The role of maternal literacy and nutrition knowledge in
determining children’s nutritional status
Parul Christian, Rita Abbi, Sunder Gujral, and Tara Gopaldas
Introduction
A mother is the principal provider of the primary care
that her child needs during the first six years of its life.
The type of care she provides depends to a large extent
on her knowledge and understanding of some aspects of
basic nutrition and health care. It is understandable that
her educational status has been reported to influence her
child-care practices.
During the past decade, evidence has accumulated
from several studies that maternal education is an
important determinant of infant and child mortality
[1, 2]. Chen [2] proposed that children born of educated
mothers have a lower mortality risk because educated
women tend to marry and have their first child at a later
age than uneducated women. They also are likely to be
more assertive and to play a greater part in intra-family
decision making in favour of their children’s needs. Their
husbands tend to be economically better off than those
of uneducated women. Educated mothers may also make
earlier and more effective use of health services. It may
be postulated that mothers’ education would affect their
children’s nutritional status by similar mechanisms, and
various studies have shown some degree of association
between mothers’ education and the nutritional status of
children [3-5].
It cannot be assumed, however, either that the mothers
of malnourished children are necessarily ignorant or that
all illiterate mothers. whether their children are healthy
or malnourished, are ignorant [6]. Their knowledge of
child nutrition and child-care practices can be expected
to have a significant bearing on their children’s nutritional
status, but conflicting results have been reported in this
regard. Whereas some studies have observed a positive
relationship between childhood malnutrition and
maternal knowledge and beliefs regarding nutrition
[7, 8]. others have shown no such relationship [9, 10].
In the present study we investigated the effects of
mothers’ literacy status and nutrition knowledge on the
nutritional status of children. We attempted to determine
whether literate mothers had better nutrition knowledge
and to elicit specifically the impact of mothers’ nutrition
Food and Nutrition Bulletin, vol. 10, no. 4 © 1988, The United Nations University.
knowledge on their children’s nutritional status,
controlling for their literacy status and for family
income, which is a well-established factor affecting child
nutrition status [8, 11].
Materials and methods
The study was carried out in rural and tribal villages of
Panchmahals district of Gujarat state, India, as part of a
baseline survey for the USAID-assisted Integrated Child
Development Services project.
A pretested questionnaire was used to collect
information on the education level and nutrition
knowledge of 2,723 mothers. Complete information was
not available for all the women, and therefore only 2,665
were included in the analysis.
Educationally, the women were categorized simply as
literate or illiterate. as only 6% had any formal education
and only 3.2% had studied beyond the primary level.
The women’s nutrition knowledge was evaluated on a
scale of 0 to 9 on the basis of their responses to a set of nine
questions, with one point given for each correct answer
and a maximum possible score of 9. The knowledge
components tested were the proper age to introduce
solid foods into a child’s diet, types of solid foods to
introduce, frequency of feeding, diet during diarrhoea,
management of diarrhoea, awareness of oral rehydration
therapy, preparation of oral rehydration solution,
causes and treatment of protein-energy malnutrition,
interpretation of growth charts, and perception of own
child’s nutritional status. As a majority of the women had
a score of 0 or a very poor score, a score of 4 or above
was considered good. The scores were divided into three
categories: 0, 1-3, and 4 or above.
The per capita monthly income of the households of
the study population was determined by interviewing
the head of the family or any other senior member in
his absence. The families were categorized as above or
below the poverty line, using Rs 65 (US$5) per capita per
month as the dividing point, as suggested by the Gujarat
Directorate of Health [12].
1
2 The role of maternal literacy and nutrition knowledge

All the children of mothers in the study 0-72 months 3rd 92 10.3 197 14.0 179 12.2
old for whom complete weight, height, and age data were
2nd 203 22.7 484 34.4 502 34.3
obtained [13] - 4,004 out of a total 4,242 children - were
included in the analysis. The children were weighed 1st 262 29.2 413 29.4 490 33.5
to the nearest 0.1 kg on a Salter-type spring balance. Normal 315 35.2 273 19.4 269 18.4
Height was measured to the nearest 0.1 cm using a Literate
portable measuring board; supine length was measured
4th 1 2.2 3 2.9 0 0.0
for children 0- 12 months old and standing height for
those one year old or over. The ages of the children were 3rd 1 2.2 9 8.6 10 1 1.1
determined by thoroughly questioning the mothers with 2nd 8 17.8 30 28.6 26 28.9
the aid of a local events calendar to assist recall. 1st 16 35.6 38 36.2 30 33.3
The cut-off points used were those suggested by the Normal 19 42.2 25 23.8 24 26.7
Indian Academy of Pediatrics [14] for weight for age Chi-square 4.476b 5.587b 5.318b
(>80%, normal; 71-80%, first-degree malnutrition; 61- a.  “4th”- “1st” indicate degrees of malnutrition.
70%, second-degree malnutrition; 51-60%, third-degree b.  Not significant.
malnutrition; <51%, fourth-degree malnutrition), and by
Waterlow [15] for weight for height >=90%, normal; 80- TABLE 2. Relation between mothers’ literacy status and
their children’s nutritional status as indicated by height
89%, mild malnutrition; 70-79%, moderate malnutrition;
for age
<70%. severe malnutrition) and for height for age
(>=95%, normal; 90-94%, mild malnutrition; 85-89%, Nutritional
moderate malnutrition; <85%, severe malnutrition). Child’s age group
statusa
Chi-square values were calculated to determine   0-12 mo 13-36 mo 37-72 mo
whether the nutritional status of the children depended   N % N % N %
on the mothers’ (i) literacy and (ii) nutrition-knowledge
Illiterate
score, and to study the association between these two
independent variables and their individual relationship Severe 48 5.7 271 19.3 326 22.3
to the income status of the family. Analysis of covariance Moderate 161 18.0 397 28.3 397 27. 1
was done to study the effect of the mothers’ nutrition Mild 309 34.5 414 29.5 400 27.3
knowledge on the children’s nutritional status, controlling Normal 378 42.2 323 23.0 340 23.2
for their literacy status. The per capita monthly income
was also included in the model to determine whether Literate
the association between maternal nutrition-knowledge Severe 3 6.7 11 10.5 13 14.4
scores and child nutritional status was still significant Moderate 2 4.4 33 31.4 25 27.8
after testing for the confounding effect of income. The Mild 15 33.3 38 36.2 32 35.6
anthropometric indicators used were expressed
Normal 25 55.6 23 21.9 20 22.2
as percentages of the National Centre for Health
Statistics median [16] and were treated as dependent Chi-square 6.464 b
5.933
b
4.494b
variables, with nutrition-knowledge score as the a.  “Severe,” “moderate,” and “mild” indicate degrees of malnutrinon.
b.  Not significant.
main effect and literacy of mothers and per capita
monthly income as covariates.
TABLE 1. Relation between mothers’ literacy status and Results
their children’s nutritional status as indicated by weight Tables 1-3 show the agreement between the mothers’
for age literacy status and the nutritional status of their children
Nutritional
by weight for age, height for age, and weight for height
Child’s age group respectively. A positive relationship appears to exist: for
statuea
each of the three indicators, a higher percentage of the
  0-12 mo 13-36 mo 37-72 mo
children of the literate mothers were of normal status or
  N % N % N % had a mild grade of malnutrition than of the children
Illiterate of the illiterate mothers, and a smaller proportion of
4th 24 2.7 38 2.7 23 1.6 the children of the literate mothers were moderately
or severely malnourished than of those of the illiterate
Parul Christian et al. 3

mothers. The chi-square test, however, indicated that TABLE 3. Relation between mothers’ literacy status and
these differences were not statistically significant. their children’s nutritional status as indicated by weight
for height
The mothers’ nutrition knowledge on the whole was
found to be poor; their mean score was 1.6 out of the Child’s age group
maximum of 9. Nutritional
0-12 mo 13-36 mo 37-72 mo
Tables 4-6 show the relations between the mothers’ status
N % N % N %
nutrition-knowledge scores and their children’s nutritional
status by the three indicators. Good agreement is seen Illiterate
between the scores and the children’s weight for age and Severe 60 6.7 77 5.5 37 2.5
height for age for all except the oldest age group (37-72 Moderate 149 16.6 345 24.6 288 19.7
months): a significantly higher percentage of the children Mild 273 30.5 608 43.3 711 48.6
0-36 months old whose mothers scored 3 or less were
Normal 414 46.2 375 26.7 427 29.2
moderately or severely malnourished than of those of the
mothers with a score of 4 or more (tables 4 and 5). A similar Literate
effect is seen in the older group, but it is not statistically Severe 2 4.4 4 3.8 2 2.2
significant. A significant relation is seen between the Moderate 5 11.1 20 19.0 11 12.2
mothers’ scores and wasting as assessed by weight for
Mild 16 35 6 40 38 1 39 43.3
height in the children in all the age groups (table 6).
Normal 22 48.9 41 39.0 38 42.2
As to the relationship between the mothers’ nutrition
knowledge and literacy, although the great majority of Chi-square 1.555a 7.760a 7.783a
both literate and illiterate mothers had scores in the poor a.  Not significant.
range (1-3 points), a significantly larger proportion of the TABLE 4. Relation between mothers’ nutrition-knowledge
literate group (20.9%) than of the illiterate group (4.6%) scores and their children’s nutritional status as indicated by
had scores of 4 or more, while 15.2% of the illiterate weight for age
group but only 4.8% of the literate group had a score of
0 (table 7). Both literacy and nutrition-knowledge scores Child’s age group
Nutritional
were significantly related to family income : a higher 0- 12 mo 13-36 mo 37-72 mo
status
proportion of illiterate mothers and those with scores of N % N % N %
0 or 1-3 were from families below the poverty line (Rs 65
Score 0
per capita per month) than their respective counterparts.
4th 5 4.2 16 6.5 5 2.3
Table 9 shows the results of the analysis of covariance
used to determine the effect of the mothers’ nutrition 3rd 31 26.3 59 23.8 32 14.4
knowledge on their children’s nutritional status. Both 2nd 41 34.7 86 34.7 84 37.8
literacy and income were found to be significant 1st 24 20.3 61 24.6 69 31.1
intervening factors in the test for the effect of the Normal 17 14.4 26 10.5 32 14.4
nutrition-knowledge score on weight for age, whereas
Score 1-3
only literacy was a significant factor in the case of height
for age and income in the case of weight for height. The 4th 18 2.4 23 1.9 18 1.5
combined effect of these factors was also significant. 3rd 60 7.9 142 12.0 151 12.2
Thus, the effect of the nutrition-knowledge scores on 2nd 157 20.6 409 34.5 417 33.7
weight for age, height for age, and weight for height was
1st 234 30.7 362 30.6 417 33.7
highly significant when controlled for literacy and family
per capita monthly income. Normal 293 38.5 248 20.9 235 19.0
4 The role of maternal literacy and nutrition knowledge

Score 3-4 TABLE 6. Relation between mothers’ nutrition-knowledge

scores and their children’s nutritional status as indicated by
4th 2 3.3 2 2.6 0 0 weight for height
3rd 2 3.3 5 6.4 6 6.5
Child’s age group
2nd 13 21.3 19 24.4 27 29.0
Nutritional
1st 20 32.8 28 35.9 34 36.6 0-12 mo 13-36 mo 37-72 mo
status
Normal 24 39.3 24 30 8 26 28.0 N % N % N %
Chi-square 69.334**** 61.599**** 14.441 Score 0
****P<.001.
Severe 18 15.3 26 10.5 8 3.6
TABLE 5. Relation between mothers’ nutrition-knowledge Moderate 23 19.5 94 37.9 61 27.5
scores and their children’s nutritional status as indicated hv
height for age Mild 38 32.2 89 35.9 95 42.8
Normal 39 33.1 39 15.7 58 26.1
Child’s age group
Nutritional Score 1-3
0-12 mo 13-36 mo 37-72 mo
status Severe 41 5.4 55 4.6 31 2.5
N % N % N %
Moderate 124 16.3 256 21.6 225 18.2
Score 0
Mild 228 29.9 528 44.6 613 49.5
Severe 13 11.0 66 26.6 50 22.5
Normal 269 48.4 345 29.1 369 29.8
Moderate 31 26.3 57 23.0 57 25.7
Score ≥ 4
Mild 30 25.4 72 29.0 67 30.2
Severe 3 4.9 0 0.0 0 0.0
Normal 44 37.3 53 21.4 48 21.8
Moderate 7 11.5 15 19.2 13 14.0
Score 1-3
Mild 23 37.7 31 39.7 42 45.2
Severe 37 49 205 17.3 276 22.3
Normal 28 45.9 32 41.0 38 40.9
Moderate 124 16.3 354 29.9 341 27.5
Chi-square 23.422**** 63.388**** 20.034***
Mild 269 35.3 354 29.9 335 27.3
***P<.005.
Normal 332 43.6 271 22.9 283 22.9 ****P<.001.

Score ≥ 4 TABLE 7. Agreement between mothers’ literacy status and

Severe 1 1.6 11 14.1 13 14.0 nutrition-knowledge scores

Moderate 8 13.1 19 24.4 24 25.8 Illiterate Literate

Score
Mild 25 41.0 26 33.3 27 29.0 N % N %

Normal 27 44.3 22 28.2 29 31.2 0 379 15.2 8 4.8

1-3 2,003 80.2 124 74.3
Chi-square 20.122*** 15.927** 6.577
**P<.025.
>=4 116 4.6 35 20.9
***P<.005. Chi-square 104.24*
****P<.001.
TABLE 8. Relation between family per capita monthly income and mothers literacy and nutritionknowledge scores

Literacy Score
Income Illiterate Literate 0 1-3 ≥4
N % N % N % N % N %
≤ Rs 65 2,972 79.0 135 56.3 488 83.0 2,439 76.6 180 77.6
> Rs 65 792 21.0 105 43.8 100 17.0 745 23.4 52 22.4
Chi-square 65 627* * * * 11.664* * *
   
*** P<.005.
**** P<.001.
Parul Christian et al.
TABLE 9. Analysis of covariance of mothers’ nutrition-
knowledge scores and their children’s nutritional-status
indicators
F value
 
Wt/age Ht/age Wt/ht
Nutrition
46.915* 11.385* 33. 577*
knowledge score
Covariates 8.420* 5.604* 3.811*
literacy 9.546* 1.018 7.471 *
income 4.138* 8.577* 0.851
* P <.05.
Discussion
Our data reveal a definite but non-significant association
between the literacy of the mothers and the nutritional
status of their children. However, it may be noted that
statistical significance is a strong function of, among
other things, the number of observations (sample size),
which in the present case is extremely skewed, with only
6% of the women in the literate category.
Other investigators [4, 17] have shown that the
number of years of education of mothers had a definite
relationship with the proportion of malnourished
children and related this to the fact that children’s mean
daily intake of nutrients increased with the increase in the
mothers’ educational level. Also, the intake of nutrients
by all the children whose mothers had an education
only up to primary and middle grades was far below the
recommended allowances. In the present study. although
the mothers’ education level was not considered because
of their very low rate of literacy, the difference in the
weight and height of children of literate and illiterate
mothers was clear.
The relationship between the nutrition knowledge of
the mothers and the nutritional status of their children
was much stronger. One study [8] reported that mothers’
nutrition-knowledge scores were associated with the
long-term well-being of children represented by height
for age. Our findings show that the mothers’ nutrition
knowledge did not affect the weight for age and height
for age of the children 37-72 months old, whereas
acute malnutrition as indicated by weight for height
was significantly related to the mothers’ knowledge
in children of all age groups. It is likely that for older
children, other factors have a stronger influence on
nutritional status than mothers’ nutrition knowledge.
Also, by the time children are three or four years old,
they may have younger siblings who require maternal
care and attention, in which case the older children are
likely to be ignored.
5
Some studies have found no relationship of mothers’
nutrition knowledge on the nutritional status of children.
On the basis of arbitrarily prepared knowledge and belief
scores, one such study reported that the mothers of well-
nourished children were as ignorant about essential
facts regarding nutrition as those of undernourished
children [9]. Similarly, another found that maternal
comprehension of home based growth charts had no
effect on children’s growth [10].
Our findings show a significant difference between
the nutrition-knowledge scores of literate and illiterate
mothers, with the former having better scores. Income
was also significantly positively related to both maternal
literacy and nutrition knowledge. The cause-effect
relationship in this instance appears to be bi-directional,
in that higher income reflects better maternal literacy
status and nutrition knowledge and vice versa. Victora et
al. [5] demonstrated that income and parental education
are strongly correlated, and that maternal education
affects child nutritional status even when family income
is taken into consideration.
The present study also shows that maternal literacy
and nutrition knowledge exerted a significant intervening
effect on at most two of the selected anthropometric
indicators. However, where significant, regardless of
confounding effects. the nutrition-knowledge score had
a significant positive effect on all the indicators of child
nutritional status. The evidence for a causal association
is strongest when it remains statistically significant
after family income is taken into consideration. Thus,
if mothers have sufficient nutrition knowledge, it is
effective in improving the nutritional status of their
children. This implies that, although all women do need
formal education, nutrition education is a short-term
intervention that will have a considerable impact on the
community. The need for such education for women is
therefore urgent and great in rural and tribal India.
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