MASENO UNIVERSITY

SCHOOL OF MATHEMATICS, STATISTICS AND ACTUARIAL

SCIENCE
DEPARTMENT OF STATISTICS AND ACTUARIAL SCIENCE

A PROJECT PROPOSAL ON THE SURVIVAL ANALYSIS OF THE

MORTALITY OF CHILDREN UNDER THE AGE OF FIVE AND ITS
ASSOCIATED RISK FACTORS

MASENO UNIVERSITY
P.O. BOX PRIVATE BAG
MASENO, KENYA.

NOVEMBER, 2022.
 DECLARATION
Declaration by the students:
We certify that this research proposal is our original work and all material herein
which is not our own work has been identified. We further certify that no material
has previously been submitted.
The following is a list of the project members
Name. Registration Number.
DOREEN KATUNGWA TAC/00011/019
JASON WEKESA TAC/00348/019
STEVE OYUGI TAC/00174/019
MARTIN MASILA TAC/0010/019
DANIEL MWENDWA TAC/00169/019
GRANDEE MALISA TAC/03001/019
ATHMAN KAZI TAC/00059/019
CYRUS MUNGUTI TAC/00162/019
PAUL KATHARE TAC/00225/019
BRANDON ANYOKA TAC/00159/019

Declaration by the Supervisor:

This project proposal has been submitted for examination with my approval as the
designated university supervisor.
Signature: __________________________ Date: _________________________
Name:
Department of Mathematics, Statistics and Actuarial Science
 ACKNOWLEDGEMENT

It is with sincerity and heartfelt gratitude that we would like to take this privilege
to pass our regards to the following people who contributed towards our successful
completion of this proposal. It also goes without mentioning the outstanding work
done by our lecturers at Maseno University in time, knowledge and experience
invested in us, not forgetting the immeasurable interaction with the students. They
have equipped us with the knowledge and skills that we could have found nowhere
else.
We wish to acknowledge Maseno University and with special thanks to our
supervisor Dr. Cynthia for her support, consideration and patience during the
period of seeking advice and guidance not only to us but other students as well.
We also wish to acknowledge our entire class of Actuarial for the challenging
times experienced and support notwithstanding.
Our acknowledgement goes to our lovely family, for their continued support.
 ABSTRACT

Child mortality is one aspect that affects a society's well-being since it is seen as
an indicator of a nation's socioeconomic standing and medical advancement. More
research was required because of the high rates of child mortality, which were
largely observed in developing countries. South-East Asia (28%) and Africa (46%)
were found to be jointly responsible for around three-quarters of all child fatalities
in a 2013 study on child mortality. More than half of these fatalities were caused
by only six countries: China, Democratic Republic of the Congo, Ethiopia, India,
Nigeria, and Pakistan. Under-five mortality rates are often greater in rural areas,
populations that are poorer and less educated, and generally speaking (MDG
2013). Children living in the northern and western regions of Kenya are more
likely to experience high mortality due to preventable diseases than children living
elsewhere. It is with thought in mind that we decided to use Maseno town, Kisumu
County as our case study. The study's primary objectives will be to examine the
key elements that endanger children's life and evaluate the plans that should be put
in place to ensure their survival. The study will also determine when a youngster
under the age of five is most likely to die. Both the Cox proportional hazard model
and the Kaplan Meir models will be used in our study. The Maseno Mission
Hospital and the Chuilambo Sub-County Hospital will be the sources of our data.
In light of this, the study will explain the uncertainty that youngsters under the age
of five confront.
Table of Contents
DECLARATION.......................................................................................................2

ACKNOWLEDGEMENT.........................................................................................3

ABSTRACT..............................................................................................................4

CHAPTER ONE........................................................................................................7

INTRODUCTION.................................................................................................7

1.1 Background of the study..............................................................................7

1.2 Statement of the problem.............................................................................9

1.3 OBJECTIVES..............................................................................................9

1.4 Null Hypothesis.........................................................................................10

1.5 Justification................................................................................................10

CHAPTER TWO.....................................................................................................11

LITERATURE REVIEW....................................................................................11

CHAPTER THREE.................................................................................................15

METHODOLOGY..............................................................................................15

Introduction.....................................................................................................15

3.1 Data sources...............................................................................................15

3.2 Statistical software.....................................................................................16

3.3 Sample size estimation..............................................................................16

3.4 Methods of data collection........................................................................17

3.5 Method of data analysis.............................................................................17

APPENDICES.........................................................................................................20
REFERENCES........................................................................................................21
 CHAPTER ONE
INTRODUCTION
1.1 Background of the study
Child mortality is the projected chance, out of 1,000 live births, that a child would
die between the time of birth and precisely the age of five. Numerous elements,
including the economic factor, social factor, culture, parenting, the environment
the kid is born into, diarrhea, pneumonia, and infectious illnesses, to mention a
few, are at play on a global scale. Neonatal, postnatal, and under-five mortality are
the three categories into which child mortality may be divided. Children are a
blessing. A nation's socioeconomic standing, health, and living standards are all
impacted by child mortality. The UN is making a lot of effort to lower rates of
child mortality.
According to Caleo, child mortality is 20% greater in developing nations than in
wealthy ones (2018). This may be linked to the provision of subpar healthcare
services as well as high poverty levels.
Globally, the child mortality rate has been on a steady decline, from 93 deaths out
of 1000 live births in 1990 reducing to 37 in 1000 in 2020. Countries facing the
highest child mortality rates are India, Nigeria, Bangladesh and Pakistan. It is
estimated that the four countries make up for nearly half of the children’s death
globally, Helleringer (2021). These countries are also associated with low literacy
of mothers. Children lack basic needs and opportunities in life.
Africa, particularly sub-Saharan Africa accounts for about 50% of the 8.8 million
yearly under five deaths at the time of this research. This is according to a research
conducted on child mortality by KEMRI (2004). Nigeria is affected by the
majority of child deaths. 80 million people out of its population of 150 million are
children. In 2012, 160 child deaths occurred out of 1000 live births. The majority
of these deaths have been attributed to pneumonia, neonatal sepsis, environmental
factors and a number of infectious diseases. There is uncertainty concerning the
overall distribution of the burden.
In Kenya, mortality rate for infants is currently at 31.771 deaths out of 1000 live
births. This is a 3.47% reduction from the 32.913 deaths out of 1000 live births
rate noted in 2021. The same research further shows 34.056 deaths out of 1000 live
births observed in 2020, which was 3.24% decline from 2019. In 2019 we
observed 35.198 deaths out of 1000 live births according to projections made by
the United Nations (2021). As shown by the figures aforementioned, there is a
trend of reduction in infant mortality rates, roughly at 3.025% per annum. United
Nations has been investigating the issue and making relevant projections since
1950.
Life expectancy at birth in Kenya is estimated at 66.99 years, World Bank (2020).
According to SDG (2021), neonatal mortality was estimated at 21 deaths out of
1000 live births, SDG aims to reduce the neonatal mortality rate to 12 and the
under-five mortality to 25 by the year 2030.
Child mortality is prevalently high in Kisumu County. Maseno Town is situated in
the north-western part of Kisumu County.
1.2 Statement of the problem
One of the factors associated with the well-being of a population is child mortality.
According to Kenya Infant Mortality rate the current infant mortality rate for
Kenya in 2022 is 31.771 deaths per 1000 live births. Kisumu is one of the counties
known to have high child mortality rate. According to Othero Oteku, infant and
child death in developing countries constitute the largest age category of mortality.
One of the main risk factors that affect child mortality and survival rate are
environmental factors, neonatal implications, pneumonia among others infectious
diseases. Our project is aimed at analyzing the risk factors that contribute to child
mortality and effective child survival strategies that will help reduce child
preventable deaths around Maseno. We are planning to use models such as
Kaplan-Meier estimate to analyze the survival rate of under-five children around
Maseno and Cox proportional mode to analyze the different risk factors associated
with child mortality.
1.3 OBJECTIVES
Main objectives
1. To identify the risk factors that are affecting child survival rate.
2. To determine child survival strategies that will help reduce preventable child
deaths in Maseno.
3. To estimate the impact of maternal, neonatal and child survival interventions.

Specific objectives
1. To determine the most common age with increased mortality rate.
2. To determine if environmental and nutrition-related factor contribute to the
survival rate of under-five children.
1.4 Null Hypothesis
Environment and nutrition-related factors have no effect on the survival rate of the
under-five children.
The specific age and sex of an under-five children has no effect on his/her survival
probability.
1.5 Justification
The research is expected to be of great relevance to the Kenya health sector at
large.
Child mortality is a vital indicator of child health and overall national
development. It provides a snapshot of current health problems, suggests persistent
pattern of risk-factors in specific communities and shows trends in specific causes
of death over time. Many causes of death are preventable or treatable and
therefore, warrant the attention of public health prevention effects.
The research will help to know the major cause of infant mortality of children
under five years. However, globally, infectious diseases including pneumonia,
diarrhoea and malaria, along with pre-term birth complications, birth asphyxia and
trauma and congenital anomalies remain the leading causes of death for children
under five.
Survival analysis is an important part of medical statistics, frequently used to
define prognostic indices for mortality or recurrence of a disease and to study the
outcome of treatment.
Lately, comparing the birth rate and death rate of a given area provides insight into
whether that population is increasing or decreasing. When the birth rate is larger
than the death rate, we know that more people are being “added” to the area than
are being “taken away” meaning the population is growing.
The study will also continuously assist in research studies as the study will provide
a reference point for literature review while conducting studies in future.
 CHAPTER TWO
LITERATURE REVIEW

Child mortality refers to the death of a child aged between one and five years.
Child mortality rate are the best indicators of social economics development
because the life expectancy at birth is determined by the survival chances of
children. The SDG’s(Sustainable Development Goals) call for an end to
preventable deaths of newborns and children under five ,with all countries aiming
to have a neonatal(relating to newborn children)mortality rate of 12 or fewer
deaths per 1000 live births and an under-five mortality rate of 25 or fewer deaths
per 1000 live births by 2030.With that mentioned our aim is to basically
restructure the health delivery system by analyzing strategies including data
management , medical treatment , and other relevant measures with the aid of two
survival analysis models namely; Kaplan-Meier model, also known as the product
limit estimator used to estimate the survival function from lifetime data and Cox
proportional Hazards Model, .a regression model commonly used in investigating
the association between the survival time of patients and one or more predictor
variables.
In Kenya high infant and under five mortality rates could be attributed to
HIV/AIDS pandemic, poverty and decline in economic well-being. The main
causes can be classified into three major categories namely infections, birth trauma
and malnutrition. In Kenya it has been found out that respiratory infections ,
especially pneumonia are the main cause of death among infants(Ewbank ,
1986).Rotavirus has been isolated in at least 30% of young children admitted to the
pediatric ward of Kenyatta National Hospital for acute diarrhea (Leeuwenburg et
al 1984).In the Kisumu longitudinal study , it has been found out that 60% of
under-five mortality is due to three diseases; malaria , diarrhea and pneumonia as
reported by Nyando Medical Officer Dr.Jonathan Billis.
Neonatal deaths tend to be dominated by factors related to the birth processes.
Conditions which cause the above causes of death include low birth weight, poor
sanitation and water supply, poverty, inadequate food supply, lack of education
and information and inadequate health care as cited in Newland’s article, 1982.
There are considerable variations too in the levels of infant and child mortality
according to mother’s education attainment, perinatal mortality and high-risk
fertility behavior.
Mother’s education attainment.
As observed in most studies, the mother’s level of education is strongly linked to
child survival. Higher levels of educational attainment are generally associated
with lower mortality rates, since education exposes mothers to information about
better nutrition, use of contraceptives to space births, and knowledge about
childhood illness and treatment. Children of women with no education are an
exception to this pattern, since they experience lower mortality than children of
women with incomplete primary education. Larger differences exist between the
mortality of children of women who have attained secondary education and above
and those with primary level of education or less. Mwaniki (1983) cited in Ewbank
et al (1986;49) found out that according to Kenya fertility survey data under-five
mortality rates of children born to mothers with incomplete primary education are
the highest (145 deaths per 1,000 live births), higher than mothers without any
education (127 deaths per 1,000 live births). Children whose mothers have at least
some secondary education have the lowest under-five mortality rates (63 deaths
per 1,000 live births)
a) Perinatal Mortality.

Pregnancy losses occurring after seven completed months of gestation (stillbirths)

plus deaths to live births within the first seven days of life (early neonatal deaths)
constitute perinatal deaths. When the total number of perinatal deaths is divided by
the total number of pregnancies reaching seven months gestation, the perinatal
mortality rate is derived. The distinction between a stillbirth and an early neonatal
death may be a fine one, depending often on the observed presence or absence of
some faint signs of life after delivery. The causes of stillbirths and early neonatal
deaths are overlapping, and examining just one or the other can understate the true
level of mortality around deliver. Pregnancies with an interpregnancy interval of
less than 15 months have a higher perinatal risk (102 deaths per 1,000 pregnancies)
than all other pregnancies. There are no apparent rural and urban differences in
perinatal mortality rates, which contradicts the findings in the previous section that
showed that neonatal mortality is higher in rural areas than in urban areas. There
are, however, considerable differences in perinatal mortality by province. Coast
Province has the highest perinatal mortality rate (57 deaths per 1,000) and Western
Province has the lowest rate (28 deaths per 1,000). Perinatal mortality rates
according to educational attainment show that women with no education
experience higher rates (54 deaths per 1,000) than those with primary (37 deaths
per 1,000) or at least some secondary (39 deaths per 1,000) education.

b) High-risk fertility behavior.

Numerous studies have found a strong relationship between children’s chances of

dying and certain fertility behaviors. Typically, the probability of dying in early
childhood is much greater if children are born to mothers who are too young or too
old, if they are born after a short birth interval, or if they are born to mothers with
high parity. Very young mothers may experience difficult pregnancies and
deliveries because of their physical immaturity. Older women may also experience
age-related problems during pregnancy and delivery. For purposes of this analysis,
a mother is classified as “too young” if she is less than 18 years of age and “too
old” if she is over 34 years of age at the time of delivery; a “short birth interval” is
defined as a birth occurring within 24 months of a previous birth; and a “high-
order” birth is one occurring after three or more previous births (i.e., birth order
four or higher). First-order births may be at increased risk of dying, relative to
births of other orders; however, this distinction is not included in the risk
categories in the table because it is not considered avoidable fertility behavior.
Also, for the short birth interval category, only children with a preceding interval
of less than 24 months are included. Short succeeding birth intervals are not
included, even though they can influence the survivorship of a child, because of
the problem of reverse causal effect (i.e., a short succeeding birth interval can be
the result of the death of a child rather than being the cause of the death of a child).
The project adopts the Kaplan Meier model considering the whole population in
Maseno in the study.
The next chapter outlines the two models used in the study; Kaplan-Meier and Cox
proportional hazard model and the theory in details giving the parameter and the
processes involved.
 CHAPTER THREE
METHODOLOGY
Introduction
This study is designed to investigate the survival analysis of children mortality
under 5 years in Maseno. In this section we present the models that are used in this
study. We therefore limit our project to the most popular ones Kaplan-Meier
Model and Cox Proportional Hazard Model which are used to assess the strength
of influence of one covariate against other to the probability of experiencing a
survival event. In addition, Kaplan-Meier methods will be used in-line with Cox
proportional hazard model since it has no power to estimate the strength of
influence of a lifetime variable on the occurrence of an event of interest. The
methods are appropriate because dependent variable in survival analysis is
composed of two parts: one is the time to occurrence of event of interest and the
other is the event status, which records if the event of interest occurred or not.
The response variable or outcome variables to be considered in this study are the
survival time of a child measured in months from birth until death of children aged
less than 60 months (5 years). And it is considered with respect to reference
period. The children who live start within the reference period are taken into
consideration. Children who will die within the reference period will be taken as
uncensored cases while those alive in that period are censored cases.
3.1 Data sources
Both primary and secondary sources will be used to provide the data for this
project. Most of our primary data for this study will be collected from Maseno
Mission Hospital, Chulaimbo Sub-County Hospital and secondary data from
KNBS as per the 2019 census.
3.1.1 Dependent variable

The response variable of this study will be the number of under 5-year deaths.
3.1.2 Independent variables

Predictors of deaths in children under the age of five may include; Age, sex,
breastfeeding, delivery means, preceding birth interval, child vaccination,
contraceptive use, age of mother at first birth and area of residence.
3.2 Statistical software
The data to be collected will be recorded in Excel and then exported to R software
version 3.5.3 for analysis.
3.3 Sample size estimation.
For calculating sample size, a formula from the National Education Association
article small sample techniques will be used.
The formula is;

x ∗N∗P [ 1−P ]
2
n=
d [ N−1 ] + x 2 P ( 1−P )
2

where;
n = Sample size (Children under five years to be studied)
N = Population size (Children under five years around Maseno)
x = table of value of Chi-Square for degree of freedom depending on parameters
2

to be
used at a desired confidence level.
d = the degree of accuracy expressed as a proportion (0.05)
P = the population proportion (assumed to be 50 % of the sample size)
3.4 Methods of data collection.
The primary data will be collected from the Hospital managements through
interviewing and recorded in online Google forms while the secondary data will be
directly downloaded from the KNBS site.

3.5 Method of data analysis

Survival analysis: Survival analysis refers to statistical methods for analyzing
survival data. Survival time refers to a variable which measure the time from a
particular starting time (e.g. Time of child birth) to particular end point of interest
(e.g. Death time).

3.5.1 Kaplan-Meier model

Kaplan-Meier estimates: Kaplan Meier estimator is nonparametric, which

requires no parametric assumptions. We can compare data from two or more
different groups by visual inspection of their respective estimated survival
functions or some statistical tests. It will be used to estimate the probability of
dying (the hazard probability), the probability of surviving and the spread of death
of children from age 0 to age 5.
Thus survival function could be estimated using Kaplan-Meier formulas. In
particularity, it first takes into account both censored and uncensored observations
secondly assume that censored times are independent to survival times while
estimating survival probabilities. The Kaplan-Meier estimator is denoted as ^S(t )
which is the survival function.
^S ( t ) = ∏ ( 1− ^
λ j)
ti =t i ≤t

di
where ^
λ j= , (1 ≤ j≤ k ) and the distribution function.
ni
 F ( t )=1− S^ (t)
^

Where: - ^S(t ) is The Kaplan-Meier estimator and it will be used to estimate the
survivor function in this study; and t i is the time after t i−1.
In this study d i represents number of children who will die whereas ni  represent
number of children at risk. The record of the child is an observation includes
censored observations. We will use KM Model to estimate the hazard rate
(instantaneous rate of mortality) among under 5 years. Furthermore, determining
how death or mortality is spread among the ages 0 to 5 using Greenwood’s
formula;
dj
Var [ S^ (t) ]= [ 1− ^
F(t ) ] ∑
2

tj n j ( n j −d j )

2 2
but [ 1− ^
F(t ) ] is [ S^ (t) ]

Where; d j - represents number of children who will die

n j represent number of children at risk.

3.5.2 Proportional Hazard (PH) Model

One of the main problem in a mortality investigation is the problem of
heterogeneity. It would be more informative to split the population into
homogenous subgroups of individuals off similar characteristics for instance
children born with disabilities, children born with inherited diseases, children born
with abnormal weight, and how these covariates are diversified with gender. One
of the most commonly used model is assessing the level of mortality is the PH
Model (The Cox model). This model proposes the following form of the hazard
function for the ithlife.

T
β∗Z i
λ ( t , Z i )= λ0 (t) ¿ e
Where;
λ ( t , Z i )– is the hazard at time t for the i th life.

λ 0 ( t )– is the baseline hazard at time t.

β – ( β 1 , β 2 , β 3 , … , β p ) represents the vector of regression parameters.

Zi – ( x i 1 , x i2 , xi 3 , … xip ) represents the vector of covariates in respect to the i th life.

This model is most community used for survival data because it is fairly easy to fit.
There is flexibility in the choice of covariate as well as the baseline hazard need
not to be explicitly defined.
A covariate is any quantity recorded in respect of each life such as; disabilities,
inherited diseases, and abnormal weight. The effects of the covariates on survival
are modelled directly such as 0 if male 1 for female, 0 for normal weight 1 for
abnormal weight etc.
First, if the vector of covariate is a zero vector, then the hazard function for the ith
individual is the baseline hazard function. It is the hazard function in the absence
of covariates or when all of the coefficients of the covariates are assumed to be
zero. Second, if we divide the above equation both sides by λ 0 ( t ), we get the
following equation which indicates where the term proportional comes from. Since
for each individual, e x 't is constant across time.

λ ( t , Z1 ) λ0(t ) ¿ e
β∗Z 1
β ( Z 1−Z 2)
= β∗Z 2
=e
λ ( t , Z2 ) λ0(t ) ¿ e

Which is read as the proportional hazard model.

APPENDICES
 REFERENCES
National strategy for child survival in Ethiopia family health department federal
ministry of health 2005.

Angeles G, Guilkey DK, Mroz TA (2005) The Impact of Community-Level

Variables on Individual-Level Outcomes: Theoretical Results and Applications.
Sociological Methods Research 34: 76-121.

Deribew A, Tessema F, Girma B (2005) Determinants of under-five mortality in

Gilgel Gibe Field Research Center, Southwest Ethiopia. Ethiop J Health Dev 21:
1-8

Mekonnen D (2011) Infant and Child Mortality in Kenya: The Role of

Socioeconomic, Demographic and Biological Factors in the previous five years
period of 2000 and 2005. 5. Alex M (2007) Multilevel Analysis of Factors
Associated with Child Mortality in Uganda.

Adedin SA, Odimegwu CO, Pono DO, Ibisomi L, Elwange BC, et al. (2012)
Regional Inequalities in Under-five Mortality in Kenya: a Multilevel Analysis.
Princeton.edu papers. pp: 1-32.

Afzal AR, Alam S (2013) Analysis and comparison of under-five child mortality
between rural and urban area in Luanda. Journal of applied quantitative methods 8:
1-10
Proposal budget
Proposed budget estimated by project members
ITEM DESCRIPTION TOTAL COST(KSh)
Writing materials Hard copy questionnaires 500
,pens
Travel Transport fee(100 per 1000
person)
Total amount 1,500

Work time plan

The research will approximately take one month. The first week, we will do a
reconnaissance of the hospitals we hope to collect our data from so as to prepare
them early enough. The second week will be for data collection and the rest of the
month, the group will analyze the data and write a detailed report on the project.