremic has begun the establishment of Men's Groups in the villages which they serve. The purpose of these groups is to provide fathers with education and guidance in better managing their family responsibilities. Like the Mother's Groups already established in these villages, the Men's Groups will provide health messages on nutrition, the importance of vaccines, and other information that will allow them to better provide for their children. The response to the establishment of these groups has been very well received. As of March 1995, 550 men had already enrolled in Men's Groups and additional groups were in the process of being formed. Continued research to evaluate the effectiveness of these groups is in the planning stagcs.

CONCLUSION

As research on the relationship between women's work and child health continues in the less developed world it is hoped that more attention will be devoted to the characteristics of substitute care givers. Those concerned with promoting enhanced opportunities for women through development projects have begun to pay attention to the effects of such projects on child welfare. Those involved with international health planning are becoming increasingly aware that child survival programs such as immunization and oral rehydration therapy may place additional demands on the time constraints which face Third World mothers [1, 23-25]. As more time is devoted to activities such as these less time becomes available for child care and the issue of substitute care givers becomes even more important. On a larger scale, research, at least within the Caribbean, has documented that international policies such as those promulgated by the International Monetary Fund and the World Bank often negatively impact poor women and their families. Structural adjustment policies in response to regional economic crisis have reduced social services and forced more women into the labor force in order to meet basic needs in response to the rising cost of living [26]. The recent political situation in Haiti has caused increased inflation [27] and forced those already desperately poor to work more to earn less. Such policies which increase the pressure for women to work outside the home translate into reduced time for child care.

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Robin B. Devin and Pamela I. Erickson

T h u s young children appear to be spending more and more time being cared for by those other than their mothers yet little research has been devoted to examining the effects of this phenomena. This study strongly suggests that alternate care givers may be inadequate for small children, particularly if they are males whose responsibilities also take them away from the household for parts of the day. Dependence on such care givers may result in compromised health and nutritional status particularly when associated with other risk factors such as close birth spacing. Further study needs to be devoted to the characteristics of these alternate care givers and to the quality of the care that they are able to provide. The effects of this trend toward what is possibly inadequate child care on the health of young children should be of major concern to researchers. Acknowledgements--This project was funded by a grant from the Operations Research budget of the Haitian Health Foundation Clinic, a USAID funded humanitarian project in Jeremie, Haiti. Support was provided by Bette Gebrian, R.N., Ph.D., Director of the Primary Care Outreach Program, and all of the HHF staff. The project was made possible by the invaluable work of research assistants, Paula S. Brunache and Louis C. Bourdeau. Special thanks to W. Penn Handwerker, Ph.D. and Pertti J. Pelto, Ph.D., for their assistance during the analysis and write-up stage. Additional funding was provided by the University of Connecticut Research Foundation. Appreciation and admiration are expressed for the kind cooperation of the remarkable women and men of Jeremie, Haiti. REFERENCES

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