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Abstract
Background
Gender-diverse individuals encounter a greater number of barriers to healthcare access, stemming from stigma, insufficient awareness, unavailability of gender-affirming healthcare, limited social support, and minimal legal protections. These barriers have a differential impact on healthcare access for the hijra, kothi, or transgender (HKT) communities in India.
Aim
We, first, developed a multidimensional access to healthcare index (MAHI) to assess disparities in access among HKT individuals; and second, identified the social (SDoH) and structural (STDoH) determinants of health that are associated with their access.
Methods
Data on a variety of healthcare access questions were collected from a representative sample of HKT individuals (n = 98). We conducted a Principal Component Analysis (PCA) to build the multidimensional index and calculate a composite score of access. An ANOVA test to identify the determinants associated with their access, and geospatial analysis to explore the spatial variability of access were conducted.
Results
PCA identified six dimensions—affordability, acceptance, accommodation, accessibility, accompaniment, and awareness—that comprehensively described MAHI. The mean score of MAHI for participants was 42.0 (minimum = 19.6; maximum = 74.7) on a scale from 0 to 100 (where 0 represented best and 100 represented worst healthcare access). The mean MAHI scores varied by two SDoH, gender identity and educational qualifications (p < 0.001), where hijras with no education had the worst access. Geospatial analysis indicated that disparities in access were linked to participant’s neighborhood characteristics and identified clusters of participants with high and low access in the southeast and northwest regions of the city respectively.
Conclusion
The MAHI recommends six strategies for improving access and mitigating health disparities among the hijra, kothi, and transgender individuals in India. It underscores the significance of recognizing the diverse nature of gender identities in health research.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Shakthi: studying healthcare accessibility among kothi, transgender hijra individuals
Residential and healthcare provider information
Where do you live? Mention the name of your "para" or neighborhood.
Where do you generally go for your health needs? Enter the name of the clinic/health center/doctor #1
Enter the location of the above-mentioned clinic health center/doctor #1:
What are the approximate fees of this doctor/clinic/health center?
Do you visit this clinic/health center/doctor for transgender-specific health needs?
Yes
No
Do you go to another clinic or a doctor? (Questions 2-6 were repeated up to 3 times if Ans = yes)
Yes
No
Skip to the next section If: do you go to another clinic or a doctor? = No
Healthcare access related questionnaire
This section will inquire about your healthcare access-related information. Just for your knowledge, some of the questions have been adopted and rephrased from the pioneering Penchansky and Thomas’s healthcare access model. This model is widely used in health studies.
How satisfied are you with the neighborhoods the doctor’s clinic is in?
Extremely satisfied.
Satisfied.
Neither satisfied nor dissatisfied.
Slightly dissatisfied.
Extremely dissatisfied.
How satisfied are you with your doctors?
Extremely satisfied.
Satisfied.
Neither satisfied nor dissatisfied.
Slightly dissatisfied.
Extremely dissatisfied.
Do the doctors/hospital staff respect you?
Always.
Sometimes.
Indifferent.
Rarely.
Never.
Have you ever been mocked by your healthcare provider?
Yes.
No.
Have you ever been molested by your healthcare provider?
Yes.
No.
Do the hospitals have gender-neutral wards?
Yes.
No.
Don’t know/haven’t heard of gender-neutral wards.
Which ward were you put in?
Female.
Male.
Gender neutral-ward.
Private cabin.
Never been admitted to a hospital.
Skip to Question 9 If: Which ward were you put in? = Never been admitted to a hospital
How comfortable do you feel in the wards?
Very Comfortable.
Comfortable.
Neither comfortable nor Uncomfortable.
Uncomfortable.
Very Uncomfortable.
Are you aware of the gender-neutral bathrooms in the health center(s) you visit?
Yes.
No.
Don’t know/haven’t heard of gender-neutral bathrooms.
Which Bathroom do you visit?
Always Female.
Always Male.
Based on how we dress.
Are you satisfied with the typical travel time to your healthcare centers?
Extremely satisfied.
Satisfied.
Neither satisfied nor dissatisfied.
Dissatisfied.
Extremely dissatisfied.
How far is the travel to the healthcare center?
Very close.
Close.
In proximate.
Far.
Very far.
Do you prefer visiting doctors located far (away from your neighborhood)?
Yes.
No.
Skip to question 15 If: you prefer visiting doctors located far (outside your neighborhood)? = No
Why do you visit doctors located far away?
Transgender friendly.
High reputation.
Lower fees.
Fear of disclosure in front of local doctors and patients.
Other: __________________________________________________
How satisfied are you with the commute to the healthcare centers?
Extremely satisfied.
Satisfied.
Neither satisfied nor dissatisfied.
Dissatisfied.
Extremely dissatisfied.
What is the mode of transportation you take to the health center?
Auto Rickshaw.
Bus.
Tram.
Train.
Car.
Uber/Ola.
Motor Bike.
Walking.
How difficult is it for you to commute to the healthcare centers?
Very convenient.
Easy.
Neutral.
Difficult.
Very Difficult.
How satisfied are you with how long you have to wait to get an appointment?
Extremely satisfied.
Satisfied.
Neither satisfied nor dissatisfied.
Dissatisfied.
Extremely dissatisfied.
What are some of the reasons that you delayed your doctor’s appointment?
Doctor’s appointments are never delayed.
You did not have money.
Difficulty in finding a trans-friendly doctor.
Intentionally deferring checkups as you are scared to disclose your identity.
You are discriminated against for being gender diverse, the clinic intentionally defers your appointment.
Was busy.
How satisfied are you with how convenient your doctors’ clinic hours are?
Extremely satisfied.
Satisfied.
Neither satisfied nor dissatisfied.
Dissatisfied.
Extremely dissatisfied.
How satisfied are you with how easy it is to get in touch with your doctor(s)?
Extremely satisfied.
Satisfied.
Neither satisfied nor dissatisfied.
Dissatisfied.
Extremely dissatisfied.
How satisfied are you with how soon you need to pay the bill?
Extremely satisfied.
Satisfied.
Neither satisfied nor dissatisfied.
Dissatisfied.
Extremely dissatisfied.
Do you have health insurance?
Yes.
No.
Skip to Question 28 If: Do you have health insurance? = No
What is the name of the insurance company?
What is the annual cost of the insurance?
Does this insurance cover transgender-specific healthcare?
Yes.
No.
Not sure/never explored.
How satisfied are you with your health insurance?
Extremely satisfied.
Satisfied.
Neither satisfied nor dissatisfied.
Dissatisfied.
Extremely dissatisfied.
How satisfied are you with the doctors’ fees?
Extremely satisfied.
Slightly satisfied.
Neither satisfied nor dissatisfied.
Slightly dissatisfied.
Extremely dissatisfied.
Was there a time in the past 12 months when you had to borrow money or take a loan to visit a doctor?
Yes.
No.
Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?
Yes.
No.
Are you aware of the transgender bill of rights and the decriminalization of section 377?
Yes.
No.
Are you aware of sources/people from whom you can get information about gender-affirming care (hormone replacements, psychiatric treatment, medicines, and surgeries)?
Yes.
No.
Skip to the ‘Social support’ section If: Are you aware of sources/people from where you can get information about gender-affirming care? = No
From where did you hear about the transgender-friendly clinic/doctor?
Community friends.
Religious leader.
social worker or NGO group.
Internet/social media.
Family.
Doctors/Physicians.
Others: __________________________________________________
Display This Question If: where did you hear about the transgender clinic/doctor? = Internet/social media
If the Internet or social media: Name of Website
________________________________________________________________
Display this question, if: where did you hear about the transgender clinic/doctor? = Internet/social media
Are you aware of an app that informs you about your transgender healthcare needs?
Yes. Which one? (1) _______________________________________________
No (2)
Display this question, if: Where did you hear about the transgender clinic/doctor? = Community friends
What is the age of the community friend from whom you heard about transgender health information? ________________________________________________________________
Display this question: Where did you hear about the transgender clinic/doctor? = Community friends
What is the gender of the community friend from whom you heard about transgender health information?
Female.
Male.
Non-binary gender.
Display this Question: Where did you hear about the transgender clinic/doctor? = Community friends
What is the education level of the community friend from whom you heard about transgender health information?
Display this question: Where did you hear about the transgender clinic/doctor? = Family
What is your relationship with the family member from whom you heard about transgender health information?
________________________________________________________________
Display this question: Where did you hear about the transgender clinic/doctor? = Family
What is the educational level of the family member from whom you heard about transgender health information?
________________________________________________________________
Display this question: Where did you hear about the transgender clinic/doctor? = social worker or NGO group
What is the name of the NGO group or social worker from whom you heard about transgender health information?
________________________________________________________________
Display this Question: Where did you hear about the transgender clinic/doctor? = social worker or NGO group
Enter the location of the social worker, NGO, or group.
________________________________________________________________
Social support in accessing healthcare
This section will focus on family members, relatives, friends, coworkers, social/NGO workers, or anybody else who will be willing to help you with taking care of your health. This may include accompanying you to doctor’s clinics, booking doctor’s appointments on your behalf, buying medicines, food, etc. for you, and reminding you to take your medications on time. These individuals cannot be your nurse or doctor.
Do you have a reliable person(s) who can accompany you to the healthcare centers?
Yes
No
Survey ends If: Do you have a reliable person(s) who can accompany you to the doctor’s clinic, hospital, or other healthcare centers? = No
Can you provide names (up to) 3:
Person 1 __________________________________________________
Person 2 __________________________________________________
Person 3 __________________________________________________
Where does (person 1) live? Mention the "para" or neighborhood?
_______________________________________________________________
Enter the address or the precise location of
Does the location/distance of your doctor’s clinic impact who accompanies you for health checkups?
Very high impact.
High impact.
Moderate impact.
Slight impact.
No impact.
What is the gender of the person 1 accompanying you?
Female.
Male.
Non-binary gender.
What is their (person 1) age?
_________________________________________________________________
What is your relationship to person 1 of the list? (Questions from 3-8 are repeated 2 times if the participants provided 3 names)
Partner/Spouse.
Child.
Sibling.
Mother.
Father.
Community friend.
Coworker.
Someone you trade sex with or sell drugs with.
Others: __________________________________________________
Notes
1 “LGBTQI + stands for lesbian, gay, bisexual, transgender, queer (or sometimes questioning), intersex, and others. The "plus" represents other sexual and gender identities, including asexual, pansexual, and Two-Spirit. The first four letters of the acronym have been used since the 1990s, but in recent years there has been an increased awareness of the need to be inclusive of other sexual and gender identities to offer better representation.
2 Gender diverse is emerging as a new term which has the aim of including all other terms outside of male and female within it and this article suggests the increase in its use to describe gender identities outside of the binary (Thorne et al., Citation2019). As, Western society’s traditional concepts of gender have been challenged, so has been the use of transgender as an umbrella identity. The idea that there are many gender identities has been increasingly recognized, for example within non-Western cultures, individuals from groups such as Two Spirit people, Fa’afafine, or Hijra are sometimes considered to comprise a gender-diverse identity that may or may not identify as transgender (Bowling et al., Citation2019).
3 South Asia, subregion of Asia, consisting of the Indo-Gangetic Plain and peninsular India. It includes the countries of Bangladesh, Bhutan, India, Pakistan, Nepal, and Sri Lanka; Afghanistan and the Maldives are often considered part of South Asia as well.