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  1. 1. Journal of Public Health|Vol.31,No.3,pp 389-397 14 May 2009 Does child gender determine household decision for health care in rural Thatta,Pakistan ? R.Nurudine,W.C.Hadden,M.R.Petersen, M.K.Lim Bharti MPH
  2. 2. Introduction <ul><li>Index Journal </li></ul><ul><li>Impact factor -1.109 </li></ul><ul><li>ISSN No. – 1464-360X (online) and 1101-1262 (print) </li></ul><ul><li>Frequency –After every 3 months </li></ul><ul><li>Year – 2009 </li></ul><ul><li>Page -389-397 , vol. 31,No.3 </li></ul><ul><li>Funding – IDRC,Canada </li></ul>
  3. 3. Authors <ul><li>R. Nuruddin , Assistant Professor 1,2 </li></ul><ul><li>W. C. Hadden , Visiting Faculty 1 , </li></ul><ul><li>M. R. Petersen , Independent Consultant 3 </li></ul><ul><li>M. K. Lim , Associate Professor 2 </li></ul><ul><li>Department of Community Health Sciences, Aga Khan University , Stadium Road, PO Box 3500, Karachi 74800, Pakistan. </li></ul><ul><li>Department of Community, Occupational and Family Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 117597, Singapore. </li></ul><ul><li>Independent Consultant, Cincinnati, Ohio, USA. Rozina Nuruddin , E-mail: [email_address] </li></ul>
  4. 4. Background <ul><li>Gender disparity in child mortality is greatest in Pakistan. </li></ul><ul><li>50% more deaths among girls between 1 st and 5 th birthdays. </li></ul><ul><li>Life expectancy of females is greater (66years)=male (64years). </li></ul><ul><li>Gender disparity in health leads to a male biased adult sex ratio (106:100) </li></ul>
  5. 5. <ul><li>Seeking timely health care. </li></ul><ul><li>Effective low cost treatments are available. </li></ul><ul><li>Studies show that boys are favoured in the use of health services . </li></ul><ul><li>Conceptual framework developed by Pokhrel and Sauerborn provides four decisions for care seeking. </li></ul>
  6. 6. Fig:1:- Conceptual framework
  7. 7. Aim <ul><li>To examine gender as a determinant of health decisions in specific conceptual and analytical framework. </li></ul>
  8. 8. Materials and methods <ul><li>Data collected :- Nov 1992 and Feb 1993. </li></ul><ul><li>Rural district (Thatta) of Sindh province , by Aga Khan University Karachi. </li></ul><ul><li>Survey :Provide baseline information on health and nutrition status. </li></ul><ul><li>More recent Pakistan social and living standard measurement survey (2006-2007) and demographic health survey (2007), Lack information about determinants of health care. </li></ul>
  9. 9. <ul><li>Infant mortality ratio / 1000 live births of 78 in 1992-93 and 91 in 2003-04. </li></ul><ul><li>Underweight prevalence - 48% for children under 3 in 1992-93 and 49% for children under 5 in 2003-04. </li></ul><ul><li>Literacy level - 32% </li></ul><ul><li>Concrete housing - 17% population in 1992-93 and 19% in 2004-05. </li></ul>
  10. 10. Study site <ul><li>Thatta predominantly rural district 60 km from east of Karachi. </li></ul><ul><li>1.1million people predominantly Muslim and speak Sindhi. </li></ul><ul><li>Health care system consist of : </li></ul><ul><li>Public health care system </li></ul><ul><li>BHU- charge nominal fees only 2 (PR) (US$ 0.06) , 1US$ =30 PR-1993) – closed after 14:00 h. </li></ul><ul><li>Private sector </li></ul><ul><li>Its routine out- patient service cost 15-50 PR </li></ul><ul><li>(US$ 0.30-1.6). </li></ul>
  11. 11. Survey sampling <ul><li>Total 43 rural administrative units of Thatta ,12 were included in the survey. </li></ul><ul><li>99 villages within 5km of primary health care selected- using a simple random sampling 250 households per PHC unit. </li></ul><ul><li>Only 9% households refused to participate. </li></ul><ul><li>2276 household were surveyed. </li></ul><ul><li>All children aged 1-59 months (3740) included. </li></ul>
  12. 12. Data collection <ul><li>Mother was asked about -: Age , Literacy status , No. of live children. </li></ul><ul><li>Health status. </li></ul><ul><li>Children age calculated using a calendar. </li></ul><ul><li>Five stages in health care seeking: </li></ul><ul><li>Recent child illness reported by mother during the past year. </li></ul><ul><li>Formal care sought at a health facility. </li></ul><ul><li>Provider choice. </li></ul><ul><li>Hospitalization for at least a day. </li></ul><ul><li>Health expenditure. </li></ul>
  13. 13. <ul><li>Illness type </li></ul><ul><li>Pneumonia </li></ul><ul><li>Measles </li></ul><ul><li>Whooping cough </li></ul><ul><li>Upper respiratory illness </li></ul><ul><li>Ear infection </li></ul><ul><li>Others fever : malaria, poliomyelitis, meningitis and diarrhoea. </li></ul>
  14. 14. <ul><li>Three indicators of household socio-economic status (SES): </li></ul><ul><li>Type of house </li></ul><ul><li>Land ownership </li></ul><ul><li>Per capita average monthly household income </li></ul><ul><li>Subject grouped :Low , middle and upper SES </li></ul>
  15. 15. <ul><li>Village headman provided information : </li></ul><ul><li>Presence of girl’s school. </li></ul><ul><li>Transport availability. </li></ul><ul><li>Village distance . </li></ul><ul><li>Mortality ratio calculated according to WHO standards </li></ul><ul><li>Mortality Ratio = Gender specific deaths during year /Gender specific live births. </li></ul>
  16. 16. <ul><li>Neonates excluded from further analysis. </li></ul><ul><li>To account for unequal selection probabilities and to reduce bias, weights calculated as inverse of sample. </li></ul><ul><li>Differences in mortality ratio between girls and boys examined. </li></ul>
  17. 17. Statistic used <ul><li>Calculated adjusted prevalence ratio using SAS Proc Genmod with binomial distribution and log- link function. </li></ul><ul><li>Adopted COPY method when the log- binomial model did not converge. </li></ul><ul><li>Clustering at village level was accounted for by the use of cluster identity for village level variables in a repeated statement using Proc Genmod. </li></ul>
  18. 18. Results <ul><li>About 1/5 th reported ill -19.4% (3740) , Died -10.6% </li></ul><ul><li>Most commonly reported illness- fever (40.1%), respiratory illness (18.5%) and diarrhoea ( 15.7%). </li></ul><ul><li>3 rd of sick children taken to a health facility visited public facilities. </li></ul><ul><li>13 % hospitalized for half of them daily expenditure </li></ul><ul><li>< than 20 PR. </li></ul><ul><li>Most mothers younger than 30 years ( 62.4%), illiterate (84.7%), four or more live children ( 54.6%). </li></ul>
  19. 19. <ul><li>No transport during emergency - 71.7% </li></ul><ul><li>No girl’s school -82.6% </li></ul><ul><li>Among neonates, 20 more boy deaths than girl’s per 1000 live births. </li></ul><ul><li>Post neonates - 25 and </li></ul><ul><li>12-59 month old children- 38 </li></ul><ul><li>( more girls deaths than boy’s per 1000 live birth) </li></ul>
  20. 20. <ul><li>Illness reporting, however significantly greater for post neonates, and if mother reported poor health. </li></ul><ul><li>Use of health facilities- significantly reduced for illness of long duration, respiratory or other causes. </li></ul><ul><li>Hospitalization was significantly less in the absence of a village girl’s school. </li></ul><ul><li>Health expenditure was significantly greater with fatal illness and less with public providers. </li></ul>
  21. 21. Figure :2 Household decision for child health care in Thatta district
  22. 22. Discussion <ul><li>Main study finding:- </li></ul><ul><li>Girl children had significantly greater mortality than boys. </li></ul><ul><li>Greater illness reporting among infants suggests their greater illness susceptibility. </li></ul><ul><li>Parent’s capacity to protect their children ,measured by SES. </li></ul><ul><li>Villages with girl’s school are likely to give importance to girl’s education and possibly also to their health. </li></ul>
  23. 23. Conclusion <ul><li>Differential care seeking for boys and girls is not seen in Thatta . </li></ul><ul><li>Creative research to identify pathways for gender differential in child mortality. </li></ul><ul><li>Influencing on child health care. </li></ul><ul><li>Modification required – poverty and girls education. </li></ul>
  24. 24. Critique <ul><li>Study is based on retrospective interview data – more biases. </li></ul><ul><li>Greater mortality ratios among girls due to less reporting of girl births. </li></ul><ul><li>Inaccurate age assessment lead to under and overestimation. </li></ul>
  25. 25. THANK YOU

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