Low-educated Mothers Research Articles

Screening for maternal depression in a low education population using a two item questionnaire

To assess a two-question screening tool, the Patient Health Questionnaire-2 (PHQ-2), for identifying depressive symptomatology in economically disadvantaged mothers of children in pediatric settings and to explore risk factors associated with a positive depression screen. A convenience sample of mothers was enrolled at an inner city well-child clinic with children age 3 days to 5 years. The PHQ-2 and Edinburgh Postnatal Depression Scale (EPDS) (as reference scale) were completed. Ninety-four mothers participated. Agreement of the PHQ-2 and EPDS was moderate. The sensitivity of the PHQ-2 for identifying a positive screen on the EPDS was 43.5%; the specificity was 97.2%. The sensitivity of the PHQ-2 was higher for mothers with education beyond high school compared to those with less education. Perceived lack of support with child care and having two or more children were associated with a positive screen. The rate of positive screen was similar for mothers with infants and with older children. Given the low sensitivity of the PHQ-2 in lower educated mothers, additional research in populations with varying sociodemographic characteristics is indicated. Similar rates of symptoms for mothers within and beyond the postpartum period and mothers previously screened support the need for periodic screening.

Evaluation of the Children With β-Thalassemia in Terms of Their Self-concept, Behavioral, and Parental Attitudes

This study was planned to explore the self-concept, behavioral, and parental attitudes of the children with beta-thalassemia major, and the factors that affect them. The study was undertaken between January and June 2004 at the Hacettepe University Ihsan Doğramaci Children's Hospital, Pediatric Hematology Unit, Ankara and 43 voluntary children with beta-thalassemia major on regular blood transfusion and iron chelation treatment between the ages of 5.0 and 18.0 years were included into the study. Age, sex, birth order, school performance, hemoglobin value, serum ferritin levels, associated illness, splenectomy status, presence of thalassemic sibling or relatives, death of thalassemic relatives, place of residence, maternal and paternal education were recorded. Parental Attitude Research Instrument, Piers-Harris Self-Concept Scale, and Child Behavior Checklist were applied. Higher educated mothers have lower overprotection (P=0.009), parental discordance (P=0.044), and discipline scores (P=0.002) than lower educated mothers. In cases with death of thalassemic relatives, democratic/equality attitude scores were decreased (P=0.034). With stepwise multiple linear regression analysis, splenectomy, good school achievement, absence of death of thalassemic relatives, and serum ferritin levels were found to increase Piers-Harris Self-Concept Scale; however, total behavior problem score was found to decrease with increasing age, splenectomy and decreasing overprotection subscale of Parental Attitude Research Instrument scores. The self-esteem and behavior problems of children with thalassemia depended not only on the variables related exclusively to the child (age, school achievement) and the illness-associated conditions (splenectomy, serum ferritin levels) but also on the parental attitude (overprotection).

Do food stamps cause obesity?: Evidence from immigrant experience

I use changes in immigrant eligibility for food stamps under the 1996 federal law and heterogeneous state responses to set up a natural experiment research design to study the effect of food stamps on Body Mass Index (BMI) of adults in immigrant families. I find that in the post-1996 period food stamps use by foreign-born unmarried mothers with a high school or lower education was 10 percentage points higher in states with substitute programs than in states that implemented the federal ban. However, this increase in FSP participation was not associated with any statistically significant difference in BMI. I find that FSP participation was associated a statistically insignificant 0.3% increase in BMI among low-educated unmarried mothers.

Transitional Phase or a New Balance?

In recent years in the Netherlands, mothers’ labor participation has increased sharply. This article examines which factors influence mothers’ employment rates and the division of household and caring responsibilities between parents. From research among 1,285 women with young children, it appears that cultural factors rather than economic motives or institutional obstacles offer the most important explanation for whether they work or not. A culture of care dominates more among women with lower than higher education levels, which clarifies the more limited labor participation of lower educated mothers. A comparison is also drawn between the various earner types of family. It appears that the one-and-a-half earner type of family with the man working full-time and the woman part-time is particularly popular among women with lesser education levels. However, for women with higher educations, the ideal is for both parents to work part-time, but for the time being, they have not yet been able to realize this.

Health impacts of macroeconomic crises and policies: determinants of variation in childhood malnutrition trends in Cameroon

It is generally hypothesized that macro economic shocks worsen child health by lowering household economic status and limiting access to health care, but this proposition seldom has been tested empirically. We examined the effects of economic crises and adjustment programmes during the 1990s in Cameroon on childhood malnutrition in population subgroups and evaluated the household and health system mediators of these effects. We used pooled cross-sectional data from two Demographic and Health Surveys conducted in 1991 and 1998. In multivariate analysis, we stratified data on child sex and age, maternal education, and place and region of residence. We used a linear regression model to estimate the net effects of changes in average household economic status and maternal health seeking behaviour (MHSB) on changes in the prevalence of malnutrition for each stratum, adjusting for all other variables. The prevalence of malnutrition in children younger than 3 years increased from 16 to 23% (P < 0.001) between 1991 and 1998. The increase in urban areas, from 13 to 15% (P = 0.391), mostly occurred in children of low-educated mothers. The increase in rural areas, from 19 to 25% (P < 0.001), mostly occurred in boys, children older than 6 months of age, those born to low-educated mothers, and those of low economic status. In urban areas, the advantage associated with higher maternal education was robust to all controls, and declines in economic status and MHSB were the mediators of increasing malnutrition. In rural areas, increase in malnutrition was higher in children with lower baseline economic status; decline in MHSB was a significant mediator of worsening nutritional status. The negative nutritional effects during economic crises and adjustment programmes of the 1990s in Cameroon were largest among children of low socioeconomic status. Declines in household economic status and access to health care were the mediators of increasing malnutrition.

Welfare Reform, Saving, and Vehicle Ownership

Eligibility rules for the AFDC/TANF program prohibit recipients from accumulating wealth in excess of certain thresholds. These asset restrictions place high implicit tax rates on asset holdings, and may also affect asset allocation decisions, because some assets such as vehicles are partially exempt. This paper examines whether asset restrictions for eligibility under the AFDC/TANF program affect the asset holdings of low-educated single mothers . Using nationally representative family-level data, I examine the impact of these restrictions on both liquid and vehicle assets , exploiting variation in asset limits and exemptions across states and over time. There are important reasons to examine vehicle assets in this context. First, vehicles make up a very significant share of total wealth for poor families. Families with limited resources are more likely to have vehicle equity than any other type of asset. Second, the variation in vehicle exemptions over time and across states far exceeds the variation in asset limits, suggesting that policy changes are particularly important for vehicle equity. Nevertheless, there is little research that examines the effects of asset restrictions on vehicle assets . Consistent with other recent research, I find little evidence that asset limits have an effect on the amount of liquid assets that single mothers hold. However, I find evidence that vehicle exemptions do have an important effect on vehicle assets. The findings suggest that moving from a $1500 vehicle exemption to a full vehicle exemption increases the probability of owning a car by 20 percentage points for low-educated single mothers relative to a comparison group. There is also evidence that more generous vehicle exemptions result in greater vehicle equity. The results indicate that single mothers are not substituting vehicle equity for liquid assets in response to more relaxed restrictions on vehicles . In addition, the findings suggest that total wealth increases in response to more generous vehicle exemptions.

Changes in the welfare caseload and the health of low-educated mothers

Declines in the welfare caseload in the late 1990s brought significant change to the lives of many low-educated, single mothers. Many single mothers left welfare and entered the labor market and others found different ways to avoid going on public assistance. These changes may have affected the health and health behaviors of these women. To date, there has been little study of this issue. In this paper, we obtained estimates of the association between changes in the welfare caseload caused by welfare policy, and four health behaviors--smoking, drinking, diet, and exercise--and four self-reported measures of health--weight, days in poor mental health, days in poor physical health, and general health status. The results of our study reveal that recent declines in the welfare caseload were associated with less binge drinking, but otherwise welfare reform had little effect on health and health behaviors.

Growing social inequalities in the occurrence of overweight and obesity among young men in Sweden

The aims of the present study are to investigate time trends and social inequalities in mean body mass index (BMI), overweight, and obesity among 18-year-old men in Sweden from 1970 to 2000 and to explore whether social inequalities in these conditions have increased. A record linkage was made between the Military Service Conscription Register, Population and Housing Censuses, the Register of Education and the Register of the Total Population. All 1,748,800 males born in 1952-82 who were living in Sweden at the age of 17 years in 1969-99 were eligible for this nationwide study. The study population comprises 1,500,499 18-year-old men with information on BMI (86% of eligible subjects). During the study period from 1970 to 2000, mean BMI increased from 20.89 kg/m2 to 22.49 kg/m2, the prevalence of overweight increased from 6.6% to 13.6% and the prevalence of obesity increased from 1.0% to 3.8%. Mean BMI and the prevalence of overweight and obesity were higher among young men with low-educated mothers than among those with high-educated mothers. A noteworthy finding was that the socioeconomic gap increased over time. Between 1970 and 2000, the prevalence of overweight increased twofold and the prevalence of obesity increased fourfold in this study population. The social inequalities in overweight and obesity have steadily increased among young men in Sweden during the past three decades.

Educational attainments of former child welfare clients – a Swedish national cohort study

We used national register data for nearly 800,000 Swedish‐born young people in eight national birth cohorts to examine educational attainments of former child welfare clients. A total of 31,355 former child welfare clients were compared with 744,425 majority population peers. Logistic regression models were used to estimate risks of having only a basic education at time of follow‐up, and of chances of having a post‐secondary education. Odds ratios for core results were recalculated into relative risks.Compared with majority population peers with low educated mothers, children who experienced interventions before ado‐lescence, or had been in long‐term stable foster care, had a two‐ to threefold elevated relative risk of entering adult life with only a compulsory education. Youths who experienced intervention during adolescence had approximately a fourfold risk of having only basic education at the time of follow‐up. Majority population peers with low educated mothers were between two and six times more likely to have a post‐secondary degree when compared with former child welfare clients.

Welfare Reform and Health Insurance of Immigrants

To investigate the effect of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) on the health insurance coverage of foreign- and U.S.-born families headed by low-educated women. Secondary data from the March series of the Current Population Surveys for 1994-2001. Multivariate regression methods and a pre- and post-test with comparison group research design (difference-in-differences) are used to estimate the effect of welfare reform on the health insurance coverage of low-educated, foreign- and U.S.-born unmarried women and their children. Heterogeneous responses by states to create substitute Temporary Aid to Needy Families or Medicaid programs for newly arrived immigrants are used to investigate whether the estimated effect of PRWORA on newly arrived immigrants is related to the actual provisions of the law, or the result of fears engendered by the law. PRWORA increased the proportion of uninsured among low-educated, foreign-born, unmarried women by 9.9-10.7 percentage points. In contrast, the effect of PRWORA on the health insurance coverage of similar U.S.-born women is negligible. PRWORA also increased the proportion of uninsured among foreign-born children living with low-educated, single mothers by 13.5 percentage points. Again, the policy had little effect on the health insurance coverage of the children of U.S.-born, low-educated single mothers. There is some evidence that the fear and uncertainty engendered by the law had an effect on immigrant health insurance coverage. This research demonstrates that PRWORA adversely affected the health insurance of low-educated, unmarried, immigrant women and their children. In the case of unmarried women, it may be partly because the jobs that they obtained in response to PRWORA were less likely to provide health insurance. The research also suggests that PRWORA may have engendered fear among immigrants and dampened their enrollment in safety net programs.

266 Academic Achievement in 19 Year Old Adolescents, Born As Preterm Infants (Ga &lt; 32 Weeks and/or Bw &lt; 1500 Gram)

Background: In view of the increasing survival rate of very preterm and very low birth weight infants, long term outcome of these infants born in 1980's is of interest not only in terms of handicaps and disabilities but also of educational achievement. Objective: The purpose of this study was to determine the highest level of completed or current education at age 19 in adolescents born as very preterm or very low birth weight. Methods: In 1983 94% of the infants born alive in the Netherlands with a gestational age less than 32 weeks or a birth weight less than 1500 grams were included in the POPS-study (Project on Preterm and Small for gestational age infants). All 959 surviving adolescents (72% of original cohort) were invited for a full examination (including physical, mental, behavioral and educational development and social participation) in a hospital at the age of 19 years. If the adolescents refused to take part in the full assessment, they were invited to complete postal questionnaires only. Education was assessed using the same categories as the Dutch Central Bureau of Statistics (CBS) in the total population at the same age (reference category). Results: There were 596 (62%) full-responders, 109 (11%) postal responders and 254 (26%) non-responders. In non-responders we found (based on previous assessments) significantly more adolescents of non-Dutch origin and of low educated mothers, and more severe handicaps. Of 705 responders, data on education were available in 688. Of POPS-adolescents, 17% had completed special education or lower vocational training (CBS: 6%) and 9% primary school only (CBS: 6%). Secondary education had been completed or was being attended by 60% (CBS: 81%) of which 21% (CBS: 29%) was currently at university. Conclusions: Academic achievement in adolescents born very preterm or very low birth weight is significantly lower than that in the general population of the same age in the Netherlands. In view of probable positive selection bias in responders, the level of completed education in non-responders will be even lower. Social participation, future employment and independency may be difficult to achieve for many of these survivors of neonatal intensive care.

Social inequalities in infant feeding during the first year of life. The Longitudinal Study of Child Development in Québec (LSCDQ 1998-2002).

The aim of this paper is to describe the source and the scope of social inequalities in infant feeding practices. It examines the extent to which different recommendations are followed in different social groups and highlights the main factors influencing the total adherence to three recommendations at the population level. The study follows a representative sample (n=2103) of the children born in 1998 in the province of Québec (Canada). Detailed information on breast-feeding and complementary feeding was collected at 5 and 17 months by face-to-face interviews with the mother. The independent variables were mother's age, mother's education level, poverty level, family type, socio-economic status (SES) and living area. Odds ratios (adjusted for baby's rank in the family, birth weight and premature birth) are presented for breast-feeding, and for formula and cows' milk consumption, at different ages. The adherence to a combined indicator cumulating three recommendations (breast-fed at birth, complementary food at 4 months or later and cows' milk at 9 months or later) is also presented. The analysis indicates that adherence to the recommendations is low in Québec. Breast-feeding initiation, duration and its exclusivity improved with mother's age and education level and SES. Adherence to the different recommendations was interrelated, indicating an accumulation of bad nutritional circumstances for children in low-SES families. The odds of being fed in accordance with the three studied recommendations, when living in a family with the highest SES, was 2.3 times higher than when living in a family with the lowest SES. When living with a highly educated mother, the odds ratio was 2.7 times higher than when living with a low-educated mother. For mother's age, the odds ratio reached 3.7 for children from mothers aged > or =35 years, in comparison with children from mothers < or =24 years old. When SES or mother's education level was combined with mother's age, the children in the best situation were >8 more times likely than the least privileged children to be fed in accordance with these recommendations. Living area was not related with infant feeding during the first year of life. Breast-feeding and nutrition could be related with different health and cognitive outcomes in childhood and later in life. Consequently, social disparities in diet during infancy could play a role in the development of social and health inequalities more broadly observed at the population level. Intervention to improve adherence to breast-feeding and nutrition recommendations in infancy should be prioritised and evaluated for its impact on the reduction on infant diet inequalities over time.

Welfare reform and health insurance coverage of low-income families

We study whether welfare reform adversely affected the health insurance coverage of low-educated single mothers and their children. Specifically, we investigate whether changes in the welfare caseload during the 1990s were associated with changes in Medicaid participation, private insurance coverage, and the number of uninsured among single mothers and their children. Estimates suggest that between 1996 and 1999, the 42% decrease in the welfare caseload was associated with the following changes in insurance coverage among low-educated, single mothers: a 7–9% decrease in Medicaid coverage; an increase in employer-sponsored, private insurance coverage of 6%; and a 2–9% increase in the proportion uninsured. Among children of low-educated, single mothers, effects were somewhat smaller. Since welfare policy was responsible for only part (e.g. one-third) of the decline in the caseload, welfare reform per se had significantly smaller effects on the health insurance status of low-income families. However, we found limited evidence that changes in the caseload due to state and federal welfare policy had fewer adverse consequences on insurance status than changes in the caseload due to other factors. This implies even smaller effects of welfare reform.

Obesity and associated modifiable environmental factors in Iranian adolescents: Isfahan Healthy Heart Program - Heart Health Promotion from Childhood.

To evaluate the prevalence of overweight and obesity among Iranian adolescents and their relationship with modifiable environmental factors. The subjects of the present study were 1000 girls and 1000 boys, aged between 11 and 18 years selected by multistage random sampling, their parents (n = 2000) and their school staff (n = 500 subjects) in urban and rural areas of two provinces in Iran. Data concerning body mass index (BMI), nutrition and the physical activity of the subjects were analyzed by SPSSV10/Win software. The prevalence of 85th percentile </= body mass index (BMI) < 95th percentile and BMI > 95th percentile in girls was significantly higher than boys (10.7 +/- 1.1 and 2.9 +/- 0.1%vs 7.4 +/- 0.9 and 1.9 +/- 0.1%, respectively; P < 0.05). The mean BMI value was significantly different between urban and rural areas (25.4 +/- 5.2 vs 23.2 +/- 7.1 kg/m2, respectively; P < 0.05). A BMI> 85th percentile was more prevalent in families with an average income than in high-income families (9.3 +/- 1.7 vs 7.2 +/- 1.4%, respectively; P < 0.05) and in those with lower-educated mothers (9.2 +/- 2.1 vs 11.5 +/- 2.4 years of mothers education, respectively). The mean total energy intake was not different between overweight or obese and normal-weight subjects (1825 +/- 90 vs 1815 +/- 85 kCal, respectively; P > 0.05), but the percentage of energy derived from carbo-hydrates was significantly higher in the former group compared with the latter (69.4 vs 63.2%, respectively; P < 0.05). Regular extracurricular sports activities were significantly lower and the time spent watching tele-vision was significantly higher in overweight or obese than non-obese subjects (time spent watching telelvision: 300 +/- 20 vs 240 +/- 30 min/day, P < 0.05). A significant linear association was shown between the frequency of consumption of rice, bread, pasta, fast foods and fat/salty snacks and BMI (beta = 0.05-0.06; P < 0.05). A significant correlation was shown between BMI percentiles and serum triglyceride, high-density lipoprotein-cholesterol and systolic blood pressure (Pearson's r = 0.38, -0.32 and 0.47, respectively). Enhanced efforts to prevent and control overweight from childhood is a critical national priority, even in developing countries. To be successful, social, cultural and economic influences should be considered.

Migration consequences of welfare reform

We investigate whether recent changes in welfare policy affect the migration of low-educated unmarried mothers. Estimates indicate that welfare reform is associated with an increase in employment-related intrastate migration, and a decrease in non-employment related migration, both within and between states. The net effect was a small increase in intrastate migration and a small decrease in interstate migration. The close link between migration and employment suggests that welfare reform has motivated low-income women to move for economic reasons. In general, welfare policy appears to have a much larger effect on residential location because of its relationship to employment than because of benefit differences between states.

The effects of welfare and tax reform: the material well-being of single mothers in the 1980s and 1990s

The tax and welfare programs that provide income and in-kind benefits to single mothers have changed dramatically in recent years. These changes began as far back as the mid-1980s and culminated with the 1996 welfare law that ‘ended welfare as we knew it.’ These tax and welfare changes have sharply increased the employment of single mothers and cut welfare rolls. However, little is know about the effects of these policy changes on the material well-being of single mothers and their children. Studies of those leaving welfare have found that a substantial percentage have problems paying rent, purchasing enough food, and paying utility bills. Other studies found a decline in income among the worst-off single mothers after 1994 or 1995. The goal of this paper is to examine the material well-being of single mothers and their families before and after recent welfare and tax reforms. Using data from two nationally representative household surveys we examine the consumption patterns of single mothers and their families from 1984–2000. We find that the material conditions of single mothers did not decline in recent years, either in absolute terms or relative to single childless women or married mothers. This pattern holds for the average single mother as well as for low-educated single mothers at both the 15th and 25th percentiles of the consumption distribution. In most cases, our evidence suggests that the material conditions of single mothers have improved slightly.

Gender-related family head schooling and Aedes aegypti larval breeding risk in southern Mexico.

To investigate if family head genre-associated education is related to the risk of domiciliary Aedes aegypti larval breeding in a dengue-endemic village of Southern Mexico. A family head was considered to have a low education level if he/she had not completed elementary school. To estimate larval breeding risk within each household, a three-category Maya index was constructed using a weighted estimation of controllable and disposable domestic water containers. A socio-economic index was constructed based on household construction characteristics. Low-level education of either family head was associated to higher larval breeding risk. Households with low-educated mothers had more larval breeding containers. These associations persisted after adjusting for household socio-economic level. These results indicate that households with female family heads with low education levels accumulate more containers that favor Ae. aegypti breeding, and that education campaigns for dengue control should be addressed to this part of the population. The English version of this paper is available too at: http://www.insp.mx/salud/index.html.

Prevalence of daily breakfast intake, iron deficiency anaemia and awareness of being anaemic among Saudi school students

Iron deficiency anaemia is one of most prevalent nutritional disorders worldwide. It is known to affect the health and cognitive ability of children and adolescents. Studies in Saudi Arabia concentrate only on the population of young children and pregnant females or girls. Studies on the whole school student population is lacking. The objectives of this study were to identify the nutritional habits and the prevalence of anaemia among school students in Jeddah, as well as to recognize the students' awareness of their anaemic nutritional status. Data were collected from a sample of Saudi school children in Jeddah City from 42 boys' and 42 girls' schools during the month of April 2000. Data collection was done by an in-person interview to collect socio-demographic factors, nutritional habits, weight and height. Haemoglobin was measured in a sample of 800 students selected at random from both genders and different age groups. Anaemia was defined according to the new WHO cut-off levels for haemoglobin as: blood haemoglobin <11.5 g/dl for the 5-11 years boys and girls; <12.0 g/dl for 12-14 years boys and girls; <12.0 g/dl for 15+ girls and <13.0 g/dl for 15+ years boys. Proportion and 95% confidence intervals (CI) were calculated and significance was considered when the 95% CI did not overlap. Anaemia was reported among 20.5% of school students. Anaemia was more prevalent among students of at least 12 years as compared to the younger age group. Also, anaemia was more marked among governmental school attendees and those born to low-educated mothers. Menstruating girls were at around double the risk of being anaemic than non-menstruating girls. Anaemia was associated with negative impact on school performance and was more marked among those who failed their exams as compared to students with excellent results. Skipping breakfast was reported by 14.9% of students and this habit did not differ by age, sex, body mass index or social class. Skipping breakfast was more marked among students with poor school performance as compared to those with very good or excellent results. Only 34.1% of anaemic school students were aware of being anaemic. Awareness was nearly equal in all age groups and social classes but girls were more aware of their anaemic status than boys. Iron deficiency anaemia appears to be prevalent among school students. At age 12 years and over, low social class and menstruating girls constitute the high-risk groups. Screening is recommended for high-risk groups and school health programs are crucial to improve students' nutritional habits, knowledge and awareness.

Public health insurance and medical treatment: the equalizing impact of the Medicaid expansions

We investigate the impact of expanding public health insurance on the medical treatment received by women at childbirth, using Vital Statistics data on every birth in the US over the 1987–1992 period. The effects of insurance status on treatment are identified using the tremendous variation in eligibility for public insurance coverage under the Medicaid program over this period. Among low education mothers who were largely uninsured before being made eligible for Medicaid, eligibility for this program was associated with significant increases in the use of a variety of obstetric procedures. Among women with more education, however, there is a countervailing effect on procedure use. Most of these women had private insurance before becoming Medicaid-eligible, and some may have been ‘crowded out’ onto the public program, moving from insurance which reimburses medical care more generously to insurance with much less generous reimbursement. This movement was accompanied by reductions in procedure use. Thus, on net, the Medicaid expansions had an equalizing effect, increasing the treatment intensity of the previously uninsured while lowering it among the previously insured.

Maternal comprehension of home-based growth chart in Bahrain.

The objectives of this study were to assess Bahrain mothers' understanding and interpretation of currently used home-based growth monitoring chart, and how their education effects their comprehension of it. A sample of 472 mothers of children who were less than 6 years old were selected from 18 health centres in Bahrain. About 73% brought the growth chart with them during their visits. The education of the mothers had a significant effect on the comprehension of the growth chart. Highly-educated mothers were more likely to read the information in the growth chart (69%) than middle (52%) and low-educated mothers (16%) (P<0.0001). Also highly-educated mothers got more benefit from the growth chart (P<0.0001) and more of them understood the reason for the colour in the chart (P<0.0001) than other groups. The majority of husbands (85%) showed no interest in reading the growth chart. Of the mothers, 42% did not know at which age the growth chart should be used. It is important, therefore, that the current growth chart should be reviewed and the mothers and health workers should be involved in the process of designing the chart. Suggestions for improvement of the growth chart currently used were provided.