1. Factors Affecting Diarrhea Among Children in Madhya Pradesh, India Factors Affecting Diarrhea Among Children in Madhya Pradesh, India Kimberly D. Peven, BSN, RN, School of Public Health and Tropical Medicine, Department of International Health and Development, Tulane University, New Orleans, LA, Velma K. Lopez, BS, School of Public Health and Tropical Medicine, Department of International Health and Development, Tulane University, New Orleans, LA, Linda L. Heron, BS, School of Public Health and Tropical Medicine, Department of International Health and Development, Tulane University, New Orleans, LA Descriptive analysis showed a significant relationship between the following variables and recent diarrhea among children: age of mother (p= 0.05), place of residence (p= 0.017), education level (p=0.009), literacy level (p=0.038), mothers currently breastfeeding their children (p=0.001), toilet facility (p=.008), and having ever heard of ORS (p<.001). Overall, younger mothers report children with a higher percentage of recent diarrhea. Diarrhea is reported more often in urban populations, and in children of respondents with high education and literacy levels. There was not a significant relationship between drinking water sources and diarrhea (p=0.728), nor was there a relationship with giving children plain water (p=0.137) or formula (p=0.613) instead of exclusively breastfeeding. See Table 1. This suggests that sanitation and hygiene practices, rather than drinking water source, are important determinants of childhood diarrhea. Given the lack of an association between diarrhea and water source and the directionality of diarrhea prevalence in the education and literacy categories, the relationship between water source and diarrhea was further examined, controlling for education as reported in Table 2. It is observed that there is a significant difference in diarrhea prevalence between an improved water source and a non-improved water source. The p-value from the initial analysis (without stratification) was calculated at 0.728. Yet, after education stratification, the water source p-value for responders without education becomes slightly significant at 0.083. From this analysis, it appears that those respondents with higher education report children with higher levels of diarrhea. A similar effect appears in table 1. To understand this effect, other variables were also investigated by stratifying for education; see Table 3. Z- scores of nutritional indicators, such as height-for-age (stunting) and weight-for-height (wasting), and malnutrition prevalence rates were averaged and viewed according to respondent education. Table 3 shows the resulting rates, which fall into the expected direction- malnutrition increases as education levels decrease. Respondents with no education had children with higher wasting (p=0.118) and stunting (p<=0.001) percentages. Based on this analysis, it can be concluded that there may be reporting bias for diarrhea prevalence throughout the dataset, based on mothers with increased levels of education. Abstract PURPOSE: Diarrhea is the second leading cause of child death in India. Diarrhea prevalence is particularly severe in Madhya Pradesh, as the state showed a 12.5% diarrheal prevalence rate compared to a national rate of 9%. Survey data was used to identify various factors associated with childhood diarrhea, in order to determine water and sanitation program targeting priorities. METHODS: The 2005-2006 Indian National Family Health Survey, which contains data on 2759 children aged 0-59 months living in Madhya Pradesh was analyzed. The key outcome measure was the percentage of children who experienced diarrhea within the last two weeks. Assessment of significance was completed using the Pearson's chi-square test. Relationships were examined between prevalence of childhood diarrhea and access to water and sanitation, the characteristics of the mother, child feeding habits, and residence. RESULTS: Analysis showed a significant relationship between the following variables and recent diarrhea among children: age of mother (p= 0.05), place of residence (p= 0.017), education level (p=0.009), literacy level (p=0.038), mothers currently breastfeeding their children (p=0.001), toilet facility (p=.0008), and having ever heard of ORS (p<.001). Surprisingly, there was no significant relationship between water sources and diarrhea, nor was there a relationship with giving children plain water or formula. This suggests that sanitation and hygiene practices are more important determinants of childhood diarrhea. RECOMMENDATIONS: Given the results, it is important to examine associations between hygiene and childhood diarrhea. Water and sanitation programs in this state should target young mothers with little education and low literacy. Purpose Each year childhood diarrhea accounts for approximately 2 million deaths in children under 5 years old worldwide and is subsequently a leading cause of all- cause child mortality in the developing world (1). In fact, diarrhea is the second leading cause of child death in the nation of India (2). According to the 2005-2006 Demographic and Health Survey, diarrheal prevalence on a national level lies at 9.0% for all Indian children under five years. However, when investigating diarrhea in the second most populous Indian state of Madhya Pradesh, the diarrheal prevalence is significantly higher at 12.5%. Diarrhea is a preventable and easily treated disease. For this reason, it is vital to have a scientific understanding of the causal mechanisms of diarrhea, especially in areas with high prevalence rates such as in Madhya Pradesh. Such an understanding will influence diarrhea program targeting priorities. This report utilized national- level survey data in a brief situational analysis to identify factors associated with childhood diarrhea in the state of Madhya Pradesh, India. Results 1.Bryce J, Boschi-Pinto C, Shibuya K, Black RE; WHO Child Health Epidemiology Reference Group (2005) WHO estimates of the causes of death in children. Lancet 365: 1147-1152. 2.Department of Health Statistics and Informatics of the Information, Evidence and Research Cluster; World Health Statistics 2009; World Health Organization; 50-51. 3.International Institute for Population Sciences (IIPS) and Macro International. 2007. National Family Health Survey (NFHS-3), 2005–06: India: Volume I. Mumbai: IIPS. 4.Manesh AO, Sheldon TA, Pickett KE, Carr-Hill R. (2008) Accuracy of child morbidity data in demographic and health surveys. Int J Epidemiol. 37(1): 194-200. 5.Bryce J, Black RE, Walker N, Bhutta ZA, Lawn JE, et al. (2005) Can the world afford to save the lives of 6 million children each year? Lancet 365: 2193-2200. 6.Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, et al. (2003) How many child deaths can we prevent this year? Lancet 362: 65-71. 7.Rudan I, Lawn J, Cousens S, Rowe AK, Boschi-Pinto C, et al. (2005) Gaps in policy- relevant information on burden of in children: A systematic review. Lancet 365: 2031-2040. Methods The analysis showed strong associations between diarrhea prevalence and younger mothers with little education in urban settings. Nevertheless, it should be noted that diarrhea prevalence has seasonal variations. Given the cross-sectional nature of the data, the prevalence rates discussed in the analysis may not reflect the diarrhea situation that children under five face year-round (3). In addition, the bivariate analysis also showed a significant relationship between toilet type and diarrhea prevalence. However, this relationship is difficult to further investigate from the given dataset, and we suspect that there is possible reporting bias as seen in the water source variable in Table 2. Previous research concerning the use of large nation-level household surveys, specifically the DHS reports, show increased rates of reported childhood diarrhea among mothers with high education levels (4). Therefore, it is difficult to draw conclusions from the initial analyses, as there is a high probability that the significant variables are also influenced by reporting bias. In order to determine targeting priorities for diarrhea programs, further research is required to tease out this bias among associated factors. There are simple, cost-effective methods and interventions of combating diarrheal disease that have the potential to decrease the number of diarrhea-caused child deaths experienced worldwide; however, there is a lack of funding to implement such interventions (5,6). In addition to the lack of funding and despite the high numbers of children suffering from diarrhea throughout the world, research concerning diarrheal disease in children has slowly been declining over the last twenty years (7). As shown in this analysis, diarrheal disease remains a problem for child health, specifically in Madhya Pradesh, India. With a renewed focus on diarrheal disease research and a drive to implement proven, cost-effective interventions, it is possible to reduce diarrhea prevalence worldwide and the resulting all- cause child mortality. The 2005-2006 Indian National Family Health Survey, which contains data on 2759 children aged 0-59 months living in Madhya Pradesh was analyzed using SPSS software, version 16. The key outcome measure was the percentage of children who experienced diarrhea within the last two weeks. Initial assessment of significance was completed using the cross-tabulation procedure and a Pearson's chi-square test. Relationships were examined between prevalence of childhood diarrhea and access to water and sanitation, the characteristics of the mother, child feeding habits, and residence. Further analysis and stratification were performed using compare means procedures and ANOVA tests. Recommendations References