EVALUATING A CHILDHOOD DIARRHEA MANAGEMENT PROGRAM IN UTTAR PRADESH, GUJARAT AND BIHAR, INDIA: DETERMINANTS OF DIARRHEA PREVALENCE, RECALL, CARE-SEEKING AND TREATMENT
Lamberti, Laura Marie
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Objective: The overall goal of this dissertation was to analyze factors of potential importance to evaluations of diarrhea management programs aiming to reduce the burden of diarrhea among children under-five. The specific research aims were to describe the household- and village-level determinants of diarrheal illness, care-seeking, and treatment with oral rehydration salts (ORS) (Paper 1); to determine the role of episode severity on caregiver recall, care-seeking and treatment of diarrhea (Paper 2); and to assess the association between observed prescribing practices and reported knowledge of ORS and therapeutic zinc supplementation (Paper 3). Methods: Diarrhea management programs in Uttar Pradesh (UP), Gujarat and Bihar were evaluated using baseline and midline cross-sectional household surveys and provider assessments. Multilevel models with random effects for village and fixed effects for household- and village-level predictors were built for the log odds of diarrhea, care-seeking and ORS treatment (Paper 1). Logistic regression models with predictors for reported diarrheal symptoms were built for the log odds of distant versus recent onset, care-seeking, and ORS/zinc treatment (Paper 2). Principal components analysis was performed on public and private sector providers’ responses to knowledge questions in order to generate a novel scale assessing ORS/zinc knowledge, and a binary indicator of whether ORS/zinc was prescribed during direct observation was regressed onto the resulting knowledge index scores (Paper 3). Results: Multilevel models for all outcomes showed evidence of statistically significant inter-village variation, and fixed effects were observed for both household- and village-level predictors (Paper 1). Symptoms suggestive of increased episode severity were associated with distant versus recent onset, care-seeking, and ORS/zinc treatment (Paper 2). As measured by a novel scale, ORS/zinc knowledge was associated with higher odds of ORS/zinc prescribing among public and private sector providers (Paper 3). Conclusions: Evaluations of diarrhea management programs should consider inter-village variation and both household- and village-level predictors in the estimation of prevalence and coverage. Cross-sectional surveys should collect data with one-week recall to avoid missing information on episode occurrence and care-seeking/treatment practices. Programmatic activities should center on increasing knowledge of ORS and zinc among public and private sector providers through biannual trainings but should also focus on ensuring sustained access to an adequate supply chain.