The impact of maternal education/literacy on child health in the developed world The UK government pledged to eradicate child poverty by 2020. The Welsh child poverty rates, in recent years, were below the UK average; however figures from 2011 show that the progress made on tackling child poverty has now stalled (Save the Children, 2011). The 2011 Child Poverty Strategy for Wales (Welsh Assembly Government, 2011) focuses on three strategic objectives: i)
to reduce the number of families living in workless households,
ii)
to improve the skills of parent/carers and young people living in low income households so they can secure well paid employment,
iii)
to reduce inequalities that exist in health, education and economic outcomes of children and families by improving the outcomes of the poorest.
This report focuses mainly on the last two strategic objectives as it explores the importance of maternal education on child health and ways in which improving maternal education will close the child health disparity existing between the richest and the poorest. Maternal education, in this report, is linked to maternal literacy as a lower reading ability is likely to be indicative of a lower education and child health and welfare are adversely affected when mothers have both a low literacy and low educational attainment (Kutner et al, 2006). Education acts as a marker for socioeconomic status, occupation and lifestyle which in turn influence income, housing and other material resources (Feldman, 1989). Studies show that socioeconomic status influences child health and this relationship grows more pronounced with age (Case et al, 2002). A child from a low socioeconomic family is four times more likely to die in an accident, is three times more likely to have a mental disorder, and is at an increased risk of developing chronic illness, respiratory infections and gastroenteritis (Palmer, 2005; Department for children, schools and families, 2007). If a child’s parents have never worked or are long term unemployed then they are 13 times more likely to die from unintentional injury and 37 times more likely to die from exposure to fire (Department for children, schools and families, 2007). Families who are more likely to have a lower socioeconomic status include workless families, ethnic minorities and migrants, homeless families and families with mothers who have no qualifications (Department for children, schools and families, 2007). Child health and welfare is dependent on the status of women (Racine et al, 2007). Data shows that 15% of the poorest mothers have problems with basic literacy and numeracy and each additional year of schooling is estimated to increase a women’s income by 10 to 20 percent (Waldfogel and Washbrook, 2010; Filmer, 1999). Income and throughout education (both measures of socioeconomic status) directly impact a child’s health and early childhood health and academic
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
achievement have far reaching effects on health and well being the life course (Stevens 2006). Work from the developing world has shown that maternal education is an important factor for improving child survival and health (Caldwell, 1979). It is suggested that more educated mothers have a better knowledge about health care and nutrition, have healthier behaviour, and provide a more sanitary and safer environment for their children. (Strauss and Thomas, 1998.) Further research has shown that this relationship is not confined to the developing world but shows that maternal education has a significant impact on child health and child poverty in developed nations as well. Child health is defined as: ‘the extent to which children are able or enabled to develop and realise their potential, satisfy their needs and develop the capacities that allow them to interact successfully with the biological, physical and social environment’ (National Research Council and Institute of Medicine, 2004). It states in article 24 of the United Nations Convention on the Rights of the Child that a child has a right to ‘enjoy the highest attainable standard of health,’ and to have access to ‘facilities for the treatment and rehabilitation of health.’ It also states that parents should be supported on education and knowledge on the basic aspects of ensuring a child’s good health (UNCRC, 1990). Therefore, service providers and state parties need to ensure that relevant structures are in place that realise these rights for children and young people. Barrera (1990) predicts that maternal education has the greatest impact on child health among children aged 0-2. Very young children are particularly sensitive to proper health choices and health related behaviours (Barrera, 1990). Breastfeeding is of considerable importance to the young infant. It is important for nutrition and development, for reducing infections and diseases and positively impacts cognition, vocabulary and intelligence (Stanley et al, 2007; Waldfogel and Washbrook, 2010). Breastfeeding has considerable long term benefits (on the child through to adulthood) such as reducing risk of obesity, asthma, type 1 and type 2 diabetes, and adult subjects who were breast fed were more likely to have a lower cholesterol and blood pressure important risk factors for heart disease (Horta et al, 2007) . Breast feeding also reduces the risk of postnatal depression, and breast and ovarian cancer in the mother (Stanley et al, 2007). Studies have shown that a lower socioeconomic status is associated with a lower uptake of breastfeeding. Skafida (2009) also acknowledges the importance of maternal education and found that higher educational qualifications are associated with an increased rate of breastfeeding take-up. While social class may predict breastfeeding uptake rates maternal education may be a more useful measure of explaining and understanding the differences in breast feeding up take in the lowest socioeconomic groups (Skafida, 2009). To reduce this health inequality across socioeconomic groups direct interventions need to be made by the state such as making antenatal classes more accessible to the disadvantaged, improve support by midwives at the time of birth (Skafida, 2009) and enable more mothers to have more contact with health visitors after the birth, such as expanding the Sure Start and Flying Start initiatives in England and Wales to encompass a greater proportion of mothers.
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
Breastfeeding rates in the UK are the lowest in Europe with rates at 66%. In Wales breast feeding rates are much lower at 48% with Merthyr Tydfil only reaching rates of 35.67% (Merthyr Tydfil County Borough Council, 2010). In 2001 the Welsh Assembly Government published a strategy ‘Investing in a better start: promoting breastfeeding in Wales’. The programme raises awareness, supports and promotes breastfeeding to the youngest mothers and those who leave school at an early age. The programme has recently been approved for continuation until 2014 (Welsh Government, 2011). Maternal low literacy and educational levels are also associated with reduced intake of folic acid (Dowd J, 2007). Folic acid intake reduces the risk of neural tube defects by 70%. A study by Ong et al, (2011) found that mothers of children with spina bifida were more likely to have a lower educational level as well as being the sole carer and unemployed. Developmental problems are also due to exposure to harmful substances in utero such as toxins from smoking and drug abuse (Tough et al, 2010). Women with a lower socioeconomic status are more likely to continue to smoke during pregnancy however a high level of education and higher age at onset of smoking decreased this association (Stephansson et al, 2001). Kleinman and Madans (1985) found that women of a lower educational attainment were more likely to smoke prior to pregnancy, less likely to stop during pregnancy and were more likely to be heavy smokers. Childhood immunisations are also shown to have poorer uptake rates with women of a lower literacy level. Childhood immunisation rates are at an all time high except among low income children aged 2 and younger. Barriers to immunisations, such as access to services, are magnified when the mother has a low literacy level. (Wilson et al, 2006.) A pilot study by Wilson found that using an easy to read guide on immunisations (see appendix 1) as well as tailored vocal information, increased a parent’s knowledge on immunisations, ultimately leading to an increased uptake of the immunisation regime. Immunisation uptake rates for Wales show for children aged one the 5 in 1 vaccines, Men C and pneumococcal vaccines are on target all exceeding 95%. For children aged 2 uptake of the MMR vaccine was 91.6% and uptake of the second MMR dose at aged 5 was 87% (NHS Wales, 2011). The data shows an inverse relationship between immunisation uptake rates and child age and although there is no explanation given future research should focus on whether maternal education has an impact on childhood immunisation uptake rates in Wales, especially as children grow older mothers have less contact with health care professionals, such as health visitors and midwifes, and may have less access to information on childhood immunisations. The Gypsy and Traveller community are another group with low childhood immunisation uptake rates and this can be partly attributed to low literacy levels (Parry, 2004).
The Gypsy and Traveller
community is a particularly excluded group in our society facing widespread poverty, discrimination and prejudice. This ethnic minority experience a complex set of exclusionary barriers which affect their ability to access health and social care services, education, accommodation and employment, all
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
of which contribute to increased levels of poverty (Cemlyn et al, 2009). 62% of Gypsies and Travellers are illiterate (Greenfields et al, 2011). Many Gypsies and Travellers are uncomfortable accessing health services and a contributor to this is due to literacy problems. According to Cleemput (2000) most Travellers want their children immunised but mothers find it hard accessing information on immunisations and most of the information gained is from the television. After the introduction of a health visitor to a travelling community in County Durham, Nelson (2003) reports a 90% immunisation uptake rate. Currently through the Flying Start Programme, a baby clinic is being run at a Gypsy and Traveller site in Cardiff. It is a successful way of delivering health information to new mothers and helps support and guide them through difficult health information and choices for their children. In general Gypsies and Travellers experience poorer health and 1 in 5 mothers experience the loss of a child, comparable to 1 in 100 in the settled community. Among the reasons for this is a lack of access to health services due to poor literacy (Aspinall, 2004). The mother is unable to read information about services available, appointment letters, health information from the internet, books and leaflets, and medication instructions (Parry et al, 2004). Mothers with poor literacy may give medication to their children at the wrong dosage or frequency and may not understand the adverse effects of a drug or the need for follow up monitoring (Yu et al, 2008). In the report ‘An insight into the health of Gypsies and Travellers’ Markie’s story tells a typical experience of many Traveller children: Markie was receiving medication for depression and anxiety. His mother would make sure he took the tablets and both his and his mother’s literacy was poor. After experiencing worsening symptoms and the intervention of The Ormiston Travellers Initiative Advocacy Service it was found that Markie was receiving three times the prescribed dose of his medication (see appendix 2)(Orniston Children and Families Trust, 2008). Therefore, medical professionals need to spend extra time explaining medication and health information to those with a lower literacy level and follow up appointments need to check that the prescribed medication dose is being taken (Cleemput, 2000). A ‘Be happy, be healthy’ 16 page picture board book, promoting positive health, was introduced to a travelling community in Durham. It contained advice on health surveillance, immunisations, home safety, diet and depression and isolation of new mothers. The key components of success were involving the Gypsy and Traveller families in the creation of the book, creating a positive and strong relationship between the health workers and the families, building on previous knowledge whilst taking into account the Gypsy and Travellers own perceptions of health, disease and health care services and including an audio tape and cassette player therefore ensuring that the information was accessible to all regardless of literacy ability (Salkeld, 2002). Similarly, Diabetes UK, as the first charity to create an equality and diversity team dedicated to helping diverse groups including Gypsies and Travellers, have produced the resource ‘Don’t leave it too late.’ A CD with an accompanying illustrated booklet provides information to raise awareness of the seriousness of diabetes and the importance of early interventions to reduce the risk of developing complications (see appendix 3).
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
Although not particularly aimed at child health it is positive that a leading charity is providing easily accessible health information, at an easy reading level, aimed at the Gypsy and Traveller community. Another group at risk of poorer health are the children of young, adolescent mothers. According to Ong et al, (2011) adolescent mothers were more likely to have lower levels of educational attainment and less likely to construct an emotionally and cognitively supportive environment for their children. Younger mothers, with lower literacy skills, were significantly more likely to report a barrier to giving their child medication and found it difficult to access health services (Sleath et al, 2006) However, it was shown that maternal educational attainment has more of a lasting effect on a child’s wellbeing than the age of the mother at birth, therefore funding and interventions are needed to support adolescent mothers to continue their education after child birth (Sullivan et al, 2001). This shows that universal programmes, such as the Sure start and Flying start schemes mentioned previously, are needed to reduce poverty in all ‘at risk’ groups because early interventions are likely to have positive outcomes for the majority of children. Children of mothers with low education levels may not receive adequate cognitive stimulation and may not be able to thrive in school and academically (Geoffroy et al, 2010). Academic performance in children is related to child health as it enables a child to ‘develop and realise their potential’ as stated in the child health definition (National Research Council and Institute of Medicine, 2004). Geoffroy found that unless children had received formal childcare, children whose mothers had a low educational attainment showed lower scores on academic readiness and achievements at age 6 and 7 years compared to children whose mothers had a higher educational attainment. A child’s literacy level is related to socioeconomic status, maternal literacy and mediation and literacy tools available at home (Aram and Levin, 2001). Only 45% of the poorest children are read to every day at age 3, this is compared to 65% in middle income families and 78% in the richest families. The poorest children are also less likely to visit libraries and places of educational interest such as museums (Waldfogel and Washbrook, 2010). Children who find reading difficult are more likely to become frustrated and unhappy at school. The negative effects of poor reading skills are likely to increase with age as the child becomes more aware of their performance compared to their peers and they may therefore suffer humiliation, anxiety and other negative emotions (Miles and Stipek, 2006). The negative effects of poor reading ability will persist into adulthood as the higher paying jobs will be blocked to individuals and the cycle of poverty will continue. Currently in the UK there is a Bookstart scheme which offers free books to children at three key ages before they start school. The scheme aims to inspire a love of reading in children in order to give them a flying start in life. Support and guidance is given to parents to encourage them to read with their children. The books are also available in Welsh. Research found that upon starting school Bookstart children were significantly ahead of their classmates in all reading and number assessments (Wade and Moore, 2000).
This shows the
importance of early intervention programmes where they can create beneficial effects on the
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
outcomes of the most disadvantaged children which can then extend into adulthood (Waldfogel and Washbrook, 2010). Socioeconomic status has been shown to affect many health outcomes across the lifespan and a study by Kaplan et al (2001) shows that the effects of low maternal education and socioeconomic status in childhood may increase the risk of Alzheimer’s disease and other dementias in adulthood. The study found that a mothers educational attainment was significantly predictive of their sons cognitive function at age 58 and 64, with a lower maternal education being associated with poorer scores on neuropsychological tests by their sons. A poorer cognitive function was associated with an increased risk of dementia. It is believed that economic and material factors, quality and quantity of parent child interactions and other processes linked to maternal education influence a child’s cognitive development; the theory suggested is that improved networks of neurons (due to increased amounts of the before listed) create a buffer against the onset of cognitive decline. It was therefore concluded from the study that activities and roles engaged in by mothers effect the cognitive development of their children which endure well into the 5th and 6th decade (Kaplan et al, 2001). Negative effects on a child in utero can also have huge consequences on the child in their later adult life. Birth weight is the most important factor in determining whether a newborn infant will survive, grow and develop healthily. Low birth weight infants are more likely to be hospitalised after birth, have disabilities, brain damage, poorer language development, show more intellectual impairments and are more likely to be in the lower socioeconomic classes (Kogan, 1995). Preterm, low birth weight infants are also at an increased risk of later adult diseases such as cardiovascular disease, diabetes and COPD. Poor socioeconomic conditions such as stress, anxiety and maternal education are significant factors in the cause of preterm births, of which maternal education is the most modifiable. (Williams, 2000). Nanyonjo et al (2002) found maternal education and length of gestation to be the most significant contributor to adverse birth outcomes. Preterm birth rates have risen from 11.9 per 1000 births in 1994 to 13.7 per 1000 births in 2003. This is an average increase of 2.2% per year. Births to mothers in the most deprived deciles had a 94% higher risk of being very preterm (before 32 weeks gestation) than those in the least deprived deciles (Smith et al, 2007). Adverse birth outcomes are believed to be partly due to more negative social aspects associated with a lower education such as smoking, substance abuse, poorer working and living conditions, depression, anxiety and being single (Arntzen et al, 1996; Kleinman and Madans, 1985). Not only does maternal education impact child health but there is evidence to suggest that a low educational attainment in mothers is associated with increased foetal and infant mortality. A study sampling 170,948 Belgian women (Cammu et al, 2010) found that foetal death rate is significantly associated with maternal education irrespective of birth weight (see figure 1.) They also found that the incidence of preterm birth, low birth weight, neonatal morbidity and foetal and infant death had an educational gradient and were least common in mothers with the highest level of education.
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
Figure 1: Maternal level of education in relation to foetal and infant mortality rates (Cammu et al, 2010)
This was further supported by a study from Oslo (Froen et al, 2001). They found that maternal education of less than ten years was associated with a fourfold increase in foetal and infant mortality. The national vital statistics report from America, based on data from 41 states, showed that the infant mortality rate was 49% higher for mothers who had completed less than 12 years of school compared to mothers who had completed 16 or more years of education, (Centres for Disease Control and Prevention, 2004; Mathews et al, 2007). Foetal and infant mortality are much affected by socioeconomic disparity and according to Stephansson et al (2001) women with the lowest socioeconomic status are more than twice as likely to be affected by foetal death. Similarly, sudden infant death syndrome was found to be more frequent amongst the poorest women and those with a lowest educational attainment (Cammu et al, 2010). It was found that if all US infants experienced the mortality rate of infants in the highest socioeconomic group then there would be 39,867 fewer deaths between 1995 and 2000 (Singh and Kogan, 2007). Infant mortality rate improved from 1999-2006 (0.63% - 0.7%) however this improvement was not seen among women with the lowest educational level (Cammu et al, 2010). Similarly data from Norway and the US show that welfare and educational attainment have dramatically improved, but the link between low maternal education and post neonatal mortality is more pronounced than ever before (Arntzen et al, 1996; Singh and Kogan, 2007). As Arntzen states the fact that the inverse association between a mothers educational level and infant mortality has increased over time should be a matter of great concern as it may indicate that the growth of the welfare state has not reached all segments of the population. By reducing the percentage of the less educated women further the global health of the population will improve, however a small and seriously vulnerable socioeconomic group may become more distinct and special health care services need to be put in place to target and help this at risk population.
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
In conclusion child poverty and health are closely linked and there exist serious health inequalities between the most and the least deprived children. Maternal education has a huge impact on child health and in order to eradicate child poverty this relationship needs to be acknowledged and acted upon by state parties. A low maternal education impacts on a child’s rights and services need to be put in place in order to deliver these rights to the children and young people. Greater periods of time need to be spent with a health visitor after birth, support programmes need to be put in place to help the youngest mothers continue their education, positive programmes like the Sure start and Flying start initiatives need to receive more funding in order to encompass a greater proportion of mothers and healthy behaviours need to be promoted to those mothers with a lower education. Access to health information needs to be made more available to those mothers with a lower literacy level and health professionals need to spend more time with low literacy level mothers. The fact that infant mortality rates are higher amongst mothers with a lower educational attainment and that this relationship is becoming more pronounced needs to be seriously acknowledged by state and welfare systems and interventions need to be made. The principle way in which state parties can tackle child poverty is through supporting the poorest children to better health. By improving maternal education, putting in place support programmes, creating early interventions for the groups most at risk and providing a better access to health care child health can improve and infant mortality rates can reduce. This will close the health disparity gap, help pull children out of poverty and deliver them their human rights therefore breaking the continuing cycle of child poverty. Article produced by Alicia Regan, Cardiff University, School of Medicine
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
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Parry G, et al. 2004. The health status of gypsies and travelers in England. Sheffield: School of Health and Related Research, University of Sheffield. Racine, A and Joyce, T. 2007. Maternal education, child immunisations and public policy: evidence from the US national immunisation survey. Social science and medicine 65, pp. 17651772 Salkeld, J. 2002. Be Happy, Be Healthy. Sedgefield: Sedgefield PCT. [Online]. Available from: http://www.health-promotion.org.uk/projects/aboutbehappy.htm [Accessed: 10 Jun 2011]. Save the Children. 2011. Child Poverty Solutions: policy context. [Online]. Available at:http://www.childpovertysolutions.com/ChildPovertySolutions_PolicyContext.aspx [Accessed: 4 Jul 2011]. Singh, G and Kogan, M. 2007. Persistent socioeconomic disparities in infant, neonatal and postneonatal mortality rates in the United States, 1969–2001. Pediatrics 119, pp. 928–939. Skafida, V. The relative importance of social class and maternal education for breastfeeding initiation. Public Health Nutrition. 2009; 12: 2285-2292. Sleath, B et al. 2006. Literacy and perceived barriers to medication taking among homeless mothers and their children. Am J Health-Syst Pharm 63, pp. 346-351. Smith et al, 2007. Socioeconomic inequalities in very preterm birth rates. Arch Dis Child Fetal Neonatal Ed 92(1), pp. 11-14. Stanley, I et al. 2007. Breastfeeding and maternal and infant health outcomes in developed countries. Evidence Reports/Technology Assessments, No.153. [Online]. Available from: http://www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf [Accessed: 6 Jul 2011]. Stephansson, O et al. 2001. The influence of socioeconomic status on stillbirth risk in Sweden. Int J Epidemiol 30, pp. 1296–301. Stevens, G. 2006. Gradients in the health status and developmental risks of young children: the combined influences of multiple social risk factors. Maternal and Child Health Journal 10(2), pp. 187-199. Strauss J, Thomas D. Health, nutrition and economic development. Journal of Economic Literature. 1998; 36(2): 766-817. Sullivan, K et al. 2001. Continuing education mitigates the negative consequences of adolescent childbearing. Matern Child Health J 15(3), pp.360-366. Tough, S et al. 2010. Maternal well-being and its association to risk of developmental problems in children at school entry. BMC Pediatrics 10, pp. 1-12. United Nations Convention on the Rights of the Child. 1990. Office of the Unite Nations high commissioner for human rights. [Online]. Available from: http://www2.ohchr.org/english/law/crc.htm#art24 [Accessed: 29 Jun 2011]. Van Cleemput, P. Health care needs of Travellers. Archives of Disease in Childhood. 2000; 82: 32-7. Wade, B and Moore, M. 2000. A Sure Start with Books. Early Years 20, pp.39-46
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
Waldfogel, J and Washbrook, E. 2010. Law income and cognitive development in the UK. London: The Sutton Trust. Welsh Assembly Government. 2011. Child Poverty Strategy for Wales. [Online]. Available at: http://wales.gov.uk/docs/dsjlg/policy/110203newchildpovstrategy2en.pdf [Accessed: 4 Jul 2011]. Welsh Government. 2011. Continuation of national breastfeeding programme 2011-2014. [Online]. Available from: http://wales.gov.uk/publications/accessinfo/drnewhomepage/healthdrs/2011/4699409/;jsessionid= XKcHNnnP7NT4lRDMKZbpw256hJQr1Fcn1tlf40snthJlpZk0jl2t!-752524540?lang=en [Accessed: 28 Jun 2011]. Williams, C et al. 2000. Mechanisms of risk in preterm low birthweight infants. Periodontol 23, pp.142-150. Wilson, F et al. 2006. Can easy-to-read immunizations information increase knowledge in urban low-income mothers? Journal of Pediatric Nursing 21, pp. 4–12. Yu, M, et al. 2008. A comparison study of psychiatric and behaviour disorders and cognitive ability among homeless and housed children. Community Mental Health Journal 44(1), pp.1-9.
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
Appendix 1 An example of the cover and a page of the revised ‘easy to read’ guide to immunisations (Wilson et al, 2006).
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
Appendix 2
Markie’s Story (Ormiston Children and Families Trust, 2008). Markie* is a young man who suffers from depression and anxiety. He was prescribed night time medication to help him sleep and to reduce his anxiety. He was told to take three 10mg tablets every night. His Mum looked after the tablets and made sure he took them. Markie’s literacy is not good and neither is his Mum’s, and they made sure the people at the surgery were aware of this. Markie was improving gradually but then started to feel worse for no real reason. He felt tired, lethargic and believed his medication wasn’t helping him. He told the people treating him and they suggested he take an extra dose of his mood stabilising medication during the day to see if that helped. The Ormiston Travellers Initiative Advocacy Service supported Markie to tell the consultant he wasn’t happy and to ask for his medication to be reviewed. The consultant contacted the surgery and went through the details of what was being dispensed. It was found that the night time medication had been changed and the dose of each of the tablets was now 30mg. Markie and his Mum had not been told, couldn’t read the packaging and Markie had been taking three times his prescribed dose at night. In addition he had taken an extra one in the daytime as he had confused the night time tablets with the mood stabilising tablets, due to them being supplied in blister packs without their branded packets *Names have been changed to protect identity
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
Appendix 3 Feeling very tired
Diabetes UK, as the first charity to create an equality and diversity team dedicated to helping diverse groups including Travellers and Gypsies, have produced the resource ‘Don’t leave it too late.’ A CD with an
Going for a wee
accompanying illustrated booklet provides information to
more, especially at
raise awareness of the seriousness of diabetes and the
night
importance of early interventions to reduce the risk of developing complications http://www.diabetes.org.uk/Guide-to-diabetes/Introduction-
Repeated skin infections or Thrush
to-diabetes/Diabetes---A-guide-for-Gypsies-Roma-andTravellers/
More thirsty than usual
Cuts and scratches are slow to heal
Blurred vision
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan
Diabetes UK also provides easy to read information aimed at the Gypsy and Traveller community.
The impact of maternal education/literacy on child health in the developed world produced by Alicia Regan