Determinants of Under-Five Mortality in Rural Communities of Zamfara State: A Community-Based Cohort Study

Background: Under-five mortality rates in Zamfara State, North West geopolitical zone, remain among the highest in Nigeria, and empirical identification of community-level determinants is essential for targeted intervention design. This study identifies the determinants of under-five mortality in rural communities of Zamfara State. Methods: A prospective community-based cohort enrolled 600 children under five years and their primary caregivers selected through multistage cluster sampling. Children were followed quarterly for 18 months. Mortality events, their timing, and associated clinical and social circumstances were documented. Cox regression and competing risks analysis identified independent predictors. Results: The cohort mortality rate exceeded national averages. Malaria, acute watery diarrhoea, and severe acute malnutrition were the primary proximate causes. Determinants at community level included lack of skilled birth attendance, non-completion of vaccination schedules, and absence of household water treatment. Maternal education was significantly protective. Conclusion: Under-five mortality in Zamfara State is driven by preventable infectious diseases and undernutrition, compounded by structural healthcare access gaps. Family medicine practitioners must lead community health worker programmes targeting malaria prevention, oral rehydration therapy, and vaccination coverage in these communities. Keywords: under-five mortality, child health, Zamfara State, determinants, community cohort