capturing and addressing community perspectives

SOCIAL DETERMINANTS OF CHILD HEALTH

30 May 2014

Frederick Marais PhD MPH

Western Cape Government Health

Stellenbosch University

Ayesha Kadir MD, MPH

London School of Hygiene & Tropical Medicine

Kings College Hospital, London

Sustainable Rural Health Research Days 2014

Social determinants of child health Growing recognition of the need to identify and address the

social determinants of child health

Dominant conventional paradigm: • quantitative design and “evidence-based” • top-down approach for research and interventions (policy and

programmatic responses)

– deficits, method of measurement, indicators, analysis, intervention development, and evaluation (“external experts”)

– scarce data on community and children’s perspectives of social determinants and required actions (“internal experts”)

Focus on health aspects of, and not addressing, social determinants = risk of perpetuating existing inequalities

Social determinants of child health Gap in understanding of the social aspects and mechanisms by

which these influence health

Lived realities and perspectives of children and communities overlooked

Increasing advocacy for multi-sector collaboration and community engagement to construct and mobilise knowledge

Disease

Methodology

Setting: Dwars River Valley,

CWD (2012 – 2103)

Community-based design:

• Qualitative participatory

approach - community members, lay community leaders, health workers guidance

on methods, analysis, interpretation, recommendations and knowledge dissemination and mobilisation

Question: what are the social determinants of child health in this rural community?

Target population: households with children <18 years old, living in deprived conditions

Methodology

Sampling (N=105)

• Purposive and snowball: poorer households (n=24) and key informants (n=8)

• Convenience: school children (n=41) and health workers (n=11)

• Community focus groups (n=21)

Data

• Child drawings (n=30; age 5-14)

• Focus group discussions (n=8)

• Semi-structured in-depth interviews (n=28)

• Documentary review

• Transect drives and walks

Methodology

Analysis: Framework analysis in NVivo 10

Validation:

- Internal: series of four open community feedback sessions and one meeting with community leaders were held to present the findings and verify accuracy

- External: triangulation between all

sources of data

Recommendations: during validation process,

community members identified and prioritised

contextually appropriate responses to address

the locally-identified social determinants of child health

Findings: POVERTY

CHILDREN

Spoke of the

experience of being

poor:

hunger

neglect

• physical

• emotional

• social exclusion

ADULTS

Described a cyclical relationship between:

insecure housing

unemployment

inability to provide for their families

lack of personal agency

• above factors led to dependence on others

Findings: CHILD HEALTH

HEALTH PROBLEMS

TB / MDR

malnutriton (HCW focus)

asthma

seasonal RTIs

diarrhoea

HIV

teen pregnancy

depression

SOCIAL PREDICTORS neglect (by carers)

hunger

substance abuse

social exclusion

poor parenting skills

family breakdown

inadequate housing

dignity

lack of agency (carers)

Children associated neglect = hunger and depression Adults associated neglect = all child health outcomes

Findings: GENERAL Existing community-led programmes: helpful in short term,

but potentially undermining parental responsibility, thus perpetuating the cycle of poverty-neglect-poor child health

Maintaining patient confidentiality: challenge within current clinic arrangements = undermining trust of the community

Unheard HCW voices: no platform to raise community observations and to respond effectively

Burnout: major concern for HCWs

Recommendations

Interventions and community:

Engage children/young people:

- identification of priority areas

- planning, implementation and evaluation

Empowerment of both children and adults:

- building on existing community assets

WCG Health:

- build trust between clinic staff, community-based health workers, and the community

- ensure patient confidentiality (consultations and records)

- inclusion of local health workers in clinic/programme planning

Concluding remarks

Main determinants of child health were lack of

personal agency amongst adults and child neglect.

Children and their families are “internal experts”.

Views and priorities of communities, particularly

those of children, give deep insight into the social

determinants of and required responses to child health outcomes.

Inclusion of children’s views led to the main findings. Sensitive and difficult to capture issues identified by children created a platform for further exploration amongst adult participants.

For maximal impact, public health research and interventions to improve child health should be developed, implemented and evaluated in partnership with the target communities and

Purposively Seek the Voices of Children!

Acknowledgments

The community engaged in the study was instrumental in making this work possible - from start to finish.

Nicola Desmond: co-supervisor

John Porter: methods guidance

Nick Spencer: methods guidance

Richard Enthoven funding

Randgold & Exploration Company Ltd. funding

Ayesha Kadir funding

Final study report: Kadir A, Marais F, and Desmond N. (2013) Community perceptions of the Social Determinants of Child Health in the Dwars River Valley. London School of Hygiene and Tropical Medicine, London

Thank You!

Tel: Fax:

www.westerncape.gov.za

Contact Us

Dr F Marais

Deputy Director: Increasing Wellness

021 483 0887 021 483 9921

Frederick.Marais@westerncape.gov.za