To save lives of children, diagnose and treat their social vulnerability
The first few hours and days of life are critical for the survival of a child and most of the factors that need to be addressed during this period are clinical in nature and are under the control of the attending nurse or physician. However, these factors are responsible for only about half the under-five deaths, because the rest of the deaths take place once children return home from the hospital. Recent research has identified that the greatest danger to children under five years is not acute illness, but prolonged, and as yet poorly described, forms of vulnerability that produce worse-than-anticipated outcomes, particularly when combined with other childhood illnesses. This research thus raised the question as to whether there is a set of underlying factors, which are not biological or clinical, that make these children far more socially vulnerable. This vulnerability arises in and from familial and wider community contexts in which these children are placed.
The concept of social vulnerability captures the environmental, socio-cultural, and temporal dimensions of childhood vulnerability and describes stages prior to clinical vulnerability and well prior to morbidity. It defines a family’s ability/inability to respond to child care needs during the three stages of: (i) everyday care and exposure to risk factors in the home; (ii) care-seeking pathways and the variation in the time taken to seek care; and (iii) nursing and follow up during the recovery phase.
More recently, using tools from anthropology, careful research at the family level has allowed the field of public health to deeply explore what factors lead to social vulnerability. In many countries, including Ethiopia, Tanzania, and India, community health workers play an important role in the delivery of primary healthcare. They often work for years in certain locations, and have an instinct about which children are more vulnerable than others. Using this instinct or social knowledge, it has been possible to co-design a social vulnerability identification tool which can help them quickly identify different family types according to the unique barriers they face (diagnosis), and to more sharply tailor their engagement with these families to target specific categories of vulnerability (treatment).
One such effort, for example, groups families into five types. (i) Survivors: experience enormous paucity of income; (ii) Conservatives: are rigidly bound by strict traditional norms of behaviour; (iii) Strivers: are perpetually short of time and need to balance multiple commitments; (iv) Potentials: have specific critical knowledge gaps; and (v) Pilots: balance every aspect of their lives in an optimal manner.
In this characterisation, the children of Survivors live in unsanitary conditions, on the remote fringes of a village making access to care much more difficult. Survivors are unable to properly care for the child once she returns home after an episode of illness. In a Conservative family, tradition defines the kind of care a child receives and the mother has little power to decide when to seek care. For the Strivers, the mother has no time to follow the given advice and often delays seeking care until the child is seriously ill. The Potentials make repeated mistakes in taking care of the child because they fail to recognise the specific risks that they are exposing the child to.
Once a health worker identifies the closest type to which a family belongs, she is able to rapidly deploy the tools necessary to address the specific social vulnerability being experienced by the family. In this example, for Survivors, it is clear that income support from the government is a must; for the Conservatives, identifying the true decision-makers within the household and then working with them to develop new norms of behaviour would be essential; for the Strivers, offering them time efficient tools and social support is key; whereas for the Potentials, drawing their attention to specific risks associated with their existing childcare practices would be very important instead of offering generalised advice. The Pilots can be relied upon to act as role models where appropriate, and to support the health worker in helping to address the specific challenges being faced by the other families.
This is only one example of a grouping that could be employed in the field. The key here is to offer groups of community health workers sufficient training and support so that they are able to create their own typologies and related heuristics, allowing them to respond rapidly with targeted guidance instead of taking a more generalised and uniform approach towards families under their care.
Nachiket Mor and Tracy Johnson are employees of the Bill & Melinda Gates Foundation
The views expressed are personal