Educational differences in mortality across age groups in Sierra Leone: Findings from the HEAL-SL national mortality survey, 2019–2024

• In Sierra Leone, neonatal mortality rates increased with increased education of household head. • Child and adult mortality rates declined with increased education of the household head. • Death rates from malaria and certain infectious diseases declined with higher education levels. • Increased education leads to overall better health and less avoidable premature mortality. Education and mortality are strongly correlated. However, few studies in low- and middle-income settings have quantified its association with child and adult mortality. This study examined age- and cause-specific mortality patterns by household education level in Sierra Leone. We used representative household and mortality data for 2019-2024 from the Healthy Sierra Leone national mortality study (HEAL-SL), covering 5% of the population using household interviews and electronic verbal autopsies with dual central physician assignment of causes. We calculated all-cause and cause-specific mortality rates by age at death and sex, and education level of household head, using cause-of-death data from HEAL-SL and demographic data from the United Nations World Population Prospects 2022 and UNICEF. Among 15,512 deaths analysed, for almost all age groups, mortality rates were highest in families with low education levels and lowest in those with higher education levels, with notable exceptions. The opposite pattern was true for neonates. Birth asphyxia and trauma were more frequent causes of neonatal deaths in higher education households, while sepsis and infections were more common in lower education households. Among adults aged 30-69 years, cardiovascular mortality increased with household education level. Mortality rates for malaria, the leading cause of death at all ages except neonates, decreased sharply with increasing education among children, but were similar among adults across education levels. The study concludes that household education level is a strong predictor of mortality across age groups and sexes in Sierra Leone. These findings reinforce the importance of nationwide mortality studies in low-income countries.