Investigating the effects of maternal health knowledge on child health in long an province

The research results show that: i maternal schooling years is somehow proyed to positively impact on child anthropometric outcomes but its effect is crowded out by maternal health knowle

VIETNAM- THE NETHERLANDS PROJECT FOR M.A ON DEVELOPMENT ECONOMICS

INVESTIGATING THE EFFECTS

OF MATERNAL HEALTH KNOWLEDGE ON CHILD HEALTH

IN LONG AN PROVINCE

A thesis submitted in partial fulfillment of the requirements for the degree of

MASTER OF ARTS IN DEVELOPMENT ECONOMICS

BY NGUYEN LE HOANG THUY TO QUYEN

BQ a tAO D~JC VA DAO TAO ;;

TRUONG DH KINH TE TP.HCMl

Academic Supervisor:

DR NGUYEN VAN PHUC

HO CHI MINH CITY, JUNE 2007

Many thanks are respectfully sent to my parents and my husband for providing me with the opportunity to pursue my goals and for their love and affection, which has

Province

And last but not least, I would express my deepest thank to 102 households at Can

enumerators during the survey

The thesis is impossibly completed without the continuous support and help of the above people

ABSTRACT

Children care and protection are greatly paid attention because children are the future of a country Their health is specially important because it links to development of adult human capital and then the national economy Child health determinants have been studied by many researchers Higher parental education has been identified as a significant contributor to the improvement of child health outcomes in many studies However, the distinct functions of formal education and general health knowledge have not been clarified This paper aims to investigate the effects of maternal health knowledge on child health based on the survey of 102 households at Can Giuoc and Can Duoc Districts, Long An Province

Household production theory is employed as a core theory to build up the child health model Other theories including material well-being, public health intervention and cultural behavioral theories are used to give further explanation on the child health determinants Anthropometric indicators of weight-for-age and height-for-age are used as proxies for child health The models are regressed separately for the weight-for-age and height-for-age Z-scores of under five children

The research results show that: i) maternal schooling years is somehow proyed to positively impact on child anthropometric outcomes but its effect is crowded out by maternal health knowledge ii) maternal access to health information through pubic media

is an important contributor to the improvement of child health iii) genetic inheritance is important but it is inferior to environmental factors such as housing sanitation, health knowledge The findings verify the feasibility of improving Vietnamese stature even under the constraints of limited access to maternal formal education Three policy implications for general education are suggested Firstly, child care attendants are targeted objects of health knowledge education Secondly, periodical training courses are proposed to ensure their acquisition of updated knowledge Thirdly, prenatal care knowledge should be emphasized In addition, the thesis has suggested efficient channels for health propaganda such as public media, child caretakers club, etc

iii

TABLE OF CONTENTS

CHAPTER 1: INTRODUCTION 1

1.1 PROBLEM STATEMENT • • ••.• • ••• 1

1.2 RESEARCH OBJECTIVES •.•• • •• •• 2

1.2.1 General objectives 2

1.2.2 Specific objectives 2

1.3 RESEARCH QUESTIONS • • • •• • 3

1.4 RESEARCH HYPOTHESES •.• • •• • • •••• ••• • 3

1.5 METHODOLOGY • ••.• • ••• •.• •• ••• • •• 3

1.6 RESEARCH SCOPE • ; • ••••• •••• •••.• • 3

1.7 THESIS STRUCTURE • •• • ••.••• 4

CHAPTER 2: LITERATURE REVIEW 5

2.1 INTRODUCTION • • •.• • • 5

2.2 DEFINITION •.•••.• •.•.•• • •.• • 5

2.2.1 Children 5

2.2.2 Child health 6

2.3 CHILDHEALTHMEASUREMENT • •• •• 7 ,

2.3.1 Mortality rates 7

2.3.2 Morbidity rates 8

2.3.3 Anthropometry 9

2.4 THEORETICAL FRAMEWORK AND EMPIRICAL STUDIES • • • 14

2.4.1 Household production theory 14

2.4.2 The material well-being theory (or nutrition based theory) 17

2.4.3 The public health intervention theory (or technology-based theory) 19

2.4.4 The cultural behavioral theory 20

2.5 THEANALYTICALFRAMEWORK •• ••• • • •• • • 22

2.5.1 Empirical model 22

2.5.2 Variables introduction 23

2.6 SUMMARY • •• •• • • ••.• 25

CHAPTER3: AN OVERVIEW OF CHILD HEALTH IN VIETNAM 26

3 1 INTRODUCTION • •.•• • • • ••.•• • 26

3 2 BACKGROUND ON CHILD HEALTH POLICIES AND OUTCOMES .•• • •.• 26

3.3 NUTRITIONAL STATUS OF CHILDREN IN VIETNAM •.• •• • • • 29

3.4 SUMMARY • •.• • •• •• • • 35

CHAPTER 4: EMPIRICAL ANALYSIS OF CHILD HEALTH IN LONG AN PROVINCE 37

4.1 INTRODUCTION • •• •• • • ••• ••• •• • • • 37

4.2 OVERVIEW OF RESEARCH PLACE • • • • • • • • • •• • •• 37

4.3 DATA DESCRIPTION • • •••• • • • 39

4.3.1 Sampling method and sample size 39

4.3.2.Description ofvariables 43

4.3.3.Descrptive statistics ofvariables 50

4.4 STRENGTH AND WEAKNESS OF COLLECTED DATA • 57

4.5 MODEL SPECIFICATION • •.•• •• • • ••• • •• ••• •• • 58

4.6 ESTIMATION STRATEGY • • •• 60

4.7 ESTIMATION RESULTS • • 61

4.7.1 Multiple regression results 61

4 7.2.Interpretation of the results 63

4.8 SUMMARY ••••.•.•.•.•• ••••.• ••.•• • •••• •• ••• • • ••• • 66

CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS 68

5.1 CONCLUSIONS •.•• • • • ••• • •• 68

REFERENCES: 71

APPENDICES: 77

APPENDIX 1: 77

APPENDIX 2: 82 '

APPENDIX 3: 83

APPENDIX 4: 85

APPENDIX 5: 90

LIST OF BOXES BOX 2.1: Vietnamese adults: 25 years, gaining 2 em high 9

BOX 4.1: Child care club at Hoa Thuan 2 Village, Truong Binh, Can Giuoc District 47

BOX 4.2: A case from Phuoc Hoa Village, Truong Binh, Can Giuoc District 66

LIST OF FIGURES FIGURE 3.1: Underweight by age and gender 30 ,

FIGURE 3.2: Stunting by age and gender 31

FIGURE 3.3: Wasting by age and gender •••.••.••.•••.•.•.• • • 32

FIGURE 3.4: Poor child nutrition by ethnicity and residence 33

FIGURE 3.5: Malnutrition rate of under five children by region and residence 34

FIGURE 3.6: Poor child nutrition by level of maternal education and residence 35

FIGURE 4.1: The distribution of stunting 85

FIGURE 4.2: The distribution of underweight 85

FIGURE 4.3: Correlation between stunting and underweight 86

FIGURE 4.4: The distribution of explanatory variable "child weight at birth" 86

FIGURE 4.5: The distribution of explanatory variable 'Jather's education" 87

FIGURE 4.6: The distribution of explanatory variable "logarithm of father's education" 87

FIGURE 4.7: The distribution of explanatory variable 'Jather's height" 88

FIGURE 4.8: The distribution of explanatory variable "mother's education" 88

FIGURE 4.9: The distribution of explanatory variable "logarithm of maternal education" 89

FIGURE 4.10: JB Test of normal distribution of residuals in HFA regression model •• • 94

FIGURE 4.11: JB Test of normal distribution of residuals in WFA regression model 99

LIST OF TABLES

TABLE 2.1: PIHO classification of poor nutrition level in the population 13

TABLE 3.1: Some basic targets of the national strategy on the health care for 2001-2010 27

TABLE 3.2: Total expenditure on health for 1996-2005 27

TABLE 3.3: Actual ratio of basic child health indicators 28

TABLE 3.4: Malnutrition rates of under five children in terns ofWFA in some Southeast Asia nations in 2004 29

TABLE 4.1: Administrative units, areas and population in Long An Province 38

TABLE 4.2: Major social indicators at Can Giuoc and Can Duoc Districts 39

TABLE 4.3: Investigated objects 42

TABLE 4.4: Coding system for flags 44

TABLE 4.5: Education level of parents 45

TABLE 4.6: Maternal health knowledge 46

TABLE 4.7: Maternal exposure to health knowledge providing media 48

TABLE 4.8: Sanitation condition 49

TABLE 4.9: Child weight at birth 50

TABLE 4.10: Descriptive statistics of explanatory variables 83

TABLE 4.11: Correlations between maternal education and health knowledge 83

TABLE 4.12: Prevalence of stunting by gender, district and age group 52

TABLE 4.13: Prevalence of underweight by gender, district and age group 54

TABLE 4.14: Stunting, underweight by maternal education 55

TABLE 4.15: Stunting, underweight by maternal health knowledge 56

TABLE 4.16: Correlations among dependent and independent variables 84

TABLE 4.17: Child health model regression, dependent variable: Height-for-age Z-score 62

TABLE 4.18: Child health model regression, dependent variable: Weight-for-age Z-score 62

TABLE 4.19: Ramsey Reset Test, HFA regression model 90

TABLE 4.20: White's General Heterocedasticity Test, HFA regression model 91

TABLE 4.21: Ramsey Reset Test, WFA regression model 95

TABLE 4.22: White's General Heterocedasticity Test, WFA regression model 96

Expanded Program of Immunization General Statistics Office

Food and Agriculture Organization Height-for-Age

Height-for-Age Z-score Jacque-Bera

Low Birth Weight Left Hand Side Ministry of Health National Center for Health Statistics Neonatal

Post neonatal Ordinary Least Square Right Hand Side Standard Deviation Under five children United Nations United Nations Children's Fund United States

Vietnam Living Standards Survey Vietnam National Health Survey Vietnam National Nutrition Survey World Bank

WFA

WAZ

WHO

Weight-for-Age Weight-for-Age Z-score World Health Organization

CHAPTER!

INTRODUCTION

The chapter starts with the introduction of research topic and places Their selection is rationalized in section 1.1 It then presents research objectives, questions, hypotheses and methodology in sections 1.2, 1.3, 1.4 and 1.5 respectively In addition, research scope is discussed in section 1.6 Finally, the chapter concludes with thesis structure in section 1 7

1.1 Problem statement

Under-nutrition is problematic in the world because it causes over a half of all child deaths (WB, 2006) To survived children, it impacts on their physical development and leads to underweight (a low weight-for-age), wasting (a low weight- for-height) and stunting (a low height-for-age) The consequence is their frequent disease, low labor productivity when becoming adults and therefore negatively impacts on long-term economic development (Schultz, 2003) In fact, poor nutrition of children 'is an implication of "perpetuate poverty" (WB, 2006)

Like other low-income countries, under-nutrition in children under five is a key issue in Vietnam (WHO, 2007) After over a decade of impressive economic growth with

developing the primary health care system and national public health programs m Vietnam (UNICEF, 2006), one fourth of the children are still under-nourished in 2005 (UNICEF, 2006) This figure is quite high according to WHO classification of malnutrition level (WHO, 1995) Moreover, it is still far away from what the other countries in the region have achieved For instance, under-nourished rates in China,

Child is under-nourished not only because of having too little food to eat (WB, 2006) Inappropriate child care practices and shortage of health knowledge are also critical chains of undernourished causes (Maire and Delpeuch, 2005) In addition, it's implicated by the cultural behavioral theory that children nutritional benefit may not be

maximized if their mothers are not empowered with health knowledge Evidence is recently accumulated that an increase in female's education accounts for 43% decline in child under-nutrition while food security only contributes to 26.1% of child under-nutrition reduction (Watson, 2006)

Education is one of the channels to provide mothers with health knowledge through which child health is improved (Glewwe, 1998) However, other channeJs are also important to raise maternal health knowledge It is obvious that health knowledge can be achieved through maternal accessing to health related information sources such as watching television, listening to the radio, reading newspapers and magazines, etc It's worth for policy implications to examine the effect of the latter on child health improvement

This paper aims at examining the effects of maternal health knowledge

perceived from various channels as mentioned above on child health at Can Giuoc and Can Duoc Districts, Long An Province

It's hoped that the findings of this research are useful for the local government and key health decision makers at local and international agencies in planning and setting priorities for education strategies to improve child health at Can Giuoc and Can Duoc Districts, Long An Province in particular and child health in Vietnam in general

1.2 Research objectives

1.2.1 General objective

The general objective of the paper is to examine the effects of maternal health

1.2.2 Specific objectives

In aiming for the above general objective, the following specific objectives will be targeted in the research;

Based on the theories and the empirical studies, it is expected the following results

of the econometric model;

(1) Increase in maternal schooling years leads to increase in the child weight- for- age (WFA) and height- for- age (HFA)

(2) Maternal access to child health information leads to increase in the child weight- age (WFA) and height- for- age (HFA)

for-1.5 Methodology

The research applies both qualitative and quantitative methods to evaluate the impact of maternal health knowledge on child health Qualitative analysis provides certain evidence on the correct selection of input factors, especially maternal attributes for child health production function Moreover, regression model is used to defit;te the contribution level of each factor mentioned above to the improvement of child health so that appropriate policy can be recommended

Cross section data which was surveyed by the author in March, 2007 are used for the research There are 124 observations of under-five children included in the survey

1.6 Research scope

Under-five children are the investigated objects of this paper Their anthropometric data in terms of weight-for-age and height-for-age are used as proxies for the health and nutrition measurement Under-nutrition is studied because Vietnamese children are more prone to under-nutrition than over-nutrition Two districts in Long An Province, namely Can Giuoc and Can Duoc are selected as research places, given the

strong desire of local authorities in improving child health Can Giuoc and Can Du~c aim

to achieve the goals of 14% and 16% of a low weight-for-age at under-five children in

2003 (GSO, 2006) In addition, the research scope is feasible to the author under the time and budget constraints

1.7 Thesis structure

Given the research purpose, the paper is organized into 5 chapters In addition to introduction chapter, the rest of the paper consists of 4 chapters with the outline as follows;

health and its measurement Theoretical frameworks regarding the determinants of child health and empirical studies are also reviewed in this chapter Finally, analytical framework with the inclusion of health production function, analysis model and its justification is presented

background of child health status in Vietnam In addition, it provides a further discussion

on the child health determinants based on the data ofVNHS 2001-2002

firstly presents background of research place, sampling method and sample size with the rational selection of research place Variables description with descriptive statistics as well as the strength and weakness of collected data are discussed to evaluate their representativity and reliability Finally, the econometric model, estimation strategy, regression results and their interpretation are presented

findings and concludes with some policy recommendations and research limitations

2.1 Introduction

CHAPTER2 LITERATURE REVIEW

The objective of this study is to examine the effects of maternal health knowledge

on child health Therefore, child health concepts, its measurements and determinants have

to be defined Firstly, the chapter starts with theoretical definition of several key concepts used in the research in section 2.2 Secondly, the measures of child health are introduced

in section 2.3 Thirdly, theoretical background and empirical studies of child health determinants are reviewed in section 2.4 Fourthly, the analytical framework is introduced in section 2.5 Finally, summary of the literature review in section 2.6 concludes the chapter

2.2 Definition

2.2.1 Children

According to the Convention on the rights of the child (CRC), child is defined as the young human beings at the age of 18 and under (UN, 2005) However, child may be classified according to different age groups or other criteria for specific purposes For the purpose of this research, children are limited to infants and pre-primary schoolers because of the following reasons;

Firstly, under-five children are the cornerstones of care for healthy growth of children (WHO, 2006) It's during this period that children are at the riskiest of infections, child morbidity and mortality, mental development and cognitive decrease if they are under-nutrition(2) In fact, the most rapid development of a child's brain takes place during the first two years of his/her life Sufficient and good quality nutrition during this childhood period will lead to an increase in learning capability and a probability of success in school and in life because a well-developed brain is not only genetically but also nutritionally predetermined (Maxwell, 2005)

<2l According to the Latin American Research Network Project, the consequences of under-nutrition at preschool period have been studied by Beaton, et al., 1993; Bhutta, et al., 1999;Bleichrodt and Born 1994; Lozoff and Wachs, 2000; Pelletier, Frongillo and Habicht 1993; Pelletier, et al., 1995; Rose, Martorell and Rivera 1992; Wachs 1995

The same pattern is repeated with child's height development The first two years

of life marks the period of the fastest linear growth velocity given good dietary (Eckhardt

Based on the limitation of child age in this paper, the following section will discuss child health concept

2.2.2 Child health

According to the U.S Committee on Evaluation of Children's Health (2004), child health is defined as the status of disease or premature mortality absence with the

individual child or groups of children are able or enabled to a) develop and realize their potential; b) satisfy their needs; and c) develop the capacities that allow them to interact successfully with their biological, physical and social environments" (Children's Health, the Nation's Wealth: Accessing and Improving Child Health, p.3, 2004) In short, it is the ability to recognize aspiration, meet needs and adapt to the environment (Starfied, 2004) The broad definition is translated by the U.S Committee on Evaluation of Children's Health into measurable categories such as "health condition", "functioning" and "health potential" Health condition reflects the childhood physical status Functioning measures how health affects child's daily life Health potential involves child competence, capacity

and developmental potential (Children's Health, the Nation's Wealth: Accessing and

Improving Child Health, 2004) However, this health definition is quite conceptual The following section will discuss how to measure it

Overall, there are three popular indicators used to measure child health e.g mortality, morbidity and anthropometry

2.3.1 Mortality rates

Mortality rates are classified into the subgroups such as neonatal, post-neonatal, infant, child and under-five child rates Neonatal mortality (NN) is the probability of dying within the first month of life Post-neonatal mortality (PNN) records the probability

of dying from the age of month 1 to month 12 while infant mortality covers the probability of dying between birth and the age of one The likelihood of dying between ages one and five is categorized as child mortality Under-five mortality includes the probability of dying between birth and the age of five

The mortality rates for neonates, infants and children under-five are defined as the number of deaths per 1,000 births in a given period except child and post-neonatal mortality rates, which are expressed as the number of deaths per 1,000 survivors at the defined age (Rutstein, 2000)

The classification of mortality rates is worth for providing appropriate health policies because each sub-group experiences different potential risks of death For instance, neonatal mortality is mainly caused by the medical technology and basic health care while the others are more relied on nutrition, hygiene, healthy caring practice, etc In addition, it is easy to identify and record the death Therefore, the data are available for research purpose

However, mortality rate does not fully describe the child health status because it does not give information on the life quality but only the fact that the child is dead or alive The next section will discuss morbidity, which is included as the child health indicator to reflect the disability or in diseased status

2.3.2 Morbidity rates

According to Indrayan and Satyanarayana (2000), morbidity in children could be in terms

of infectious or chronic diseases, which cause certain uncomfortable state or restriction in performing the normal activities of life Murray and Chen (1993) classified it as self-perceived and observed morbidity Self-perceived morbidity is relied on the reports of the respondents disregarding the source of their appraisals relating to the health status On the contrary, observed morbidity is the records of health status based on the judgments of trained physicians

This distinction is much relied on three types of morbidity (a) observable but not perceivable morbidity such as hypertension (b) perceivable but not observable morbidity such as pain and (c) observable and perceivable morbidity such as retinopathy

Data on child morbidity can be collected by the number of children affected, the number of episodes of sickness, duration of illness and severity of illness The terms of prevalence and incidence are frequently used in this case Prevalence refers to the existing cases (the presence of morbidity) and incidence refers to the new cases (fresh occurrence)

Data on child morbidity are calculated on the basis of percent, per thousand or per million persons at a point or period However, it is quite demanding in collecting the data because of various prevalence and incidence of diseases Moreover, the severity of illness can vary according to the people's perception and may lead to over-reporting or under-reporting the sickness This explains for the case that less developed countries have reported lower morbidity rates than developed countries As a result, it is not easy to

economic analyses The shortcomings of mortality or morbidity have motivated a popular tendency of using anthropometry to analyze child health these days The following section will be discussed it in details

2.3.3 Anthropometry

Anthropometric indicators are based on physical body measurements There are many indicators used for the health of children and adults such as mid-upper arm circumference; weight-for-age, weight-for-height and height-for-age; skin-folds, body mass index, head circumference, etc However, this section only discusses the most common health measurement used in children that is the body growth indicators (e.g weight-for-age, weight-for-height and height-for-age) Such a selection is justified by the following reasons;

Firstly, it is empirically evidenced that child poor nutrition is one of the most popular reasons causing child mortality and morbidity in many countries in the world (Pelletier & Frongillo, 2002) As a result, many studies limited the assessment of child

2003)

Secondly, like other low-income countries, the prevailed threat to child physical development in Vietnam is poor nutrition, which then challenges the Vietnamese stature

disadvantage (Government Decree No.37/CP issued in June, 1996) This becomes a topical issue in Vietnam

Box 2.1 PhD Doctor Tran Thi Minh Hanh, Institute of Nutrition, Ho Chi Minh City

Vietnamese adults: 25 years, gaining 2 centimeters high Anthropometric data recorded in 1975 showed that the heights of Vietnamese male and female adults were 160 centimeters and 150 centimeters respectively In 2000, after 25 years, their average heights were 162.3 centimeters (male) and 152.3 centimeters (female) It means that the heights of Vietnamese people have increased just 2 centimeters for 25 years Comparison was made with the Japanese and it was found that the Vietnamese men and women were shorter than their Japanese counterparts at 10 centimeters and 6 centimeters respectively, given the Japanese characteristics of short stature

It's time to have the action on how to improve the Vietnamese stature

<3> For the rest of this paper, "child health" and "child nutrition" are interchangeably used

Finally, the data on child weight/height are frequently recorded by child caregivers Therefore, it is inexpensive and relatively easy to collect this type of child health data during the survey

Weight-for-height (WFH) measures body weight relative to height Low WFH in a child of the same gender and age in the international reference population group is referred to as "thinness" The severe case of low WFH is referred to as "wasting" Weight-for-height measures a child's current nutritional status Wasting indicates a current under-nutritional status as a consequence of diarrhea, childhood diseases or insufficient nutrient intake Wasted children can quickly gain weight after recovering from diseases with sufficient nutrient intake Therefore, this indicator can be significantly used to evaluate the effects of a short-term child health intervention program, which is however, not the purpose of this paper Moreover, wasting can mislead the children health in case of their poor growth in both weight and height Consequently, child health status will be over-reported if using this indicator

Weight-for-age (WFA) measures the body mass relative to age Low WFA in a child of the same gender and age in the international reference population group is referred to as "lightness" The severe deficit in WFA is referred to as "underweight"

time However, this indicator does not distinguish the effects of short-term and long-term nutritional problem and fails to distinguish between short children of adequate weight and tall, thin children

Height-for-age (HFA) reflects a cumulative linear growth measured in the standing position Length refers to the measurement in recumbent position, applied for under- two children Low HF A in a child of the same gender and age in the reference population group is referred to as "shortness" The extreme deficit in HFA is referred to

as "stunting" It is caused by the failure to reach genetic potential as a result of interaction between poor diet and disease It's also a consequence of poor nutrition before and during pregnancy, during the first six months, and during the early years of children's lives In short, it is a long-term children health indicator for accumulative under-nutrition related

to environmental and socio-economic circumstances (WH0,1995;1996) The prevalence

of stunting in the country also reflects its poverty

Though each of the three above indicators have merits and shortcomings, two of them e.g WFA and HFA are selected as proxies for child health used in this paper because the author aims to examine the effects of maternal health knowledge on the improvement of the child height and weight, given age and gender

There are three ways to express anthropometric indices, which are constructed based on comparisons with a healthy reference population;

Z-score (standard deviation score) is the difference between the measured or observed value of an individual and the median value of the reference population at the same age and gender or height, divided by the standard deviation of the reference population

Percent of median is ratio of the measured or observed value of an individual to the median value of the reference population at the same age and gender or height

Percentile is the rank position of an individual on a given reference distribution, stated in terms of what percentage of the group the individual equals or exceeds

Among the three indices, Z-score system is widely used because it is the most appropriate descriptor of nutritional status for both individual and population-based applications Summary statistics such as mean, standard deviation for the population can

be constructed from Z-scores while this cannot be meaningfully done with percentiles Percent of median also has certain disadvantage For instance, it does not show where the position of the individual in the distribution is As a result many health and nutrition

The paper selected Z-scores and used the U.S National Center for Health Statistics (NCHS)/WHO reference data, which is the most commonly used and recommended by the WHO

There have been many debates on the inappropriate application of NCHS population standard for children in developing countries in recent years with certain evidences on the ethnic differences between groups or genetic differences between

individuals However, these differences, according to the report of a WHO working group (1986a) are not large enough to confound the general use of NCHS population standard because it's scientifically proved that infants and children up to the age qf five from different geographical regions of the world experience very similar growth patterns when their health and nutrition needs are met (WHO, 2006) In addition, the development

of statistica1ly valid national reference values is costly Moreover, these standards are widely recognized and applied by health agencies in Vietnam because no local standard

Hi is the height of child i

Hr is the median height of healthy children at the same age and gender from international reference population

SDr is standard deviation of child height at the same age and gender from the international reference population

wi is the weight of child i

Wr is the median weight of healthy children at the same age and gender from international reference population

SDr is standard deviation of child weight at the same age and gender from the international reference population

The most universal cut-off point used for all indicators to define abnormal anthropometry is -2 Z-score For example, stunted children are those under five years old whose height for age, given the gender is less than minus two standards deviations from the median for the international reference population at ages 0-60 months The WHO has proposed the reference classification of poor nutrition level in the population by Z-scores

in table 2.1 below However, it also recommends that the child nutritional level should be locally categorized taking into account its specific nutritional nature of each nation and region

Table 2.1 WHO classification of poor nutrition level in the population

The terms of malnutrition, under-nutrition and over-nutrition are clearly defined

by WHO (2006) Under-nutrition is the loss of body weight as a result of cumulative insufficient food intake as opposed to dietary energy requirements It also reflects the poor absorption of consumed nutrients On the contrary, over-nutrition is the overweight and/or obesity as a result of excess food intake as opposed to dietary energy requirements Malnutrition refers to the status of deficiencies or excesses of energy and/or nutrients intake Based on this definition, it is found that the term "malnutrition" does not only refer to under-nutrition as it is frequently used these days but also correctly uses for over-nutrition

This paper limits to the evaluation of under-nutrition status of the children Therefore, only under-nutrition degrees of Vietnamese children are discussed They are categorized into the followings;

Degree 1 or moderate under-nutrition (-3 S.D < Z-score < -2S.D)

Degree 2 or severe under-nutrition (-4 S.D < Z-score < -3 S.D)

Degree 3 or very severe under-nutrition (Z-score <-4S.D)

In conclusion, the discussion in section 2.3 provides the general view about the child health indicators In addition, it justifies for the use of height-for-age Z-score (HAZ) and weight-for-age Z-score (W AZ) as proxies for child health Section 2.4 below will discuss its determinants

2.4 Theoretical framework and empirical studies related to determinants of child health

This section introduces four theories relating to the determinants of child health First, household production theory is applied as the core theory to examine the linkages between maternal health knowledge and child health This theory and the related empirical studies are presented in section 2.4.1 The other three theories including material well-being, public health intervention and cultural behavioral theories are used

to further explain the determinants of child health in sections 2.4.2, 2.4.3 and 2.4.4 respectively

2.4.1 Household production theory

Household production theory is the center of human capital approach based on which health related models were constructed

According to Becker (1965), household is not only seen as a consumer of goods and services but also a producer of commodities It's assumed that households maximize utility derived from the basic commodities it produces under money, time and technology constraints

Grossman (1972a, b) developed a model of demand for health based on household production framework in which health is defined as a durable capital stock It is assumed that individuals derive utility from the output yielded by health capital and from the consumption of other commodities

These ideas of the health production theory are adapted to construct to the utility function form of households as follows;

(2.1) Household is assumed to choose the combination of other goods (C) and child health (H) as inputs for the utility function and it is maximized subject to the constraints

of health production function and budget

The utility function is assumed to be quasi-concave Equation (2.1) shows that household's welfare depends on consumption of other goods (C) and child health (Hi) The relative preferences among the commodities are affected by observed characteristics such as household characteristics (Xh) and maternal characteristics (Xm) Child health production function is assumed as follows;

Child health output depends on inputs including child characteristics, community

characteristics, household health and nutritional inputs

Household's choice in order to maximize its utility function is limited by the budget constraint (Ih)· In this frame-work, the function related to child health production, our interest for this research is represented by the following reduced-form equation

H =f(Xi Xc, Xh, lh, Xm) (2.3)

Equation (2.3) shows that child characteristics (Xi) is one of the determinants of child health They include all of child attributes such as gender, age, etc and the genetic factors endowed with child health

Regarding age, Glewwe (1998) empirically evidences that child health varies with age The pattern is that child health decreases in the first two years of age, then levels off and even increases The studies of Handa (1999), Christiaensen and Alderman (2001) confirm and expand the pattern Child health declines until the age of three and then

are also consistent with the previous studies The pattern can be easily understood because smaller children have more probability of being affected by fever, cough, respiratory diseases and diarrhea When the age is increased, the immunity will be developed and the result is better health outcome (Shehzad, 2005)

The regression results ofPonce et al (1998) reveal that Vietnamese children in the age group of 19-24 months are more prone to health disadvantages Based on the review

of the child health patterns relative to age found by previous studies, especially the study

of Vietnamese child health, the author realizes that age is an important determinant of child health outcome

In relation to gender, the report of WHO (2003) noted that the rates of boy mortality in the countries like China, India, Pakistan, etc are lower than girl This may result in the logic assumption of gender discrimination in the determinants of child health The research on Chinese health of Chen and Li (2006) finds the gender effect against girl It is rational due to the tradition of son preference in China This results in favorable treatment of parents to boy However, the finding of Kock and Nguyen Bui Linh (2002) when regressing the model with VLSS 98 data indicates that boy is more prone to malnourished than girl in Vietnam This is consistent with the review on child malnutrition in Ethiopia of Christiaensen and Alderman (200 1 ), in Indonesia of J3lock and Webb (2003) and in Pakistan of Shehzad (2005) The finding challenges the assumption of gender discrimination The models of Glewwe (1998) based on child health data from Morocco, Handa (1999) based on data of child health in Jamaica and Kovsted et al (2002) based on data of child health in Bissau, the capital of Guinea-Bissau (West Africa) prove that gender is an insignificant variable in explaining child health and nutrition This is further confirmed in the studies on child health of Haughton and Haughton (1999), Ponce et al (1998), Desai (2000) using the VLSS 93 data set The findings of previous studies on Vietnamese children health can be justified as the effect

of applying family planning policy with the encouragement of having only two children per couple As a result, parents tend to treat children equally despite their gender Therefore the assumption of gender bias may not be crucial in Vietnam

It is true that genetic attributes play a key role in determining a child height, an important indicator of child health However, it is difficult to observe and the ability of

proposed by Glewwe (1998) to include parental height and weight as proxies of the

genetic endowment of child height in the model because they are likely inherited by children He finds that they are important determinants of child height because they are positive and highly significant The result is further tested and confirmed in the models for health of Vietnamese children (Haughton and Haughton, 1999; Ponce et al., 1998; Kock and Nguyen Bui Linh, 2002) The literature review shows the necessity to include parental heights in the analysis to capture child health endowment

In addition to genetic inherits, non-genetic factors are also important Children can only reach their potential health if other non-genetic factors (e.g community or environment, caring practice, nutrient intakes, etc) are favorable

It is derived from equation (2.3) that household and nutritional inputs determine

knowledge and caring practice (Xm) These variables will be discussed in line with the related theories in section 2.4.2 and 2.4.4 respectively

Community characteristics (Xc) in equation (2.3) reflect public health intervention

at community level or environmental conditions where the child lives The variables will

be presented together with the related theory in section 2.4.3

2.4.2 The material well-being theory (or nutrition based theory)

This theory implicates that health outcome is improved as a result of increase in food consumption thanks to material prosperity In short, wealthier leads to healthier Therefore, household income is a key determinant of the health outcome

According to Osmani and Bhargava (1998), this theory is empirically evidenced

by various researchers such as Forgel (1992, 1994), Subbarao and Raney (1995)

because child health is improved through the provision of both energy and health care services This argument is supported in the study of Osmani and Bhargave by providing

(1992) and Bouis (1994) that higher income may not lead to higher calories intake • Their research also verifies this by showing the regression result of Von Braun and Kenedy (1994) that higher income can reduce hunger instead of under-nutrition In fact, food

17

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TRUdNG ElH KINH TE TP.HCM

could not get children become less vulnerable to infectious diseases if other factors (e.g caring practice, medical services, hygienic condition, etc) are not improved The research

of Osmani and Bhargava (1998) shows the finding of Scrimshaw et al (1968), Mata (1975), Biesel (1984) that nutrient intake affordability becomes non-sense with infectious disease because it reduces children appetite

Notwithstanding the debate on the impact of this economic factor on child health,

it is included in the econometric models of many studies under various forms e.g per capita family income, expenditure, assets and other proxies The models of Thomas et al

child health in Brazil and Pakistan respectively This is empirically proved by Chen and

Li (2006) in their research on child health in China Moreover, the latter also shows that income variable becomes insignificant when including health environment variables in the analysis This result suggests that the effect of income can attribute to better sanitation, location of the house

Expenditure or assets is also a popular explanatory variable which is used as a proxy of household resource The studies by Handa: (1999), Christiaensen and Alderman (2001), Block and Webb (2003) found that the coefficient of household expenditure is positive and statistically significant Olaniyan (2002) also confirms this effect in the study of Nigerian child health through the positive and significant coefficient of assets variable The finding of Glewwe (1998) verifies the consistent effect of income t:hfough the impact of parental education on child health

Two recent studies on Vietnamese child health done by Ponce et al (1998) and Kock and Bui Linh Nguyen (2002), however, present little effect of this economic factor The former uses per capita household expenditure as its proxy while the latter even switches to the use of sanitation because income is considered as a result of different choices of a household such as working time, education levels, etc This may be justified

on the grounds of an achievable calorie intake at over 2500 kcal/person/day (F A0,2006), which satisfies the recommended nutrition requirement for Vietnamese (Appendix 2)

In conclusion, income may not directly enhance children health though nutrient intake but indirectly impact children health through accessing better sanitation, health care services and improving health knowledge, healthy behavior of child caregivers In short, income effect may be crowded out by other household factors such as parental education, sanitation

2.4.3 The public health intervention theory (or technology-based theory)

This theory emphasizes the role of government in public health intervention in fighting infectious diseases The importance of hygienic conditions in the community and basic health care is insisted According to Osmani and Bhargava (1998), it is empirically proved by Szreter (1998) that the availability of safe water, garbage disposal service, oral dehydration therapy for diarrhea positively and significantly impacts on child health The

case, the advantage of better food consumption may be removed For instance, contaminated water may cause acute diarrhea, which leads to the incapability of absorbing the required energy for body growth despite its availability In practice, the rich can improve their children health by affording necessary medical care but they also need some community level actions For example, it is out of household control in case of occurring contagious diseases i.e SARS, avian flu, etc in the community Therefore, the literature review advises the use of community related explanatory variables which are commonly included in previous studies such as basic health care (e.g immunization, low birth weight prevention, etc), environmental sanitation (e.g availability of public piped water, garbage removal services, etc) as determinants of child health

According to Thomas et al (1990), their research shows the positive effects of the availability of public garbage removal services on child health while piped water effect is significantly reported by Horton (1986), Barrera (1990) and Strauss (1990) The findings are consistent with the regression results of Olaniyan (2002) in the study of Nigerian child health

Besides the hygienic condition, vaccination and low birth weight prevention are in action plans of many developing countries in the world to improve the child health

Osmani and Bhargava (1998) finds the negative and significant effect of LBW on child health in their research on the quality of health and nutrition in emerging Asia However, most of studies on Vietnamese child health exclude the important explanatory variables

in the analysis model except the study of Vo Thi Bao Huong (200 1 ), which shows significant effects of vaccination and birth weight on Vietnamese child health The;efore,

it is motivated to include the variables in the Vietnamese child health model to verify their consistent effects on child health

2.4.4 The cultural behavioral theory

This theory explains different health outcome given the availability of food and health services because health improvement much depends on how people correctly utilize resources (e.g food, health services) In case of child health, health knowledge and behavior of care-givers are very important because under-five children completely rely

on their decision about health treatment

Normally, mothers are the major children caregivers in the household in Asia (Osmani and Bhargava,1998) Therefore, this theory can be implicitly understood that maternal health knowledge and caring practice are the key determinants of child health Maternal healthy performance much relies on the awareness or health knowledge of the mothers, which can be obtained through formal education (Glewwe, 1998) The significant and positive effect of maternal education on child health is empirically proved

by many researchers According to Osmani and Bhargava (1998), their analysis shows the expected result which is consistent with the findings of Caldwell (1986), Cleland and Ginneken (1988), Hobcraft (1993), Behrman (1990) on the evidences of positive effect of maternal schooling years on child health This is further verified in the child health models of Glewwe (1998), Handa (1999), Christiaen and Alderman (2001), Olaniyan (2002), Kovsted et al (2002), Shehzad (2005) Glewwe (1998) reviews the ways th[ough which maternal education can improve child health (Schultz,1984) and clarifies them Firstly, it is obvious that more educated mothers tend to efficiently use a mix of health goods to produce more health output In other words, they can increase productivity of health inputs Secondly, they may be more effective at producing child health at a given

amount of health goods Thirdly, education can help increase the mother's income It means that the maternal opportunity cost of time is risen, which leads to the preference of fewer children As a result, better child health can be achieved given the available resources for child rearing The above argument makes clear the structural impacts of education on child health and certain contrary effects of education are revealed For instance, more educated mothers spend more time working outside The consequence is

However, this effect may be compensated by better health knowledge, healthy care and high non-breast milk calories intake because education leads to better economic status, health knowledge and healthy behavior The total effect of education is, therefore, positive

In short, it is not debatable that education improves child health because it is widely known and demonstrated However, it is not worth for policy makers to focus only on increasing maternal schooling years to raise child health This is justified by the findings of Wolfe and Behrman (1987) in the literature review of Glewwe (1998) The effect of maternal education on child health in Nicaragua becomes insignificant when Wolfe and Behrman (1987) use the data on mother's siblings education to control for family fixed effects

Therefore, the argument that maternal health knowledge is the root of healthy behavior that improves child health is rational Health knowledge can be achieved through formal education and general education is important because it enhances the capability to process and evaluate information As a result, it is more likely to engage in health seeking behavior The second potential source to improve maternal health knowledge is through their exposure to the media such as radio, television and newspapers (Thomas et al., 1990) However, the general exposure to information cannot ensure the perception of health knowledge This is only confirmed when mothers acknowledge that it is provided by this channel Finally, region (Kock and Nguyen Bui Linh, 2002), religion (Ponce et al., 1998) and ethnicity (Ponce et al., 1998) may also impact on child health because it is logically deduced that these factors can influence

maternal cultural behavior However, the effects of the factors can only be evaluated if the data are surveyed in a broad area i.e national level where there is a large disparity among the factors Therefore, this may be not applicable in this paper

The impact of maternal health knowledge on child health in Can Giuoc and Can

of studies on Vietnamese child health relating to this matter is, therefore necessary Haughton and Haughton (1999), Glewwe (1999) find that mother education, one channel

of health knowledge provision positively and significantly impact on child health However, this finding is not consistent with the analysis result of Kock and Nguyen Bui Linh (2002) Despite the contrary result, it is not surprising because it can be justified in the above literature review However, such a conflict finding motivates the author to study the effect of maternal health knowledge on child health because maternal health knowledge seems to fully capture the concept of cultural behavioral theory

It's also noted that schooling years of father also positively impact on child health but the effect is less than the mother's (Osmani and Bhargava,1998) However, the effect

of father education on child health is not consistent It is insignificant in the models of

explained by the inferior role of father in child care

2.5 The analytical framework

This section consists of two parts First, the empirical model of child health

production function is derived from the literature review Second, variables are introduced with the justification of their inclusion in the model

2.5.1 Empirical model

In short, the research mms at investigating the effects of maternal health knowledge on child health This chapter presents the definition of child health and its measurement Child health is finally measured by two indicators including HAZ and

WAZ

Theories and empirical studies relating to the child health determinants have been reviewed in this chapter Child attributes, community characteristics, household features

and maternal attributes are key factors impacting on child health As a result, the suggested research models are as follows;

The health production equations (2.3.1) and (2.3.2) describe the relationship between child health (HAZ and W AZ are used as the proxies) and its determinants The Left Hand Side (LHS) of equations (2.3.1) and (2.3.2) are dependent variables and the Right Hand Side (RHS) are independent variables

It's rational to expect the positive relationship between child height and parental height

Community characteristics (XJ reflect the role of public health intervention in improving child health They may include community infrastructure and basic health care such as hospital or commune health center, trained physicians, hygienic condition, immunization, prevention of low birth weight However, the research areas in this study are not so large As a result, the variables at community level such as number of hospital,

commune health center, trained physicians, hygienic condition seem to have fixed effects because of their little difference In addition, the study does not focus deeply on the analysis of community characteristics Therefore, child weight at birth will be included as

a proxy of basic health care with the prediction of negative impact of LBW on child

feasibility of data collection

Birth weight is the child weight at birth, measured in kilograms Low birth weight refers to the child with the weight below 2.5 kilograms at birth

Household characteristics (X 1J are defined as household attributes They include household size, housing quality, household income, father education Household size and household income is likely correlated The larger family may lead to less resources allocated to their members This assumption is verified with the evidence of World Bank's report in the research of Olaniyan (2002) Moreover, it is difficult and expensive

to measure lifetime income Therefore, current income is normally used as the proxy However, even current income is hard to measure because the respondents may not know

or reveal their exact income As a result, the study may encounter the problem of inaccuracy income The practical status of data collection and literature review leads to the selection of housing quality and father education as proxies for household income It's expected that both variables positively effect on child health

Housing quality is measured by the availability of permanent building of in-house toilet, safe garbage disposal and safe water

Father education is measured by total number of schooling years of the father

Maternal attributes (X,,J can be measured through the following explanatory variables: maternal religion and ethnicity, maternal education, exposure to media, health knowledge and healthy behavior Information exposure can help the accumulation of health knowledge and adoptability of healthy prenatal and postnatal care As a result, child health will be improved The total effect of exposure to media is assumed in a logic deduction However, further test is requested to ensure its consistency for suitable health education policy via the media

Maternal religion is categorized into religion and non-religion and the study aims

to examine the religious effects on child health through the assumption that mother can achieve certain health knowledge when they go to Church or Pagoda

Maternal ethnicity is categorized into Kinh and others with the aim of evaluating different "cultural behavior" due to different ethnicity

Maternal education is measured by total number of schooling years of the mother Maternal exposure to media is measured by the channels (television, radio, newspapers) providing her health knowledge

Maternal healthy behavior is measured by scoring the correct caring practice based

on the knowledge of basic health care such as vaccination, breastfeeding, supplementary food and weaning

Maternal health knowledge is measured by scoring maternal understanding about stunting, underweight, the importance of vitamin D and the impact of diarrhea and worm illness on stunting, underweight is scored and it is a proxy of health knowledge

2.6 Summary

This chapter presents literature review of child health determinants Household production theory is used as a core of the child health model Child height-for-age and weight-for-age are the proxy variables of health indicators Four groups of variables including child characteristics, household resources, maternal attributes and comrimnity factors are defined as explanatory variables of child health The material well-being, public health intervention and cultural behavioral theories and empirical studies strongly support the appropriation of the constructed analytical framework

In general, child age, gender, parental height, child weight at birth, housing quality, parental education, maternal religion, ethnicity, access to media, healthy behavior and healthy knowledge are justified in the model as child health determinants The next chapters will present further analysis of their rational inclusion and effects on child health outcome

children in section 3.3 with more discussion about the determinants of children health based on the data ofVNHS 2001-2002 Finally, a summary of child health background in Vietnam in section 3.4 concludes the chapter

In Vietnam, children care and protection are the top priority of the Govenunent and people In fact, Vietnam is the second country in the world ratifying the Convention

on the Rights of the Child in February 1990, which was followed by many legal documents regarding the child protection, care and education such as the Law on Protection, Care and Education of Children, Law on Education, the Labor Code, the Civil Code, the Ordinance on Prostitution Prevention and Combat, etc (UN, 2005)

development have been formulated since 1990 such as the National Programs of Action for Children for 1991-2000 and enactment of the 1994 Government Decree No 118/CP

to establish the Vietnam Committee for Protection and Care of Children (CPCC) This organization was then merged into the Committee on Population, Family and Children on

5 August, 2002 to focus on the care, protection and education of children Among these activities, child health has been placed at the center of human capital development This was verified in the targets of the second National Programs of Action for Children for 2001-2010 In addition, program on child health improvement was always at national level (Decision No 2112001/QD-TTg dated 22 February, 2001; Decision No 7112001/QD-TTg dated 4 May,2001, Decision 190/2001/QD-TTg dated 13 December,

200 1 ) In principle, the following targets are specified in most of child health improvement programs:

Table 3.1 Some basic targets of the national strategy

on the health care for 2001-2010

Infant mortality rate

Under-five mortality rate

Low birth weight

Malnutrition prevalence, weight for age (% of children under five)

Rate of mother with appropriate knowledge and practices on nutrition

for children with illness

Rate of female youth to be trained on nutritional and maternal skills

Source: Decision 2112001/QD-TTg dated 22 February 2001

Source: WHO (2007) Vietnam-National Expenditure on Health

The action plan together with an increased total expenditure on health over the years has proved the Vietnamese efforts in improving the medical care Table 3.2 shows that the absolute value of total expenditure on health increases triple in 2005 compared to 1996's

Health care system is strengthened by national health programs, especially· those for important public health problems As a result, Vietnam has succeeded in the

of immunization (EPI), which provides free of charge six types of vaccine against the following diseases: tuberculosis, poliomyelitis, tetanus, whooping cough, diphtheria and

measles The rate of immunized children in Vietnam is relatively high with over 95% (UNICEF,2007) It was recorded that poliomyelitis and tetanus were successfully

with over 90% of Vietnamese using iodized salt has recently achieved (UNICEF, 2007) Such success shall greatly contribute to the increase in child health

In addition, healthcare systems have been established in all communes with certain

communes and wards in the country had resident doctors and health workers as opposed

1990 (UNICEF, 2007)

In short, after more than two decades of impressive policies on child health intervention made by the Government, the health outcomes of Vietnamese children have greatly improved with considerable decrease in mortality, morbidity and under-nutrition rates

Table 3.3 Actual ratio of basic child health indicators

Basic targets Infant mortality rate

Under-five mortality rate

Low birth weight

Under-nutrition prevalence, weight for age (% of children

under five)

<*>Vietnam Data Profile, The World Bank Group,2007

<**>Annex B, UN, 1998 http://www.un.org.vn/undocs/undaf/annexb/common3.htm

<***> UNICEF estimates of the incidence of low birth weight, 2004

<****> MOH,2007

1990 46%o(**) 53%t*) 9.8%(**) 48%(**)

2000 2005 23%o(*) 16%o(*) 30%o(*) 19%o(*) 9%(***) 8%(****) 33.8%(*) 25.2%(*)

Table 3.3 shows that the goals of reduction in infant, under-five mortality rates and malnutrition prevalence in terms of weight for age have been successfully achieved

rates were 16% and 19% respectively, which are much lower than the targets of 2010 (25% and 32% for infant and under-five mortality rates respectively) Low birth weight has been reduced significantly during 1990-2005 but the obtained rate in 2005 has not met the target Therefore, more health intervention should be focused at prenatal phase because poor healthcare during the pregnancy is the major cause ofLBW

Table 3.4 Malnutrition rates of under-five children in terms of weight for age

in some Southeast Asia nations in 2004 Nations

In conclusion, table 3.4 shows that children health in Vietnam has been improved remarkably Malnutrition rates in terms of weight for age of under-five children in Vietnam are moderate compared to other nations of Southeast Asia However, it is still high according to WHO classification (see table 2.1)

3.3 Nutritional status of children in Vietnam

Malnutrition is a key contributor to the burden of mortality and morbidity There are several indicators of malnutrition such as low weight-for-age (underweight), low height-for-age (stunting), low weight-for-height (wasting) and overweight However, this section will focus on describing the poor nutrition pattern of Vietnamese children based

on different determinants

Figure 3.1 Underweight by age and gender (VNHS 2001-2002)

>-N

~ ~

(\l (\l Q) Q)

Figure 3.2 Stunting by age and gender (VNHS 2001-2002)