Delampady Narayana

Can microcredit help improve the health of poor women? Some findings from a cross-sectional study in Kerala, India

BackgroundThis study examines associations between female participation in a microcredit program in India, known as self help groups (SHGs), and womens health in the south Indian state of Kerala. Because SHGs do not have a formal health program, this provides a unique opportunity to assess whether SHG participation influences womens health via the social determinants of health.MethodsThis cross-sectional study used special survey data collected in 2003 from one Panchayat (territorial decentralized unit). Information was collected on womens characteristics, health determinants (exclusion to health care, exposure to health risks, decision-making agency), and health achievements (self assessed health, markers of mental health). The study sample included 928 non elderly poor women.ResultsThe primary finding is that compared to non-participants living in a household without a SHG member, the odds of facing exclusion is significantly lower among early joiners, women who were members for more than 2 years (OR = 0.58, CI = 0.41–0.80), late joiners, members for 2 years and less (OR = 0.60, CI = 0.39–0.94), and non-participants who live in a household with a SHG member (OR = 0.53, CI = 0.32–0.90). We also found that after controlling for key womens characteristics, early joiners of a SHG are less likely to report emotional stress and poor life satisfaction compared to non-members (OR = 0.52, CI = 0.30–0.93; OR = 0.32, CI = 0.14–0.71). No associations were found between SHG participation and self assessed health or exposure to health risks. The relationship between SHG participation and decision-making agency is unclear.ConclusionMicrocredit is not a panacea, but could help to improve the health of poor women by addressing certain issues relevant to the context. In Kerala, SHG participation can help protect poor women against exclusion to health care and possibly aid in promoting their mental health.

Women’s health in a rural community in Kerala, India: do caste and socioeconomic position matter?

Objectives: To examine the social patterning of women’s self-reported health status in India and the validity of the two hypotheses: (1) low caste and lower socioeconomic position is associated with worse reported health status, and (2) associations between socioeconomic position and reported health status vary across castes. Design: Cross-sectional household survey, age-adjusted percentages and odds ratios, and multilevel multinomial logistic regression models were used for analysis. Setting: A panchayat (territorial decentralised unit) in Kerala, India, in 2003. Participants: 4196 non-elderly women. Outcome measures: Self-perceived health status and reported limitations in activities in daily living. Results: Women from lower castes (scheduled castes/scheduled tribes (SC/ST) and other backward castes (OBC) reported a higher prevalence of poor health than women from forward castes. Socioeconomic inequalities were observed in health regardless of the indicators, education, women’s employment status or household landholdings. The multilevel multinomial models indicate that the associations between socioeconomic indicators and health vary across caste. Among SC/ST and OBC women, the influence of socioeconomic variables led to a “magnifying” effect, whereas among forward caste women, a “buffering” effect was found. Among lower caste women, the associations between socioeconomic factors and self-assessed health are graded; the associations are strongest when comparing the lowest and highest ratings of health. Conclusions: Even in a relatively egalitarian state in India, there are caste and socioeconomic inequalities in women’s health. Implementing interventions that concomitantly deal with caste and socioeconomic disparities will likely produce more equitable results than targeting either type of inequality in isolation.

“Health divide” between indigenous and non-indigenous populations in Kerala, India: Population based study

BackgroundThe objective of this study is to investigate the magnitude and nature of health inequalities between indigenous (Scheduled Tribes) and non-indigenous populations, as well as between different indigenous groups, in a rural district of Kerala State, India.MethodsA health survey was carried out in a rural community (N = 1660 men and women, 18–96 years). Age- and sex-standardised prevalence of underweight (BMI < 18.5 kg/m2), anaemia, goitre, suspected tuberculosis and hypertension was compared across forward castes, other backward classes and tribal populations. Multi-level weighted logistic regression models were used to estimate the predicted prevalence of morbidity for each age and social group. A Blinder-Oaxaca decomposition was used to further explore the health gap between tribes and non-tribes, and between subgroups of tribes.ResultsSocial stratification remains a strong determinant of health in the progressive social policy environment of Kerala. The tribal groups are bearing a higher burden of underweight (46.1 vs. 24.3%), anaemia (9.9 vs. 3.5%) and goitre (8.5 vs. 3.6%) compared to non-tribes, but have similar levels of tuberculosis (21.4 vs. 20.4%) and hypertension (23.5 vs. 20.1%). Significant health inequalities also exist within tribal populations; the Paniya have higher levels of underweight (54.8 vs. 40.7%) and anaemia (17.2 vs. 5.7%) than other Scheduled Tribes. The social gradient in health is evident in each age group, with the exception of hypertension. The predicted prevalence of underweight is 31 and 13 percentage points higher for Paniya and other Scheduled Tribe members, respectively, compared to Forward Caste members 18–30 y (27.1%). Higher hypertension is only evident among Paniya adults 18–30 y (10 percentage points higher than Forward Caste adults of the same age group (5.4%)). The decomposition analysis shows that poverty and other determinants of health only explain 51% and 42% of the health gap between tribes and non-tribes for underweight and goitre, respectively.ConclusionsPolicies and programmes designed to benefit the Scheduled Tribes need to promote their well-being in general but also target the specific needs of the most vulnerable indigenous groups. There is a need to enhance the capacity of the disadvantaged to equally take advantage of health opportunities.

Reducing inequalities in health and access to health care in a rural Indian community: an India-Canada collaborative action research project.

BackgroundInadequate public action in vulnerable communities is a major constraint for the health of poor and marginalized groups in low and middle-income countries (LMICs). The south Indian state of Kerala, known for relatively equitable provision of public resources, is no exception to the marginalization of vulnerable communities. In Kerala, women’s lives are constrained by gender-based inequalities and certain indigenous groups are marginalized such that their health and welfare lag behind other social groups.The researchThe goal of this socially-engaged, action-research initiative was to reduce social inequalities in access to health care in a rural community. Specific objectives were: 1) design and implement a community-based health insurance scheme to reduce financial barriers to health care, 2) strengthen local governance in monitoring and evidence-based decision-making, and 3) develop an evidence base for appropriate health interventions.Results and outcomesHealth and social inequities have been masked by Kerala’s overall progress. Key findings illustrated large inequalities between different social groups. Particularly disadvantaged are lower-caste women and Paniyas (a marginalized indigenous group), for whom inequalities exist across education, employment status, landholdings, and health. The most vulnerable populations are the least likely to receive state support, which has broader implications for the entire country. A community based health solidarity scheme (SNEHA), under the leadership of local women, was developed and implemented yielding some benefits to health equity in the community—although inclusion of the Paniyas has been a challenge.The partnershipThe Canadian-Indian action research team has worked collaboratively for over a decade. An initial focus on surveys and data analysis has transformed into a focus on socially engaged, participatory action research.Challenges and successesAdapting to unanticipated external forces, maintaining a strong team in the rural village, retaining human resources capable of analyzing the data, and encouraging Paniya participation in the health insurance scheme were challenges. Successes were at least partially enabled by the length of the funding (this was a two-phase project over an eight year period).

Alcohol use and its consequences in South India: Views from a marginalised tribal population

BACKGROUND Alcohol consumption in India is disproportionately higher among poorer and socially marginalised groups, notably Scheduled Tribes (STs). We lack an understanding of STs own views with regard to alcohol, which is important for implementing appropriate interventions. METHODS This study was undertaken with the Paniyas (a previously enslaved ST) in a rural community in Kerala, South India. The study, nested in a participatory poverty and health assessment (PPHA). PPHA aims to enable marginalized groups to define, describe, analyze, and express their own perceptions through a combination of qualitative methods and participatory approaches (e.g. participatory mapping and ranking exercises). We worked with 5 Paniya colonies between January and June 2008. RESULTS Alcohol is viewed as a problem among the Paniyas who reported that consumption is increasing, notably among younger men. Alcohol is easily available in licensed shops and is produced illicitly in some colonies. There is evidence that local employers are using alcohol to attract Paniyas for work. Male alcohol consumption is associated with a range of social and economic consequences that are rooted in historical oppression and social discrimination. CONCLUSION Future research should examine the views of alcohol use among a variety of marginalised groups in developing countries and the different policy options available for these populations. In addition, there is a need for studies that untangle the potential linkages between both historical and current exploitation of marginalized populations and alcohol use.

Insular pathways to health care in the city: a multilevel analysis of access to hospital care in urban Kerala, India

Objectives  To identify individual and urban unit characteristics associated with access to inpatient care in public and private sectors in urban Kerala, and to discuss policy implications of inequalities in access.

Debt, shame, and survival: becoming and living as widows in rural Kerala, India

BackgroundThe health and well-being of widows in India is an important but neglected issue of public health and women’s rights. We investigate the lives of Indian women as they become widows, focussing on the causes of their husband’s mortality and the ensuing consequences of these causes on their own lives and identify the opportunities and challenges that widows face in living healthy and fulfilling lives.MethodsData were collected in a Gram Panchayat (lowest level territorial decentralised unit) in the south Indian state of Kerala. Interviews were undertaken with key informants in order to gain an understanding of local constructions of ‘widowhood’ and the welfare and social opportunities for widows. Then we conducted semi-structured interviews with widows in the community on issues related to health and vulnerability, enabling us to hear perspectives from widows. Data were analysed for thematic content and emerging patterns. We synthesized our findings with theoretical understandings of vulnerability and Amartya Sen’s entitlements theory to develop a conceptual framework.ResultsTwo salient findings of the study are: first, becoming a widow can be viewed as a type of ‘shock’ that operates similarly to other ‘economic shocks’ or ‘health shocks’ in poor countries except that the burden falls disproportionately on women. Second, widowhood is not a static phenomenon, but rather can be viewed as a multi-phased process with different public health implications at each stage.ConclusionMore research on widows in India and other countries will help to both elucidate the challenges faced by widows and encourage potential solutions. The framework developed in this paper could be used to guide future research on widows.

Patients' Choice for Non-Allopathic Providers for Acute Illness: Evidence from a Rural Setting in Kerala

Although various national and state level health policies and programmes in India have, from time to time, tried to promote and integrate various non-allopathic systems into the country’s official health system, there have been very few attempts to understand the factors that show a strong association with people’s choice of various non-allopathic healthcare providers. Moreover, there is limited evidence regarding people’s experience with the non-allopathic healthcare providers assessed at the end of episodes of illness. The present paper is an attempt to meet this evidence gap by answering the following questions: (a) Do the patients who mostly opt for nonallopathic healthcare show some distinct household and individual characteristics in comparison to the patients who opt for allopathic healthcare providers? (b) How do the patients who utilized non-allopathic providers fare in comparison to the patients who utilized allopathic providers in terms of the healthcare experience measured by select indicators at the end of the episodes? We have used data on 3653 acute episodes (with only OP visits) from a year-long panel survey carried out in a north Kerala district in 2003-04. It has been found that about 20 per cent of the select acute episodes sought healthcare from non-allopathic providers. Females (OR=1.03), children (OR=1.12), individuals residing in households with low landholdings (OR=1.05) and those having episodes of longer duration (ORs=1.09, 1.22) are more likely to utilize non-allopathic providers. The average experience suggests that seeking healthcare from non-allopathic providers involves less median cost per episode (Rs. 12 as against Rs. 90) but a higher chance of shifting to allopathic providers during the course of a severe episode (62.9 per cent as against 37.1 per cent), lengthier (median) duration of episode (10 days as against 7 days) and a higher (average) number of OP visits (1.4 as against 1.9). Although no causal relationship is established, there is an indication that non-allopathic providers are utilized more for the easier access and cheaper price they offer rather than other reasons, such as their quality and efficacy.