Heavy agricultural workloads and low crop diversity are strong barriers to improving child feeding practices in the Bolivian Andes

Abstract

Most nutrition initiatives to date aimed at improving infant and young child feeding (IYCF) have emphasized addressing knowledge gaps through behavior change messaging with less focus on addressing the underlying environmental barriers that may shape these behaviors. This research integrates an analysis of longitudinal dietary data with qualitative data on barriers to improved child feeding to identify the nature and extent of the barriers caregivers face to improving IYCF practices in a farming region of the Bolivian Andes, and to determine the relative influence of these barriers on caregivers' abilities to improve IYCF practices. Sixty-nine caregivers were selected from a sample of 331 households that participated in a longitudinal survey assessing changes in IYCF practices among caregivers with children aged 0–36 months from March 2009 to March 2010. Forty-nine barriers within 12 categories of barriers were identified through semi-structured interviews with the 69 caregivers. The most frequently reported barriers were those related to women's time dedicated to agricultural labor, the limited diversity of household agricultural production, and lack of support for child feeding from spouses and mothers-in-law. In multivariate analyses controlling for several variables that could potentially influence IYCF practices, these barriers were negatively associated with changes to the diversity of child diets, child dietary energy intake, and child meal frequency. While knowledge gaps and individual-level influences affected IYCF practices, physical and social caregiving environments in this region of Bolivia were even more important. Behavior change communication alone will likely not address the social and environmental barriers to improved child feeding that often prevent translation of improved knowledge into action. Particularly in rural regions, agriculture may strongly influence child feeding, not only indirectly through household food security, but also directly by affecting women's caregiving capacity.

Introduction

Over the past two decades, the nutrition community has increasingly recognized the importance of “care” for mothers and children as a critical underlying determinant of child nutrition. This concept of “care” refers to many different practices that caregivers, mostly women, perform that influence the nutrition, health, and cognitive development of children (Engle, Menon, & Haddad, 1997). A central component of care is infant and young child feeding (IYCF), a set of practices that includes breastfeeding, complementary feeding and the multiple factors that inform these practices (Dewey, 2003).

This increasing recognition of the importance of IYCF is reflected in the many recent nutrition initiatives that have included IYCF as an explicit focus or key component of their programs (AED, 2006; Caulfield, Huffman, & Piwoz, 1999; Dewey & Adu-Afarwuah, 2008; Menon et al., 2007; Penny et al., 2005). These programs frequently employ behavior change communication (BCC) strategies (Finnegan & Viswanath, 2008), targeting individual pregnant and lactating mothers, or groups of these women, for behavior modification through counseling and media messages.

Many of these programs have documented improvements to child diets and child growth, yet it is not clear that insufficient knowledge or poor attitudes and perceptions about IYCF are the most important limiting factors to improving how young children are fed and cared for in low-income settings. A recent Lancet review of interventions that work to reduce maternal and child undernutrition revealed that complementary feeding support and educational strategies benefited populations with adequate incomes and sufficient access to appropriate foods, while in food-insecure populations, these strategies were effective only when combined with food supplements (Bhutta et al., 2008). This suggests that some foundation of food and livelihood security must exist to adequately capture the benefits of behavior change communication efforts. Indeed, as compared to normative systems of beliefs and knowledge, environmental influences on food and livelihood security as well as social constraints on individuals' actions may play equally important or even dominant roles in determining behaviors (Bronfenbrenner, 1979; McLeroy, Bilbeau, Steckler, & Ganz, 1988; Pepitone, 1981; Stanton, Black, Engle, & Pelto, 1992; Stokols, 1996).

The fields of public health and health promotion, as well as nutritionists in high-income countries researching obesity, often use ecological models for addressing health-related behaviors (Hermstad, Swan, Kegler, Barnette, & Glanz, 2010; Kaufman & Karpati, 2007; Killingsworth, 2003; Merzel & D'Afflitti, 2003; Miller, 2011; Sallis, Neville, & Fisher, 2008). Some intervention programs focused on IYCF have recognized the importance of physical, social, and policy environments in shaping behaviors (Briscoe & Aboud, 2012; Paul et al., 2011), yet the operational activities of most IYCF programs to date have emphasized behavior change messaging and provision of fortified or improved complementary foods.

This research examines the barriers that caregivers face to improving IYCF practices in the northern Potosí region of Bolivia, a rural farming and herding region located in the central highlands of the country. For individuals in communities that depend on agriculture as their principal source of livelihood, like those in northern Potosí, agriculture and the natural environment influence many aspects of daily life, particularly for women. Women comprise 25 percent of the agricultural labor force in South America and 43 percent in all developing countries (FAO, 2011). In many countries, including Bolivia, the percentage of women involved in agriculture has increased in the past 30 years (in Bolivia the percentage has risen from 33 percent in 1980 to 42 percent in 2010) (FAO, 2011).

Agriculture may affect IYCF practices in several ways. For example, agricultural labor may take time away from child care (Paolisso, Hallman, Haddad, & Regmi, 2001), or force caregivers to feed children in work environments that are not amenable to nurturing interactions between the mother and child (Narayanan, 2008; Ukwuani & Suchindran, 2003). High agricultural workloads, occupational health risks, as well as exposure to toxins and disease through agricultural activities (Hoddinott, 2011) can deleteriously affect women's health and nutrition which may have important negative consequences for maternal lactation (Rasmussen, 1992) and child feeding behaviors. Despite recent attention to the linkages between agriculture and nutrition, both in the academic literature (Arimond et al., 2010; Masset, Haddad, Cornelius, & Isaza-Castro, 2012) and in high-level policy circles (Fanzo, 2011), the implications of changes to agricultural production systems and rural livelihoods on caregiving and IYCF practices have received less attention than the potential for agriculture to influence nutrition by increasing food availability and household incomes.

This research seeks to identify the nature and extent of the barriers caregivers face to improving IYCF practices in northern Potosí, Bolivia and to determine the relative importance of these barriers by examining the association between barriers and caregivers' abilities to improve IYCF practices.