|Year : 2016 | Volume
| Issue : 4 | Page : 276-281
Children's growth pattern and mothers' education and socio-economic status in Riyadh, Saudi Arabia
Suliman Ibrahim Alhaidari1, Abdullah Omar Al Houssien1, Mohammad Ahmed Alteraiqi1, Assad Mohammed Al Arafah2, Rana Omar Al Houssien1, Omar Ibrahim Alhaidari3, Aamir Ibrahim Omair4
1 College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Family Medicine, King Abdulaziz Medical City, Riyadh, Saudi Arabia
3 College of Medicine, Al-Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia
4 Medical Education, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
|Date of Web Publication||12-Oct-2016|
Abdullah Omar Al Houssien
King Saud bin Abdulaziz University for Health Sciences, Riyadh
Background: An important indication of a child's well-being is evidence of having a normal growth pattern. A child's growth pattern is influenced by multiple factors, genetic and/or environmental. From an environmental point of view, the socio-economic status of the mother plays an important role in a child's growth during the early stages of childhood.
Aim: The aim of this study was to explore the association between mothers' educational and socio-economic status on their children's growth in Riyadh.
Methods: A cross-sectional study was conducted in eight hospitals in Riyadh. The target population was children aged between 1 month and 7 years and their mothers visiting the vaccination clinics. The mother's data were collected using a structured interview, and the child's weight and height were measured and plotted on growth charts.
Results: A total of 744 mothers and children were screened (392 males, 352 females). The proportion of children with weight and height under the 25 th percentile was 40% and 29%, respectively. In terms of education, the height of a higher proportion of children (33%) was under the 25 th percentile if the mother had a high school education compared with 25% when the mother had a college education (P = 0.02). Private sector-employed mothers had a lower proportion of children (26%) with weight below the 25 th percentile compared to mothers who were government-employed or unemployed (both 41%). Mothers living in an apartment had a significantly lower proportion of children (24%) with height under the 25 th percentile compared to mothers living in a house (33%) (P = 0.04). In addition, mothers living in a rented residence had a significantly lower proportion (40%) of children with weight under the 25 th percentile than mothers living in owned ones (42%) (P = 0.02).
Conclusion: Underweight and short stature among children are associated with less educated and unemployed mothers and with mothers who live in a house. The mother's socio-economic background provides various indicators that could be further researched to identify children who are at risk.
Keywords: Children, education, employment, growth, mother, Saudi
|How to cite this article:|
Alhaidari SI, Al Houssien AO, Alteraiqi MA, Al Arafah AM, Al Houssien RO, Alhaidari OI, Omair AI. Children's growth pattern and mothers' education and socio-economic status in Riyadh, Saudi Arabia. J Health Spec 2016;4:276-81
|How to cite this URL:|
Alhaidari SI, Al Houssien AO, Alteraiqi MA, Al Arafah AM, Al Houssien RO, Alhaidari OI, Omair AI. Children's growth pattern and mothers' education and socio-economic status in Riyadh, Saudi Arabia. J Health Spec [serial online] 2016 [cited 2019 Nov 15];4:276-81. Available from: http://www.thejhs.org/text.asp?2016/4/4/276/191909
| Introduction|| |
A child's growth pattern is an essential health indicator to monitor.  It is a complex subject which targets many aspects of a child's life including emotional, psychological and physical aspects.  In general, the normal physical growth of a child is an indication of well-being. Children's growth is multi-factorial, with nutrition, including breastfeeding and supplements, being an important factor.  Parents, specifically the mother, play an important role in the child's growth.  Monitoring the child's growth in the early stages will assist healthcare professionals to detect abnormalities affecting the child's quality of life and facilitate early intervention. An added advantage is that healthcare professionals become proficient in diagnosing and treating abnormalities in an early stage of a child's life and, if possible, determine how to prevent abnormalities from occurring. 
To be able to determine whether a child is growing normally, the child's growth pattern has to be compared to what is accepted as a normal growth pattern for the child. A child's development can be measured in various ways including height, weight as well as cognitive and psychomotor skills. One method to monitor a child's growth is using a growth chart, which charts the weight for age, height for age and weight for height measurements and compare the results with the expected normal growth trajectory for the child.  The rate of growth differs and depends on the age of the child. It is higher in the first few months after birth and the period after puberty, called a growth spurt, with more moderate growth happening between growth spurts. ,
There are many conditions and factors that can affect the normal growth of a child.  These factors, including infectious, genetic and exogenous, can alter the growth at any age from the birth of the child till growth terminates. Growth can be affected negatively during pregnancy if the mother is an alcoholic or smoker. ,, Infections, human immunodeficiency virus, specifically during pregnancy, may also cause growth complications.  In addition, genetics plays a vital role in determining the rate of growth.  Some genetic disorders cause growth alterations through genetic defects in the growth hormone such as insulin-like growth factor-I. 
It has been reported in the literature that a mother's educational level is influential to the growth of her child. A study by Maddah et al., conducted in Rasht City, Iran, found that children of less and highly educated mothers were at a higher risk of undernutrition than those of intermediate-educated mothers.  A Dutch study carried out by Bouthoorn et al., found that children of less-educated mothers had smaller head circumferences than children of higher educated mothers.  An Italian study, done by Lazzeri et al., showed that lower mothers' educational levels resulted in a higher prevalence of obese children  while a Brazilian study by Matijasevich et al., found that the children's height is proportional to mothers' levels of education.  In a Mexican study done by Leroy et al., it was found that there is a positive association between the household's wealth and the child's linear growth, being greater in households with a more-educated mother.  From a Saudi Arabian perspective, several studies showed that mothers' socio-economic status was significantly associated with children's growth and development. , A Saudi study conducted in Madina by Bella et al., showed that the mothers' educational level was significantly associated with different developmental items including the four developmental domains (social, fine motor, language and gross motor) of the child.  In support, Al Alwan et al., reported in a study conducted in Riyadh that overweight and obesity among Saudi children are associated with educated mothers and a higher family income. 
Saudi Arabia has a high incidence of obesity and nutritional abnormalities among children, assumed to be the effect of poor knowledge of food choices and lack of physical activities among children.  However, there are limited local data exploring the causes and factors that could play an important role in children's growth. Local data about mothers' educational and socio-economic status and children's growth are sparse and what is available is not comprehensive. The aim of this study was to explore the association of mothers' educational and socio-economic status on the growth of their children, <7 years, attending paediatric vaccination clinics and family medicine clinics at eight different hospitals in Riyadh, Saudi Arabia.
| Methods|| |
Using a cross-sectional design, data were collected from mothers and their children using paediatric clinics, specifically vaccination clinics, of the paediatric and family medicine department at eight primary, secondary and tertiary hospitals (King Abdullah Specialized Children Hospital, King Fahad Medical City, King Faisal Specialized Hospital, Special Forces Hospital, Yamamah Hospital, National Guard Comprehensive Specialized Clinics, Health Care Specialty Clinics and Yarmouk Clinics) in Riyadh, Saudi Arabia. The inclusion criteria were all children of both genders, aged 1 month to 7 years who have a living biological mother. The exclusion criteria were children born prematurely or diagnosed with a genetic abnormality. The sample size was estimated to be 325 for each group (children of highly educated vs. less educated mothers) based on 95% confidence level and 80% power to determine a difference of 10% or more in the growth patterns.
The data collected from the children were the weight and height, and the measurements were charted on growth charts (<25 th percentile, 25 - 75 th percentile or >75 th percentile).  Data collected from the mothers focused on their educational levels, employment status, socio-economic status, monthly income and chronic illnesses. The data were collected by interviewing the mothers and completing a structured data collection form. Data collection was done by the research investigators. Participant mothers, signed informed consents to be included. The study was approved by the Institutional Review Board of King Abdullah International Medical Research Center.
Data were entered and analyzed using the International Business Machines Statistical Package for the Social Sciences (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp). In the descriptive statistics, frequency and percentage were used for categorical variables, for example, mothers' education, and median and interquartile range (IQR) were used for numerical variables, for example, age of children. Using inferential statistics, Chi-square test was used to compare the growth parameters of the children from different categories of mothers' social status. P < 0.05 was considered statistically significant.
| Results|| |
The final sample size of 744 children aged between 1 month and 7 years included 392 (53%) males and 352 (47%) females, after excluding 26 children who did not fit the inclusion criteria. The median age was 24 months (IQR = 10, 53 months). Data were collected from one primary care hospital which consists of three primary care clinics, one secondary care hospital and four tertiary care hospitals [Table 1].
|Table 1: Percentage of the sample collected from each primary, secondary and tertiary hospital|
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The socio-economic status of the mothers indicated that in terms of education, 51% (n = 379) had a high school level of education or lower. The majority of the mothers (72%, n = 526) was unemployed with no personal income and one-fifth of the sample (21%, n = 154) worked in the governmental sector. The majority of the sample (55%, n = 365) lived in apartments, and almost half (49%, n = 323) owned their residence. A small proportion of the mother sample reported having a chronic disease (14%, n = 98), the most frequent of which was diabetes [Table 2].
|Table 2: Frequencies and percentage of mothers' socio-economic status and chronic diseases (n = 744)|
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Of the 744 children in the study, almost a third (29%, n = 213) was below the 25 th percentile for height and 40% (n = 300) for weight. There was no significant difference in the proportions in the percentile groups for height (P = 0.54) [Figure 1] and weight (P = 0.35) [Figure 2].
[Table 3] illustrates the association between the children's height and the mothers' social status. The height of the children sample was significantly associated with the level of education of the mother sample (P = 0.02). For mother in the lower education category, a third of the children sample (33%, n = 123) were in the <25 th percentile group compared to 25% (n = 90) of mothers in the college and higher education category. In terms of employment, there was a borderline association (P = 0.053) between the children sample's height and mothers' employment. Unemployed mothers had a higher proportion (31%) of children below the 25 th percentile as compared to those working in the government (26%) and private (16%) sectors. Type of residence also had a significant association (P = 0.04) with the children sample's height. The height of a third (33%, n = 98) of children living in a house was below the 25 th percentile compared to 25% of the children's sample living in an apartment. No significant association was found between the children's height percentile and residence ownership or mothers' monthly income.
|Table 3: The association between mothers' socio-economic status and children's height (n = 744)|
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[Table 4] displays the association between the children sample's weight percentile categories and their mothers' socio-economic status categories. There was no association between the weight categories and mothers' education (P = 0.70), monthly income (P = 0.50) and type of residence (P = 0.20). However, employment was significantly associated (P = 0.02). For both unemployed and government employed variables, the weight of 41% of the children sample was below the 25 th percentile. In terms of home ownership (P = 0.02), the proportions of weight below the 25 th percentile were 42% (n = 323) for those living in owned residence and 40% (n = 132) for those living in rented residence. The proportions of weight above the 75 th percentile were 21% (owned residence) compared to 14% (rented residence). In addition, no association was found between the children's heights and weights and their mothers' chronic illnesses such as asthma, diabetes, hypertension or thyroid conditions.
|Table 4: The association between mothers' socio-economic status and children's weight (n = 744)|
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| Discussion|| |
In this study, mothers and children were recruited to explore the association between mothers' educational and socio-economic status and their children's growth (constituting height and weight). The results indicate that there was an association between children's height and the mothers' educational level, employment status and the residence type while the children's weight was associated with the mothers' employment status and the type of ownership of the residences.
Several studies are reported in literature with similar aims as in this study. A Brazilian study reported by Matijasevich et al., found that mothers' educational levels were positively related to their children's height with an average difference of 3 cm in height between high levels of education in comparison to lower levels of education.  In the current study, significant results were found that associate lower educational levels to poorer development in height, with better height development when the mother is better educated. A possible explanation of this finding is that generally an increase in education positively correlates with an increase in awareness and better employment opportunities, thus better an improved socio-economic situation for the family. An Iranian study by Maddah et al., also reported that children of less-educated mothers had a higher risk to develop undernutrition, which affects the overall health of the child. 
Significant results were found in this study linking mothers' employment status with their children's height and weight. Being employed in the private sector was associated with a higher proportion of children in the above 75 th percentile for both height and weight. Support for the findings is reported by Morrissey et al., in an American study, in which they found that children of employed mothers had a 10% increase in their body mass index (BMI) every 5.3 months.  Another American study by Morrissey showed that mothers' employment status was significantly linked to preschool age children's physical development; employment was associated with an increase in children's BMI.  A study conducted in Ethiopia by Negash et al., had similar results to the current study's findings, in which they found that mothers' employment provided financial power and independency leading to better child care and, therefore, a better height and weight.  On the other hand, studies from Indonesia  and India  showed contradicting results as they had found that children of unemployed mothers weighed more and were taller than children of employed women. The differing results between mothers' employment status and their children's development require further studies to clarify this relationship.
Other factors including the mother's type of residence (house or apartment) and type of ownership of this residence (rented or owned) were found to have a significant relationship with children's growth. It was found that children who lived in apartments were taller than children who lived in a house. A suggested possible explanation for this finding is that apartments are usually smaller and more contained than houses, which means that children spend more time under the direct supervision of their caregivers in contrast to children who live in houses. Results also showed that children of mothers who lived in rented residences had weighed more than children of mothers who lived in owned residences.
Several strengths support the study. Measures were put in place to prevent duplicate data by collecting medical record numbers of the participants, and data were collected from eight hospitals in Riyadh. The data collection was done by the research investigators to insure accuracy when interviewing mothers as well as screening and measuring children.
Some difficulties that were experienced during the study included the outbreak of the Middle East Respiratory Syndrome Coronavirus in Saudi Arabia which was an obstacle for the data collection process. Two limitations are reported for the study. First, data about mothers' chronic illnesses were not verified with their medical records. Second, the study focused on mothers' educational and socio-economic status only, and excluded the fathers' status, which is an important factor. This is a cross-sectional study which was conducted in different hospitals in Riyadh city only; hence, it should be repeated in the Eastern and Western regions of Saudi Arabia for a more complete understanding of the association between children's growth pattern and mothers' educational and socio-economic status in Saudi Arabia.
| Conclusion|| |
Underweight and short stature among children are associated with less educated and unemployed mothers and with mothers who lived in a house. These findings indicate the necessity for introducing the importance of the mothers' educational and socio-economic status on children's growth patterns during parent counselling.
Our sincere gratitude is hereby extended to the College of Medicine of King Saud bin Abdulaziz University for Health Sciences and to King Abdullah International Medical Research Center for the overwhelming support which never ceased till this paper is structured. We as well show appreciation to Dr. Susanna Wright for the valuable effort in editing the paper.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]