In this chapter we consider three markers of child health: two indicators of nutritional status and another indicator to reflect immunisation status, which are regarded as dependent variables in three separate models. In the followings, we illustrate how these dependent variables are measured.
(A) Nutritional status
In order to measure children’s nutritional status, we consider standardised anthropometric indicators i.e. height-for-age and weight-for-age, which are generally used to indicate children’s physical growth. The standardisation, which is termed as Z transformation, is done by comparing the sample children’s anthropometric indicators with the World Health Organization (WHO) reference children’s growth standards. The WHO actually provides a Stata macro for computing the Z score transformation, which we have used in our analysis. Height-for-age Z-score (HAZ) and weight-for-age Z (WAZ) score are defined by the following expressions: h j j ij i σ h h HAZ and w j j ij i σ w w
WAZ , respectively. Where, hij is the observed height of the child- i in group- j, wij is the observed weight of the child- i in group- j; where group j is defined according to child’s gender, and the age in days. The terms hj ,
wj ,
h
j
and wj
are the median height, weight, and standard deviation, respectively in group j, based on the WHO reference children. The WHO reference children are based on an international sample of ethnically, culturally, and genetically diverse healthy children living under optimum conditions that are conducive to achieving a child’s full genetic growth potential. The rationale behind comparing against the WHO child growth standards is that well-nourished children of all population groups follow very similar growth patterns before puberty. These growth standards can, therefore, be used to assess the nutritional status of children all over the world, regardless of ethnicity, social and economic influences, and feeding practices (WHO, 2006). The Governments in many countries including Bangladesh and the United Nations (UN) agencies, therefore, rely on the WHO growth standards tomeasure the general well-being of populations, formulate health and related policies, and plan interventions and monitor their effectiveness (NIPORT et al., 2016; WHO, 2006).
A child who is more than two standard deviations below the median (-2 SD) of the WHO reference population in terms of height-for-age, is considered short for his or her age i.e. stunted. This condition reflects the cumulative effect of chronic malnutrition. If a child is below three standard deviations (-3 SD) from the reference median, then he or she is considered to be severely stunted. Generally, stunting reflects a failure to receive adequate nutrition over a long period and is worsened by recurrent and chronic illness. Height-for-age, therefore, reflects the long-term effects of malnutrition in a population and does not vary appreciably according to recent dietary intake (NIPORT et al., 2016). Among the sample children, about 41 percent children are stunted and 18 percent are severely stunted.
Weight-for-age (WAZ) is a composite index of weight-for-height and height-for-age. A child can be underweight for his age either because he is stunted or is wasted (too thin), or both. Children whose weight-for-age is below two standard deviations (-2 SD) from the median of the WHO reference population are classified as underweight. Children whose weight-for-age is below three standard deviations (-3 SD) from the median of the reference population are considered severely underweight. Thus WAZ is an overall indicator of a population’s nutritional health (ibid). Child wasting has been well recognised as an important underlying cause of young child death (UNICEF, 2003). The WAZ can also be regarded as an indicator of children’s short-term nutritional status because body weight loss is the most immediate consequence of under-nutrition. Among the sample children, 21 percent were underweight and 10 percent were severely underweight.
(B) Immunisation status
Immunisation is a globally recognised factor for reducing infant and child morbidity and mortality, hence immunisation status captures the parents’ attitude towards using preventive health care service. The BIHS collected immunisation information from the mothers of all children under the age of two years. During the survey, the enumerator confirmed the vaccination status from the respective child’s immunisation card. The vaccines for which information was collected are BCG, 3 doses of DPT, 3 doses of Hepatitis B, 3 doses of Penta, 3 doses of OPV, Measles, and Vitamin A. Counting the number of vaccines given to a child yields the variable ‘immunisation status’.
(C) Education10
In this chapter, our key independent variable is education. We measure education in terms of the number of completed years of schooling. The BIHS has collected information on the completed years of education. We consider both mothers’ education as well as fathers’ education. The range of the education variable is 0 to 17 years.
(D) Pathway variables
As it has already been stated, we consider a range of pathway variables in our analysis. We will describe below how the seven potential pathways are defined in our study.
1. Engagement in Income Generating Activities (IGAs): A mother is considered engaged in IGAs if she works or runs a business that brings in cash, food, or allows accumulation of assets for the household. The BIHS has collected this information from the mothers, which we use to generate an indicator such that 1 means the mother is engaged in IGAs, and otherwise 0. Mothers’ engagement in IGAs may contribute to child health both positively and negatively. It may be related positively because mothers’ involvement in IGAs is likely to supplement household income and thereby it may enable parents to choose better health and nutrition inputs. By contrast, it can adversely affect child health, if mothers’ time for providing care is compromised by such engagement. Since women’s participation in the labour market in Bangladesh is not a correlate of educational attainment rather poverty-driven, mothers’ engagement in IGAs may also pick up the negative effect of a poor socioeconomic condition of a household. Thus the relation between mothers’ participation in IGAs and child health could be either positive or negative.
2. Autonomy: We construct an index of autonomy of expenditure decision-making based on the responses to question regarding who decides how to spend on food, housing, health, education, and clothing. All expenditure categories are equally weighted. If the mother alone or jointly with a spouse or other household member takes decisions on how to spend money in those five categories, a value 1 is assigned otherwise 0. Thus the autonomy index of expenditure decision-making ranges between 0 and 5. The
10The education system in Bangladesh is divided into three levels (i) primary (grades 1 to 8), (ii) secondary (grades 9 to 12), and (iii) tertiary (3 or 4 years bachelor, and 1 or 2 years masters, 5 years MBBS).Secondary education is further divided into two categories: secondary (grades 9 to 10) and higher secondary (grades 11 to 12) (BBS, 2016b).
higher the number, the more autonomous the mother is. There is considerable evidence that women with discretionary power tend to allocate resources in such a way that benefits their children. A priory we expect to see a positive relation between autonomy and child health.
3. Exposure to media: A mother is considered to have exposure to media if she listens to the radio, or watches television, or does both. We measure this as a dummy variable, 1 indicating mother watches TV or listens to radio or both, and 0 otherwise. In Bangladesh, important health information especially child vaccination, date of a public campaign for free vitamin A and polio capsule, information on hygiene practice, child nutrition, the nearest point of contact for child emergency and so on are regularly being transmitted on mass media. We expect that rural women who are educated are more likely to have exposure to mass media than their uneducated counterparts and that educated mothers are better able to reap information from the media. The effect of exposure to media on child health may, therefore, be positive.
4. Access to health information sources: The BIHS asked the respondent mother whether she had learnt about sentinel practices from health workers, nurses, medicine shops, BRAC (NGO) or health centres. We use this information to create an indicator of mothers’ access to health information sources, 1 indicating yes and otherwise 0. Educated mothers are more likely to be confident in accessing such sources than non- educated women. Moreover educated mothers are more likely to be better able to deal with the health advice from those sources. Thus it may positively transmit the effect of education on child health.
5. Health knowledge: Health knowledge score is based on the following 10 questions related to infant feeding, hygiene practices, and nutritional knowledge of respondent mother. A score of 1 is assigned for each correct answer and 0 otherwise. Thus it ranges between 0 and 10.
i. What should a mother do with the ‘first milk’ or colostrums?
ii. Can you mention one that can happen to children if they do not get enough iron? iii. What seasoning (food item) is often fortified with iodine (a nutrient important
for brain development)?
v. When should you wash your hands?
vi. What food does a young child (<24 months) need in order to grow and develop their brain?
vii. Do you know breastfeeding should be started immediately after delivery within 1 hour?
viii. Do you know a baby should be exclusively breastfed (give only breast milk) up to six months?
ix. Do you know a child should be fed adequate quantity of family foods in addition to breastmilk from 7-24 months?
x. Do you know a child older than 6 months should be fed animal foods (fish, egg, liver, meat) at least once in a day?
Mothers’ education may raise women’s general knowledge and exposure to different networks, which may ultimately improve her health knowledge. Thus it would be reasonable to gauge mothers’ health knowledge has a positive effect on child health. 6. Use of antenatal service: Use of antenatal service not only helps to monitor proper
foetus development in the womb, but it may also make pregnant mothers aware of special dietary requirements (e.g. eating iron-rich food) and the consequence of bad lifestyle and habit (e.g. smoke, alcohol, narcotics). Since education may bring about change in perception, educated mothers may better understand the importance of having specialists’ advice and the advantage of being monitored during pregnancy in order to ensure normal foetal development. This can be crucial for a baby’s birth weight which is an important determinant of children’s survival and postnatal growth. By regularly visiting antenatal care mothers may become aware of these. In this study, we define mothers’ use of antenatal service as whether they attended antenatal care at least 4 times during pregnancy either in the hospital, health care centre or private clinic.
7. Dietary diversity: Education may increase mothers’ knowledge about nutrition as well as nutritional values of different food. This knowledge may persuade mothers, who are generally responsible for meal preparation and nutrition, to prepare meals that are as diverse and balanced as possible so that it meets the nutritional requirements of children. Thus household diets composition may serve as a pathway through which
mothers’ education impacts children’s health. We have measured dietary diversity through food consumption score which is a weighted score based on the frequency of a household’s consumption of nine food groups over past seven days. The food groups along with their corresponding weights in parenthesis are as follows: staples (2), legumes/pulses (3), vegetables (1), fruits (1), meat/fish/eggs (4), milk/dairy (4), oil (0.5), sugar (0.5), and condiments (0). The choice of food groups and its corresponding weights are derived from the guidelines of the World Food Programmes (WFP, 2008). One of the underlying causes of under-nutrition is the lack of dietary intake from diversified food. A greater variation in households’ diet composition would mean a greater extent of food security, and children in food secure households are more likely to get balanced diets.
In the above, we have illustrated how we measure the key variables of interest in this chapter. Having done this, we have also pointed out a probable direction of operation of the potential pathways. Given the wide range of information used to define those potential pathways, we expect that controlling for them in the child health regression model will effectively separate out any potential bias from the unobserved maternal characteristics.