HOUSEHOLD in the Demographic and Health Surveys:

Experiences from research on health inequity

Tanja AJ Houweling Dept. Epidemiology & Public Health, UCL

Commission on Social Determinants of Health

Tanja AJ Houweling

Outline presentation

1. Health inequalities research– use of concept of household – focus on inequalities in childhood mortality in low/middle

income countries, DHS data

2. Problems with use of ‘household’ in DHS

3. Implications for policy making & research

1. HEALTH INEQUALITIES RESEARCH

Tanja AJ Houweling

Under-5 mortality rate

Source: www.who.int/

Tanja AJ Houweling

Under-5 mortality by wealth group

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50

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Und

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Peru Indonesia Mali

RichestFourthMiddleSecondPoorest

Tanja AJ Houweling

The average is not the only messagedistribution

Reducing health inqualities within countries: increasingly important policy objective

Tanja AJ Houweling

Health inequalities research

Comparing health outcomes between socially stratified groups on basis of characteristics measured at level of:– individual (education, occupation)– household (economic status: wealth, income)

Child health low/middle income countries:– maternal education, household wealth

Tanja AJ Houweling

Demographic and Health Surveys

Set up as primary source health & population data

1984 - present75 low and middle income countries in Africa, Asia, Latin America, North Africa/Near East

nationally representative hh surveyswomen aged 15-49

child mortality (retrospective birth histories)

direct determinants: e.g. immunizationeducation & household assets

Tanja AJ Houweling

Household ownership assets:durable consumer goodshousing characteristicswater and sanitation facilitieselectricity

Principle Components Analysis

Household wealthIncome/expenditure data unavailable

Relative position in national wealth hierarchy

Some problems. Further research needed

Tanja AJ Houweling

Under-5 mortality rate by wealth group

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50

100

150

200

250

300

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poorest quintile

richest quintile

average MozambiqueUzbekistan

Cameroon

Namibia

Bolivia

Mali

Source: Houweling 2007

Tanja AJ Houweling

0

10

20

30

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50

60

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Bangladesh

Nepal

Chad

Niger

Pakistan

Morocco

Nigeria

India

Guatemala

Uganda Mali

Burkina Faso

Ghana

Mozambique

Kenya

Côte d’Ivoire

C.A.R.

Haiti

Senegal

Zambia

Tanzania

Bolivia

Madagascar

Indonesia

Togo

Comores

Malawi

Peru

Philippines

Cameroun

Benin

Nicaragua

Paraguay

Namibia

Zimbabwe

Turkey

Viet Nam

Colombia

Brazil

Dominican Rep.

Uzbekistan

Kyrgyz Rep.

Kazakstan

Niger

Peru

Richest quintile

Poorest quintile

India

Skilled delivery attendance by wealth group

Source: Houweling 2007

Tanja AJ Houweling

Irregular patternsUnder-5 mortality by wealth group

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Und

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Chad

RichestFourthMiddleSecondPoorest

2. SOME PROBLEMS

Tanja AJ Houweling

Why measure economic status at household level in research on child health?

Theoretical: “household production of health”: households as a locus of provision of care & production of health. Level at which resources are pooled for daily needs & decisions that influence child health are made.

Practical: no info. on income/expenditure levels in DHS. Assets: assumed to be characteristics at level of household

BUT: does the DHS definition correspond with ‘household production of health’ model?

Tanja AJ Houweling

DHS definition household

“A person or group of people that usually lives andeats together”.

– If people eat in one household and sleep in another: “consider the person to be a member of the household where he sleeps” (source 1)

Source 1: DHS Interviewer’s manual

Tanja AJ Houweling

i. Definition & lived reality

Details on definitions & implications in specific contexts: not readily available in DHSAssessing extent of problem difficult– Polygyous compounds: one or

separate households?– Complex living arrangements /

resource pooling arrangements– Differences in operationalisation

of ‘household’ between countries?

Could this partly explain cross-country differences in household structure?

Tanja AJ Houweling

i. Definition & lived reality

Co-residential group: not necessarily the same as group that poolsresources for daily living -> problems measurement economic status

Eg. sisters with respective husbands and children living under one roof, but not pooling resources for food (Jakarta)

If asset of both sisters would be included in the household asset index: - overestimation of economic resources available for child health - understimation mortality inequalities

Tanja AJ Houweling

i. Definition & lived reality Household as process

DHS is static: no info on household formation & dissolution Household economic status: associated with household composition – e.g. poor households in Jakarta send family members

away to live in other households as part of survival strategy. Richer households are able to take up others (distant relatives, domestic workers, etc).

– Research DHS SSA: nuclear families: poorer, lower educated adults, children worse health, lower immunisation coverage and ORT use

Need indepth research – processes that may influence child health

Tanja AJ Houweling

ii. Intra-household diversity

Economic status measured at household level -> all household members attributed same economic statusViz. definition social class in Britain: occupation male household head to determine social class all household membersdon’t take intra-household diversity into account

Intra household allocation: – Unequal allocation, for example along gendered lines – Allocation for child health: maternal education & income ownership

important role

Need to look at what goes on within the household

Tanja AJ Houweling

iii. Excluded groups

Sampling households/dwellings:

Socially excluded groups: homeless, street children, refugees, prisoners, mobile groups: not in surveys – > perhaps underestimation of

mortality inequalities, depending on relative size of this excluded group

Tanja AJ Houweling

iv. Fit for purpose?

Data and methods (incl definitions) should be fit for question asked (*)Need comparable definition of household across countries & time periods to answer some important questions for which DHS has been set upInequalities: broad patterns, key findings not explained by definition problemsSpecific detailed patterns, outliers, perhaps explained? Other research questions: standardized definition as in DHS less useful.

(*) Measurement and Evidence Knowledge Network CSDH

3. IMPLICATIONS

Tanja AJ Houweling

i. Implications for surveysNeed more detailed & accessible documentation: definitions + general and country specific implications of definitions

– definition: rural/urban

Excluded groups: esp. in countries where relative size of these groups is large (monitoring)

– Targeted studies that suplement the surveys?– Information should be publicly acessible, along side larger survey

results.

Measure wealth at level of mother in addition to hh wealth??– importance of money in hands of mother

Surveys: distinction residential unit & cooking unit?

Tanja AJ Houweling

ii. Implications for interventions

Reaching the poor & targetting: Who is poor? Who is not?

Intra-household allocation– Be careful with targetting: problems with identifying

poor women & children – Measure economic status at level of the mother?

Tanja AJ Houweling

iii. Implications for research: the need for more inter- and multidisciplinary research

Household – strong argument multi and interdisciplinary research:

Social epidemiology: broad patterns/general trends. National level generalizability. household as black box. Certain questions can only be answered by unpicking this black box (Anthropology)– Who pools resources for daily needs? – Dynamics of household composition (formation, change, dissolution of

households) as consequence of social change (economics; disease (HIV/AIDS)

– Explaining outliers & irregular patterns. Due to definition household? – In which countries is DHS definition of household especially a problem?

Also other concepts western bias: e.g. socio-economic status. Need to deconstruct this concept, in context of low/middle income countries