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Health inequalities
P63 Mandated attendance at parenting workshops improves women's healthcare knowledge but may widen health inequities in low and middle income countries
  1. I Forde1,
  2. T Chandola1,
  3. M G Marmot1,
  4. O Attanasio2
  1. 1Department of Epidemiology and Public Health, University College London, London, UK
  2. 2Department of Economics, University College London, London, UK


Background Conditional cash transfer schemes (CCTS) are relatively new policies in low and middle income countries which aim to improve the health and welfare of poor families by investing in their knowledge, skills and resources. Families are offered regular cash as long as they comply with certain conditions. One of these is that mothers/carers attend workshops where parenting and children's healthcare issues are discussed. We hypothesised that presence of a CCTS in Colombia would be associated with an increase in women's healthcare knowledge.

Design and Setting We analysed data from Familias en Acción, Colombia's national CCTS. Households from participating areas and control areas (matched on environmental and socioeconomic criteria) were prospectively surveyed in 2002 and 2006. Women were asked three questions on home-management of acute diarrhoeal illness (ADI), an important cause of childhood mortality for which cost-effective, home-based interventions are available. The sample comprises 5047 women from areas where Familias was operating and 3461 women from control areas.

Outcome Measure and Analysis A marker of healthcare knowledge was constructed from responses to survey items on home-management of ADI, using WHO guidelines to identify correct responses. The effect of Familias was estimated using an ordered probit model, controlling for individual, household and regional characteristics.

Results Familias was associated with nearly three-fold higher workshop attendance (×2.6, p<0.05) and improved knowledge at follow-up (probit coefficient, β=0.160, p=0.010). Multivariate analysis indicated that women's age (β=−0.002, p=0.042), literacy (β=0.221, p<0.001), level of completed formal education (β=0.260, p<0.001) and involvement in community activities (β=0.057, p=0.033) were independently associated with improved knowledge. Household wealth (β=0.045, p=0.030) and head-of-household literacy were also independently associated (β=0.072, p=0.015). Women's literacy (76%) did not improve.

Conclusions Familias is associated with increased healthcare knowledge amongst participating women. Women who are younger, literate, better educated, involved in their community and who live in better-off households with a literate head-of-household, however, show greater knowledge gain relative to other households. CCTS may widen health inequities by leaving behind women with lowest levels of completed formal education, household resources and community participation. Further thought must be given to the role these workshops play in relation to overall CCTS objectives. The most marginalised households may benefit from additional support to overcome illiteracy and strengthen community involvement.

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