Introduction

Diarrhoea disease is defined as the loss of stool consistency, with pasty or liquid stools, and/ or an increase in stool frequency to more than three stools in 24 hours with or without fever, or vomiting [1]. Deaths due to diarrhoea are usually preventable; unfortunately, the burden remains high [2]. The highest burden of diarrhoea is observed in low-and middle-income countries [3]. The Global Burden of Diseases, Injuries, and Risk factors study, 2016 [4] estimated that diarrhoea was the third leading cause of death among children under five in 2015, responsible for an estimated 330,000 deaths and 30 million severe cases worldwide. Persistent diarrhoea leads to undernutrition [5] and profoundly impairs the growth and development of children under the age of five [6]. It has been reported that diarrhoea is associated with micronutrient deficiencies, impaired neurodevelopment, and increased morbidity and mortality from other childhood diseases [5, 6].

The management of diarrhoea is very important for children in sub-Saharan African countries. As a result, several interventions have been implemented including effective treatment modalities such as oral rehydration therapy, zinc treatment, continued feeding, and antibiotic treatment for certain bacterial diarrhoea, noting that almost all deaths due to diarrhoea could be prevented if these treatment modalities are highly accessed [2, 3]. Zinc and oral rehydration therapy are known to have significant roles in childrens’ ability to recover from diarrhoea [3, 7]. Despite the evidence-based effectiveness of diarrhoea treatment in preventing diarrhoea-related child mortality, the accessibility of diarrhoea treatments remains low in sub-Saharan Africa (SSA), even though these treatments are available [7–9]. Ugwu et al. [9] reported that the prevalence of zinc treatment and oral rehydration therapy (ORT) for diarrhoea were 6% and 21%, respectively in Nigeria. Another study in East Africa [10] reported the prevalence of diarrhoea treatment to be 15.1% in Burundi, 8.2% in Kenya, 20.1% in Zimbabwe, 28.4% in Malawi, and 40.5% in Uganda.

Several factors are associated with accessing treatments for diarrhoea among children in SSA. A study by Kawakatsu, et al. [11] in Kenya reported that household wealth and severity of diarrhoea were significantly associated with accessing diarrhoea treatment. It was indicated that children who belonged to the middle wealth quintile had twice the odds of receiving treatment for diarrhoea compared to children of the lower wealth quintile. Also, childhood diarrhoea with blood presented an increased likelihood of accessing treatment, compared to childhood diarrhoea without blood. The type of facility a child is taken to is also reported to be associated with diarrhoea treatment, as Sood and Wagner [12] found that children who receive treatment from private facilities are less likely to be given ORT for diarrhoea. Another study in Uganda [13] indicated that price and convenience of service are key predictors of diarrhoea treatment accessibility. In that study, it was further stated that free access to diarrhoea treatment significantly increased the likelihood of accessing treatment for diarrhoea. Also, households’ convenience to health facilities increased odds of accessing treatment for diarrhoea. Another study in East Africa reported that high maternal education and high community media exposure were significantly associated with a higher prevalence of diarrhoea treatment utilization [10]. Other studies have found knowledge about treatment and area of residence as the factors that are significantly associated with accessing diarrhoea treatment [14–17].

Given that diarrhoea-related deaths among children in SSA can be prevented, it is important to scale up diarrhoea interventions, including treatment in SSA. Despite the many advantages of diarrhoea treatment among children, treatment prevalence is low in SSA [9, 10]. There have been studies in SSA that have been on diarrhoea treatment and associated factors; however, these studies are mostly country level and use different statistical methods, making it difficult to generalize findings at the sub-Saharan African regional level. Therefore, this study was conducted to fill the gap in literature accordingly. As this study is the first to assess the prevalence and predictors of diarrhoea treatment at the sub-Saharan African regional level, findings can provide a basis for scaling up diarrhoea treatment in SSA.

Materials and methods

Data source and study design

Data for the study were pooled from the most recent Demographic and Health Surveys (DHS) of thirty countries in SSA published from 2010 to 2020. The study included countries whose datasets had information on diarrhoea treatment and the other variables considered in this study. Specifically, we pooled the data from the child’s recode file (KR File). The DHS provides a comparably-representative dataset on health and social indicators such as child and maternal health of which diarrhoea treatment is a component, in over 85 low-and-middle countries where the survey is conducted periodically [18]. DHS employed a cross-sectional study design to collect data from the respondents. The respondents were sampled using a two-stage cluster sampling technique. The first stage of sampling in the DHS consisted of compiling a list of primary sampling units (PSUs) or enumeration areas (EAs) that covered the entire country and were obtained from the most recent national census. The EAs were then divided into standardized segments. Then, with a probability proportional to the size of the EA, a random sample of a predetermined segment is chosen. In the second stage, households were systematically selected from a list of previously enumerated households in each selected EA segment, and those who were regular residents of the selected households or visitors who slept in the households the night before the survey were interviewed. Structured questionnaires were used to collect data from the respondents. The total number of children 30,217 was included in the final analyses. This sample consisted of only those with complete observations of the variables of interest (Table 1). The dataset used in our study is freely available at https://dhsprogram.com/data/available-datasets.cfm.

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Table 1. Description of the study sample.

https://doi.org/10.1371/journal.pone.0275495.t001

Results

Prevalence of diarrhoea treatment in sub-Saharan Africa

Fig 1 shows the prevalence of diarrhoea treatment among children under five in SSA. The study found that the prevalence of diarrhoea treatment among children in SSA was 49.07% (95% CI = 44.50–53.64). The prevalence of diarrhoea treatment ranged from 23.93% (95% CI = 20.92–26.94) in Zimbabwe to 66.32% (95% CI = 61.67–70.97) in Liberia.

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Fig 1. Forest plot showing the prevalence of oral rehydration therapy, zinc, and other treatments for diarrhoea among children under five in sub-Saharan Africa.

https://doi.org/10.1371/journal.pone.0275495.g001

Chi-square test showing the distribution of diarrhoea treatment across explanatory variables

Table 2 outlines the results of the Chi-square test showing differences in diarrhoea treatment across the explanatory variables. The study found that age of child (p < 0.001), size of child at birth (p = 0.001), marital status (p = 0.010), current working status (p = 0.001), postnatal care (PNC) attendance (p < 0.001), person who usually decides on respondent’s health care (p < 0.001), getting medical help for self: permission to go to the health facility (p < 0.001), getting medical help for self: getting money for treatment (p < 0.001), exposure to watching television (p = 0.022), exposure to listening to radio (p = 0.014), head of household (p < 0.001), and wealth index (p = 0.001) were significantly associated with diarrhoea treatment.

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Table 2. Distribution of diarrhoea treatment across the explanatory variables.

https://doi.org/10.1371/journal.pone.0275495.t002

Predictors of diarrhoea treatment among children in sub-Saharan Africa

Fixed effect results.

Table 3, Model III outlines the predictors of diarrhoea treatment among children in SSA. Compared to children aged below 1 year, those aged 1 to 4 years had higher odds of receiving diarrhoea treatment. The odds of diarhoea treatment increases with increasing maternal educational level, with the highest odds among women with secondary or higher level [aOR = 1.19, 95% CI = 1.07, 1.32]. Children whose mothers attended postnatal care [aOR = 1.21, 95% CI = 1.13, 1.29] and mothers who believed that permission to go for medical care is a problem [aOR = 1.12, 95% CI = 1.03, 1.22] had higher odds of diarrhoea treatment. Relative to partner’s with no formal education, those with at least primary education were more likely to seek diarrhoea treatment. The odds of diarrhoea treatment increased with wealth index with the highest odds in those with the highest wealth quintile [aOR = 1.33, 95% CI = 1.18, 1.50]. Children from Central [aOR = 3.81, 95% CI = 3.24, 4.48], Eastern [aOR = 2.16, 95% CI = 1.88, 2.48], and Western Africa [aOR = 3.45, 95% CI = 2.97, 3.99] were more likely to receive diarrhoea treatment compared to those from the Southern Africa. However, children whose mothers were cohabiting, those whose mothers were exposed to watching television, and those who lived in female-headed households were less likely to undergo diarrhoea treatment compared to their counterparts.

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Table 3. Fixed and random effect analysis of predictors of diarrhoea treatment among children in sub-Saharan Africa.

https://doi.org/10.1371/journal.pone.0275495.t003

Discussion

The study assessed the prevalence and predictors of diarrhoea treatment among children in SSA. The study found the prevalence of diarrhoea treatment among children in SSA to be 49.07%. The low prevalence of diarrhoea treatment observed in this study is similar to a recent study conducted among LMICs which reported low rates of ORT coverage in some central sub-Saharan Africa countries (Cameroon, 24.2%; Gabon, 32.8%), and parts of western (Ghana, 39.8%; Nigeria, 40.8%) and eastern SSA (Ethiopia, 28.1%) [20]. Previous studies have attributed this low coverage rate to doctor and patient knowledge about ORT, ORS supply, cost, and taste; and access to clean water [21, 22]. Empirical evidence have shown that improvements in ORT coverage can be driven by changes in governmental policies, media campaigns, and community culture and beliefs concerning diarrhoeal treatment [20, 23, 24]. The prevalence of diarrhoea treatment ranged from 23.93% in Zimbabwe to 66.32% in Liberia. A plausible reason for this finding in the case of Liberia could be attributed to the implementation of the Community Health Worker (CHW) program which significantly led to the improvement in children’s rate of receiving paediatric treatment from a qualified health provider, especially in the remote areas [25].

The study found that children who were aged 1 year and above were more likely to undergo diarrhoea treatment compared to children who were aged below 1. A possible reason for this finding could be that one main way of suspecting diarrhoea at the household level is the passage of watery stool; since babies aged below 1 mostly pass watery stools due to the foods they eat, symptoms of diarrhoea may be missed and treatment not sought compared to children aged 1 year and above whose stools are not expected to be watery due to the food eaten. Hence any watery stool can be an indication of diarrhoea and treatment sought [26, 27]. Also, children aged one year and above can express any discomfort to parents and seek medical treatment compared to those aged 0 who might not be able to express discomfort well [28, 29].

Children whose mothers had attained at least primary education were more likely to seek diarrhoea treatment for their children than those whose mothers had no formal education. Educated women could have been more knowledgeable about the diverse diarrhoea treatment options, increasing their likelihood to access diarrhoea treatment services for their children experiencing diarrhoea [30]. This findings could imply that the education acquired could have also increased their understanding and knowledge on the importance of early health care seeking, thus, early diarrhoea treatment.

Children whose mothers had postnatal care visits were more likely to undergo diarrhoea treatment than those whose mothers did not have postnatal care visits. Women who had frequent postnatal care visitations could have been educated on the importance of timely diarrhoea treatment, resulting in their increased likelihood of treating their childrens’ diarrhoea [31, 32]. The study also found that children whose mothers believed that permission to go and get medical help for self was a big problem were more likely to access diarrhoea treatment compared with those whose mothers believed that permission to go and get medical for self was not a big problem. The plausible explanation for this is that the permission to go and get medical treatment could be a big problem for self (mothers themselves) but not for children; hence, they got permission to seek treatment for children.

Children whose mothers’ partners had attained at least primary education were more likely to undergo diarrhoea treatment than those whose mothers’ partners had no formal education. Educated male spouses may have been well informed about the importance of accessing timely diarrhoea treatment services for their children suffering from diarrhoea disease and are more likely to convince their partners to undergo diarrhoea treatment in such instances [33, 34].

Similar to the findings of other previous studies [11, 26, 35], this study found that children whose mothers’ were wealthy were more likely to undergo diarrhoea treatment compared with those whose mothers were not. A possible reason for this finding could be that wealthy women have the financial capacity to afford diarrhoea treatment options such as zinc treatment, ORT, and antibiotics, increasing their likelihood to access diarrhoea treatment [11, 36]. Aside from paying the health services cost, wealthy women are more likely to afford transportation costs as they seek health services [36].

However, children whose mothers were cohabiting were less likely to undergo diarrhoea treatment compared to those whose mothers were married. An acceptable reason for this finding could be that women who are cohabiting are not financially empowered, reducing their likelihood to access appropriate diarrhoea treatment modalities including zinc tablets, ORT, and antibiotics [37]. Moreover, this study has noted that children whose mothers made healthcare decisions with their partners were less likely to undergo diarrhoea treatment compared with those whose mothers’ healthcare decision was determined by someone else or others. This could plausibly be due to the effect of gender roles and relations which give men the power to make decisions in the family; hence, if the man decides that treatment should not be sought for diarrhoea, women mostly are obliged to abide by it [38].

The positive influence of mass media exposure on maternal and child health-seeking behaviors has been well documented in the literature [39–42]. However, our study finding is counter-intuitive with the above-mentioned evidence from previous studies. We found that children whose mothers were exposed to watching television were less likely to undergo diarrhoea treatment compared with those whose mothers were not exposed to watching television. Further studies are needed to provide the possible explanation for this seemingly counter-intuitive finding.

It is clear from literature [43, 44] that female households do not face the barrier of seeking permission from anybody before utilizing health services for their children and themselves, and would expect them to have higher odds of seeking treatment for children. However, this study noted that children whose household head was female were less likely to undergo diarrhoea treatment compared with those whose household head was male. This could plausibly due to health seeking going beyond just permission to include other socio economic factors such are financial challenges [45]. We, therefore, suggest that further studies be conducted to address this contradiction with available studies.

Conclusion

The study found that the prevalence of diarrhoea treatment among children in SSA was relatively low. Between-country variations in the prevalence of diarrhoea treatment was recorded. The sub-regional estimates of diarrhoea treatment and identified associated factors can support country-specific needs assessments targeted at improving policy makers’ understanding of within-country disparities. Planned interventions (e.g., provision of quality and affordable supply of ORS, zinc, and other treatments) should focus on scaling up diarrhoea treatment among under-five children in SSA, with much focus on the factors identified in this study.

Acknowledgments

We thank MEASUREDHS for granting us access to the dataset.