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 Table of Contents  
Year : 2014  |  Volume : 3  |  Issue : 3  |  Page : 254-265

Mothers' caregiving resources and practices for children under 5 years in the slums of Hyderabad, India: a cross-sectional study

School of Health Systems Studies, Tata Institute of Social Sciences, Mumbai, India

Date of Web Publication23-May-2017

Correspondence Address:
Rajini Peter
School of Health Systems Studies, Tata Institute of Social Sciences, V N Purav Marg, Deonar, Mumbai 400088
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DOI: 10.4103/2224-3151.206748

PMID: 28612810

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Background: The extended care model of the United Nations Children’s Fund (UNICEF) identifies knowledge/beliefs, nutritional status, mental health, control of resources/autonomy, workload/time constraints and social support as important caregiver resources for childcare. The aim of this paper is to examine the role of mothers’ caregiving resources in child-care practices in slums.
Methods: A cross-sectional study was conducted in 10 slums of Hyderabad, to appraise the caregiving practices and health status of children under 5 years. Data were collected from 506 households, selected through multistage stratified random sampling, and data relating to 451 children aged 6–59 months were analysed. Four caregiving practices were studied: psychosocial stimulation, as assessed by the Home Observation Measurement of the Environment inventory; hygienic care rated by spot-check observation; and meal frequency and dietary diversity based on maternal recall. The role of the mother’s caregiving resources was examined using bivariate and multivariate logistic regression analyses.
Results: More than 50% of the children received good psychosocial stimulation and close to 60% had good hygienic care. About 75% of the children aged 6–23 months had the recommended minimum meal frequency and 13% had the recommended dietary diversity. Mother’s media exposure (odds ratio [OR] 2.25, 95% confidence interval [CI] 1.35–3.77), participation in household budgeting (OR 2.19, CI 1.25–3.83) and husband’s support (OR 2.04, CI 1.28–3.24) were predictors of psychosocial stimulation. Mother’s younger age (OR 1.11, CI 1.04–1.18), poor media exposure (OR 1.95, CI 1.15–3.29), dissatisfaction with life (OR 1.84, CI 1.05–3.24), workload (OR 1.79, CI 1–3.18) and having no money for their own use (OR 1.52, CI 0.95–2.45) placed children at higher odds for receiving poor hygienic care. Leisure time (OR 2.75, CI 1.25–6.06) and participation in budgeting (OR 1.97, CI 1–3.86) were predictors of meal frequency.
Conclusion: Mother’s workload, poor media exposure, dissatisfaction with life, lack of husband’s support and absence of economic autonomy are constraints to good child care in slums.

Keywords: caregiving practices, caregiving resources, dietary diversity, hygienic care, meal frequency, psychosocial stimulation, slum

How to cite this article:
Peter R, Kumar K A. Mothers' caregiving resources and practices for children under 5 years in the slums of Hyderabad, India: a cross-sectional study. WHO South-East Asia J Public Health 2014;3:254-65

How to cite this URL:
Peter R, Kumar K A. Mothers' caregiving resources and practices for children under 5 years in the slums of Hyderabad, India: a cross-sectional study. WHO South-East Asia J Public Health [serial online] 2014 [cited 2021 Mar 7];3:254-65. Available from: http://www.who-seajph.org/text.asp?2014/3/3/254/206748

  Introduction Top

Caregiving practices or behaviours are proximal aspects of a child’s environment which influence their growth and development. The United Nations Children’s Fund (UNICEF) extended child-care framework [Figure 1][1] highlights caregiver characteristics as important caregiving resources. Studies on national data from India and Ethiopia, and research from Accra,[2],[3],[4] indicate that caregiver characteristics/resources affect caregiving practices for children. The World Health Organization (WHO) underscores the need for research on the nature and determinants of child care.[1] India has witnessed a remarkable growth of its urban population and consequently of slums. As per the 2011 Census, onesixth of all urban households (17.4%) in India are slum households.[5] A recent study has shown that growth in populations living in urban slum conditions increases infant and child mortality rates in developing countries.[6] Studies have shown that the health and nutritional status of children of the urban poor in India are similar or worse than children in rural areas, and that they also receive inadequate care.[7],[8],[9] Hyderabad is a fast-growing metropolitan city in India, with 31.8% of all households in the municipal corporation area residing in slums.[5]
Figure 1: The extended model of care (UNICEF) Source: WHO, 2004[1]

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The purpose of this paper is to identify the role of mothers’ caregiving resources on caring practices for children under 5 years in the slum settlements of Hyderabad, India. It is expected that even when poverty and a hazardous environment predispose to undernutrition and ill-health, good caregiving practices will optimize the use of existing resources. It is hypothesized that the mother’s caregiving resources will be significant predictors of child-care practices in slums.

  Methods Top

A cross-sectional survey was conducted in 10 slums of Hyderabad, India, from December 2012 to April 2013, to appraise the caregiving practices, nutritional status and development of children under 5 years of age. Most recent surveys by the Greater Hyderabad Municipal Corporation have estimated the slum population in Hyderabad to be 2 million in listed slums.[10] The population of unlisted slums is estimated at roughly 0.6 million. Data were collected from 506 households with at least one child under 5 years whose mother was alive and staying with the child. If there was more than one child, the last born was selected for data collection. Data from children aged 6–59 months were used. Informed verbal consent was taken from all respondents. Approval from the research and development department of the Tata Institute of Social Sciences was obtained prior to initiation of the study.

The sample size for the child-health survey was estimated as 506, based on the 32.4% prevalence of stunting in Hyderabad slum populations reported in the National Family Health Survey-3 (NFHS-3), with confidence level at 95%, 5% margin of error and a design effect of 1.5. There were 451 children aged 6 months and above in this sample, whose data were studied for this paper.

Multistage stratified random sampling was done, ensuring proportional representation of the population from the central as well as peripheral areas of the city and slums, from the government list of slums and unlisted slums. First, three municipal wards from the central region and two wards from the peripheral regions were randomly selected. Ten slums were randomly picked from selected wards: six slums (four listed [two per ward], two unlisted [one per ward]) from the central region; and four slums (three listed [two per ward and one random], one unlisted [random from three wards]) from the peripheral regions of the city. If unlisted slums were not present in the selected wards, the ones located nearby were included. About the same number of households (51 listed/50 unlisted) from each slum were included to reach the sample size of 506.

In order to select mother–child dyads from the slums, a lane was randomly selected to begin the survey and households with under-fives were enrolled in the study. Once the first lane had been surveyed, eligible households from the adjacent lane were approached and so on until the required number for each slum was reached. Children who were acutely ill or had congenital defects, and those whose mothers had migrated to the city in the past 6 months or were not willing to participate in the study were excluded.

The details of household, child and mother characteristics were obtained from personal interviews with the mother. A semistructured interview schedule was developed based on the caregiver and household determinants of child health reported in the literature. The tool was pretested in 25 households. All interviews were conducted in local languages.

The caregiving practices studied were psychosocial stimulation, hygienic care, meal frequency and dietary diversity. Psychosocial stimulation refers to the extent that the environment provides physical stimulation through sensory input, as well as emotional stimulation provided through an affectionate bond between the caregiver and the child.[11] It was measured by the Home Observation Measurement of the Environment-Short Form (HOME-SF), a standardized inventory for measuring the quality of a child’s home environment.[12]

HOME-SF is a modification of the HOME inventory[12],[13] and comprises observation and mother reports measuring emotional support and cognitive stimulation provided to children. It has four parts, one part each for: children under 3 years, those between the ages of 3 and 5 years, ages 6–9 years, and 10 years and older. In the present study, the first two parts were used with slight modifications for the slum population, after translation into the local languages. Hygienic care was assessed by a spot-check observation of 13 hygiene aspects, namely: cleanliness of the mother; the child’s hands and body; the child’s bottom; the child’s play area; the house; the compound; the cooking and serving vessels; observation of whether the child had any underwear; whether drinking-water was kept covered; whether there was any stagnant water in and around the house; whether there was any soap near the hand-washing area; whether there was any detergent near the utensil-washing area; and asking how stool last passed by the child was disposed of. Each positive observation was scored one and a total score was calculated. For assessing feeding practices, the mother was asked to list all foods and liquids consumed by the child in the previous 24 hours.

The mother’s caregiving resources [Table 1] were selected based on UNICEF’s extended care model [Figure 1]. Maternal literacy and media exposure were included as proxies of the mother’s knowledge and beliefs, and body mass index (BMI) indicated nutritional status. Questions were asked about the mother’s happiness and general satisfaction with married life, the financial situation of the family, her own health, and the child’s health and care. A composite score derived by principal component analysis was used as a proxy for measuring the mother’s lack of stress and mental health. Control of resources or financial autonomy of the mother was assessed by asking whether she was currently employed, had money that she alone could decide how to use, and whether she participated in family budgeting. The mother’s workload was assessed by the amount of leisure time available per day and social support obtained from the husband in helping to care for the child and in home tasks. The mother’s age was also included in the resources list, as older age has been proven to be advantageous for child care. Based on previous research, several covariates were considered as potential confounders of the relationship between the mother’s resources and caregiving practices; these are listed and explained in [Table 1].
Table 1: Characteristics of children, households and mothers

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Psychosocial stimulation was evaluated by computing the summated scores of each child derived from the HOME-SF inventory. As the maximum score varies by age (6–35 months, 36–60 months), HOME score quartiles of each group were calculated separately and children were grouped as having high, moderately high, medium or poor HOME scores. Total scores obtained for each child for hygienic care fell into three groups and children were categorized as having good, average or poor hygiene. Minimum meal frequency and dietary diversity are two important indicators proposed by WHO to assess infant and young child feeding of children aged 6–23 months.[14] Hence, for this study, the feeding behaviours of only 248 out of 451 children aged 6–23 months were considered. For breastfed children, the following were considered the minimum requirements: a meal frequency of two times if the child was 6–8 months, and three times if 9–23 months. For non-breastfed children, a frequency of four times for all ages was considered the minimum needed. For calculating dietary diversity, a score based on seven food groups was created. The food groups used for calculation were grains, roots, tubers; legumes and nuts; dairy products; flesh foods; eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. For each food group, one point was added to make a final score out of seven; scores more than or equal to four are considered adequate by WHO standards.

Logistic regression analysis was done to determine the predictors of child-care practices. The role of mother’s caregiving resources was tested using bivariate and multivariate logistic regression. For regression analyses, scores in the two lower quartiles were considered as unsatisfactory outcomes (<62% of the total score) for psychosocial stimulation, and for hygienic care the two lower tertiles (≤69% of the total hygiene score) were considered unsatisfactory. As dietary diversity including four groups or more was infrequent in slum children, analysis was done for factors facilitating consumption of at least three food groups. In the bivariate analysis, the association of caregiving practices with each dependent variable was assessed. All variables of interest with a probability value less than 0.30 on bivariate analysis were included in the multivariate analysis. Two models were examined: one with caregiving resources alone, and another controlling for potentially confounding child and household characteristics. The analyses were done using SPSS version 15.0.

  Results Top

Out of 451 children, 248 (55%) were aged 6–23 months, 271 (60%) were male children, 111 (25%) were third or more in birth order, and 70 (16%) had less than 24 months of preceding birth interval. Sixty-nine per cent (311) had fathers who were literate, and 37% (165) had fathers who were unskilled labourers. Most of the children (304 [68%]) belonged to nuclear families. Out of the 451 households, 267 (59%) belonged to the three lower quintiles of the wealth index, 228 households (51%) had doubtful food security and 120 (27%) did not have any toilet. Seventy per cent (317) of households depended on a public tap or tanker trucks for drinking water, and 294 (65%) households were crowded and had to accommodate four or more persons in a sleeping room. About 28% of families were residing in unlisted slums [Table 1].

Regarding the mother’s caregiving resources, the mean age of the mothers was 24.8 ± 3.9 years. About 42% (188) were illiterate, only 156 (35%) had good exposure to the media, and 110 (24%) had a BMI of less than 18.5 kg/m2. Despite living in slums, 80% (362) of mothers were generally satisfied and happy with their lives. Out of 451 mothers, only 76 (17%) were employed, 312 (69%) had money of their own that they alone could decide how to use, and 308 (68%) participated in family budgeting. Eighty-four (19%) mothers did not get even 2 hours leisure time per day, and 228 (51%) did not receive any support from their husbands in child care or home tasks [Table 1].

Caregiving practices

[Table 2] shows the psychosocial stimulation and hygienic practices of children under 5 years in the slums of Hyderabad, India. Classification of children aged 6–35 months and 36–59 months based on their HOME scores are listed, along with range and mean scores. Among 451 children aged 6–59 months, 122 children (27%) received high cognitive and psychosocial stimulation (78–100% of total scores) at their homes. While another 26% (117) received moderately high levels (65–78% of total scores) of stimulation, the remaining 45% (212) received only poor-to-medium levels (28–61% of total scores) of stimulation in their homes. The hygiene scores of 185 (41%) households were not satisfactory (range 1–9; 8–69% of total scores). Among 248 children aged 6–23 months, 74% (183) received at least the minimum number of feeds/meals required; however, the quality of feeds or dietary diversity of 87% (215) of children was suboptimal (fewer than four food groups) and 55% (137) of children had a diet of items from fewer than three food groups.
Table 2: Caregiving practices for children aged 6–59 months in the slums of Hyderabad, India

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Bivariate analysis

[Table 3] presents the results of bivariate analyses examining the association between the mothers’ caregiving resources and caregiving practices for children. All mothers’ characteristics except BMI and employment status were associated with psychosocial stimulation. BMI, participation in budgeting and support from husbands were the only factors not associated with hygienic care. Mothers’ literacy, media exposure and satisfaction with life had very strong (P <0.01) associations, and having money for own use had moderately strong (P <0.05) associations with psychosocial stimulation and hygienic care. As to feeding practices for children under 24 months, not many maternal factors demonstrated association. While mothers’ participation in budgeting (P <0.1) and amount of leisure time per day (P <0.05) were associated with meal frequency, media exposure and BMI were weakly associated with dietary diversity (P <0.1).
Table 3: Association of mothers' caregiving resources with caregiving practices for children: bivariate analyses using logistic regression

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[Table 4] presents the results of bivariate analyses, testing the association of child and household characteristics with caregiving practices. Child’s birth order, preceding birth interval, father’s literacy, occupation, food security, wealth index, toilet facilities, source of drinking water, type of slum and crowding were strongly associated with psychosocial stimulation (P <0.01). In the same way, all the above characteristics except birth interval and crowding (P <0.05), along with family type, were strongly associated (P <0.01) with hygienic care. Child’s age (P <0.01); family type, food security and toilet facilities (P <0.05) were found to influence a child’s meal frequency. Child’s age (P <0.01), wealth index, crowding and source of drinking water (P <0.05) were the factors associated with dietary diversity for children aged 6–23 months.
Table 4: Association of child and household characteristics with caregiving practices for children: bivariate analyses using logistic regression

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Multivariate analysis

In model 1 of the multivariate logistic regressions, where all maternal resource variables were included, adjusting for their combined effects on child care, maternal literacy (OR 2.04), media exposure (OR 3.09), participation in family budgeting (OR 1.75) and support from the husband (OR 1.46) retained associations with psychosocial stimulation. Model 2 shows ORs derived after adjusting for the confounding child and household variables, and all except maternal literacy proved to be predictors of psychosocial care: media exposure (OR 2.42; 95% confidence interval [CI] 1.51–3.88), participation in family budgeting (OR 2.19; 95% CI 1.25–3.83) and support from the husband (OR 2.04; 95% CI 1.28–3.24) [Table 5]. The association with mothers’ leisure time was not significant (P <0.1) when child and household factors were controlled.
Table 5: Predictors of satisfactory psychosocial stimulation and good hygienic care for children aged 6–59 months in the slums of Hyderabad, India: logistic regression (multivariate with alternative models)

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With respect to hygienic care, mothers’ age (OR 1.1), literacy (OR 2.31), media exposure (OR 1.95), satisfaction with life (OR 2.14) and leisure time per day (OR 2) maintained associations in model 1. When all covariates were included in the analysis (model 2), maternal literacy showed no significance. Maternal age (OR 1.11; 95% CI 1.04–1.18), media exposure (OR 1.95; 95% CI 1.15–3.29), satisfaction (OR 1.84; 95% CI 1.05–3.24) and leisure time (OR 1.79; 95% CI 1–3.18) were significant predictors of hygiene. Interestingly, the mother having her own money demonstrated a non-significant association (P <0.1) when child and household factors were controlled. [Table 6] shows the multivariate analysis results relating to the feeding practices of children under 2 years. In model 1, leisure time/day (OR 2.47; 95% CI 1.2–5.07) demonstrated a significant association with meal frequency. Association of participation in budgeting was not significant (P <0.1). None of the maternal factors was significantly associated with children’s dietary diversity except for media exposure and BMI, which showed a non-significant association (P <0.1). In model 2, available leisure time (OR 2.75; 95% CI 1.25–6.06) and participation in budgeting (OR 1.97; 95% CI 1–3.86) demonstrated significant associations with children’s meal frequency. Except for BMI demonstrating a weak association (OR 1.7; 95% CI 0.92-3.13), none of the maternal factors was associated with dietary diversity. The child’s preceding birth interval and household wealth index were associated with psychosocial stimulation; birth order, wealth index and source of drinking water were associated with hygienic care; family type and the child’s age were associated with meal frequency; and the child’s age was significantly associated with dietary diversity.
Table 6: Predictors of minimum meal frequency and dietary diversity (≥3 food groups) in children aged 6–23 months in the slums of Hyderabad, India: logistic regression analysis (multivariate with alternative models)

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  Discussion Top

This study was intended to identify the maternal resources or characteristics that influence caregiving practices and to evaluate their relative importance while controlling for household and child factors.

Psychosocial and cognitive stimulation is an important child-rearing practice directly related to child development and this has been corroborated by studies on HOME scores and child development.[15],[16] HOME scores assess the quality and quantity of support for and stimulation provided to children at home. It has been proved that psychosocial stimulation also promotes children’s growth and nutrition.[17] Hygiene practices also play an important role in the health and nutrition of children by reducing infections and promoting appetite, and thereby food intake. A slum study in Kenya demonstrated that good hygiene behaviour reduced the risk of diarrhoea.[18]

The present study establishes the mother’s exposure to media and economic autonomy as beneficial for psychosocial stimulation and hygienic care. The media exposes mothers to modern child-care practices and reinforces the importance of hygiene, play, toys and parental involvement in care. For women who live in slums and who barely move out of their homes (the few employed women went to nearby workplaces), television is the most accessed (73%) medium and opens windows to the outer world. It familiarizes the women with the practices and lives of their counterparts in higher socioeconomic groups, and these subsequently affect their behaviour. Exposure to television and radio were found to be more effective than community events in raising awareness about hand-washing in Ghana.[19] Media exposure has also proved to be an important factor for good feeding practices for children in India,[2] Ethiopia[3] and Sri Lanka[20] and this underscores it as an important resource for women.

Autonomy in financial matters gives women the freedom to allocate money for items they consider important. Involvement in the family budget allows a woman to allocate resources for child-care equipment, and having money in her hand will allow her to use it for items such as soap when they are needed rather than depending on her husband. It will instil a sense of accountability in the mother that will positively affect the quality of child care. This is supported by a study proving that women’s autonomy is beneficial for children’s nutrition.[21]

Support by the husband, shown to be a positive factor for psychosocial stimulation, is a morale booster for women, providing companionship and extra time, and thereby improving the quality of child care. Its effect was shown to be larger in the second model, reiterating that if child and family characteristics remain constant, support by the husband is an important determinant of the quality of child care. Socioeconomic status and parental education have been found to be consistently associated with HOME, both in this and earlier studies.[17],[22] Maternal literacy was not significant in this study, probably because the stimulation activities assessed are associated with a higher level of education, which is not the case in slums.

Mother’s age, dissatisfaction with life and workload were also found to affect hygienic care. With each added year of maternal age, the odds of hygienic care being good increased 1.11 times. Very young women might not be physically and mentally ready for the additional responsibilities of child care and societal expectations of family life. Similarly, high workload deprives mothers of the much-needed time and energy for child care. When the mother feels happy or satisfied with life, it reflects the absence of stress and anxiety, and psychological well-being. The mother’s mental health or presence of a mental disorder has been established as an important determinant of childhood infections and nutrition in countries including India, and the pathway for mental health to child health and nutrition will be through child care.[23],[24] The mother’s satisfaction with life was found to be beneficial for hygiene in this study, and this suggests to the possibility of infections when satisfaction is lacking.

Minimum meal frequency and dietary diversity are indicators that measure the quantity and quality of complementary feeding of children 6–23 months old, which is the age when major growth problems occur. It was interesting that different sets of maternal resources were found to be connected with the two indicators in the bivariate analyses; this indicates that quantity and quality are decided by different maternal capabilities.

While age, literacy, workload, support by the husband and participation in budgeting showed a connection with meal frequency; media exposure, BMI, satisfaction, employment and participation in budgeting were loosely connected with dietary diversity. This is probably because dietary quantity needs time and support to use the food already available, while quality requires a conscious initiative from the mother. The multivariate analyses found workload and budget participation to be associated with meal frequency, but it did not find any maternal factor associated with dietary diversity. Financial autonomy has been proven to be beneficial for child feeding.[25]

It was very hard for employed women in slums to find time for child care. Unsurprisingly, children belonging to nuclear families were at higher odds for not having minimum meals, which underscores the need for community support systems for working mothers in slums.

This study of a representative sample from the slum population of Hyderabad investigated caring practices of a fairly large age group of children (6–59 months). A major limitation was that there was only one observation set for all practices.

In order for the care received by slum children to be improved, their mothers should be exposed to the media and have more financial autonomy. Health messages through media and context-specific empowerment programmes might also help. Encouraging the husband’s involvement in child care and mobilizing community support systems for slum women will also be beneficial.

A focus on caregiving practices without concern for resources might lead to the unfortunate result of accusing the mothers of inadequate child care, rather than recognizing a lack of resources available to them. Policy-makers will find the above-mentioned measures less capital intensive and more effective in building a resurgent slum populace.

Source of Support: None.

Conflict of Interest: None declared.

Contributorship: RP: concept, design, acquisition, analysis and interpretation of data and drafting the article; KAK: concept, design, editing and revision of the article.

Acknowledgements: The authors would like to acknowledge the help received from Dr N Balakrishna, Scientist, National Institute of Nutrition, Hyderabad, in the statistical analysis for the study.

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