Volume 96, Issue 4
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



The overwhelming majority of evidence about the health of children in low- and middle-income countries is based on reports by parents. There is limited evidence on whether these reports suffer from systematic bias, particularly related to the gender of the child. We investigate differences in symptom reporting by child gender in a sample of countries in sub-Saharan Africa. Data from 35 Demographic and Health Surveys and 10 Malaria Indicator Surveys conducted since 2005 were analyzed. Parental reports of child symptoms were compared for girls and boys. In a subsample of data from Nigeria, we also compared the accuracy of parental reports of fever between girls and boys. Then, potential explanations for observed reporting differences were explored. Finally, country-level relationships between gender differences in symptom reporting and differences in child health outcomes were estimated. Parents reported fewer episodes of fever and diarrhea for girls as compared with boys. Less frequent symptom reporting for girls does not appear to be due to reduced exposure to illness-causing agents nor increased treatment seeking. Lower fever reporting for girls relative to boys is associated with higher relative infant mortality for girls at the country level, consistent with a potential link between underreporting and health outcomes. From a measurement perspective, estimates of gender imbalances in child morbidity and treatment based on parental reports may be inaccurate. From a public health perspective, parental underreporting of symptoms in girls may indicate untreated illness that goes unnoticed.


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  1. Sen A, , 2002. Health: perception versus observation. BMJ 324: 860861.[Crossref] [Google Scholar]
  2. Kleinman A, Eisenberg L, Good B, , 1978. Culture, illness, and care: clinical lessons from anthropologic and cross-cultural research. Ann Intern Med 88: 251258.[Crossref] [Google Scholar]
  3. Young A, , 1982. The anthropologies of illness and sickness. Annu Rev Anthropol 11: 257285.[Crossref] [Google Scholar]
  4. Subramanian SV, Subramanyam MA, Selvaraj S, Kawachi I, , 2009. Are self-reports of health and morbidities in developing countries misleading? Evidence from India. Soc Sci Med 68: 260265.[Crossref] [Google Scholar]
  5. Manesh AO, Sheldon TA, Pickett KE, Carr-Hill R, , 2008. Accuracy of child morbidity data in demographic and health surveys. Int J Epidemiol 37: 194200.[Crossref] [Google Scholar]
  6. United Nations Children's Emergency Fund (UNICEF), 2012. Pneumonia and Diarrhoea: Tackling the Deadliest Diseases for the World's Poorest Children. Geneva, Switzerland: UNICEF. [Google Scholar]
  7. Hill K, Upchurch DM, , 1995. Gender differences in child health: evidence from the demographic and health surveys. Popul Dev Rev 21: 127151.[Crossref] [Google Scholar]
  8. Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, Bellagio Child Survival Study Group; , 2003. How many child deaths can we prevent this year? Lancet 362: 6571.[Crossref] [Google Scholar]
  9. United Nations Children's Emergency Fund (UNICEF), 2012. Levels and Trends in Child Mortality: 2012 Report. Estimates Developed by the UN Inter-Agency Group for Child Mortality Estimation. New York, NY: UNICEF, WHO, World Bank, United Nations Population Division. [Google Scholar]
  10. Walker SP, Wachs TD, Gardner JM, Lozoff B, Wasserman GA, Pollitt E, Carter JA, International Child Development Steering Group; , 2007. Child development: risk factors for adverse outcomes in developing countries. Lancet 369: 145157.[Crossref] [Google Scholar]
  11. Nathanson CA, , 1984. Sex differences in mortality. Annu Rev Sociol 10: 191213.[Crossref] [Google Scholar]
  12. Waldron I, , 1983. Sex differences in human mortality: the role of genetic factors. Soc Sci Med 17: 321333.[Crossref] [Google Scholar]
  13. Corsi DJ, Neuman M, Finlay JE, Subramanian SV, , 2012. Demographic and health surveys: a profile. Int J Epidemiol 41: 16021613.[Crossref] [Google Scholar]
  14. MEASURE DHS, MEASURE Evaluation, President's Malaria Initiative, Roll Back Malaria, United Nations Children's Fund, 2013. Malaria Indicator Survey: Basic Documentation for Survey Design and Implementation. Calverton, MD: MEASURE Evaluation. [Google Scholar]
  15. National Population Commission of Nigeria, National Malaria Control Programme of Nigeria, ICF International, 2012. Nigeria Malaria Indicator Survey 2010. Abuja, Nigeria: NPC, NMCP, and ICF International. [Google Scholar]
  16. Garenne M, , 2003. Sex differences in health indicators among children in African DHS surveys. J Biosoc Sci 35: 601614.[Crossref] [Google Scholar]
  17. Waldron I, , 1998. Sex differences in infant and early childhood mortality: major causes of death and possible biological causes. Too Young to Die: Genes or Gender?. New York, NY: United Nations, 6483. [Google Scholar]
  18. Choi Y, El Arifeen S, Mannan I, Rahman S, Bari GL, Darmstadt R, Black RE, Baqui AH, Projahnmo Study Group, , 2010. Can mothers recognize neonatal illness correctly? Comparison of maternal report and assessment by community health workers in rural Bangladesh. Trop Med Int Health 15: 743753.[Crossref] [Google Scholar]
  19. Jayachandran S, Kuziemko I, , 2011. Why do mothers breastfeed girls less than boys? Evidence and implications for child health in India. Q J Econ 126: 14851538.[Crossref] [Google Scholar]
  20. Chakravarty A, , 2012. Gender Bias in Breastfeeding and Missing Girls in Africa: The Role of Fertility Choice. Mimeo. London, United Kingdom: University College. Available at: http://www.homepages.ucl.ac.uk/∼uctpabc/Gender%20Bias%20in%20Breastfeeding%20in%20Africa.pdf. [Google Scholar]
  21. Young Infants Clinical Signs Study Group, 2008. Clinical signs that predict severe illness in children under age 2 months: a multicentre study. Lancet 371: 135142.[Crossref] [Google Scholar]
  22. Sen G, Östlin P, , 2008. Gender inequity in health: why it exists and how we can change it. Glob Public Health 3: 112.[Crossref] [Google Scholar]
  23. Kornrich S, Furstenberg F, , 2013. Investing in children: changes in parental spending on children, 1972–2007. Demography 50: 123.[Crossref] [Google Scholar]
  24. Pande RP, Yazbeck AS, , 2003. What's in a country average? Wealth, gender, and regional inequalities in immunization in India. Soc Sci Med 57: 20752088.[Crossref] [Google Scholar]
  25. Chen LC, Huq E, D'Souza S, , 1981. Sex bias in the family allocation of food and health care in rural Bangladesh. Popul Dev Rev 7: 5570.[Crossref] [Google Scholar]
  26. Grant MJ, Behrman JR, , 2010. Gender gaps in educational attainment in less developed countries. Popul Dev Rev 36: 7189.[Crossref] [Google Scholar]
  27. Sen A, , 1990. More Than 100 Million Women are Missing. New York Review of Books. New York, NY: New York Review of Books. Available at: http://www.nybooks.com/articles/1990/12/20/more-than-100-million-women-are-missing/. Accessed December 1, 2015. [Google Scholar]
  28. Flatø M, Kotsadam A, , 2014. Droughts and Gender Bias in Infant Mortality in Sub-Saharan Africa. Working Paper No. 02/2014. Oslo, Norway: Department of Economics, Oslo University. [Google Scholar]
  29. Friedman J, Schady N, , 2012. How Many More Infants Are Likely to Die in Africa as a Result of the Global Financial Crisis? Working Paper, World Bank Policy Research. Washington, DC: World Bank. [Google Scholar]
  30. Grantham-McGregor S, Cheung YB, Cueto S, Glewwe P, Richter L, Strupp B, International Child Development Steering Group; , 2007. Developmental potential in the first 5 years for children in developing countries. Lancet 369: 6070.[Crossref] [Google Scholar]
  31. Banco L, Veltri D, , 1984. Ability of mothers to subjectively assess the presence of fever in their children. Am J Dis Child 138: 976978. [Google Scholar]
  32. Einterz EM, Bates ME, , 1997. Fever in Africa: do patients know when they are hot? Lancet 350: 781.[Crossref] [Google Scholar]
  33. Black RE, Brown KH, Becker S, Yunus MD, , 1982. Longitudinal studies of infectious diseases and physical growth of children in rural Bangladesh I. Patterns of morbidity. Am J Epidemiol 115: 305314.[Crossref] [Google Scholar]
  34. Eisele TP, Silumbe K, Yukich J, Hamainza B, Keating J, Bennett A, Miller JM, , 2013. Measuring coverage in MNCH: accuracy of measuring diagnosis and treatment of childhood malaria from household surveys in Zambia. PLoS Med 10: e1001417.[Crossref] [Google Scholar]
  35. Das J, Hammer J, Sanchez-Paramo C, , 2012. The impact of recall periods on reported morbidity and health seeking behavior. J Dev Econ 98: 7688.[Crossref] [Google Scholar]
  36. United Nations Children's Emergency Fund (UNICEF), 2006. Women and Children: The Double Dividend of Gender Equality. The State of the World's Children, Vol. 7. Geneva, Switzerland: UNICEF. [Google Scholar]

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  • Received : 31 Mar 2016
  • Accepted : 14 Dec 2016
  • Published online : 30 Jan 2017

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