Do Household Structure and Household Economic Resources Predict Childhood Immunization? Evidence from Jamaica and Trinidad and Tobago
Jacinta Bronte-Tinkew, Ph.D.
Child Trends, Inc.
4301 Connecticut Ave, NW
Suite 100
Washington DC, 20008
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Gordon F. DeJong, Ph.D.
Population Research Institute
Pennsylvania State University
506 Oswald Tower
University Park, PA 16801
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Phone: (814) 863-2277
Fax: (814) 863-7216
Abstract
This study assesses the influence of household structure and resource dilution characteristics on children’s immunization coverage in Jamaica and Trinidad and Tobago. The study has three objectives: 1) to compare the impact of different types of household structures (e.g. single parent, two-parent, cohabiting and extended) on child immunization; (2) to examine the effects of household income, and resource dilution on child immunization; and (3) to determine whether household structure and resource dilution interact to affect child immunization in these contexts.
We use data from the Jamaica 1996 and Trinidad and Tobago 1997 Living Standards Measurement Study Survey and a series of logistic regression models to test hypotheses derived from the current child well-being literature. The results show that household income and household structures selectively predict children’s immunization coverage in both contexts, with significant interaction effects enhancing the interpretation for Jamaica. The key policy implications that emerge from this study are that household structure and income are crucial for understanding child immunization in the Caribbean.
Key words: Caribbean Child well-being Household resources Immunization
INTRODUCTION
Despite a growing awareness in the anglophone Caribbean of the importance of the social well-being of children for development (Coreil 1983; Desai 1992; Handa 1993; Horton & Miller 1989; Louat, Grosh & Van der Gaag 1993; Tienda & Salazar 1982; Wyss 1995), there is little understanding of how specific living arrangements place children at risk, and specifically how the household structures in which they reside influence their access to resources both within and outside the household. Children in the Caribbean region remain part of a neglected and under researched group. Measures of children’s immunization against several childhood diseases provide an opportunity to directly measure how household resources are used for children’s health and is a useful indicator of intrahousehold resource allocation (Gage et al.1997a, 1997 b; Amin et al.1992; Valadez & Weld 1992).
This study has three objectives. The first is a comparative analysis of the impact of different types of household structures (e.g. single-parent, two-parent, cohabiting and extended) on child immunization in Trinidad and Jamaica. The second is to examine the effects of household income, sibsize, gender, biological status, and birth order on this outcome. These factors are important because they determine resource availability and predict the household’s willingness to invest in children. The third objective is to determine whether household structure and resource dilution interact with each other in predicting child immunization in these contexts.
The under-investment in children has far reaching consequences for human and overall national development. The lack of access to, and utilization of primary care services such as immunizations puts children at risk of developing preventable conditions or having existing conditions needlessly worsened (Bowman & Zvetina 1992). Many studies show that deprived children suffer from impaired physical growth, cognitive development and socio-emotional development. The effects of high levels of deprivation among children are ultimately realized in their adult years (Lichter 1997). The under investment in children also has consequences for economic productivity and economic growth rates because it limits human development and ultimately results in obstacles to reducing rapid population growth rates (Sathar & Lloyd 1996). The influence of household structure and resource dilution on child well-being in the Caribbean is not well understood as evidenced by a lack of scholarship on the subject. What also remains unanswered is how household structure interacts with resource dilution factors to impact immunization in the Caribbean region.
CONTEXT OF STUDY
Both Jamaica and Trinidad and Tobago are islands in the Anglophone Caribbean. In both countries, the state is heavily involved in subsidizing child services, have articulated National Plans of Action regarding child welfare, and observe the Articles on the convention on the Rights of Children (UNICEF 1988). The fundamental difference between both countries is evidenced by their levels of economic development as measured by their respective GNP per capita figures $4, 250 for Trinidad and $1,550 for Jamaica (Population Reference Bureau 1999). Both Trinidad and Tobago and Jamaica have both witnessed improvements in their levels of development-but beginning in the 1970s for Jamaica, and early 1980s for Trinidad, low economic growth, macroeconomic shocks, inappropriate policy responses, and continued high unemployment have plagued both their economies.
Since the Alma-Ata Conference (World Health Organization 1978), Primary Health Care has become the leading strategy to improve health in both contexts, and Universal Child Immunization is the cornerstone of this Primary Health Care Strategy adopted by governments in both contexts. In both Jamaica and Trinidad and Tobago, universal immunization has been given high priority as both countries have embarked on Expanded Programs on Immunization (EPI). Recent estimates indicate that in Jamaica, child immunization coverage is almost universal (World Bank 1998), but this is slightly lower in Trinidad and Tobago (World Bank 1995)
While the state is committed to the social well-being of children in both contexts, it appears that social and geographic inequities continue to limit some children’s access to health services which can be potentially harmful to their well-being. The presence of inequities in the allocation and distribution of resources, poor strategies for the targeting of basic needs by the state, insufficient legal information systems, mentoring mechanisms, frequent political changes, and structural adjustment policies have created scenarios that have potentially negative implications for children’s health care, accessibility, and possibly immunization coverage. In sum, despite state involvement in both of these contexts in improving the welfare of children, the ultimate responsibility for accessing such services rests with their households.
LITERATURE REVIEW
The Relationship between Household structure and Child Well-being
Households provide two key resources to children –money and time (Thomson, Hanson & Mc Lanahan 1996). Not to be ignored as well is the household’s role in gaining access to other social, community and national resources on behalf of children (Lloyd 1996). The household acts as a context for the child as well as a mediator that provides the support associated with positive child well-being outcomes (Thompson et al. 1996). Different types of households however, have different outcomes for children –single-parent, two-parent households (nuclear), extended households and two-parent cohabiting households. Households are not homogenous in terms of their discharge of duties and there are significant variations between households, within households as well as between different settings with respect to how households use time and resources for children’s well-being.
Single-parent Households
Previous research conducted in the US has shown that living in a single-parent household may have may have negative outcomes for children (Wu 1996; Blake 1981; Schiller 1996; Mayer 1997; Thomson et al.). In single-parent female-headed households for example, it has been shown that with women’s less favorable market conditions, children are often poorer and more vulnerable to economic shifts compared to households where there are two-parents present (Louat et al.1993). The effect of a father’s absence is to substantially lower children’s economic status as well as to increase the likelihood of poverty as well as its duration and severity (Schiller 1996). Much work done in the United States shows that female headed households face budget and time constraints, which can have negative welfare implications for children.
According to Schiller (1996) women in general spend longer hours on the combination of income generating activities and domestic duties that can affect child well-being. Children in female headed households in the United States are usually at a well-being disadvantage compared to children in two-parent households because of the constraints of time, money and by extension less supervision (Amato 1987; Dawson 1991; McLanahan & Booth 1989; Schiller 1996) .
Children in single-parent households headed by males may also be at a well-being disadvantage in terms of their outcomes. In the United States, children in male- headed single-parent households with step parents or cohabiting partners of their fathers present may not necessarily have positive outcomes. These adults may be competitors with the child for the time and energy of their fathers (Eggebeen et al.1996). Downey (1996) also finds that children in male-headed single-parent households do poorly in the academic domain, not necessarily because of economic deprivation, but because of a lack of interpersonal resources (frequency of talk, and parent’s educational expectations). The well-being of such children can therefore be jeopardized. Based on this review, the following hypothesis will be tested:
Hypothesis 1: Children in single-parent households will be less likely to be fully immunized compared to children in two-parent households.
Cohabiting Households
Most research on children in cohabiting unions finds that children in such household structures may be disadvantaged compared to two-parent households (Manning & Lichter 1996; McRae 1993). While the household may benefit from the additional income, cohabitation is not a substitute for marriage. Cohabitation may be a logical household strategy, but doubling up with an unmarried partner means that children still face high rates of poverty. The education, employment and income of parents as well as the cohabiting partner still resembles the economic circumstances of a single-parent household. Whether children in cohabiting unions benefit positively is a function of social and economic circumstances, whether the child is the biological offspring of both parents, whether cohabitation is a step to marriage, whether the union is stable, or whether the cohabiting parent fulfills the role of caregiver.
In studies in some less developed contexts, the negative effects of cohabitation for children are also evident. Bruce and Lloyd (1996) find that in Latin America, children with parents in consensual unions (informal marriages) have lower nutritional status than married couple households controlling for the socio-economic level of the household. Lloyd (1993) also finds that financial exchange tends to be precarious when parents are not linked to each other through marriage. In fact, the extent of the cohabiting father’s support is dependent on sexual access to the mother of the children. McRae (1993) in a study of cohabiting mothers in Britain also finds that cohabitation often implies a lack of commitment to fatherhood, and that cohabitation and marital relationships differ with respect to durability. Based on this review of the literature, this study will test the following hypothesis:
Hypothesis 2: Children in cohabiting unions would be less likely to be fully immunized than children in two-parent (nuclear) households.
Two-parent Households
Two-parent households are believed to be the ideal setting for children in most United States research. The presence of a partner or spouse is believed to increase the family time devoted to child rearing functions as well as resources necessary for optimal child well-being outcomes (Amato 1987; McLanahan & Sandefur 1994; McLanahan & Booth 1989). Hogan and Lichter (1995) in work done on the United States for example find that poverty among children living with two full time working parents is virtually non-existent. The secondary earner strategy in the two-parent household reduces the likelihood of childhood poverty.
Work in some developing country contexts has also emphasized that the two-parent household may result in more favorable outcomes for children. In Ghana for example, per capita levels of consumption have been found to be substantially lowered in families headed by divorced and widowed women than in those headed by women who were married but with an absent spouse (Lloyd & Gage-Brandon 1993). Based on this review, we test the following hypothesis:
Hypothesis 3: Children in two-parent households compared to other household structures are the most advantaged in terms of their immunization outcomes.
Extended Family Households[1]
Previous research on extended family households in the US (Angel & Tienda 1982) shows that extended family household structures may decrease the economic well-being of children by straining already limited resources. These findings support the notion that in extended families, non-nuclear members may be helped more that they help. Extended family units tend to rely on immediate relatives or non-nuclear members within the family for support when social and economic demands are great. In spite of the supplemental income in such families, this does not offset the labor market disadvantages that heads of extended families already face. Children in such family structures can then be at a well-being disadvantage although the presence of additional household members may widen the immediate resource base of their families.
In some developing country contexts however, reality differs from this model in many ways that have implications for child well-being. Among extended family households in Sub-Saharan Africa, there is the belief that kin residing together in very close proximity to each other have the ability to meet many of the social and economic needs of family members including children. In modified extended families, two-parent families and communal families where other family members reside, there may be those who provide housekeeping and child-care services (Desai 1992). This is because co-residence implies an exchange between family members with respect to production, consumption and child-rearing functions.
Gage, Sommerfelt and Piani (1997) show for example, that in Nigeria, laterally extended families are associated with an environment in which childhood immunization services were used more effectively. Children in extended families are therefore not worse off than those in nuclear families in terms of full immunization. Lloyd and Desai (1992) however find that in Latin America and the Caribbean that the role of the extended family in child support is not as extensive, and in some countries in that region, children in extended family households are less likely to be well nourished. The consequences of weaker conjugal bonds in extended family households for children’s welfare are therefore more apparent in this region. Based on previous research on the extended family in Latin America and the Caribbean, we test the following hypothesis:
Hypothesis 4: Children in extended household households will be less fully immunized compared to children in two-parent households.
The Relationship between Resource Dilution and Child Well-being
Child outcomes are often affected by the absence of household income, many siblings, gender and birth order. Mayer (1997) acknowledges that the absence of household income decreases the quality of non monetary investments such as parent’s interactions with children. This limits children’s chances for success and it diminishes parental ability to provide supportive, consistent and involved parenting. Diminished income hurts the social and emotional development of children, which limits their educational and social opportunities. In short, it leads to coping strategies and material deprivations that are detrimental to children’s outcomes.