Social inequality and children’s health in Africa: a cross sectional study

Heaton et al. International Journal for Equity in Health (2016) 15:92 DOI 10.1186/s12939-016-0372-2 RESEARCH Open Access Social inequality and children’s health in Africa: a cross sectional study Tim B. Heaton1*, Benjamin Crookston2, Hayley Pierce1 and Acheampong Yaw Amoateng3 Abstract Background: This study examines socioeconomic inequality in children’s health and factors that moderate this inequality. Socioeconomic measures include household wealth, maternal education and urban/rural area of residence. Moderating factors include reproductive behavior, access to health care, time, economic development, health expenditures and foreign aid. Methods: Data are taken from Demographic and Health Surveys conducted between 2003 and 2012 in 26 African countries. Results: Birth spacing, skilled birth attendants, economic development and greater per capita health expenditures benefit the children of disadvantaged mothers, but the wealthy benefit more from the services of a skilled birth attendant and from higher per capita expenditure on health. Conclusion: Some health behavior and policy changeswould reduce social inequality, but the wealthy benefit more than the poor from provision of health services. Keywords: Socioeconomic inequality, Children’s health, Africa Background Social determinants have a profound influence on health inequality and should receive due consideration when developing health policy [1, 2]. Sociology has long recognized that social inequality is a fundamental dimension of social institutions and there is growing interest in apply this insight to health related behavior and outcomes [3, 4]. Social determinants play a particularly important role in children’s health, survival, and nutritional status as a result of a child’s inherent vulnerability and reliance on others to protect their health [5]. Research has identified disparities in child mortality and nutritional status associated with socioeconomic factors in many different contexts [6, 7]. Reducing socioeconomic disparity is one important means of improving child health globally. The purpose of this study is to document social inequality in child health in Africa and identify possible factors that reduce the deleterious impact of socio-economic determinants on child nutritional status and child survival. First, the project will estimate the * Correspondence: 1 Department of Sociology, Brigham Young University, 2033 JFSB, Provo, UT 84602, USA Full list of author information is available at the end of the article association between key socio-economic indicators (education, urban residence and household wealth) and standard measures of child health (infant mortality, survival through age five and nutritional status). We address this question in regression models predicting each health outcome. The second objective is to assess the degree to which critical healthy behaviors at the individual level (birth spacing, delivering with a skilled birth attendant and immunization) and macro-level factors (economic development, health expenditures, foreign aid for water development, and change over time) moderate the influence of socio-economic indicators on health outcomes. We address this issue by including interaction terms between socio-economic characteristics, healthy behaviors and macro-level factors. Children born in Africa are at great risk of undernutrition and death. More than one million (1,208,000) babies die before they reach 1 month of age [8] while another three million (3,192,000) children, who survived their first month of life, die before their first birthday [9]. Child undernutrition is more common in Africa than any other region of the world. Child stunting, a measure of chronic undernutrition, exceeds forty percent in several African countries © 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Heaton et al. International Journal for Equity in Health (2016) 15:92 (http://www.measuredhs.com). Even though the Millennium Development Goals (MDGs) on child health in many sub-Saharan African nations lagged far behind target, there was progress in several low-income countries. While the MDGs targeted for 2015 were attained through immediate strategic investments in selected evidence-based interventions and targeted health systems strengthening in some areas, this was not the case in most African countries [10]. Unfortunately, even though these trends show promise, they are the exception rather than the rule. With a toll of more than 13,000 deaths per day, sub-Saharan Africa accounts for more half of the world’s maternal and child deaths. In addition, an estimated 880,000 babies are stillborn in sub-Saharan Africa each year and remain invisible on the policy agenda [11]. It is against the background of the limited progress and socioeconomic inequality in health outcomes in 26 sub-Saharan Africa that we undertake the current project. We use several waves of the Demographic and Health Survey data to examine the possibility that improved healthy behavior, economic growth, and greater investment in health will contribute to better child health and lower socioeconomic disparities. Key social determinants Child health has been linked to socio-economic conditions including household income, maternal education, paternal education, household size, household structure, employment, and indicators of standard of living [12–16]. In addition to the direct influence these factors exert on health, they also largely determine whether family members are able to maintain standards of cleanliness, access goods and services, and have food security [13, 15]. Economic status has been singled out as a key social determinant in the millennial development goals, but maternal education [17, 18], and type of residence [19] are also important. It is important to disentangle the relative importance of socioeconomic variables because of their policy implications [20]. Moderating factors The theory of fundamental causes implies that health outcomes can be improved by weakening the link between socioeconomic factors and health outcomes [2]. While recent policy discussions have addressed the impact of social determinants (http://www.who.int/social_ determinants/en/), [21], several factors inhibit policy attempts to reduce socioeconomic gaps in child health [22]. “Elucidating specific mediating mechanisms is important both to understanding what the main drivers of health di (...truncated)