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Background: The objective of this study is to investigate the magnitude and nature of health inequalities between indigenous (Scheduled Tribes) and non-indigenous populations, as well as between different indigenous groups, in a rural district of Kerala State, India. Methods: A health survey was carried out in a rural community (N= 1660 men and women, 18-96 years). Age- and sex-standardised prevalence of underweight (BMI<18.5 kg/m2), anaemia, goitre, suspected tuberculosis and hypertension was compared across forward castes, other backward classes and tribal populations. Multi-level weighted logistic regression models were used to estimate the predicted prevalence of morbidity for each age and social group. A Blinder-Oaxaca decomposition was used to further explore the health gap between tribes and non-tribes, and between subgroups of tribes. Results: Social stratification remains a strong determinant of health in the progressive social policy environment of Kerala. The tribal groups are bearing a higher burden of underweight (46.1 vs. 24.3%), anaemia (9.9 vs. 3.5%) and goitre (8.5 vs. 3.6%) compared to non-tribes, but have similar levels of tuberculosis (21.4 vs. 20.4%) and hypertension (23.5 vs. 20.1%). Significant health inequalities also exist within tribal populations; the Paniya have higher levels of underweight (54.8 vs. 40.7%) and anaemia (17.2 vs. 5.7%) than other Scheduled Tribes. The social gradient in health is evident in each age group, with the exception of hypertension. The predicted prevalence of underweight is 31 and 13 percentage points higher for Paniya and other Scheduled Tribe members, respectively, compared to Forward Caste members 18-30 y (27.1%). Higher hypertension is only evident among Paniya adults 18-30 y (10 percentage points higher than Forward Caste adults of the same age group (5.4%)). The decomposition analysis shows that poverty and other determinants of health only explain 51% and 42% of the health gap between tribes and non-tribes for underweight and goitre, respectively. Conclusions: Policies and programmes designed to benefit the Scheduled Tribes need to promote their well-being in general but also target the specific needs of the most vulnerable indigenous groups. There is a need to enhance the capacity of the disadvantaged to equally take advantage of health opportunities. [ABSTRACT FROM AUTHOR]

Background: The health and well-being of widows in India is an important but neglected issue of public health and women's rights. We investigate the lives of Indian women as they become widows, focussing on the causes of their husband's mortality and the ensuing consequences of these causes on their own lives and identify the opportunities and challenges that widows face in living healthy and fulfilling lives. Methods: Data were collected in a Gram Panchayat (lowest level territorial decentralised unit) in the south Indian state of Kerala. Interviews were undertaken with key informants in order to gain an understanding of local constructions of 'widowhood' and the welfare and social opportunities for widows. Then we conducted semi-structured interviews with widows in the community on issues related to health and vulnerability, enabling us to hear perspectives from widows. Data were analysed for thematic content and emerging patterns. We synthesized our findings with theoretical understandings of vulnerability and Amartya Sen's entitlements theory to develop a conceptual framework. Results: Two salient findings of the study are: first, becoming a widow can be viewed as a type of 'shock' that operates similarly to other 'economic shocks' or 'health shocks' in poor countries except that the burden falls disproportionately on women. Second, widowhood is not a static phenomenon, but rather can be viewed as a multi-phased process with different public health implications at each stage. Conclusion: More research on widows in India and other countries will help to both elucidate the challenges faced by widows and encourage potential solutions. The framework developed in this paper could be used to guide future research on widows. [ABSTRACT FROM AUTHOR]

Background: Inadequate public action in vulnerable communities is a major constraint for the health of poor and marginalized groups in low and middle-income countries (LMICs). The south Indian state of Kerala, known for relatively equitable provision of public resources, is no exception to the marginalization of vulnerable communities. In Kerala, women's lives are constrained by gender-based inequalities and certain indigenous groups are marginalized such that their health and welfare lag behind other social groups. The research: The goal of this socially-engaged, action-research initiative was to reduce social inequalities in access to health care in a rural community. Specific objectives were: 1) design and implement a community-based health insurance scheme to reduce financial barriers to health care, 2) strengthen local governance in monitoring and evidence-based decision-making, and 3) develop an evidence base for appropriate health interventions. Results and outcomes: Health and social inequities have been masked by Kerala's overall progress. Key findings illustrated large inequalities between different social groups. Particularly disadvantaged are lower-caste women and Paniyas (a marginalized indigenous group), for whom inequalities exist across education, employment status, landholdings, and health. The most vulnerable populations are the least likely to receive state support, which has broader implications for the entire country. A community based health solidarity scheme (SNEHA), under the leadership of local women, was developed and implemented yielding some benefits to health equity in the community—although inclusion of the Paniyas has been a challenge. The partnership: The Canadian-Indian action research team has worked collaboratively for over a decade. An initial focus on surveys and data analysis has transformed into a focus on socially engaged, participatory action research. Challenges and successes: Adapting to unanticipated external forces, maintaining a strong team in the rural village, retaining human resources capable of analyzing the data, and encouraging Paniya participation in the health insurance scheme were challenges. Successes were at least partially enabled by the length of the funding (this was a two-phase project over an eight year period). [ABSTRACT FROM AUTHOR]

Background: In the Indian context, a household's caste characteristics are most relevant for identifying its poverty and vulnerability status. Inadequate provision of public health care, the near-absence of health insurance and increasing dependence on the private health sector have impoverished the poor and the marginalised, especially the scheduled tribe population. This study examines caste-based inequalities in households' out-of-pocket health expenditure in the south Indian state of Kerala and provides evidence on the consequent financial burden inflicted upon households in different caste groups. Methods: Using data from a 2003-2004 panel survey in Kottathara Panchayat that collected detailed information on health care consumption from 543 households, we analysed inequality in per capita out-of-pocket health expenditure across castes by considering households' health care needs and types of care utilised. We used multivariate regression to measure the caste-based inequality in health expenditure. To assess health expenditure burden, we analysed households incurring high health expenses and their sources of finance for meeting health expenses. Results: The per capita health expenditures reported by four caste groups accord with their status in the caste hierarchy. This was confirmed by multivariate analysis after controlling for health care needs and influential confounders. Households with high health care needs are more disadvantaged in terms of spending on health care. Households with high health care needs are generally at higher risk of spending heavily on health care. Hospitalisation expenditure was found to have the most impoverishing impacts, especially on backward caste households. Conclusion: Caste-based inequality in household health expenditure reflects unequal access to quality health care by different caste groups. Households with high health care needs and chronic health care needs are most affected by this inequality. Households in the most marginalised castes and with high health care need require protection against impoverishing health expenditures. Special emphasis must be given to funding hospitalisation, as this expenditure puts households most at risk in terms of mobilising monetary resources. However, designing protection instruments requires deeper understanding of how the uncovered financial burden of out-patient and hospitalisation expenditure creates negative consequences and of the relative magnitude of this burden on households. [ABSTRACT FROM AUTHOR]

Background: This study examines associations between female participation in a microcredit program in India, known as self help groups (SHGs), and women's health in the south Indian state of Kerala. Because SHGs do not have a formal health program, this provides a unique opportunity to assess whether SHG participation influences women's health via the social determinants of health. Methods: This cross-sectional study used special survey data collected in 2003 from one Panchayat (territorial decentralized unit). Information was collected on women's characteristics, health determinants (exclusion to health care, exposure to health risks, decision-making agency), and health achievements (self assessed health, markers of mental health). The study sample included 928 non elderly poor women. Results: The primary finding is that compared to non-participants living in a household without a SHG member, the odds of facing exclusion is significantly lower among early joiners, women who were members for more than 2 years (OR = 0.58, CI = 0.41-0.80), late joiners, members for 2 years and less (OR = 0.60, CI = 0.39-0.94), and non-participants who live in a household with a SHG member (OR = 0.53, CI = 0.32-0.90). We also found that after controlling for key women's characteristics, early joiners of a SHG are less likely to report emotional stress and poor life satisfaction compared to non-members (OR = 0.52, CI = 0.30-0.93; OR = 0.32, CI = 0.14-0.71). No associations were found between SHG participation and self assessed health or exposure to health risks. The relationship between SHG participation and decision-making agency is unclear. Conclusion: Microcredit is not a panacea, but could help to improve the health of poor women by addressing certain issues relevant to the context. In Kerala, SHG participation can help protect poor women against exclusion to health care and possibly aid in promoting their mental health. [ABSTRACT FROM AUTHOR]

Objectives To identify individual and urban unit characteristics associated with access to inpatient care in public and private sectors in urban Kerala, and to discuss policy implications of inequalities in access. Methods We analysed the NSSO survey (1995–1996) for urban Kerala with regard to source and trajectories of hospitalization. Multinomial multilevel regression models were built for 695 cases nested in 24 urban units. Results Private sector accounts for 62% of hospitalizations. Only 31% of hospitalizations are in free wards and 20% of public hospitalizations involve payment. Hospitalization pathways suggest a segmentation of public and private health markets. Members of poor and casual worker households have lower propensity of hospitalization in paying public wards or private hospitals. There were important variations between cities, with higher odds of private hospitalization in towns with fewer hospital beds overall and in districts with high private–public bed ratios. Cities from districts with better economic indicators and dominance of private services have higher proportion of private hospitalizations. Conclusions The private sector is the predominant source of inpatient care in urban Kerala. The public sector has an important role in providing access to care for the poor. Investing in the quality of public services is essential to ensure equity in access. [ABSTRACT FROM AUTHOR]

Abstract: Background: Alcohol consumption in India is disproportionately higher among poorer and socially marginalised groups, notably Scheduled Tribes (STs). We lack an understanding of STs own views with regard to alcohol, which is important for implementing appropriate interventions. Methods: This study was undertaken with the Paniyas (a previously enslaved ST) in a rural community in Kerala, South India. The study, nested in a participatory poverty and health assessment (PPHA). PPHA aims to enable marginalized groups to define, describe, analyze, and express their own perceptions through a combination of qualitative methods and participatory approaches (e.g. participatory mapping and ranking exercises). We worked with 5 Paniya colonies between January and June 2008. Results: Alcohol is viewed as a problem among the Paniyas who reported that consumption is increasing, notably among younger men. Alcohol is easily available in licensed shops and is produced illicitly in some colonies. There is evidence that local employers are using alcohol to attract Paniyas for work. Male alcohol consumption is associated with a range of social and economic consequences that are rooted in historical oppression and social discrimination. Conclusion: Future research should examine the views of alcohol use among a variety of marginalised groups in developing countries and the different policy options available for these populations. In addition, there is a need for studies that untangle the potential linkages between both historical and current exploitation of marginalized populations and alcohol use. [Copyright &y& Elsevier]