Introduction Diarrhea is the leading cause of illness and death among under-five children in low and middle income countries. Through the provision of zinc supplements has been shown to reduce the severity and duration of diarrhea, as well as the risk of mortality, the use of zinc for the treatment of diarrhea is still very low in low-income countries. Therefore, this study was conducted to determine the prevalence and associated factors of zinc utilization among under-five children with diarrhea in East Africa. Methods A secondary data analysis of the recent Demographic and Health Surveys (DHS) of East African countries were used to determine the prevalence and associated factors of zinc utilization among under-five children with diarrhea in East Africa. A total weighted samples of 16,875 under-five children with diarrhea were included in the study. A generalized linear mixed model (using Poisson regression with robust error variance) was used. Prevalence Ratios (PR) with their 95% confidence interval (CI) were calculated for those variables included in the final model. Results The overall prevalence of zinc utilization among under-five children with diarrhea in this study was 21.54% (95% CI = 20.92–22.16). Of East African countries, Uganda had the highest prevalence of zinc utilization (40.51%) whereas Comoros had the lowest (0.44%). Maternal primary education (Adjusted Prevalence Ratio(aPR) = 1.29, 95% CI: 1.16–1.44), secondary education (aPR = 1.36, 95% CI = 1.19–1.55) and higher education (aPR = 1.91, 95% CI = 1.52–2.40), high community women education (aPR = 1.12, 95% CI = 1.02–1.24), high wealth index (aPR = 1.12, 95% CI = 1.01–1.24), high community media exposure (aPR = 1.17, 95% CI = 1.06–1.29) were associated with a higher prevalence of zinc utilization. Conclusion The prevalence of zinc utilization among under-five children was found to be low in East Africa. Maternal education, wealth index, community women education, and community media exposure were significantly associated with zinc utilization. Increased mass media exposure, maternal education and wealth index is recommended to improve zinc utilization among under-five children with diarrhea.
This study was conducted in East Africa, the eastern region of the African continent. For this study, the standard DHS survey which is typically collected every five years was used. It is a nationally representative survey that collects data on basic health indicators including zinc utilization among under-five children. The DHS Program used pretested standard Demographic and Health Survey questionnaires to collect data on the population and health issues relevant to each country. The questionnaire was conceptualized to the different countries context and the data were collected by trained data collectors. The appended kids datasets (KR datasets) of the 9 most recent Demographic and Health Surveys (DHS) of East African countries (Ethiopia 2016, Madagascar 2008, Burundi 2016/17, Kenya 2014, Comoros 2012, Malawi 2015, Tanzania 2015, Uganda 2016, and Zimbabwe 2015) were used to determine the prevalence of zinc utilization and associated factors among under-five children with acute diarrhea in East Africa. Those East African countries with no data on zinc utilization were excluded from the analysis. The DHS surveys of these countries and the detailed data quality control mechanisms of the survey can be found at https://dhsprogram.com/data/dataset_admin/index.cfm. A total weighted sample of 16,875 under-five children with diarrhea in the last two weeks preceding the survey were included. The outcome variable was zinc utilization, which was determined by asking the mother whether zinc is given or not for her child at any time since started diarrhea and then dichotomized as yes if the zinc is given for the child and no otherwise. Since our outcome variable was zinc utilization among children who had diarrhea, only those children who had diarrhea in the last two weeks before the survey were included. The independent variables for this study include both individual and community level factors. The individual level variables were: marital status(never married, currently married and formerly married), maternal education level(no education, primary education, secondary education and higher education), wealth index(low, middle and high), sex of household head (male or female) and media exposure, a composite variable generated by the aggregation of reading newspaper, listening radio and watching television. Media exposure was dichotomized as yes “if the mother has exposure to either of the above three mentioned media sources” and no “if she doesn’t have exposure to all of the three media sources. The community level variables include: residence (urban or rural), community women education level(aggregate values of community-level maternal education measured by the proportion of women with a minimum of primary level of education derived from data on mothers level of education), community poverty level (proportion of women in the poorest and poorer quintile derived from data on wealth index which is categorized) and community media exposure (proportion of women who had media exposure derived from data on respondents media exposure status (those who had exposure). As stated above, the last three community-level factors were created by aggregating their respective individual level factors at the cluster level (not directly found in DHS) and categorized as high and low based on national median value(their value were not normally distributed) (Fig 1). To identify the determinant factors of zinc utilization, STATA 14 software was used. Sampling weight was done before any statistical analysis to adjust for the non-proportional allocation of the sample to different countries and the possible differences in response rates. Since the DHS data has hierarchical nature, measures of community variation/random-effects (Intraclass Correlation Coefficient (ICC), Median Odds Ratio (MOR), and Proportional Change in Variance (PCV)) were estimated. The values of these measures were significant, and hence the use of multilevel model is appropriate. In addition, since the outcome variable was common (21.54%) we used a Poisson regression with robust variance, using generalized linear mixed modeling. Model comparison was done using deviance between the null-model (a model with no independent variable), model I (a model with only individual-level factors), model II (a model with community-level factors) and model III (a model that contain both individual and community level independent variables). A model with the lowest Deviance (model III) was the best fitted model. Both bivariable and multivariable multilevel Poisson regression model was performed to identify the determinant factors of zinc utilization in East Africa. All variables with a p value < 0.25 at bi-variable multilevel Poisson regression analysis were entered into the multivariable multilevel Poisson regression model. P value ≤ 0.05 was used to declare statistically significant variables in the final model. Since we used a secondary analysis of DHS data, obtaining ethical approval is not necessary. However, to access the datasets, we have registered and received a permission letter to download and use the data files from DHS Program.
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