Governance and health: Moral suasion, coercion and trust in authorities in the improvement of child health
In spite of existing knowledge on effective interventions to improve child survival 10 million children die each year, primarily due to diarrhoea and pneumonia. During 25 years around 1900 child mortality due to these causes declined rapidly in Stockholm, and social differentials in child mortality have continued to decline throughout the 20th century. The political prioritisation of reduced child mortality and the implementation of general interventions, partly based on coercion and trust in authorities, seems to have benefited lower social classes more than higher classes in Sweden. In Mozambique similar improvements of sanitation implemented from the independence in 1975 to the civil war 1982 contributed to improved child survival.
The project will study the importance of political leadership to child survival in different historical and geographic contexts, with the example of Stockholm around 1900 and Mozambique 100 years later. How does moral suasion, coercion and trust in authorities affect children's survival chances? Which social classes are benefited by general and selective interventions to improve health? What concept of risk construction in the population is required for the success of sanitary reform? Methods will include document analysis and analysis of individual data on child survival 0-9 years in both countries - in Stockholm based on Rotemansarkivet 1878-1925 (110,000 children); in Mozambique based on health interview surveys 1997 (24,000 children) and 2003.
Bo Burström, Karolinska Institutet
Overall objective
The overall objective of the project is, through a combination of qualitative and quantitative studies, to contribute to the understanding of mechanisms which facilitate the implementation of health reform to bring about an equitable health improvement and mortality decline in the population.
This original objective applied to a comparison of the decline of child mortality in Stockholm at the turn of the 19th century, with the temporary decline of child mortality in Mozambique during the 1970s, with respect to what factors made this happen in relation to contemporary social and political movements and to the risk constructions employed in the respective context. An unintended deviation from the overall objective occurred as the work planned in Mozambique could not be realised as planned, because of a delay in obtaining ethical permission from Mozambique. However, efforts are continuing to complete also that part of the study.
Three main findings
The three main findings of the project were largely based on the studies of Swedish data, as the Mozambican part of the project could not be realised as planned. However, the Swedish results have also been discussed in their potential relevance to countries such as Mozambique.
1. Political commitment, infrastructural investments in water and sanitation, and the enforcement of sanitary improvements by a strong implementing organisation were instrumental in reducing diarrhoea mortality and thereby overall child mortality in Stockholm
2. General interventions (e g improved water and sanitation) with extensive coverage may have a greater effect among more vulnerable children than in the general population, particularly when coupled with targeted interventions
3. The effect of interventions (e g improved water and sanitation) may take a long time to be noticed, and may not always be measurable at individual level only
Our studies revealed that the decline of child mortality in Stockholm was the result of a successful combination of strong political commitment of the local leadership and influential citizens of the city of Stockholm to improve child health and social differentials in child health, the concurrent and longstanding work to improve structural facilities for clean water and appropriate sanitation, and the forceful and concrete work of local health inspectors with coercive powers. In addition to these factors, health education efforts by the city officials and by voluntary organisations informed the population to adopt more health-promoting behaviours in relation to water and sanitation.
Studying the decline in diarrhoea mortality over time among different socioeconomic groups, it was evident that the decline was stronger among lower than higher socioeconomic groups, particularly from 1900-1925 when the provision of clean water and proper sanitation had become more widespread. Around the same time, several voluntary organisations were operating to support vulnerable children with feeding advice and children born out of wedlock were recognised to need extra support. By 1925 there was no clear social gradient in diarrhoea mortality.
Although the expansion of water and appropriate sanitation started in the 1860s it took until 1900 to see effects in terms of a decline in diarrhoea mortality. Furthermore, it was not possible to show effects of improved water on an individual or household level, but on area level (comparing local areas with respect to their development of diarrhoea mortality and overall mortality. This is likely due to the fact that diarrhoea is a disease dependent on wider environmental conditions and proper utilisation of available facilities.
New research questions generated by the project
Several original research questions in the project have not yet been properly addressed, because of lack of data from Mozambique. However, it is hoped that this can be solved in future studies. One additional question arising from the present project concerns the role of policy and legislation in relation to survival of foster children. Foster children in Stockholm had an extremely high mortality rate before 1900. A new law in 1902 enabled inspection of foster homes. In only a span of 10-15 years, the inspection of foster homes with advice on child care and nutrition, and occasionally change of foster home, the mortality rate of foster children was reduced to similar levels as other children. Although not part of the original research questions, these analyses (a combination of qualitative analyses of historical records and quantitative analysis of individual socio-demographic and mortality data) have resulted in a manuscript for submission for publication.
The two most important publications of the project
This research project coincided in time with the work of the Commission on Social Determinants of Health (CSDH), initiated by the World Health Organization, which was presented in August 2008. In relation to this, work was initiated in the NEWS (Nordic Experience of Welfare States) project, organised by the Centre for Health Equity Studies, to contribute to the CSDH work. A commissioned report to the NEWS project, based on results from the present project was used in the recent publication Nordic Experience of Welfare States and Public Health (2008).
Another important publication from the project was "The dialectics of child mortality", published in the International Journal of Health Services (2006). This is perhaps the best example of the combination of a qualitative and quantitative approach, which has been a hallmark of the project. Altogether 8 publications have been produced under the umbrella of the project.
Other types of dissemination of project results
This project has been very useful and illustrative in the context of teaching. It has been taught in lectures to medical students, students of public health (bachelor and master level) since 2005. It has been the topic of project group work for medical students in their last year of study at Karolinska institutet since 2005 (four groups of 8 students - 32 students - every year 2005-2008). Three medical students have made in-depth project work for 5-7 weeks on the topic; one Erasmus Mundus Scholarship student was supervised to do his Master of Public Health thesis on the basis of the project data.
The results have also been presented and discussed at different conferences and seminars.