EDITORIALS

 

Impact of non-health policies on infant mortality through the social determinants pathway

 

 

Manisha Nair; Premila Webster; Proochista Ariana

Department of Public Health, University of Oxford, Rosemary Rue Building, Old Road Campus, Headington, Oxford, OX3 7LF, England. Correspondence to Manisha Nair (e-mail: dr.manisha.das@gmail.com).

 

 

Infant mortality is an indicator of population health and a measure of global health inequalities.1 Despite advances in medical sciences and acknowledgement of the role of hygiene and sanitation, survival of infants continues to be a challenge worldwide. Evidence suggests that the survival of infants after the age of one month is mainly influenced by the external environment in which the infant lives,2 hence, non-health policies targeting the socioeconomic environment are as important as health policies for post-neonatal mortality.3

Studies both in India and globally suggest that poverty and household income are important upstream determinants of infant mortality.4,5 The Government of India's Mahatma Gandhi National Rural Employment Guarantee Act targets unemployment and underemployment, and therefore poverty, by providing "at least 100 days of guaranteed paid employment every year to households whose adult members volunteer to do unskilled manual work".6 Improved income triggers a cascade of structural and behavioural factors such as better housing and living conditions, food security, access to clean water and proper sanitation, access to health care, infant care and feeding practices that influence the proximal risk factors of infant mortality - malnutrition, diarrhoea and acute respiratory infections. Thus, while the employment programme addresses the central issues of rural poverty, it is likely to transcend its intended goals to improve infant survival.

A review of wage-for-employment programmes in 13 countries in Africa and three countries in Asia (Bangladesh, China and India) demonstrates their positive impact on household income and food security.7 However, these studies do not demonstrate the impact of such programmes on actual food consumption and nutrition of the target population, or the consequences on child health. Some studies have analysed the impact of employment programmes on infant-feeding practices8 and child nutrition,9 but none has demonstrated the composite pathways through which employment may influence child survival.

Studies in 19th-century England show higher infant mortality in households with a working mother, which they attribute to the lack of mother's time for infant care, inadequate care, early introduction of artificial feeding and poor living conditions.10 The Maternal and Infant Nutrition Intervention study in Matlab, in rural Bangladesh, showed that improved household food security is associated with inadequate feeding practices in infants aged less than six months.8 The authors explain this as an adverse effect of improved household food security, because increased availability of cow's milk, fruit and fruit juices resulted in early weaning of infants.8 This shows that employment does not act on health in isolation, but through a pathway of determinants, the direction and strength of which is greatly influenced by the role of factors such as infant-feeding practices.

In its 2010 report, the World Health Organization's Commission on Social Determinants of Health presents a conceptual framework of the determinants pathway, starting with the biological and behavioural risk factors at the proximal end (closest to the disease), followed distally by the sociocultural and economic factors and finally policies (health and social), governance and the sociopolitical context.11 Further, the theories of social epidemiology, such as the social production of disease/political economy of health, and ecosocial theory of Krieger,12 reinforce the concept that the determinants of health are interconnected in a complex web. Non-health policies do not act on health in isolation but in a composite synergistic pathway of structural, sociocultural, behavioural and biological determinants.

Some work has been done to evaluate the impact of non-health policies on health, for example: a housing estate regeneration project in the United Kingdom of Great Britain and Northern Ireland;13 agriculture, food and nutrition policies in Slovenia;14 and a conditional cash transfer programme in Mexico.15 However, what is needed is a framework or model to help analyse the dynamic interactions of the causal pathways of socioeconomic, behavioural and biological determinants through which the policy impacts are transmitted, and relevant quantitative and /or qualitative research is needed to develop and test this framework.

Understanding this pathway involves studying the effect of human behaviour, household conditions, structural factors, culture and context as social determinants that act between the intervention and outcome. Such an approach towards understanding the impacts of non-health policies on health will contribute towards developing a practical proposition for the concepts of WHO's Commission on the Social Determinants of Health and the Adelaide Statement on Health in All Policies.16 It will also help to provide the evidence for the possible impact of non-health policies on health, will contribute towards identifying appropriate policy interventions and inform policy-makers.

 

References

Available at: http://www.who.int/bulletin/volumes/89/11/11-093799        

 

References

1. Graham H. Unequal lives: health and socio-economic inequalities. Maidenhead: Open University Press; 2007.         

2. Bourgeois-Pichat J. An analysis of infant mortality. Popul Bull UN 1952;2:1-14.         

3. Marmot MG, Wilkinson RG, Brunner E. Social determinants of health. New York: Oxford University Press; 2006.         

4. Foetal, infant and early childhood mortality: volume II, biological, social and economic factors. New York: United Nations Department of Economic and Social Affairs; 1954.         

5. Claeson M, Bos ER, Mawji T, Pathmanathan I. Reducing child mortality in India in the new millennium. Bull World Health Organ 2000;78:1192-9.PMID:11100614        

6. The Mahatma Gandhi National Rural Employment Guarantee Act, 5 September 2005. New Delhi: Ministry of Rural Development, Government of India; 2005.         

7. Braun J, Teklu T, Webb P. Labour-intensive public works for food security: experience in Africa. Int Labour Rev 1992;121.         

8. Saha KK, Frongillo EA, Alam DS, Arifeen SE, Persson LÁ, Rasmussen KM. Household food security is associated with infant feeding practices in rural Bangladesh. J Nutr 2008;138:1383-90. PMID:18567765        

9. Mascie-Taylor CG, Marks MK, Goto R, Islam R. Impact of a cash-for-work programme on food consumption and nutrition among women and children facing food insecurity in rural Bangladesh. Bull World Health Organ 2010;88:854-60. doi:10.2471/BLT.10.080994 PMID:21076567        

10. Mooney G, Tanner A. Infant mortality, a spatial problem: Notting Dale special area in George Newman's London. In: Garrett E, Galley C, Shelton N, Woods R, editors. Infant mortality: a continuing social problem. Aldershot: Ashgate Publishing; 2006:169-90.         

11. Priorities for research on equity and health: implications for global and national priority setting and the role of WHO to take the health equity research agenda forward. Geneva: World Health Organization; 2010.         

12. Krieger N. Theories for social epidemiology in the 21st century: an ecosocial perspective. Int J Epidemiol 2001;30:668-77. doi:10.1093/ije/30.4.668PMID:11511581        

13. Bonnefoy J, Morgan A, Kelly MP, Butt J, Bergman V. Constructing the evidence base on the social determinants of health: a guide. Measurement and Evidence Knowledge Network, Commission on Social Determinants of Health. Geneva: World Health Organization; 2007.         

14. Lock K, Gabrijelcic-Blenkus M, Martuzzi M, Otorepec P, Wallace P, Dora C et al. Health impact assessment of agriculture and food policies: lessons learnt from the Republic of Slovenia. Bull World Health Organ 2003;81:391-8.PMID:12894321        

15. Gertler P. Do conditional cash transfers improve child health? Evidence from PROGRESA's control randomized experiment. Am Econ Rev 2004;94:336-41.doi:10.1257/0002828041302109        

16. Adelaide Statement on Health in All Policies: moving towards a shared governance for health and well-being. In: Health in All Policies International Meeting, Adelaide, 13-15 April 2010. Geneva: World Health Organization;2010.         

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