An analytical framework for the study of child survival in developing countries. 1984.

This essay proposes a new analytical framework for the study of the determinants of child survival in developing countries. The approach incorporates both social and biological variables and integrates research methods employed by social and medical sciences. The framework is based on the premise that all social and economic determinants of child mortality necessarily operate through a common set of biological mechanisms or proximate determinants to exert an impact on mortality. The key to the model is the identification of a set of proximate determinants that directly influence the risk of morbidity and mortality. All social and economic determinants must operate through these variables to affect child survival. The proximate determinants are grouped into 5 categories: maternal factors; environmental contamination; nutrient deficiency; injury and personal illness control. A novel aspect of this conceptual model is its definition of a specific disease state in an individual as an indicator of the operation of the proximate determinants rather than as a cause of illness and death. In this way the social as well as medical roots of the problem are emphasized. The model also provides for the measurement of morbidity and mortality in a single variable. The level of growth faltering among surviving children in a population is combined with the mortality experience into a nonspecific measure of the level of adverse conditions facing the population. The validity of such an index is assessed by examining the current procedure for scaling malnutrition in children (weight-for-age). To achieve maximum analytical value the proximate determinants should also be measurable in population-based research. A range of socioeconomic determinants (independent variables) are examined and the way in which they operate through the proximate determinants to influence the level of growth faltering and mortality illustrated. The socioeconomic dterminants are grouped into 3 broad categories: individual-level (productivity norms/attitudes); household-level (income/wealth) and community-level variables (ecological setting political economy health system). The model is intended to advance research on social policy and mecdical interventions to improve child survival.