Introduction:
Child health inequality between genders is a persisting problem throughout low and middle-income countries, including India. (1) It has often been visualized that identity-driven-societal-values between boys and girls may lead to differential treatment, care and resource allocation towards son preference and discrimination of girls. These phenomena are also interconnected with various socio-cultural, political and economic factors. (2) Despite demanding equal rights to health and wellbeing between men and women, there is a profound reflection of inequalities in health status and access to health services through world statistics. (3) There are continuing traditions of stereotypes and conceptions of what it means to be a woman or a man, which are embedded in systems and practices. Now the time has changed. The United Nations Task Force on Child and Maternal Health has recommended strengthening the primary healthcare system and community-driven intervention to secure the health and wellbeing of mothers and their dependent children. (4) However, the facilities and qualities of healthcare are restricted in India, specifically for the poorer group, who often depend on local healthcare centres and Hospitals. (5)
With the limited sources of child health care facilities, parental and other senior members' values and expertise may have played a vital role in shaping the upbringing of child health and minimizing the inequalities to sustain the equity. Minhas et al. argued that the micro-level understandings are equally significant as gender inequality started from the household level, where parental roles and attitudes hold a crucial determinant for proper child physical and psycho-social development compared to macro-level understandings. (6) The reflection of the parental attitudes and behaviour for healthy children is mainly visible through their healthcare practices and is often unsatisfactory, like in the Indian context. (7) Therefore, this study sought to explore the parent and other guardians' roles in a child's health inequalities with these backdrops. The present study investigates child health differences based on birth information, child immunization, feeding patterns, the morbid and nutritional condition between boys and girls and explores parental roles on curative measures and general perception of children.
Materials and Methods
Study area and population selection: This observational, retrospective and cross-sectional study was carried out in the North 24 Parganas district of West Bengal state in India. This district is the 2nd largest populated district in India. (8) The population under study was comprised of the representation of urban, rural and peri-urban settlements. The study was also focused on different Bengali speaking Hindu, Muslim and Scheduled Tribe (ST) ethnic groups. A total of 208 households with 413 children aged less than eight years were considered for the present study. We have collected the data only from households with at least one child of each sex, i.e. one boy and one girl.
This study adopted the multistage cluster sampling method, where six blocks out of 22 blocks were selected using the Probability Proportional Sampling (PPS) model.
Data Collection and analysis:
Both quantitative, as well as qualitative data were collected by the researchers through the door to door household survey using structured schedules. Socio-economic and demographic data consist of age, sex, parent's and guardian's education and occupation, sources of drinking water, type of family, household assets and type of house and media exposure etc. Data on birth information comprised of mothers' Anti-Natal Check-up (ANC), place of delivery, birth weight, type of delivery, and delivery costs. Data on immunization of children includes specific immunization status and complete vaccination status of the studied children. Data on breastfeeding and complementary feeding practices were also collected using structured schedules by knowing breastfeeding initiation after birth, exclusive and complete breastfeeding status.
In contrast, we also documented the nature of complementary feeding and its sources. For understanding the child health status, reported morbid condition before three months of the survey and the treatment received with timing were gathered through separate structured schedules. All data were cross-verified accordingly.
The height (cm) and weight (kg) of the children were measured according to the standard procedures. (9) We had used an anthropometer and a portable weighing machine for the measurements of height and weight. Before taking the measurement, each subject was asked to stand erect without footwear. Height was recorded to the nearest 0.1 cm, and weight was to the nearest 0.5 kg. The individual with physical deformities was excluded from the study. Technical error of measurements (TEM) was incorporated and found within accepted limits. (10)
In qualitative data, eight Focus Ground Discussions (FGD) of different groups (grandmother, mother, father and parents together, separately) were conducted in the studied areas. The group was composed of 6-7 members. Besides, six separate case studies (three of them presented in this study anonymously as X, Y, Z) about the illness and treatment of the studied children were also collected from respective mothers.
Height for age z score and weight for age z score were calculated using WHO standard growth data to understand the children's nutritional status. Then <-2 SD Z score was considered as the cut-off values for categorizing the children as stunted (height for age) and underweight (weight for age), respectively.
A pre-tested and pre-structured Likert scale was used to understand parental roles and attitudes towards the studied parents towards their children. All the parameters of the child health were categorized as per standard procedure as <2500 gm birth weight was designated as low birth weight, whereas Standard of Living Index (SLI) was calculated by summing up all household assets. (11)
We took the ethical approval from the Institutional Ethics Committee of West Bengal State University, Barasat. The present data were collected from August 2018 to November 2019 in successive instalments.
The data were primarily shown as a percentage distribution of all the different socio-economic and demographic variables, birth information, immunization status, morbid condition and treatment, nutritional status, etc., at household and individuals levels. The chi-square test was used to understand the gender-wise distribution of child health parameters. The odds ratio was calculated to see the settlement and ethnic group-wise percentage distribution of curative measures of child health. Finally, another chi-square test was also used to see settlement and ethnic group-wise percentage distribution of roles of parents towards their children among the study population. All the statistical analyses were done with the help of SPSS 16.0, and the significance level was considered at p<0.05.
Results
Table 1 depicts the summary of the household-level variables. The households under study were representative of rural (50.0%), peri-urban (26.0%) as well as urban (24.0%) settlements. It was observed from the table that majorities of the households were used Tube well (69.7%) as their drinking water source, live in Kancha house (63.5%), had possessed single living room (66.8%) and belonged to lower Standard of Living Index (SLI) group (73.1%). On the other hand, the studied households were also composed of three different social groups as Hindu (26.9%), Muslim (51.9%) and Scheduled tribes (21.2%).
Table 1: Household level summery variables of the studied community (n = 208) |
Variable |
no |
% |
Settlement |
|
|
Rural |
104 |
50.0 |
Peri-urban |
54 |
26.0 |
Urban |
50 |
24.0 |
Social group |
|
|
Hindu |
56 |
26.9 |
Muslim |
108 |
51.9 |
Scheduled Tribe (Oraon & Bhumij) |
44 |
21.2 |
Drinking water sources |
|
|
Tap water |
63 |
30.3 |
Tube well |
145 |
69.7 |
House type |
|
|
Kaccha |
132 |
63.5 |
Pakka |
76 |
36.5 |
Number of living room |
|
|
1 |
139 |
66.8 |
2 & Above |
69 |
33.2 |
SLI group |
|
|
Low (up to 5) |
152 |
73.1 |
High (6 & above) |
56 |
26.9 |
SLI: Standard of Living Index |
Table 2 characterizes individual level summary variables of the parents' and guardians' and their children. Out of all studied children, majorities belonged to the 3-6 years age group. At the same time, most of the women belonged to less than 30 years of age and engaged in household activities (96%). It was observed that 79.2% of women were literate but mainly studied up to the secondary level (83.2%). In male folks, most of them belonged to more than 30 years of age and were literate (76.7%). However, majorities of the male individuals were studied up to the secondary level (74.3%). In the studied households, majorities of the males engaged in business (39.3%) followed by daily wage labour activities (34.9%).
Table 2: Individual level summary variables of the studied population |
Variable |
no |
% |
Age-group of children under study (n = 460) |
Up to 2 years |
133 |
28.9 |
3 to 6 Years |
206 |
44.8 |
Above 6 years |
121 |
26.3 |
Women age group (n = 255) |
Up to 30 years |
193 |
75.7 |
Above 30 years |
62 |
24.3 |
Women literacy status (n = 255) |
Literate |
202 |
79.2 |
Illiterate |
53 |
20.8 |
Women Extent of literacy (n = 202) |
Primary |
33 |
16.3 |
Secondary |
168 |
83.2 |
Higher Secondary & Above |
01 |
0.5 |
Women working status (n = 255) |
Not working |
170 |
96.0 |
Working |
07 |
4.0 |
Male age group (n = 249) |
Up to 30 years |
91 |
36.5 |
Above 30 years |
158 |
63.5 |
Male literacy status (n = 249) |
Literate |
191 |
76.7 |
Illiterate |
58 |
23.3 |
Male Extent of literacy (n = 191) |
Primary |
47 |
24.6 |
Secondary |
142 |
74.3 |
Higher Secondary & Above |
02 |
1.0 |
Male Occupation (n = 249) |
Unemployed |
16 |
6.4 |
Agricultural Labour |
21 |
8.4 |
Agriculture |
27 |
10.8 |
Business |
98 |
39.3 |
Daily wage Labour |
87 |
34.9 |
Table 3 represents the gender-wise percentage distribution of birth information and immunization status of the studied children. It was found that more than 80% of the mothers received Anti -Natal Check-up (ANC), gave birth in the local Hospital (89.6%), faced normal delivery (74.1%) and did not spend money for the birth of the child (71.2%). It was noted that the percentage of low birth weight (< 2500 gm) was slightly higher in the case of girls than boys among the present child group. The gender-wise percentage differences of the parameters of birth information were insignificantly distributed. After the children's birth, immunization status is one of the essential factors for child health and their growth and development. It was found that more than 90% of children of both sexes had received BCG, DPT and Polio vaccines followed by Measles vaccines. Most of the vaccines occurred in the local health sub-centres in the respective localities. However, it was observed that 25.7% of children did not get all vaccines on time and to date, where the percentage was higher in girl children (30.2%) than their boys' counterparts (20.9%), and the distribution was also statistically significant (p<0.05).
Table 3: Gender-wise percentage distribution of birth information and immunization status of the studied children (up to 8 years) |
Variable |
Boys |
Girls |
Total |
no. |
% |
no. |
% |
no. |
% |
Birth Information |
Total ANC of Mothers (n = 413) |
Yes |
174 |
86.6 |
178 |
84.0 |
352 |
85.2 |
No |
27 |
13.4 |
34 |
16.0 |
61 |
14.8 |
Place of birth (n = 413) |
Hospital |
184 |
91.5 |
186 |
87.7 |
370 |
89.6 |
Home |
17 |
8.5 |
26 |
12.3 |
43 |
10.4 |
Birth weight (n = 408) |
< 2500 gm |
77 |
38.7 |
96 |
45.9 |
173 |
42.4 |
≥2500 gm |
122 |
61.3 |
113 |
54.1 |
235 |
57.6 |
Type of delivery (n = 413) |
Normal |
146 |
72.6 |
160 |
75.5 |
306 |
74.1 |
C-Section |
55 |
27.4 |
52 |
24.5 |
107 |
25.9 |
Delivery cost (n = 413) |
No cost |
142 |
70.6 |
152 |
71.7 |
294 |
71.2 |
Spent money |
59 |
29.4 |
60 |
28.3 |
119 |
28.8 |
Child Immunization |
Place of immunization (n = 413) |
Hospital |
24 |
11.9 |
23 |
10.8 |
47 |
11.4 |
Health sub center |
177 |
88.1 |
189 |
89.2 |
366 |
88.6 |
Taken BCG vaccine (n = 413) |
Yes |
199 |
99.0 |
205 |
97.6 |
406 |
98.3 |
No |
02 |
1.0 |
07 |
2.4 |
07 |
1.7 |
Taken DPT vaccine (n = 413) |
Yes |
189 |
94.0 |
198 |
93.4 |
387 |
93.7 |
No |
12 |
6.0 |
14 |
6.6 |
26 |
6.3 |
Taken Polio vaccine (n = 413) |
Yes |
191 |
95.0 |
194 |
91.5 |
385 |
93.2 |
No |
10 |
5.0 |
18 |
8.5 |
28 |
6.8 |
Taken Measles vaccine (n = 413) |
Yes |
167 |
83.1 |
181 |
85.4 |
348 |
84.3 |
No |
34 |
16.9 |
31 |
14.6 |
65 |
15.7 |
Taken all vaccines timely and till date (n = 413)* |
Yes |
159 |
79.1 |
148 |
69.8 |
307 |
74.3 |
No |
42 |
20.9 |
64 |
30.2 |
106 |
25.7 |
*p<0.05 |
Table 4 demonstrates the gender-wise percentage distribution of breastfeeding and complementary feeding practices among the children. It was evident that 50.6% of children were stared to take breast milk with an hour of their birth, where the number of boys was slightly higher than girls. Similarly, the boys consumed a somewhat higher percentage in exclusive breastfeeding up to six months (63.1%) than girls' counterparts (60.8%). Likewise, boys received a higher total breastfeeding duration (57.4%) than their girls' counterparts (48.3%). However, distributions were not statistically significant. In the case of complementary feeding practice among the studied children, it was observed that most of the children consumed solid food (93.8%) and home-based food (88.9). There was hardly any difference between genders.
Table 4: Gender-wise percentage distribution of Breast feeding and complementary feeding practices among the children (up to 8 years) |
Variable |
Boys |
Girls |
Total |
no. |
% |
no. |
% |
no. |
% |
Breast feeding practices |
Time of initiation of breastfeeding after birth (n = 413) |
Within 1 hours |
104 |
51.7 |
105 |
49.5 |
209 |
50.6 |
After 1 hours |
97 |
48.3 |
107 |
50.5 |
204 |
49.4 |
Whether given exclusive breastfeeding for six months? (n = 386) |
Yes |
118 |
63.1 |
121 |
60.8 |
239 |
61.9 |
No |
69 |
36.9 |
78 |
39.2 |
147 |
38.1 |
Total duration of breastfeeding (only children after 2 years of age, n = 331) |
Below 24 months |
66 |
42.6 |
91 |
51.7 |
157 |
47.4 |
24 months and above |
89 |
57.4 |
85 |
48.3 |
174 |
52.6 |
Complementary feeding practices |
Nature of food for complementary feeding (n = 386) |
Solid |
175 |
93.6 |
187 |
94.0 |
362 |
93.8 |
Semi solid and Liquid |
12 |
6.4 |
12 |
6.0 |
24 |
6.2 |
Type of complementary food (n = 386) |
Home based food |
167 |
89.3 |
176 |
88.4 |
343 |
88.9 |
Bio-fortified food |
20 |
10.7 |
23 |
11.6 |
43 |
11.1 |
Table 5 shows the gender-wise percentage distribution of morbid condition and nutritional status among the studied children. It was evident that majorities of the children suffered from the common cold, cough with fever before three months of survey (44.8%) and received treatment from their parents (96.6%). The mode of treatment was mainly Allopathic (85.7%) compared to Homeopathy and others (14.3) with insignificant gender differences. In case of nutritional status, it was evident that girl children were a slightly higher percentage of both the stunting (26.0%, -2 SD height for age) and underweight (20.3%, <-2 SD weight for age) compared to their boys' counterparts (23.9% stunting and 18.3% underweight).
Table 5: Gender-wise percentage distribution of morbid condition and nutritional status among the studied children (up to 8 years) |
Variable |
Boys |
Girls |
Total |
no. |
% |
no. |
% |
no. |
% |
Morbid condition |
General aliment before 3 months prior to survey (n = 411) |
No |
42 |
20.9 |
45 |
21.4 |
87 |
21.2 |
Stomach Pain |
15 |
7.5 |
13 |
6.2 |
28 |
6.8 |
Respiratory distress |
05 |
2.5 |
03 |
1.4 |
08 |
1.9 |
Cold and cough |
24 |
11.9 |
28 |
13.3 |
52 |
12.7 |
Cold, cough with fever |
89 |
44.3 |
95 |
45.2 |
184 |
44.8 |
Diarrhea |
10 |
5.0 |
12 |
5.7 |
22 |
5.4 |
Skin problem |
16 |
8.0 |
14 |
6.7 |
30 |
7.3 |
Treatment taken by the parents (n = 324) |
No |
04 |
2.5 |
07 |
4.3 |
11 |
3.4 |
Yes |
156 |
97.5 |
157 |
95.7 |
313 |
96.6 |
Mode of treatments (n = 313) |
Allopathy |
134 |
85.9 |
134 |
85.4 |
268 |
85.7 |
Homeopathy and others |
22 |
14.1 |
23 |
14.6 |
45 |
14.3 |
Nutritional status |
Height for age z score (n = 401) |
Stunted (<-2SD) |
47 |
23.9 |
53 |
26.0 |
100 |
24.9 |
Normal (= - 2 SD) |
150 |
76.1 |
151 |
74.0 |
301 |
75.1 |
Weight for age z score (n = 399) |
Underweight (<-2SD) |
36 |
18.3 |
41 |
20.3 |
77 |
19.3 |
Normal (= - 2 SD) |
161 |
81.7 |
161 |
79.7 |
322 |
80.7 |
Tables 6 and 7 demonstrate the settlement and ethnic group-wise percentage distribution of curative measures (Time taken for the action of treatment as next day & Later) and role and attitudes of parents towards their children. In most cases, girls' children have received treatment next and later days if they suffered any health problems compared to boys. The percentage differences between boys and girls were higher in Muslim groups compared to Hindus. It was observed that Muslim girls of urban areas 2.755 times (p<0.05) are more likely to be getting treatment the next day and later than their boys' counterparts. When parents were asked to put their opinion against the statement "A man with only daughters is unfortunate", it was evident that a higher percentage of mothers agreed to this statement than fathers and statistically significant in the peri-urban Muslim group (p<0.05). On the contrary, when we asked for another statement from the respective parents (A daughter is a burden on the family), most Muslim fathers agreed, and the Hindu group noted the opposite results. The distributions of percentages were significantly varied (p<0.05) in urban and rural Muslim groups, respectively.
Table 6: Settlement and ethnic group wise percentage distribution of curative measure of health (Time taken for the action of treatment as next day & Later) among the study population |
Gender |
Urban |
Peri-urban |
Rural |
Hindu |
OR |
Muslim |
OR |
Hindu |
OR |
Muslim |
OR |
Hindu |
OR |
Muslim |
OR |
Girls |
75.0 |
3.000 |
58.8 |
2.755* |
50.0 |
1.000 |
54.8 |
1.470 |
51.7 |
1.500 |
64.3 |
2.100 |
Boys |
25.0 |
41.2 |
50.0 |
45.2 |
48.3 |
35.7 |
OR = Odds ratio, *p<0.05 |
The contextual understandings of parents' and guardians' perceptions of child health equity were revealed using Focus Group Discussion (FGD) and case studies from different ethnic groups in various settlements. We have conducted FGD among the grandmothers, mothers, fathers, and mothers and fathers separately. In the grandmother's case, all participants were concerned about the child health and the disparities of health-seeking behaviour between genders. When we asked "whether they had any preference of getting boys during the pregnancy of their daughter-in-law?" they replied that they had no preference on gender. However, one participant said, "It was good if my daughter-in-law gave birth to a boy instead of girls". Subsequently, another participant agreed with that statement.
Table 7: Settlement and ethnic group wise percentage distribution of roles of parents towards their children among the study population |
Gender |
Urban |
Peri-urban |
Rural |
Hindu |
Χ2 |
Muslim |
Χ2 |
Hindu |
Χ2 |
Muslim |
Χ2 |
Hindu |
OR |
Muslim |
Χ2 |
A man with only daughters is unfortunate (n = 354) |
Mother |
50.0 |
1.11 |
59.3 |
1.37 |
50.0 |
1.33 |
56.4 |
7.85* |
62.8 |
5.52 |
53.8 |
2.95 |
Father |
50.0 |
40.7 |
50.0 |
43.6 |
37.2 |
46.2 |
A daughter is a burden on the family (n = 354) |
Mother |
66.7 |
1.33 |
30.0 |
6.16* |
60.0 |
1.20 |
43.8 |
4.33 |
60.9 |
4.70 |
42.1 |
7.07* |
Father |
33.3 |
70.0 |
40.0 |
56.2 |
39.1 |
57.9 |
*p<0.05 |
Meanwhile, another participant said that "I had more loved for my granddaughter instead of the grandson. I believed that when a grandson would be an adult, he would have been involved in earning. Simultaneously the granddaughter would have to give birth to a child and look after household duties. It would require similar power for their existence". They all claimed they had been given similar treatment when their grandson or granddaughter felt ill.
One participant engaged in Integrated Child Development Scheme (ICDS) said that "daughters-in-law were the main responsible to the child health care, we had supported them to execute properly". In the case of mothers FGD, all participants agreed that they had given equal care towards their boys and girls children for their health care and education.
One participant said, "my son is always unhealthy compared to my daughter. So I had to take care more of my son. Whenever my son felt seek, I rushed to the local allopathic doctor. I took medicine". Another participant told me that "my daughter is much older than the son, so my daughter mainly looked after my son". Another participant lastly said, "I had some pressure to give birth a son than daughter from my mother and father- In-Law. Still, after birth, they accepted well of my daughter".
Interestingly, when we asked about the gender preference among the fathers' group, they had replied similar views as grandmothers and mothers. Only two participants told us that "Sons will have to do any work for their earning, they should have built their body perfect. In contrast, there would be no compulsion for the daughter to earn. But we never felt any pressure to have a daughter in our families. We always take care both equally as they are small now".
When we asked similar questions to the group formed by mothers and fathers, they also agreed to the above statement as they had equal health care facilities for boys and girls. Only one couple told us that "We had not any pressure for our son to deposit money for their future, but we had in our mind to save money for our daughter due to her marriage".
As the mothers were mainly responsible for looking after the child health care practices, we took case studies from different ethnic groups in various settlements by pointing out the specific cases of morbid condition or initiation of breastfeeding. The general morbid condition before three months of the survey was cold and cough of children. Our informant X, aged 25 years, told us - "My daughter felt ill with cold, cough and fever one month before, and I took her to Hospital after viewing two days. Initially, we gave her home remedies like Ginger mixed with honey. My son subsequently felt ill after my daughter, we took him immediately to the local reputed allopathic doctor, and both of them happily cured now".
Another informant, Y, aged 28 years, had twin children in one boy and one girl. When we took the case study of the initiation of breastfeeding about these children, our informant told us- "I had twin children, i.e. one boy and one girl. At the time of birth, my son was slight ill than my daughter. So my son started breastfeeding within an hour whereas my daughter started to take breast milk after 6 hours".
Lastly, informant Z, aged 22 years mother, had one son and one daughter. We took a case study of her son's suffering from breathing trouble and her daughter's suffering from diarrhoea three months before the survey. In this regard, our informant told us- "My son suffered severely and had breading trouble. We immediately took him to the Barasat Hospital and admitted him. Although the doctor cured him within two days, he requested the doctor for his overall body check-up for the illness. So he spent six days there. On the other hand, my daughter suffered from severe diarrhoea last month. We also took her to the Barasat Hospital, and she spent only one day there. Her severity was not much".
Interestingly she also stated us- "Having a son in a family is a little good but not compulsory. It depends upon one's luck".
Discussion
The role of parents and other senior family members like a grandmother may have contributed to minimizing child health inequalities between genders. The present study summarizes the differences in child health conditions in terms of immunization status, breastfeeding and complementary feeding practices, and nutritional and morbid condition between boys and girls aged less than eight years in India's 2nd largest populated district. Besides, this study also explores parental roles on curative measures and general perception of children using both quantitative and qualitative approaches. The study finds that no significant difference existed between boys and girls for the aforementioned health inequalities parameters. But altogether, girls had a disadvantageous position in getting delayed health care facilities after illness, inappropriate breastfeeding patter, stunting and being underweight. The Muslim children suffered more from health inequalities compared to Hindu children. However, the qualitative approach revealed that parents and guardians did not discriminate between boys and girls for their upbringing in health care facilities. Still, specific case studies, the parental statements and participant observation exposed the crude facts of preferring nature towards boys than girls in the thought process of the parents and guardians in the present study. Prusty and Kumar also argued after analyzing time-series data of the National Family Health Survey that gender disparity in terms of child health, precisely immunization status, was reduced or minimal over time in India. (12) Besides, they also suggested putting importance on the Muslims community for their maximum gender disparity of child healthcare practices in the current time. Still, they were not considered any qualitative understandings.
In general socio-economic and demographically, the studied populations mainly live in rural areas, had below the standard of living than the average SLI score and represented the Muslim population (51.9%). The majority of the children under study belonged to the pre-school group. Although their parents were literate primarily, the extent of literacy was up to a secondary level. The prominent earning members of the family were the father of the studied children, but they either engaged in business and uncertain daily wage labour activities. Overall, the population under study was the representation of poor socio-economic conditions.
Before the determination of sex, most of the mothers received ANC and gave birth in the Hospital. However, after birth, although both sexes received the essential vaccines from local health-sub centres, a significantly higher percentage of girls' children did not complete total vaccination than boys' counterparts. This may be a long term problem in India's complete child vaccination. Laxinarayan and Ganguly suggested that these conditions may be due to the several reasons as small government invent, more focus on polio vaccines rather than others and ignorance of vaccination by uneducated population. (13) Similar kind of differentiation was observed to breastfeeding patterns. Comparatively higher number of boys started to consume breast milk within one hour after birth than girls. Similar boys' advantage was noted in the case of exclusive breastfeeding and total breastfeeding duration. However, the distributions were insignificant. Likewise, the boys of the rural Bijapur district of Karnataka state in India received slightly better breastfeeding practices (Initiating breastfeeding within one hour of birth) than the girls. (14) However, there were not many gender differences were observed in the case of complementary feeding practices.
The present studied children mainly suffered from cold, cough with fever before the survey's three months, and most of them received allopathic treatment from local doctors. There was not much gender difference existing in morbid condition, but girls were more stunted and underweight than boys. Significant gender difference exists in the case of time taken for treatment, where girls were taken to any treatment well after a day and later compared to boys. This disadvantageous position was noted mainly in the case of the Muslim group. Most Muslim parents, specifically fathers, agreed that the statements like "A man with only daughters is unfortunate" and "A daughter is a burden on the family". A comprehensive systematic review on gender-related differences in child care-seeking behaviour (neonates) among the parents also revealed that the girl's children were discriminated against over boys, in terms of care-seeking throughout South Asian countries, including India, irrespective of a religious group. (15)
This aforementioned quantitative understanding was also rechecked by using FGDs and specific case studies. These reveal that most of the group members claimed that they had not discriminated between boys and girls in terms of nurturing them and giving them proper food and treatment on time. Still, the statement received from some Muslim fathers and mothers showed their inner motives to prefer boys to girls. They often said that "Boys have to do some work for their survival, but girls would be members of other families after marriage". Therefore, there were some discrepancies between the statement and other quantitative findings. The treatment preference for boys than girls was also reflected in the case studies of the present study. These may be the classic example and practical evidence of the impact of socio-cultural factors on child health, which ultimately created a solid societal value towards son preferences and reflected in child health inequalities. (16)
Conclusion
Therefore, it may be concluded from the present findings that child health inequalities existed to some extent in the current scenario. These need serious public health intervention at the community level to adequately address the gender equality of child health and sustain health equity. Besides, this study also highlighted using a complex mixed-methods approach to get the actual scenario of the child health inequalities and its parental and guardian roles. However, further large scale studies are required to examine boys centric of parental and other guardians' behaviour, specifically, grandmother's towards their grandchildren. So that specific intervention and priority groups would be identified for knowledge generation and ensure gender equity.
Strengths
This study merited considering both the quantitative and qualitative approaches. It demonstrated the importance of using FGD and case study and participant observation to validate the quantitative approaches of gender differences of child health inequalities and the role of parents and guardians. Besides, this may be the first attempt to understand child health disparities in the context of parents and other family members in 2nd largest populated district as North 24 Parganas in West Bengal; Statue in India.
Limitations
The study has several limitations as the sample size; however, we have used the proper sampling strategies, and there were extremely hard to find the specific households with the presence of boys and girls aged less than eight years as per the study's inclusion criteria. The study itself was cross-sectional; therefore, this did not establish any causal relationship between covariates.
Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding: We are thankful to the Indian Council of Social Science Research (ICSSR), New Delhi, for funding this study (F.No. SC-2/2017-18/ICSSR/RP, dated: March 27, 2018).
Acknowledgements: We sincerely acknowledge the contributions of project staff for their extensive dedication to data collection. We are grateful to our study participants for their wholehearted participation.
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