Public Health (2004) 118, 151–158

Demographic and socio-economic factors affecting

the physical development, haemoglobin and
parasitic infection status of schoolchildren in
Sanliurfa province, Turkey
M. Ulukanligil*, A. Seyrek

Department of Microbiology, School of Medicine, Harran University, Sanliurfa 63100, Turkey

Received 4 April 2003; received in revised form 1 June 2003; accepted 18 June 2003

KEYWORDS Summary A cross-sectional population-based survey was undertaken to evaluate the

Schoolchildren;
Nutrition; Haemoglobin;
Parasitic infections;
Demographic and socio-
economic factors
relationship between nutritional status and parasitic infections of schoolchildren and
demographic, socio-economic factors in Sanliurfa province, southern Turkey. Nine
hundred and eight schoolchildren took part in the survey: 57.2% boys and 42.7% girls.
The children’s mean z scores were as follows: height for age—0.8 (^ 1.0) and weight
for age—1.0 (^0.9). The mean haemoglobin concentration was 123 g/l (^ 2.1) and the
prevalence of parasitic infections was 55.1%. In total, 50.2% of children were hungry
when they arrived at school and 13.4% worked after school. Over 70% (70.4%) of
mothers and 18.1% of fathers were illiterate, 16.1% of fathers were unemployed and
46.3% of fathers were engaged in low-income labour. The mean number of children in
each family was 5.4 (^ 2.5), and the mean number of children from each family who
attended school was 2.1 (^ 1.1). The school-attendance ratio was 0.4 (^1.0). Data
indicated that older children had significantly lower mean z scores of height ðP ,
0:0001Þ and weight for age ðP , 0:0001Þ than younger children, and boys had
significantly lower mean z scores of height for age than girls ðP , 0:0001Þ: Children
living in shantytown areas had significantly lower mean z scores of height for age
ðP , 0:0001Þ and weight for age ðP , 0:0001Þ; lower mean haemoglobin concentrations
ðP : 0:003Þ and a worse parasitic infection status ðP , 0:0001Þ than those living in
apartment areas. Children who were hungry when they arrived at school had
significantly lower mean haemoglobin concentrations than those who had eaten ðP :
0:04Þ: Multiple regression analyses indicated that mean z scores of height for age were
significantly related to maternal (multiple R ¼ 0:183; P , 0:0001) and paternal
illiteracy (multiple R ¼ 0:216; P : 0:004). Mean z scores of weight for age were
significantly related to maternal illiteracy (multiple R ¼ 0:154; P , 0:0001), as was
parasitic infection status (multiple R ¼ 0:261; P , 0:0001) and the number of children
in the family (multiple R ¼ 0:267; P : 0:005). Hunger status was significantly related to
maternal (multiple R ¼ 0:095; P : 0:016) and paternal illiteracy (multiple R ¼ 0:104;
P : 0:005), as was belonging to a large family (multiple R ¼ 0:104; P : 0:009).
These findings indicate that school health programmes may improve the nutritional
and health status of schoolchildren. The participation of the local community, which

*Corresponding author.
E-mail addresses: mulukan@ttnet.net.tr; mulukan@bigfoot.com(M. Ulukanligil)

0033-3506/$ - see front matter Q 2003 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.puhe.2003.06.003
152 M. Ulukanligil, A. Seyrek

such a programme would entail, may help to increase maternal awareness regarding
the feeding of their children before sending them to school. School health programmes
may also motivate parents to send their daughters to school, thus increasing maternal
literacy in the future. In turn, better levels of maternal literacy will positively affect
the socio-economic development of society.
Q 2003 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights
reserved.

Introduction These questions should be answered in order to

Most developing countries have experienced an
important decrease in child mortality rates largely
due to successful vaccination programmes.1,2 How-
ever, while child mortality rates have declined,
many children face health problems such as
malnutrition, anaemia and parasitic infections
that compromise their physical development,
school attendance and ability to learn.3 – 5 Children
who lack certain nutrients in their diet or suffer
from protein – energy malnutrition, hunger, para-
sitic infections or other diseases do not have the
same capacity for learning as healthy, well-nour-
ished children.6,7
Several factors influence the poor nutrition of
children: political factors (governmental social
support, energy intake per capita, gross national
product and distribution of income), social factors
(female educational and social status, family size
and child population), economic factors (avail-
ability of food, purchasing power and utilization)
and health factors (infant mortality rate, access to
safe water, access to health services and parasitic
diseases).8
There is substantial variability in these factors
within regions, among nations within regions, and
among provinces within nations.8 The south-eastern
region of Turkey differs socio-economically from
other regions with regard to dependence on
agriculture, feudal social structure, population
dynamics (heavy migration to the cotton planta-
tions for income generation), inequity of income
distribution, high female illiteracy rates and large
family size.9
The purpose of this paper is to evaluate factors
associated with child malnutrition at a local
province level in the region. Which factors affect
child malnutrition? How great a role does parental
illiteracy play in the health and nutritional status of
children? How much of an impact does paternal
employment status have on the health and nutri-
tional status of children? Does the number of
children in a family play a role in their health and
nutritional conditions? Which factors are respon-
sible for children being hungry on arrival at school?
determine the most appropriate intervention strat-
egies to improve health and nutritional conditions
in children.
Methodology and sampling
Study areas
Sanliurfa province is in an underdeveloped region of
south-eastern Turkey. It is on the crossroads
between the Mediterranean, the Anatolian plateau
and Mesopotamia. It is situated on a semi-arid plain
at 550 m above sea level. The climate of the area
has an average temperature of 18.1 8C, a minimum
temperature of 2 12.4 8C in February and a maxi-
mum temperature of 46.5 8C in August. The average
annual relative humidity is 49%, and the average
rainfall is 463 mm.10 In the province, the main
industrial structure is the south-eastern project
(GAP), a massive dam and waterways project that is
currently under construction. GAP has attracted
many people from rural areas to migrate to the
province. These people tend to inhabit shantytowns
in the city outskirts, constructing mud/brick houses
around a small central courtyard. In these areas,
sanitary conditions are poor with household liquid
and rubbish accumulating in the streets. Residents
of higher socio-economic status have settled in new
apartment buildings in the north of the city. In
contrast to the shantytowns, the apartment areas
have good sanitation conditions.
The Sanliurfa province is composed of 66
districts with a population of 513,575.11 Forty-
three of the 66 districts (65.1%) are shantytowns,
housing 63.6% of the population. The remaining 23
districts (34.8%) are apartment areas, housing
36.2% of the population.12 Seventy-four thousand
children are enrolled in 44 primary schools in the
province: 46,768 children (63.2%) are enrolled in
30 (68.2%) primary schools in shantytown districts,
while 27,232 children (36.8%) are enrolled in 14
(31.8%) primary schools located in apartment
districts.13
Demographic and socio-economic factors affecting the physical development, haemoglobin
and parasitic infection status of schoolchildren in Sanliurfa province, Turkey
Sample design
The study was carried out between January and
June 2001. The multistage random cluster
sampling technique was used to select the study
sample.14 In the first stage, the urban area of the
province was stratified into two strata on the basis
of socio-economic and environmental conditions:
shantytowns and apartment areas. In the second
stage, a total of 17 schools (clusters), 12 schools
in shantytown areas and five schools in apartment
areas, were selected at random based on the
proportional size of each stratum. The sample size
was adapted from the World Health Organization’s
sampling strategy in order to provide enough
samples for nutritional surveys.11 In the third
stage, a class (including 9 – 10-year-old children)
was selected at random in each school. This was
because the peak prevalence and intensity of
helminthic infections is found in this age group,
children of this age suffer from nutritional
deficiencies and are undergoing a period of
intense physical and mental development, and
because experience shows that there is generally
good compliance from both children and
parents.15
A total sample of 1022 children, 710 from
shantytown schools and 312 from apartment
schools, were included in the selected classes in
the schools. Leaflets were distributed to children
in the selected classes for their parents’ infor-
mation and consent. The survey team asked
children to read the leaflets to their parents if
they were illiterate, and obtain their signatures if
they approved. The following day, the team
members checked parental approval and col-
lected samples from those pupils who
had received approval. They organized the survey
as a flow chart while the children remained
seated.
We tried to include all 1022 children in the survey
but 114 (11.1%) did not obtain parental approval: 49
(15.7%) of the 312 apartment schoolchildren and 65
(9.2%) of the 710 shantytown schoolchildren. We
asked these children why their parents would not
let them be involved in the survey. Most non-
participants from apartment schools said that their
parents did not want their children to be exposed to
any harmful effects from the blood sampling, and
added that their children had already been involved
in another survey from a different hospital. How-
ever, it is interesting that most of the non-
participants in the shantytown school had a
different reason for not allowing their children to
participate. These parents said that various surveys
153
had been carried out on their children, and nothing
had been given to them in return, so they did not
give approval for their children to be included in the
survey. Although we explained in the leaflets that
this survey would be accompanied with deworming
activities, this was not enough to convince this set
of parents. It was essential to receive parental
approval due to the ethical manner of this survey,
so we excluded any children who did not receive
parental permission from our survey. The percen-
tage of non-participants (11.1%) is not thought to
have caused any bias to our results.
Questionnaire survey
A form (including the child’s name, date of birth,
sex, height, weight, haemoglobin concentration,
helminth infections and a questionnaire) was used
during surveys. The questionnaire was intended to
evaluate the local community’s socio-economic
conditions: maternal and paternal literacy;
paternal employment status and occupation; num-
ber of children in the family; the number of children
in the family attending school; whether the child
was hungry on arrival at school; and whether he/she
worked after school.
Nutritional and parasitological surveys
A portable weight and height calculator (NAN
Corporation) was placed near a table in each
classroom, and children’s weights and heights were
measured to the nearest 0.1 kg. Samples (2 ml) of
venous blood were drawn from each participating
child in the class. The haemoglobin concentration
was measured by Boehringer’s cyanmethaemoglobin
method using a 5110 spectrophotometer with an
accuracy of 0.1 g/l. Stool samples were examined
using the Kato technique16 for the eggs of intestinal
helminths (Ascaris lumbricoides, Trichiuris tri-
chiura, Hymenolepis nana and Taenia spp.).
Data entry and statistical analyses
Data entry and management were done using the
Epi-Info computer program.17 Statistical analyses
were undertaken using SPSS for Windows 9.5.18
Anthropometric indices were calculated using New
Anthro 1.02 software including the NCHS/WHO
international reference values.19 Two anthropo-
metric indices, height for age and weight for age,
were expressed as differences from the median in
standard deviation units or z scores. These indices
were calculated assuming a mid-year age for each
child because of doubts over the correct date of
birth. We used Chi-squared test, Student’s t-test,
154 M. Ulukanligil, A. Seyrek

and multiple regression analyses for statistical 55.1% of children with the following prevalence: A.
analyses. P values of , 0.05 were taken to indicate lumbricoides 40.7%; T. trichiura 18.2%; H. nana
a statistically significant result. 11.7%; and Taenia spp. 1.3%.
The variations in the children’s mean z scores of
height for age and weight for age, haemoglobin
Results concentrations and parasitic infections according
to sex, age, hunger and working status, type of
Demographic and socio-economic status settlement, parental education, paternal employ-
ment status and occupation, and family size are
A total of 908 children, 674 (74.2%) from shanty- shown in Table 2.
town schools and 234 (25.7%) from apartment Older children had significantly lower mean z
schools, took part in the surveys: 57.1% boys and scores of height and weight for age than younger
42.8% girls. The mean age was 9.7 years (^ 1.1). children ðP , 0:0001Þ: Older children also had a
Although the survey was designed to evaluate 9 – 10- higher rate of parasitic infection than younger
year-old children in the third grade, 20.8% of children ðP : 0:001Þ; but there was no association
children were found to be over 10 years of age. between mean haemoglobin concentration and age.
The rates of maternal and paternal literacy, Boys had significantly lower mean z scores of height
paternal employment status and occupation, the for age than girls ðP , 0:0001Þ; but this did not occur
incidence of children working after school and with weight for age. The sex of the children was not
being hungry on arrival at school, the mean number significantly associated with mean haemoglobin
of children in the families, the mean number of concentration and parasitic infection status. The
children in a family attending school, and school- children living in shantytown areas had significantly
attendance rates are shown in Table 1. lower mean z scores of height for age ðP , 0:0001Þ
and weight for age ðP , 0:0001Þ; lower mean
Nutritional and parasitic infection status haemoglobin concentrations ðP : 0:003Þ and a
worse parasitic infection status ðP , 0:0001Þ than
The mean z score for height for age was—0.8 (^ 1.0) those living in apartment areas. Children classified
and that of weight for age was—1.0 (^ 0.9). Mean as hungry on arrival at school had significantly lower
haemoglobin concentration was 123 g/l (^ 2.1). At mean haemoglobin concentrations ðP : 0:04Þ; but
least one type of helminthic infection was found in hunger was not significantly associated with mean z
scores of height for age, weight for age and in the
acquisition of parasitic infection. Children classi-
Table 1 The rate of some socio-economic factors affecting
children’s nutritional and parasitic infections.
fied as working after school had significantly lower
mean z scores of height for age ðP : 0:02Þ; but did
nð%Þ not significantly differ in weight for
age, haemoglobin concentration and parasitic
Maternal education
infection status. Children infected with parasites
Illiterate 639 (70.4)
Literate 269 (29.6) had significantly lower mean z scores of height for
Paternal education age than non-infected children ðP : 0:01Þ; but did
Illiterate 164 (18.1) not have significantly lower z scores of weight for
Literate 744 (81.9) age or lower haemoglobin concentrations.
Paternal employment status
The effects of socio-economic factors such as
Unemployed 146 (16.1)
Employed 762 (83.9) maternal and paternal literacy, paternal employ-
Paternal occupation ment status and occupation, and family size on the
Low income labour 420 (46.3) children’s anthropometric indices, haemoglobin
Better income labour 488 (53.7) concentration, parasitic infections and hunger sta-
Working after school
tus were examined by multiple regression analyses.
Working 122 (13.4)
Not working 786 (86.5) The mean z score of height for age was significantly
Children’s feeding status related to maternal (multiple R ¼ 0:183; P , 0:0001)
Hungry 456 (50.2) and paternal illiteracy (multiple R ¼ 0:216;
Fed 452 (49.7) P : 0:004). The other indices were not found to be
Mean number of children per family 5.4 (^2.5)
significantly related to the mean z score of height for
Mean number of children from family 2.1 (^1.1)
attending school age. The mean z score of weight for age was
School-attendance ratio 0.4 (^1) significantly related to maternal illiteracy (multiple
R ¼ 0:154; P , 0:0001). Other socio-economic indi-
^ : Standard deviation.
cators were not related to the mean z score of
Demographic and socio-economic factors affecting the physical development, haemoglobin 155
and parasitic infection status of schoolchildren in Sanliurfa province, Turkey

Table 2 The distribution of children’s mean z scores of height for age and weight for age, mean haemoglobin concentrations and
prevalence of parasitic infections according to selected demographic and socio-economic variables.

Factors Mean Mean Mean Parasitic

(SD) z scores of height for age (SD) z scores of weight for age (SD) of Hb conc. infections
(g/dl) (%)

Age
7–10 years old 20.7 (1.0) 20.9 (0.9) 124 (2.0) 49.6
11–15 years old 21.3 (1.1)* 21.3 (0.8)* 121 (2.3) 65.0*
Gender
Male 21.0 (1.0)* 21.0 (0.9) 123 (2.1) 54.5
Female 20.7 (1.1) 20.9 (0.8) 124 (2.4) 56.0
Type of settlement
Shantytown 21.0(1.0)* 21.1 (0.8)* 122 (1.2)* 62.1**
Apartment 20.5 (1.0) 20.8 (1.0) 128 (0.7) 37.3
Maternal education
Illiterate 21.0 (1.1)*** 21.1 (0.8)*** 123 (2.2) 62.9***
Literate 20.5 (1.0) 20.8 (1.0) 127 (1.7) 36.0
Paternal education
Illiterate 21.2 (1.1)*** 21.2 (0.9) 119 (2.2) 64.7
Literate 20.8 (1.1) 20.9 (0.9) 125 (2.1) 52.0
Paternal employment status
Unemployed 20.9 (1.1) 21.1 (0.9) 123 (2.4) 65.2
Employed 20.8 (1.1) 21.0 (0.9) 123 (2.1) 52.5
Paternal occupation
Low income labour 20.9 (1.0) 21.0 (0.9) 125(2.1) 59.4
Better income labour 20.8 (1.1) 20.9 (0.9) 123 (2.0) 48.0
Number of children
1–4 children 20.6 (1.0) 20.6 (1.0) 123 (2.0) 44.6
5 þ children 21.0 (0.8) 21.0 (1.1) 124 (2.1) 62.0***
Working after school
Working 21.1 (1.1)* 21.1 (0.9) 122 (2.1) 64.0
Not working 20.8 (1.1) 21.0 (0.9) 124 (2.3) 53.4
Children’s feeding status
Hungry 20.9 (1.1) 21.0 (0.9) 121 (2.2)* 58.1
Fed 20.8 (1.1) 20.9 (0.9) 126 (2.0) 50.8
Parasitic infections
Present 21.0 (0.8)* 20.9 (1.1) 124 (2.1) –
Absent 20.8 (0.9) 20.7 (1.0) 124 (2.1) –

*Variables significantly associated using Student’s t-test; **variables significantly associated using Chi-squared test; ***variables
significantly related using multiple regression analyses.

weight for age. The mean haemoglobin concen-
tration was not associated with any socio-economic
indicators. The children’s parasitic infection status
was significantly related to maternal illiteracy
(multiple R ¼ 0:261; P , 0:0001) and family size
(multiple R ¼ 0:267; P : 0:005), but the other indi-
cators were not associated with parasitic infections.
The children’s hunger status was significantly
related with maternal (multiple R ¼ 0:095;
P : 0:016) and paternal illiteracy (multiple R ¼
0:104; P : 0:005), and increased family size (multiple
R ¼ 0:104; P : 0:009).
Discussion
This survey provided baseline data about socio-
economic factors affecting nutritional and parasitic
infection status of schoolchildren in Sanliurfa
province, Turkey. These data clearly show that
maternal illiteracy is strongly related to children’s
nutritional status, parasitic infections and being
hungry on arrival at school. These results are strong
evidence supporting the need for school health
programmes aimed at improving children’s poor
nutritional status, parasitic infections and hunger
on arrival at school. The data also suggest that
maternal education programmes aimed at increas-
ing maternal awareness regarding the feeding of
their children before sending them to school may
alleviate short-term hunger in children.
The data indicated that boys had lower z scores
of height and weight for age than girls, in agree-
ment with other cross-sectional studies in Ghana,
Tanzania, Vietnam and Indonesia.20,21 The data also
indicated that 20% of children were over 10 years
156
old in selected third-grade classes. These children
tended to have lower z scores of height and weight
for age than the younger children. The presence of
older children in these classes may be because most
of the shantytown residences are seasonal workers
and all family members migrate to the cotton
plantations between May and December every
year.30 Thus, some children start to attend school
late in the year, and others may fail to attend
school altogether.
The data indicated that the type of settlement
was significantly associated with mean z scores of
height for age ðP , 0:0001Þ and weight for age ðP ,
0:0001Þ; mean haemoglobin concentrations ðP :
0:003Þ and parasitic infections ðP , 0:0001Þ: The
type of settlement reflects the socio-economic
conditions of the population and environmental
sanitation. The high prevalence of parasitic infec-
tions in shantytown settlements was due to poor
environmental sanitation conditions. However,
lower z scores of height and weight for age and
lower haemoglobin concentrations can be directly
attributed to the socio-economic conditions rather
than to the type of settlement itself.
This survey indicated that the infected children
had significantly lower z scores of height for age.
Many reports have shown that low z scores of height
and weight for age are common consequences of
parasitic infections,22,23 and are strongly associated
with a deficit in mental function.6,24
The data indicated that it was common for
children to attend school without eating breakfast
or lunch (50%). Most of the children ate tomato
paste sandwiches to satisfy their hunger at school.
Although our data only show that short-term hunger
lowers haemoglobin concentration, there is evi-
dence that short-term food deprivation, such as
missed breakfasts or lunches, can also affect
cognitive functions of school-age children, particu-
larly those who are already suffering from malnu-
trition.4,7 Children’s hunger status was significantly
related to maternal and paternal illiteracy and an
increased number of children in the family, but not
with paternal unemployment status or low income.
This result clearly shows that education pro-
grammes aimed at increasing maternal awareness
regarding the feeding of their children before
sending them to school may alleviate short-term
hunger in children.
The data also indicated that 13% of children
were working after school. They were generally
street vendors, shoe shiners, or bag carriers at the
bazaar. The working children had lower mean z
scores of height for age than non-working chil-
dren. This is in agreement with the results of
other studies.2,4
M. Ulukanligil, A. Seyrek
These data clearly show that maternal illiteracy
was an underlying factor affecting children’s health
and nutritional status. Maternal illiteracy had a
negative effect on children’s mean z scores of
height and weight for age, increased the rate of
acquiring parasitic infection and being hungry on
arrival at school. This result was confirmed by other
studies which indicate that women’s educational
and social statuses are important underlying deter-
minants of the nutritional status of children.25 – 27
This may be due to the fact that illiterate mothers
may be unaware about the nutritive value of
feeding and hygiene practices. They may fail to
prepare breakfast or lunch, and only send their
children to school with bread and pepper sauce.
Thus the schoolchildren who are fed insufficiently
become hungry after coming to school. The children
chronically fed on poor nutritive diets may have
suffered from malnutrition, which would be further
aggravated by parasitic infections. Many reports
have indicated that schoolchildren who suffered
undernutrition underachieve scholastically, cannot
benefit fully from formal education, and do not
develop skills and abilities. Consequently, these
children suffer further in terms of productivity and
employment prospects, with implications for the
economic development of the community.2,4,28
The data also showed that paternal illiteracy was
significantly correlated with children’s height for
age and being hungry on arrival at school. Illiterate
fathers cannot be hired for skilled jobs and tend to
have lower incomes.29 Poor purchasing power leads
to poor living conditions and poor sanitary facilities,
aggravating children’s malnutrition and parasitic
infections.29
Both maternal and paternal illiteracy are a
consequence of non-enrolment, absenteeism or
early drop out from school.2 However, primary
education is compulsory in Turkey, and parents
must enrol their children in primary school at 7
years of age. The questionnaire survey revealed
that 60% of school-age children (between 7 and 18
years old) had dropped out of school or were truant
from school, indicating that the majority of school-
children become truants or drop out over time.
There were several reasons for children’s absentee-
ism in this locality. First, most of the shantytown
residents are seasonal workers and all family
members migrate to the cotton plantations
between May and December every year.30 Thus,
these children leave their schools 2 months early
and return to the city 3 months after the schools
begin. Therefore, some children start to attend
their schools late in the year, whereas others may
fail to attend school altogether. Second, some
parents need their children as a source of income,
Demographic and socio-economic factors affecting the physical development, haemoglobin
and parasitic infection status of schoolchildren in Sanliurfa province, Turkey
especially in low-income families. In addition,
several social and behavioural factors may be
involved in female absenteeism. First, some
parents may consider 1 or 2 years of education to
be enough for females to achieve literacy. Second,
some parents may believe that female children
should be removed from school when they enter
puberty. Third, some parents may need them for
domestic work, especially in large families. Female
children who drop out of school early do not have
the opportunity to develop basic skills for their
health and prospects.2 Furthermore, they cannot
complete their social development and will follow
the same behavioural patterns as their mothers.
Any health programme aiming to improve the socio-
economic development level of the community
should begin with the education of female children
who will become mothers in the future. It is
expected that the school health programmes will
promote a dialogue with local community mem-
bers, and that as a result, parents may become
more strongly motivated to send their daughters to
school.
Our study has certain limitations concerning the
accuracy of children’s dates of birth, which affects
z scores of height and weight for age. Most of the
children’s birthdays were 1 January according to
the school records, and the children did not know
their exact birth dates during interview, so we took
mid-year age. Also, the cross-sectional study did
not allow the exact determination of effects of
socio-economic factors on the children’s nutritional
and parasitic status. A longitudinal cohort study
would be necessary to provide information about a
community’s social, educational, economic and
behavioural characteristics. However, this survey
provided baseline information about demographic
and socio-economic factors impacting on children’s
nutritional, parasitic infections and hunger con-
ditions. When establishing school health pro-
grammes, parents may become involved in
deworming and feeding activities which may
increase their awareness about the importance of
health and education, and subsequently they may
become more active in struggling against illiteracy,
ignorance and poverty.
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