Inequalities in child mortality in sub-Saharan Africa: A social epidemiologic framework

In the past twenty years or so, the study of the determinants of child survival in low-income countries has been based on demographic conceptual frameworks. The most widely known has been the Mosley and Chen framework [1]. In that framework, the key concept was a set of proximate determinants, or intermediate variables, that directly influence the risk of morbidity and mortality. It assumes that all the more distal social and economic determinants must operate through these variables to affect child survival. The proximate determinants were grouped into five categories largely centred around household/family level influences: [1] maternal factors (age, parity, and birth interval); 2) environmental contamination (air, food/water/fingers; skin/soil/inanimate objects; insects; insect vectors); 3) nutrient deficiency (calories, protein, micronutrients (vitamins and minerals)); 4) injury (accidental, intentional) and 5) personal illness control personal preventive measures such as handwashing and medical treatment. This framework has been at the heart of the conception of the Demographic and Health Surveys [2] which has increased knowledge of the various determinants of child survival in many countries. However, the framework gives emphasis to more proximate determinants and has lead research to focus on more individual-level decision making. Infant and child mortality has declined in many developing countries especially in Latin America, Caribbean, North Africa and Asia [3]. These achievements have to some extent been a result of Inequalities in child mortality in sub-Saharan Africa: A social epidemiologic framework