Interview with Hinke Haisma, University of Groningen

Hinke Haisma explains how Amartya Sen’s capability approach is used in the field of child growth by examining how capabilities of mothers and children affect health outcomes.

Interview conducted on May 4th, 2014

1. What do you think about current concepts of equity and equality? What concept do you use?

In our research, we try to work from Amartya Sen’s capability approach. I think this approach provides a lot of insights and possibilities in which we can examine all sorts of social problems from different perspectives. Specifically, we incorporate this approach in the field of child growth. We try to address questions such as, what are the capabilities of mothers, of children, and how do these capabilities affect health outcomes in the end? That, in a sense, is our framework related to equity. So what are the capabilities of a mother, of children and how do they affect health outcomes in the end?

We envision equity as being very much about fairness and equal opportunity.
But then the issue of freedom of choice is also important and relevant. This is simply because it is imperative that the opportunities exist, but then which opportunities people take and don’t take in some respect is also a matter of choice.

2. What do you think are the main causes of inequities? What are the structural issues that don’t enable children to grow up in a world that is more fair?

That is a very big question. Part of it starts at the political level. Inequity is almost inherent to our neoliberal political system. But there are also matters of unequal distribution which express themselves both globally and regionally. Poverty is also an important component. We would normally like to think that the more affluent households have more opportunities than the poor, but what I actually found in my research in Brazil is that in some respects the opposite was true. In a sense, the poorer children were doing better than the more affluent ones in some respects. Let me explain.

My research was on the differences in energy utilization between rich and poor children. I had hypothesized that the poorer children would expend more energy because they would suffer from health issues more often than the more affluent ones, and thus expend more energy in the fight against infections for example. But in the end I found out that the poorer children were using more energy but it wasn’t because they were ill more often, but because they were expending more energy in activities.

These findings are in line with the fact that at this stage of development in Brazil it is the children from more affluent households whom we find with more weight problems, being heavier than those who are poor. All of this lead us to question the extent to which children from high socioeconomic status should be taken as the norm, and then also as the norm of those multicenter growth standards that have been developed by the World Health Organization (WHO). These findings are very interesting given that what we see is that inequality is not unidirectional.

3. What can your current research contribute to increased equity for children?

My current research, in a team of researchers including Dr. Sepideh Yousefzadeh, Shirish Darak and Zaina Mchome, looks at growth-monitoring tools. At the moment, measuring child growth involves only looking at weight and height. We feel this doesn’t give health professionals a good tool to advise mothers in their respective positions. One of the main problems is that these growth curves are based on children from high socioeconomic status and that this is seen as the standard. Thus, what we see is that these growth-monitoring tools only offer the medical dimension. There is no assessment of context, whether biological, socioeconomic, or cultural. In the end, if the child is being weighed and measured and is plotted against these curves, the advice provided to mothers is as one-dimensional as it is being monitored. What we would to see is other dimensions being incorporated into the monitoring tools, all of which can be applied when translating the growth of the child back to the mother.

Some of the dimensions we are exploring are cognitive, social, and physical growth itself. And in terms of context, we would like to know whether the mother works for example, whether the child is being breastfed, and whether there is an extended family to care for the child. All these things matter if you think about caring for a child. A child’s health is not just constituted by weight and height. It is this multidimensional picture that needs to be considered. Much of this is not being done at the moment or only on an ad-hoc basis as it involves spending more time with a mother and asking some of these important questions.

In this particular study, we will look to examine these relationships in Brazil, Netherlands, Tanzania, and India. We are trying to cover a wide range of realities in an effort to show that one size does not fit all. We want to include even cases at the end of the spectrum; asking mothers in Tanzania preferably from a hunting and gathering tribe, for example, how they perceive growth in their children. We also want to do this in the Netherlands, to compare these two extremes and examine our findings.

4. When these extreme cases are considered, do your indicators or the methodology you use vary?

That is a very good question. In the end, it could be that at the global level if you want to compare the growth of children across countries, there need to be a set of indicators that have some universal applicability; thus the questions would be the same. But to then translate your advice back to mothers at the local level, you would probably use different the different findings you obtained in the case of Tanzania for mothers in that country, and not the Netherlands. In this case, the tools ought to be different. At this moment this is not being done, but many people realize that it should.

5. What recommendations would you have for the health sector, or any other sector concerned with social and economic development?

I think for the health sector it is important for the focus of their approach to be “context based”, as we discussed before. This recommendation seems very obvious but we must keep in mind that the approach also varies and is very much dependent upon the discipline your work in. If you work in medical science, it’s so little practice actually to look at anything other than medical parameters, but its also so necessary. The world is too complex to just look at it from one disciplinary perspective.

6. Anything else you would like to share that may be of interest in terms of your research and the promotion of equity for children?

One of the most important points, what I found in Brazil is that the poorer children were actually moving more, were spending more energy in activity. And when we looked at reasons why they did, we were a bit puzzled given that they were only eight months. The lingering question was, “how can a child who is eight months old move more, I mean they can’t even crawl yet?” So then immediately you come to another question, “what is behind these numbers?” What we found to explain the energy expenditure between the children was crowding, which is the number of people who share a bedroom. You can immediately imagine that more people who are poor tend to sleep in a single bedroom. The children of the affluent sleep in a crib quietly, whereas the poorer children sleep in a bed with more people and they go from their mother, to an aunt, to a sister. Thus, in that sense there is much more mobility. But this mobility is a result of their living condition and has a lot more to do with maternal behavior, all which made me more interested in the behavioral aspects and the context in which children live.

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