Impact of non-health sector determinants on child health the role of the Sustainable Development Goals : models, practices and perceptions in Cambodia and globally

Background. Child health has improved significantly over the last decades in Cambodia and globally. With the global adoption of the Sustainable Development Goals (SDGs) in 2015, a broad set of interlinked global goals to promote sustainable development was introduced. However, a systematic assessment of how the SDGs influence child health, the role of multisectoral collaboration and the determinants of child mortality and morbidity from infectious diseases are not well understood in Cambodia or globally.

Aims. The overall aim of the thesis was to explore the non-health determinants of child health in Cambodia and provide an updated investigation of the determinants of child mortality as well as morbidity from infectious diseases in Cambodia and in low- and middle-income countries (LMICs). There were four specific aims: Study I. To investigate the interactions between child health and the SDGs in Cambodia. Study II: To understand how stakeholders perceive the SDGs, child health in the era of the SDGs and multisectoral collaborations for child health in Cambodia. Study III: To explore factors that are associated with under-five mortality and child morbidity from infectious diseases in Cambodia. Study IV: To investigate determinants of under-five mortality and morbidity from infectious diseases in LMICs in the SDG era.

Material and Methods. SDG Synergies approach (Study I): Based on the semi-qualitative SDG Synergies approach, an interdisciplinary Cambodian stakeholder group evaluated 272 interactions between 16 Cambodian SDGs and child health. From this, a cross- impact matrix was derived, and network analysis was applied to determine the first- and second-order effects of the interactions, with a focus on child health. Qualitative investigation (Study II): Through purposive sampling, semi- structured interviews were conducted with 29 key child health stakeholders from a range of government and non-governmental organizations in Cambodia. Guided by the research aim through framework analysis, themes, subthemes, and categories were derived. Combining Demographic Health Survey data with traditional and machine learning methods in Cambodia (Study III) and globally (Study IV): Using the most recent Demographic Health Survey (DHS) in 2021-2022, we applied a multivariable logistic regression model and a conditional random forest to explore possible determinants of under-five mortality and morbidity in Cambodia from infectious diseases. Based on DHS from 44 LMICs that had available data after 2015, we used a survey-weighted multivariable logistic regression model and a conditional random forest to explore individual, maternal and household determinants of under-five mortality and under-five child morbidity from infectious diseases.

Results. Except for SDG 15 (Life on land) the interactions are perceived to be synergistic between child health and the SDGs, and progress on Cambodian SDG 16 (Peace, justice and strong institutions) could have the largest potential to contribute to the achievement of the Cambodian SDGs (Study I). We found that the adoption of the SDGs led to increased possibility for action and higher ambitions for child health in Cambodia. There is a discrepancy between the desired step-by-step theory of conducting multisectoral collaboration and the real-world complexities (Study II). Maternal determinants such as contraceptive use was associated with under-five mortality, while household determinants in the form of geographical region, water source, and wealth quintile were associated with infectious disease in Cambodia (Study III). Expanding the analysis to LMICs globally after 2015, we found child-specific (sex, twin and birth order) and more general socioeconomic determinants of the mother and household (for example the education level of the mother and household access to electricity) to be associated with under-five mortality and infectious diseases (Study IV).

Conclusions. To improve child health in Cambodia there is a need to capitalize on the synergies between the SDGs while carefully handling potential trade-offs. The adoption of the SDGs promoted an aspirational perspective on child health allowing for multisectoral collaborations to be effective if implemented in a grounded context. Nevertheless, fundamental child, maternal and household characteristics still determine vulnerabilities of children in Cambodia and globally. A focus on the most vulnerable children and a holistic approach to designing interventions should be considered to accelerate improvements in child health in Cambodia and globally.

List of scientific papers

I. A stakeholder group assessment of interactions between child health and the Sustainable Development Goals in Cambodia. Daniel Helldén, Thy Chea, Serey Sok, Linn Järnberg, Helena Nordenstedt, Göran Tomson, Måns Nilsson, Tobias Alfvén. Nature Communications Medicine. 2022 Jun 16;2:68.
https://doi.org/10.1038/s43856-022-00135-2

II. Sustainable development goals and multisectoral collaborations for child health in Cambodia: a qualitative interview study with key child health stakeholders. Daniel Helldén, Serey Sok, Thy Chea, Helena Nordenstedt, Shyama Kuruvilla, Helle Mölsted Alvesson, Tobias Alfvén. BMJ Open. 2023 Nov 21;13(11):e073853.
https://doi.org/10.1136/bmjopen-2023-073853

III. Exploring the determinants of under-five mortality and morbidity from infectious diseases in Cambodia – a traditional and machine learning approach. Daniel Helldén, Serey Sok, Alma Nordenstam, Nicola Orsini, Helena Nordenstedt, Tobias Alfvén. [Submitted]

IV. Determinants of under-five mortality and morbidity from infectious disease in low- and middle-income countries. Daniel Helldén*, Alma Nordenstam*, Serey Sok, Nicola Orsini, Helena Nordenstedt, Tobias Alfvén. *Equal contribution. [Manuscript]