Nousheen Akber Pradhan  ( Department of Community Health Sciences, Aga Khan University )
Tazeen Saeed Ali  ( School of Nursing and Midwifery and Department of Community Health Sciences )
Fauzia Basaria Hasnani  ( Department of Community Health Sciences, Aga Khan University )
Shireen Shehzad Bhamani  ( School of Nursing and Midwifery, Aga Khan University, Pakistan )
Rozina Karmaliani  ( School of Nursing and Midwifery and Department of Community Health Sciences )

Objective: To determine the socio-economic status of a peri-urban community.
Method: The cross-sectional study was conducted at Deh Chuhar village, Gaddap Town, Karachi from December 2015 to February 2016. The Water/Sanitation, Assets, Maternal Education and Income Index was used. All variables were given a score on the scale of 0-8. The resulting index was illustrated in the form of quintiles.
Results: A total of 254 households were surveyed. Total population was 2117 with mean number of household members being 8±4. Mean index score was 0.39±0.14 and the median score was 0.375. Percentile distribution of the score indicated that 152(60%) households scored below 0.40 whereas, 51 (20%) were in the highest quintile with a score above 0.50.
Conclusion: Water/Sanitation, Assets, Maternal Education and Income index suggested poor socio-economic status of the community studied.
Keywords: Socio-economic status, WAMI index, Health outcomes, Deh Chuhar, Developing SES. (JPMA 68: 709; 2018)

Introduction

Socio-economic status (SES) helps to gauge family\'s and community\'s standing in relation to society. SES can be broadly defined as an individual\'s and community\'s access to financial, social, cultural and human capital resources.¹ Along with resource accessibility; it serves as an important determinant to assess quality of life at individual, household, community and national levels. In population and public health researches, SES has been linked to assess various health outcomes such as nutritional status, accessibility, acceptability, utilisation of services, morbidity and mortality in the longer run.^2,3 In educational researches, association of SES has been studied to see its effect on development,⁴ academic  attainment⁵ and school attendance⁶ of children.In addition, SES has also been linked with maternal health outcomes⁷. There is no single best approach in estimating SES,⁸ therefore researchers often get confused in deciding the indicator to use for measuring SES. Literature, however, provides different quantitative approaches such as, using different variables to measure SES at a community level or at a national level.^1,8-10 Health  researches in developed countries have used various indicators to measure SES, including income, education, occupational status, living conditions such as housing, leisure activity and ownership of assets etc.¹¹ Developing countries, on the other hand, have taken into consideration housing characteristics like wall and roofing material, cooking and lighting fuel, source of drinking water, sewage system, tenure¹² alongside education, occupation and income to measure SES. To develop a SES measure, contextual factors must also be considered such as urban/rural differences accounting for variations between and across the countries.¹³ For collecting information on income, several challenges have been identified due to informal work, monthly fluctuation and reporting biases.^14,15 As an alternative to income, data is collected on different household assets, possessions and infrastructure.^16-19 This has been the most widely used approach of supplementing data on income.^13,16,20 World Bank has pioneered the use of an \'asset index\' to estimate household wealth .^17,21 However, debate revolves around the use of \'assets\' as a measure of income and their interpretation. Ownership of household possessions, for instance, may not capture the quality of assets. Data collected on ownership of assets, for example a TV set, and can also fail to distinguish between affluent and an impoverished household that may own TV sets at economically varied ranges. Nonetheless, this does not alter the overall picture of wealth.^16,19 In addition, Principal Component Analysis (PCA) is the commonly used approach for measuring wealth index on the basis of household assets.^17,22 Information on parental education attainment is also considered as one of the measures of SES.^1,22,23 In this regard, 16 years of education is considered for either of the parents or by the head of the household.^22,24 Through Hollingshead measure24 the SES score is computed by giving a score to formally acquired education starting from 7th grade up to graduate training. Alongside parental education, parental occupation is also used as a measure for SES in Hollingshead system ²⁵ and has also been recommended for estimating SES. ¹ Occupation is also considered as a measure of SES in relation to individual\'s social standing, income and intellect.⁸ Within the occupational category, current or longest held occupation of a person is also used by several studies.¹³ However, with increasing interest in the role of SES, parental occupation is used as an indicator of childhood socioeconomic position.²⁶ Community\'s access to safe drinking water and better sanitation is a critical component for improved health and socioeconomic development.²⁷ Therefore, access to improved water and sanitation is taken as an important determinant for improved health outcomes and is thus considered for estimating/constructing SES index.^17,22 In this regard, World Health Organization (WHO) criterion for improved water and sanitation facilities for classification purposes has been referred by the researchers.²⁷ Under housing characteristics and overall infrastructure, various aspects are assessed, including housing condition (material of dwelling, overcrowding etc.), ownership status of the house, number of rooms, ownership of farm etc. This also includes household amenities such as availability of hot and cold water, presence of central heating, carpets, use of bathrooms and toilets, location of toilet such as inside or outside the house, ownership of a refrigerator, washing machine or telephone. All of these household amenities are considered markers of material circumstances. ⁸Moreover, information can also be obtained on the neighborhood which may include availability of parks, buildings, and the percentage of population varying in their socio-economic status. This serves to provide a rich construct to SES.¹ In order to obtain comprehensive socio-economic information, composite measures (with multiple SES indicators) have been widely used and advocated as these capture several aspects of SES.^{9,12,19,22,28} To name a few SES indices, Duncan\'s index29 takes into account education and income, Living Condition Index assess housing, health, leisure activity and ownership of durables to estimate well-being.11 Asset Index is a proxy measure of the household wealth and has been used in demographic and health surveys (DHS) to overcome the problem in absence of information on income.^21,30 Lately, Water/Sanitation, Assets, Maternal Education and Income (WAMI) index has been used in multiple developing countries to measure SES.²² For measuring SES, young researchers often face problems in coming up with a set of variables and deciding its measurement criteria. To our knowledge, no consolidated SES measure has so far been recommended for use in low-middle income countries (LMIC) setting. The current study was planned to determine the SES of a peri-urban community using the WAMI index.

Subjects and Method

The cross-sectional study was conducted at Deh Chuhar village, Gaddap Town, Karachi, from December 2015 to February 2016. This village has eight union councils with over 400 villages. The Deh Chuhar area is a cluster of 34 villages. The total households in the village were 2,052 with approximately 10,750 population, predominantly Sindhi-speaking.³¹

The sample size was calculated in Open EPI using the formula:

The sample was inflated by about 20 per cent as insufficient data of the enrolled subjects was expected. After approval was obtained from the ethics review committee of the Aga Khan University, Karachi, we startedour household survey among those who furnished written informed consent. Households with women of child-bearing age (15-49 years) were recruited. Houses in >3km range from the local government school and women of child-bearing age not having a child in the household were excluded. The sample was drawn using a systematic sampling technique. We sampled every Kth house, where K represents the constant sampling interval (every third house) based on the number of households to be sampled from total households in each village. Only one woman of child-bearing age with at least one child was interviewed. All study subjects were interviewed by trained interviewers using pre-tested close-ended survey questionnaire. The questionnaire was adapted from the Pakistan Demographics and Health Survey (PDHS) instrument.¹⁹ The questionnaire collected information on demographics, health status, school enrollment status, maternal health and domestic violence. The questionnaire was pre-tested in nearby villages on approximately 5-10% of the actual sample to assess the flow and clarity of the questions. Needed modifications were carried out in the questionnaire which was administered in Urdu and Sindhi languages as per the convenience of the participant. For measuring SES, we adapted the WAMI index which has been used earlier across multiple sites in resource-limited settings.²² The choice of the index depended upon several factors. Firstly, the index has been applied in multiple countries, including Pakistan. Secondly, WAMI index could be used for comparison purpose in the country because of the available estimates of the SES in a peri-urban site. Thirdly, the construct validity of the index has been established by an earlier study.²² Our adapted index also comprised four variables. This included access to improved water and sanitation, presence of eight priority assets, mother\'s year of schooling up to 16 years, and monthly household income (Table-1).



WHO standards on improved water and sanitation source were used.²⁷ each variable was measured on a scale of 0-8. All four scores once obtained were summed up and divided by 32 to get WAMI index range from 0 to 1, with 0 representing poor SES, and 1 representing high SES. For the purpose of analysis, WAMI scores were converted into quintiles.

Results

A total of 254 households were surveyed. The total population was 2117 with the mean number of household members being 8±4. Children under the age of five years numbered 318(15%), while there were 486(22.9%) women. Demographic details were all noted down (Table-2).



Mean WAMI score was 0.39±0.14 with a median score of 0.375. Of all the households surveyed, 152(60%) were below the score of 0.40, whereas 51 (20%) were with a score above 0.50. (Table-3).

Discussion

The current study used a comprehensive approach by constructing an index for measuring SES. Our SES index comprised of water and sanitation, assets, maternal education and household income in the community residing in a peri-urban area of Karachi. The study showed that 60% of the households fell under the lowest quintile and only 20% in the highest. Likewise, the national level survey has also reported poor SES, particularly in the rural areas of the country.¹⁹ According to the World Bank, majority of the population in Pakistan is clustered around the poverty line.³² The mean WAMI score obtained in our study is very low. Its mean being 0.39 indicates very poor social standing of the community. Poverty, as determined by SES, continues to be the root cause of other proximate correlates such as access to education, healthcare, nutrition, housing and large family size.^33,34 In this regard, association of SES  with health and education is widely documented in literature.^{20-26,28-30,34,35} Various studies have examined the relationship between student\'s academic performance with their social and economic background,  where low SES proved to be one of the contributors towards students\' low academic performance.^36,37 On the other hand, health outcomes
are largely shaped and affected by SES.⁹ Importantly, but not exclusively, maternal and child health outcomes are widely studied in the context of developing countries and its adverse health effects on mother and child is linked to parental education, family income etc.^38,39 Deh Chuhar, being a disadvantaged community due to poor SES, will be at high risk of facing these issues. This, therefore, calls for the attention of local non-government organisations (NGOs) and government authorities to plan risk protection strategies as well as a sustainable development programme for the community. Inability to compare our findings with other studies at the national level is a big limitation of the current study due to variation in the approaches to measure SES which exists not only at the country level but also at the regional and international levels. For instance, PDHS2012-1319 used the Wealth Index which mainly takes into consideration household ownership of assets. On the other hand, use of varied indicators in SES index used in different studies doesn\'t allow researchers to draw comparisons among different countries. This poses a big challenge to the researchers and the stakeholders interested in drawing comparisons on the basis of SES. In the absence of a standard measurement of SES, researchers in the past have typically used their own socioeconomic indicators. This approach has made comparisons very difficult and implausible.⁹ Economic evaluations are instrumental in informing resource allocation for comparisons across sites, groups and communities. Lack of standard measurement of SES will open avenues for subjective decision making to judge SES parameters for resource allocation.⁴⁰ As a way forward, we recommend systematic research to be conducted on different measures of SES being used in health researches both at national and regional levels. In the absence of a recommended SES measure, WAMI Index would be helpful to researchers in selecting a set of SES measures according to their study\'s requirements. Further, there is a dire need for a recommended comprehensive SES index which can be safely used for comparison purposes within and among countries. A need for an SES index, instead of individual variables, is stressed as there is always a need for multi-dimensional perspective to measure SES.^9-22 In the context of developing countries especially in rural areas where multiple factors influence social determinants of health, there is a need for a comprehensive measure to assess SES; which was well taken care of in this study. In general, information on SES is not readily available for peri-urban locations; therefore, SES of this study can serve as an estimate for similar sociogeographic locations. Another major strength of the study is the use of a validated SES index and the validity of the WAMI index is also carefully and appropriately documented.²² Additionally, WHO and the United Nations International Children\'s Emergency Fund (UNICEF) defined criteria for measuring improved water and sanitation were used in the study.²⁷ Our approach in estimating SES has few limitations. Though occupation is also one of the measures of estimating SES, its use has mainly been cited in the context of developed countries.²⁹ In the absence of any objectively established criteria for occupational category, we could not incorporate occupation in our SES index. This, however can be used as a measure of SES estimate in LMICs with a well-defined criteria to facilitate researchers in rating the occupational rank. We did not take into consideration paternal education in our index. In future studies, along with maternal education status, paternal education can also be given due attention for inclusion in the comprehensive SES index.

Conclusion

The study comprehensively measured SES of a peri-urban settlement in Karachi using WAMI index. It indicated poor SES of the community studied. Poverty significantly affects social determinants of health and the poor SES status should draw the attention of all concerned.

Disclaimer: None.
Conflict of Interests: None.
Source of Funding: Rural Educational Development and Promotion Society (REPDS), Karachi.

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