An Equity Study Of Children’s Survival Status

Background:Children’s health status is an important index to reveal the health conditions of different countries and areas. Children’s survival, protection and development are the prerequisite concerns globally. The mortality rate of infants and of children under the age of five serve as key index to reveal the health status and social development of countries and societies.One essential issue to improve children’s health condition is to improve the equity situation. Our country is under a period of social transition, with increasingly prominent social problems such as disparity between the rich and the poor, inequity of allocation and opportunities. Currently, inequity is presented everywhere, particularly in the health care system. Social stratification can reveal unequal relations of social groups; in recent years, using social stratification to study health equity has become a heated topic in sociology. The social-economical level is an important social stratification standard, and is the utmost important factor influencing health equity. The impact of social-economical level on children’s health equity has been attracting more and more attention. Based on the social stratification theory, this study applies case investigation and data monitoring to study the impact of social-economical level on children’s health conditions, with the aim to investigate the mechanism of how the social-economical level impacts on children’s health conditions, and to propose valuable policy-making guidelines to improve children’s overall survival status.Methods:With a combination of quantitative and qualitative studies, a theoretical framework was developed for empirical analysis, which included the following two parts.1) A survey on the death cases of children under the age of five. A questionnaire’ survey of death cases of children under five years’ was self-designed and assigned to the staff in charge of death monitoring in 30 counties (cities and regions) of Zhejiang Province. Retrospective reviewing of data from 2012 to 2014 was carried out among parents or guardians of the corresponding death cases. A logistic regression model was established, and the impact of social-economical factors (such as parents’ profession, education level, family income) on children’s death including death places, pre-death treatment, diagnosis and mortality causes was analyzed.2) Monitoring data of Zhejiang Province from 2005 to 2014 was collected. The concentration curve and the concentration index were used to evaluate equity status of children’s survival and the trend of change. Furthermore, geographic information system was used as a tool to compare the survival status of children in regions at different social-economical levels.Results:1. Case survey on deaths of children under five years1.1 General informationA total number of 3498 valid questionnaires were returned, with an effective rate of 99.15%. On gender of death cases, males accounted for 55.5% and females 44.5%. Of all cases,28.0% were from urban areas and 72% from rural areas. On household distribution,51.8% had local household registration and 48.2% had no local household registration. Based on the social economical stratification,9.4% were in the upper level, 16.4% in the middle-upper level,41.3% in the middle level,16.4% in the middle-lower level and 9.9% in the lower level.1.2 Deaths of children under five years in the monitoring regionsWith regard to death places,52.2% died in the hospitals,14.2% on the way to hospitals, 33.6% at home and 17.6% were not treated; on death diagnosis locations, provincial and city hospitals accounted for 45.2%, county level hospitals 44.8%, community hospitals or under 4.9%, not treated 5.1%; analysis on death causes revealed that birth anomalies accounted for 20.2%,28.5% died from newborn diseases (eg. prematurity),28.4% from accidents and 22.9% from other diseases.1.3 Impact of social-economical level on children’s deathBased on the logistic regression model, after controlling by gender, birth weight, gestational age, death age and birth model, urban or area and local registration, logistic regression model revealed that children in families with high levels of social-economical stratification were more likely to die in hospitals; the probability was 2.193 folds higher than children from lower level; and the probability of access of hospitalization treatment was higher,2.904 folds of the lower level; the probability of death causes diagnosis level was also much higher,3.233 folds of provincial or city level hospital diagnosed in the upper level than the lower level (P<0.01). In addition, children with parents having high-level profession, education and family year income were less likely to die from accidents, but more likely to die from newborn diseases and birth anomalies (P<0.01).2. Equity analysis of survival status of children in Zhejiang Province from 2005 to 20142.1 Trend of mortality rate during 2005-2014 period in Zhejiang provinceMortality rates of children showed a trend of decreasing during the period of 2005-2014. The disparity of different regions, urban-rural areas and with or without local registration decreased with most remarkable in urban-rural areas. Mortality rate in 2014 was similar in urban and rural areas, but still remarkably different between the floating population and resident population.2.2 Relationship between children’s mortality rate and economical levelWe used scatter plot and correlation coefficient to analyze the relationship between children’s mortality rate of different regions and per capita GDP. The result revealed that the mortality rates of newborns, infants and children under five years were negatively associated with per capita GDP. Mortality rates of newborns, infants and children under five years were lower in the regions with much higher per capita GDP. We divided the 30 monitoring regions into three tiers based on per capita GDP:tiers 1 to 3. Overall, all regions had a decreasing trend in mortality rate of children under five years. Regions at the tier 3 (low GDP) had the greatest decreasing amplitude; disparity of mortality rates between the three tiers reduced. No obvious difference was found between tiers 2 (middle GDP) and 3 (low GDP).2.3 Equity analysis of children’s survival statusConcentration curve of children’s mortality showed the survival status curve of children was approaching the equity curve. Concentration indexes of newborns, infants and children under five years were -0.105,-0.107 and -0.118 respectively. The results revealed that children’s mortality rate was correlated with the economical status. The value was small, suggesting that the equity of survival status of children from the 30 monitored regions was fair. Temporal-spatial profile on regions’ GDP and children’s mortality rate showed that regions with low per capita GDP had much higher children’s mortality rate, particularly within the migrating population.ConclusionsOverall, children’s mortality rate of Zhejiang province decreased during the period of 2005-2014. The children’s survival rate of Zhejiang province is among the highest in China and approaching the status of the developed countries. Disparity between regions, urban and rural areas were gradually reducing. However, children’s mortality rate of the migrating population was still higher than that of the residential population. In Zhejiang province, children’s mortality rate showed weak negative correlation with the economical levels, revealing fair equality. Regional social-economical level is not the sole determinant of children’s mortality rate, and factors such as policy execution also have influences. Compared with literature reports, the social-economical index stratification standard of different families established in this study is both scientific and operative. Meanwhile, our data reveals that the family’s social-economical level not only influences the biological background of children, making’infant diseases’the major cause of childhood death, but also influences the children’s survival through working on the access to the public health service and the familial environment. Based on this research, it is advised that during public policy making, the regulatory target should be moved to the earlier stage, and the following is proposed: it is important to increase the social-economical level of pregnant women; education should be focused and to increase the intervention on accidental injuries of children with low social-economical levels; multiple measures should be undertaken to strengthen the social economical equity of maternal and childhood health services utilization; classification guidance to focus on increasing children’s survival status and promote the execution of the health strategies should be adopted; banning the household registration system to improve the supportive system for people in regions with low social-economical level should be considered, as well as increasing the investment to optimize the maternal and childhood health care.