Fathers' Perception of Child Health: a Case Study
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Health Transition Review 5, 1995, 191 - 206 Fathers’ perception of child health: a case study in a squatter settlement of Karachi, Pakistan* Albrecht Jahna and Asif Aslamb aUniversity of Heidelberg, Institute of Tropical Medicine and Public Health bUNICEF Pakistan, Karachi, formerly Aga Khan University, Karachi Abstract This study looks at child health from a father’s perspective. While the close relationship between children and mothers has been acknowledged, and brought about the concept of Mother and Child Health (MCH), little attention has been paid to the role of fathering. In Pakistan, where the study was undertaken, a high infant and under-five mortality coincides with a low acceptance of MCH services and a tradition of female seclusion, , which severely limits women’s movements in public. Purdah is often cited as an important cause for the low MCH-coverage, indicating an inappropriate design of established MCH-services with its exclusive focus on mothers, and prompting the questions taken up in this study: what is the role of fathers in child health, how do they define child health needs and how do they participate in child care? The study was undertaken in the squatter settlement Orangi in Karachi where the Aga Khan University is involved in a PHC program. A set of qualitative methods was used including key informant interviews, focus group interviews with fathers, group interviews with women and community health workers with a total of 61 informants, and observation of father-child interaction. Apart from their basic role as breadwinners, most fathers participate directly in child care. As far as working hours allow, fathers spend time with their children by taking them out or playing with them. Among 174 cases of child holding in roads and places, 75 per cent were carried by the father; this was true for the majority of children even in the mother’s presence. One-third of children brought to general practitioners were accompanied by the father. Fathers help their wives in child care in activities like feeding, soothing, bathing and giving medicine; a considerable minority even changes nappies. In the socio-cultural context, the high level of male involvement especially in caretaking outside the house can be seen as a coping mechanism with the tradition of female seclusion. The qualities of fathers as key decision-makers and second line caretakers and *This study was a joint collaboration between the University of Heidelberg and the Aga Khan University, Karachi, and formed part of a thesis for an M.Sc. Course in Community Health and Health Management at the University of Heidelberg. The authors are much indebted to Prof. J. Bryant, former head of the Department of Community Health Sciences of AKU, for his encouraging support and advice. We gratefully acknowledge the help of Ms. N. Khatoon in moderating the focus groups, of Mr. Mastullah for interpreting and organizational support and of Ms. T. Jamal and the other members of the Orangi PHC-team. We also want to thank our informants in Orangi for their friendly collaboration.We are particularly thankful to Prof. S. Rifkin, who as the thesis tutor supported this study throughout with valuable advice and interest and critically reviewed the manuscripts. 192 Albrecht Jahn and Asif Aslam mothers’ role as primary caretakers call for a two-pronged approach to child health, addressing and involving both parents. Up to now child health problems have been addressed almost exclusively in the context of Mother and Child Health (MCH) programs. There are valid reasons for regarding mothers and their status as crucial for their children’s future: mothers’ education and their autonomy in decision-making have been repeatedly found to be strong determinants of child health (Caldwell 1986; Doan and Bisharat 1990). However, little attention has been paid to the role of fathering. Regarding non-Western Societies Hewlett (1991) concluded: The researchers do not know much about the father’s role and simply claim that it is minimal. These factors have contributed to the complete absence of systematic studies in non-Western societies of the father’s role in infant and child development. Although fathers’ contribution to child health has been acknowledged (Williams, Baumslag and Jelliffe 1985: 154, 181, 271; Reitmeier 1989), only minimal attention has been given to fathers’ perception of child health needs, and fathers have not been addressed in the context of child health programs. In an attempt to counterbalance this deficiency, the study focuses on fathers as contributors to child health with special emphasis on fathers’ concept of child health needs and fathers’ participation in child care. Considering the lack of previous research to build on, the primary intention was to gather baseline information and to prepare the ground for more specific research. The study context According to the United Nations Development Programme, Pakistan belongs to the low- income group of developing countries with a third of its 112 million inhabitants living below the poverty line. The South Asian country has a population growth of 3 per cent per year (UNDP 1991); basic health indicators for 1991 show high infant and under-five mortality rates of 97 and 139 per 1000 live births (World Bank 1993). This has coincided with low coverages in Mother and Child Health. In 1982 coverage for antenatal care was 26 per cent, for vaccination 5 per cent and growth monitoring 3 per cent (Mahmud 1986). Despite considerable efforts to expand MCH services in the course of the Accelerated Health Programme, launched in 1983, vaccination coverage could be increased till 1991 to 35 per cent only and coverage of antenatal care remained unchanged with 26 per cent (National Institute of Population Studies 1992). Polio, reduced to almost zero in most developing countries and targeted for eradication by WHO, is on the increase with 1803 registered cases in 1993 (WHO 1995). A mismatch of the established way of service delivery with the tradition of female seclusion, Purdah, with its restrictions on women’s appearance and movement in public, was repeatedly identified as an important reason (World Bank 1989; Aga Khan University 1990). Purdah consists of a set of rules ensuring the segregation of sexes outside well defined categories like extended family and next kinship. This is achieved either by seclusion of women at home or by the use of the burqa, a concealing veil. Related to Purdah, South Asian Muslims follow a system of arranged marriages, usually among cousins (Papanek 1982). The study was conducted in Karachi in the squatter settlement Orangi, where there has been a Primary Health Care Programme of the Aga Khan University (AKU) since 1986. Health Transition Review Fathers’ perception of child health in a squatter settlement, Karachi 193 The study area Situated in Karachi’s District West, Orangi has an estimated population of one million and is reported to be the largest squatter settlement in South Asia. Fifty per cent of its population are below 15 years old. Ninety per cent of the population are Mohajirs, Muslim immigrants from India and the former East Pakistan, now Bangladesh; the remaining 10 per cent are migrants from other parts of Pakistan: Punjabis, Balochis and Pathans. The pattern of cousin marriage is found in about half of couples. The literacy rates are 62 per cent in males and 41 per cent in females, which is above the national average of 57 per cent in males and 32 per cent in females but below the national average for urban areas with 73 per cent and 57 per cent respectively (National Institute of Population Studies 1992). The average monthly family income in 1991 was 2300 rupees, equivalent to 92 US dollars. Occupations among Orangi residents include skilled office workers, permanently employed factory workers in a steel mill and garment factories, small-scale home-based industries, artisans, street vendors and a large group of day labourers. Ninety per cent of the houses have piped water, and almost all have electricity; however, the supply of both is frequently interrupted. Drug addiction has emerged as a major social problem in recent years. A countrywide survey in 1988 revealed over a million heroin addicts, roughly one per cent of the population (Government of Pakistan 1993), the estimate for urban squatter areas being at least twice as high. The Primary Health Care field site of Aga Khan University in Orangi covers a defined geographical area with 9517 registered inhabitants in 1506 households (93% of all households in the area), including 1383 children under five years. In 1991 the infant mortality rate was 77 per thousand live births and the prevalence of malnutrition according to the Gomez Classification was 36 per cent for first, 6 per cent for second and 1 per cent for third degree malnutrition. The most common diseases were diarrhoea, cough and feverish illnesses including malaria; the leading causes of death in under-fives were diarrhoea, respiratory tract infections, malnutrition, low birth weight and fever. Polio accounted for 30 per cent of childhood disability, followed by meningitis and perinatal problems with 15 per cent each. Within the field site the main MCH interventions are performed by a team of female community health workers (CHW) through monthly household visits, and include growth monitoring, vaccination, antenatal care and health education. This service is backed by a Primary Health Care centre which offers also curative care. Outside the field site, MCH service delivery follows the usual centre-based approach with dispensaries, hospitals and private clinics as the main outlets. According to survey findings and field site reports of Aga Khan University, the household-based approach has resulted in an increased coverage of MCH interventions. Complete vaccination coverage was 80 per cent within the field site against 41 per cent in other areas of Orangi and 46 per cent in urban areas on a national level (National Institute of Population Studies 1992).