Does it Take a Village? Essays on Social Context and Child Development in India

Abstract

International discourse on community determinants of child health largely draws from evidence on high income countries. Adverse social and contextual exposures are deeply rooted in local histories, oppressions, and societal hierarchies, which may inform child health and development in unique ways distinct from western settings. As such, these diverse community contexts warrant their own dedicated scholarship in the international social epidemiology literature, to better understand and target child health inequities in interventions that may then account for local perspectives.

Guided by social ecological theories in child development and intersectionality, this dissertation focuses on measuring and estimating how contextually relevant community factors may shape distributions of child health and development in India. Despite considerable research and policy attention on child development in the last decade in India, community exposures are understudied and hardly ever considered in the epidemiology of child health in India. While focused on India, these findings likely have ramifications in South Asia, where community contexts share commonalities.

In chapter 1, I estimated children’s area level exposure to protracted internal conflicts rooted in local histories and insurgencies and studied their associations with child anthropometric outcomes. I merged geocoded conflict events data over 2010-2020 from an international conflicts database with residential clusters of children sampled in two waves of the Demographic Health Surveys data (2015-16 and 2019-21), to determine areas I defined as conflict exposed. Within these areas, using Log Poisson regressions with fixed effects for state, year, and area, family, and child level covariates, I found children who were exposed to violence in two developmental periods- in-utero and in early childhood had higher prevalence of stunting and underweight, but not wasting. Specifically, children exposed to violence between 0-3 years had 1.16 times (95% CI: 1.11,1.20) higher risks of stunting, 1.08 (1.04, 1.12) times higher risks of underweight, with no changes in risks for wasting, among children = 5 years. In-utero violence exposure was associated with 1.11 times (95% CI: 1.04, 1.17) higher risk of stunting, 1.08 (95% CI: 1.02, 1.14) times higher risk of underweight, and no change in risk for wasting, in children = 2 years. Children from minority castes and religions, and poor households who were already behind their advantaged counterparts, saw further drops in anthropometric scores under violence exposure.

However, deleterious community exposures often do not manifest singularly. Communities are inherently formed by multiple, interacting social exposures that both shape and are shaped by the lives of their constituents. The caste system, India’s historical system of social stratification based on inherited occupations, is premised on decreeing social norms based on hierarchical ordering of communities in their local environments. Yet, limited studies have quantitatively measured caste inequity at a community level or studied its role in informing child development outcomes. In chapter 2, based on the 2011-12 India Human Development Survey’s rural sample of 1,474 villages, I estimated typologies of village caste inequity context as a community level latent construct, using nine input variables that captured multiple intersecting dimensions of historically relevant structural disparities, and perceived social divisions. I then studied the association of village caste inequity context with adolescent learning outcomes, and found that children from villages I characterized as high on both structural inequities and perceived social divisions (HH), and those I described as high on structural inequities but low on perceived social divisions(HL), had 1.84 (95% CI:1.57, 2.10) and 1.45 (95% CI: 1.19,1.71) times the risks of not recognizing numbers compared to children living in villages who were low on both structural factors and perceived social divisions(LL). Importantly, relative risks for children from the most disadvantaged castes, Schedule Castes, in HL and HH villages were over twice and thrice that of their counterparts in LL villages, thus indicating significant interactions of village case inequity context with individual caste identity, to the detriment of historically oppressed castes.

In paper 3, I explored interactions in two historically rooted dimensions of social identity in India, that tend to be treated as unique in epidemiological analysis. Using nationally representative survey data from five waves of National Family Health Surveys over 30 years, and based on an intersectional framework, I estimated joint disparities by Muslim and caste/tribal identities in children of =5 years. Predicted prevalence of stunting in different subgroups were as follows- Hindu Other: 34.7% (95%CI: 33.8 , 35.7), Muslim Other: 39.2% (95% CI: 38 , 40.5), Hindu Other Backward Classes (OBCs): 38.2 (95%CI: 37.1 , 39.3), Muslim OBC: 39.6% (95%CI: 38.3 , 41), Hindu Schedule Castes (SCs): 39.5% (95%CI: 38.2 , 40.8), Muslims identifying as SCs: 38.5% (95%CI: 35.1 , 42.3), Hindu Schedule Tribes (STs) : 40.6% (95% CI: 39.4 , 41.9), Muslim STs: 39.7% (95%CI: 37.2 , 42.4). The highest Hindu advantages (relative to Muslims) were observed among Forward or Other castes. While Hindu OBCs and Hindu SCs also had advantages over their Muslim counterparts, they were less pronounced, such that negative effects of backward caste identity seemed to override those of Muslim identity. These findings supported religion and caste/tribe identities as simultaneous, interacting axes of social inequities in India and South Asia, that warrant joint consideration. Treating them independently obscures the scale and nature of child health inequities in India, and masks vulnerable subgroups who could benefit from targeted policy action.

Thus, using different datasets and analytic methods, I measured aspects of the community embedded in local histories, power structures and social stratification systems, and estimated their associations with different measures of child development, at different sensitive periods. My work calls for more intentional integration of community exposures as active drivers of child development in India and other LMICs, and consideration of their interactions with individual minority identity of children, with a goal towards reducing child health disparities.