Abstract
BackgroundEach year 2.5 billion cases of diarrheal disease are reported in children under five years, and over 1,000 die. Country characteristics could play a role on this situation. We explored associations between country characteristics and diarrheal disease in children under 5 years of age, adjusting by child, mother and household attributes in developing countries.MethodsThis study included 348,706 children from 40 nations. We conducted a multilevel analysis of data from the Demographic and Health Surveys and the World Bank.ResultsThe prevalence of acute diarrhea was 14 %. Country inequalities (OR = 1.335; 95 % CI 1.117–1.663) and country’s low income (OR = 1.488; 95 % CI 1.024–2.163) were associated with diarrhea, and these country characteristics changed the associations of well-known determinants of diarrhea. Specifically, living in poor countries strengthens the association of poor household wealth and mother’s lack of education with the disease. Other factors associated with diarrhea were female sex of the child (OR = 0.922; 95 % CI 0.900–0.944), age of the child (OR = 0.978; 95 % CI 0.978–0.979), immunization status (OR = 0.821; 95 % CI 0.799–0.843), normal birthweight (OR = 0.879; 95 % CI 0.834–0.926), maternal age (OR = 0.987; 95 % CI 0.985–0.989), lack of maternal education (OR = 1.416; 95 % CI 1.283–1.564), working status of the mother (OR = 1.136; 95 % CI 1.106–1.167), planned pregnancy (OR = 0.774; 95 % CI 0.753–0.795), a nuclear family structure (OR = 0.949; 95 % CI 0.923–0.975), and household wealth (OR = 0.948; 95 % CI 0.921–0.977).ConclusionsInequalities and lack of resources at the country level in developing countries -but not health expenditure- were associated with acute diarrhea, independently of child, family and household features. The broad environment considerably modifies well-known social determinants of acute diarrhea and public health campaigns designed to target diarrhea should consider macro characteristics of the country.
Highlights
Each year 2.5 billion cases of diarrheal disease are reported in children under five years, and over 1,000 die
We considered in the initial models country homicide rates and total country population, but these variables were omitted in the final models because of their lack of association with diarrheal disease and their negative effects on the model’s validity, measured using residual files and reliability estimates
This study explored the association of per capita gross domestic product (GDP), income inequalities (Gini coefficient) and health expenditure with diarrheal disease in a large, multinational population adjusting by individual, family and household characteristics, using a multilevel design
Summary
Each year 2.5 billion cases of diarrheal disease are reported in children under five years, and over 1,000 die. We explored associations between country characteristics and diarrheal disease in children under 5 years of age, adjusting by child, mother and household attributes in developing countries. In spite of global efforts to improve child health, millions of children under the age of five die mostly from preventable causes, including 6.6 million in 2012 [1]. The majority of these deaths occurred in developing countries, predominantly in Asia, Africa and Latin America [2]. Researchers have found heterogeneity across countries in regards to the prevalence of diarrhea, suggesting that the social and economic context at the country level play a role in the incidence of the disease [13]
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