gms | German Medical Science

Diarrheal disease remains the second leading cause of death for children under five. Household water treatment (HWT) practices such as boiling, chlorination, and filtration, are a low-cost and effective intervention to improve drinking water quality and prevent diarrheal disease. In terms of diarrhoea treatment, oral rehydration therapy (ORT) is a low-cost and timely intervention, which can reduce disease related mortality by up to 93%. Understanding where and when efforts to increase the coverage of ORT and HWT have been successful (or failed) is critical to adapt strategies, target vulnerable populations, and thus reduce preventable childhood death from diarrhoea.

Method: In this review we analysed all available 424 Multiple Indicator Cluster Surveys (MICS) and Demographic Health Survey (DHS) datasets from 1985 to 2021, covering a total 98 low-and middle-income countries. For the indicators of the diarrhoea treatment module and each survey and country, we summed up the number of children who received diarrhoea treatment and divided them by the total number of children with diarrhoea in the preceding two weeks. To determine HWT prevalence we calculated the proportion of household members that self-reported the use of HWT practices, again for each country and survey. We used the survey package in R to account for complex survey design when calculating prevalence rates. Prevalence rates for each indicator were calculated on the country level and additionally stratified by place of residence (urban vs. rural) and sex (male vs. female), region and income group.

Results: Our study found overall improvements for all indicators, except for HWT. As such, ORT use increased from 30.6% (1986) to 52.1% in 2020, appropriate feeding practices increased from 29.9% (1986) to 37.4% in 2020 and appropriate feeding including ORT use improved from 12.0% in 1987 to 27.0% in 2020. In contrast to that, HWT coverage decreased from 29.3% in 1992 to 26.5% in 2020, with slight improvements in HWT applying adequate methods (19.6% in 1992 to 21.2% in 2020). However, substantial variations between countries remain and coverage rates are still far behind original targets set several years or even decades ago. With regard to socioeconomic difference, we find improvements for the majority of indicators and stratification levels.

Discussion: Despite some progress, global health efforts to promote Oral Rehydration Therapy and Household Water treatment to alleviate mortality from childhood diarrhoea have failed to reach their targets for coverage. Our study suggests that tailoring intervention efforts to specific subgroups, such as rural dwellers, low-income-economies and particular regions, can increase their effectiveness and help to address missed opportunities to avoid unnecessary child mortality.