Geographical perspectives on the social determinants of inequalities in under-five mortality in Nigeria: towards an integrated approach

Abstract

Nigeria is the highest contributor to under-five mortality in the Sub-Saharan African region and the second highest in the world. Annual rates of reduction have remained consistently lower than the Sub-Saharan regional average and wide inequalities have been rep0rted. In addition, Nigeria continues to rank last in the Commitment to Reducing Inequality (CRI) index indicating that Nigeria’s effort at reducing inequalities is the worst in the world. Addressing inequalities in the under-five mortality rate problem requires a contextualised understanding of the social determinants of under-five mortality and the complex processes shaping unequal distribution of risk factors in most vulnerable populations. This study aims to explore the social determinants and the processes shaping inequalities in under-five mortality rates at multiple geographical scales using mixed-methods: a combination of global statistical methods and ArcGIS-based spatial statistics and semi-structured interviews. To date, international research from the perspectives of the geographies of health on the relationship between place, agency and the social determinants of health remain very limited. This study is the first within the Nigerian context to incorporate the lay narratives of mothers into statistical modelling of area-level data in an attempt to demonstrate how and why the social determinants of under-five mortality interlock simultaneously, to create inequalities in the health experiences of groups and individuals. In addition, this study goes beyond risk discourses to explore individual agency and the collective responses of mothers to perceived child health-risk factors in their local context. This study moves beyond risk narratives to examine the power dynamics mediating people’s capabilities to choose informed responses to health-risks. The findings highlight complex underlying interrelationships in the social determinants of under-five mortality, alongside marked geographical and social inequalities. The findings suggest the need to steer away from the dominant one-size-fits-all biomedical policy approach to addressing health inequalities and calls for research and policy practice to be sensitive to the social context of women’s lives in which inequalities in child health are embedded.