Mapping geographical inequalities in oral rehydration therapy coverage in low-income and middle-income countries, 2000–17

Abstract

Background Oral rehydration solution (ORS) is a form of oral rehydration therapy (ORT) for diarrhoea that has the potential to drastically reduce child mortality; yet, according to UNICEF estimates, less than half of children younger than 5 years with diarrhoea in low-income and middle-income countries (LMICs) received ORS in 2016. A variety of recommended home fluids (RHF) exist as alternative forms of ORT; however, it is unclear whether RHF prevent child mortality. Previous studies have shown considerable variation between countries in ORS and RHF use, but subnational variation is unknown. This study aims to produce high-resolution geospatial estimates of relative and absolute coverage of ORS, RHF, and ORT (use of either ORS or RHF) in LMICs. Methods We used a Bayesian geostatistical model including 15 spatial covariates and data from 385 household surveys across 94 LMICs to estimate annual proportions of children younger than 5 years of age with diarrhoea who received ORS or RHF (or both) on continuous continent-wide surfaces in 2000-17, and aggregated results to policy-relevant administrative units. Additionally, we analysed geographical inequality in coverage across administrative units and estimated the number of diarrhoeal deaths averted by increased coverage over the study period. Uncertainty in the mean coverage estimates was calculated by taking 250 draws from the posterior joint distribution of the model and creating uncertainty intervals (UIs) with the 2•5th and 97•5th percentiles of those 250 draws. Findings While ORS use among children with diarrhoea increased in some countries from 2000 to 2017, coverage remained below 50% in the majority (62•6%; 12 417 of 19 823) of second administrative-level units and an estimated 6 519 000 children (95% UI 5 254 000-7 733 000) with diarrhoea were not treated with any form of ORT in 2017. Increases in ORS use corresponded with declines in RHF in many locations, resulting in relatively constant overall ORT coverage from 2000 to 2017. Although ORS was uniformly distributed subnationally in some countries, withincountry geographical inequalities persisted in others; 11 countries had at least a 50% difference in one of their units compared with the country mean. Increases in ORS use over time were correlated with declines in RHF use and in diarrhoeal mortality in many locations, and an estimated 52 230 diarrhoeal deaths (36 910-68 860) were averted by scaling up of ORS coverage between 2000 and 2017. Finally, we identified key subnational areas in Colombia, Nigeria, and Sudan as examples of where diarrhoeal mortality remains higher than average, while ORS coverage remains lower than average. Interpretation To our knowledge, this study is the first to produce and map subnational estimates of ORS, RHF, and ORT coverage and attributable child diarrhoeal deaths across LMICs from 2000 to 2017, allowing for tracking progress over time. Our novel results, combined with detailed subnational estimates of diarrhoeal morbidity and mortality, can support subnational needs asses...

Oral rehydration therapies in Senegal, Mali, and Sierra Leone: a spatial analysis of changes over time and implications for policy

“…The study locations, data sources, spatial covariates, and statistical analyses for this study are consistent with those employed in our previous study [ 6 ], with a few modifications. First, we restricted the analysis to just three countries: Senegal, Sierra Leone, and Mali.…”

“…First, we restricted the analysis to just three countries: Senegal, Sierra Leone, and Mali. We selected these countries because each (1) had experienced changes in ORS and/or RHF during the study period [ 6 ], (2) had implemented policies or interventions aimed at improving ORS coverage during the study period (see the “ Analysis of policy changes ” section below), and (3) had at least 6 years of survey data available. Second, we created mutually exclusive and collectively exhaustive ORT indicators such that each child was placed into exactly one of three categories (any ORS, only RHF, and no ORT).…”

“…We employed methods from our previous study to adjust for differences in RHF definitions and survey questions from 2000 to 2018 [ 6 ]. In brief, RHF questions were classified as including options of (1) recommended or acceptable home fluids, (2) sugar and salt solutions, (3) other home fluids, and/or (4) other liquid foods.…”

“…In a previous geospatial analysis, we found that the use of ORS increased and the use of RHF decreased between 2000 and 2017 in various low- and middle-income countries (LMICs) at both national and subnational levels [ 6 ]. These patterns were particularly striking in subnational areas of Sierra Leone, Mali, and Senegal, countries where diarrhea mortality rates remain high and effective diarrhea treatment is critical to save child lives [ 7 ].…”

“…Adapting the Bayesian geostatistical methods from our previous study [ 6 ], we estimated the percent of children that received three diarrhea treatments (any ORS, only RHF, and no ORT) from 2000 to 2018 at the district/cercle/department level in Sierra Leone, Mali, and Senegal, respectively. To our knowledge, this represents the first spatial analysis of changes in ORT over time in the context of changing policies and access to healthcare.…”