Does social status predict adult smoking and obesity? Results from the 2000 Mexican National Health Survey.

Socioeconomic status is generally associated with better health, but recent evidence suggests that this 'social gradient' in health is far from universal. This study examines whether social gradients in smoking and obesity in Mexico - a country in the midst of rapid socioeconomic change - conform to or diverge from results for richer countries. Using a nationally representative sample of 39,129 Mexican adults, we calculate the odds of smoking and of being obese by educational attainment and by household wealth. We conclude that socioeconomic determinants of smoking and obesity in Mexico are complex, with some flat gradients and some strong positive or negative gradients. Higher social status (education and assets) is associated with more smoking and less obesity for urban women. Higher status rural women also smoke more, but obesity for these women has a non-linear relationship to education. For urban men, higher asset levels (but not education) are associated with obesity, whereas education is protective of smoking. Higher status rural men with more assets are more likely to smoke and be obese. As household wealth, education and urbanisation continue to increase in Mexico, these patterns suggest potential targets for public health intervention now and in the future.

Diffusion of ideas about personal hygiene and contamination in poor countries: evidence from Guatemala.

In this paper, we explore the diffusion of beliefs pertaining to the causes of childhood diarrhea in rural Guatemala. The analysis focuses on the importance of interpersonal and impersonal contacts as conduits for information and norms related to hygiene and contamination. Estimates from multivariate models reveal that there is evidence of a diffusion process through social contacts, primarily through interpersonal ones. The analysis also identifies striking differences between (1) the diffusion process related to hygiene (e.g. dirtiness) and that related to contamination (e.g. pathogens); and (2) beliefs about the causes of diarrheal illness among children in general and those among respondents' own children.

Demography and the environment.

Demographers' interest in the environment has generally been enmeshed in broader issues of population growth and economic development. Empirical research by demographers on environmental issues other than natural-resource constraints is limited. In this paper, I briefly review past demographic thinking about population and the environment and suggest reasons for the limited scope of demographic research in this area. Next, I describe more recent demographic research on the environment and suggest several newer areas for demographic research. Finally, I consider the future of research on the environment in the field of demography.

The use of calendars to measure child illness in health interview surveys.

BACKGROUND: During the past two decades, health interview surveys have become an increasingly common source of information about current morbidity patterns and utilization of health services in developing countries. This study describes a recent effort to enhance the utility of these surveys by incorporating a calendar format. METHODS: A calendar of morbidity and treatment behaviour during the 2-week period prior to interview was implemented in the Guatemalan Survey of Family Health (EGSF), a large-scale sample survey that was fielded in 60 communities in rural Guatemala in 1995. A total of 2872 women aged 18-35 were interviewed and provided information on 3193 children born since 1990. RESULTS: The EGSF calendar data provide estimates of diarrhoeal illness that are consistent with those obtained from more conventional questionnaire designs. However, in contrast to conventional health survey questions, these calendar data: (1) permit a much more complete evaluation of the accuracy of reporting; and (2) offer a richer and more complex description of child illness and treatment behaviour. For example, the results demonstrate that even the preferred 2-week recall period suffers from underreporting of diarrhoeal illness, that the majority of children with diarrhoea experience at least one additional symptom, and that mothers assess severity of diarrhoea from the type and number of accompanying symptoms. CONCLUSIONS: The findings indicate that additional implementation and evaluation of calendar formats is warranted in order to provide the most useful and accurate data possible at relatively low cost.

Prenatal and delivery care and childhood immunization in Guatemala: do family and community matter?

In this paper we investigate family choices about pregnancy-related care and the use of childhood immunization. Estimates obtained from a multilevel logistic model indicate that use of formal (or "modern") health services differs substantially by ethnicity, by social and economic factors, and by availability of health services. The results also show that family and community membership are very important determinants of the use of health care, even in the presence of controls for a large number of observed characteristics of individuals, families, and communities.

Social inequality and children's growth in Guatemala.

This paper is an investigation of the effects of social inequality in Guatemala on children's health and nutritional status as measured by attained height. Guatemala remains a highly stratified and poor society. We examine the association of land distribution, land tenure, occupation, and other aspects of family social and economic status with children's height between the ages of three months and 36 months, using data from a cross-sectional survey. An important consequence of the poverty and poor living conditions of the majority of the Guatemalan population is substantial deficits in children's growth. Our results suggest that children's growth is affected by ethnicity, their father's occupation, land distribution in the area where they live, and maternal education. Substantial growth deficits are observed among children living at altitudes above 1500 metres; we hypothesize that this is because, in Guatemala, higher altitude is associated with land scarcity, poorer agricultural conditions, and greater remoteness from transport networks and other public services.

PIP: Population researchers used data from the 1987 National Survey of Maternal and Child Health, 1981 census of population and housing, and the 1979 agricultural census to examine the relationship between land distribution, land tenure, occupation, and other characteristics of family socioeconomic status with children's growth between the ages of 3 months to 36 months in Guatemala. 57.8% of the children were stunted. 71.9% of the children lived in rural areas characterized as poor and in inferior living conditions. Characteristics influencing children's growth included ethnicity (indigenous children shorter than ladinos), father's occupation (agriculture or unskilled occupations had a negative effect on growth), land distribution (the smaller the farm, the greater the deficit in height), and maternal education. Children living at altitudes greater than 1500 meters were shorter than those living at elevations less than 1500 meters (p 0.05). Land scarcity, poorer agricultural conditions, and greater distance from transport networks and other public services were likely responsible for the association between altitude and growth. Indigenous populations were more likely to live at higher elevations than ladinos, partly because, over the last 200 years, ladinos appropriated the more productive, accessible, and desirable lands at moderate elevations. Father's occupation, land ownership, housing quality, possession of consumer goods, residency, and size of farms in area accounted for about 24% of the variation in height-for-age. These findings show that poverty and poor living conditions for most of the population adversely affect children's growth.

Health cards, maternal reports and the measurement of immunization coverage: the example of Guatemala.

Immunization against major childhood diseases has been an essential component of health policies in developing countries. However, despite its importance and the efforts invested by many organizations in promoting immunization programs, consistent and accurate measurement of immunization coverage has not yet been achieved. In this paper, we explore the implications of alternative methods of measuring immunization coverage rates in Guatemala, using data from the 1987 Encuesta Nacional de Salud Materno Infantil, and we consider the dangers of making inferences about levels and trends in coverage from cross-sectional data. The results indicate that (1) service statistics may well lead to overestimates of coverage; (2) survey estimates derived from health cards can also produce severely biased estimates; and (3) in spite of problems associated with maternal recall, mothers' reports of their children's vaccination status probably result in substantially improved estimates of immunization coverage.

Childhood immunization and pregnancy-related services in Guatemala.

In this paper we examine the experience of one poor country, Guatemala, that provided childhood immunization partly through a major national campaign, and provided pregnancy-related services through government health facilities, during the 1980s. Specifically, we compare the breadth of coverage of these two types of services using national sample survey data collected in 1987. We then draw upon results of previous qualitative studies to explore the social, cultural, and organizational factors that may account for differences between the use of immunization and the use of pregnancy-related health services.

Mortality and use of health services surveys in rural Zaire.

The Combatting Childhood Communicable Disease (CCCD) project is a comprehensive public health programme designed to reduce child mortality by 25% through the use of the following strategies: vaccination, oral rehydration therapy, and prompt treatment for malaria. To evaluate this programme, cross-sectional surveys were conducted in neighbouring health zones in Zaire in 1984 to determine the use of selected medical services by the population and to estimate the child mortality rate before the CCCD programme began. A reinterview survey was conducted on a subsample of women previously interviewed to determine the reliability of the mortality estimates. In both health zones 84-85% of women used antenatal services, 45% of children under age 6 who had had fewer were treated with an anti-malarial drug, 19-22% of children age 12-23 months had been vaccinated against measles, and virtually no children who had had diarrhoea were treated with oral rehydration therapy. Women's underreporting of births and deaths resulted in low estimates of mortality in both surveys. The reinterview survey provided more accurate estimates of mortality and led to a better understanding of the factors influencing underreporting. The estimated infant mortality rate was 74 deaths per 1000 livebirths; and the probability of dying before age 5 was 191 per 1000. Because births and deaths reported with incomplete dates were excluded from analysis, the mortality rates from the reinterview survey are underestimates. Given the difficulty in obtaining accurate estimates of mortality, primary importance should be given to developing and improving routine health information systems that measure changes in health status and provide information to evaluate programmes.

Birth spacing and child mortality in Bangladesh and the Philippines.

This analysis uses data from Bangladesh and the Philippines to demonstrate that children who are born within 15 months of a preceding birth are 60 to 80% more likely than other children to die in the first two years of life, once the confounding effects of prematurity are removed. The risks associated with short conception intervals are confined to children who are also high birth order; they persist in the presence of controls for prior familial child mortality, breast-feeding, mother's age, and socioeconomic status. In Bangladesh but not in the Philippines, these effects are confined to the neonatal period.

Birth spacing and infant mortality: evidence for eighteenth and nineteenth century German villages.

Data from an historical population in which fertility control was minimal and modern health services were mostly unavailable are used to show that there appears to have been a strong association between previous birth interval length and infant mortality, especially when the previous child survived. Although only imperfect proxies for breast-feeding practices and other potentially confounding factors are available for this population, the results suggest that the association between previous interval length and infant mortality in this population is not solely, or primarily, a function of differences in breast-feeding behaviour or socioeconomic status. Other factors, e.g. maternal depletion or sibling competition, are more likely to explain the observed association.

PIP: In order to untangle the relationships between maternal age, birth spacing, family size, birth order and infant and child mortality, this study selected a data set which represented minimal fertility control and had no modern health services. 14 German villages with historical data from parish and civil registers on 48,000 births and 9000 reproductive histories were selected in this study of the relationship between reproductive patterns and infant mortality. The regions of Baden, Wurttemberg, Bavaria, Waldeck, and East Friesland represented different demographic conditions. The infant morality rate was 228/1000; there was wide variation in the prevalence and duration of breastfeeding. In East Friesland villages, breastfeeding was used by a majority of mothers for an average duration of a year, there is evidence to suggest that breastfeeding patterns are related to variations in infant mortality. Factors affecting the relationship between birth interval length and level of infant mortality and the nature of their effect are identified in the discussion and in chart form. 3 hypotheses are discussed: 1) short birth intervals do not permit adequate maternal recovery time; 2) the association between previous birth interval length and child survival is due to competition for food and care between the index child and the next oldest sibling; and 3) closely space children are more likely to spread infectious diseases to each other. The results showed that infant mortality risks declined as birth interval length increased before plateauing at 24-28 months. For children whose previous sibling died in infancy, there is not consistent relationship between birth interval length and infant mortality. In the multivariate analyses of those children whose next oldest sibling survived infancy, birth interval length is divided into 2 categories in order to capture the nonlinear relationship. Infant mortality rates were higher for older women, so age of the mother 35 was a variable. Analyses were conducted by birth order separately. In the logit analysis with maternal age and paternal occupation constant, for all birth orders with probability of dying decreases consistently as birth order increases. Older maternal age has no effect on birth orders higher than 6. Little association between occupation and mortality risks exists. Region and number of infant deaths are strongly related to infant mortality, where lower regions of breastfeeding had higher mortality. Regional variations are described in different analyses to confirm that ameliorative effects of breastfeeding on child survival, but differences in breastfeeding behavior are not solely responsible for interval length and mortality. Breastfeeding effects and previous infant deaths may reflect lower birth weight, poorer parental practices, and lower living standards. The results suggest that factors (breastfeeding and use of health services and family planning) may not be adequate to explain the relationship. Further understanding is required of the factors affecting interval length in order to make conclusions about the causal mechanisms.

The impact of a public-health intervention on sex differentials in childhood mortality in rural Punjab, India.

This paper examines the effects of a public-health intervention program on sex differentials in health and mortality during childhood. Among the different health-service packages offered as part of the experimental design, those including nutritional services seem to have been more successful in reducing excess female mortality. The reason for this success appears to have been careful follow-up of undernourished children by project workers. The results also indicate that, consistent with earlier research, girls with surviving older sisters had higher mortality rates after their first month of life. Contrary to earlier research, however, boys with surviving older brothers also have higher mortality rates, at least between the ages of one and three years. We conclude that these effects for boys and girls cannot be attributed to problems associated with larger family size, since the number of older siblings of the opposite sex (regardless of survival status) does not generally appear to be related to children's chances of survival.

Premarital sexuality in urban Nigeria.

This study examines changes and differentials in premarital sexual activity in Nigerian cities. The incidence of sexual activity before marriage provides an indication of the extent of erosion in traditional practices and in family control of young women's behavior in urban areas. Pregnancy and childbirth outside of marriage and traditional family support systems have also become a matter of increasing concern in many African cities, especially in the public health community. The results suggest that premarital sexual behavior has become more common over time, as Nigerian society has undergone marked social change, and that premarital sexual behavior appears to be more common among women who come from nontraditional backgrounds. Relatively few premaritally sexually active women attempted to avoid pregnancy by using a contraceptive method, although premarital contraceptive use is more common in younger cohorts, and among more educated women. Much of the contraceptive use that occurs, however, is use of efficient methods.

[Legalization of consensual unions in Mexico]. / Legalizacion de uniones consensuales en Mexico.

PIP: Data examined in this study are from the 1976 Mexican Fertility Survey. The authors review previous findings and compare information from this survey with data from the 1969 PECFAL Survey. They then examine the types of consensual union and factors such as women's age, educational status, occupation, premarital fertility, and rural or urban residence. The focus of the study is on the extent to which consensual unions eventually become legal marriages. The authors also investigate the increasing probability of termination of marriage through divorce or separation, especially in urban areas.^ieng

Evaluation of contraceptive history data in the Republic of Korea.

The consistency of retrospective and current status data on contraceptive use from a series of national fertility surveys carried out during the 1970s in Korea is investigated. Aggregate consistency is examined among random samples from the same cohort or cohorts of women interviewed in each survey. The results indicate that estimates of trends in contraceptive use from a retrospective history in one survey, or from cross-sectional estimates in a series of surveys, can each yield misleading findings. Data from the 1974 Korean National Fertility Survey (KNFS) appear to be more reliable than those from other surveys, possibly because an interval-by-interval contraceptive history was used, explicit definitions of contraceptive methods were given prior to taking the contraceptive history, and the KNFS involved longer interviewer training and, perhaps, less time pressure during interviews.

PIP: This report investigates the consistency of retrospective and current status data on contraceptive use from a series of national fertility surveys carried out during the 1970s in Korea. Aggregate consistency is examined among random samples from the same cohort or cohorts of women interviewed in each survey. The results indicate that estimates of trends in contraceptive use from a retrospective history in 1 survey, or from cross-sectional estimates in a series of surveys, can each yield misleading findings. Data from the 1974 Korean Fertility Survey (KNFS) appear more reliable than those from other surveys. This is possibly the result of 1) the use of an interval by interval contraceptive history; 2) presentation of explicit definitions of contraceptive methods prior to taking the contraceptive history; or 3) the KNFS involving longer interviewer training and perhaps less time pressure during interviews. The results clearly show that there are dangers inherent in estimating trends in contraceptive use. On the other hand, evidence from the 1974 survey indicates that contraceptive use data of reasonable quality can be collected in a retrospective history, given adequate questionnaire design and interviewer training and effort. The fact that the results indicate large intersurvey differences in the completeness of reporting of use stresses the importance of evaluating contraceptives use data before they are analyzed.

Contraceptive use during lactation in developing countries.

Contraceptive use by breastfeeding women in developing countries has led to concern about potentially harmful effects of steroid contraceptives on the health of breastfed children. In this paper, breastfeeding women's use of the pill and hormonal injections is investigated using survey data from 17 Latin American, Asian, and African countries. The results indicate that while the proportions of breastfeeding women who use these methods were small in most countries at the time of the surveys, the proportion using the pill was not inconsequential. In general, younger lactating women with higher education and more live births who live in urban areas are more likely to use the pill than other breastfeeding women.

PIP: Contraceptive use by breastfeeding women in developing countries has led to concern about potentially harmful effects of steroid contraceptives on the health of breastfed children. In this paper, breastfeeding, women's use of the pill, IUD, and hormonal injections is investigated using survey data from 17 Latin American, Asian, and African countries. The results indicate that while the proportions of breastfeeding women who use these methods were small in most countries at the time of the surveys, the proportion using the pill was not inconsequential. In general, younger lactating women with higher education and more live births who live in urban areas are more likely to use the pill than other breastfeeding women. The data for this study come from 2 series of surveys carried out during the last decade. For 14 of the countries, data come from surveys conducted by each country under the auspices of the World Fertility Survey (WFS). In each survey women aged 15-49 (20-49 in Costa Rica and Panama) were interviewed. This analysis includes only ever married women. Each survey contained a variety of questions on a woman's pregnancy and birth history, marital history, educational and employment background and contraceptive use. Findings show that in several countries a relatively large number of women use the pill in the 1st 3 months of lactation, the period during which an infant depends on breastfeeding for most or all of his diet. Indonesia's samples are unusual. About 20% of Indonesian women who were breastfeeding at the interview were also using the pill. Indonesian women who are lactating also use the IUD more frequently than women in other countries. The source of contraceptive supply clearly indicates the need for better information on where lactating women obtain contraceptives, if oral contraceptives are in fact shown to be harmful to breastfed infants. A crucial factor, not considered in this paper, is the change currently occurring in the traditional pattern of breastfeeding and contraceptive use in many developing countries. If the breastfeeding incidence continues to decline as contraceptive use increases, more frequent contraceptive use among breastfeeding women will probably result, but the number of breastfeeding women will decrease (as in Costa Rica).

The potential impact of changes in fertility on infant, child, and maternal mortality.

In this paper we explore the relation between changes in reproductive behavior, such as those that might result from an effective family planning program in developing countries, and changes in child and maternal mortality. Specifically, we use the results from recent multivariate studies to estimate the changes in mortality that might result from altering maternal age, birth order, and birth spacing distributions of live births. Our results indicate that if childbearing were confined to the "prime" reproductive ages of 20-34, then infant and child mortality rates would fall by about 5 percent. Limiting childbearing to ages 20-39 may also reduce the maternal mortality ratio by 11 percent. The elimination of fourth and higher order births would reduce the maternal mortality ratio by about 4 percent. Universal adoption of an "ideal" spacing pattern in which all births subsequent to the first are spaced at least two years apart may reduce infant mortality by about 10 percent and child mortality by about 21 percent.

Calculation of life tables from survey data: a technical note.

Life table calculations from survey data are frequently based on events for which exact dates are not available. When these dates are coded in monthly form (e.g., century months), estimates should take into account the fact that the first duration interval--the interval which captures events occurring in the first month of exposure--is half the length of all remaining intervals. Although failure to do so has a trivial effect on many demographic calculations, estimates which are based on events which occur with high frequency in the first few months of exposure can be substantially biased. Estimates of fecundability for four countries in the World Fertility Survey are used to illustrate this bias.