Global determinants of mortality in under 5s: 10 year worldwide longitudinal study
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6427 (Published 08 November 2013) Cite this as: BMJ 2013;347:f6427
- Matthieu Hanf, research fellow12,
- Mathieu Nacher, professor in epidemiology and public health34,
- Chantal Guihenneuc, professor in biostatistics 15,
- Pascale Tubert-Bitter, research director12,
- Michel Chavance, research director12
- 1Biostatistics, CESP Centre for research in Epidemiology and Population Health, U1018, Inserm; Villejuif, France
- 2Université Paris Sud 11, UMRS 1018, Villejuif, France
- 3Centre d’Investigation Clinique Epidémiologie Clinique Antilles Guyane CIC-EC INSERM CIE 802, Cayenne General Hospital, Cayenne, French Guiana
- 4Université des Antilles et de la Guyane, EPaT EA3593, Cayenne, French Guiana
- 5Université Paris-Descartes, Sorbonne Paris Cité, EA 4064, Laboratoire Santé Publique et Environnement, Paris, France
- Correspondence to: M Hanf INSERM U1018, Centre de Recherche en Epidémiologie et Santé des Populations Equipe 1 Biostatistique, 16 avenue Paul Vaillant Couturier, 94807 Villejuif Cedex, France matthieu{at}hanf.fr
- Accepted 30 September 2013
Abstract
Objective To assess at country level the association of mortality in under 5s with a large set of determinants.
Design Longitudinal study.
Setting 193 United Nations member countries, 2000-09.
Methods Yearly data between 2000 and 2009 based on 12 world development indicators were used in a multivariable general additive mixed model allowing for non-linear relations and lag effects.
Main outcome measure National rate of deaths in under 5s per 1000 live births
Results The model retained the variables: gross domestic product per capita; percentage of the population having access to improved water sources, having access to improved sanitation facilities, and living in urban areas; adolescent fertility rate; public health expenditure per capita; prevalence of HIV; perceived level of corruption and of violence; and mean number of years in school for women of reproductive age. Most of these variables exhibited non-linear behaviours and lag effects.
Conclusions By providing a unified framework for mortality in under 5s, encompassing both high and low income countries this study showed non-linear behaviours and lag effects of known or suspected determinants of mortality in this age group. Although some of the determinants presented a linear action on log mortality indicating that whatever the context, acting on them would be a pertinent strategy to effectively reduce mortality, others had a threshold based relation potentially mediated by lag effects. These findings could help designing efficient strategies to achieve maximum progress towards millennium development goal 4, which aims to reduce mortality in under 5s by two thirds between 1990 and 2015.
Footnotes
We thank Valérie Briand, Alexandre Dumont, and Michel Cot for their advice and comments about the draft.
Contributors: MH initiated the study, participated in the research design, performed data analysis and interpretation, and prepared the manuscript. He is the guarantor. MN, CG, and PTB helped in interpretation and participated in manuscript revision. MC participated in the research design, provided guidance on data analyses, and was involved in the interpretation of data and manuscript revision. All authors read and approved the final manuscript. The corresponding author (MH) confirms that he had full access to all the data in the study and had final responsibility for the decision to submit for publication. He affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted.
Funding: This study was supported by the Agence Nationale de la Recherche. The funder had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: Not required.
Data sharing: No additional data available.
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