Geographical variations of the associations between health interventions and all-cause under-five mortality in Uganda

Abstract

Background: To reduce the under-five mortality (U5M), fine-gained spatial assessment of the effects of health interventions is critical because national averages can obscure important sub-national disparities. In turn, sub-national estimates can guide control programmes for spatial targeting. The purpose of our study is to quantify associations of interventions with U5M rate at national and sub-national scales in Uganda and to identify interventions associated with the largest reductions in U5M rate at the sub-national scale.

Methods: Spatially explicit data on U5M, interventions and sociodemographic indicators were obtained from the 2011 Uganda Demographic and Health Survey (DHS). Climatic data were extracted from remote sensing sources. Bayesian geostatistical Weibull proportional hazards models with spatially varying effects at sub-national scales were utilized to quantify associations between all-cause U5M and interventions at national and regional levels. Bayesian variable selection was employed to select the most important determinants of U5M.

Results: At the national level, interventions associated with the highest reduction in U5M were artemisinin-based combination therapy (hazard rate ratio (HRR) = 0.60; 95% Bayesian credible interval (BCI): 0.11, 0.79), initiation of breastfeeding within 1 h of birth (HR = 0.70; 95% BCI: 0.51, 0.86), intermittent preventive treatment (IPTp) (HRR = 0.74; 95% BCI: 0.67, 0.97) and access to insecticide-treated nets (ITN) (HRR = 0.75; 95% BCI: 0.63, 0.84). In Central 2, Mid-Western and South-West, largest reduction in U5M was associated with access to ITNs. In Mid-North and West-Nile, improved source of drinking water explained most of the U5M reduction. In North-East, improved sanitation facilities were associated with the highest decline in U5M. In Kampala and Mid-Eastern, IPTp had the largest associated with U5M. In Central1 and East-Central, oral rehydration solution and postnatal care were associated with highest decreases in U5M respectively.

Conclusion: Sub-national estimates of the associations between U5M and interventions can guide control programmes for spatial targeting and accelerate progress towards mortality-related Sustainable Development Goals.

Keywords: Bayesian proportional hazards geostatistical models; Demographic and health survey; Geographical variations; Interventions; Sub-national scale; Uganda; Under-five mortality.

Fig. 1

Geographical distribution of the associations (Hazard rate ratios) of malaria interventions with under-five mortality; (*statistically significant association of interventions and protective against mortality); a Percentage of population with access to an ITN within their household, b Percentage of existing ITNs used by the population in a household the previous night of the survey

Fig. 2

Geographical distribution of the associations (Hazard rate ratios) of water, sanitation and hygiene practices with under-five mortality; (*statistically significant effect of interventions and protective against mortality); a Percentage of households with improved source of drinking water, b Percentage of households using improved sanitation facilities

Fig. 3

Geographical distribution of the associations (Hazard rate ratios) of reproductive health interventions with under-five mortality; (*statistically significant association of interventions and protective against mortality); a Percentage of married women using any family planning method, b Percentage of women who received intermittent preventive treatment for malaria during pregnancy, c Percentage of births that took place with the assistance of a skilled provider, d Percentage of newborns receiving first postnatal checkup from a skilled provider within 2 days after delivery

Fig. 4

Geographical distribution of the associations (Hazard rate ratios) of breastfeeding and vaccinations with under-five mortality; (*statistically significant association of interventions and protective against mortality); a Percentage of infants who started breastfeeding within 1 h of birth, b Percentage of children with complete vaccination of DPT, c Percentage of children vaccinated against measles

Fig. 5

Geographical distribution of the associations (Hazard rate ratios) of micronutrients intake and treatments with under-five mortality; (*statistically significant association of interventions and protective against mortality); a Percentage of children receiving vitamin A supplements in the past 6 months, b Percentage of children given deworming medication in the past 6 months, c Percentage of children with diarrhoea given fluid from oral rehydration solution sachets or recommended home fluids, d Percentage of children with fever during the 2 weeks prior to the survey and took artemisinin-combination therapy