The Associations Between Maternal Education And Child Health In Poor Minority Region

Child health has always been the focus of research on health in the developing countries, which is because child health is a sensitive and an important index which represents the health condition and living standards in a counry. Childish health will be related to adult health, income and attainment.Since its founding 60years ago, child health of China has been sharply improved with the region differences and urban and rural differences. In 2007 infant mortality and mortality of children under five years old in countryside are 141.6%,142.2% higher than in city separately; child malnutrition rates under five years old in countryside triple that in city; the proportion of low birthweight is 200% higher in countryside. In 2000 field survey in 6counties of 6 provinces show that stunting rate of poor rural child is 43%, which nearly double higher than national rural average rate(22.6%), and especially it is as high as 72%. The child health is essentially restricted by unilateral economic growth, which ignore the comprehensive, coordinated economic and social development, the low level of education and culture is its long-term factors.It is broadly focused in international social demography, ecnomics and health policy filed that maternal education as one of exogenous social ecnomic determinants significantly protects child health. The evidence that maternal education exerts positive effects on child health is found in many countries, which is mostly and particularly the less-developed countries of Asia, Africa, Latin America and the Pacific and partly developed countries. However, the effects are not always definite and there are the differences between countries and regions, which are strong or slight, and even lost. Moreover whether maternal education or income is more important in determining child health is in debate. Therefore, research interests turns to how maternal education interacts with other household and community endowments and through which paths or mechanism maternal education influences child health, which is expected to explain these phenomena. The direction of interaction effects is inconsistent, which is different in different countries, regions and with different household and community variables and shows complementary or substitutive effects or even no significance. Three paths which mediate effects maternal education predicts child health are nature/gene effect, economic/income effect, nurturing/behavior effect suggested by researchers. The evidence-based study on nurturing/behavior path, simple and effective muti-dimention measurment scale for nurturing effect and rigorous tests of mediation effects are scarce, which result in disputable relative importance of them. Few resarches are focused on child morbidity and malnutrition rate, while mostly on child mortality; the data are overwhelmingly from DHS of one country or more countries, the result of which is not persuasive and specific.Domestic research in the field are not broadly conducted and only few researchers on economic systematically explore the associations between maternal education and child health. The direction and significance of associations between them is variable; mediate effects and interactive effects are just separately explored while they are not both involved in the research. Data are dominantly from national survey, which are secondary data and moslty before 2000. While the significance of maternal education and its nurturing path vary with the economic development, to what extent and through which does maternal education influence child health and how is effectively improved child health in contemporary social economic cultural situation in poor minority region. New evidence-based research will answer these questions, which help timeliness and effectiveness of health policy.The general objective of this study is:based on the theoretical study and the evidence-based analysis, establish and verify a theoretical model which explains how maternal education influences child health in poor minority region, and put forward some suggestions of improving child health via female edeucation human capital investment and health education. The specific objectives include:establishing a theoretical model which explains how maternal education influences child health; analyzing whether and to what extent maternal education influences child health and the interaction effect between maternal education and household or community variables; identifying the factors influencing health literacy; revealinging the mediate mechanism between maternal education and child health.The study complements evidence from China cultural setting for international research on maternal education and child health, especially scarce researches on maternal education and child nutrition, broadens the research thought of a proxy for nurturing effect, and provides rigorous analysis approach to mediate effect. Meanwhile, the study complements evidence for a pilot intensive study and provides a powerful statistical model for domestic study.Data and MethodsThe data sources of this study include all kinds of published or unpublished literature, physical measurements with standard protocol and questionnaire for children, household questionnaire and key informant interview. Using purposive sampling, this study selected 7 rural primary schools in three counties-Yuanzhou district, Xiji county, Pengyang county of Guyuan city in Ningxia Hui Autonomous Region as the study sites.2017 children were involved in physical examination and questionnaire,1474 children’s caregivers including 1209 mothers in the household questionnaire in June 2010. The key informant interview involved 13 mothers of school-aged children (5 the Hans and 8 the Huis; 6 illiterate,5 primary and 2 second educationed),2 directors of township health center,2 maternal and child heath professionals and 2 teachers of primary school in Xiji and Pengyang county in November 2010. Considering the survey costs and the local dialect, we trained the 33 undergraduates from Ningxia Medical University and 12 graduates from Shandong University to complete the survey.The content analysis was used to analyze the qualitative data. For the quantitative data, we first showed some descriptive and comparative statistic results about the demographic-social-economic status of the whole sample and the children health of the stratified sample for the illiterate and literate mothers, the poor or non-poor households, and the chuan, the montanic and the hilly residence place. Then the status of child health (indicated by height for age, weight for age and BMI for age) were described and compared for the whole and different demographic characteristic sample, and then the Mixed Linear Model with control of random error associated with household level was applied to analyse the associations between maternal education and child heath(indicated by height for age) and meanwhile the interaction effect between maternal education and residence or household income. Lastly the original health literacy indicators were described and compared among different educationed mothers, and we successively extracted 5 health literacy factors and 1 high-order factor by factor analysis, and then the path analysis was used to reveal the mediate mechanism of maternal education and child health (indicated by height for age). The analysis of quantitative data was done by SPSS 13.0 software.Main results(1)Description of maternal education and social economic and child health of stratified sample:the proportion of illiterate mothers is 44.7%, and maternal average schooling years are only 3.48. The proportions of poverty, illiterate fathers, montanic redidence, Hui nationality in stratified sample of illiterate mothers are respectively 1.5 times,3.90 times.1.95 times and 1.85 times as many as those of literate mothers. The proportions of illiterate mothers, illiterate fathers, non-tap water, montanic redidence in stratified sample of poor household are respectively 1.58 times,1.61 times,1.07 times and 1.20 times as many as those of non-poor household. The proportions of illiterate mothers, illiterate fathers, poverty, non-tap water, Hui nationality in stratified sample of montanic residence are respectively 1.61 times,1.71 times,1.17 times,1.07 times and 1.44 times as many as those of literate mothers. It takes more time to access the nearest health facilities for illiterate mothers, poor household and montanic residence. HAZ, WAZ for children of illiterate mothers and montanic residence are significantly lower, while those of poor and non-poor household show no significance.(2) Description of child health:The average HAZ, WAZ and BAZ vary between-1 and 0, and are significantly lower than reference standards of WHO. Stunting rate, underweight rate, wasting rate, overweight rate and obesity rate are 11.8%,12.4%, 11.5%,5.8% and 1.5% respectively. The nutritional problems of child are dominantly malnutrition and scarcely overweight and obesity in poor minority region.(3) The main effect and interaction of maternal education and residence place:In mixed linear model random effect analyses show that the scores for HAZ are clustering in family, and ICC (intra-class correlation coefficients) in household level is 0.1804, which means that between-household variation associated with child HAZ is 18.04% and mainly derived from gender difference. In MLM fixed effects analyses show that with control of interference including child individual endowment, household and community endowment and the interaction effect between maternal education and residence place maternal education significantly protects child HAZ(main effect), which specified that child HAZ increases 0.0897 with the growth of 1 year of naternal schooling. My findings support a complementary effect between maternal education and residence place, which specified that with control of other determinants the gap of child HAZ between the Chuan and the montanic residence is widened by 0.0609 with increasing lyear of maternal schooling, which means that the better community environment is more beneficial to child health from advantageous households with higher education. However, the interaction between maternal education and household income shows no significance. Household income, child age and nationality have significant effect on child HAZ. Child HAZ rises by 0.2104 with increasing one unit of logarithm of household income. Child HAZ of the Hui nationality is 0.2170 less than that of the Han nationality. Child HAZ declines by 0.0703 with increasing 1 year of child age.(4) Influencing factors of health literacy:5 factors including "health knowledge" "health instrument operational ability", "health information presentation ability" "health belief and "health behavior" are extracted by exploratory factor analysis, and total factor score of health literacy is constructed by high-order factor analysis based on the evidenced data. Single or multi-variate analyses show that maternal education is the main determinant of maternal health literacy and explains 47.4% variation of health literacy. Maternal health literacy decreases with the growth of maternal age. Paternal education has "spillover effect" on maternal health literacy. Health literacy of mothers with the Han nationality in the chuan, the hilly residence place is higher than that of ones with the Hui nationality in the montanic residence. Maternal health literacy increases with household income rising. In multi-variate analysis maternal education, maternal age and paternal education are common determinants of 5 health literacy factors. Qualitative analysis shows that health literacy of educated mothers is higher, and the level of education of mothers with the Hui nationality in remote monatic residence is very lower, and combines with lower health belief and rural farming burden to hinder maternal health care behavior.(5) The paths through which maternal education influence child health:In path analysis of the simultaneous effects, mediation effects that household income, health literacy and both exert are 0.0158,0.0649 and 0.0807 respectively when maternal education predicts child health, and common mediation effect accounts for 21.84%of total effect and explains 1.14% of variation of child health. T test verifies that the path of health literacy is more important than that of household income. In path analysis of the separate effects, health knowledge, health belief, and health behavior partly mediate the effects that maternal education predicts child health, while health instrument operational ability and health information presentation ability have no significant mediate effects.Conclusions and policy implicationsIn poor minority region the low-quality maternal education has strong positive impact on child health, and strong complementary interaction effects with community endowment (indicated by residence place) which results in child health inequity. The children of the less educated mothers have disadvanged household and community resources, and similarly the availability and accessibility of public and health resources. Household income and maternal health literacy partly mediate the association between maternal education and child health, and health literacy path is more important. The status of maternal education, health literacy and child health are different in different community and nationality. Consequently, the reinforce of maternal or female child education human capital investment and health education interventions may be helpful in improving the whole child health to some extent in the long or short run, nevertheless, attributed to the difference in communities and nationalities, the effects would be restricted and the gap between child heath is widen if infrastructure, public and medical facilities and service and ethnic culture in montanic area were not simultaneously strengthening.We put forward the following suggestion for the improvement of child health and health inequity:(1) reinforcing the rural female education human capital investment, especially the Hui female child to exert intergenerational benefits and accelerate rural economic development; (2) Strengthening infrastructure and medical facilities, especially in montanic residence, to relieve the heavy farm burden, promote information communication and ensure health and resource equity; (3) implementing health education intervention to improve maternal health literacy, and the less educated Hui mothers residing in mountains are the target population, thus the child health equity is ensured and accompanied by the growing whole level.