COORDENADAS EXTERNAS

Following the same procedure of analysis, a total of five interactions were included in the final multivariate model for respiratory infections or the onset of fever. The interactions in order of their significance were: illnesses ever suffered with the number of children dead in the household; incidence of diarrhoea with the illnesses ever suffered; the total number of household members with the type of toilet facility; religion with the number of living children in the household; and the age of the child with the number of under five children in the household (see Table 6.8 and graphical presentation in figures 6.9 to 6.13).

6.6.2.1. Illnesses suffered and number dead

The interaction between the two variables presents a cross-over effect between illnesses ever suffered and the number of children dead in a household. The results suggest that children in households where no child deaths had occurred and none of the living children had ever suffered from any serious illnesses like chicken-pox, measles or pneumonia and bronchitis were at the lowest risk of respiratory infections. The odds for these children was as low as 0.34 compared with children belonging to households where one or more children had died and who had suffered from life-threatening illness. Children included in the former category were also around 0.26 times less likely to contract fever than children in households with no child deaths but who had ever suffered from one of the serious illnesses. These children were equally at a lower risk of about 0.25 compared with children belonging to households with one or more child deaths but who were not victims to any of the fatal illnesses mentioned above (Figure 6.9).

The overall results indicate that children in households with one or more deaths were the most vulnerable group, whether the child ever suffered from a serious illness or not. However, within the two categories of children belonging to households with at least one child death, the risks are higher by 1.36 for those who did not suffer from the specified serious and immunizable diseases compared with children included in the reference

Figure 6.9 Risk of respiratory infection by illnesses ever contracted and number of children dead

Illnesses contracted Fatal —O— Non-fatal

e 1-

Number of children dead

category. These children were also 1.04 times more likely to contract fever than those who had suffered from a fatal illness but belonged to households with no reported child deaths. The results point to both the level of m other’s perception and knowledge of illness and seasonality effect.

First, children in the highest-risk group were those who were reported to have ever suffered only from diarrhoea and fever or some other illness not included in the category of fatal illnesses. Nonetheless, these children belonged to households where one or more child deaths had occurred, suggesting that the living children were subject to biological or nutritional influences or generally weak health and were vulnerable to repeated attacks of re sp ira to ry infections. M others o f these children perhaps did not p erceiv e the abovementioned causes as serious or needing greater and more timely nutritional, medical or maternal attention. Secondly, these children may have ever suffered from a serious illness but because of the mothers’ low level of awareness were perhaps neither perceived nor reported as fatal. This explanation is plausible considering that these mothers had already experienced one or more child deaths.

6 .62.2. Diarrhoea and illnesses ever suffered

The results for this interaction follow a similar direction to those obtained for the previously discussed interaction. The main effects reveal that children who had not suffered from any serious illness considered but were suffering from diarrhoea in the four weeks before the survey were at a high risk (7.29) of getting fever than those who had ever suffered from fatal illnesses but were not suffering from diarrhoea during the morbidity study period. These children were also 5.35 times and 5.46 times more likely to get fever than those who had experienced illnesses other than fatal and did not have diarrhoea and those who ever suffered from life-threatening illnesses and were suffering from diarrhoea, respectively. The results are as expected and logical, in the light of the perceptual and seasonality explanations given above. Otherwise too, as the results indicate, biologically and physiologically, children suffering from diarrhoea would be more susceptible to mal­ absorption and disfunctioning of other organs which may well lead to high temperature, and, which if not given timely attention, would worsen the general health of the child.

Figure 6.10 Risk of respiratory infection by incidence of diarrhoea and illnesses ever contracted

Diarrhoea

—E3_ Yes

Non-fatal

Illnesses ever contracted Source: Child Health Survey, Rawalpindi, 1992.

As can be seen in Figure 6.10, on an average, children who were not suffering from diarrhoea, whether having ever suffered from serious illnesses or not, were at a lower risk of contracting fever than those who had experienced an episode of diarrhoeal illness. Amongst those who had not suffered from diarrhoea, children other than those who had a serious illness in the past were 1.36 times more likely to get fever than children in the reference category. It should be noted that the odds of getting fever in this group is exactly the same (1.36) as for those (in the previous interaction) who did not ever suffer from life- threatening illnesses but belonged to households where one or more child had died. According to the explanations already given, these children were also 1.02 times more likely to contract fever than the group of children who were suffering from diarrhoea and who had ever suffered from one of the diseases included in the list as being fatal.

6.6.2.3. Type o f toilet and number of family members

Unhygienic living conditions associated with the type of toilet facility and exacerbated by the total number of household members are well demonstrated through the interaction between these two variables. Susceptibility to infections was lowest for children living in households with a maximum of five members and with a flush toilet in the house. These households probably represented families where the parents were living with one to three children. The parents of these children were most likely to be educated or perhaps more aware of the benefits of a flush toilet and the advantages of keeping it clean. The small household size also meant that the family lived independently (not in an extended family) where the mother could exert greater decision-making powers about the household affairs. With fewer family members, she was perhaps better able to manage the household work, such as keeping the house clean and providing better nutrition to the children along with devoting more time and attention to a smaller number of children (Figure 6.11).

Conversely, the results also suggest that children of families living in households with a toilet without a flush mechanism were at the highest risk (3.80) of contracting the infection compared with children in the reference category. This, however, is plausible as a large number of smaller families, though living independently, were living in houses shared by

Figure 6.11 Risk of respiratory infection by type of toilet and number of household members

Type of toilet — ' ---- Flush

— — Without flush

Number of household members

two to three households. In almost all such houses, only one water pipe and one toilet was used by the members of each household. It would be rather difficult for one mother who perhaps was more particular about hygiene, to always keep the toilet clean, especially when it was continually used by persons other than the family, who might not necessarily bother about the unhygienic living conditions leading to greater susceptibility to various infections.

Overall, the results suggest that children living in households, small or large, with a flush toilet, were at a lower risk of contracting respiratory infections than those belonging to households, small or large, which had a toilet without a flush. Within the two categories with a toilet without flush, children in households with six or more family members were around 0.51 times less likely to suffer from an infection leading to fever than those belonging to households with fewer members. This was mainly due to the fact that in larger and extended families there was more than one female to share the household work or perhaps large families, for example, with up to 22 family members were living in bigger houses with more than one toilet. Also, these single and large or extended families would be more responsible for keeping their immediate surroundings clean than those sharing with another household and disputing over whose turn it was to do the cleaning.

6.62.4. Religion and number o f living children

The results of the interactive effect of these two variables show that Muslim children belonging to households with 1-3 living children were at greater risk of contracting infections leading to fever than children in any other category, whether Muslims or Christians. Muslim children in households with 4-11 living children were 0.63 times at a lower risk than children in the reference category, indicating that a greater number of living children meant healthier surviving children who were at lower risk of infections and cross-infections. Although the mother had borne a relatively large number of children, she probably had greater knowledge about child health and was better able to provide an environment conducive to child health. Her greater child-care experience and the help of

Figure 6.12 Risk of respiratory infection by religion and number of children alive

Religion

— Musl i m

_43_ Christian

Number o f children alive

an older daughter would definitely be an added advantage. This, however, does not necessarily suggest that a sm aller num ber of living children was associated with inexperience or younger mothers. However, it does reflect a greater proportion of children dead, suggesting that the surviving children were relatively young and were being raised in similar conditions adverse to child health leading to a higher risk and susceptibility of infections and cross-infections (Figure 6.12).

However, in contradiction to the above finding, results for children born in Christian families suggest that those belonging to households with fewer children were at less risk (0.35) of contracting an infection than children in the reference category or for that matter children in any other category. Whether having experienced a child death or otherwise, these women were perhaps more particular about child health in general and specially in perceiving the condition as an illness in its early stages and in providing timely and appropriate treatment. Many Christian women were likely to take the sick child to a nearby hospital rather than to a nearby privately run clinic, unless the case was considered urgent, as going to the hospital meant spending more time waiting for the attention.

Christian children belonging to families with a large number of living children were at a lower risk of 0.79 than Muslim children in households with fewer living children, but were 1.25 and 2.26 times more likely to contract an infection compared with Muslim children living in households with a large number of children and Christian children living in households with fewer living children, respectively. Children in this group perhaps belonged to Christian mothers who had experienced fewer child deaths; although they did use the health care services, they had less knowledge about child health, but being older depended on their past experience which led to the survival of greater number of children. These children were probably also neglected because of lack of proper maternal attention

due to a large number of household members.