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Gender difference in quarterly out of pocket expenditure on Diabetes care in Thoothukudi – a cross-sectional study

*Author for correspondence: Dr. Sudharshini Subramaniam, MD, Associate Professor, Institute of Community Medicine, Madras Medical College, Chennai-03. Email id : sudharshini.subramaniam90@gmail.com ABSTRACT Background: Diabetes Mellitus is a long term disease which require higher medical expenditure. If inadequately treated or undiagnosed, it leads to multiple chronic complications, which again increase the expenditure multi-fold. Gender has got implications in diabetes care due to sex differences as well as that of social inequities entrenched within gender. This study is done to compare quarterly Out of Pocket expenditure (OOPE) on diabetes care with gender as a covariate. Methods : Quarterly OOPE is defined as any expenditure incurred by households as a payment to health practitioners and suppliers of pharmaceuticals, therapeutic appliances and other goods and services during the last three months due to diabetes. A cross sectional study was done in Thoothukudi Corporation among 180 diabetic patients using a semi structured questionnaire. Results: Among the study participants, 49.2%were males and 50.8% were females. The median quarterly OOPE for males was Rs.2387 with an interquartile range of Rs.2742 and that of females was Rs.1249.42 with an interquartile range of Rs.2836 which was statistically significant(p value -.0.01). The proportion of family monthly income spent on diabetes care was also significantly lower for women(2.6%) compared to men (4.48%). Conclusion: The quarterly OOP expenditure was significantly lower among women compared to men. In a country like India, where larger share of health expenditure is contributed through OOPE, this finding is revealing that gender equity in diabetes care is nowhere near its reach.


INTRODUCTION
Gender inequity is a phenomenon which is well recognised in health and also in access to health care. [1][2][3][4][5][6] The prevalence of diabetes is increasing most rapidly among women. Also, women with diabetes are at increased risk of developing complications like coronary artery disease, kidney disease, blindness and depression than their male counterparts. Women also have the higher prevalence of risk factors of Diabetes like overweight, physical inactivity compared to men. 7 Diabetes Mellitus is of concern not only because of the impact it creates physically, but also because it creates an impact on the emotional, psychological, social and economic aspects of the individual as well as that of their family. [8][9][10][11][12][13][14][15][16] Diabetes Mellitus is a long term disease which requires higher medical expenditure. 17 If inadequately treated or undiagnosed, it leads to multiple chronic complications, which again would increase the expenditure multifold. 15,18 Diabetes which is called as a costly disease by United Nations, with weaker public health system in addition would warrant a higher out of pocket expenditure from the patients. 17 Women's higher risk of getting diabetes and its complications, could not only be explained by the biological differences, but also social structure plays a significant role. 19 Gender has got implications in diabetes care, due to sex differences and the social inequities entrenched with gender. While studies have looked at various social covariates and diabetes outcomes as well as expenditure, gender has not been looked closely. 20,21 Studying gender from close quarters would pave way for improving equity in diabetes care. Quarterly OOPE is defined as any expenditure incurred by households as a payment to health practitioners and suppliers of pharmaceuticals, therapeutic appliances and other goods and services due to diabetes in 3 months recall period. OOPE includes direct medical cost (money spent on consultation, investigation, medication, hospitalization, management and treatment of complications), direct nonmedical cost ( money spent on transport to health facilities and lifestyle modification) and indirect cost(income lost to the patient and caregiver due to absenteeism). The findings of this study will help in understanding gender inequity in OOPE and explore strategies to bring in parity. The objectives of this study is to study the gender difference in the quarterly OOPE and the factors influencing the difference.

National Journal of Research in Community Medicine│Apr-Jun.2019│ Vol 9 │Issue 2│
This study is a sub study of another study which aimed at assessing the quarterly OOP expenditure incurred towards diabetes care.

METHODS
A community based cross sectional study to assess the out of pocket expenditure on diabetes care was conducted among people with diabetes mellitus in urban areas of Thoothukudi Corporation of Tamilnadu during April 2016 to June 2016.The district sex ratio is 1023, which is higher than Tamilnadu's sex ratio of 996.Thoothukudi had relatively lesser gender inequity if sex ratio were to be considered as a proxy measure of gender equity. The study population included diabetic patients, more than 18 years of age with at least 3 months elapsed since the diagnosis of the disease, residing in the selected wards of Thoothukudi corporation. Gestational Diabetes Mellitus and guests who were present in the house were excluded from the study. The operational definition for Diabetic patients was those who had a history/clinical record for "physician diagnosis of diabetes and/or current use of medications for diabetes (insulin or oral hypoglycaemic agents). The sample size was calculated for the main study with the objective of estimating the OOPE. The Mean quarterly OOPE was estimated to be Rs.3208.99 and Standard deviation Rs.2095.90 based on a pilot study. Therefore for a 95% confidence level and 10% relative precision of estimate, the sample size calculated was 164. Allowing 10% non-response rate, total sample size required came around 180.The sampling for the study population was carried out as Multi stage sampling method. In the first stage, two zones were selected of the four zones randomly. In the second stage five wards were randomly chosen from the selected zones. In the selected wards, a street was randomly selected from the list of streets. Then a random direction from the centre of the street was randomly selected by a spin of a pen. The houses in that direction were visited till 18 diabetic patients were obtained. In each house, all individuals who were fulfilling the criteria of operational definition were selected for the study. The study tool was a semi-structured interview-based questionnaire administered by the investigators which was validated with the help of experts and pilot study and necessary modification was done after the pilot study. The questionnaire included details on socio-demographic details, disease profile, diabetes treatment seeking behaviour, details of expenditure on diabetes care in 3 months recall period and coping mechanism for increasing health-care expenditure. To avoid recall bias , the study participants were given sufficient time to reflect and think before answering and the self-reported information was verified through proxy sources like medical records, prescription and lab reports, bills, medicine blister packs. Socio-economic classification was done according to B.G. Prasad Classification based on the Consumer Price Index of May 2016. 22 Recent fasting and post-prandial blood glucose values taken during the past three months were obtained from available clinical records. A person was said to be under good glycemic control if the FBS value was < 126g/dl and PPBS <200g/dl in the most recent laboratory investigation done within last 3 months.Individuals who did not have blood sugar values tested in the last 3 months were considered glycemic level unknown. The clinical and expenditure details collected from the participants were crosschecked with records and bills available at the time of visit. Among the study participants, anybody with history of hospitalisation had all the bills. Among others, bills were available for verification with nearly 40% of the participants. In case of unverifiable bills, self-reported expenditure was cross verified with the routine cost of medicine, lab investigations and consultation fee based on the market price. Ethical approval for the study was obtained from the Institutional Ethics Committee. Information sheet was read to the individual and the purpose of the study was elaborated to the participants. After obtaining informed written consent from the individual, face to face interview was done based on the semi-structured questionnaire.
Analysis: Data was collected from 180 diabetic patients. Three individuals' data which was found to be incomplete and erroneous were excluded from the study. Thus the total study population accounted to 177 diabetic individuals. Data was analysed using Statistical Package for Software Solutions (SPSS) version 16. Due to the skewed distribution of the variables, the median values and interquartile ranges are reported. Median test was used for intergroup comparisons. Chi-square test was used for comparison of proportions.

Background characteristics:
Of the 177 patients interviewed, 87 were males (49.2%) and 90 were females (50.8%). From table 1, it is found that there is no significant difference in the background characteristics like age, religion and socio economic status between men and women. But there was a significant difference in the marital status, education level, occupation and financial dependency status. The findings of the demographic characteristics were as per the general patterns prevailing in the Indian society. While 70% of women were dependent on others for their finance, only 10% of men were dependent. There was no significant difference between males and females with regards to diabetes treatment seeking behaviour as shown in table 2. But with respect to the outcome, it is found that more women suffered from more than two complications and poor glycemic control. Among the study population, the median quarterly OOPE  There was a statistically significant difference in the quarterly OOPE on diabetes between men and women (Mann-Whitney U test, P 0.01). Among the study participants, 5 men (5.7%) and 5 women (5.6%) were hospitalised in the past 3 months. The reason for hospitalisation among men was myocardial infarction and diabetic ulcer and among women it was myocardial infarction, ulcer, nephropathy cataract and cerebrovascular Accident.  As shown in Table 3,there is an increase in the quarterly OOPE spent on Diabetes with age up to 70 years of age among males. The gender difference is very evident in all the age groups, with a wider difference in the 51-60 age group. Among very old (71-80 years ) females are spending more than the males. With regards to marital status, when they are living together females tend to spend less than when they are alone, while the reverse is true in males. In either cases, females are spending less than the male counter parts. Similarly, women who are financially dependent on others spend only half of what independent women do, but the irony is irrespective of the financial dependence status, females spend less than what the males do. Religion wise, there is a gender difference among Hindus.  Among non-hospitalised patients, females are spending less than the males, which was statistically significant. With increase in duration of diabetes, the amount spent on diabetes increases in both the sexes, but the gender difference continues to persist. From table 4, it is also evident that gender difference continue to persist irrespective of the mode of diagnosis, type of health sector approached for diabetes care, number of comorbidities and complications present. With regards to glycemic control, there was no difference in the OOPE between men and women if their glycemic status was not known. But at the same time, there was a statistically significant difference in the quarterly OOPE incurred between men and women who had a poor glycemic control.
From table 5, it is evident that both the gender had to cope with the OOPE from the personal savings. While 9.2% of the males had the benefit of medical insurance, only 3.3% of the females had it.

DISCUSSION
There are various studies which had provided evidence for gender inequality in health and access to health care services. [1][2][3][4][5][6] While various studies has looked at difference in OOPE, across economic class and place of residence, gender is often neglected. [23][24][25] It is evident from this study, that there is a gender difference in quarterly out of pocket expenditure for diabetes care, where women spend almost only half of what their male counterparts do. In a Low Middle income country like India, where major contribution towards health expenditure is through OOPE, this finding carries a huge significance. 26 This is important in the context that 21.92% of the population in India are living below the poverty line. 27 Thoothukudi, where the present study is conducted can be considered as a district with lesser gender inequity by considering sex ratio as a proxy measure for inequity. But even in this district, it is evident from the study that women do not enjoy similar social status as what men do. Women lag behind men in terms of education, which has an effect on occupation and financial dependency status. In all these factors women were at a disadvantaged position than men. Gender difference in OOPE is not unique to Thoothukudi district or to diabetes. A study was done to assess the gender difference in Health care expenditure towards different morbidity using two rounds of the longitudinal, nationally representative survey known as the India Human Development Survey (IHDS), - IHDS 1 (2004-205) and IHDS 2(2012-13).It was found that irrespective of the type of morbidity and survey rounds, females spent lesser than males. 28,29 A secondary data analysis of the National Sample Survey Organization (NSSO) data of the 55 th (1999)(2000) and the 64 th (2007)(2008) rounds also showed that higher amount is spent on elderly males for health and food than on elderly females in all regions of India. Though the health expenditure on the elderly women had increased from the first to the second survey period, a huge disparity was still seen between the two gender. 30 The scenario in developed countries is a little different wherein females spend high OOPE compared to males. 31,32 But that doesn't mean these countries are progressive in terms of gender equity, as in developed countries most of the health expenditure is borne by mechanisms other than OOPE. 33 In such a context, women spending higher OOPE males is a grave sign of gender inequity despite economic progress.
In the present study, it is found that the gender difference was the highest among the richest economic class and the least among the poorest class. Similar finding was also found in other studies, which showed the gender difference in health care expenditure was seven times higher among the richest quintile compared to the lowest quintile. 28,29 The gender difference is seen across all age group, education status and economic class. . Illiteracy level was high among women and majority of the women in the study group were unemployed. This could contribute to the gender difference in the outcome of the disease as uneducated, unemployed people with diabetes who cannot afford or do not have access to even minimum healthcare facilities are likely to be diagnosed late. They are at increased risk of developing diabetes related National Journal of Research in Community Medicine│Apr-Jun.2019│ Vol 9 │Issue 2│ complications due to delays in diagnosis and/or improper treatment. 21 It is important to note that 70% of the women who participated in the study are financially dependent on some body, whereas only 10.3% of the men were dependent. The gender difference in OOPE towards diabetes care is further perpetuated by the financial dependency status. The sequelae of this financial dependence is that they have little say in decision making. This is evident from the gender difference in proportion of monthly family income being spent towards diabetes care, while men spend 4%, women spend only 2% on an average. It is also evident from the study, even among financially independent women, the median quarterly OOPE incurred by women is less than that of the men. It is spelled by different studies that utilisation of health care by women is mediated by their role in decision making and resource allocation within households. It is also found that a woman is more likely to be included in the decision making process provided she earns more or as equal to that of her husband. 28,34 These findings clearly point out that women due to lack of access to paid employment, irrespective of her education status due to the social norm of engaging in household work which is yet not accounted for economic outcome and less say in decision making process in the family, tend to spend less for their health, delaying or not utilising the health care facility. It is well established that OOPE acts as a barrier to access health care. The socio-economic disadvantages faced by the women further amplifies the risk of developing worse outcomes of the disease, who are already at greater risk of developing the disease and the complications compared to men. Gender disparity in OOPE cannot be considered as a random occurrence and dismissed, for it has an impact on the outcome of the disease. It is evident from the study that women spend less than men and also larger proportion of women suffer from poor glycemic control than men. Lower spending on diabetes care could be a causal effect of poor glycemic control. Studies had established that OOPE prevent more women than men from utilising essential health services. 34 Studies have also shown that patients tend to forego medicines depending on their ability to pay. [35][36][37] The gender difference in OOPE is prominent if there was no hospitalisation. Among hospitalised there is no gender difference. The vulnerable by cutting the cost on primary and secondary prevention, tend to bear higher cost at a later stage due to complications, because of failure of prevention. The cost of treatment is high but the cost of doing nothing is far greater. 38 This is evident from this study, as the cost of hospitalisation is much higher. Social security measures like medical insurance was the coping strategy adopted by 9% of men compared to 3% of women which is again a reflection on how women are being left out from the social protection mechanisms. Conclusion: It is quiet evident from the present study, that women are spending less OOPE on diabetes care than men. The gender difference in OOPE was persistent at all education level, economic position, marital status and financial dependency status. Self-report response bias and recall bias could be a limitation of the study .However measures were taken to reduce the bias by triangulating the information given by the participant with the records and bills that were available with the participant whenever available. It is also important simultaneously to look at strategies to reduce the gender difference in OOPE towards diabetes care.