Exploring maternal birthplace and child gender disparities in markers of neglect and maltreatment among young children of immigrants by Ariel Pulver A thesis submitted in conformity with the requirements for the degree of Doctor of Philosophy in Epidemiology Dalla Lana School of Public Health University of Toronto © Copyright by Ariel Pulver June 2019 Exploring maternal birthplace and child gender disparities in markers of neglect and maltreatment among young children of immigrants Ariel Pulver Doctor of Philosophy in Epidemiology Dalla Lana School of Public Health University of Toronto 2019 Abstract Significant immigration to Canada has brought many cultures and parenting practices together, highlighting differences in child health and wellbeing. Given the increasingly large amount of migration from countries with high gender inequality, it is unknown how parental immigration interacts with child gender to affect healthcare and wellbeing in early childhood. In this dissertation, I present four studies regarding variation in routine preventive health care and maltreatment in very early childhood by maternal birthplace and child gender. The first study is a scoping review where I mapped the use of gender-based analysis in research on the health of children in immigrant families. I found that child gender is an understudied aspect of immigrant children’s health, thereby presenting an opportunity for further research. Next, in three population-based retrospective cohort studies, I compared the risk of three markers of child health care and well-being across immigrant maternal birthplaces in comparison to mothers born in Canada—immunizations, well-child visits at 24 months, and early child maltreatment at five years of age. To explore whether son preference affects child routine preventive care and maltreatment, I also compared outcomes between daughters and sons within families. ii I demonstrate that children of immigrants are well cared for concerning routine immunizations and are less likely to experience maltreatment in early childhood than children of non- immigrants. Maternal birthplaces associated with high levels of gender inequity do not seem to place daughters at risk of adverse outcomes compared to sons, except for a select case. Results support addressing vaccine hesitancy and child maltreatment in the general population to promote well-being in early childhood, as well as select targeted approaches among specific immigrant groups. My studies provide a model (including data sources, study design, and analytic techniques) to monitor and detect gender inequality in the general population as well as among minority groups. My research adds to the evidence around gender equity, which will hopefully ensure girls continue to achieve the same level of health care and well-being as boys. iii Table of Contents Abstract ......................................................................................................................................................... ii List of Tables .............................................................................................................................................. vii List of Figures ............................................................................................................................................ viii List of Appendices ....................................................................................................................................... ix Dissertation Overview .................................................................................................................................. x Dissertation Layout ...................................................................................................................................... xi Chapter 1 Literature Review and Rationale .......................................................................................... 1 1.1 Global gender inequity and the phenomenon of missing girls ...................................................... 1 1.2 Global gender disparities in child healthcare and well-being ....................................................... 2 1.3 Sex Ratios among Immigrant Populations .................................................................................... 5 1.4 Gender disparities in young immigrant children’s health ............................................................. 6 1.5 Markers of child health care and well-being ................................................................................. 6 1.5.1 Immunizations ....................................................................................................................... 7 1.5.2 Well-child visits .................................................................................................................... 7 1.5.3 Child abuse and maltreatment ............................................................................................... 8 1.6 Health and well-being among children of immigrants .................................................................. 9 1.7 Terminology ................................................................................................................................ 11 1.8 Gender-based Analysis ............................................................................................................... 13 1.9 Rationale and Objectives of Dissertation Studies ....................................................................... 13 1.10 My role in this work .................................................................................................................... 17 1.11 References ................................................................................................................................... 18 Chapter 2, Study 1: A Scoping Review of Female Disadvantage in Health Care Use Among Very Young Children of Immigrant Families ...................................................................................................... 25 2.1 Abstract ....................................................................................................................................... 26 2.2 Introduction ................................................................................................................................. 27 2.2.1 Gender inequity in children’s health around the world ....................................................... 27 2.2.2 Gender inequity in immigrant children’s health ................................................................. 28 2.2.3 Theoretical Framework ....................................................................................................... 29 2.3 Methods....................................................................................................................................... 30 2.3.1 Search Strategy ................................................................................................................... 30 2.3.2 Screening & Data Management .......................................................................................... 31 2.3.3 Quality Assessment ............................................................................................................. 33 2.4 Results ......................................................................................................................................... 34 iv 2.4.1 Characteristics of the Studies .............................................................................................. 34 2.4.2 Study Populations ............................................................................................................... 35 2.4.3 Consideration of Immigrant Status ..................................................................................... 36 2.4.4 Consideration of Gender and the Use of Statistical Comparisons ...................................... 37 2.4.5 Health Care Utilization Outcomes ...................................................................................... 37 2.4.6 Gender-Specific Reports of Study Outcomes ..................................................................... 38 2.4.7 Quality Assessment ............................................................................................................. 40 2.5 Discussion ................................................................................................................................... 41 2.5.1 Importance of Gender-Based Analysis ............................................................................... 42 2.5.2 Methodological Considerations for Health Care Research of Immigrant Children ............ 43 2.5.3 Strengths and Limitations of the Study ............................................................................... 46 2.5.4 Conclusion .......................................................................................................................... 49 2.6 References ................................................................................................................................... 51 Chapter 3, Study 2: Differences in the receipt of infant preventive primary care among Ontario-born children across varied maternal countries of birth ...................................................................................... 64 3.1 Abstract ....................................................................................................................................... 65 3.2 Introduction ................................................................................................................................