Background
Globally, an estimated 5.8 million deaths in children less than 5 years old occurred in the world in 2015 [
1]. The millennium development goal four (MDG-4) was not met in 28 countries, 11 of which had a under-5 mortality in excess of 100 per 1000 livebirths. Experts argue that that MDG-4 could not be accomplished since childhood diarrhea which accounts for about 10% of all under-5 child deaths [
2] was not effectively tackled owing to inadequate implementation of existing evidence-based interventions for diarrhea [
3,
4]. Though a 60% reduction of child mortality rate from diarrhea has been achieved between 2000 and 2013, a further reduction targeted during the sustainable development goals (SDG) era requires a further improvement in coverage and quality of diarrhea case management [
5].
In 1978, the World Health Organization (WHO) recommended that Oral Rehydration Salts (ORS) or Recommended Home Fluids (RHF) be used for all acute watery diarrheas among children to prevent deaths from diarrhea dehydration [
6] leading to the establishment of diarrheal diseases control programs with technical support from United Nations Children’s Fund (UNICEF) [
7] and WHO member states [
8]. Later, WHO-UNICEF joint strategy aimed to improve the proportion of children with diarrhea who receive ORS and increased fluids to 80% by 2000 [
9]. Case management of diarrhea under Integrated Management of Childhood Illness strategy (IMCI) [
10] by training the healthcare providers (HCP) has been shown to improve their case management skills [
11].
Scaling up the existing evidence-based interventions may avert most of the diarrheal deaths [
12‐
14]. Yet, only a third of under-5 children with diarrhea are given an appropriate and prompt healthcare [
15]. Therefore, a Global Action Plan for Pneumonia and Diarrhea (GAPPD) [
16] has underscored the importance of studying caregivers’ knowledge about symptoms, recognition of danger signs, healthcare seeking behavior and identifying the barriers of access to [
17]. Estimating total burden of under-5 children incorrectly managed for diarrhea would help prioritizing disease-specific interventions to further reduce under-5 mortality, and policy making and advocacy control of childhood diarrhoea.
In many low- and middle-income countries (LMICs), healthcare seeking behavior and caregivers’ recognition of childhood illnesses is inadequate and use of oral rehydration therapy (ORT) for diarrhea is unacceptably low [
18]. The reasons are not clearly understood due to the complexity of caregivers’ decision making process [
19]. To close the gap between the burden of childhood illnesses and appropriate healthcare given to the sick children, 52 countdown countries have adopted community case management (CCM) strategies [
20] and methods for monitoring trends of community-based treatment coverage for childhood illnesses using households surveys are being explored [
21]. We aimed to assess the trends of diarrhea case management indicators in LMICs from national-level household surveys to better understand the impact of IMCI scale-up on those indicators.
Discussion
Our key findings were that a very little progress had been made in case management of diarrhea in LMICs over the period 1985–2012. Our data suggests that seeking treatment from a HCP as well as use of ORS and/or RHF for childhood diarrhea increased slightly over the period while rates of
‘increased fluids’ during childhood diarrhea had decreased. None of the case management indicators had reached anywhere near the target of 90% set by the global community [
25]. Rates for use of ORS, ORS-RHF and ‘increased fluids’ had in fact decreased in some countries. Adding to the concern that these data generate is the fact that earlier studies have illustrated the difficulties in preparing Recommended Home Fluids correctly [
26]. The household surveys reviewed in this study did not collect data on knowledge on recipes of RHF, nor on the quality of the fluids actually prepared.
The diarrhea case management indicators in LMICs are consistent with previous studies which have shown that progress in the use of ORT has been slow after 1990 [
18,
27]. After IMCI was implemented phase-wise from 1996 till early 2000s in over 100 LMICs [
28,
29] diarrhea case management indicators were expected to improve as IMCI also emphasizes on improving healthcare seeking behavior [
10]. After IMCI implementation, some countries have experienced a substantial progress in diarrhea management not only in the 1990s [
6] but also in the 2000s demonstrating that high utilization rates of ORT are possible [
18,
30]. Bangladesh is a notable example for making positive strides in diarrhea case management by reaching up to 80% in ORT use rate and this has been attributed to the commitment shown by various stake holders [
31]. Country-level progress in diarrhea case management will help identify reasons for the bottlenecks in low performing countries and learn from strategies and policies of high performing.
An intriguing question that arises is “Why has there not been significant improvement in diarrhea case management?” despite the significant efforts put on diarrhea control program [
8] through various approaches [
10] and platforms [
13] for more than three decades. Some of the explanatory factors being discussed are inefficient communication strategies to the caregivers, knowledge-action gap for giving ORT, [
32] inadequate education and understanding of the caregivers about the childhood illnesses [
33] and competing priorities of the caregivers in poor households when children fall sick [
19]. Stallings has argued that taking a child to a HCP may affect fluid and food intake negatively during episodes of diarrhea, as the HCP may not promote ‘increased fluids’ and ‘continued feeding’ but rather treat the illness with pills, syrups, injections or intravenous fluids [
25,
32]. Over-prescription of drugs in diarrhea case management have been documented earlier [
34]. DHS-based reports from sub-Saharan Africa and India have shown that private HCPs were less likely to provide ORT and more likely to provide other treatments than the public HCPs [
35,
36] and in-depth interviews of Indian HCPs have suggested that a lack of direct dispensing of ORS in the private sector is a major barrier to its use [
36]. A rather surprising finding is the declining trend of ‘increased fluids’. This finding could be attributed to the validity of the indicator itself (mothers recall use of ORS better than increased fluid intake) or it may reflect decreased intensity in communicating the message on the importance of giving a child with diarrhoea more fluids to drink than usual.
Continued low use rates for ORS/RHF in diarrhea case management may reflect that activities targeted at an entire population can only reach a certain level of success after which further intervention efforts will need to focus on high-risk groups, such as poor and less educated persons [
37]. Diarrhea incidence is associated with lower socio-economic status whereas ORT use has been correlated with higher socio-economic status [
38]. Experts have also argued that replacement of disease-specific public health programs, such as diarrheal disease control by more integrated approaches such as IMCI may have negatively affected individual component of IMCI [
28]. Lastly, weak health systems and poor access to healthcare in resource-limited settings may be central impediments to scaling up the interventions to improve diarrhea case management irrespective of the program approach adopted [
17]. More resources, including well-trained HCPs and community health workers, may be essential elements in advancing diarrhea case management further [
39]. Collaborative efforts have been undertaken by the WHO and UNICEF to identify barriers to progress in diarrhoea management and the organisations have jointly suggested solutions for improving case management of childhood diarrhea [
40]. Applying an equity lens and socially inclusive policies in child health programs may be essential for making further progress [
41].
The DHS and MICS surveys are in most instances the best, and often the only, available sources of national-level data in low- income countries. They provide a unique and historic opportunity for cross-country and time-trend analysis. Still, our results should be interpreted with some caution as household survey data may be affected by various sources of errors, among them recall and reporting biases [
42]. Such biases need not be systematic, however, in which case they will have minor influence on the conclusions here.
A potential limitation of this study is that the included survey data only provides information on the children who are alive [
30]. This may not be a factor of signiificant importance but if there were children in the households who had died from diarrhoea they would have been more likely to have received poor treatment than not. Hence, not including them is more likely to have led to an overestimation rather than an underestimation of proper case management practices. We could not test socio-economic or geographic differentials in 2-week prevalence of diarrhea and case management indicators since the data analysed were aggregated. However, association of diarrhea with lower socio-economic status has been illustrated in previous reports [
35,
38] and geographic variations within countries are well documented in DHS reports [
32]. The validity of the indicators that were carefully selected by the WHO and UNICEF after field studies and technical consultations, has been questioned. We believe that validity of the indicators may vary. For instance, recalling the actual amount of fluid intake should be more difficult than recalling the type of treatment received [
43]. Nevertheless, our report is comparable to previous studies and also updated data, improved the methods and made a cross-country comparison of indicators [
14,
18]. Data on continued feeding during diarrhea and zinc treatment for diarrhea was not included in our analyses since these indicators were only available from 90 DHS but not in MICS and we included the comparable data available from both the surveys to obtain greater coverage to improve generazability of our findings. We hope that future studies of this type will be in a better position to assess the use of this important treatment as more data becomes available from the global surveys.