A Pioneering Study in Mozambique Analyses How Social, Family, and Environmental Factors Influence Access to and Use of Child Healthcare

Children in low- and middle-income countries bear a disproportionate burden of morbidity and mortality, especially in sub-Saharan Africa, where infectious diseases, malnutrition, and environmental exposures converge during the first years of life, a particularly vulnerable stage for child development.

A new study conducted in the Manhiça district, in southern Mozambique, has identified how social, family, and environmental conditions during the first years of life influence the utilization of child healthcare services. The research was led by the Barcelona Institute for Global Health (ISGlobal), a center supported by the ”la Caixa” Foundation, in collaboration with the Manhiça Health Research Centre (CISM), which has operated a unique, long-standing child morbidity surveillance system. 

The work, published in Environment International, is part of the study of the exposome, a conceptual framework that integrates all environmental and social exposures to which a person is subjected from the earliest stages of life. The team analysed data from 17,145 children under five years of age from the Manhiça demographic and health surveillance system and evaluated 47 factors related to the physical environment, housing conditions, socioeconomic status, and family structure. 

Hospital visits were used as a proxy indicator of morbidity, recognizing that they also reflect healthcare-seeking behaviors and differential access to care. Three complementary statistical methodologies were combined, allowing the identification of the most relevant exposures of the child exposome and the construction of multi-exposure models capable of describing their association with morbidity. Of the 47 exposures evaluated, 23 showed a significant relationship with hospital visits. 

More resources, family support, and connectivity associated with higher use of health services 

The results of the study show that children living in households with better socioeconomic conditions, higher maternal educational levels, access to electricity, and paternal presence presented higher rates of hospital visits than those from less favored backgrounds. Likewise, those residing in more urbanised areas and closer to roads attended health services more frequently, which could reflect better access to healthcare, though also exposure to risks associated with urbanisation processes. 

On the other hand, mobile phone ownership, an indicator previously linked to better prenatal care and more favorable perinatal outcomes, was also associated with a higher frequency of hospital visits across all conducted analyses. This suggests that connectivity can play an important role in access to and utilisation of health services. 

First external exposome study in a low-income country 

Until now, exposome research has been developed primarily in high-income countries, especially in Europe and the United States. Consequently, evidence from sub-Saharan Africa remains scarce, despite the high burden of social and environmental vulnerabilities that characterises the region. 

This is the first exposome study conducted in a low-income setting that examines how multiple social and environmental exposures during the first years of life jointly affect child health. “By applying a conceptual framework based on the exposome, instead of focusing on isolated risk factors, the study provides a more comprehensive understanding of the determinants of childhood morbidity in a population sparsely represented in research,” suggests Stefan Sieber, ISGlobal researcher and first author of the study. 

The authors note that, as the conceptual framework of the exposome continues to evolve, it will be necessary to conduct research in diverse geographical contexts, including currently underrepresented regions, to better understand the heterogeneity in the exposome's influence on child health. 

“Our findings are especially relevant in a global context marked by urban growth, climate change, and persistent health inequalities, particularly in access to health services,” highlights Cathryn Tonne, ISGlobal researcher and senior author of the study. 

Reference

Sieber, S., Coloma,F., Curto, A., Nunes, J, Milà, C, Cirach, M., Anguita-Ruiz, A., Cossa, H, Matsena, T., Hunguana, A., Sacoor, C., Jamisse, E., Sitoe, A., Vrijheid, M., Bassat, Q., Saute, F., Tonne, C. Early life social and environmental exposures and all-cause hospital visits among children under five in southern Mozambique. Environment International, 2026. Doi: 10.1016/j.envint.2026.110331