The epidemiology of inequalities in health and health care in rural Mexico
The objective of this study was to document the social inequalities existing in both health status and health care utilization in rural areas of the Mexican state of Tlaxcala. Whilst previous studies on the subject undertaken in Mexico and elsewhere have focused on examining differences between heterogeneous socio-economic groups within urban areas and between urban and rural areas, this investigation concentrated on analysing differences between groups and communities within rural areas which are considered to be more homogeneous. Particular attention was paid to examining differences between agricultural and non-agricultural occupations and between agricultural groups. To compare the overall health of groups and areas, three different kinds of health measures were used: self-reported morbidity, childhood mortality, and positive health (based on self-appraisal of health state). Four types of morbidity measures were used: overall morbidity, number of symptoms reported, morbidity of high severity, and type of illness reported. Health care utilization was analysed in relation to perceived need. Social markers included both individual and area-based measures of socio-economic status. The. former included measures such as educational level, occupation, land tenure and type, social class, source of medical care, entitlement to social security, frequency of meat consumption and housing conditions. The area-based measures included a composite index of living conditions and size of. the locality. The data were collected during a health interview survey of 1238 households (6622 individuals), sampled from households in localities with less than 15,000 inhabitants in the state of Tlaxcala. The sample was drawn by a multistage stratified cluster sampling scheme. The general trend found was a significant rise in morbidity with decreasing socio-economic position, living standards and size of the locality. Agricultural occupations showed worse perceived health conditions than non-agricultural occupations, and among the former, waged labourers and peasants with access to poor-quality-land tended to have higher morbidity rates and appraised more unfavourably their health. Among females, those working at their homes had worse health conditions. Amongst the morbidity measures, the one based on severity of illness displayed the largest differentials and showed an inverse association between socio-economic status and prevalence of gastrointestinal diseases and musculoskeletal problems. Nervous and mild psychiatric problems were more prevalent in deprived small villages. Childhood mortality was higher among children in families whose head had less schooling, a lower agricultural occupation, no social security, poor housing conditions, and among those living in the most deprived villages. Findings on unfavourable ratings of health paralleled those on perceived morbidity and showed the largest differentials between, social groups. Among the social measures, education allowed the construction of groups that displayed the widest differentials. The results showed a decreasing trend in health care utilization (illness-related and preventive contacts) with decreasing socio-economic position and living standards. The pattern of utilization suggests that the access to the health services is highly stratified and does not reflect the level of real need. The relatively high use of private services suggests a poor quality of the public services. The advantages and limitations of the different health indicators and social measures used is discussed. The results have implications for health policy and planning at both central and local levels. The recommendations suggested have implications which are far wider than the health sector alone.