MAHI: A multidimensional access to healthcare index for hijra, kothi, and transgender individuals

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.

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.

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.

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.

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.