Social EpidemiologyDeterminants of child morbidity in Latin America: A pooled analysis of interactions between parental education and economic status
Introduction
More than 10 million children under the age of five die every year (UNICEF, 2004). Diarrhea and respiratory infections, abetted by undernutrition, account for more than two-fifths of all deaths among children under five (Black, Morris, & Bryce, 2003). These diseases disproportionately affect poor children in low- and middle-income countries. Socioeconomic inequalities in the distribution of child mortality and morbidity are well documented, both among countries and regions of the world and within individual societies (Victora et al., 2003). For instance, under-five mortality rates in Nicaragua are almost three times higher among those in the poorest economic quintile than among those in the wealthiest quintile; in Brazil rates are six times higher among the poorest quintile (Wagstaff, 2000).
Many researchers have documented the paramount importance of socioeconomic factors for child health outcomes. An important question that has received less attention, however, is whether education and economic status operate synergistically or independently to influence children's risk of illness and death. Put differently, does a mother's education play the same protective role for children in poor households as it does for better-off children, or does the effect of education change with economic status? Confirming the presence and direction of an interaction between education and household wealth is important for effective targeting of education and development policies. A finding that there is a synergy between education and economic status, for instance, would imply that educational interventions alone would have limited effectiveness for improving child health in the absence of simultaneous economic development programs. In contrast, a significant negative interaction between economic status and education would imply that educating women in the lowest economic strata will have the greatest impact.
Among the few previous efforts to address this question, the evidence has been conflicting. In a cohort study of infant mortality in Nicaragua, Peña, Wall, and Persson (2000) found that the protective effect of maternal education was greater in poor households than nonpoor households. They hypothesize that education may empower poor women to better cope with harsh living conditions, while maternal education may provide little additional benefit to children in nonpoor households whose basic needs are already satisfied. Case studies from Kerala State in India provide evidence that significant investments in women's education can lead to very good child health outcomes even in resource-poor settings (Thankappan & Valiathan, 1998). In contrast, Dargent-Molina, James, Strogatz, and Savitz (1994) found that maternal education was protective only in economically and socially advantaged communities, but had no effect in the more disadvantaged communities. They posit that women's access to basic resources may be a necessary precondition for education to have the expected effect on child health. From a third perspective, Desai and Alva (1998) have argued that maternal education largely proxies for the family's socioeconomic status and area of residence, implying that education may not have an independent, causal effect. Others have also emphasized the importance of the contextual effects of local economic conditions for the association between maternal education and child health (Fotso & Kuate-Defo, 2005; Griffiths, Madise, Whitworth, & Matthews, 2004; Larrea & Kawachi, 2005).
In this article, we use readily available secondary data to clarify these associations and interactions at the household level. We pool household survey data from the Latin America and Caribbean region to analyze the socioeconomic determinants of diarrhea and respiratory infections among children under five, specifically testing for the presence of interactions between parental education and economic status. We hypothesize that the effects of both mothers’ and fathers’ education are likely to vary by level of economic status and proceed to identify the direction of this interaction.
Section snippets
Data
We analyzed 7 nationally representative Living Standards Measurement Surveys (LSMS), two national LSMS-type surveys, and 12 Demographic and Health Surveys (DHS) from countries across Latin America. After creating standardized variables, we grouped comparable national datasets into two pooled datasets, increasing our ability to detect underlying trends that are often obscured by noise in individual datasets.
The 21 household surveys included in our analysis were supported by national governments
Model
In their seminal conceptual framework, Mosley and Chen (1984) classified the determinants of child mortality into “proximate” factors (such as environmental contamination or nutrient deficiency), which contribute in an immediate and direct fashion to children's risk of mortality, and “distal” factors (economic status, education, cultural norms, and government policies), which influence exposure to the proximate factors. We base our analysis on a modified version of Mosley and Chen's framework,
Outcome variables
We investigate two binary child morbidity outcomes reported during the survey recall periods: (1) an episode of diarrhea and (2) a respiratory illness. For the respiratory outcome, the phrasing of survey questions forces inclusivity: the DHS questionnaires usually asked whether children had been “sick with a cough” during the past two weeks, while the LSMS questionnaires asked about a list of respiratory ailments including cough, cold, flu, bronchitis, pneumonia, and/or pertussis. We excluded
Univariate and bivariate results
Between one-fifth and one-third of children in the LSMS surveys reported an episode of diarrhea during the past month or two weeks (Table 1). In the DHS surveys, slightly lower rates were reported. Substantially higher rates of respiratory illness were reported in both types of surveys, ranging from one-third to more than one-half of children surveyed.
Table 2 compares the sample distributions of the key distal variables for the four pooled databases as well as bivariate results for both
Discussion
This analysis used logistic regression methods to identify the effect of economic status and parental education on children's risk of diarrhea and respiratory illness, and tested for the presence of interactions among these distal factors. We took advantage of a rare opportunity: a wealth of comparable, under-analyzed data from across Latin America and the Caribbean. When pooled, these datasets provided very large sample sizes and hence greater statistical power to reveal underlying trends that
Acknowledgments
This publication was made possible through support provided by the Office of Health, Infectious Diseases, and Nutrition, Global Health Bureau, US Agency for International Development, under the terms of Award No. HRN-A-00-96-90006-00 the Family Health and Child Survival Cooperative Agreement. The opinions expressed herein are those of the authors and do not necessarily reflect the view of the US Agency for International Development.
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