Social Science & Medicine 351 (2024) 116979

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Climate vulnerability and child health outcomes in developing countries:

Do women’s political empowerment and female education make
the difference?
Suzie Imelda Foudjo a, Joseph Keneck-Massil a, b, *
a
CEREG- University of Yaoundé II Soa , Cameroon
b
Source - University of Versailles, Saint - Quentin -en- Yvelines, France

A R T I C L E I N F O A B S T R A C T

Keywords: Health as a common good is of paramount importance for the world, especially in developing countries. This
Climate vulnerability paper contributes to the literature by analysing the effect of climate vulnerability on child health outcomes in a
Child health outcomes sample of 107 developing countries over the period 2000–2020. We also analyse the mediating role of women’s
WPE
political empowerment and women’s education in the relationship between climate vulnerability and child
Women education
Gender roles
health outcomes. Using the method of generalised moments in a two-stage system and linear regression
absorbing several levels of fixed effects, we found robust evidence that climate vulnerability worsens child health
outcomes. We also found that women’s political empowerment (WPE) and women’s education mitigate the
negative effect of climate vulnerability on child health outcomes. These results remain robust against several
alternative tests and therefore highlight the need to better examine how the health consequences of climate
vulnerability are structured by gender in developing countries. Given the importance of women as agents of
change, it would be more beneficial for policymakers to include them in the decision-making process.

1. Introduction
Health as a common good for humanity is of paramount importance
for the whole world, especially the developing world. Despite efforts to
improve the quality of health care, child mortality remains a persistent
health problem. Worldwide, the mortality rate has fallen. Every year,
child mortality decreased by around 17,000 children compared with
1990 (UN IGME, 2019). Despite this fall, premature loss of life is un­
evenly distributed according to place of birth. Indeed, for every 5 deaths
of children under the age of 5 recorded, 4 come from developing
countries (UN IGME, 2019). According to the UN IGME (2023), children
born in sub-Saharan Africa are 15 times more likely to die before the age
of 5 than those in Europe and North America, and 19 times more likely
to die than those in Australia and New Zealand. According to the same
report, by 2021, more than 5 million children worldwide will have died
before the age of 5, an average of 38 deaths per 1000 births, with only 5
deaths per 1000 births in high-income countries and 67 deaths per 1000
births in low-income countries. Furthermore, in 2021, the number of
children who did not receive any dose of vaccine was 18.1 million, an
increase of 12.9 million compared to 2019. Given this, SDG 3,
“empowering people to live healthy lives and promote well-being at all
ages,” puts the spotlight back on the importance of driving the best
health outcomes, especially among the most vulnerable by 2030,
particularly as most of these premature deaths are due to preventable
causes (UN IGME, 2023), including climate change.
In recent decades, the world has experienced extreme weather
events. In fact, the increase in the frequency and scale of natural di­
sasters is increasing the vulnerability of economies to climate hazards,
which is reflected in a disproportionate vulnerability between econo­
mies (Kling et al., 2021). Climate vulnerability has a strong impact on
the prevalence of several diseases, with implications for human health
and longevity in younger people (Pottier et al., 2021; WHO, 2014). As
Sen (1998) points out, mortality is a key indicator of human and eco­
nomic development. As illustrated by the UN IGME report (2023) and
Notre Dame Gain, between 1995 and 2020, the countries most vulner­
able to climate change were also those with a high infant mortality rate.
For example, of the 10 most vulnerable countries, three have a high
infant morbidity and mortality rate. This justifies the importance of such
a study. Several studies emphasise that climate change is an important
indicator of health (Grossman, 1972). These authors postulate that

* Corresponding author. University of Yaoundé II Cameroon, Cameroon.

E-mail addresses: suzieimeldafoudjo@gmail.com (S.I. Foudjo), Joseph.keneckmassil@gmail.com, joseph.keneck-massil@uvsq.fr (J. Keneck-Massil).

https://doi.org/10.1016/j.socscimed.2024.116979
Received 18 October 2023; Received in revised form 30 April 2024; Accepted 14 May 2024
Available online 19 May 2024
0277-9536/© 2024 Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
S.I. Foudjo and J. Keneck-Massil
elements such as air pollution (Tanaka, 2015; Genowska et al., 2015;
Greenstone and Hanna, 2014), rising ambient temperature (Son et al.,
2017; Kudamatsu et al., 2012), natural disasters (de Oliveira et al., 2023;
Lafortune et al., 2021), and climate change (Helldén et al., 2021;
Rylander et al., 2013), contribute significantly to the deterioration in
children’s health outcomes. Furthermore, de Oliveira et al. (2023) find
that climate vulnerability degrades health outcomes in both children
and adults with direct, indirect, and delayed impacts. For Pacheco
(2020), climate vulnerability multiplies the risks of infant morbidity and
mortality associated with heat waves, increases the rate of undernour­
ishment, and increases vector-borne diseases. From this point of view, an
increase in infant mortality is linked to the fact that children are
dependent on adults who are already affected by climate change.
Although previous studies have made considerable contributions, they
have in common a focus on a particular aspect of climate vulnerability,
namely the exposure of systems to climate hazards, but climate
vulnerability includes exposure, sensitivity, and adaptive capacity
(Chen et al., 2015). As pointed out by Thornton et al. (2014), consid­
ering climate change solely in terms of exposure, i.e., changes in average
levels of temperature and precipitation, is restrictive as it un­
derestimates the real implications of climate change on health out­
comes. To this end, this study highlights the importance of climate
vulnerability as a factor in explaining the high level of mortality among
children. Climate vulnerability can be defined as the degree to which a
system or resource is susceptible to damage from the adverse effects of
climate change (Chen et al., 2015).
Recent literature highlights the importance of girls’ and women’s
education and women’s political empowerment (WPE) as an effective
strategy for mitigating the negative effects of climate change on chil­
dren’s health outcomes. Despite women making up more than half the
world’s population, they are underrepresented in positions of power
(Iyer and Mani, 2019) and are the most undereducated (Sims, 2021).
According to the World Economic Forum (2022), in 2021, the gap in
terms of women’s political participation stood at 73.9%, with disparities
between regions. In Latin America and the Caribbean, for example, only
28.7% of women have political autonomy, compared with 26.1% in
South Asia, 21.3% in sub-Saharan Africa, 15.1% in the Middle East and
North Africa, and 13.3% in East Asia and the Pacific. Whereas improving
women’s political participation is paramount for modern states
(Sundström et al., 2017). Sims (2021) suggests that investing in girls’
education and women’s leadership is one of the most powerful ways to
address the climate emergency. Fair access to quality education for
women and girls could not only improve health and wealth but also
increase the capacity of societies to cope with climate change. The effect
of climate vulnerability on children’s health outcomes depends on the
mother’s level of education and her concern for environmental issues
and social involvement (Rustagi and Akter, 2022; Striessnig et al., 2013;
Blankespoor et al., 2010). Studies suggest that the mortality rate in
sub-Saharan Africa could fall by 60%–70% by 2050 if women aged be­
tween 20 and 39 complete secondary educations (Striessnig et al.,
2013). For every additional year of schooling a girl receives, her coun­
try’s resilience to climate-related disasters improves by 3.2 points
(Kwauk and Braga, 2017; Blankespoor et al., 2010). Countries with a
high level of female education will be better able to manage and adapt to
climate stress. Whereas economies with low levels of female education
will have difficulty adapting to climate change, resulting in poor child
health outcomes. In light of these arguments, this study seeks to examine
and understand whether women’s level of education plays a significant
role in the relationship between climate vulnerability and child health
outcomes in developing countries.
Despite the captivating literature on the effect of climate change on
health outcomes, very little analyses the mitigating role of socio-
economic changes, notably women’s education and women’s political
empowerment. Where it exists, the work that looks at it is limited on
mother’s education. For example, Davenport et al. (2017) set up sce­
narios of positive socio-economic change and climate change and
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Social Science & Medicine 351 (2024) 116979
assumed that high levels of maternal education and access to clean water
mitigate the negative effects of climate change on children’s health.
Similarly, Grace et al. (2015) postulate that maternal education and
access to education can be a means of protecting children from climate
hazards. On the other hand, Rustagi and Akter (2022) point out that
women’s political empowerment improves children’s health outcomes.
According to them, this relationship is only possible if women’s partic­
ipation in political decision-making leads to greater participation of
women in the economic sphere, increased health spending, reduced
fertility rates among teenagers, and assisted childbirth by qualified
personnel. Quamruzzaman and Lange (2016) explain how women’s
political participation reduces the infant mortality rate and increases
measles vaccination coverage. Meanwhile, Asongu et al. (2022) argue
that women’s political empowerment reduces their vulnerability to
climate change. As a result, a greater capacity to adapt to climatic
hazards due to women’s participation in political decision-making could
improve children’s health outcomes. In this way, women’s education
and WPE could be conducive to child health.
This study contributes to the literature in at least four ways. Firstly,
we are contributing to the literature on the effects of climate vulnera­
bility in developing countries. Indeed, developing countries are
disproportionately vulnerable to climate change and have the highest
infant mortality rates. We therefore provide the first study of the rela­
tionship between vulnerability to climate change and health outcomes
in children in developing countries. Secondly, beyond the analyses of the
relationship between climate vulnerability and child health outcomes,
our study identifies and analyses the catalysts of the relationship. Thus,
our study is the first, in light of our knowledge, to analyse the role of
women’s education and women’s political empowerment in the rela­
tionship between climate vulnerability and child health outcomes. In
addition, we highlight the extent to which education and WPE affect the
relationship between climate vulnerability and children’s health out­
comes. In addition, through the mediation approach, we estimate the
proportion of effect transmitted by mediators in order to assess their role
in the relationship between climate vulnerability and children’s health
outcomes. We hypothesise that better female education and empower­
ment reduce the negative effects of climate change vulnerability and
health outcomes in children. Thirdly, rather than using the aggregate
measure of WPE, this paper also highlights the other dimensions of the
WPE index, which define women’s political participation, participation
in civil society, and civil liberties. Seen from this angle, the WPE plays a
fundamental role not only in climate change adaptation strategy but also
in promoting the health and well-being of individuals. Finally, analyses
are based on 107 developing countries, including both countries with a
high level of female education and WPE and those with a low level.
The rest of the article is structured as follows: The second section
presents the data and the empirical approach. The third section presents
the results and the fourth section presents the discussion. Finally, the last
section serves as a conclusion.
2. Data and methods
2.1. Data sources and measures
The aim of this study is to analyse the effect of climate vulnerability
on children’s health outcomes, focusing on the mitigating role of female
education and WPE over the period 2000–2020. In this study, we focus
on a panel of 107 developing countries, including 41 countries in Sub-
Saharan Africa, 8 countries in South Asia, 10 countries in the Middle
East and North Africa, 15 countries in Latin America and the Caribbean,
18 countries in Europe and Central Asia, and 15 countries in East Asia
and the Pacific. The 107 developing countries are made up of 22 lower-
income countries, 45 lower-middle-income countries, and 40 upper-
middle-income countries. The database consists of a non-cylindrical
annual panel selected according to data availability.
S.I. Foudjo and J. Keneck-Massil
2.1.1. Dependent variables
The main dependent variable is child health outcomes. We oper­
ationalize child health outcomes using five variables according to the
indicators present in the empirical framework above: (i) the infant
mortality rate, which captures the number of infants dying before
reaching one year of age, per 1,000 live births in a given year; (ii) the
neonatal mortality rate, which highlights the number of children dying
between 0 and 28 days per 1,000 live births; and (iii) the under-5
mortality rate, which highlights the number of children dying before
the age of 5 years, expressed per 1,000 live births. (iv) Measles immu­
nisation coverage, which measures the percentage of children aged be­
tween 12 and 23 months who have been immunized against measles;
and (v) diphtheria, pertussis and tetanus (DPT) immunisation coverage,
which measures the percentage of children aged between 12 and 23
months who have been immunized against DPT before the age of 12
months.
2.1.2. Independent variable
The independent variable here is the climate vulnerability index
provided by the Notre Dame Global Adaptation Index (ND-GAIN). This
index is made up of 74 variables that form 45 basic indicators to help
understand the environmental vulnerability and adaptive capacity of
181 countries. The vulnerability index ranges from 0 to 1 and has the
advantage of taking into account three aspects of climate change, in
particular the exposure, sensitivity and adaptive capacity of economies
to climate hazards, which are affected in parallel by economic, institu­
tional, geographical, and social conditions (Kling et al., 2021; Chen
et al., 2015). Exposure to climate change measures the degree to which
economies are stressed by physical and external factors. Climate sensi­
tivity refers to how key sectors of the economy are affected by climate
Fig. 1. Relationship between climate vulnerability and child health outcomes.
Source: Author’s construction.
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Social Science & Medicine 351 (2024) 116979
change. Adaptive capacity measures the degree to which economies or
individuals protect themselves from climate change through adaptation
(Chen et al., 2015). For reasons of scale, we have multiplied the climate
vulnerability index by 100 to better approximate the measures of chil­
dren’s health outcomes.
Fig. 1 shows the correlation between the climate vulnerability index
and child health outcomes in developing countries. We find that there is
a positive correlation between climate vulnerability and child mortality,
and a negative correlation between climate vulnerability and immuni­
sation coverage. These trends are in line with our basic hypotheses.
2.1.3. Interaction variables
Two main interaction variables are used in the case of this study,
namely women’s political empowerment and female education, from V-
DEM version 13.1 and the World Bank indicator database, respectively.
The literature recognises the role of women in improving living
conditions and adapting to climate change. The political empowerment
of women is described as increasing women’s capacities and favouring
greater freedom of decision, choice, and action not only in the political
sphere but also in society. So, in addition to focusing on the political
sector, it also focuses on women’s legal and effective rights. The WPE
index comprises three dimensions: fundamental civil liberties, women’s
open discussion of political issues and participation in civil society or­
ganizations, and the descriptive representation of women in official
political positions. The index takes into account women’s civil liberties,
participation in civil-society, and political participation (Sundström
et al., 2017). It varies between 0 and 1 (0 when they are weakly
autonomous and 1 otherwise).
In addition, women’s education refers to the representation of
women and girls of all ages in educational fields aimed at improving
S.I. Foudjo and J. Keneck-Massil
their knowledge and skills. It includes both literary and non-literary
education. The enrolment rate of girls in the three main levels of edu­
cation (primary, secondary, and tertiary) according to the World Bank
classification (2022). The gross enrolment ratio is the ratio of total
enrolment, regardless of age, to the population of the age group that
officially corresponds to the level of education shown.
2.1.4. Control variables
Consistent with the literature on the determinants of child health
outcomes, eight control variables are used (four in the base model and
four in the robustness check) in this study including:
(1) Total natural resource rent as a percentage of GDP, which cap­
tures the sum of rents from oil, natural gas, coal, minerals, and forest
resources and measure the degree to which economies are dependent on
natural resources (Tadadjeu et al., 2023; Bellinger and Fails, 2020;
Madreimov and Li, 2019). (2) The natural logarithm of GDP per capita in
constant international dollars (Rustagi and Akter, 2022). (3) Govern­
ment spending on health as a percentage of GDP (Bokhari et al., 2007),
provided by the WHO, which refers to government spending to ensure
the quality of care. It guides the flow of resources, informs health policy
development, and promotes the transparency and accountability of
health systems (WHO, 2022). (4) Political corruption refers to the extent
to which political power is perverted by the system. The data come from
V-DEM Version 13.1. The degree of political corruption is measured on a
scale of 0–1. The index tends towards 0 when the system is weakly
corrupt and towards 1 when the level of corruption is high. This measure
is preferred because it is a compilation of the corruption index for the
public sector, the executive sector, the legislative sector, and the judicial
sector (McMann et al., 2017). (5) Net official development assistance
received per capita in current international dollars from OCDE. (6)
Trade openness in percentage of GDP. (7) Adolescent fertility rate, and
(8) urban population growth annual percentage (Kavakli and Rotondi,
2022; Noori et al., 2022; Byaro et al., 2021; Zhang et al., 2019; Eckert
and Kohler, 2014; Alirol et al., 2011). The choice of these variables is
lead by the literature on the determinants of children’s health outcomes.
The data is from the WDI database. Table A2 in the Appendix sets out the
definition, measurement and various data sources.
2.2. Empirical models
We now specify the econometric models that will be estimated in
order to analyse the effect of climate vulnerability on children’s health
outcomes while emphasizing on the mitigating role of female education
and WPE. First, we specify a model in which we estimate the direct
relationship between climate vulnerability and children’s health out­
comes, based on the work of Grossman (1972), who argues that health is
a function of various inputs such as environmental, lifestyle and
socio-economic variables. In equation (2), we extend the analysis by
incorporating interaction variables to assess the mitigating role of fe­
male education and WPE. The models are specified as follows:
Yit = α + β0 CVit + β1 Xit + μi + γt + εit (1)
where Yit represents children’s health outcomes. CVit represents the
measurement of climate vulnerability, which measures the exposure,
sensitivity and capacity of economies to adapt to climate change. Xit
refers to the matrix of control variables that explains child health out­
comes in the literature. μi captures unobserved country fixed effects, γt
captures the time fixed effects that could potentially affect climate
vulnerability. β captures the immediate effect of meteorological shocks
and depends on the current and past vulnerability level of economies. εit
represents the error term.
To estimate the effect of climate vulnerability on child health out­
comes and the mitigating role of female education and WPE, we apply a
linear regression absorbing several levels of fixed effects inspired by the
work of Kalkuhl and Wenz (2020). This method is a generalisation of
4
Social Science & Medicine 351 (2024) 116979
linear regression models with numerous dummy variables. To overcome
the problem of endogeneity arising from the reverse causality between
climate vulnerability and health outcomes due to the fact that the
vulnerability variable is partly influenced by the economic, political,
social, and geographical contexts of countries, which in turn determine
health outcomes, the method commonly used is that of instrumental
variables, in particular 2SLS and GMM. The GMM method in the system
will be used for this study due to the difficulty associated with 2SLS in
finding completely exogenous instruments (Farhadi et al., 2015). The
equations are formulated as follows:
Yit = α + λYit− 1 + β0 CVit + β1 Xit + μi + γ t + εit (2)
Yit = α + λYit− 1 + β0 CVit + β1 interit + β2 (CVit ∗ interit ) + β3 Xit + μi + γt + εit
(3)
where Yit− 1 represents the lagged value of children’s health results.
interit represents the mitigating variables that take into account female
education (primary, secondary and tertiary education) and WPE. CVit ∗
interit highlights the interaction between climate vulnerability, female
education and WPE.
However, equation (3) does not show to what extent WPE and
women’s education affect the relationship between climate vulnera­
bility and children’s health outcomes. To remedy this shortcoming, a
mediation analysis was carried out based on the work of MacKinnon
et al. (1995). The approach consists of estimating two models, the first of
which evaluates the relationship between climate vulnerability and the
mediators (model 1), and the second which evaluates the direct effect
while taking into account the effect of the mediators (model 2). The
coefficients associated with climate vulnerability represent the magni­
tude of the direct effect. The difference between the total effect and the
direct effect represents the indirect effect, which measures the degree to
which climate vulnerability affects health outcomes through WPE and
women’s education. Fig. 2 below illustrates how the relationship
evolves.
In addition, to check the quality of our results, a set of sensitivity tests
(by income level and by region) are established. In fact, the World Bank
classification (2022) distinguishes seven geographical zones, namely
Sub-Saharan Africa, East Asia and the Pacific, Europe and Central Asia,
North America, South Asia, the Middle East and North Africa, and Latin
America and the Caribbean. However, the literature points to the
disproportionate vulnerability of Sub-Saharan African (SSA) countries
and the higher risk of infant mortality compared with other regions.
Indeed, according to the UN IGME (2022), children born in SSA are 15
times more likely to die before the age of 5 than in other regions of the
developing world. With this in mind, in our sensitivity analysis, we
separate the SSA countries from the other developing countries. More­
over, robustness tests (adding additional control variables and using a
competing estimator to the GMM such as Lewbel’s approaches) are
established, by re-estimating equation (2).
3. Results
3.1. Descriptive statistics
The aim of this study is to analyse the effect of climate vulnerability
on children’s health outcomes, focusing on the mitigating role of edu­
cation and WPE. We are particularly interested in 107 developing
countries (see Appendix A1) selected according to the World Bank
classification (2022), which considers developing countries as those
classified as low income, middle income and lower middle income.
Table 1 (see additional materials) presents the descriptive statistics for
the variables used in this study over the period from 2000 to 2020 (i.e.,
21 years). These are specifically the dependent variables, the indepen­
dent variable, the interaction variables, and all the control variables. We
find that, on average, the percentages of measures of child mortality
S.I. Foudjo and J. Keneck-Massil Social Science & Medicine 351 (2024) 116979

Fig. 2. Mediation effect.

Source: Authors modified from MacKinnon et al. (1995).

vary between 38.8%, 21.3%, and 55.12%, with a wide variation ranging
from 2.5% to 138.1% for infant mortality, 1.2%–60.9% for neonatal
mortality, and 3.4%–227.7% for under-five mortality. The average
percentages of DPT and measles vaccination coverage show similar
trends, at 83.07% and 82.18%, respectively, ranging from 16% to 99%.
The climate vulnerability index had an average variation of 48.9%,
ranging from 33.4% to 70%, which suggests that the level of climate
vulnerability in developing countries is very high. With regard to the
interaction variables, we observe a large variation in the indicators
around the mean, with a more pronounced variation in the ratio of fe­
male enrolment in tertiary education. Table 2 presents the correlation
matrix (see additional materials).
3.2. Main results
The regression estimates of equation (1) are presented in Table 1 for
the five outcome variables. The table shows that there is a positive
relationship between climate vulnerability and child mortality and a
negative relationship between climate vulnerability and immunisation
coverage. In fact, a one-point increase in the level of climate vulnera­
bility is associated with deterioration in child health outcomes of 1.1,
0.56, 2.7, 0.9, and 0.8 points respectively, in the infant mortality rate,
neonatal mortality, under-five mortality, and measles and DPT immu­
nisation coverage.
The estimations of equation (2) are presented in Table, which dis­
cusses the endogeneity bias between climate vulnerability and child
health outcomes. The regression coefficients reveal a positive correla­
tion between climate vulnerability and mortality outcomes and a posi­
tive correlation with immunisation rates. Other things being equal, a
one-point increase in the degree of vulnerability to climatic hazards
worsens health outcomes by 0.18, 0.05, 0.13, 0.34, and 0.34 points,
respectively. The lower part of Table 2 presents the validation statistics
for the generalised method of moments. We see that the number of
instruments in all specifications is less than the number of countries. In
addition, it is important to note that the number of observations varies
between Tables 1 and 2 because of the dynamics of our panel. Tables 7
and 8 in the additional materials present the robustness check by
modifying the specification of the equation and adding additional con­
trol variables. The results are consistent with those in Table 2 despite a
slight variation in the coefficients.
3.3. Heterogeneity analysis
We carried out several heterogeneity analyses as part of this study.
First, we verified the existence of geographical variations in the effect of
climate vulnerability on children’s health outcomes. To this end, the
regression distinguishes SSA countries from other regions of the devel­
oping world. Columns 1 to 5 show the regression results for SSA, and
columns 6 to 10 show the regressions for countries in other regions. The
regression coefficients presented in Table 5 (see additional materials)
indicate that increasing the level of vulnerability of economies to
climate change has significant effects on mortality outcomes and
vaccination rates in all regions, but with more persistent effects in SSA
countries. In all specifications, the coefficients associated with the child
health outcome measures are statistically significant. We then assessed
whether there were variations according to income level. The results are
summarised in Table 6 (see additional materials). We distinguish be­
tween upper-middle-income countries (columns 1 to 5) and low- and
lower-middle-income countries (columns 6 to 10). We find that an in­
crease in the degree of climatic vulnerability is associated with a dete­
rioration in children’s health outcomes. In all specifications, the
coefficients attached to measures of child health outcomes are statisti­
cally significant, with a more persistent effect in low- and lower-middle-
income countries. The results are consistent with those in Table 2,
despite a variation in the value of the coefficients between different
regions.

Table 1
Baseline results with panel linear regression absorbing multiple levels of fixed effects.
Dependents variables IMR Neonatal mortality Under_5 Mortality Measles Immunisation DPT immunisation

(1) (2) (3) (4) (5)

Vulnerability 1.105*** 0.560*** 2.798*** − 0.944*** − 0.802***

(0.062) (0.029) (0.103) (0.041) (0.047)
Total natural resources 0.444*** 0.195*** 0.654*** − 0.353*** − 0.327***
(0.031) (0.014) (0.057) (0.037) (0.040)
Log GDP per capita − 9.950*** − 4.497*** − 0.024*** 1.086*** 1.107***
(0.532) (0.248) (0.004) (0.313) (0.313)
Government health expenditure − 0.126*** − 0.092*** − 0.329*** 0.128*** 0.155***
(0.029) (0.013) (0.053) (0.028) (0.031)
Political corruption 2.395*** 1.039** 1.704 − 3.528*** − 3.717***
(0.893) (0.415) (1.630) (0.898) (0.953)
Constant 60.510*** 29.138*** − 71.057*** 128.582*** 121.829***
(6.553) (3.049) (6.013) (2.194) (2.314)

Observations 1923 1923 1923 1953 1953

R2 Adjusted 0.75 0.75 0.70 0.46 0.47
Year/Country FE YES YES YES YES YES

Note: Linear regression absorbing multiple levels of fixed effects. p < 0.10, **p < 0.05, ***p < 0.01. Robust standard errors in parentheses.
Source: authors.

5
S.I. Foudjo and J. Keneck-Massil Social Science & Medicine 351 (2024) 116979

Table 2
Two-step system GMM result.
Dependents variables: IMR Neonatal mortality Under_5 Mortality Measles Immunisation DPT immunisation

(1) (2) (3) (4) (5)

Lag dependents variables 0.920*** 0.940*** 0.938*** 0.545*** 0.784***

(0.012) (0.010) (0.004) (0.029) (0.025)
Vulnerability 0.186*** 0.056*** 0.133*** − 0.342*** − 0.349***
(0.052) (0.019) (0.024) (0.083) (0.112)
Total natural resources 0.015* 0.141*** 0.105** − 1.015*** − 0.243***
(0.008) (0.035) (0.046) (0.114) (0.061)
Log GDP per capita − 0.098** − 0.363*** − 0.041** 1.319*** 1.460***
(0.039) (0.059) (0.016) (0.432) (0.435)
Government health expenditure − 0.028* − 0.832*** − 0.646*** 0.072* 0.091
(0.015) (0.195) (0.209) (0.043) (1.075)
Political corruption 0.840*** 0.029 0.198** − 1.524*** − 0.299
(0.263) (0.099) (0.087) (0.501) (0.493)
Constant − 6.728*** 0.675 − 3.295*** 61.155*** 36.639***
(2.096) (0.983) (0.982) (5.411) (9.629)

Observations 1872 1839 1872 1872 1872

Number of Country 107 107 107 107 107
Number of instruments 42 46 44 48 45
AR (1) 0.09 0.00 0.13 0.00 0.00
AR (2) 0.68 0.23 0.31 0.12 0.39
Hansen OIR 0.46 0.03 0.12 0.00 0.01

Note: Twostep System GMM regression. p < 0.10, **p < 0.05, ***p < 0.01. Robust standard errors in parentheses.
Source: authors.

3.4. The role of women’s education and women’s political empowerment
in the relationship between climate vulnerability and child health outcomes
We explore the mitigating elements of the negative link between
climate vulnerability and children’s health outcomes. To this end, two
main strategies are adopted. First, we make an interaction between
climate vulnerability and WPE on the one hand and women’s education
on the other. Equation (3) is therefore re-estimated by substituting the
“inter” rating with the WPE and the women’s education. Table 4 and
Table 10 (see additional materials) present the results of the estimation
of the role of WPE and his dimensions in the relationship between
climate vulnerability and child health outcomes. It shows a negative
correlation between the coefficients of the interaction and child mor­
tality outcomes and a positive relationship with immunisation rates,
with a significance level of 1%. We find that the attenuating effect of
WPE in this relationship is more persistent when we look at women’s
political participation.
Table 5 presents the results of the estimation of equation (3), taking
into account women’s education as an interaction variable. We observe
that there is a positive correlation between women’s education and the
vaccination rate and a negative correlation with child mortality rates at
the 1% threshold. Holding all other variables, Table 4, 10, and 5 support
the hypothesis that education and WPE mitigate the negative effect of
climate vulnerability on children’s health outcomes. Furthermore, it is
important to notify that in Table 5 the observations vary in the different
panels due to the lack of data on women’s enrolment rates in the three
categories. As seen from the descriptive statistics presented in Table 1,
these measures total a number of observations equal to 1736, 1356, and
1295, respectively (gross female primary, secondary, and tertiary
enrolment rates).
Then, a mediation analysis was performed to assess the extent to
which education and WPE mitigate the negative effect of climate
vulnerability on children’s health outcomes following the approach
popularised by Mackinnon et al. (1995). The coefficients associated with
climate vulnerability represent the magnitude of the direct effect. The
difference between the total effect and the direct effect represents the
indirect effect, which measures the degree to which climate vulnera­
bility affects health outcomes through WPE and women’s education. The
panels in Table 12 (see additional materials) report the estimates for the
WPE and the three measures of women’s education. Panel 12.A
describes the effect of climate vulnerability on the WPE and the effect of
climate vulnerability on child health outcomes, while taking into ac­
count the role of the WPE. We find that in all specifications, the WPE
reduces the effects of climate vulnerability on children’s health out­
comes and is statistically significant. Panels 12.B, 12.C, and 12.D of
Table 12 respectively present the effect of climate vulnerability on
women’s primary, secondary, and tertiary education and the effect of
climate vulnerability on children’s health outcomes while taking into
account the role of the three dimensions of women’s education. We find
that, in all specifications, women’s education is favourable to reducing
the effect of climate vulnerability on children’s health outcomes and is
statistically significant.
Table 3 presents the statistics for the Sobel-Goodman mediation
tests. The results suggest that the three indirect effect tests (Sobel,
Aroian, and Goodman) are different from zero. Indeed, the P-value is less
than 5% in all specifications, which means that the null hypothesis of no
mediator is rejected. Over the study period, the data revealed that WPE
and women’s education play an important mediating role in the rela­
tionship between climate vulnerability and children’s health outcomes.
Indeed, the effect of climate vulnerability on child health outcomes
decreases by approximately 22%, 20.9%, 20.1%, 13%, and 10%
following the inclusion of WPE in all specifications, respectively.
Explicitly, this means that approximately 2 out of 10 children likely to
die naturally due to climate vulnerability can be saved by improving the
WPE. In addition, the WPE enables more than one child in 10 to benefit
from doses of vaccine in the face of climate vulnerability. Similarly, the
effect of climate vulnerability decreases by around 50%, 39%, 33%,
49%, and 48% for primary education, 69%, 35%, 44%, 51%, and 50%
for secondary education, and 12%, 22%, 21%, 11.4%, and 11.9% for
tertiary education. Theoretically, this suggests that at least 3 out of 10
children are likely to be saved and benefit from doses of measles and the
DPT vaccine as a result of women’s increased educational attainment in
the context of climate vulnerability. Overall, there is a positive rela­
tionship between WPE, education and children’s health outcomes.
4. Discussion
In recent decades, developing countries have experienced a sharp
increase in climatic conditions, leading to a rise in the frequency and
scale of natural disasters. This change in weather patterns has resulted in

6
S.I. Foudjo and J. Keneck-Massil Social Science & Medicine 351 (2024) 116979

Table 3
Sobel-Goodman mediation test.
Mediation effect of WPE Mediation effect of Female primary Mediation effect of Female secondary Mediation effect of Female tertiary
school school school

Coef. Std err. Coef. Std err. Coef. Std err. Coef. Std err.

IMR
Mediation test
Sobel 0.088*** 0.022 0.509*** 0.071 0.635*** 0.028 0.031*** 0.008
Aroian 0.088*** 0.022 0.509*** 0.072 0.635*** 0.028 0.031*** 0.008
Goodman 0.088*** 0.022 0.509*** 0.071 0.635*** 0.028 0.031*** 0.008
Composition of the effects
Indirect effect (Sobel) 0.088*** 0.022 0.509*** 0.071 0.635*** 0.028 0.031*** 0.008
Direct effect 0.300*** 0.061 0.503** 0.208 0.275*** 0.031 0.219*** 0.036
Total effect 0.388*** 0.064 1.012*** 0.205 0.910*** 0.027 0.251*** 0.036
% of total effect mediated 0.227 0.503 0.698 0.125
Neonatal mortality
Mediation test
Sobel 0.078*** 0.020 0.152*** 0.025 0.953*** 0.080 0.096*** 0.024
Aroian 0.078*** 0.020 0.152*** 0.025 0.953*** 0.080 0.096*** 0.025
Goodman 0.078*** 0.020 0.152*** 0.025 0.953*** 0.080 0.096*** 0.024
Composition of the effects
Indirect effect (Sobel) 0.078*** 0.020 0.152*** 0.025 0.953*** 0.080 0.096*** 0.024
Direct effect 0.296*** 0.067 0.237*** 0.079 1.756*** 0.104 0.335*** 0.108
Total effect 0.374*** 0.069 0.389*** 0.080 2.709*** 0.075 0.432*** 0.109
% of total effect mediated 0.209 0.390 0.352 0.223
Under_5 mortality
Mediation test
Sobel 0.151*** 0.033 0.195*** 0.032 1.587 0.092 0.134*** 0.033
Aroian 0.151*** 0.033 0.195*** 0.031 1.587 0.092 0.134*** 0.033
Goodman 0.151*** 0.033 0.195*** 0.031 1.587 0.092 0.134*** 0.032
Composition of the effects
Indirect effect (Sobel) 0.151*** 0.033 0.195*** 0.032 1.587 0.092 0.134*** 0.033
Direct effect 0.601*** 0.090 0.395*** 0.098 1.966 0.113 0.493*** 0.134
Total effect 0.752*** 0.095 0.590*** 0.100 3.553 0.087 0.627*** 0.135
% of total effect mediated 0.201 0.330 0.447 0.214
DTP Immnisation
Mediation test
Sobel − 0.028*** 0.007 − 0.090*** 0.013 − 0.084*** 0.019 − 0.020*** 0.007
Aroian − 0.028*** 0.007 − 0.090*** 0.013 − 0.084*** 0.019 − 0.020*** 0.007
Goodman − 0.028*** 0.007 − 0.090*** 0.013 − 0.084*** 0.019 − 0.020*** 0.007
Composition of the effects
Indirect effect (Sobel) − 0.028*** 0.007 − 0.090*** 0.013 − 0.084*** 0.019 − 0.020*** 0.007
Direct effect − 0.164*** 0.029 − 0.090*** 0.028 − 0.079*** 0.031 − 0.157*** 0.038
Total effect − 0.184*** 0.029 − 0.180*** 0.030 − 0.163*** 0.036 − 0.178*** 0.038
% of total effect mediated 0.131 0.499 0.514 0.114
Measles Immunisation
Mediation test
Sobel − 0.017*** 0.006 − 0.085*** 0.013 − 0.092*** 0.020 − 0.021*** 0.007
Aroian − 0.017*** 0.006 − 0.085*** 0.013 − 0.092*** 0.020 − 0.021*** 0.007
Goodman − 0.017*** 0.006 − 0.085*** 0.013 − 0.092*** 0.020 − 0.021*** 0.007
Composition of the effects
Indirect effect (Sobel) − 0.017*** 0.006 − 0.085*** 0.013 − 0.092*** 0.020 − 0.021*** 0.007
Direct effect − 0.149*** 0.027 − 0.089*** 0.028 − 0.091*** 0.029 − 0.153*** 0.038
Total effect − 0.166*** 0.028 − 0.174*** 0.030 − 0.183*** 0.035 − 0.174*** 0.037
% of total effect mediated 0.100 0.488 0.501 0.119

Note: Sobel-Goodman mediation tests. p < 0.10, **p < 0.05, ***p < 0.01. Robust standard errors in parentheses.
Source: authors.

the disproportionate vulnerability of developing countries to climatic health outcomes.

hazards, with significant health implications, especially for young peo­
ple. While Grossman (1972) highlights the importance of health in the
process of human capital accumulation and sustainable economic
development. In this article, we analyse the effect of climate vulnera­
bility on children’s health outcomes, with an emphasis on the mitigating
role of women’s political empowerment and women’s education in 107
developing countries over the period 2000–2020. The aim of this study
is to analyse the effect of climate vulnerability on children’s health
outcomes in developing countries, focusing on the mitigating role of
education and women’s political empowerment. To this end, two main
hypotheses are established. The first postulates the existence of a
negative relationship between vulnerability to climate change and
children’s health outcomes. The second postulates that education and
WPE reduce the adverse effect of climate vulnerability on children’s
With regard to the first hypothesis, the results are obtained by means
of linear regressions absorbing several levels of fixed effects and the
method of generalised moments in a two-stage system. In addition, we
explore the heterogeneity of the effect as a function of income level and
by region. Furthermore, we perform a set of robustness tests with the
addition of additional control variables and the use of an alternative
endogeneity correction method. We find that vulnerability to climate
change worsens children’s health outcomes in all the countries in our
sample. These results can be explained by several factors. Climate
vulnerability has adverse effects on household livelihoods in the form of
lower productivity and the destruction of health infrastructure. This
sensitivity of economies affects healthcare provision by jeopardising
infrastructure, due to the inability of governments to collect the tax
resources needed to finance public goods (Tsopmo et al., 2022).

7
S.I. Foudjo and J. Keneck-Massil Social Science & Medicine 351 (2024) 116979

Table 4
The role of WPE in the relationship.
Dependents variables: IMR Neonatal mortality Under_5 mortality Measles Immunisation DPT immunisation

(1) (2) (3) (4) (5)

L.Lag dependents variables 0.959*** 0.968*** 0.936*** 0.844*** 0.837***

(0.006) (0.003) (0.006) (0.034) (0.024)
Vulnerability 0.012** 0.013*** 0.097*** − 0.144*** − 0.147***
(0.005) (0.003) (0.034) (0.032) (0.050)
WPE − 1.637* − 1.264*** − 2.404** 3.996* 7.113***
(0.922) (0.154) (1.182) (2.284) (2.006)
Vulnerability # WPE − 0.023*** − 0.023*** − 0.143*** 0.226*** 0.208***
(0.008) (0.005) (0.048) (0.048) (0.073)
Total natural resources 0.016* − 0.004** − 0.024 0.122 − 0.053
(0.009) (0.002) (0.020) (0.421) (0.248)
Log GDP per capita − 0.178** − 0.072*** − 0.052 0.319*** 0.489***
(0.073) (0.017) (0.132) (0.117) (0.035)
Government health expenditure − 0.027* − 0.187*** − 0.905*** 0.135*** 1.352***
(0.014) (0.056) (0.334) (0.035) (0.334)
Political corruption 0.160** 0.027 0.345** − 0.661 0.634
(0.080) (0.047) (0.150) (1.021) (0.637)
Constant 2.053*** 1.641*** 5.909*** 3.808** − 0.557
(0.770) (0.240) (1.464) (1.918) (1.679)

Observations 1872 1836 1836 1839 1836

Number of Countries 107 107 107 107 107
Number of instruments 74 51 46 52 53
AR (1) 0.10 0.10 0.13 0.00 0.00
AR (2) 0.48 0.22 0.35 0.32 0.34
Hansen OIR 0.17 0.44 0.61 0.46 0.61

Note: System GMM regression. p < 0.10, **p < 0.05, ***p < 0.01. Robust standard errors in parentheses.
Source: authors.

Similarly, this vulnerability can degrade access to healthcare, which is
likely to influence the quality of prenatal and postnatal care and lead to
poor patient management, therefore incomplete vaccination, or even
death (Datar et al., 2013). In addition, exposure to climatic hazards
increases physical risks, which can result in children drowning because
of their dependence on adults. The economic vulnerability of households
due to the drop in productivity linked to climate change reduces the
demand for healthcare by vulnerable households, increasing the risk of
morbidity among the youngest (Pacheco, 2020; Barbier and Hochard,
2018). On the other hand, climate vulnerability increases exposure to
diseases and pathogens, which in turn weakens children’s immune
systems, leading to respiratory failure and higher mortality rates (DeS­
ouza et al., 2022; Dasgupta, 2018; Bateson and Schwartz, 2007).
While it is true that very few studies in the literature allow us to
compare our results, Mahapatra et al. (2023), in a study of 674 Chinese
districts, showed that a 1% increase in vulnerability to climate change
reduced immunisation by 0.12, while the proportions of underweight
children increased by 0.07 and 0.10. Compared with this study, we find
a more severe effect of climate vulnerability on children’s health out­
comes. Compared with this study, we find a more severe effect of climate
vulnerability on children’s health outcomes. In fact, for a one-point
variation in the level of climatic vulnerability, we observe an increase
in the infant, neonatal, and under-five mortality rates of 0.186 points,
0.056 points, and 0.133 points, respectively, and a drop in measles and
DPT immunisation coverage of 0.342 points and 0.349 points, respec­
tively. In other words, any increase in the level of climatic vulnerability
leads to the premature death of 2 children under the age of one, 1 child
under the age of 28 days, and 2 out of 10 children under the age of five.
Similarly, an increase in the level of climatic vulnerability prevents
around 4 out of 10 children from having access to measles and DPT
vaccinations.
Regarding the second hypothesis that education and WPE mitigate
the adverse effect of climate vulnerability on health outcomes, there are
two main pieces of information. Firstly, we observe that by interacting
measures of WPE and climate vulnerability, we obtain a negative rela­
tionship for measures of child mortality and a positive relationship for
measures of immunisation coverage. This suggests that WPE reduces the
adverse effect of climate vulnerability on children’s health outcomes.
Indeed, women’s participation in the political sphere improves the
quality of institutions, resulting in an efficient allocation of resources to
social sectors such as health and education (Keneck-Massil et al., 2024;
Hornset and de Soysa, 2022). This reallocation of resources increases the
supply and demand for healthcare, making it easier to care for patients
following climatic hazards. Furthermore, women’s participation in po­
litical decision-making increases pro-environmental investment, which
helps to reduce greenhouse gas emissions and safeguard biodiversity by
reducing deforestation (Mujeed et al., 2021; Lv and Deng, 2019), which
in turn reduces the climate risks that could lead to an improvement in
the health of young people. In addition to the aggregate measure of
WPE, the role of different dimensions of WPE in the relationship be­
tween climate vulnerability and child health outcomes is an interesting
result and an important contribution to our study. We find a significant
effect of women’s political participation and civil participation respec­
tively, in the relationship between climate vulnerability and child health
outcomes. Although very few studies allow us to discuss our results,
previous work allows us to establish an intrinsic link between climate
vulnerability, WPE and child health outcomes. They point out that WPE
reduces individuals’ vulnerability to climate change (Asongu et al.,
2022) and that WPE improves children’s health outcomes (Rustagi and
Akter, 2022).
Second, we find that interacting measures of female education and
the climate vulnerability index reveal a negative association between
the interacting variables and infant mortality, neonatal mortality, and
under-five mortality respectively, and a positive association between
them and measures of measles and DPT immunisation coverage. Spe­
cifically, our results suggest that overall, women’s education mitigates
the adverse effect of climate vulnerability on children’s health out­
comes. These results can be explained by the fact that women’s educa­
tion enables them to understand climate risks and better prepare
themselves to protect their families and communities (Mahapatra et al.,
2023). Women are therefore better able to anticipate climatic risks and
store basic necessities to ensure their children’s development. In addi­
tion, better-educated women generally have fewer children and space
out births, which means that younger children are no longer solely

8
S.I. Foudjo and J. Keneck-Massil Social Science & Medicine 351 (2024) 116979

Table 5
The role of female education in the relationship between climate vulnerability and child health outcomes.
Dependent variables: Female primary school enrolment

IMR Neonatal mortality Under_5 mortality Measles Immunisation DPT immunisation

(1) (2) (3) (4) (5)

Lag dependent variables 0.956*** 0.968*** 0.936*** 0.880*** 0.758***

(0.002) (0.006) (0.003) (0.020) (0.040)
Vulnerability 0.036*** 0.083** 0.861*** − 0.117** − 0.319**
(0.004) (0.038) (0.330) (0.050) (0.128)
Female primary school − 0.266*** − 0.971** 5.686 1.676*** 6.172***
(0.072) (0.394) (3.797) (0.648) (1.909)
Vulnerability # Female primary school − 0.008*** − 0.019** − 0.177** 0.027** 0.065**
(0.001) (0.008) (0.071) (0.011) (0.028)
Control variables Yes Yes Yes Yes Yes
Constant 1.858*** 4.784** − 26.255 2.169 − 9.086
(0.350) (1.870) (17.721) (2.571) (7.543)

Observations 1625 1627 1627 1598 1598

Number of Countries 105 105 105 105 105
Number of instruments 81 36 64 76 56
AR (1) 0.06 0.38 0.09 0.00 0.00
AR (2) 0.42 0.10 0.48 0.03 0.95
Hansen OIR 0.16 0.33 0.44 0.45 0.74

Female secondary school enrolment

IMR Neonatal mortality Under_5 mortality Measles Immunisation DPT immunisation

Lag dependent variables 0.923*** 0.965*** 0.919*** 0.779*** 0.838***

(0.010) (0.006) (0.012) (0.043) (0.022)
Vulnerability 0.037** 0.005* 0.077*** − 0.174*** − 0.075***
(0.016) (0.003) (0.028) (0.049) (0.020)
Female secondary school − 1.351*** − 0.204** − 1.858** 0.070*** 0.880**
(0.407) (0.088) (0.738) (0.016) (0.379)
Vulnerability # Female secondary school − 0.010** − 0.002** − 0.019*** 0.038*** 0.016***
(0.004) (0.001) (0.007) (0.012) (0.005)
Control variables Yes Yes Yes Yes Yes
Constant 7.156*** 1.002** 9.979*** 24.656*** 9.470***
(2.000) (0.464) (3.589) (5.147) (1.249)

Observations 1268 1268 1268 1268 1242

Number of Countries 102 102 102 102 101
Number of instruments 38 47 36 59 86
AR (1) 0.15 0.35 0.16 0.00 0.00
AR (2) 0.29 0.00 0.30 0.04 0.26
Hansen OIR 0.51 0.25 0.35 0.80 0.53

Female tertiary school enrolment

IMR Neonatal mortality Under_5 mortality Measles Immunisation DPT immunisation

Lag dependent variables 0.938*** 0.945*** 0.976*** 0.959*** 0.857***

(0.005) (0.007) (0.008) (0.001) (0.018)
Vulnerability 0.075*** 0.060*** − 0.070 0.009*** − 0.013**
(0.017) (0.012) (0.050) (0.002) (0.006)
Female tertiary school 0.005*** 0.001** 0.155** − 0.008*** − 0.005
(0.002) (0.001) (0.078) (0.002) (0.004)
Vulnerability # Female tertiary school − 0.001*** − 0.001*** − 0.004** 0.001** 0.001***
(0.001) (0.001) (0.002) (0.000) (0.000)
Control variables Yes Yes Yes Yes Yes
Constant − 1.423 − 2.707*** 2.592 4.466*** 6.985***
(1.040) (0.614) (2.126) (0.097) (1.300)

Observations 1211 1222 1222 1222 1212

Number of Countries 103 104 104 104 103
Number of instruments 32 38 39 93 75
AR (1) 0.16 0.83 0.07 0.00 0.02
AR (2) 0.03 0.07 0.13 0.21 0.99
Hansen OIR 0.07 0.54 0.19 0.45 0.34

Note: System GMM regression. p < 0.10, **p < 0.05, ***p < 0.01. Robust standard errors in parentheses.
Source: authors.

dependent on their parents but also on their much older elders (Finlay
et al., 2017). As a result, in the event of natural disasters, the latter are
less vulnerable because they are less dependent on their mothers. Also,
in the event of natural disasters, children are less vulnerable because
they are less dependent on their mothers. Similarly, women’s education
increases access to healthcare, which is necessary for better child health
(Sandiford et al., 1995). Our results are similar to those of Davenport
et al. (2017) and go further by looking at several outcome variables,
including infant mortality rate, neonatal mortality rate, under-five
mortality rate, measles vaccination coverage, and DPT.
One of the limitations of this study is that it is carried out on a panel
that is unbalanced due to missing observations. Indeed, limiting the
study to countries with complete data on the variables of interest would
have meant limiting the sample, specifically for the analysis of the
interaction relating to women’s education. However, analysing the role
of women’s education in the relationship between climate vulnerability

9
S.I. Foudjo and J. Keneck-Massil
and children’s health outcomes requires a highly balanced sample. It
would be useful for future research to analyse whether women’s edu­
cation affects their spouse’s behaviour on the issue related to children’s
health outcomes in the context of climate vulnerability. In addition, it
would be beneficial to analyse in the short and long term the effect of
education and WPE on the relationship between climate vulnerability
and children’s health outcomes. It would also be beneficial for future
studies to identify and test other elements that could mitigate the
adverse effect of climate vulnerability on children’s health outcomes,
such as the concentration of political power within an elite or ethnic
group. Furthermore, the method of linear regression absorbing several
levels of fixed effects has several advantages: beyond a simple linear
relationship, it calculates the degrees of freedom lost due to fixed effects.
In addition, it iteratively removes the default singleton groups to avoid
biasing the standard errors and works for both cylindrical and non-
cylindrical panels, increasing the speed of estimation without
imposing additional costs. Despite the advantages of this estimator, it
does not correct for the endogeneity. To solve this bias, GMM is used.
The advantages of GMM are that it deals with the endogeneity bias of all
explanatory variables using internal instruments, solves the reverse
causality problem, and provides valid instruments (Roodman, 2009).
The system GMM estimator of Arellano and Bover (1995) and Blundell
and Bond (1998) allow the use of difference and level lags of the
explanatory variables and solves the problem of weak instruments in the
difference GMM estimator. In this study, we apply the Windmeijer
(2005) correction insofar as it takes into account the downward bias.
To sum up, using the method of generalised moments in a two-stage
system and linear regression absorbing several levels of fixed effects,
four main results are retained. (i) Climate vulnerability reduces chil­
dren’s health outcomes. (ii) WPE mitigates the negative effect of climate
vulnerability on children’s health outcomes. (iii) Women’s political
participation, women’s participation in civil society, and women’s civil
liberties mitigate the negative effect of climate vulnerability on chil­
dren’s health outcomes and (iv) women’s education mitigates the
negative effect of climate vulnerability on children’s health outcomes. In
addition, we find out from various robustness tests that climate
vulnerability degrades children’s health outcomes and that women’s
political participation and better education are bulwarks against this
problem.
5. Conclusion
Our study shows that vulnerability to climate change worsens chil­
dren’s health outcomes. This implies that human-induced climate
change jeopardises children’s quality of life. Therefore, this study
highlights the risks incurred by children under the effects of climate
change. Governments will benefit from implementing policies that
reduce the negative effects of human action on the climate. Further­
more, we highlight the important mitigating role played by education
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.org/10.1016/j.socscimed.2024.116979.
10
Social Science & Medicine 351 (2024) 116979
and WPE in the relationship between climate vulnerability and chil­
dren’s health outcomes. This research warrants further examination of
the ways in which education and WPE mitigate the negative effect of
climate vulnerability on children’s health outcomes. Thus, policies
relating to quality education and increased WPE must strongly factor
into policy decisions. In the sense that better education and WPE in­
crease the socio-economic development of the latter, which in turn has a
positive impact on reducing the level of climate vulnerability, with
positive implications for children’s health outcomes through improved
knowledge of climate risks, investment in pro-environmental activities,
improved quality of institutions and lower fertility rates, all of which
help to improve children’s health outcomes.
AI-assisted technologies statement
The authors confirm that no AI generator was used in this work.
Furthermore, the conclusions, observations and discussion in this work
are based on the authors’ own research. In this study, artificial intelli­
gence was used to improve the quality of English in order to correct
typological and grammatical problems.
CRediT authorship contribution statement
Joseph Keneck-Massil: Writing – review & editing, Writing –
original draft, Supervision, Formal analysis, Conceptualization. Suzie
Imelda Foudjo: Writing – review & editing, Writing – original draft,
Software, Methodology, Formal analysis, Data curation,
Conceptualization.
Declaration of competing interest
The observations, discussions and conclusions of this study are the
property of the authors. As such, it is not attributed to any international
body, institution or country.
The authors certify that no donor has supported the production of
this scientific document that could influence the established results.
Data availability
Data will be made available on request.
Acknowledgements
The authors would like to thank the Editor and the anonymous re­
viewers for their comments and suggestions to improve this work. They
also would like to thank Ms Akwo Bolling Agbor, Ms Magoum Tedom
Ornela and Dr. Ta Tii Nchofoung for their outstanding work in proof­
reading this paper. However, the authors remain solely responsible for
any residual errors.
S.I. Foudjo and J. Keneck-Massil Social Science & Medicine 351 (2024) 116979

Appendix

Table A1
Countries list.

Afghanistan Belarus Comoros Fiji Iraq Madagascar

Angola Brazil Cabo Verde Gabon Jamaica Maldives
Albania Bhutan Costa Rica Georgia Jordan Mexico
Argentina Botswana Cuba Ghana Kazakhstan Macedonia
Armenia Chad Djibouti Guinea Kenya Mali
Azerbaijan China Dominican Rep. Gambia, The Kyrgyz Rep. Myanmar
Burundi Cote d’Ivoire Algeria Equatorial Guinea Cambodia Mongolia
Benin Cameroon Ecuador Guatemala Lao PDR Mozambique
Bangladesh Congo, Dem. Rep. Egypt, Arab Rep. Indonesia Sri Lanka Mauritania
Bulgaria Congo, Rep. Eritrea India Morocco Mauritius
Thailand Colombia Ethiopia Iran, Islamic Rep. Moldova Malawi
Uzbekistan Venezuela Vietnam Vanuatu Yemen, Rep. South Africa
Ukraine Uganda Tanzania Turkiye Tunisia Timor-Leste
Malaysia Russian Fed. Namibia Rwanda Niger Sudan
Nigeria Senegal Nicaragua Solomon Islands Nepal Sierra Leone
Pakistan El Salvador Peru Serbia Philippines Zimbabwe
Togo Eswatini Paraguay Tajikistan Zambia
Syrian Arab Rep. Papua New Guinea Sao Tome and Principe Bosnia and Herzegovina Central African Rep.

Table A2
Data description.

Variables Description Definition Source

Infant mortality rate (IMR)
Neonatal mortality
Under five mortality
Mealse immunisation
DPT immunisation
Climate vulnerability
Total natural resources
Log GDP percapita
Government health
expenditure
Political corruption
ODA
Trade openness
Adolescent fertility
Urban population
Women political
empowerment (WPE)
Women political
participation (WPP)
Women civil social
participation (WCSP)
Women civil liberty (WCL)
Mortality rate, infant (per 1,000 live
births)
Mortality rate, neonatal (per 1,000 live
births)
Mortality rate, under-5 (per 1,000 live
births)
Immunisation, measles (% of children ages
12–23 months)
Immunisation, DPT (% of children ages
12–23 months)
The vulnerability index ranges from 0 to 1 (1 when the level of vulnerability is higher and 0 otherwise)
Total natural resources rents (% of GDP)
Natural logarithm of GDP per capita in
constant international dollars 2015
Government health expenditure in % of
GDP
Interval, from low to high (0–1)
Foreign direct investment, net inflows (%
of GDP)
Trade (% of GDP)
Adolescent fertility rate (births per 1,000
women ages 15–19)
Urban population growth (annual %)
Interval, from low to high (0–1)
Interval, from low to high (0–1)
Interval, from low to high (0–1)
Interval, from low to high (0–1)
Infant mortality rate is the number of infants dying before reaching one year of age, per 1,000 WDI
live births in a given year.
Neonatal mortality rate is the number of neonates dying before reaching 28 days of age, per WDI
1,000 live births in a given year.
Under-five mortality rate is the probability per 1,000 that a newborn baby will die before WDI
reaching age five, if subject to age-specific mortality rates of the specified year.
Child immunisation, measles, measures the percentage of children ages 12–23 months who WDI
received the measles vaccination before 12 months or at any time before the survey. A child is
considered adequately immunized against measles after receiving one dose of vaccine.
Child immunisation, DPT, measures the percentage of children ages 12–23 months who WDI
received DPT vaccinations before 12 months or at any time before the survey. A child is
considered adequately immunized against diphtheria, pertussis (or whooping cough), and
tetanus (DPT) after receiving three doses of vaccine.
ND-
GAIN
Total natural resources rents are the sum of oil rents, natural gas rents, coal rents (hard and WDI
soft), mineral rents, and forest rents.
GDP per capita is gross domestic product divided by midyear population. GDP is the sum of WDI
gross value added by all resident producers in the economy plus any product taxes and minus
any subsidies not included in the value of the products. It is calculated without making
deductions for depreciation of fabricated assets or for depletion and degradation of natural
resources. Data are in constant 2015 U.S. dollars.
refers to government spending to ensure the quality of care WHO
Political corruption refers to the extent to which political power is perverted by the system. V-DEM
Foreign direct investment is the sum of equity capital, reinvestment of earnings, other long- OCDE
term capital, and short-term capital as shown in the balance of payments. This series shows
net inflows (new investment inflows less disinvestment) in the reporting economy from
foreign investors, and is divided by GDP.
Trade is the sum of exports and imports of goods and services measured as a share of gross WDI
domestic product.
Adolescent fertility rate is the number of births per 1,000 women ages 15–19. WDI
Urban population refers to people living in urban areas as defined by national statistical WDI
offices. It is calculated using World Bank population estimates and urban ratios from the
United Nations World Urbanization Prospects.
defined as a process of increasing capacity for women, leading to greater choice, agency, and V-DEM
participation in societal decision-making.
to include women’s descriptive representation in the legislature and an equal share in the V-DEM
overall distribution of power
Include open discussion of political issues, participation in civil society organizations, and V-DEM
representation in the ranks of journalists
Include freedom of domestic movement, the right to private property, freedom from forced V-DEM
labor, and access to justice.
(continued on next page)

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S.I. Foudjo and J. Keneck-Massil Social Science & Medicine 351 (2024) 116979

Table A2 (continued )
Variables Description Definition Source

Female primary school
Female secondary school
Female tertiary school
School enrolment, primary, female (% Primary education provides children with basic reading, writing, and mathematics skills WDI
gross) along with an elementary understanding of such subjects as history, geography, natural
science, social science, art, and music.
School enrolment, secondary, female (% Secondary education completes the provision of basic education that began at the primary WDI
gross) level, and aims at laying the foundations for lifelong learning and human development, by
offering more subject- or skill-oriented instruction using more specialized teachers.
School enrolment, tertiary, female (% Tertiary education, whether or not to an advanced research qualification, normally requires, WDI
gross) as a minimum condition of admission, the successful completion of education at the
secondary level.

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