Maternal Education and Child Health: An Exploratory ... No. 7, 2002 Maternal Education and Child...

Issue No. 7, 2002

Maternal Education and Child Health: An Exploratory

Investigation in a Central Australian Aboriginal Community

Dan Ewald, Bob Boughton

The ideas and opinions presented in this occasional paper are the authors’ own, and do not necessarily reflect the ideas and opinions of the CRCATH, its board, executive committee or other stakeholders.

ISBN 1 876831 90 1

“working together...making a difference”ii

First published in 2002 byThe Cooperative Research Centre for Aboriginal and Tropical Health (CRCATH)PO Box 41096Casuarina NT 0820

© Dan Ewald, Bob Boughton & CRCATH 2002

This occasional paper is copyright. Apart from any fair dealing for the purposes of private study, research, criticism or review, as permitted under the Copyright Act, no part may be reproduced by any process without written permission. Please forward all enquiries to the Cooperative Research Centre for Aboriginal and Tropical Health (CRCATH) at the above address.

The ideas and opinions presented in this occasional paper are the author’s own and do not necessarily reflect the ideas and opinions of the CRCATH, its board, executive committee or other stakeholders. ISBN 1 876831 90 1

Designed by Sarah Walton, CRCATHEdited by Michael Duffy, CRCATH

“working together...making a difference”iii

AbstractInternational research has established that education, and particularly maternal education, is a strong determinant of child health and survival. In the setting of Australian Aboriginal health, the little research that has been done suggests the association is not so straightforward. This paper reports on an opportunistic exploratory project utilising child health and adult education data obtained from an evaluation of health outcomes associated with a housing and sewerage project in a large Central Australian community. Our aim was to explore the association between ‘carer-mothers’ (not always the biological mother) education and their children’s health, using combined qualitative action research and quantitative methods.

Health markers for 183 children included trachoma, scabies, growth indices and purulent skin sores, nose or ears. Education markers for 123 ‘carer-mothers’ included years of schooling, qualifications, literacy, having attended a boarding college and employment. Most data fields were incomplete. The data were examined for statistical associations between education, employment and health.We sought both to gather an understanding of community beliefs about the association between education and health and to provide information on the international research experience in this field. The quantita-tive data gathering process, which involved a range of people, was combined with and used as a vehicle for qualitative discussions and workshops, assisting people to become more active in health and educa-tion debates.

We found a trend for better health among children whose ‘carer-mothers’ were employed, but not for those whose mothers had more education. Our community informants generally held the view that education was linked with better health, but describing the pathway(s) proved difficult. There was a high level of concern about the state of physical and social health of young people in the community. We discuss lessons learnt from conducting this type of work in Central Australia and highlight some aspects of the possible associations between education, employment and health for future research.

“working together...making a difference”iv

“working together...making a difference”1

IntroductionStrong relationships between education and health outcomes have been demonstrated in many coun-tries of the world, favouring the survival and health of children born to more educated parents, especially mothers (Caldwell, 1993). Cross national comparisons in Africa, Asia and South America regularly show that countries with higher rates of maternal schooling have significantly higher rates of child survival, for the same or lower levels of health expenditure. Adult literacy programs, for example in Nicaragua, have also had a positive impact on the health of both the participants and their children (Sandiford, Cassel, Montenegro, & Sanchez, 1995). Studies combining quantitative research with com-munity ethnography have identified several possible pathways though which education has its effect on health:

• by altering power relationships in families and communities;

• by changing household behaviour; and

• by improving people’s capacity to understand health messages and deal with primary health services (Cleland, 1990).

Boughton’s (2000) review of this work for the Cooperative Research Centre for Aboriginal and Tropi-cal Health (CRCATH) explored its relevance to Indigenous health research in Australia, including potential links to other research on the social determinants of health, particularly the so-called ‘con-trol factor’ (Corin, 1994; Marmot, Bosma, Hemingway, Brunner, & Stansfeld, 1997; Wilkinson & Marmot, 1998). However, most maternal education studies have examined Third World, or ‘develop-ing’ countries, and neither these nor the more general studies on social determinants have paid much attention to the special situation of Indigenous peoples living as minorities within wealthy First World states. For these ‘Fourth World’ peoples (Indigneous Australians), there are issues of language, culture and power embedded in the history of their relationships with the dominant settler majority which make the education system’s health effects more complex and difficult to unravel.

Two reported empirical studies in Australia support this. Gray (1988) analysed 1986 census data for evi-dence of the effect of maternal education levels on Indigenous child survival rates. While he found that an increase in years of schooling was associated with better child survival, there were anomalies, which may or may not have been an effect of better reporting by more educated mothers. More recently, Gray and Boughton (2001) analysed self-reported health-seeking behaviour by Indigenous mothers, using data from the 1994 National Aboriginal and Torres Strait Islander Survey (NATSIS). They found rela-tively high levels of health action were taken for two groups of children, those whose mothers had the least education and those whose mothers had the most education. The authors concluded that it was important to supplement such statistical studies with more qualitative surveys and ethnographic study at regional and community levels.

This echoed an argument made a decade earlier, by Kunitz (1990), who warned against treating mater-nal education “as though it were just another biomedical intervention” to be prescribed in yearly doses:

“To think of education as a vaccine that prevents infant mortality in the way measles vaccine prevents measles is to ignore the cultural and socio-political context within which education occurs and which endows it with significance (our emphasis).” (p.105)

The solution Kunitz advocated was to employ both epidemiological and ethnographic approaches, allowing each to ‘cross-fertilise’ the other, rather than become ideological weapons for distinct profes-sional interests to use against each other.


Some education researchers question the value of attempting to establish statistical links between (west-ern) education levels and health outcomes (Christie, 1998; Malin, 2000). Nonetheless, there are seri-ous problems in education access, participation and outcomes in Indigenous communities in the N.T. The recent Collins review, Learning Lessons, for example, drew attention to:

• very low retention rates in secondary schooling;

• high proportions of enrolled secondary students undertaking pre-secondary, ungraded programs;

• low levels of English language literacy and numeracy, with most young people leaving school in remote communities having achieved only Year 2 or Year 3 levels; and

• resource inequities underlying this situation, including the fact that there are no govern-ment high schools outside the major towns of Darwin, Katherine, Tennant Creek and Alice Springs (Northern Territory. Department of Education, 1999).

On the face of it, given the overwhelming international evidence of the importance of education to health, it seems reasonable to ask whether or not there might be some connection between these known problems in education delivery and the equally well-known problems in child health. This paper presents results from a small preliminary and exploratory study jointly conducted by Territory Health Services and Menzies School of Health Research in Central Australia between July and October 2000, which trialled both quantitative and qualitative techniques for asking such questions in one remote Aboriginal community.1 To our knowledge a project like this had never before been attempted in an Indigenous community in a first world country.

We note that the major education inequalities which may affect health are between Indigenous and non-Indigenous people, as shown above. This study however only explores the effects of inequalities within the Indigenous population in this community, not the inequalities between this population and the wider society.

The first section presents the study itself, in a standard ‘scientific’ format, describing the context and aims, the methods and the results. The second section returns to the more general questions the study raised, in an effort to draw out the lessons we learned which might be applied to the design and con-duct of future research in this area.

1 The principal investigator was Dan Ewald, who was working as an epidemiologist in Health Development at

THS in Alice Springs. His co-investigator was Bob Boughton, formerly a Research Fellow at Menzies School of Health Research, now works as a consultant researcher with the Central Australian Aboriginal Congress. The late Dr Alan Gray, from the Institute of Population and Social Research at Mahidol University in Thailand was an adviser to the project. Gill Hall (National Centre for Epidemiology in Public Health) and Joan Cunningham (MSHR) also provided helpful advice. We would like especially to acknowledge the large number of people from Yuendumu community who assisted us with this study. In particular, Connie Wallett, Lottie Robertson, Jeannie Egan, Barbara Martin, Nancy Oldfield, Alma Robertson, Michael Harris, Wendy Baarda and Andrew and Belinda Lloyd assisted in both data collection and in helping us understand the results.


Study Context and AimsThe study was made possible through an opportunistic collaboration between two projects within sepa-rate programs of the Cooperative Research Centre for Aboriginal and Tropical Health (CRCATH):

• an evaluation by the Health Development section of THS of the National Aboriginal Health Strategy Environmental Health Program (NAHS - EHP) in a community in Cen-tral Australia; and

• the ‘Systematic Review’ Project of the CRCATH’s Indigenous Health and Education Pro-gram, which included the international literature review and the NATSIS statistical study mentioned above.

The cooperation of the Regional Managers of THS and NT Education allowed the project to access staff in the health service and the school to assist in this study, which might otherwise have proved beyond the funds available. Another key factor was the support of Yuendumu Community Council and several other agencies in the community, including the Women’s Centre, the Old People’s Service and Warlpiri Media. The Alice Springs Institutional Ethics Committee provided ethical approval.

Yuendumu, the study community, is home to approximately 1000 people. The vast majority of resi-dents speak Warlpiri as their first language.2 The region has a very recent history of non-Indigenous occupation and settlement, achieved at a high cost in Indigenous lives, with the last recorded massacre of Indigenous people by settlers occurring in 1927 (Vaarzon-Morel & Nungarrayi, 1995). The ‘native welfare’ authorities established the settlement in 1947 as a ration station and mission. In the 1960s, infant mortality rates as high as 250 per 1000 were reported. The community is now serviced by one of the many remote community health centres that form the NT government primary health care service in the region. It is staffed by itinerant visiting medical officers, resident remote area nurses and Aborigi-nal Health Workers. All health services are free and health centre utilisation studies in Yuendumu have shown typical overall utilisation patterns of 120 occasions of service per 100 residents per month. Highest utilisation rates are among 0-4 and over 50 year olds (Ewald D & Hall G, In press).

The first school was established in the 1950s, and recent years have seen a growing number of trained Warlpiri teachers take their place within the school, encouraged by a strong emphasis on bilingualism (Baarda, 1994). While the community is seen as an educational pacesetter in Central Australia, only a few students reach senior secondary level.

Our aim was to explore the association between a variety of education markers for ‘carer-mothers’ and the child health markers of scabies, trachoma, growth, purulent skin sores, purulent nose and ears. To do this we first needed to map children to appropriate women as their ‘carer-mother’ as guided by community co-researchers. To help us interpret the findings, context and implications of this quantita-tive work, we adopted qualitative research methods to investigate the nature and range of community beliefs about the links between education and health.

To supplement this work, and deliver some benefit to the community, we held discussions and con-ducted workshops on the impact of education on health in other settings and supported, as far as possible, community mobilisation and initiatives in health and education. Finally, because of the exploratory and innovative nature of the study, we wanted to identify methodological issues and prob-lems in undertaking such work so as to improve future research design.

2 Small groups speaking other local languages, including Anmatyerre, Luritja, Kukatja and Pintupi.


MethodsQuantitative methodsInformation about the presence of the child health markers was collected during a systematic screen-ing of children under 13 years of age in November 1998 for the NAHS-EHP evaluation (Ewald D & Hall G, In press). This included 80% of children associated with the community (present or away). Weights were measured using portable electronic scales with the children wearing light clothing and no shoes. Heights were measured in socks or bare feet using a tape measure fixed to the wall. Weight-for-age (WAZ) and height-for-age (HAZ) Z scores were calculated using the Epi Info nutritional program (Dean AG et al, 1994). In the calculation of weight-for-age and height-for-age scores values more than five standard deviations from normal (-5 < z < 5) were treated as outliers and were checked against the original data collection sheets for data entry problems or indications of poorly collected data. A Z-score outside these limits was considered biologically implausible and was excluded from analysis. By convention a WAZ score of less than -2 is termed underweight and HAZ score of less than -2 is termed stunted.

Information about the amount of schooling, qualifications, and employment of adults had been col-lected in November 1998 as part of a community census (Ewald D & Hall G, In press). A second census conducted in June 1999 provided an opportunity to recollect information on schooling and qualifica-tions at the time of the first census. Census data collection teams included a member from public health services and a local community person to facilitate understanding and communication, and to guide conduct in the community. For each adult over the age of 15 years and not known to be still attending school we asked:

“How old were you / they when you stopped going to school?”; and

“Have you / they got a certificate or diploma or degree after leaving school?”

The years of schooling was calculated by subtracting six from the age when a person stopped going to school.

A list of people thought to be the mothers of the children included in the screening was compiled from consent forms, and local knowledge. This list of ‘probable mothers’ was discussed with local Indigenous and long-staying non-Indigenous health and school staff, and with students in the senior boys and senior girls classes. Through this technique, the list was enhanced and modified to become a list of the ‘carer-mothers’. For example, if a child was being brought up by a grandmother, then the grandmother was regarded as the ‘carer-mother’.

Information on the amount of schooling, literacy and post schooling qualifications for the identified ‘carer-mothers’ was augmented by a survey and information from key informants in August - September 2000. The date of birth of the ‘carer-mothers’ was obtained from the survey of ‘carer mothers’ and health service records.

A simple survey was used to collect missing education data on the ‘carer-mothers’. The process of con-ducting the survey provided opportunities to discuss the area of education and health with a number of people. A range of local people were involved as surveyors and subjects, and this helped to mobilise thinking, discussion, community involvement and possibly action in the area of education links with health. In response to local interest, and because of its possible impact on health behaviour, the survey included a question on whether or not the respondent had attended boarding school (Kormilda or Yirara).


We classified ‘carer-mothers’ into two broad groups of literacy based on their ability to read the simple English language survey questionnaire. Additionally, a long term resident non-Indigenous teacher, who had taught a large proportion of the ‘carer-mothers’, and a local Indigenous teacher combined to rate subjects as being able to read the survey form on their own. Local advice had suggested that only people with English literacy could read Warlpiri, and that English literacy was unlikely to have been learned anywhere other than in the school system. Table 1, below, summarises data sources for ‘carer-mother’ factors.

Table 1. Summary of data sources for ‘carer-mother’ factors, Yuendumu.

Associations between the education and health variables were tested by univariate (single factor associa-tions) and multivariate (checking for an association between factors while adjusting for the presence of other factors that may distort the result) logistic or linear regression analysis as appropriate using SPSS (SPSS Inc., 1999).

Qualitative methodsWe conceived our study in part as an action research project, involving members of the community in an active process of helping to collect and analyse the data, and reflecting on why we were doing it and what it might reveal. The widespread interest generated by the study, evidenced by the large number of people who agreed to help with different aspects, allowed us to enter into ongoing dialogue with community members, Aboriginal and non-Aboriginal. These discussions were recorded in field notes, which were subsequently reviewed to identify recurring themes and issues.

We not only sought peoples’ views, but we also provided input of our own to these discussions, such as the international research evidence, and the data we had on school retention in the NT and nation-ally. This interventionist approach drew on a model of adult education practice called ‘popular educa-tion’ (Boughton, 2001; Faraclas, n.d.; Hurst, 1995). The administration of the survey, which was done by Aboriginal teaching staff, health centre staff, and people in the women’s centre and arts centre with our assistance, also generated considerable discussion about the study among those administering the survey and those completing it. We convened a community workshop after we had completed the statistical analysis reported above, attended by approximately a dozen Aboriginal adults who had been involved at some stage. Following this workshop, a final round of discussions was held with some of the local people who had been most involved.

carer-mother factors

Schooling data Literacy Qualifications Employment Boarding school

census 1 Yes

census 2

Data combined from two censuses, average used if disagreement between sources

No Data combined from two censuses No

No

Survey of selected women

Yes Yes Some additional data

No Yes

Assessment by local Indigenous and non-Indigenous teachers

No Yes No No Yes

‘ ’


ResultsQuantitative resultsOne hundred and eighty three children under 13 years of age and 123 carer mothers were included in the data sample. The ‘carer-mothers’ ages ranged from 17 to 73 years with a median of 28 years. Not all data was complete and the data coverage for the children and for their carer mothers is summarised in Tables 1 and 2 and Figure 1, below.

Table 2. Coverage of each data fi eld and prevalence of health markers among the children, Yuendumu, November 1998.

Table 1 shows that the infectious conditions of trachoma, scabies, purulent nose and purulent sores were very common among the children. As “stunted” and “under weight” are defined as being more than two standard deviations below the median reference values, the proportion of children stunted or under weight is similar to that of the reference population.

Stunted Under

weight

Purulent

ear

Purulent

nose

Scabies Infectious

Trachoma

Purulent

sores

N valid 170 170 183 183 169 182 157

%

coverage

92.9 92.9 100 100 92.3 99.5 85.8

N with

condition

9 (5%) 7 (4%) 8 (4%) 63 (34%) 99 (58%) 74 (40%) 12 (8%)


Table 3. Coverage and prevalence of education markers for ‘carer-mothers’ and children, Yuendumu, November 1998.

* ‘Carer-mothers’ were divided into two education categories, “higher” for those with >8years of schooling or a qualification or literate and the other without any of these markers.# This is the percentage of those with valid data.

Figure 1. Years of schooling for ‘carer-mothers’ from NAHS-EHP evaluation census.

Years of schooling for "carer-mothers" from project census data, Yuendumu.

0

5

10

15

20

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

Years of schooling


The proportion of ‘carer-mothers’ who were employed is low (27%), despite 20% of them having some post schooling qualification (most at certificate level). About two thirds had 10 or more years of school-ing. However, very few of those attending to secondary school age would have been exposed to second-ary school curriculum.

The results of the regression analyses for associations between the ‘carer-mothers’ and the child health data are summarised in Table 3. Further details are provided in Appendix 1.

Table 4. Summary of trends and statistically signifi cant results, ‘carer-mothers’ and children Yuendumu, November 1998.

(Key: + = ‘beneficial’ or ‘protective’ association”, +/- = odds ratio close to or equal to one, - = ‘detri-mental’ association, ? = numbers too small to warrant reporting, * = statistically significant by 95% confidence intervals.)

The table reveals a consistent trend for an association between the employment of ‘carer-mothers’ and better child health. This was most clear for the employment category with regular jobs rather than “work for the dole” programs suggesting a ‘dose response’ relationship between carer’s employment and child health. The mean number of sicknesses per child decreases as the carer’s employment cat-egory moves from nil to ‘work for the dole’ to employed (not statistically significant).

There is no clear pattern of positive association between the markers of the ‘carer-mother’s’ education and child health. While there was some association between education and employment, multivariate regression modelling did not result in any education factors becoming statistically significant. However, using the combined schooling / education marker ‘Education group’ (literate, >8yrs school, any quali-fication) for ‘carer-mothers’ and the combined child sickness markers suggests that the better educated group had less sicknesses and better child growth outcomes among their children.

Though no associations with growth indices were statistically significant, the mean HAZ-score was higher for children whose mothers were in the more educated group, or employed, or had more years of schooling, or post school qualifications, or been to a secondary boarding school. Contrary to this trend, those children whose ‘carer-mothers’ were literate had a lower mean HAZ score. The mean WAZ-score was higher for children whose ‘carer-mothers’ had regular jobs or qualification(s) but lower for those with more years of schooling or deemed to be literate.


Some indication of internal validity was shown by the mean years of schooling for literate group being 10.4yrs and for those labelled illiterate being 9.0yrs (difference not statistically significantly). Addition-ally, those with post schooling qualifications had higher mean number of years of schooling. There was 100% agreement between survey derived and teacher derived classification of literacy (n=21). However there were only two cases of “not literate” in the survey sample, compared to about 25% “not literate” in the teacher’s opinion sample.

Validating the educational data proved very difficult. The years of schooling could be partially vali-dated from school records and by repeat interview at the second NAHS-EHP evaluation census and by comparing census and survey derived data for the same individuals. The mean difference between the census derived data and the survey data collected two and a half years later was 1.1 years (SD 1.9). It is possible (our impression) that there was a selection bias in favour of better collection of educa-tion markers for the more educated ‘carer-mothers’. This would have led to exaggerated estimates of the levels of education and employment among the ‘carer-mothers’. The data for having attended a secondary boarding college was very incomplete, so interpretation of analysis of this variable has to be particularly guarded.

Qualitative resultsOver the four months of the study, we made regular visits to the community, during which many people, both Aboriginal and non-Aboriginal, offered valuable insights and suggestions which added some human ‘flesh’ to the dry bones of the numeric data above. In general, community members and staff all believed that there was a link, and that people with more education were more likely to have healthier children. On only one occasion did someone suggest that education was not a factor in better child health; this was a non-Aboriginal community worker, who pointed to the fact that some older women with virtually no school education had successfully raised many children.

However, there was a clear consensus that better community health would result from more young people getting better secondary schooling. This was often located in statements of more general con-cern about young people. Most of our informants were women in their thirties and forties, many of them grandmothers. They expressed considerable distress and frustration about the health and well-being of children, of young people, and of the community generally. To place these concerns in con-text, the shocking fact is that in the short period of our study, one young person from this community suicided, another died in a car accident, a third was seriously injured from being burned in a petrol sniffing incident and a fourth, a young woman who had worked at the school, died from renal failure. There were also two other deaths of older people, including the loss of a senior women in her fifties who had done enormous work developing the school’s bilingual program. One clear message from our informants was their belief that more and better education would give young people more choice and more control over their environment.

Explaining schooling’s perceived health effects proved a more difficult question for our informants, and our ability to evaluate the various explanations was limited by our own lack of local language skills. While all our informants communicated in English with us, and some had considerable ‘western’ edu-cation, it is important not to underestimate the difficulties associated with cross-cultural communica-tion on such complex issues. 3

3 Communication of health information is a separate sub-stream of the CRCATH Health and Education Program. See Lowell (1998) for a more detailed discussion of these issues.


Some people told us that employment options resulted from better education, and that income was a factor in parents’, especially mothers’, capacity to maintain better health for their children. A number of informants associated schooling with acquiring greater skills in household management, including hygiene practices. An experienced non-Aboriginal teacher was convinced that women who had the experience of the secondary boarding colleges, Yirara and Kormilda, adopted significantly different practices in this regard, which is why we sought to collect some detailed data on this. One young male student thought that better educated parents ‘get the good houses’, which he and his classmates defined as ones with functioning showers and hot water systems.

On several occasions in the community, and in discussions with outside agencies about our study, we encountered what Baarda (1994) called the ‘good old days’ view, which is that education outcomes had deteriorated since the end of the ‘Welfare’ regime in the 1970s, and that this was a factor in continuing poor health.

We specifically discussed whether or not ‘western’-style schooling contradicted ‘traditional’ Aboriginal education, and all our informants said this was not the case. This needs to be qualified by the fact that virtually all these informants had some strong association with the school or health service, and had already argued for the positive affects of schooling.

Both Aboriginal and non-Aboriginal informants were particularly worried about the lack of education opportunities for young women. This included specific concerns about reproductive health education, and about how to care for young children. These issues are dealt with in a specific, but under-resourced, program from the Women’s Centre.

There was significant reluctance to speak in terms of individual cases, which was explained to us in terms of the ‘shame’ associated with not being able to maintain children’s health. So while there was vigorous discussion of the effects of drinking and gambling, and of non-attendance at school, on par-enting capacity in general, almost all our informants were unwilling to speak about specific examples where maternal attitudes or behaviour associated with early school leaving had directly affected child health. Similar issues arose when we discussed English language literacy. Even though it was considered important in general, people were reluctant to discuss how illiteracy might inhibit parents’ capacity to maintain their children’s health, because this might be seen as attributing ‘blame’ or ‘shame’ to identifiable individuals.


Part Two. Discussion and Reflection: Theory and MethodsNeither our quantitative nor our qualitative data provides unequivocal evidence of direct links between the education levels of ‘carer mothers’ and the particular health markers of the children in this com-munity. However, there is a clear association with employment, and there is a possible link revealed when the various education measures and the health measures are combined as composites. Given such a small sample, and the methodological problems we encountered obtaining reliable valid data on education, the inconclusive nature of the results is understandable. Nevertheless, we believe this has been an important exercise, both for people interested in research into the social determinants of Indigenous health, and for the community itself. In this section, we draw out and reflect on the lessons this study provides.

Policy implicationsResearch into links between education levels and community health outcomes has direct policy impli-cations. If the lack of education services has negative impacts on child health, then what appear to be ‘savings’ in government education budgets - e.g. from not providing secondary schools in bush communities4 - may simply be a transfer of costs ‘downstream’, to primary, and especially secondary, health care services. The social costs of not providing adequate education, in terms of the impact on a community’s capacity to provide its residents with a reasonable quality of life, are potentially also very great. On the other hand, if the hypothesis regarding the health effects of education is proven incor-rect in the specific setting of N.T. Indigenous communities, then the health sector should seek other explanations for the continued persistence of Indigenous ill-health and abandon what some education administrators have seen as the ‘scapegoating’ of the education system. In either case, we can look forward to more evidence-based policy if future research is framed by such policy concerns.

Action research, popular education and community health developmentThis study shows that it is possible to combine the techniques of epidemiology and population health with survey techniques and community development education, so as to engage the community itself in investigating possible causes of its health. The rationale for this methodology, explained elsewhere in more detail (Boughton, 2001), is based on the view that health research itself can and should con-tribute to the process whereby a community becomes more able to take control of those factors which impact on health.

We chose education, in part because of what is already known internationally about its potential to improve health, and partly because, as Caldwell has acknowledged, it is one of the factors which can more easily be quantified. But we might also have chosen other potential determinants as our primary focus, such as employment, or income levels, or some aspect of household behaviour.

4 The national average cost of one year’s government secondary education for one student is approximately $6000 for a junior secondary student, and $8000 for a senior secondary student, inclusive of buildings and infrastructure. The cost in a remote area like Yuendumu could well be higher, especially if schools have to cater for much lower numbers.


The point, in general, is to assist the community to collaborate in investigating the social production of its own patterns of health and illness. Such investigation is not undertaken simply for its own sake, but to inform the community’s own efforts to mobilise around issues which are inhibiting its achieve-ment of better health. In modern parlance, this is termed ‘capacity-building’, but it has long been recog-nised in the study of health transitions internationally that levels of education in a society, particularly women’s education, may reflect underlying traditions of mobilisation and political activity in pursuit of greater equality and better health (Caldwell, 1992; Nag, 1990).

Research design and methodologyThis exploratory study was constrained by the size of the available population. Within the intended sample some items of information were incompletely collected, and this may have led to bias particu-larly in the carers’ education markers. We may have gathered more data on the more educated ‘carer-mothers’. There was also a gender bias in terms of our informants, because of the gendered nature of education and health work.

Potential misclassification will have tended to decrease the chance of showing the true associations that exist. The most likely problematic areas are the allocation of the appropriate ‘carer-mother’ for specific children, and the education markers. Focusing on female carers may have been inappropriate in this setting despite the clear links between maternal education and child health seen in international stud-ies. It may be the education of a combination of ‘mothers’, or ‘fathers’, or other relationships that are important for determining a child’s health. This is an issue that might be clarified through further anthropological work.5

Validity of the measures of maternal education may have been poor. We do not know which aspect(s) of education or schooling are important, so we are looking for markers of a poorly defined factor. The measures we have been able to use may have missed the ‘factor(s)’.

Maternal education may be a partial but not sufficient determinant of child health. There were some children with high health scores but low maternal education scores, therefore maternal education is not a totally necessary component of the pathway to good child health.

Previously-used markers of education, such as self-reported years of schooling or data from school enrolment records may not be valid in a setting like Yuendumu. We found that a standard question regarding school leaving age, derived from NATSIS and the Australian Bureau of Statistics census, was on occasions interpreted to mean the age a person left Yuendumu school (to go to another school); or the age a person finished a post-school course, which ran from the same building. Enrolments, on the other hand, do not necessarily reflect attendance or participation, especially for families with high mobility.

We made no attempt to canvass in detail the question of cultural or Aboriginal education. Work under-way in other parts of the NT indicates this may be a determinant of health and well-being (Katona, Cahill, Lawurrpa, Biritjalawuy, & Lowell, 2000; Maidment, White, Wright, & Lochowiak, 1999).

Some of the problems we had, such as language, were anticipated, but the solution - using skilled inter-preters familiar with both the community languages and the language of social research - was mostly beyond the project resources. However, this may have affected both our data quality and our ability to enter into effective dialogue about the issues we were studying.

5A study in Turkey by Gürsoy-Tezcan (1992) argued that the relative importance of mothers’ and fathers’ education levels reflects “household and cultural conditions”, and it was these, rather that specific attributes of the mothers, which were determinant of child mortality.


The limited sample size in this study gives rise to chance findings, of either an apparent association or of no association between the factors. Small samples are more susceptible to the influence of ‘outliers’. Future work should be based on a somewhat larger population base including several communities, perhaps a whole region.

Neither this study nor the NATSIS analysis rules out the possibility that schooling and other forms of education might significantly affect child and community health, especially in interaction with other factors such as health service provision and improved housing and environmental health conditions. The major pathway linking education with health may be at a community level, through improved com-munity capacity. This could not be demonstrated with this study design. A regional study collecting individual level data across several communities could clarify this issue.

Finally, we recognise that educational differentials within this community, or even within larger Indig-enous populations, may not be as significant in terms of potential health effects as the educational differentials between the Indigenous and settler populations. Establishing a link between education differentials and health differentials may require a study design which incorporates both Indigenous and non-Indigenous people; while more detailed understanding of the pathways by which education (and other social factors) have their health effects may best be done at a community level, and may be culture-specific.

Given all these limitations, the value of this study lies, we believe, as much in the questions that it raises as in its results. We have found, as did the NATSIS study, that the linkage between education and health in Indigenous communities is complex, and that health improvements cannot simply be read off from rising schooling levels, certainly not at the micro- level of mother-child dyads.

The ‘good old days’?The view expressed by some people that Aboriginal children received a better education under the mis-sion and native welfare regimes of the 1950s and 1960s warrants critical investigation. The evidence cited is often one or more outstanding individuals who gained their education in the 1950s and 1960s, who speak fluent English and read well, and play key roles as community leaders. There is a number of problems with this view. Those who gained their education in the mission and welfare schools of the 1950s and 1960s were part of a cohort of people whose survival rates, including at birth, were consider-ably lower than subsequent generations.6 Moreover, the ‘well-educated’ of this generation were very much a minority, even of their peers, according to experienced observers (Baarda, 1994). In fact, most Aboriginal people in the 1950s and 1960s gained less education than they do now, even though a small number may have gained more. The evidence for this is clear from surveys done in the 1970s on Alice Springs Town Camps whose populations are drawn from throughout the region (Beck, 1979).

Employment and education: pathways to better health? We did find a trend for association between employment and better child health, in that the children of women in employment were less likely to show up as having one or more of the conditions for which we screened.

6 Middleton MR & Francis SH. Yuendumu and its children : - life and health on an Aboriginal settlement. Canberra: Australian Government Publishing Service, 1976.


Maternal employment may lead to better child health through various pathways. Unlike many Third World countries, health services are free and relatively accessible in this community. Consequently this is not simply an effect of capacity to pay for health care, but higher incomes may alter access to other health factors eg food. Those women who are employed may be the ones with more stable and organised lives, and this in turn could be promoted by the employment itself. As one informant sug-gested, employment provides access for the children to the facilities of the employing agency, including functioning bathrooms, toilets and kitchens. Employed people may have a stronger sense of control and self-determination. There was some support in our qualitative data for all these explanations, and these should be examined more systematically in further research.

Because there is substantial evidence that education does improve the likelihood of obtaining employ-ment we should be wary of concluding that there is no association between education and health (Hunter, 1996). In other words, education, by being a pathway to employment, may also ultimately be a pathway to better child health even though this did not show up in this particular study.

Among other potential pathways for the impact of education on health investigated overseas has been a greater use of primary health care (PHC) services by people with more education, based on settings with more limited PHC access. Health Centre utilisation data in this community shows that there is a relatively high level of access and utilisation, so it is unlikely that those where mothers have more educa-tion do so more regularly. It may still be possible that more educated people do so more effectively e.g. by more timely visits or better utilisation of treatment advice. However, it does not appear to have translated into lower incidences of the illnesses for which these children were screened.


Conclusion The possibility remains that specific factors in this community militate against education and school-ing having the effect it has been observed to have elsewhere in the world. Among the possible factors, we might include:

• other social conditions such as social or economic powerlessness or lack of peace and order may inhibit the health benefits of education;

• any education effect has been overwhelmed by the counter-effect of the poor environmen-tal health conditions both at the household level, and within the community overall, though this is contrary to the evidence from third world settings;

• some aspects of contemporary Aboriginal identity or culture may inhibit carrying out healthy behaviours that may otherwise be associated with education; and

• the overall amount of education provided to the community as a whole has not reached a sufficient ‘critical mass’ to counter the effect of generally low education levels overall.

In thinking about these issues, it has been useful to conceptualise education’s potential effects in terms of the diagram below.

Figure 2. Pathways from education to health

Education may have an effect on the health of an individual that is exposed to it, which can be modi-fied or even blocked by the environmental, social, cultural and ‘peace and order’ conditions in which the person lives. Education may also have an impact on health through an indirect or community path-way. This may be mediated through collective power, community health infrastructure, community services and community behaviours. In other words, the education of one person may improve the health of another by the beneficial impact on community factors. This indirect pathway will also be modified by the social, cultural, environmental and peace and order context of the community. The real impact of education on health is the sum of both of these pathways, shown here as the total (Fig. 2). This simplified schema is made more complex because the direct and community level effects of education will probably impact on the effect modifiers themselves.


This model accounts for the apparent evidence that simply advancing a few more individual women further along the education road does not necessarily result in any appreciable direct child health effect in this community. For education to have an impact on child health, it may be necessary for other fac-tors to exist. This is because the risks to health in this community, including to child health, are likely to be based in community-wide levels of alienation and powerlessness relative to society as a whole.

Our study design focused only on the direct pathway. In the light of the lessons learned in this study, further research should now be undertaken with sufficient scale and scope to investigate thor-oughly these more complex pathways through which education and employment may become factors in improved health.


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