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
