Spheres of Influence: The Family Adapted from: APHRC (2002) figure 3: socioeconomic gradients in infant and child mortality in kenya figure 4: socioeconomic gradients in childhood diarrhea within slums in nairobi and within rural areas of kenya 36
<strong>Total</strong> <strong>Environment</strong> <strong>Assessment</strong> <strong>Model</strong> <strong>for</strong> <strong>Early</strong> <strong>Child</strong> <strong>Development</strong> natal, infant, child, and under-five mortality rates are highest among those who reside in Nairobi’s urban slums. However, rather than a clear threshold, Figure 3 [94] shows that there appears to be a clear gradient effect by residential location (urban versus rural versus slum), albeit minimally, <strong>for</strong> neonatal mortality. A similar pattern emerges <strong>for</strong> diarrhea rates among children 0-35 months, with rates of 32% <strong>for</strong> slum children, 17 <strong>for</strong> rural children, and 13 <strong>for</strong> children in Nairobi [95]. Remarkably in fact, even within slum areas in Nairobi and rural areas of Kenya, there exist socioeconomic gradients in diarrhea (see Figure 4). This is not to minimize the profound ill effects of common notions of poverty. Rather, it illustrates that there is no definitive divide in well-being between the ‘haves’ and the ‘have nots,’ even in nations where those existing in extreme poverty and those in extreme wealth seem world’s apart. People’s resources and welfare are separated by incremental differences. We are far more connected to one another than a solely poverty-based approach might have us believe. Third, the gradient cannot be explained away by reverse causation or differential mobility [96, 97]. <strong>Early</strong> on, the evidence base <strong>for</strong> socioeconomic gradients in health largely came from studies that were cross-sectional in nature. This resulted in considerable ambiguity regarding the ‘direction’ of the association between ses and health; did declining health status result in downward social drift (due to loss of employment and income), or was low ses responsible <strong>for</strong> ill health Subsequent studies have demonstrated that the overwhelming portion of the relationship represents a “causal” link from ses to health rather than the reverse. This was demonstrated through a variety of means, including longitudinal studies [97] as well as a consistent association between educational attainment (a measure of ses, and one that is most often obtained temporally prior to measurement of health) and health outcomes [98]. Further, <strong>for</strong> children’s outcomes, it is far less likely or plausible that poorer developmental health is the cause of declines in family ses. The preceding points characterize ses gradients in their general <strong>for</strong>m, providing the universal qualities of gradients in every society. The next points attend to the patterns that emerge when we simultaneously examine socioeconomic gradients in different societies, as in Figure 2. These properties suggest the role played in early child development by society and its various institutions and aggregations. That is, the following points put into broad societal context the role of family socioeconomic conditions as a determinant of early child development. The remaining chapters in this volume further detail the possible aspects of the broader societal context that are highly influential <strong>for</strong> families’ (and thus children’s) resources. One discernable property is that across populations or societies, the ‘steepness’ of the gradient (i.e. the strength of the linear association) is not uni<strong>for</strong>m. That is, if one plots on a graph the ses gradients in health in different societies (as depicted in Figure 2), the lines do not fall on top of one another, suggesting that the additional gains to health from increased ses are larger in some societies than in others. In fact, the pattern that emerges suggests that, across nations, differences in health outcome at high levels of ses are far smaller than at lower levels. In other words, those societies with a ‘shallow’ ses gradient (indicating less socioeconomic inequality in developmental health) do not get that way by ‘pulling down’ the health of the high ses groups, but rather by ‘pulling up’ the health of the lower groups. It then also follows that the average health of ‘shallow gradient’ societies tends to be better than ‘steep gradient’ societies. International comparisons have shown this <strong>for</strong> the development of literacy and numeracy skills across oecd countries [1] and <strong>for</strong> health status across the European community [82]. The fourth characteristic of ses gradients then, is that those societies which produce the least inequality in health and human development across the socioeconomic spectrum also have the highest average levels of health and development. This pattern is sometimes referred to as the “flattening up” of the ses gradient [99]. The fifth characteristic of socioeconomic gradients is that the arrangement or ordering Spheres of Influence: The Family 37
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