Examining the Causal Pathways Between Health Education Exposure and Under-Five Mortality Outcomes in Nigeria: A Structural Causal Modelling Approach

Despite widespread health education interventions targeting child health in Nigeria, the causal pathways through which health education exposure translates into reductions in under-five mortality remain poorly specified. This study applied structural causal modelling to examine causal pathways between health education exposure and under-five mortality outcomes in Nigeria, using a nationwide secondary data analysis. Secondary data from the 2021 Nigeria Demographic and Health Survey were merged with data from the National Immunisation Surveys and State Primary Health Care Agency programme records across all 36 states and the Federal Capital Territory. Directed acyclic graphs were developed based on theoretical models and expert consultation to guide identification of causal structures. Path analysis and mediation analysis using the potential outcomes framework were employed. Results demonstrated that maternal health education exposure significantly reduced under-five mortality, with approximately 58 percent of this effect mediated through improved immunisation uptake and 29 percent through improved exclusive breastfeeding practices. Child marriage, household poverty, and rural residence were significant confounders of the health education-mortality relationship. The study provides a rigorous causal framework for understanding how health education investments affect child mortality in Nigeria. Recommendations include equity-focused health education programme targeting. Keywords: under-five mortality, health education exposure, structural causal modelling, Nigeria, directed acyclic graphs