This project examines the influence of preventative health care practices and community characteristics on child mortality in sub- Saharan Africa. The research is prompted by recent evidence of stagnation and reversal of child mortality decline in several countries since the late 1970s, during which time immunization coverage, use of oral rehydration therapy, access to potable water, and female literacy increased. The conflicting trends suggest that recent child health programs and health-related social policies in Africa have not had their anticipated favorable effects on child survival. Multilevel analyses with generalized estimating equations are conducted to investigate how effects of individual and household characteristics that presumably enhance child survival, particularly maternal education, are conditioned by macro-level factors such as the geographic isolation and economic structure of villages, and community waste disposal practices. The project thereby builds on recent theoretical contributions of anthropologists, epidemiologists and sociologists that emphasize the constraints on individual agency posed by limited health service availability, ecological settings, and sociocultural traditions in Africa. The project also demonstrates how hierarchical modeling procedures applied successfully in fertility research can be used to improve understanding of determinants of child survival. Findings from contextual models will be used to quantify the impact on child survival at the population level of immunization and household water and sanitation programs implemented by African governments and international donors in the 1980s, and to inform the choice of appropriate health interventions in future. The projects uses heretofore unavailable data on community characteristics and immunization histories of deceased children collected by the Demographic and Health Surveys (DHS) in 13 African countries since 1990. These data are far more promising for the study of child health and mortality than were data collected in the initial phase of the DHS project.
