Zinc utilization and associated factors among under-five children with diarrhea in East Africa: A generalized linear mixed modeling

PLoS ONE, Volume 15, No. 12 December, Year 2020

Interpretation

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.

AI Digest

Study Justification:

– Diarrhea is a major cause of illness and death among children under five in low and middle income countries.
– Zinc supplementation has been shown to reduce the severity and duration of diarrhea and the risk of mortality.
– However, the use of zinc for the treatment of diarrhea is still very low in low-income countries.
– This study aimed to determine the prevalence and associated factors of zinc utilization among under-five children with diarrhea in East Africa.

Study Highlights:

– The overall prevalence of zinc utilization among under-five children with diarrhea in East Africa was 21.54%.
– Uganda had the highest prevalence of zinc utilization (40.51%), while Comoros had the lowest (0.44%).
– Maternal education, wealth index, community women education, and community media exposure were significantly associated with higher prevalence of zinc utilization.
– Increased mass media exposure, maternal education, and wealth index are recommended to improve zinc utilization among under-five children with diarrhea.

Study Recommendations:

– Increase mass media exposure to promote awareness and knowledge about the benefits of zinc supplementation for diarrhea treatment.
– Improve maternal education to enhance understanding and acceptance of zinc utilization.
– Enhance wealth index to ensure affordability and accessibility of zinc supplements.
– Strengthen community women education to empower mothers and promote health-seeking behaviors.
– Implement targeted interventions in countries with low prevalence of zinc utilization, such as Comoros.

Key Role Players:

– Ministry of Health: Responsible for policy development and implementation of interventions related to child health and diarrhea management.
– Non-Governmental Organizations (NGOs): Involved in advocacy, awareness campaigns, and program implementation to promote zinc utilization.
– Health Workers: Provide education and counseling to mothers on the importance of zinc supplementation for diarrhea treatment.
– Community Leaders: Engage in community mobilization and support initiatives to improve zinc utilization.
– Researchers and Academics: Conduct further studies to explore barriers and facilitators of zinc utilization and evaluate the effectiveness of interventions.

Cost Items for Planning Recommendations:

– Mass media campaigns: Budget for designing and broadcasting educational messages on TV, radio, and newspapers.
– Training and capacity building: Allocate funds for training health workers and community leaders on promoting zinc utilization.
– Supply chain management: Ensure availability and distribution of zinc supplements in health facilities and communities.
– Monitoring and evaluation: Set aside resources for monitoring the implementation and impact of interventions.
– Research and evaluation: Allocate funds for conducting further studies and evaluations to inform future interventions.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study utilized a large sample size and a nationally representative survey to determine the prevalence and associated factors of zinc utilization among under-five children with diarrhea in East Africa. The study used a robust statistical analysis method and included both individual and community level factors. However, the study is based on secondary data analysis, which may have limitations in terms of data quality and potential confounding variables. To improve the strength of the evidence, future studies could consider conducting primary data collection to ensure data accuracy and address potential confounders. Additionally, including a control group of children without diarrhea could provide a better comparison for assessing the impact of zinc utilization on diarrhea outcomes.

Abstract

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.

Materials

N/A

Innovations

Based on the information provided, the study conducted in East Africa identified several factors associated with low zinc utilization among under-five children with diarrhea. The study recommended the following innovations to improve access to maternal health:

1. Increased mass media exposure: Promoting awareness and education about the benefits of zinc supplementation through mass media channels such as television, radio, and newspapers can help increase knowledge and understanding among mothers and caregivers.

2. Maternal education: Providing education and information about the importance of zinc supplementation to mothers with children under five can help improve their understanding and encourage them to utilize zinc for the treatment of diarrhea.

3. Improved wealth index: Addressing socioeconomic disparities and improving the wealth index of communities can contribute to better access to maternal health services, including the availability and utilization of zinc supplementation.

4. Community women education: Enhancing the education level of women within communities can have a positive impact on maternal health outcomes, including the utilization of zinc for the treatment of diarrhea in under-five children.

These innovations aim to address the identified factors associated with low zinc utilization and improve access to maternal health services in East Africa.

AI Innovations Description

Based on the study conducted in East Africa, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Increase mass media exposure: The study found that high community media exposure was associated with a higher prevalence of zinc utilization among under-five children with diarrhea. Therefore, an innovation could be to leverage mass media platforms such as radio, television, and newspapers to disseminate information about the importance of maternal health and the use of zinc supplements for the treatment of diarrhea. This can help raise awareness among mothers and caregivers, leading to increased utilization of zinc for the management of diarrhea in children.

2. Improve maternal education: The study found that maternal education, including primary, secondary, and higher education, was associated with a higher prevalence of zinc utilization. Therefore, an innovation could be to implement educational programs targeting mothers and caregivers, providing them with knowledge and skills on maternal health, including the use of zinc supplements for diarrhea management. This can be done through community-based workshops, mobile applications, or online platforms, making the information easily accessible and tailored to the specific needs of the target population.

3. Enhance wealth index: The study found that a high wealth index was associated with a higher prevalence of zinc utilization. To improve access to maternal health, an innovation could be to implement income-generating programs or microfinance initiatives targeting low-income communities. By improving the economic status of families, they will have better access to healthcare services, including the availability and affordability of zinc supplements for the treatment of diarrhea in children.

Overall, the recommended innovations aim to address the factors identified in the study that are associated with low zinc utilization among under-five children with diarrhea in East Africa. By increasing mass media exposure, improving maternal education, and enhancing the wealth index, access to maternal health can be improved, leading to better health outcomes for both mothers and children.

AI Innovations Methodology

The study you provided focuses on the prevalence and associated factors of zinc utilization among under-five children with diarrhea in East Africa. To improve access to maternal health, here are some potential recommendations based on the findings of the study:

1. Increase maternal education: The study found that higher levels of maternal education were associated with a higher prevalence of zinc utilization. Therefore, promoting and providing access to education for women can improve their knowledge and understanding of the importance of zinc supplementation for their children.

2. Enhance community women education: The study also found that higher community women education was associated with a higher prevalence of zinc utilization. Implementing community-based education programs that specifically target women can help increase awareness and knowledge about the benefits of zinc supplementation.

3. Improve wealth index: The study identified a positive association between high wealth index and zinc utilization. Efforts should be made to address poverty and improve economic conditions, as this can positively impact access to maternal health services, including the availability and affordability of zinc supplements.

4. Increase mass media exposure: The study found that high community media exposure was associated with a higher prevalence of zinc utilization. Utilizing mass media platforms such as radio, television, and newspapers to disseminate information about the importance of zinc supplementation can help raise awareness and promote its utilization.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed as follows:

1. Define the target population: Identify the specific population group that will be the focus of the simulation, such as women of reproductive age or under-five children with diarrhea in East Africa.

2. Collect baseline data: Gather relevant data on the current prevalence of zinc utilization, maternal education levels, community women education levels, wealth index, and community media exposure in the target population.

3. Develop a simulation model: Create a mathematical model that incorporates the baseline data and simulates the impact of the recommendations on access to maternal health. This model should consider the interrelationships between the different factors and their potential effects on zinc utilization.

4. Input intervention scenarios: Input different scenarios into the simulation model that represent the potential impact of the recommendations. For example, simulate the effect of increasing maternal education levels by a certain percentage or improving community media exposure through targeted campaigns.

5. Analyze the results: Evaluate the simulation results to determine the potential impact of the recommendations on improving access to maternal health. Assess the changes in zinc utilization rates and other relevant indicators.

6. Validate the model: Validate the simulation model by comparing the simulated results with real-world data, if available. This will help ensure the accuracy and reliability of the model.

7. Refine and iterate: Based on the simulation results, refine the recommendations and iterate the simulation model to further optimize the impact on improving access to maternal health. Continuously monitor and evaluate the outcomes to inform future interventions.

By following this methodology, policymakers and stakeholders can gain insights into the potential impact of the recommendations and make informed decisions to improve access to maternal health in East Africa.

Authors & Co-Authors

Statistics:

Citations: 7

Authors: 5

Identifiers:

DOI: 10.1371/journal.pone.0243245

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

Burundi, Comoros, Ethiopia, Kenya, Madagascar, Malawi, Multi-Countries, Tanzania, Uganda, Zimbabwe

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Male & Female