Gender inequities in health care utilisation for common infections children under-5 in India
Item statusRestricted Access
Embargo end date30/11/2021
Brondi, Luciana Maria Gomes
Common infectious diseases like pneumonia, diarrhoea and malaria, are the leading causes of mortality in young children aged below 5 years, especially in low and middle-income countries (LMICs). Globally, India is the country with the largest number of children under five years old (U5) and the largest number of deaths in this age group and where diarrhoea is the second biggest killer of children. Immunisations, medical treatment and hospital care are some of the available life-saving interventions for children affected by these three common infectious diseases. Nonetheless, not all children benefit equally from these interventions. In South Asia and in India, gender-based discrimination leads to differences in health outcomes and healthcare access, especially among young children. The estimated excess mortality of young girls (compared to young boys) in India reaches an average of 239,000 excess deaths every year. However, the current body of evidence showing gender-based inequities affecting health care utilisation in the region is less compelling. Furthermore, there is a scarcity of empirical research using nationally representative data and taking into account the theoretical basis of determinants of health care seeking behaviours for children. This thesis aimed to estimate the effect of gender and other determinants on health care seeking for common infections in young children in India, especially in the case of diarrhoea. A systematic review of the literature was conducted looking at gender inequalities in hospital admissions and care seeking for common infections in children from South Asia. The results showed that for acute lower respiratory infections - ALRI (predominantly pneumonia) - most of the studies reported significantly higher rates of hospital admissions for boys compared to girls. Although a much smaller number of studies for diarrhoea were selected, the studies from South Asia also reported a higher incidence rate ratio of admissions for boys compared to girls. Of the three studies, which reported in-hospital case fatality ratios for diarrhoea, girls were almost twice as likely to die when compared to boys (pooled Odds Ratio 1.81 (95% CI 1.55-2.11)). For care seeking behaviours, most studies reported a lower likelihood of girls receiving treatment for common infections compared to boys. Similarly, nearly all of the studies on nutrition and immunisation reported better nutrition outcomes and vaccination coverage for boys compared to girls. Building on the results from this literature review, and drawing on theoretical concepts from the social sciences, a conceptual framework was developed. An interdisciplinary approach integrating intersectional, ecosocial and epidemiological perspectives was used to allow for the improvement of interpretation of findings. A quantitative analysis of care seeking behaviours for young children with diarrhoea was conducted, using data from the two recent rounds of large-scale demographic health surveys in India - National Family Health Survey (NFHS-3 and NFHS-4). In the analysis of the NFHS-3 (2005-06), the combined effect of gender and wealth on care seeking for diarrhoea was assessed using a multivariable logistic regression model adjusting for other potential effect modifiers. A lower prevalence of care seeking outside the home for diarrhoea was significantly associated with being a girl (Adjusted Odds Ratio, 0.84 (95% CI, 0.72-0.99)), or belonging to a poorer family (P values varying from 0.024 richer versus richest to <0.001 poorest vs. richest). A further analysis using a heuristic model informed by intersectionality, combined sex and economic class into ten different categories. The results of this further analysis suggest that, in terms of care seeking, boys tend to be less affected by the lower economic status of the household when compared to girls. Subsequently, data from NFHS-4 (2015-16) were analysed and nine different types of care seeking behaviours for diarrhoea were explored, including type of treatment, place where care was sought, delay in seeking care and level and cost of care sought. Coverage for all of these care seeking behaviours for girls and boys were estimated and compared. For most of these care seeking behaviours, carers were more likely to pursue care and treatment for diarrhoea for boys than girls. Apart from gender, the other potential determinants of care seeking behaviours analysed were age, place of residence(rural/urban), number of siblings, social class (i.e. wealth quintile), mother’s education level, religion, belonging to a scheduled caste or tribe & backward class, region of residence and distance to nearest health care facility. A bivariate logistic regression analysis was conducted looking at sex and other determinants and the use of the costliest type of care available for diarrhoea (i.e., outpatient consultation in a private hospital/doctor/clinic). When compared to other types of care available, boys more often than girls received the costliest type of care. The adjusted results showed that girls in India are on average 16% less likely to receive the costliest type of care for diarrhoea when compared to boys (Odds Ratio 0.86 (95%CI 0.78–0.94)). Infants (children younger than 1-year-old), were also more likely to receive the costliest type of care available (Adjusted OR 0.78 (95%CI 0.71–0.86)). Other important and statistically significant determinants of the use of costly care were wealth index, with children in the poorest quintile being the ones less likely to get costly care (OR 0.33 ((95%CI 0.23 (0.18–0.30)) and the mother’s level of education. Similarly, the analysis revealed a clear regional pattern with a contrast between the group of four most populous High Focus States (i.e., Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh.), and other states in India. For example, the effect of gender and mothers’ level of education on use of the costliest type of care for diarrhoea remains significant when the four states of Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh are analysed as a separate group. However, the analysis of the remaining states did not show the same effects of gender and mothers’ level of education on care seeking. This study reveals important differences in care seeking behaviours for diarrhoea among children in India. These differences were largely driven by gender, age, socio economic class, mothers’ level of education and region. The results highlight the importance of gender and its relationship with social class and geography in child health in India. It also reveals a regional pattern in the determinants of child health care seeking. Policy initiatives targeting equity in access to health care should utilize intersectionality-informed analysis, considering the combined impact of gender with other axes of marginalisation and systems of social oppression, operating at different levels. Clarifying the pathways in which gender affects girl’s health in South Asia, as a whole, and India in particular, is a crucial step in the efforts to promote equity in health for all children.