Literacy is power: structural drivers of child malnutrition in rural Liberia

Abstract

BackgroundIn Liberia, an estimated 32% of children under 5 are stunted. Malnutrition and hunger worsened during the country’s civil war and were further exacerbated by the 2014–2016 outbreak of Ebola virus disease. Studies examining adherence to recommended infant and young child feeding practices frequently do so with an emphasis on the knowledge, attitudes and beliefs of mothers and caregivers. Often overlooked are the structural factors that enable or constrain their agency to practise evidence-based recommendations.MethodsBetween July and December 2017, we surveyed 100 Liberian mothers to assess the sociodemographic factors associated with the risk of severe acute malnutrition in children in Maryland County, Liberia. We also conducted 50 in-depth interviews at two government health facilities to qualitatively explore mothers’ experiences, as well as health workers’ understandings of the determinants of malnutrition in the region. We applied logistic regression to analyse quantitative data and inductive content analysis to thematically interpret qualitative data.ResultsMothers were less likely to have a child with severe acute malnutrition if they had an income greater than US$50 per month (adjusted OR (aOR)=0.14, p<0.001), were literate (aOR=0.21, p=0.009) or exclusively breast fed during the first 6 months of life (aOR=0.18, p=0.049); they were more likely to have a child with severe acute malnutrition if they were married or in domestic partnerships (aOR=8.41, p<0.001). In-depth interviews elucidated several social, economic and programmatic factors that shaped suboptimal feeding practices, as well as decisions for and against seeking formal care for malnutrition.DiscussionThe lived experiences of Liberian mothers and health workers illustrate that child malnutrition is a direct consequence of abject poverty, food insecurity, illiteracy, the precarious nature of formal and informal work, and the lack of robust social protection. Behaviour change and health education interventions that do not seek to alleviate structural barriers to compliance are unlikely to be effective.

Understanding malnutrition management through a socioecological lens: Evaluation of a community-based child malnutrition program in rural Uganda

“…Women’s lack of access to education and employment increased their financial dependency upon their husbands and left them in precarious situations when they were unmarried. While many studies on malnutrition highlighted that poverty and maternal sociodemographic characteristics could influence children’s nutritional status, 11,54,58 few evaluations of CMAM program consider societal determinants of health in their analysis. Many studies on nutrition nevertheless recommended assessing economic and food needs of entire households, family dynamics, domestic violence, and women empowerment.…”

“…While many studies on nutrition highlight that maternal education, poverty and gender inequality can influence children’s nutritional status (Kajjura et al, 2019; Kumeh et al, 2020; Nankinga et al, 2019; Uddin et al, 2021), few evaluations of CMAM programs consider these factors in their analysis. These studies recommend assessing economic and food needs of entire households, family dynamics, domestic violence, and women’s empowerment (Shah More et al, 2018; Sharma & Subramanyam, 2021; Tette et al, 2016).…”

The future of human malnutrition: rebalancing agency for better nutritional health

“…In turn, inadequate education (< 10 years) and in particular illiteracy, constrain women’s health, agency and opportunities to obtain better paid work which would enable the purchase of (typically costlier) healthier and diverse foods, and also to break out of poverty [ 119 , 120 ]. Working long hours in the informal economy, or returning to school/vocational training (for younger mothers) also means that women have limited contact with infants, limiting the opportunity to breastfeed [ 121 , 122 ]. Collectively, these structural factors not only maintain food insecurity, but also increase maternal stress and mental ill health and undermine their ability to fulfill their roles as mothers [ 123 ].…”

“…Collectively, these structural factors not only maintain food insecurity, but also increase maternal stress and mental ill health and undermine their ability to fulfill their roles as mothers [ 123 ]. Left unaddressed, this cycle of disadvantage is likely to repeat across generations, whereby chronic malnutrition mediates the role of poverty in undermining physical health, cognitive development and academic ability [ 122 , 124 ]. In the most severe conditions, individuals may assert agency against such constraints through collective action.…”

Interplay between Literacy and Health Services Access: The Case of Elderly Exemption Beneficiaries in Tanzania

“…For instance, Sandiford et al (1995) points out that if access to health services were minimal, a child of a literate mother would have more chances of obtaining health care compared to that of an illiterate mother. Further, Kumeh et al (2020), noted that there is positive relationship between the literacy of a mother and child's malnutrition status. This means that regardless of asymmetry in the supply of public goods or services illiterate individuals have significantly less chances of benefiting.…”