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Original research
Testing the socioeconomic and environmental determinants of better child-health outcomes in Africa: a cross-sectional study among nations
  1. Corey J A Bradshaw1,
  2. Sarah P Otto2,
  3. Alicia A Annamalay3,
  4. Sam Heft-Neal4,
  5. Zachary Wagner5,
  6. Peter N Le Souëf3
  1. 1Global Ecology, College of Science and Engineering, Flinders University, Adelaide, South Australia, Australia
  2. 2Department of Zoology, University of British Columbia, Vancouver, British Columbia, Canada
  3. 3Discipline of Paediatrics, University of Western Australia, Crawley, Western Australia, Australia
  4. 4Center on Food Security and the Environment, Stanford University, Stanford, California, USA
  5. 5Rand Corporation, Santa Monica, California, USA
  1. Correspondence to Professor Corey J A Bradshaw; corey.bradshaw{at}


Objective We sought to test hypotheses regarding the principal correlates of child-health performance among African nations based on previous evidence collected at finer spatial scales.

Design Retrospective, cross-sectional study.

Setting All countries in Africa, excluding small-island nations.

Primary and secondary outcome measures We defined a composite child-health indicator for each country comprising the incidence of stunting, deaths from respiratory disease, deaths from diarrhoeal disease, deaths from other infectious disease and deaths from injuries for children aged under 5 years. We also compiled national-level data for Africa to test the effects of country-level water quality, air pollution, food supply, breast feeding, environmental performance, per capita wealth, healthcare investment, population density and governance quality on the child-health indicator.

Results Across nations, child health was lowest when water quality, improved sanitation, air quality and environmental performance were lowest. There was also an important decline in child health as household size (a proxy for population density) increased. The remaining variables had only weak effects, but in the directions we hypothesised.

Conclusions These results emphasise the importance of continued investment in clean water and sanitation services, measures to improve air quality and efforts to restrict further environmental degradation, to promote the UN’s Sustainable Development Goal 3 target to ‘… end preventable deaths of newborns and children under 5’ and Goal 6 to ‘… ensure access to water and sanitation for all’ by 2030.

  • epidemiology
  • health economics
  • infectious diseases
  • nutrition & dietetics
  • paediatrics
  • public health

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  • Contributors CJAB, AAA, SPO, ZW and PNLS conceived and designed the study. CJAB compiled the data and did the analyses. SH-N provided the air-quality data. CJAB led the writing of the manuscript, with contributions from all authors.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Disclaimer The funding sources had no role in the study.

  • Map disclaimer The depiction of boundaries on the map(s) in this article do not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. The map(s) are provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data and R script supporting the findings of this study are available at under a GNU General Public License v3.0.

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