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The role of maternal literacy and nutrition knowledge in determining children's nutritional status

Parul Christian, Rita Abbi, Sunder Gujral, and Tara Gopaldas

Introduction

A mother is the principal provider of the primary care that her child needs during the first six years of its life. The type of care she provides depends to a large extent on her knowledge and understanding of some aspects of basic nutrition and health care. It is understandable that her educational status has been reported to influence her child-care practices.

During the past decade, evidence has accumulated from several studies that maternal education is an important determinant of infant and child mortality [1, 2]. Chen [2] proposed that children born of educated mothers have a lower mortality risk because educated women tend to marry and have their first child at a later age than uneducated women. They also are likely to be more assertive and to play a greater part in intra-family decision making in favour of their children's needs. Their husbands tend to be economically better off than those of uneducated women. Educated mothers may also make earlier and more effective use of health services. It may be postulated that mothers' education would affect their children's nutritional status by similar mechanisms, and various studies have shown some degree of association between mothers' education and the nutritional status of children [3-5].

It cannot be assumed, however, either that the mothers of malnourished children are necessarily ignorant or that all illiterate mothers. whether their children are healthy or malnourished, are ignorant [6]. Their knowledge of child nutrition and child-care practices can be expected to have a significant bearing on their children's nutritional status, but conflicting results have been reported in this regard. Whereas some studies have observed a positive relationship between childhood malnutrition and maternal knowledge and beliefs regarding nutrition [7, 8]. others have shown no such relationship [9, 10].

In the present study we investigated the effects of mothers' literacy status and nutrition knowledge on the nutritional status of children. We attempted to determine whether literate mothers had better nutrition knowledge and to elicit specifically the impact of mothers' nutrition knowledge on their children's nutritional status, controlling for their literacy status and for family income, which is a well-established factor affecting child nutrition status [8, 11].

Materials and methods

The study was carried out in rural and tribal villages of Panchmahals district of Gujarat state, India, as part of a baseline survey for the USAID-assisted Integrated Child Development Services project.

A pretested questionnaire was used to collect information on the education level and nutrition knowledge of 2,723 mothers. Complete information was not available for all the women, and therefore only 2,665 were included in the analysis.

Educationally, the women were categorized simply as literate or illiterate. as only 6% had any formal education and only 3.2% had studied beyond the primary level.

The women's nutrition knowledge was evaluated on a scale of 0 to 9 on the basis of their responses to a set of nine questions, with one point given for each correct answer and a maximum possible score of 9. The knowledge components tested were the proper age to introduce solid foods into a child's diet, types of solid foods to introduce, frequency of feeding, diet during diarrhoea, management of diarrhoea, awareness of oral rehydration therapy, preparation of oral rehydration solution, causes and treatment of protein-energy malnutrition, interpretation of growth charts, and perception of own child's nutritional status. As a majority of the women had a score of 0 or a very poor score, a score of 4 or above was considered good. The scores were divided into three categories: 0, 1-3, and 4 or above.

The per capita monthly income of the households of the study population was determined by interviewing the head of the family or any other senior member in his absence. The families were categorized as above or below the poverty line, using Rs 65 (US$5) per capita per month as the dividing point, as suggested by the Gujarat Directorate of Health [12].

All the children of mothers in the study 0-72 months old for whom complete weight, height, and age data were obtained [13] - 4,004 out of a total 4,242 children - were included in the analysis. The children were weighed to the nearest 0.1 kg on a Salter-type spring balance. Height was measured to the nearest 0.1 cm using a portable measuring board; supine length was measured for children 0- 12 months old and standing height for those one year old or over. The ages of the children were determined by thoroughly questioning the mothers with the aid of a local events calendar to assist recall.

The cut-off points used were those suggested by the Indian Academy of Pediatrics [14] for weight for age (>80%, normal; 71-80%, first-degree malnutrition; 61-70%, second-degree malnutrition; 51-60%, third-degree malnutrition; <51%, fourth-degree malnutrition), and by Waterlow [15] for weight for height >=90%, normal; 80-89%, mild malnutrition; 70-79%, moderate malnutrition; <70%. severe malnutrition) and for height for age (>=95%, normal; 90-94%, mild malnutrition; 85-89%, moderate malnutrition; <85%, severe malnutrition).

Chi-square values were calculated to determine whether the nutritional status of the children depended on the mothers' (i) literacy and (ii) nutrition-knowledge score, and to study the association between these two independent variables and their individual relationship to the income status of the family. Analysis of covariance was done to study the effect of the mothers' nutrition knowledge on the children's nutritional status, controlling for their literacy status. The per capita monthly income was also included in the model to determine whether the association between maternal nutrition-knowledge scores and child nutritional status was still significant after testing for the confounding effect of income. The anthropometric indicators used were expressed as percentages of the National Centre for Health Statistics median [16] and were treated as dependent variables, with nutrition-knowledge score as the main effect and literacy of mothers and per capita monthly income as covariates.

TABLE 1. Relation between mothers' literacy status and their children's nutritional status as indicated by weight for age

a. "4th"- "1st" indicate degrees of malnutrition.
b. Not significant.

TABLE 2. Relation between mothers' literacy status and their children's nutritional status as indicated by height for age

a. "Severe," "moderate," and "mild" indicate degrees of malnutrinon.
b. Not significant.

Results

Tables 1-3 show the agreement between the mothers' literacy status and the nutritional status of their children by weight for age, height for age, and weight for height respectively. A positive relationship appears to exist: for each of the three indicators, a higher percentage of the children of the literate mothers were of normal status or had a mild grade of malnutrition than of the children of the illiterate mothers, and a smaller proportion of the children of the literate mothers were moderately or severely malnourished than of those of the illiterate mothers. The chi-square test, however, indicated that these differences were not statistically significant.

The mothers' nutrition knowledge on the whole was found to be poor; their mean score was 1.6 out of the maximum of 9.

Tables 4-6 show the relations between the mothers' nutrition-knowledge scores and their children's nutritional status by the three indicators. Good agreement is seen between the scores and the children's weight for age and height for age for all except the oldest age group (37-72 months): a significantly higher percentage of the children 0-36 months old whose mothers scored 3 or less were moderately or severely malnourished than of those of the mothers with a score of 4 or more (tables 4 and 5). A similar effect is seen in the older group, but it is not statistically significant. A significant relation is seen between the mothers' scores and wasting as assessed by weight for height in the children in all the age groups (table 6).

As to the relationship between the mothers' nutrition knowledge and literacy, although the great majority of both literate and illiterate mothers had scores in the poor range (1-3 points), a significantly larger proportion of the literate group (20.9%) than of the illiterate group (4.6%) had scores of 4 or more, while 15.2% of the illiterate group but only 4.8% of the literate group had a score of 0 (table 7). Both literacy and nutrition-knowledge scores were significantly related to family income : a higher proportion of illiterate mothers and those with scores of 0 or 1-3 were from families below the poverty line (Rs 65 per capita per month) than their respective counterparts.

Table 9 shows the results of the analysis of covariance used to determine the effect of the mothers' nutrition knowledge on their children's nutritional status. Both literacy and income were found to be significant intervening factors in the test for the effect of the nutrition-knowledge score on weight for age, whereas only literacy was a significant factor in the case of height for age and income in the case of weight for height. The combined effect of these factors was also significant. Thus, the effect of the nutrition-knowledge scores on weight for age, height for age, and weight for height was highly significant when controlled for literacy and family per capita monthly income.

TABLE 3. Relation between mothers' literacy status and their children's nutritional status as indicated by weight for height

a. Not significant.

TABLE 4. Relation between mothers' nutrition-knowledge scores and their children's nutritional status as indicated by weight for age

****P<.001.

TABLE 5. Relation between mothers' nutrition-knowledge scores and their children's nutritional status as indicated hv height for age

**P<.025.
***P<.005.

TABLE 6. Relation between mothers' nutrition-knowledge scores and their children's nutritional status as indicated by weight for height

***P<.005.
****P<.001.

TABLE 7. Agreement between mothers' literacy status and nutrition-knowledge scores

****P<.001.

TABLE 8. Relation between family per capita monthly income and mothers literacy and nutritionknowledge scores

*** P<.005.
**** P<.001.

TABLE 9. Analysis of covariance of mothers' nutrition-knowledge scores and their children's nutritional-status indicators

* P <.05.

Discussion

Our data reveal a definite but non-significant association between the literacy of the mothers and the nutritional status of their children. However, it may be noted that statistical significance is a strong function of, among other things, the number of observations (sample size), which in the present case is extremely skewed, with only 6% of the women in the literate category.

Other investigators [4, 17] have shown that the number of years of education of mothers had a definite relationship with the proportion of malnourished children and related this to the fact that children's mean daily intake of nutrients increased with the increase in the mothers' educational level. Also, the intake of nutrients by all the children whose mothers had an education only up to primary and middle grades was far below the recommended allowances. In the present study. although the mothers' education level was not considered because of their very low rate of literacy, the difference in the weight and height of children of literate and illiterate mothers was clear.

The relationship between the nutrition knowledge of the mothers and the nutritional status of their children was much stronger. One study [8] reported that mothers' nutrition-knowledge scores were associated with the long-term well-being of children represented by height for age. Our findings show that the mothers' nutrition knowledge did not affect the weight for age and height for age of the children 37-72 months old, whereas acute malnutrition as indicated by weight for height was significantly related to the mothers' knowledge in children of all age groups. It is likely that for older children, other factors have a stronger influence on nutritional status than mothers' nutrition knowledge. Also, by the time children are three or four years old, they may have younger siblings who require maternal care and attention, in which case the older children are likely to be ignored.

Some studies have found no relationship of mothers' nutrition knowledge on the nutritional status of children. On the basis of arbitrarily prepared knowledge and belief scores, one such study reported that the mothers of well-nourished children were as ignorant about essential facts regarding nutrition as those of undernourished children [9]. Similarly, another found that maternal comprehension of home based growth charts had no effect on children's growth [10].

Our findings show a significant difference between the nutrition-knowledge scores of literate and illiterate mothers, with the former having better scores. Income was also significantly positively related to both maternal literacy and nutrition knowledge. The cause-effect relationship in this instance appears to be bi-directional, in that higher income reflects better maternal literacy status and nutrition knowledge and vice versa. Victora et al. [5] demonstrated that income and parental education are strongly correlated, and that maternal education affects child nutritional status even when family income is taken into consideration.

The present study also shows that maternal literacy and nutrition knowledge exerted a significant intervening effect on at most two of the selected anthropometric indicators. However, where significant, regardless of confounding effects. the nutrition-knowledge score had a significant positive effect on all the indicators of child nutritional status. The evidence for a causal association is strongest when it remains statistically significant after family income is taken into consideration. Thus, if mothers have sufficient nutrition knowledge, it is effective in improving the nutritional status of their children. This implies that, although all women do need formal education, nutrition education is a short-term intervention that will have a considerable impact on the community. The need for such education for women is therefore urgent and great in rural and tribal India.

References

1. Caldwell JC. Maternal education as a factor in child mortality. World Health Forum 1981;2:75-78.
2. Chen LC. Primary health care in developing countries: overcoming operational, technical and social barriers. Lancet 1986;2:1260-65.
3. Bhuiya A, Zimicki S, D'Sonza S. Socioeconomic differentials in child nutrition and morbidity in a rural area of Bangladesh. J Trop Pediatr 1986;32:17-23.
4. Bhuiya A, Wojtyniak B, D'Souza S, Zimicki S. Socio-economic determinants of child nutritional status: boys versus girls. Food Nutr Bull 1986;8(3):3-7.
5. Victora CG, Vaughan PJ, Kirkwood BR, Martinez JC, Barcelos LB. Risk factors for malnutrition in Brazilian children: the role of social and environmental variables. Bull WHO 1986;64:299-309.
6. Kimati VP. Who is ignorant? rural mothers who feed their well nourished children or the nutrition experts? the Tanzanian story. J Trop Pediatr 1986;32:130-36.
7. Srikantia SG, Sastry CY. Effects of maternal attributes on malnutrition in children. Proceedings of the First Asian Congress of Nutrition. Hyderabad, India. 1972:584
8. Smith MF, Paulsen SK, Fougers W, Ritchey SJ. Socioeconomic, education and health factors influencing growth of rural Haitian children. Ecol Food Nutr 1983;13:99-lOX.
9. Walia BNS, Gambhir SK. The relationship between childhood malnutrition and maternal knowledge and beliefs regarding nutrition. Ind Pediatr 1975; 12: 563-68.
10. Grant K, Stone T. Maternal comprehension of home-based growth charts and its effect on growth. J Trop Pediatr 1986;32:255-57.
11. Bairagi R. Dynamics of child nutrition in rural Bangladesh. Ecol Food Nutr 1982:13:173-78.
12. Gujarat Directorate of Health, Medical Services and Medical Education. Health statistics. Ahmedabad, Gujarat, India, 1984.
13. Jelliffe DB. The assessment of nutritional status of the community. WHO Monograph Series, no. 53. Geneva: World Health Organization, 1966.
14. Indian Academy of Pediatrics. Classification suggested by the Nutrition Subcommittee of the Indian Academy of Pediatrics, 1971-72. Ind Pediatr 1972;6:360.
15. Waterlow JC. Medical practice. Br Med J 1972;3:566-69.
16. National Center for Health Statistics. NCHS growth curves for children: birth-18 years. United States. DHEW publication 78-1650. Washington, D.C.: Department of Health, Education, and Welfare. 1977.
17. Devdas RP, Rajlakshmi R. Kaveri R. Influence of family income and parents' education on the nutritional status of preschool children. Ind J Nutr Dietet 1980; 17:237-43.

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