Child health and mortality in resource-poor settings: a life-course and systemic approach

While there has been a staggering decline in global child mortality, sub-Saharan Africa (SSA) has consistently contributed the largest share. The 2020 global estimates on child mortality indicate SSA contributing 42%, 53% and 61% of neonatal, under-five, and 5-9 deaths, respectively. Moreover, the 1990-2020 child mortality data indicate an upward trend in SSA’s contribution in all age groups. The persistent high child mortality within the region could be attributed, amongst others, to inequities in health services’ access within countries. Additionally, there have been limited interventions that target children aged 5 years and beyond due to the limited research and data systems. As the focus of this paper-based thesis, Uganda as the study area shows the same issues within the SSA context. Therefore, it presents a novel opportunity to understand child health and mortality mechanisms among children aged 0-9 years. Guided by the concepts of interdependence, social interactions and health service delivery systems’ drawn from social and health systems and life-course perspectives, the thesis’ specific objectives are to: 1) determine the under-10 mortality age-specific estimates; 2) assess the epidemiological shift in the under-10 mortality risk factors and causes of death; 3) assess the role of Low Birth Weight (LBW) in mediating the new-born mortality risk factors and the role of institutional delivery in new-born mortality; 4) identify key community and household predictors of suspected pneumonia and diarrhoea, and 5) examine how multiple factors concurrently affect access to appropriate health care services. Using a decade (2005-2015) of event history data collected by Iganga-Mayuge Health and Demographic Surveillance Site (HDSS) in Eastern Uganda in Chapter 31, I found that the under-10 and 5-9 years of age mortality probabilities were 99 per 1000 live births and 11 per 1000 children aged 5-9 years, respectively. The new-born mortality and perinatal mortality were estimated at 22 and 31 per 1000 live births, respectively, with death within the first day of life (0-1 day) contributing the largest share (62%). I found that the magnitude of the association of the risk factors with under-10 mortality varied by age, with a stronger association observed among infants. The order of the top causes of mortality altered with age, with gastrointestinal infections and injuries emerging among 5-9 years old, but malaria and malnutrition remaining among the leading four mortality causes. Using Iganga-Mayuge HDSS data in Chapter 42, I found that institutional delivery had an insignificant inverse effect on new-born mortality. The LBW mediated multiple factors, including adolescence age, rural residence, multiple births and unmarried marital status. The novel machine learning technique applied on 2006-2016 Uganda DHS data in Chapter 53 helps us identify rural-urban differentials in the deterministic pattern of a child’s diarrhoea and acute respiratory infection (ARI). The study findings confirm the notion that ARI and diarrhoea risk factors overlap. These factors relate to the household’s structure and composition, which is characterised by poor hygiene and sanitation and poor household environments that make children more suspectable of developing these diseases; maternal socio-economic factors such as education, occupation, and fertility (birth order); individual risk factors such as child age, birth weight and nutritional status; and protective interventions (immunisation). Furthermore, the qualitative data analysis collected in Chapter 64 revealed how multiple factors concurrently affect access to obstetric and child health care services. Chapter 6 findings were used to develop a multisectoral and multidimensional implementation framework for obstetric and child health care services in resource-poor settings. Overall, the application of life course and systemic approach in the analysis and interpretation of the results provides an insight into the need for holistic interventions (social, structural, and health systems) throughout the stages of child development. Each paper brings new insights into the mechanisms and determinants of under-10 mortality in resource-poor settings. Together, the papers help us build a stronger life-course and health systems framework for child health and survival, contributing to the recent call for redesigning child health programs.