An Analytical Framework for the Study of Child Survival in Developing Countries
This study proposes an analytical framework for the study of child survival akin to the proximate determinants of fertility that integrates the approaches of social science and medical science. It framework is based on several premises: (1) in an optimal setting, over 97 percent of newborn infants can be expected to survive through the first 5 years of life; (2) reduction in this survival probability in any society is dues to the operation of social, economic, biological, and environmental forces; (3) socioeconomic determinants (independent variables) must operate though more basic proximate determinants that in turn influence the risk of disease and the outcome of disease processes; (4) specific diseases and nutrient deficiencies observed in a surviving population may be viewed as biological indicators of the operations of proximate determinants; (5) growth faltering and ultimately mortality in children (the dependent variables) are the cumulative consequences of multiple disease processes (including their biosocial interactions) only infrequently is a child's death the result of a single isolated disease episode. The proximate determinants are: Maternal factors: age; parity; birth interval Environmental contamination: air; food/water/fingers; skin/soil/inanimate objects; insect vectors Nutrient deficiency: calories; protein; micronutrients (vitamins and minerals) Injury: accidental; intentional Personal illness control: personal preventive measures; medical treatment The socioeconomic determinants (which operate through the prox determinants) are: Individual-level variables: individual productivity (fathers, mothers) skills/education, health, time; traditions/norms/attitudes power relationships within the household, value of children, beliefs about disease causation, food preferences Household-level variables: income/wealth quantity and quality of food, water, clothing/bedding, housing, fuel/energy, transportation, hygienic/preventive care, sickness care, and information Community-level variables: ecological setting; political economy organization of production, physical infrastructure, political institutions; health system institutionalized actions, implementation of them, cost subsidies, public info/educ/motivation, technology The dependent variable that Mosley and Chen propose is an index of death and growth faltering. They argue that an exclusive focus on mortality handicaps research because death is a rare event, the measurement of which necessitates the study of large populations or the cumulation of the mortality experience of smaller populations over long periods. In order to combine counts of the dead with observations of the living into a unified scale or index of the health status of a population, Mosley and Chen propose to create an index combining the level of growth faltering (expressed as a percentage of the expected weight-for-age) among survivors with the level of mortality of the respective birth cohort. An important note: although growth faltering has sometime been considered to by synonymous with malnutrition, there is now abundant evidence that it is due to many factors and that it may be more appropriately considered a nonspecific indicator of health status. Since growth faltering indicates the current health status of a population, it can serve as a measure of the relative risk of various subgroups of that population to mortality in the future, but it will not serve as a valid index to relate specific absolute levels of mortality across populations.