Development of the Global Network for Women’s and Children’s Health Research’s socioeconomic status index for use in the network’s sites in low and lower middle-income countries

Abstract

Background: Socioeconomic status (SES) is an important determinant of health globally and an important explana‑ tory variable to assess causality in epidemiological research. The 10th Sustainable Development Goal is to reduce disparities in SES that impact health outcomes globally. It is easier to study SES in high-income countries because household income is representative of the SES. However, it is well recognized that income is poorly reported in lowand middle- income countries (LMIC) and is an unreliable indicator of SES. Therefore, there is a need for a robust index that will help to discriminate the SES of rural households in a pooled dataset from LMIC. Methods: The study was nested in the population-based Maternal and Neonatal Health Registry of the Global Net‑ work for Women’s and Children’s Health Research which has 7 rural sites in 6 Asian, sub-Saharan African and Central American countries. Pregnant women enrolling in the Registry were asked questions about items such as housing conditions and household assets. The characteristics of the candidate items were evaluated using confrmatory factor analyses and item response theory analyses. Based on the results of these analyses, a fnal set of items were selected for the SES index. Results: Using data from 49,536 households of pregnant women, we reduced the data collected to a 10-item index. The 10 items were feasible to administer, covered the SES continuum and had good internal reliability and validity. We developed a sum score-based Item Response Theory scoring algorithm which is easy to compute and is highly cor‑ related with scores based on response patterns (r=0.97), suggesting minimal loss of information with the simplifed approach. Scores varied signifcantly by site (p<0.001). African sites had lower mean SES scores than the Asian and Central American sites. The SES index demonstrated good internal consistency reliability (Cronbach’s alpha=0.81). Higher SES scores were signifcantly associated with formal education, more education, having received antenatal care, and facility delivery (p<0.001). Conclusions: While measuring SES in LMIC is challenging, we have developed a Global Network Socioeconomic Sta‑ tus Index which may be useful for comparisons of SES within and between locations. Next steps include understand‑ ing how the index is associated with maternal, perinatal and neonatal mortality. Trial Registration NCT01073475 Plain English summary: Socioeconomic status (SES) is an important determinant of health globally, and improving SES is important to reduce disparities in health outcomes. It is easier to study SES in high-income countries because it can be measured by income and what income is spent on, but this concept does not translate easily to low and mid‑ dle income countries. We developed a questionnaire that includes 10 items to determine SES in low-resource settings that was added to an ongoing Maternal and Neonatal Health Registry that is funded by the National Institutes of Child Health and Human Development’s Global Network. The Registry includes sites that collect outcomes of pregnancies in women and their babies in rural areas in 6 countries in South Asia, sub-Saharan Africa and Central America. The Registry is population based and tracks women from early in pregnancy to day 42 post-partum. The questionnaire is easy to administer and has good reliability and validity. Next steps include understanding how the index is associated with maternal, fetal and neonatal mortality