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7 Point Plan

Data used in this report

Data used in this reportThe data used in this report were derived from a range of sources, which are summarized below.

Childhood diarrhoea burden

Estimates of the global and regional number of diarrhoea cases and deaths are based on the Global Burden Disease project, and are for the year 2004 (the latest year estimates are available). The project provides a comprehensive assessment of mortality and loss of health due to diseases, injuries and risks for all regions of the world. When reviewing these estimates, it is important to note that the distribution of under-five deaths by cause refers to the primary cause of death. The estimated percentage distribution of cause-specific mortality for the year 2004 was applied in this report to the 2008 envelope of total under-five deaths worldwide (8.8 million in 2008) to arrive at the number of under-five deaths due to diarrhoea globally.

Prevention and treatment coverage

Data on prevention and treatment interventions were derived largely from national-level household surveys, notably the Multiple Indicator Cluster Surveys (MICS), supported by UNICEF, and the Demographic and Health Surveys (DHS), supported by the United States Agency for International Development (USAID). Information from the surveys are compiled by UNICEF Headquarters and made available in a series of public-access databases found at www.childinfo.org, which are also published annually in The State of the World’s Children report.

Multiple Indicator Cluster Surveys are nationally representative, standardized sample surveys to which UNICEF provides financial and technical support. Since their inception in 1995, nearly 200 MICS have been carried out globally. The latest round of surveys (MICS3) was conducted in more than 50 countries between 2005 and 2006. The next round is scheduled for 2009-2010. More information is available at www.childinfo.org.

Demographic and Health Surveys are also nationally representative, standardized surveys that are usually implemented every five years with funding from USAID. The DHS is designed to collect a variety of data on a broad range of demographic and health issues and to be comparable over time and across countries. More information is available at www.measuredhs.com.

Indicators

Prevention indicators
The indicators to monitor prevention coverage (such as immunization, nutrition, and water and sanitation) presented in this report are based on well known and long-standing child survival indicators that are regularly used to monitor progress towards global goals and commitments. For example, data on water supply and sanitation are based on the work of the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (www.wssinfo.org). Further information on these prevention indicators, such as definitions and data sources, are available at www.childinfo.org.

Treatment indicators
Oral rehydration therapy with continued feedingProportion of children aged 0-59 months with diarrhoea receiving oral rehydration salts or recommended homemade fluids or increased fluids, and continued feeding during the diarrhoea episode. This indicator reflects the UNICEF and WHO programme recommendations for diarrhoea treatment (with the exception of zinc). The recommendations were developed on the basis of broad consensus by leading experts in the field during a UNICEF and WHO advisory meeting in 2004,45 and re-confirmed in a 2007 follow-up technical conference.46

ORS packetsProportion of children aged 0-59 months with diarrhoea receiving oral rehydration salts during the diarrhoea episode. This indicator is based on information provided by mothers or caregivers. Caregivers are asked whether their children suffered from diarrhoea in the two weeks prior to the survey. If so, they are then asked if the child received a fluid made from a special packet of ORS or a pre-packaged ORS fluid (where applicable) during the diarrhoea episode.

Recommended homemade fluidsProportion of children aged 0-59 months with diarrhoea receiving a government-recommended homemade fluid (to be customized based on national guidelines) during the diarrhoea episode. This indicator is based on information provided by mothers or caregivers. Caregivers are asked whether their children suffered from diarrhoea in the two weeks prior to the survey. If so, they are then asked if the child received a government-recommended homemade fluid during the diarrhoea episode. This question should be customized prior to starting survey work to include the specific fluids recommended by national guidelines to treat diarrhoea.

Increased fluidsProportion of children aged 0-59 months with diarrhoea receiving more to drink during the diarrhoea episode. This indicator is based on information provided by mothers or caregivers. Caregivers are asked whether their children suffered from diarrhoea in the two weeks prior to the survey. If so, they are then asked if (during this illness) the child received none, much less, somewhat less, about the same, or more to drink than usual. Children reported to have received more to drink than usual during the illness are considered to have received this intervention.

Continued feedingProportion of children aged 0-59 months with diarrhoea receiving more, about the same or somewhat less food during the diarrhoea episode. This indicator is based on information provided by mothers or caregivers. Caregivers are asked whether their children suffered from diarrhoea in the two weeks prior to the survey. If so, they are then asked if (during the illness) the child received none, much less, somewhat less, about the same, or more food than usual. Children reported to have received either somewhat less, about the same, or more food than usual during the illness are considered to have received this intervention.

Methodology
Regional and global estimates – These are based on population-weighted averages, weighted by the total number of children under five years of age. These estimates are presented only if available data cover at least 50 per cent of total children under five years of age in regional or global groupings. The list of countries included in these groupings is available at www.childinfo.org.

Trends over time – Changes in treatment indicator definitions over the years have resulted in a relative lack of comparable data from the 1990s in order to assess trends over time. To the extent possible, data collected through previous surveys have been reanalysed for the purposes of this report to conform to the current indicator definition (ORT with continued feeding) to monitor treatment coverage.

For each of the treatment indicators, regional assessments of trends over time were conducted on the basis of a subset of countries with two or more comparable data points around the time periods 2000 and 2007. A linear regression line was then fitted through all available data points for each country included in the assessment to derive an estimate for the earlier (2000) and later time periods (2007). A regional estimate was then presented in this report if the subset of countries included in the trend analyses represented at least 50 per cent of the total children under five in the regional or global grouping.

Interpreting treatment coverage data from household surveys
The interpretation of treatment coverage must take into account a number of important issues:

First, the indicator to monitor current treatment guidelines (ORT with continued feeding) reflects the multiple components of this recommendation (with the exception of zinc). As mentioned previously, this indicator definition was developed and agreed upon by leading experts at a UNICEF and WHO meeting in 2004, and was recently re-confirmed during a Countdown to 2015 technical meeting in 2007.47 It is important to evaluate the contribution of each individual component of the indicator to the overall coverage value, and this assessment was presented in this report.

Second, for some countries, comparisons of treatment coverage based on the current indicator definition with previously used indicators may result in markedly different values. There may also be a different assessment of trends over time depending on the indicator used. It is therefore important for countries to adopt and promote the latest recommendations for treating diarrhoeal diseases, and to monitor these programmes using the appropriate indicators.

Growth Monitoring

Third, prevalence estimates derived from national-level household surveys may vary markedly by season and by timing of outbreaks (such as cholera). Prevalence estimates are also affected by the survey respondents’ understanding of what constitutes a diarrhoea episode. The survey does not measure the type of diarrhoea experienced by the child (including its length and severity), nor the extent of dehydration resulting from the diarrhoea episode. These prevalence estimates are used to derive the denominator for diarrhoea treatment coverage values.

Fourth, information is not collected on the number and timing of interventions used during the diarrhoea episode, including whether children received early ORS administration, the number of ORS packets received during the course of the illness, or whether homemade fluids were correctly prepared. In addition, different countries have different guidelines on what constitutes a recommended homemade fluid. These policies are not always clearly defined, and survey questions may therefore not be customized for countries according to their specific national guidelines prior to starting survey work. In these cases, survey respondents must decide for themselves if the fluid the child received was a government-recommended one, leading to major data quality issues.

Fifth, while questions on diarrhoea treatment have been incorporated into major national-level household surveys, such as the DHS, since the 1980s, there have been a number of slight changes to the construction of these questions over time, as well as their response categories. Here again, it is important to note that survey questionnaires are translated into different languages, which may also result in slight differences in the wording of questions across countries and over time – affecting data collected not only for the diarrhoea treatment indictors, but for other information as well. Further research is needed to determine the extent to which these slight wording changes may have affected overall coverage values.

The change in response categories for the continued feeding indicator around 2000 has particularly affected the availability of data to report on this indicator as well as the ORT with continued feeding indicator. For example, prior to 2000, caregivers were asked if the child received more, the same or less to eat during the diarrhoea episode. After that time, the response categories were revised to include ‘somewhat less’ and ‘much less’ in addition to the other categories. Children are considered to have received the continued feeding intervention if they received the same, more or somewhat less to eat during their illness. This leads to a lack of available data to measure this indicator definition prior to 2000, given that the caregiver responses did not include a ‘somewhat less’ category.