EFFECT OF MATERNAL LITERACY ON NUTRITIONAL STATUS 0-5 YEARS
CHAPTER TWO
REVIEW OF LITERATURE
INTRODUCTION
Our focus in this chapter is to critically examine relevant literature that would assist in explaining the research problem and furthermore recognize the efforts of scholars who had previously contributed immensely to similar research. The chapter intends to deepen the understanding of the study and close the perceived gaps.
Precisely, the chapter will be considered in three sub-headings:
- Conceptual Framework
- Theoretical Framework
2.1 CONCEPTUAL FRAMEWORK
Concept Of Maternal literacy
Maternal education is an important topic for economists, sociologists, healthcare practitioners, and politicians as a potential determinant factor in child health. Although education is important for every individual, it is especially significant for girls and women (World Bank, 2013). According to the International Conference on Population and Development (ICPD) Programme of Action, paragraph 4.2, “education is one of the most important means of empowering women with the knowledge, skills and selfconfidence necessary to participate fully in the development process” (Promoting Gender Equality, 2013). This statement is true not only because educational attainment is an avenue to newer and better prospects such as more autonomy, greater skills and better paid jobs, but also because women’s education has a continuing effect on the family and community, and possibly for the following generation. Mothers who are more educated may have a positive effect on child health status via improved knowledge about nutrition and health care behaviors, provision of better sanitary conditions and safer environmental surroundings (Desai & Alva, 1998; Glewwe, 1999; Currie & Moretti, 2003; Lindsay et al., 2009). Mothers with higher schooling are more likely to be healthier, ensuing better genetic traits via genetic imprinting, which may impart better health to their children 4 (Behrman, Hrubec, Taubman, & Whales, 1980; Behrman & Wolfe, 1987; Ishida & Moore, 2012). A better understanding of how a mother’s education influences children’s health will shed light on how improving local, national, and global public health policies regarding maternal education will enhance children’s health outcomes (Chen & Li, 2009). In summary, the nutritional environment encountered by the fetus during gestation affects his/her health not only at birth but also during infancy and adulthood (Langley-Evans S.C. 2014). Pregnancy is a dynamic period where the mother’s energy is in high demand, and either qualitative or quantitative suboptimal consumption of nutrients may predispose the future child to lifelong health problems such as metabolic syndrome, weakened immune system, and cardiovascular diseases (Tarry-Adkins & Ozanne, 2011). Furthermore, child health status has become a key indicator of economic development given its association with educational attainment, productivity, and income (Case, Lubotsky, & Paxson, 2001). Among the potential determinants of child health status, the mother’s education via better nutritional knowledge, better health care, and healthier behavior plays a crucial role in averting children’s unhealthy outcomes. Reducing the childhood morbidity and mortality by improving maternal health is of great importance for the improvement of children’s health and future generations.
Concept Of Nutrition
The major purpose of this series of four textbooks on nutrition is to guide the nutrition student through the exciting journey of discovery of nutrition as a science. As apprentices in nutrition science and practice students will learn how to collect, systemize, and classify knowledge by reading, experimentation, observation, and reasoning. The road for this journey was mapped out millennia ago. The knowledge that nutrition – what we choose to eat and drink – infl uences our health, well-being, and quality of life is as old as human history. For millions of years the quest for food has helped to shape human development, the organization of society and history itself. It has infl uenced wars, population growth, urban expansion, economic and political theory, religion, science, medicine, and technological development. It was only in the second half of the eighteenth century that nutrition started to experience its first renaissance with the observation by scientists that intakes of certain foods, later called nutrients, and eventually other substances not yet classifi ed as nutrients, infl uence the function of the body, protect against disease, restore health, and determine people’s response to changes in the environment. During this period, nutrition was studied from a medical model or paradigm by defi ning the chemical structures and characteristics of nutrients found in foods, their physiological functions, biochemical reactions and human requirements to prevent, fi rst, defi ciency diseases and, later, also chronic noncommunicable diseases. Since the late 1980s nutrition has experienced a second renaissance with the growing perception that the knowledge gained did not equip mankind to solve the global problems of food insecurity and malnutrition. The emphasis shifted from the medical or pathological paradigm to a more psychosocial, behavioral one in which nutrition is defi ned as a basic human right, not only essential for human development but also as an outcome of development. In this fi rst, introductory text, the focus is on principles and essentials of human nutrition, with the main purpose of helping the nutrition student to develop a holistic and integrated understanding of this complex, multifaceted scientifi c domain.
Concept of Undernutrition
Undernutrition, is defined as the inadequate food intake or faulty assimilation, and includes low birth weight, stunting, wasting, underweight and micronutrient deficiencies (World Food Programme, 2012). Malnutrition is the leading cause of death among children under the age of five (WHO, 2012), causing nearly half (45%) of child deaths, and accounting for at least 3.1 million deaths in 2011 (Black et al., 2013). Often associated with poverty, malnutrition has been regarded not only as a public health issue, but also as a medical, social, political and economic problem (Monte, 2000; (Muller & Krawinkel, 2005)). The short- and long-term adverse effects of malnutrition on the wellbeing of children are well established in the scientific literature (Caulfield, Richard, Rivera, Musgrove, & Black, 2006). Adequate nutrition is necessary for early childhood to support proper growth, organ formation, cognitive development, and immune system function (Muss, 2011; Monte, 2000; Gonzalez-Barranco & Rios-Torres, 2004). Also, the nutritional status of the mother plays an essential role during pregnancy and fetal development, and as such is influenced by biological, social and environmental factors (Guoyao, Bazer, Cudd, Meininger, & Spencer, 2004). Research suggests that a mother’s nutritional status during and even before pregnancy exerts a powerful influence on lifelong health of a child (Barker D. J., 1997). The environment that the fetus encounters in utero shapes everything from disease susceptibility to metabolism, and brain function (Barker, 2004). An abundance of evidence from epidemiological, experimental, and clinical studies demonstrates that early-stage events play an influential role in the predisposition, later in life, to a plethora of metabolic disease issues (Gluckman, Hanson, Cooper, & Thornburg, 2008) as well as neurological and cerebral health (Schilling, Aseltine, & Gore, 2007; Georgieff, 2007). Sound nutrition can positively alter a child life by supporting physical, mental and emotional development. It thus helps to build a strong foundation that may result in higher educational achievement and greater labor productivity. The current health of a nation, to a significant degree, reflects the past and present health of its children as human development and economic growth require well-fed populations that can acquire new skills and think critically to contribute positively to their communities (Black et al., 2008; Liu et al., 2012; Horton, Alderman, & Rivera, 2008). Pregnancy is a dynamic, anabolic state in which the mother-to-be experiences many physiological adaptations, including cardiovascular, renal, and respiratory (Iva, 2013). Also, gestation is a period characterized by continuous change in maternal energy needs, to support the energy demands of the growing fetus (King, 2000). The anabolic state of the mother-to-be during pregnancy, as a consequence of the constant breakdown and synthesis of tissues, leads to an increased need for energy. However, the energy expenditure of pregnancy changes according to gestational periods. (Lain & Catalano, 2007). Hence, caring for the health of the future mother in conjunction with the prenatal and postnatal periods is crucial for the health of the child (Williams & Ross, 2007; Hypponem, Power, & Smith, 2004). Child health has increasingly been recognized as a key indicator of economic development and considered by many experts as an accurate reflection of society’s progress (Boyle et al., 2006; Ducan, Brooks-Gunn, & Klebanov, 1994; McLoyd, 1998). Furthermore, child health has also been linked to other economic indicators, such as, educational attainment, productivity, and income (Knudsen, Heckman, Cameron, & Shonkoff, 2006; Case, Lubotsky, & Paxson, 2001; Currie & Hyson, 1999). There are a number of contributing factors to consider; while some have been studied at length, others have been given insufficient attention yet very few have solid conclusions. Elucidating the complex multifactorial determinants that influence children’s health is of vital importance to the children, their families, and society in general (Neligan & Prudham, 1976; Blau, 1999; Silberg, Hermine, & Lindon, 2012; Fuentes-Leonarte, Jose, & Ferran, 2008). Among the key mediating factors affecting child health, maternal education has been shown to have a positive impact (Behrman & Wolfe, 1987).
Maternal Education And Children’s Health Status
James Wolfensohn, former President of the World Bank, once quoted an African proverb: “If we educate a boy, we educate one person. If we educate a girl, we educate a family—and a whole nation” (Knowles, Lorgelly, & Owen, 2002). The World Bank states that a women’s education is the “single most influential investment that can be made in the developing world” given that women’s education is not only a powerful instrument of change but also increases economic growth and improves child health (World Bank, 2013). Several studies have indicated that improving a woman’s educational attainment leads to her emancipation and autonomy within the household, allowing her to make critical decisions as well as to attain participatory influence over the allocation of resources (Caldwell, 1979; Caldwell, Reddy, & Caldwell, 1982). Moreover, apart from the acquisition of knowledge and values conducive to social development, maternal education facilitates the expansion of logical and critical thinking. By breaking away from old attitudes, beliefs, and practices mothers are encouraged to accept newer approaches regarding healthcare procedures, which lead to healthier outcomes for their children (Glewwe, 1999). In addition, a mother’s education may have a transgenerational effect because mothers who are more educated are more likely to engage in healthseeking behavior, which may leads to healthier children (Schultz, 1984; Behrman & Wolfe, 1987). Although there is a general consensus on the inverse association between maternal education and child health, the mechanisms by which this relationship affects child health is not well understood or agreed upon (Caldwell, 1979; Schultz, 1984; Behrman, 1990; Desai & Alva, 1998; Bicego & Boerma, 1993; Miller & Rodgers, 2009). 6 John Caldwell investigated the role of maternal education on child mortality in Nigeria and proposed possible pathways through which mother’s educational attainment may affect child health (Caldwell, 1979). Subsequently, a large body of research has suggested that maternal education is the most important contributing factor to a child’s well-being, even more important than paternal education, socioeconomic status, and the utilization of healthcare services (Caldwell, 1979; Schultz, 1984; Martin, Trussel, Salvail, & Shah, 1983; Glewwe, 1999). A better understanding how maternal education affects child health may help shed some light on the complexity of the factors involved in a child’s well-being. Schultz (1984) contended that mothers’ education may affect child health in at least five different ways: (1) education may impart better utilization of health inputs in the production of a healthier child; (2) mothers who are more educated may change their perceptions regarding how best to allocate resources for the betterment of children’s health; (3) educated mothers may enhance family wealth status—even though many times they do not participate in the labor force but engage in positive assortative mating, marrying wealthier men; (4) schooling may incline parents’ preferences for fewer but healthier children; and (5) more educated mothers may ascribe a higher value to their time, particularly when they work outside the home. Paradoxically, education could be a negative factor in child health by reducing both the duration of the breastfeeding and the time allocated to healthcare (Murtagh & Moulton, 2011).Validating Schultz’s point of view, Glewwe (1999) also argued that a mother’s education is the primary predictor of child health by two principal arguments connected to health knowledge:
- Health knowledge may be the most significant skill that mothers indirectly acquire from their schooling years that equips them with the necessary tools to contribute to their children's health.
- Health knowledge’s actual impact on child health may be underestimated due to endogeneity bias.
- In addition, Glewwe reasoned that mothers who are more educated are more likely to have greater household assets and income than mothers who are less educated. Hence, mothers who are more educated have greater access to better food, housing, and modern health services, which leads to better child health. Conversely, while it has been asserted that maternal education is the most significant predictor of child health, there still is a considerable debate over the extent to which this relationship operates. More recently, it has been suggested that despite the high correlation between maternal education and the health status of the child, mother’s education functions as a substitute for the socioeconomic status of the family and geographic area of residence (Desai & Alva, 1998; Hobcraft, 1993). Moreover, is suggested that education of other members of the household does have a significant if not sometimes a larger effect (Lindelow, 2008). Additionally, child health may be influenced by other factors such as maternal alcohol consumption, prenatal/postnatal care, and birth order (Maitra, Peng, & Zhuang, 2006). Simply, maternal education effects decline considerably once these factors are in play. None of these studies suggest that female education has no impact on child health, rather they suggest that the relative contribution of other pathways may be of equal or higher importance to the health of the children such as socioeconomic, demographic, and environmental determinants. 8 Education, maternal education in particular, has been stressed by a number of studies as a powerful instrument for change, and a vital contributor to economic, social, and political development in society (WHO, 2013). Women who are more educated are healthier, have fewer children and are able to provide better health care and education for their children, are better able to participate in the labor force and earn more income, all of which improves the well-being of all family members and in turn can lift the household out of poverty (World Bank,2013). Furthermore, promoting female education considerably improves the health status of the next generation. Although Schultz (1984) and Glewwe (1999) contended that the mother’s education is the primary predictor of child health status by changing perceptions, gaining general knowledge, and improving wealth status, others, such as Desai (1998) and Hobcraft (1993), have argued that, while maternal education is a significant predictor of child health, there are other predictors, such as socioeconomic and environmental factors, of equal or higher importance.
Socioeconomic Status And Children’s Health Status
Socioeconomic status (SES), whether measured by education, occupation or material wealth is considered as a key predictor of children’s health ( Bradley & Corwyn, 2002). Given that children born to well-off parents and/or parents who are more educated have better access to education, food, health care, and benefit more from material and genetic inheritances than disadvantaged parents and mothers who are less educated (Boyle et al., 2006; Adler et al., 1994; Bradley & Corwyn, 2002). Also, evidence demonstrates that socioeconomic status is associated with mortality and morbidity rates, anthropometric measurements, cognitive development and emotional problems (Adler & Newman, 2002; Hackman & Farah, 2009). These outcomes begin prior to birth and 9 continue into adulthood (Bradley & Corwyn, 2002). A significant indicator of a society’s development is the mortality rate among infants as child health is positively associated with educational attainment and increased power to buy goods and services (Cleland & Ginneken, 1988).Moreover, women who are more educated are more likely than less educated women to find better jobs, allowing them to increase family income and assets, which in turn gives them access to more nutritious food and shelter (Barret & Browne, 1996). Additionally, women who are more educated are likely to marry husbands with better education and higher income compared to less educated women (Barret & Browne, 1996; Cleland & Ginneken, 1988) The influence of maternal education on child health is not only due the mothers’ individual contributions, but also to the total contribution of other family members and other households. Together, they provide the necessary factors to promote healthy development (Collins, Maccoby, Steinberg, Hetherington, & Bornstein, 2000). Fathers, on the other hand, have typically been defined by their income role (Mosley & Chen, 1984). However, they play other roles that are essential to a child’s psychological and physical development, such as physical security, emotional support, and models of behavior (Coley, 1998). For example, a father’s occupation is strongly associated with neonatal, infant, and child mortality (Bicego & Ahmad, 1996). On the other hand, fathers are also involved in raising and nurturing their children, resulting in their higher educational achievement and improved emotional state (Flouri, 2006; Sarkadi, Kristiansson, Oberklaid, & Bremberg, 2008). The multifaceted nature of socioeconomic status (SES) includes not only income, but also education, occupation and social prominence (American Psychological 10 Association, 2014). Parental socioeconomic status can influence child health outcomes over and beyond early development (Bradley & Corwyn, 2002). Disadvantaged children have poorer physical, social, emotional, and cognitive development than children from higher socioeconomic strata (Najman et al., 2004). Greater household income allows parents to purchase better food and cleaner water and provide better education and better healthcare. Thus, mothers, fathers, extended family, and public health officials can increase the likelihood of a child to have a happy and healthy life by improving living conditions and providing physical, social, cultural, emotional, and intellectual support (Seabrook & Avison, 2012).
Household Environment And Children’s Health Status
The effects of the home environment have emerged as a strong predictor of children’s well-being (Evans G. W., 2006). The place where they live, learn and grow including house, school, and neighborhood as well as exposure to toxic chemicals, noise, and crowding have a profound effect on their health status (WHO, 2008). Children are distinct from adults in their susceptibility to the harmful health effects of biological, chemical and environmental threats because children are anatomically and physiologically different from adults. Proportionate to their body weight, children drink more water, eat more food and breathe more air (National Academy of Sciences, 1993). Also, children’s metabolic pathways, especially in the first months of life, are not fully developed and they can be easily either impaired or disrupted by exogenous toxins, when compared to those of adults, (Landrigan & Garg, 2002). Therefore, they are particularly vulnerable to a multitude of environmental insults in general, and in particular to indoor 11 air pollution and pathogenic microorganisms (Committee on Environmental Health, 2004). Indoor air pollution plays a substantial threat to child health. It increases the risk of chronic obstructive pulmonary disease (COPD) and acute lower respiratory infections in childhood—the leading cause of death among children under five years of age (Bruce, Perez-Padilla, & Albalak, 2000). In developing countries, there are two main sources of indoor air pollution that affect children development: parental cigarette smoking and the burning of solid fuels (WHO, 2012). The association between parental cigarette smoking and children’s pulmonary function is well stablished in the scientific literature. Despite the fact that it is difficult to differentiate the independent influences of smoking during intrauterine and extrauterine development, (Strachan & Cook, 1997), there appears to be a causal relationship between maternal smoking during pregnancy and acute lower respiratory illnesses, lower birth weight, and preterm delivery (Chiolero, Bovet, & Paccaud, 2005). In addition to parental smoking, there is another important source of indoor air pollution that significantly affects children’s health—the burning of solid fuels. Approximately three billion people worldwide use solid fuels, such as biomass, coal, wood, crop residue, and dung to cook and heat their homes, using either open fires or leaky stoves (WHO, 2013). The incomplete combustion of these household fuels exposes those inside—mostly young children and their mothers—to a plethora of hazardous pollutants. Many pollutants regularly found in indoor air, such as CO, CO2, methane, and black soot, have been shown to adversely affect children’s physical development including inflammation of the airways and lungs, TB, and COPD (Bruce, Perez-Padilla, & Albalak, 2000; Misra, Srivastava, Krihnan, Sreenivaas, & Pandav, 12 2012), and some evidence exists associating indoor air pollution to low birth weight and stillbirth (Pope et al., 2010). Diarrheal disease is the second leading cause of infant mortality worldwide, mostly predominant in developing countries (WHO, 2009). In 2009, it was estimated that 1.5 million children under the age of five died from diarrhea, caused mostly by contaminated water and food (WHO, 2009). Even though some diarrheas are caused by errors of metabolism or chemical irritations, the vast majority is due to a pathogenic infection, either viral, bacterial, or parasitic infection (Cairncross, 1979; Gracey, 1997). Improving domestic hygiene practices is conceivably one of the most efficacious behaviors in decreasing the incidence of diarrhea in young children worldwide (Curtis, Cairncross, & Yonli, 2000). Based on the studies discussed, it can be inferred that conditions within the household are of crucial significance for children’s health. Compared to adults, children breathe more air, drink more fluids, and eat more food in proportion to their body weight when compared to adults, making them more vulnerable to the detrimental effects of indoor pollutants, unsafe water, and contaminated food (May, 2000). Consequently, their developmental growth may be hindered when they are exposed to toxins, and faulty nutrition and other stressors (Grantham-McGregor, et al., 2007). Many determinants, including indoor air pollution, disease vectors, and water and food quality may affect child health (Stieb, Chen, Esshoul, & Judek, 2012; UNICEF, 2013).Disease vectors, along with water contamination, may harbor pathogenic organisms capable of causing gastrointestinal disturbances that may trigger diarrhea, one of the leading causes of child death around the world (Chelala, 2014). To improve children’s health, it is imperative 13 that we accurately assess the causes and consequences of the different routes of contamination as well as ways to remedy such household pollutants.
Stunting and Wasting
Stunted growth or stunting occurs when a child is short for his or her age, when compared to international growth references for children of same sex and age. It is caused by long-term failure to meet micro/macro nutrient requirements for proper growth, especially in utero or during the first two years of life (UNICEF, 2012). Children whose height-for-age was more than two standard deviations bellow the median of the NCHS/CDC/WHO international references standard for children of the same sex were categorized as stunted (WHO, 1995). Children’s age, sex, and height were gathered into the Children’s Recode according to standardized protocols set forth by the Demographic 28 and Health Surveys. Stunting reflects the extent to which a child is either experiencing long-term nutritional shortages or suffering the detrimental consequences of other factors, including chronic or recurrent illness (WHO/UNICEF, 2013). The adoption of these standards is based on the observation that well-nourished children in all population groups follow very similar patterns in growth as they age. Consequently exhibiting the same distributions of weight and height at given ages (de Onis & Habicht, 1996). Wasting occurs when a child’s weight is too low for his or her height, and is a strong predictor of mortality among children under the age of five. Wasting is a shortterm condition, usually the result of either acute malnutrition or chronic disease, including parasitic infections and diarrhea, both of which cause weight loss. A child is classified as wasted when his/her z- score for weight-for-height is less than two standard deviations below the median of the NCHS/CDC/WHO international references standard for children of the same sex and age (WHO, 1995).
Low Birth Weight
Low birth weight (LBW) is defined as being born weighing less than or equal to 2,500 g, due to either premature birth or fetal growth restriction, or a combination of both (UNICEF/WHO, 2004). The Demographic and Health Surveys for the aforementioned countries collected both a subjective and objective measure of birth weight. However, we used only objective measurements for our analysis because subjective measures may not represent the actual weight of the baby due to biased interpretations.
2.2 THEORETICAL FRAMEWORK