Social identity, health networks, and health knowledge

Health knowledge, is a critical factor for the achievement of good health outcomes. Analysing data from the Indian Human Development Survey 2004-05, this article examines how knowledge regarding fluid intake for children with diarrhoea is created, and whether caste/religious affiliation play a role. It further explores the importance of health networks – in terms of access, quality, and homophily – in this context.

Children are not the main ‘producers’ of their own health outcomes and must rely on their parents to make the right decisions on their behalf when they fall ill. Childhood diarrhoea is the second leading cause of death (after pneumonia) among children under five years of age (World Health Organization (WHO), 2013). Yet, many deaths due to childhood diarrhoea could possibly have been prevented if the affected children had received adequate fluids, ideally combined with oral rehydration therapy. Unfortunately, many parents are (still) not aware that a child suffering from diarrhoea has an increased need of fluid intake.

In recent research (Blunch and Datta Gupta 2020a, Blunch and Datta Gupta 2020b), we examine how knowledge regarding fluid intake for children with diarrhoea is created and what its relationship is with caste/religious affiliation. Further, we examine how access to health networks (that is, having a healthcare worker amongst one’s relatives or aquaintances) affects the creation of such health-related knowledge, and in particular, which aspect of health networks – access (knowing any healthcare worker), quality (knowing a doctor), or homophily (knowing a healthcare worker of the same caste or religion) – matters the most for this purpose.

Social identity and health knowledge

It is well-known that education either creates health knowledge directly (that is, via attending classes and from the curriculum) or indirectly by enabling people to read and understand public service health information and messages. While many studies have empirically established education as one of the key factors associated with health knowledge (Kenkel 1991, Atlindag et al. 2011), not much is known about how this knowledge varies by social background, and in particular how health knowledge is created among deeply marginalised groups in Indian society. There is exclusion of certain groups – such as on the basis of caste – from attaining education of good quality, from living in clean neighbourhoods, or from access to public health facilities such as public latrines and clean water. This implies that their starting point for gaining health knowledge, and thereby making healthy choices, is substantially impaired compared to more privileged groups. Even when they access health networks, their networks may be weaker meaning that they would have fewer social connections with doctors or other higher level medical personnel. It is not surprising therefore, that belonging to a lower caste or being Muslim in India, has been associated with not only poorer economic outcomes (Das 2012, Mosse 2018, Barrientos-Q et al. 2018) but also worse health outcomes (Borooah 2012, Borooah et al. 2012, Mosse 2018).

To understand the role played by low caste and minority religious background, we examine both the levels and the gaps in health knowledge among mothers in such groups compared to upper-caste mothers (also of religious majority background, that is, Hindu), regarding the proper management of diarrhoea among children with increased fluid intake.¹ We analysis data from the 2004-05 Indian Human Devlopment Survey (IHDS).² In our empirical analyses, we estimate health knowledge regressions to identify the effects of information exposure and health network access.

Overall, health knowledge levels are shockingly low across all groups. Only a little over half of the mothers in our sample know the correct treatment in terms of fluid intake when their children have diarrhoea. Even so, there are significant caste/religious differences in health knowledge. Applying ‘decomposition’ methods, we can quantify the part of health knowledge gaps between lower-caste and religious minority mothers and upper-caste mothers that is due to differences in characteristics, and the part that is ‘unexplained’. For instance, the former may capture the effect of upper-caste mothers having more education or better access to health networks than lower-caste or religious minority mothers. The ‘unexplained’ part, on the other hand, captures the health knowledge gap between upper and lower-caste mothers even when they have the same level of education or same access to health networks. This is often taken to represent discrimination and indeed, when talking about severely marginalised groups in society, it may be relevant to treat it as such. We find that raw health knowledge gaps regarding the treatment of child diarrhoea favour upper-caste women. Second, upper-caste women not only have higher levels of endowments or characteristics – notably, health networks, education, and income – but also higher returns to these characteristics. This leads to a widening of health knowledge gaps across castes.

Role of health networks

It may be difficult to give a causal interpretation to the effects of health networks and information access on health knowledge, because a mother’s health knowledge is likely to be strongly simultaneous with her information exposure and health network access. This could arise, for instance, if low health knowledge causes mothers to seek out health networks and information, or if an unobserved third factor such as motivation or engagement in child upbringing affects the generation of both health knowledge and information/network access. To take into account such ‘endogeneity’³ of information exposure and health network access, we use the share of the population in the district with information exposure and health network access as an ‘instrument’⁴ that would affect health knowledge only through the individual mother’s information exposure and health network access.⁵

We find that all three aspects of health networks – access, quality, and homophily – are important for health knowledge, and in about the same degree. These effects are stronger in urban areas relative to rural areas. The single most important factor that explains gaps in health knowledge across caste/religion groups is access to health networks. When stratifying by caste/religion, it turns out that network homophily is sometimes more important for low-caste women than the other aspects. For Adivasi⁶ women, network homophily reduces the discrimination component of the health knowledge gap. Thus, for these women in particular, it may not be enough to obtain access to health networks or for their health networks to be of good quality; such networks have to be homophilous to have an effect. However, the finding around homophily does not extend to women from other caste or religious groups, plausibly due to the smaller sample sizes for some of these groups.

How homophily works

Why do low-caste/religious minority women especially benefit from knowing a member of the healthcare profession of their own caste or religious group? We explore the mechanisms behind why network homophily matters for health knowledge by analysing data on the self-perceived treatment quality received by women who went for diarrhoea-related consultations. We find that in almost all cases, network access increases the share of those who report being treated “nicely” and decreases the share reporting “somewhat nicely” or “not nicely”. Similarly, having network access increase the share who report having “a great deal” of confidence in hospitals and doctors to provide good treatment, and correspondingly decreases the share who report “only some” or “hardly any” confidence. Although these findings are based on small sub-samples and are therefore only indicative, the implication may be that having access to health network members from one’s own social group may be important for breaking down barriers and fostering better relations with members of the medical profession.

Finally, although our main focus is on understanding the determinants of health knowledge, we repeat the analysis for child mortality and find very similar results. Health networks and network homophily contribute significantly to the child mortality gap across caste/religion groups and overall, there is a strong relationship between health knowledge and child mortality.

Key findings and implications

Our research shows that health knowledge and health network access are important building blocks for achieving sustainable development in the area of child health in India. Our findings on network homophily underscore the importance of ‘meeting people where they are at’ in a diverse society, if better outcomes are to be achieved. However, even though health networks and background characteristics explain part of the gap in health knowledge of low-caste/religious minority women vis-à-vis upper-caste women, a substantial part of this gap is left unexplained, consistent with the presence of discrimination against these systematically marginalised groups. Our results also show belonging to a minority or marginalised group in India means that deprivation occurs simultaneously along several socioeconomic margins.

These findings, coupled with the low levels of health knowledge overall, point to deep, structural, and endemic public policy challenges for the country where improving public health is concerned.

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Notes:

A study similar to ours is Patra et al. (2013), which links a comprehensive index of mothers’ health knowledge to childhood morbidity, medical care, and medical care expenditure in India. However, it does not focus on the role of health networks.
We utilise the special questionnaire on health and education that was given to ever-married women in the 18-49 age group.
An endogeneity problem occurs when the outcome of interest and the explanatory factor are determined simultaneously, or when both are correlated with another factor that is not a part of the analysis – making it difficult to establish that the explanatory factor causes the outcome.
Instrumental variables are used in empirical analysis to address endogeneity concerns. An instrument is an additional factor that allows us to see the true causal relationship between the explanatory factor and the outcome of interest. It is correlated with the explanatory factor but does not directly affect the outcome of interest.
We argue that the district shares of information exposure and health network access are less likely to be affected by internal migration as there would be more mobility between villages than between districts.
Adivasis (officially Scheduled Tribes) are India’s tribal population.