In a groundbreaking study addressing child mortality in Pakistan, researchers have unveiled critical insights into the intricate relationships between healthcare professional availability, environmental hygiene, and maternal education. This comprehensive investigation sheds light on modifiable factors that can substantially decrease under-five mortality rates, an urgent public health challenge in many low- and middle-income countries. Drawing from a dataset of 8,022 children surveyed under the Pakistan Demographic and Health Survey (DHS), the research presents compelling evidence linking the presence of qualified healthcare workers with improvements in environmental conditions and, consequently, child survival outcomes.
Pakistan’s under-five mortality rate remains a significant concern, with approximately 4.09% of children succumbing before their fifth birthday. The distribution of the sample revealed a near-equal sex ratio at birth, with slightly more males (52.08%) compared to females (47.92%). The study encompassed both rural (54.82%) and urban (45.18%) populations, reflecting the country’s diverse living environments. Average maternal age was 29.55 years, and education levels were notably low, with an average of only 4.52 years of schooling, highlighting the socio-economic challenges faced by many families. Famously, households in the sample largely fell below the poverty line, reflected in a mean family wealth index of -0.09.
Essential to the study was the classification of healthcare provision, distinguishing between professional care providers, non-professionals, and cases where no formal care was administered. Remarkably, 83.34% of healthcare interactions involved professionals, demonstrating the dominate role of skilled care providers in this context. Meanwhile, 15.24% received no formal care, underscoring gaps in healthcare access. Environmental hygiene was quantified through a composite index, scoring a neutral average with a standard deviation of 1.23, illustrating variability in sanitation and living conditions, which directly influence child health outcomes.
The researchers employed bivariate regression analyses initially to identify variables directly impacting under-five mortality and environmental hygiene. Intriguingly, the child’s sex and maternal age did not show statistically significant correlations with either outcome, leading to their exclusion from subsequent multivariate modeling. The absence of multicollinearity in the dataset assured confidence in the regression models applied, as variance inflation factors remained below 5, thus eliminating concerns about confounded relationships among predictor variables.
Delving deeper, multivariate regression models unveiled profound effects of professional healthcare access on child mortality. In the first model, adjusted hazard ratios indicated that an increase in encounters with professional healthcare workers reduced the risk of under-five deaths by nearly 73%, a statistically significant finding (p < 0.05). This striking effect underscores the vital importance of qualified medical personnel in safeguarding young lives. The study further demonstrated, in model two, that healthcare professional presence positively influenced environmental hygiene, with a 30% increase in hygiene scores associated with a unit rise in professional care compared to non-professional care.
Crucially, the interplay between healthcare professionals and environmental hygiene unveiled mediation effects on mortality. Model three incorporated both variables and revealed that environmental hygiene served as a partial mediator, with improved sanitation and living conditions contributing to reductions in child mortality. Healthcare professionals alone still contributed a major decrease of 75% in mortality risk, even when accounting for environmental factors, emphasizing their multifaceted role in child health beyond direct medical intervention.
Maternal education emerged as a potent moderating variable in the final model. The authors introduced an interaction term between environmental hygiene and maternal education to understand its influence on mortality outcomes. Findings showed that maternal education significantly enhanced the protective effect of environmental hygiene against under-five deaths (p < 0.001). This synergy suggests that beyond healthcare and sanitation infrastructure, women’s educational attainment amplifies the efficacy of these interventions by fostering knowledge, practices, and behaviors conducive to child survival.
To rigorously assess these pathways, the study conducted a detailed decomposition of effect sizes utilizing 5,000 bootstrap repetitions, applying bias-corrected bootstrap confidence intervals (BCCI) for robust inference. The direct effect of healthcare workers on mortality was significant, with a coefficient indicative of reduced hazard, while mediation by environmental hygiene accounted for a lesser but still meaningful portion of the effect. Notably, maternal education’s moderating influence varied with its level; lower educational attainment correlated with a more pronounced mortality reduction effect, whereas the impact attenuated at higher education strata.
This nuanced insight portrays maternal education as a critical factor in leveraging healthcare and environmental improvements to save children’s lives. The findings caution against one-size-fits-all interventions, instead advocating tailored strategies that consider socio-educational contexts. For policy makers, these results highlight the compounded benefits of integrating education, sanitation, and healthcare workforce development in public health programs aimed at reducing under-five mortality.
The conceptual model developed in the study vividly illustrates these complex moderated-mediation relationships, positioning healthcare professional availability as a primary driver influencing environmental hygiene and maternal education, which together orchestrate child survival outcomes. This model challenges traditional approaches that isolate variables, advocating for a holistic understanding of child health determinants in Pakistan’s socio-economic landscape.
Overall, the study reinforces the indispensable role played by skilled healthcare professionals not only in delivering immediate medical care but also in fostering environments and behaviors that prevent disease transmission and promote child well-being. Importantly, the positive feedback loop involving maternal education enhances intervention effectiveness, suggesting that empowering women through education yields compounding benefits for community health.
These findings have powerful implications for international health policy. Investments in professional healthcare provision, coupled with efforts to improve sanitation infrastructure and bolster female education, represent synergistic pathways to accelerating progress towards achieving global child mortality reduction targets. The study’s methodological rigor, leveraging nationally representative data and advanced statistical techniques, offers robust evidence supporting integrated, multisectoral health strategies.
In conclusion, this research advances our understanding of the delicate interplay between healthcare delivery, environmental factors, and social determinants in shaping under-five mortality. It calls upon governments, NGOs, and global health agencies to design interventions that recognize and operationalize these interconnected influences. By doing so, the devastating loss of young lives can be significantly curbed, paving the way for healthier futures across Pakistan and similar contexts worldwide.
Subject of Research:
The investigation focuses on the complex relationship between healthcare professional availability and under-five mortality in Pakistan, specifically analyzing the mediating role of environmental hygiene and the moderating effect of maternal education.
Article Title:
The relationship between healthcare professionals and under-five mortality: the mediating role of environmental hygiene and the moderating effect of maternal education.
Article References:
Nawaz, R., Khalid, N., Zhou, Z. et al. The relationship between healthcare professionals and under-five mortality: the mediating role of environmental hygiene and the moderating effect of maternal education. Humanit Soc Sci Commun 12, 1788 (2025). https://doi.org/10.1057/s41599-025-06037-7
Image Credits: AI Generated
DOI:
https://doi.org/10.1057/s41599-025-06037-7
