LeFevre Amnesty E, Mohan Diwakar, Mazumder Sarmila, Lamberti Laura L, Taneja Sunita, Black Robert E, Fischer-Walker Christa L
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Centre for Health Research and Development, Society for Applied Studies, New Delhi, India.
J Glob Health. 2016 Dec;6(2):021001. doi: 10.7189/jogh.06.021001.
India has the greatest burden of diarrhea in children under 5 years globally. The Diarrhea Alleviation through zinc and oral rehydration salts (ORS) Therapy program (2010-2014) sought to improve access to and utilization of zinc and ORS among children 2-59 months in Gujarat and Uttar Pradesh (UP), India, through public and private sector delivery channels. In this analysis, we present findings on program's effect in reducing child-health inequities.
Data from cross-sectional baseline and endline surveys were used to assess disparities in key outcomes across six dimensions: socioeconomic strata, gender, caregiver education, ethnicity and geography.
Careseeking outside the home for children under 5 years with diarrhea did not increase significantly in UP or Gujarat across socioeconomic strata. Declines in private sector careseeking were observed in both sites along with concurrent increases in public sector careseeking. Zinc, ORS, zinc+ORS use did not increase significantly in UP across socioeconomic strata. In Gujarat, increases in zinc use (20% overall; 33% in the Quintile 5 (Q5) strata) and zinc+ORS (18% overall; 30% in the Q5 strata) were disproportionately observed in the high income strata, among members of the most advantaged caste, and among children whose mothers had ≥1 year of schooling. ORS use increased significantly across all socioeconomic strata for children in Gujarat with diarrhea (23% overall; 33% in Q5 strata) and those with dehydration + diarrhea (33% overall; 38% in Q5 strata). The magnitude of increase in ORS receipt from the public sector was nearly twice that observed in the private sector. In Gujarat, while out of pocket spending for diarrhea was significantly higher for male children, overall costs to users declined by a mean of US$ 2; largely due to significant reductions in wages lost (-US$ 0.79; < 0.003), and transportation costs (-US$ 0.44; < 0.00).
While significant improvements in diarrhea treatment were achieved in Gujarat, new strategies are needed in UP, particularly in the private sector. If national-level reductions in diarrheal disease burden are to be realized, improved understanding is needed of how to optimally increase coverage of zinc and ORS and decrease contraindicated treatments amongst the most disadvantaged across geographic areas and axes of gender, ethnicity, education and socioeconomic status.
在全球范围内，印度5岁以下儿童的腹泻负担最为沉重。“通过锌和口服补液盐（ORS）疗法缓解腹泻”项目（2010 - 2014年）旨在通过公共和私营部门的供应渠道，改善印度古吉拉特邦和北方邦（UP）2至59个月儿童获取和使用锌及ORS的情况。在本分析中，我们展示了该项目在减少儿童健康不平等方面的效果。
来自横断面基线调查和终期调查的数据用于评估六个维度关键结果的差异：社会经济阶层、性别、照料者教育程度、种族和地理位置。
在北方邦或古吉拉特邦，不同社会经济阶层中，5岁以下腹泻儿童到医疗机构就诊的情况没有显著增加。在这两个地区，私营部门就诊率均有所下降，同时公共部门就诊率相应上升。在北方邦，不同社会经济阶层中，锌、ORS、锌 + ORS的使用量没有显著增加。在古吉拉特邦，高收入阶层、最优势种姓群体成员以及母亲接受过≥1年教育的儿童中，锌的使用量（总体增加20%；五分位数5（Q5）阶层增加33%）和锌 + ORS的使用量（总体增加18%；Q5阶层增加30%）的增长比例过高。古吉拉特邦腹泻儿童（总体增加23%；Q5阶层增加33%）以及腹泻伴脱水儿童（总体增加33%；Q5阶层增加38%）在所有社会经济阶层中ORS的使用量均显著增加。公共部门ORS的获取量增加幅度几乎是私营部门的两倍。在古吉拉特邦，虽然男童腹泻的自付费用显著更高，但使用者的总体成本平均下降了2美元；这主要是由于工资损失大幅减少（-0.79美元；<0.003）以及交通成本降低（-0.44美元；<0.00）。
虽然古吉拉特邦在腹泻治疗方面取得了显著改善，但北方邦需要新的策略，特别是在私营部门。若要在全国范围内减轻腹泻疾病负担，需要更好地理解如何在不同地理区域以及性别、种族、教育和社会经济地位等方面，以最优方式提高锌和ORS的覆盖率，并减少最弱势群体中禁忌治疗的情况。
