The influence of Mothers’ Socioeconomic status on Pneumonia in Childhood (Case study in Khartoum State-Sudan)

 

Afaf Tag Elsir Mahgoub¹*, Khalil A. Elmedani¹, Mofida Y. Elkhalifa²

 

¹Traditional Medicine Research Institute, National Center for Research, Sudan.

 

 

INTRODUCTION:

Pneumonia is one of the leading causes of childhood morbidity and mortality in developing countries, Sudan is one of them. Annual health statistical report 2007 shows that in Khartoum State pneumonia represents the highest percentage (29.9%) among diseases leading to health units (children less than five years). According to the causes of deaths in hospitals for children less than five years during 2007; pneumonia is the second cause and represent 13% of all cause of death.

 

Among the factors that have been postulated to increase the risk of pneumonia among children in developing countries are the following: malnutrition, indoor air pollution, and socio-demographic factors such as large family size, low income, and low level of parental education, poor housing, and inappropriate child care practices (Townsend and Davidson, 1982; Abbas, 1994; Bansal and Saxena, 2002; Hatt and Waters, 2006 and Cameron and Jenny, 2009).

 

Many studies were concerned with family health but few were interested in the relationships between socio-economic status of mothers and prevalence of pneumonia among their children. Economic status was found to be a strong influencing factor in the family health and the spread of infectious diseases such as pneumonia.

 

Some studies concerned about the relationship between household's economic status and family's health, such as Abdalla (2003), Eltahir (2001) and Cameron (2009). Some studies focused in the significant role played by education factor and it is effect on health, such as Caldwell (1979) and Lindelow (2004). However, Lica (2011) found that in infants the risk of developing pneumonia is inversely associated with the head of household income and with the woman educational level.

 

In some areas of Sudan, the people still preferred early marriage to their daughters. Madawi (1979) mentioned in his study that one of the reasons for early marriage in Sudan, the little chance of education. It is well known that early marriage have a negative effect on mother and the child health as reported by Ghulam (1979), that the early marriage increases infant mortality rate, indeed in neonatal period, low birth weight and malnutrition. Malnutrition is a problem of a considerable magnitude in most of the developing countries, Sudan not exception. WHO (2011) reported that, the underweight during the period 2000-2009 was 31.7% to children less than five.

 

Poverty and insufficient income for the family is the main cause of nutritional anemia, which adversely affected person's activities. Beenstock (1980) mentioned the negative effect of iron deficiency anemia on productivity. Preventing children from developing pneumonia in the first place is essential for reducing child deaths. Key prevention measures include promoting adequate nutrition (including breastfeeding and zinc intake), raising immunization rates and reducing indoor air pollution.

 

Traditional medicine is embedded in the Sudanese culture. Many authors talked about its old roots in Sudanese societies (Ibn def alla, 1974), (Alsafi, 1970)…etc. In Sudan popular health system play a major role in the health of people. The mother usually treats and prevents physical and spiritual diseases in home. Many mothers use some medicinal plants to treat common diseases like; Boswellia carterii or Acacia nilotica with Seasmum indicum oil used externally in diseases of the respiratory system and Pneumonia.

 

The aims of this study were to determine the prevalence of pneumonia among the under ten children in Khartoum State and to investigate some of the associated factors.

 

MATERIALS AND METHODS:

This research was conducted in Khartoum State. Khartoum is a cosmopolitan area representing people from different social backgrounds. The study used a comparative approach between different socio-economical areas.  Research sample was 400 families; 120 families from Alriyad to represent the high socio-economical status (HSS), 180 families from Gebra representing the middle socio-economical status (MSS), and 100 families from Alremala representing the lower socio-economical status (LSS).  The unit of the study is the family, where the main respondent was the mother.  Both quantitative and qualitative methods of data collection were used. Interviews guided by structured questionnaires were used to collect data on socio-demographics. The study aims at determining the prevalence of pneumonia in Khartoum state_ Sudan. Also it investigates in the relation between mothers’ socio economic status and prevalence of pneumonia among their children, during 2011. The survey was carried out (December, January, February, and March), which is the winter season in Sudan. The most common infectious disease during this season is pneumonia. The data was entered and analyzed using a computer program SPSS program (statistical package for social sciences). Anthropometric measurements were focused on weights and heights of the150 children (50 from each area). Then data was transformed into weight for height Z-scores to determine the prevalence of malnutrition among this population.

 

RESULTS AND DISCUSSION:-

Table (1) Demographic characteristics of mothers

Age/ Marriage age/ Education/ Income	Area			Total	P value
	Alriyad	Gebra	Alremela
Age;             ≤ 40	48	98	45	191
	40.0%	54.4%	45.0%	47.8%	0.04
≥ 41	72	82	55	209
	60.0%	45.6%	55.0%	52.2%
Marriage age ≤ 19	35 29.2%	65 36.1%	52 52.0%	152 38.0%	0.002
≥ 20	85 70.8%	115 63.9%	48 48.0%	248 62.0%
Education;            < university	70.8%	114	74	222
	28.3%	63.3%	74.0%	55.5%	0.000
≥ university	86	66	26	178
	71.7%	36.7%	26.0%	44.5%
Income; < 2001	5	168	95	268	0.000
	4.2%	93.3%	95.0%	67.0%
> 2000	115	12	5	132
	95.8%	6.7%	5.0%	33.0%

 

 

The table above shows the demographic characteristics of mothers in three areas. In Alriyad city (HSS), most of mothers belong to the age group ≥ 41 years (60%), while in Gebra (MSS) (45.4%) mothers and in Alremela (LSS) (55 %) of mothers belong to this age group.

 

In Alriyad only 29.2% mothers got married before they reached their 20 ͭ ͪ birthday and in Gebra 36.1 % of the mothers married in age ≤ 19, whereas in Alremela the percentage significantly increase to reach 52% of mothers got married at the age of 19 or less. This reflects a strong association between age of marriage and economic class (p=0.002).

 

Concerning mother's education; in Alriyad up to 71.7% of mothers have either university or above level of education, whereas in Gebra and Alremela only 36.7% and 26% respectively of this level of education. It is clear that the education level significantly increase as the economic status increase (p=0.000).

 

Concerning family’s monthly income; in Alriyad (HSS) only (4.2%) of families earn less than 2001SGP, while in Gebra (MSS) and Alremela (LSS) up to  93.3% and 95% of families respectively earn monthly this amount of money (p=0.000). It is clear that as the income and education levels increase, the socio- economical status increases. Therefore residential area can be used as a strong indicator of the socio-economical status of mothers.

 

Table (2) Children infected by Pneumonia

Pneumonia	Area			Total
	Alriyad	Gebra	Alremela
yes	26	66	51	143
	32.5%	57.9%	77.3%	55.0%
no	54	48	15	117
	67.5%	42.1%	22.7%	45.0%
Total	80	114	66	260
	100.0%	100.0%	100.0%	100.0%

P= 0.000

 

Table (3) the relation between families incomes and infected by pneumonia

Income	Pneumonia		Total
	yes	No
less than 2001	107	61	168
	63.7%	36.3%	100.0%
more than 2001	36	56	92
	39.1%	60.9%	100.0%
Total	143	117	260
	55.0%	45.0%	100.0%

P=0.000

 

The relation between residential areas and pneumonia was negative relation, the spread of pneumonia increased in low residential class. This was confirmed by chi square test (P= 0.000). Pneumonia is an infectious disease, and increased in unhealthy and poor environment in homes and the surrounding areas. Poor home environment probably due to the smaller home sizes and the lower degree of sanitation. This confirmed by analyzing the relation between family’s income and prevalence of pneumonia.

 

Among all the socio-economical factors studied, family’s income was found to be the most powerful significant factor that decrease the risk of being infected by pneumonia (table 3). This was confirmed by chi-square test (P=0.000). It is clear the negative relation between economic status and spread of pneumonia, which spread more in low economic status. However, pneumonia associated with over crowdedness, malnutrition and poor environment condition. Generally the adequacy of health care is important to decrease the spread of all diseases, and access to health care is related to economic status.

 

Table (4) Causes of death to children less than five

Cause of death	Frequency	Percentage
Infectious disease (pneumonia)	23	32.9%
Malnutrition	1	1.4%
Other causes	46	65.7%
Total	70	100%

 

Concerning cause of death (table 4) a high percentage (32.9%) of cause of death is infectious diseases and pneumonia one of them. This mentioned by (AHSR, 2007) pneumonia is the second cause and represent 13% of all cause of death. Although pneumonia is a major cause of death in Sudan, little is known about community beliefs and practices surrounding the disease. In this study, up to 50% from mothers believed that pneumonia is normally symptoms in the teething period for children less than two.

 

Table (5) Nutritional status of less than ten years children

Health status	Frequency	Percentage
Obese	32	21.3%
Normal	74	49.3%
Malnourish	44	29.3%
Total	150	100%

 

Malnutrition was the most important risk factor for childhood pneumonia in the study population, with anthropometric indices - low weight-for height. The study found that 29.3% of children are malnourish (mild, moderate and severe malnutrition). This large figure reflects the weak nutritional health status of children, which make them more vulnerable to pneumonia.

 

Low per capita income lead to deficiency in daily calories, which lead to diseases appearance and high death rate as confirmed by Beenstock (1980). This has a negative reflection on economic development in general. Generally the nutritional status in Sudan for children under five is bad, as maintained in WHO (2011) report, the underweight during the period 2000-2009 was 31.7%.  The WHO found many factors affecting children under five, important factors were early marriage, early and more frequencies pregnancy and decreased foods intake. Early marriage leads to many health problems one of them low birth weight.

 

Table (6) the relation between mother’s education and pneumonia infected

Mother’s education	Pneumonia		Total
	yes	no
less than university	74	55	129
	57.4%	42.6%	100%
University and above	69	72	141
	48.9%	51.1%	100%
Total	143	117	260
	55.0%	45.0%	100.0%

P=0.05

 

Table (6) shows that 57.4 % from children their mothers have less than university level of education, infected by pneumonia. Mother's level of education is important because it improves their knowledge about the prevention and treatment of diseases, and how to promote health. This knowledge affected her attitudes and behavior towards nutritional foods, personal hygiene and home sanitation, and healthy environment to her family, which affecting directly the prevalence by pneumonia.

 

Table (7) the relation between heath status and pneumonia infected

Health status	Pneumonia		Total
	yes	no
Obese	17	15	32
	53.1%	46.9%	100%
Normal	43	31	74
	58.1%	41.9%	100%
Malnourish	26	18	44
	59.1%	40.9%	100%
Total	86	64	150
	57.3%	42.7%	100.0%

 

Nutritional status of children is another influencing factor affecting pneumonia prevalence; a healthy child has many natural defenses that protect its lungs from the invading pathogens that cause pneumonia. However, children and infants with compromised immune systems have weakened defense. This clears in table (7) a high percentage (59.1%) from malnourish children infected by pneumonia. Generally the nutritional status in Sudan for children under five is bad, in WHO (2011) report, the underweight during the period 2000-2009 was 31.7%.

 

Table (8) the relation between prevalence of pneumonia and house size

Number of rooms		Children pneumonia		Total
		Yes	No
	1-2	44	18	62
		71.0%	29.0%	100.0%
	3	25	21	46
		54.3%	45.7%	100.0%
	4-6	60	58	118
		50.8%	49.2%	100.0%
	More than 6	14	20	34
		41.2%	58.8%	100.0%
Total		143	117	260
		55.0%	45.0%	100.0%

 

The table above shows that 71% of families who have houses included (1-2 rooms) their children were infected by pneumonia, 54.3 % of children infected with pneumonia live in (3 rooms), the percentage was decreased to 50.8% when the number of rooms increased to (4-6), finally the percentage was decreased to 41.2% when the number of rooms increased to more than 6. According to chi square test (P=0.02). This probably maybe due to that pneumonia is infectious disease and can spread easily by breathing in crowded places. This results agrees with those found by Bansal (2002), he reported that; when the available per capita floor area decrease, the communicable diseases, parasitic diseases and respiratory diseases increase.

 

It is observed that the common type of families in Sudan is the extended families. Therefore, the grandmother still plays a major role in providing health care for the all members of the family (she determined the foods, types of treatment, home remedies tc). 35.7% mothers from whom their children infect by pneumonia used traditional medicine as the first step in the treatment. 33.3% from them used Boswellia carterii or Nigella sativa with Seasmum indicum oil used externally. 21.7 % used Acacia nilotica externally. 27.5% mothers gave their children  Hibiscus sabdariffa as hot drink. It is worth to say that medical care is very expensive in Sudan and not available to most persons. Therefore, using of home remedies increased in low status for cheep and availability. This agree with the result in Abdalla's (2003) study, she found that the used of traditional remedies increase in low economic status to treat some infectious diseases

 

 

CONCLUSION:

Pneumonia is one of the leading causes of childhood morbidity and mortality in Sudan. In Khartoum State a high percentage (32.9%) of cause of death is infectious diseases and pneumonia one of them. The study found that 55% of children infected by pneumonia in the last month more than once time. This figure considered big and reflected children bad health. Among the factors that have been postulated to increase the risk of pneumonia among children in Khartoum State; family income, mother educational level, nutritional and health status of children and house size. The study found that there is a negative relation between economic status and spread of pneumonia (P=000), which spread more in low economic status. Mother’s level of education is important because it improves their knowledge about the prevention and treatment of diseases, and how to promote health. This confirmed by the result found in this study; According to chi square test it is apparent that there is a significant association (P=0.05) between prevalence of pneumonia and mothers level of education. Nutritional status of children is another influencing factor affecting pneumonia prevalence among children studied a high percentage (59.1%) from malnourish children infected by pneumonia. Moreover, there is appositive relation between house size and pneumonia prevalence. The overcrowded houses lead to the spread of pneumonia, 71% of families who have houses included (1-2 rooms) their children were infected by pneumonia.

 

Mothers can greatly participate in improving their families' health. Therefore, education is the key to increase the knowledge and awareness of mothers regarding the effective ways of preventive measures.

 

Economical status is influencing factor affecting family's health. Therefore, reducing poverty is important to improve family health. Hence the government must states policies to improve standards of living as general. This can be achieves by increasing occupation opportunities.

 

REFERENCES:-

1.       Abbas, S (1994). Effect of environmental sanitation on child health. A comparative studies. Master of science in environmental studies. U of K. Sudan.

2.       Abdalla, W. (2003). The socio-cultural, economic, and environment factors affecting health. PhD thesis. U of K. Sudan.

3.       Alsafi  A. (1970). Native medicine in the Sudan. Sudan research unit, University of Khartoum, KUP. Sudan.

4.       Bansal R. K.,  Saxena D. M (2002). Overcrowding and health. Indian Journal of Medical Sciences. 56 (4): 177-179.

5.       Beenstock M., (1980). Health, Migration and development. Gower publishing company limited, England.

6.       Caldwellt. J. C. (1979). Population Studies. Education as a Factor in mortality decline. An examination of Nigerian data. JSTOR, 33 (3): 395-413.

7.       Cameron L. and Jenny W. (2009). Is the relationship between socioeconomic status and health stronger for older children in developing countries? Demography 46(2): 303–324.

8.       Eltahir. A, (2001). Nutritional Status of Sudanese Schoolgirls (6-14years). M. Sc in Nutrition. U of K. Sudan.

9.       Hatt L. E., Waters H. R. (2006). Determinants of child morbidity in Latin America: A pooled analysis of interactions between parental education and economic status. Social Science and Medicine, 62 (2): 375-386.

10.     Ibn def alla, (1974). Altabagat book. University of Khartoum, KUP. Sudan.

11.     Lícia KAM Thörn, Ruth Minamisava, Simonne S Nouer, Luiza H Ribeiro and Ana L Andrade (2011). Pneumonia and poverty: a prospective population-based study among children in Brazil. BMC Infectious Diseases 2011, 11:180

12.     Lindelow, M. (2004). Health care decisions as a family matter - intra-household education externalities and the utilization of health services. The World Bank in its series Policy Research Working Paper Series with number 3324.

13.     Townsend, P. and Davidson, N. (1982). Inequalities of Health: The Black report. Penguin. Cited in Helman, C, 2000. Culture, health and illness. Fourth edition. Butterworth Heinemann. London.

 

Reports:-

1.       Annual Health Statistics Reports (2007). Republic of Sudan Federal Ministry of    Health National Health Information Centre.

2.       Ghulam.J.Laila. Early teenage child birth and it is consequences for both mother and child in Oman. Seminar; Traditional practices affecting the health of women and children. WHO/ EMRO Technical publication No.2.

3.       Modawi. O. (1979). Traditional practices affecting the health of women and children. WHO\EMRO Technical publication No.2.

4.       WHO (2011) .World health. Statistics. WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland