A Review Study of the Role of Socioeconomic Status and its Components in Children’s Health

INTRODUCTION

The impact of economic status on children is among the most debated issues in human rights. Economics is defined as the science concerned with fighting poverty, the science governing wealth that is the study of the production, distribution, and consumption of wealth, the study of human well-being, and the science of using scarce resources.^[1,2] In other words, economics is the science of the behavior of goods and services. All the main elements of economics are somehow gathered in the commodity, and the process of commodity production, distribution, and consumption are among the topics discussed in economics.^[3-5]

The way children learn economic behavior in childhood is among the important factors affecting their economic behavior in adulthood. Family is the primary institution for individuals’ attitude formation and learning, and later these teachings are strengthened, reproduced, and evolved.^[6]

There is a direct relationship between children’s knowledge of money and the extent to which they have experience with it as well as between parents’ attitudes toward money and their spending habits. Children’s awareness of money and economic issues is formed, developed, and consolidated during the process of socialization. Therefore, educating children and familiarizing them with economic behaviors seem to be necessary to enable them to manage money responsibly and use it in the right way.^[7-9]

Obviously, there is a direct relationship between the economic status of the family and the health level of individuals, because, first, the ease of access to health care services increases with the improvement of the family’s economic status. Second, the economy both directly and indirectly affects the social components of health.^[10,11] Socioeconomic factors have been considered to be more than 50% effective in children’s health.^[12] However, some studies have reported the role of social factors up to 70%.^[13] Parents play an important role in children’s health, and various physical and environmental factors, beliefs, socioeconomic status (SES) of households, etc., are among the factors affecting it.^[14] Some believe that parents’ level of education as a socioeconomic factor is a more stable criterion than economic variables such as income, because household income changes from year to year and is not stable, and some maintain that education is the main factor affecting children’s health, because parents with high level of education have enough information about children’s health and nutrition, so they provide healthier food and environment and have healthier children.^[15-17] Moreover, the parents with higher education usually have better health status and then provide the necessary conditions for better health status of their children.^[15-17]

“Parental employment” is another factor affecting children’s health. The effect of maternal employment on children’s health is theoretically very vague. There are some contradictory hypotheses. One of the simplest mechanisms is that maternal employment has a positive effect on children’s health, as it is associated with an increase in household income and ultimately leads to increased household spending on the health of family members. However, the physical presence of mothers at home makes it possible for them to spend more time with their children and care more about them, which affects children’s mental health. Providing nutritious meals, clean and healthy home environment, and the absence of anxiety caused by the work environment and its transmission to children lead to the hypothesis that maternal employment has a negative impact on children’s health. Another assumption is that mothers’ involvement in the labor market may be associated with their education, skills, preferences, and abilities which provide greater potential for raising healthy children. By reviewing the literature, this study aims to identify socioeconomic mechanisms affecting children’s health.^[18-22]

NUTRITION

Malnutrition is a general term that describes an inadequate or excessive intake of food and can be due to low calorie/protein intake for cell growth and health or the body’s inability to use the food consumed. Furthermore, high calorie intake as well as unbalanced intake of some nutrients can cause eating disorders. According to the World Health Organization (WHO), malnutrition is the most important threat to general health in the world. Approximately, half of all deaths in children under 5 years are attributable to undernutrition; undernutrition puts children at greater risk of dying from common infections, increases the frequency and severity of such infections, and delays recovery.^[23,24]

Food insecurity refers to a lack of access to food and encompasses perceptual aspects such as insufficient quantity and quality of food and its social unacceptability.^[25,26] It is a consistent experience that starts with worrying about food at the household level and progresses to the onset of hunger in children. In other words, one-fifth of low-income households have energy deficiency and half of the population has micronutrient deficiency.^[27] Food insecurity ranges from concerns about access to adequate food at the household level to severe hunger among children with no access to food. The WHO estimated that approximately 60% of child mortality in developing countries is due to chronic hunger and malnutrition.^[28] Poverty and insecurity reduce mental, physical, and brain development in children and efficiency in adults and ultimately decrease the rate of economic, social, and national development.^[29,30]

Rahman et al. (2018) investigated the nutritional status and eating habits of 302 primary school children in association with SES of households in Dhaka, Bangladesh. They found that there was a statistically significant correlation between body mass index (BMI) and family size and income, maternal education, and dietary diversity score (HDDS).^[31]

Karaoğlan et al. (2017) studied the socioeconomic factors affecting the children’s health in Turkey. They considered location (city or village), number of family members, father’s presence, parents’ education, employment status, and wealth index based on household assets as SES indicators. In this study, living in the city was introduced as a factor facilitating access to health services, even without considering other SES components. The maternal education was also considered important in determining the child’s health status, because educated mothers are more likely to have specialized information to care for their children.^[32]

In a cohort study, Poulain et al. (2019) examined the relationship between SES and health of 2998 children aged 3-18 years old. In this study, the strengths of the relationship between SES and children’s health did not differ depending on SES indices (education, occupation, and income).^[33]

By conducting a cross-sectional study, Safarpour et al. (2014) investigated food insecurity in households of 400 female students aged 9–11 years old in Bandar-e Anzali, Gilan province, Iran. The prevalence of food insecurity was 51% in this population. There was a significant correlation between food insecurity and economic status of the family, the number of employed family members, the number of children in the family, parents’ level of education, and home ownership. The mean weight of children in families with food insecurity was significantly lower than the other group.^[25] Madvari et al. (2013) carried out a cross-sectional study on 500 households with children aged 4–5 years old under the auspices of urban health centers and health houses in Mehriz, Iran. The prevalence of food insecurity in the studied households was 39.6%. In this study, there was a statistically negative correlation between food insecurity and parents’ education, parents’ job position, monthly household income, and mother’s height. Furthermore, there was a significantly direct correlation between food insecurity and maternal age and household size.^[34] Yeganeh et al. (2018) studied 400 mothers with children aged 1-2 years old in Bushehr, Iran, and reported food insecurity rates as 51.5%, 22.3%, and 11.3% at household, individual, and child levels, respectively.^[35] Dorosty et al. evaluated food insecurity in households with children aged 6–11 years old in Yazd, Iran, and reported the prevalence of food insecurity as 30.5%.^[36] Furthermore, according to a study conducted on residents of Asadabad, Tabriz, the prevalence of food insecurity was estimated to be 36.3%.^[37] Poverty and food insecurity increase mortality and disability, decrease mental, physical, and brain development in children and efficiency in adults, and ultimately reduce the rate of economic, social, and national development. Based on traditional thinking, symptoms such as underweight and slimming have been introduced as consequences of food insecurity. However, nowadays, another model has been proposed, suggesting the possibility of obesity.^[38-40] Sotoudeh et al. found that food insecurity along with extreme hunger in overweight short children was significantly correlated with poor economic status, living in a rented house, employment of the household head as a worker, mother’s employment, and low level of education of the household head.^[41] In their study, Honarpisheh et al. reported that 161 children (16.2%) were malnourished and 31.1% lived in families of 7 or more and there was a statistically significant correlation between children’s malnutrition and monthly household income, family size, and maternal education.^[42] In the study by Beni et al.,^[43] the relationship between malnutrition in children under 5 years of age and the factors affecting was evaluated in Chadegan, Iran. The results showed that the prevalence of malnutrition based on wasting, underweight, stunting, and obesity indices were 17.8%, 34.5%, 37%, and 2.2%, respectively. There was a statistically significant correlation between wasting index and child’s age, place of residence, onset of complementary feeding, history of disease, and history of hospitalization of child. A significant correlation was also observed between underweight index and child’s age and gender, ethnicity, place of residence, history of disease, and history of hospitalization of child. There was a statistically significant relationship between stunting index and child’s gender, father’s occupation, maternal education, ethnicity, place of residence, and history of disease [Table 1].

GROWTH

Although growth and development are two separate categories, they occur simultaneously. Growth and development are specific in every individual and starts from head to toe and from midline to periphery in spurt, slow, and critical growth periods. During the formation of the sexual organs, growth is very rapid. It progresses until the age of 5 and then remains constant. The growth rate increases again during puberty, after which it remains almost constant. Growth and development are progressive changes. In other words, their process is always ascending and irreversible. During the embryonic stage, the growth rate is higher than ever and, then, the growth increases in the first year of life and during puberty. The girls’ height and weight suddenly grow around ages 10–11, while it occurs a little later in boys that is at the ages of 12–13. Sun exposure, good housing, adequate lighting and ventilation, psychological factors, parasitic infections, and socioeconomic factors such as age gap between children, birth order, birth weight, and parents’ level of education affect growth and development. Measuring children’s weight, height, and head and arm circumference is the best way to assess their growth.^[44,45]

Kabiri et al. conducted a study to investigate the relationship between physical growth of children aged 0–2 years old referring to health centers in Karaj, Iran, and their parents’ economic, social, and cultural status, and found that there was a statistically significant correlation between children’s weight and maternal education and father’s employment status. This suggests that the economic status of the family (father’s employment) was effective on the child’s weight gain.^[46] Ahmadpour et al. studied factors affecting the growth of 250 toddlers in Ardabil, Iran. The results showed that there was a statistically significant correlation between child growth and socioeconomic factors, maternal education, and place of residence. The maternal education, family size, birth order, time interval from the previous birth, and age of starting complementary food, as SES indicators, indicated the extent of care and attention to the child and were significantly correlated with the child growth.^[47]

MOTOR PROFICIENCY

SES is among the most important environmental factors affecting the fetus before birth, infant at birth, and child after birth. SES affects various aspects of life including the type of leisure activities and the rate of sports activities. Starfield suggested that parents’ SES from childhood too early and late adolescence may affect their levels of physical activity. Accordingly, it can be argued that SES has a stable relationship with children’s levels of physical activity and ultimately has a profound effect on their motor development. According to the study by Chen et al., childhood’s stable pattern is among the growth patterns for describing the relationship between SES and physical activity, suggesting that differences in SES are established in the early life and its effects remain constant on child and adolescent development. SES is associated with the quality of the living environment, which in turn affects health.^[48,49]

Contemporary views of motor development, despite focusing on environmental and individual contributions to motor development, have considered childhood as an important period. Preschool years (4–6 years old) and the first years of primary school (up to 9 years old) are known as critical periods for the development of basic motor skills. These skills, such as building blocks, are efficient and effective movements that provide the child with a way to explore the environment and knowledge about the surrounding world.^[48,49] Shahrzad et al. conducted a study to evaluate the direct and interactive effect of SES and birth weight on children’s motor proficiency, and found that motor proficiency of children with low SES was lower than that of children with high SES. Furthermore, high SES had the ability to moderate the negative effects of low birth weight on motor development. Therefore, it is important to emphasize the role of SES in the health of children with very low and normal birth weight.^[50]

Silva compared the motor development of 9-year-old children with very low and normal birth weight, and showed that there was a significant difference in motor skills between VLBW and NBW children.^[51]

INTELLIGENCE QUOTIENT (IQ)

Intelligence is a very complex concept and manifests itself in many different aspects. Old scholars considered intelligence to be a general factor or trait that manifests itself in a wide range of behaviors. However, later, psychologists stated that intelligence is a set of relatively independent capabilities. Intelligence is a complex combination of hereditary and environmental influences. Studies have indicated that SES and ethnicity, an organized and stimulating environment, and parental affection predict better speech ability and IQ scores in infancy and early childhood. In general, children living in poverty have shown a gradual decline in IQ scores and do not make good academic progress when they reach school age.^[52] Motlagh et al. (2015) examined the role of socioeconomic factors in primary school children’s IQ in Bandar-e Anzali, Iran. The results revealed that children’s IQ was significantly correlated with parental employment status and education, economic status, and number of employed family members. However, there was no significant correlation between children’s IQ and the mean weight and height of mother and child, father’s employment, home ownership, and the number of children in the family.^[53]

Nejati et al. (2016) evaluated the effect of household food security status and some socioeconomic factors on preschool children’s IQ in Mashhad, Iran, and reported that the mean verbal, practical, and overall IQs in the food insecure group without hunger were 75.98, 102.94, and 84.100, respectively, which were lower than the mean IQs in the food secure group. IQ was significantly correlated with household head’s occupation (being an employee), mother’s employment, higher education of the household head and mother, private housing, and good economic status. Therefore, economic status, as a stressor that affects the whole family, can influence IQ through its effect on nutrition.^[54] Tavoosi et al. (2005) examined the impact of economic conditions on mathematical abilities of children. The results showed that the accuracy of the answers among children with high economic status was higher than children with low economic status. However, there was no statistically significant difference in the speed of implementation of strategies between students with different socioeconomic conditions.^[55]

DENTAL HEALTH

Obviously, better SES increases access to dental care services. Piroozian et al. (2019) conducted a study on 225 preschool children aged 3-7 years old to examine decay-missing-filled (DMF) index and its relationship with socioeconomic factors. The highest mean DMF was observed among children from low SES families.^[56]

In their study, Nematollahi et al. (2008) found that children whose parents, especially mothers, had higher levels of education and better economic status, had lower decayed, missing, and filled teeth (DMFT) index and the prevalence of dental caries was lower among children with working mothers than children whose mothers were housewives.^[57] Gholipour et al. (2016) also concluded that children whose parents had higher levels of education, income, and dental insurance had better oral and dental health and mother’s employment and living in rural areas were identified as the factors which reduced oral and dental health. The results showed that children’s dental caries was associated with parental education (especially mothers). Therefore, it is necessary to implement training programs to prevent dental caries in children, especially in children from low SES families.^[58] Khosravani et al. (2013) evaluated the relationship between dental caries and growth indices in 974 children aged 9–11 years old in Shiraz, Iran. The results indicated that there was a significant relationship between DMFT and BMI. Furthermore, the mean DMFT was significantly reduced in underweight children compared to obese children. Underweight and overweight are the most common disorders in childhood and adolescence indicating malnutrition, and malnutrition is among the components affected by low SES.^[59]

Shahraki et al. (2015) examined the effect of parents’ SES on the health of 400 children under one year of age in Tehran, Iran. The results demonstrated that high educational levels of fathers and mothers increased children’s health by 2.6% and 3.5%, respectively. Maternal employment reduced children’s health by 6.7% and the probability of health of twin children was 8.97% lower than other children. Furthermore, it was found that parents’ high level of education reduced the probability of underweight children by 0.9% and 1.5%, respectively, and mothers’ employment increased the probability of underweight children by 4%.^[60]

ACCIDENTS

According to the Declaration of the Rights of the Child, which has been ratified by almost all the governments, children around the world are entitled to live in safe environments and be protected from injuries and violence. Unfortunately, some studies have shown that child mortality from accidents has recently increased worldwide compared to declining child mortality from chronic and infectious diseases. Nowadays, accidents, whether intentional or unintentional, are considered among the most important causes of millions of deaths and disabilities among children around the world and impose a heavy financial burden on the health care system of communities. Accidents are a leading cause of hospitalization among children and account for 13% of the total disease burden among children aged 15 and younger. According to a joint report by the WHO and United Nations Children’s Fund, more than 2,000 children die from accidents every day.

In addition, one in four children requires medical care after an injury every year. It is noteworthy that more than 95% of child injury-related deaths occur in low- and middle-income countries.^[61,62]

Hasaniha et al. (2015) conducted a study, entitled “Evaluation of Socioeconomic Factors in Injured Children,” to investigate 650 injured children under the age of 15 years old referring to Hospitals in Zanjan, Iran. In this study, the variables of parents’ education and occupation, place of residence, family income, and housing status were examined. The results showed that mostly those children whose fathers were workers, mothers were housewives, and parents had low levels of education were injured. Furthermore, the frequency of injuries was significantly correlated with family income, population density, and economic status.^[63] According to the study by Abadi et al. (2016) unfavorable economic conditions reduce the occurrence of behaviors preventing home injuries in children under 5 years old.^[64]

The results of these studies highlight the importance of implementing training programs for target groups such as students and their parents, especially families with low SES, to reduce the risk factors for accidents in the child’s living environment.

PSYCHOLOGICAL FACTORS

Kazemini et al. (2012) conducted a study on 50 people, entitled “Study of the Role of Family SES and Educational Level in Delinquent Behavior of Adolescents.” Parents’ occupation and monthly income, parents’ education, and having facilities were among the socioeconomic factors. The results showed that there was a correlation between family SES and educational level and adolescents’ delinquent behavior. The correlation test analysis revealed that there was a significant correlation between adolescents’ delinquent behavior and the number of family members, place of residence, parental education, and family SES. Therefore, it can be argued the family SES and educational level can play a crucial role in tendency of individuals to delinquency.^[65] According to the study by Pourhossein et al. (2002) self-concept was influenced by the SES; However, gender had no effect on the evolution and organization of self-concept. Furthermore, families with high SES had better condition.^[66] Naji et al. (2018) reported that disorders were more prevalent among children who had immigrant or large families, low economic status, illiterate and unemployed parents, or grew up without parents.^[67] The results of study by Mahmoudi et al. (2019) showed that the family of children with attention deficit/hyperactivity disorder (ADHD) have low income, inadequate living space, lack of a child’s room, low level of education, lack of awareness about child’s disorder and single/multi parent. These factors may increase the symptoms of ADHD.^[68]

MORTALITY

Nearly 11 million children die every year in the world that is approximately 30,000 children per day and 20 children per minute before reaching the age of five. However, most of the statistics are not recorded. These deaths occur mainly in low- and middle-income countries, especially those located in sub-Saharan Africa and South Asia. Among the above countries, poor people suffer more deaths than others.^[69] According to the study conducted by Hosseinpoor et al. (2005), inequality in under-five mortality rate between the lowest and highest quintiles was significant in all the provinces and in favor of wealthy groups. However, inequality rate varied between different provinces.^[70] Mohseni et al. (2012) evaluated the effect of social, economic, and demographic factors on under-five mortality rate in Gotvand, Iran. This study indicated that better parental employment status and increased frequency of prenatal care reduced under-five mortality rate, while maternal age less than 18 years and more than 35 years at delivery and preference for sons increased under-five mortality rate.^[71] Moeni et al. (2010) found that the higher the development index of the provinces including socioeconomic factors such as literacy rate of men and women, employment rate, life expectancy at birth, mean monthly household income, and the amount of drinking water supply, the lower the infant mortality rate will be.^[72] Emami et al. (2010) conducted a retrospective, descriptive, and comparative study on two groups of 121 deceased and not-deceased children under 1 year of age supported by health centers in Isfahan, 1996–2000 and reported that there was a statistically significant correlation between mortality rate of children under 1-year-old and parents’ education, parents’ occupation, breastfeeding, frequency of child care, and prenatal care.^[73] Nejad et al.^[74] evaluated the causes of death of 110 infants in neonatal intensive care units (NICUs) of Hospital affiliated with Zabol University of Medical Sciences. In this study, low economic status of the family was recognized as an influential factor in infant mortality [Table 2].

CONCLUSION

The child’s economic operations are influenced by adults. According to several studies, children from middle- and high-SES families, unlike low-SES children, have precise and logical policies, because their parents provide logical explanations in response to their children, and consequently, their children have more cultural capital. This is the family that gives the child sociolinguistic competences. This review study showed that growth rate, nutritional quality, mental health, academic performance, IQ, mortality rate, and accidents were associated with the economic status of parents, especially mothers. Therefore, it is necessary to implement training programs on proper nutrition, accident prevention, dental health, and psychological interventions for families with low SES.