Childhood diarrhoeal disease in South Asian countries: a population-based analysis

Abstract

Introduction

Despite advancements in water sanitation and vaccination, childhood diarrhoeal diseases (CDDs) continue to pose significant public health challenges, especially in South Asia. This study aims to estimate the pooled prevalence of CDDs in South Asia and identify the key factors contributing to its persistence, providing crucial insights for future policy and intervention strategies.

Methods

This study utilised data from the most recent Demographic Health Surveys conducted between 2015 and 2022 in Afghanistan, Bangladesh, India, Nepal, the Maldives and Pakistan, focusing on children under 5 years old. Descriptive statistics were used to measure the prevalence of CDDs and multivariable logistic regression was performed to identify significant factors. A p value of <0.05 was considered as the level of significance.

Results

The overall pooled prevalence of CDDs was 10.13% (95% CI 9.83 to 10.45). Afghanistan had the highest rate of childhood diarrhoea in the South Asian region, with a prevalence of 29.15% (95% CI 28.01% to 30.31%), while the Maldives had the lowest prevalence at 4.17% (95% CI 3.20% to 5.42%). Higher odds of CDDs were associated with younger children, male sex, younger mothers, mothers with little or no education, larger households, unimproved drinking water and type of toilet facilities, lack of access to antimicrobial agents for handwashing and limited electronic media access. However, these factors varied from country to country.

Conclusion

This study highlights the persistently high prevalence of childhood diarrhoea in South Asia. Country-specific findings underscore the urgency for focused interventions, particularly in Afghanistan and Pakistan, to effectively reduce CDDs in the region.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• Diarrhoeal disease is a major contributor to child morbidity and mortality worldwide, with a particularly high prevalence in low and middle-income countries, despite significant improvements in water sources and sanitation.

WHAT THIS STUDY ADDS

• To the best of our knowledge, this study is among the first efforts to investigate country-specific associated factors of childhood diarrhoeal diseases (CDDs) in South Asia and reveals a concerning prevalence in Afghanistan and Pakistan. This study also reports various factor-associated CDDs across different South Asian countries.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• This study indicates that greater attention is needed in Afghanistan and Pakistan to reduce CDDs in South Asia, where prevalence rates are alarmingly high. Policymakers can use the results of country-specific varied associated factors to create targeted interventions and policies to combat the ongoing issue of CDDs in the region.

Introduction

Diarrhoeal disease is one of the leading causes of child morbidity and mortality all over the world. Despite the improvements in water, sanitation and vaccination, about 1.7 billion childhood diarrhoeal cases occur globally each year.¹ Diarrhoeal disease is the second leading cause of childhood deaths, contributing to about 444 000 children’s deaths in 2021 globally.^{2 3} Diarrhoea causes 9% of the total under-5 deaths, which translates to 1200 young children perishing every day, while about 1.5 million cases are severe enough to require critical care.^{3 4} It has been linked to 72.8 million disability-adjusted life years (DALYs) as well as worsening family and healthcare system financial circumstances.^{5 6} However, the prevalence of CDDs is relatively lower in developed countries than in low and middle-income countries.⁷

Sub-Saharan Africa and Southern Asia accounted for more than 80% of the deaths among under-5 children in 2020, while childhood diarrhoea was among the top cause of death.⁸ Most of these deaths occur in resource-poor settings, where access to clean water, sanitation and healthcare is limited.⁹ Although diarrhoeal diseases are preventable and easily manageable with low-cost interventions like oral rehydration solutions, the morbidity due to diarrhoeal disease remains stable in the Southeast Asian region, which led to one of the top causes of hospitalisation in many countries.^{10 11} According to the Global Burden of Diseases, Injuries and Risk Factors Study 2021 (GBD 2021), diarrhoeal diseases accounted for 1.17 million deaths worldwide, including approximately 56 200 deaths among children under 5 in the South Asian region.¹² Indeed, the prevalence of diarrhoea may differ across countries. For instance, in Bangladesh, the prevalence was documented as 17% among under-5 children, while in Afghanistan, about 26.2% of total under-5 children suffered due to CDDs.^{13 14} A geo-spatial study indicated that overall 9.19% of Indian under-5 children suffered due to diarrhoeal infections, while it was observed to be 7.4% in Pakistan.^{15 16} Other studies reported that the prevalence of CDDs is about 10.65% in the Maldives and 11.9% among Nepali under-5 children.^{17 18} Indeed, the data sources and study settings were different from country to country; therefore, the results may not be comparable. It was assumed that the improvements in water use, sanitation facilities and hygiene were the prime causes of the decline in diarrhoeal infections in various settings.719,21

Numerous studies have highlighted the correlation between the incidence of diarrhoeal infections and various socioeconomic and demographic variables.^{22 23} Individual-level factors such as age and educational status of mothers, mothers’ hygiene and feeding practices, particularly during the weaning period, and exclusive breastfeeding could minimise the burden of childhood diarrhoeal illness in many settings.^{24 25} Furthermore, various household-level factors such as wealth status, the type of toilet and hand-washing facilities, the place of residence, the family size and the number of under-5 children in the household are some crucial factors associated with CDDs.^{19 26} Various behavioural factors, such as the washing of hands before meals and after defecation with soap and running water and consuming seafood, are significantly associated with diarrhoeal infection.^{18 27 28} In developing countries, diarrhoea-related mortality and morbidity are directly linked with limited access to improved water and proper sanitation systems.²⁹ Although a myriad of country-specific literatures is available focusing on CDD in the Southeast Asian region, such studies are not comparable due to a lack of pooled prevalence of CDD using the latest nation-wide household-level data.14,1828

Current knowledge of CDD rates is restricted to specific countries only and missing region-wise representation. To bring these issues to the frontline, this study tried to estimate the pooled prevalence of CDDs and to sort out the factors associated with CDD in the Southeast Asian countries. The findings would be beneficial to outline effective measures mitigating CDDs with allocating resources to various segments of populations with higher needs. This study would also provide evidence for future policy and targeted interventions in the South Asian region and other regions as well.

Methods

Data source

This study analysed data from the most recent Demographic Health Surveys (DHS) conducted in the South Asian Region: Afghanistan, Bangladesh, India, Nepal, the Maldives and Pakistan from 2015 to 2022.³⁰ The two remaining South Asian countries were not included in this study because of Bhutan’s data unavailability on DHS, and data for Sri Lanka are not available in the public domain. DHS is a nationwide household-level survey. One of the key aims of The DHS programme is to collect data that are comparable across countries. After obtaining the authorisation letter from DHS authorities for this study, the corresponding country’s dataset was accessed and downloaded using the official DHS programme website. DHS has adopted a uniform sample design representing national-level surveys that are designed to collect demographic and health indicator information using the standard DHS data collection tools. The DHS uses a standardised methodology designed to ensure comparability across countries over time. Surveys are typically conducted using a uniform two-stage stratified sampling design, based on the most recent national census frames. In the first stage, primary sampling units (PSUs) are selected with probability proportional to size within geographic and urban/rural strata. In the second stage, a fixed number of households are systematically selected from each PSU. Standardised questionnaires and recoding procedures help maintain consistency.³¹ More details of the specific survey methodology, sample and data collection procedure have been published elsewhere.32,37 In the present study, children aged up to 5 years were included as the study participants and interviews were conducted with the mothers (aged 15–49 years) of the study participants. The final analysis was restricted to a weighted sample of 260 888 under-5 children from six South Asian countries by excluding incomplete responses and missing data.

Variables

The primary outcome of interest was the occurrence of diarrhoeal disease among under-5 children. As per DHS, mothers were requested to give information about diarrhoea of their under-5 children in the past 2 weeks preceding the survey. The presence of diarrhoea was coded as ‘1’, and ‘0’ otherwise. Based on the literature review and dataset, several explanatory variables such as age, sex and gender of the under-5 children, age and educational status of the mother, households’ source of drinking water, number of living children, place of residence, size of the households, type of toilet facility, usage of essential antimicrobial agent for handwashing, access to electronic media and wealth status were included in this study. Children’s age was categorised as ‘<12 months’, ‘12–23 months’, ‘24–35 months’, ‘36–47 months’ and ‘48–60 months’. The sex of the children was labelled as ‘male’ and ‘female’, and maternal ages were labelled as <20 years, 20–34 and above 34 years. Maternal educational status was categorised as ‘no education’, ‘primary’, ‘secondary’ and ‘higher education’. The number of children was classified as ‘<3’ and ‘three or more children’. Household size was categorised as small (<4 members), medium (5–15 members) and large (>15 members). Households’ source of drinking water was classified as ‘improved water sources’ and ‘unimproved water sources’. Households with access to improved water sources were defined as those that make use of piped water, public taps, standpipes, tube wells, boreholes, protected dug wells and springs, rainwater collection systems, tanker trucks, carts with small tanks, packaged water and community reverse osmosis facilities. Conversely, households that obtained their water from unprotected wells, unprotected springs and surface water sources (such as rivers, dams, lakes, ponds, streams, canals or irrigation channels) were classified as reliant on unimproved sources of water.

Similarly, the type of toilet facility was classified as ‘improved’ toilet facility (eg, toilet with flush that flushes water, septic tank), ‘unimproved’ toilet facility (eg, open pit latrine, hanging toilet) and ‘open defecation’. For households with access to the essential antimicrobial agent for handwashing, this was classified as ‘yes (if soap or any other antimicrobial agent used during handwashing) and ‘no’ if otherwise. According to DHS, a household’s socioeconomic status was measured by calculating the wealth index using principal component analysis. It was a combined measure of the cumulative living standard and calculated by using selected household’s assets through generating a factor score as a weight. The procedure includes calculating factor coefficient scores and standardising indicator variables. Finally, indicator values were multiplied by the factor loadings to generate the index value per household.³⁸ For this subset analysis, the wealth index was measured as per the DHS guidelines and categorised into the ‘poorest’, ‘poorer’, ‘middle’, ‘richer’ and ‘richest’ quintiles.³²

Data analysis

Descriptive statistics were calculated for frequency, proportion, and the 95% CI was applied for measuring the prevalence of diarrhoea according to the background variables. A forest plot was used to show the pooled prevalence and country-specific distribution of childhood diarrhoea, all in one figure.³⁹ Bivariate analysis was performed to observe the association with CDDs and background characteristics of the study sample (online supplemental table 1). Finally, factors associated with childhood diarrhoea were determined by multivariable logistic regression analysis and reported as an adjusted OR with 95% CIs. Adjusted ORs were calculated by including all variables that were significant in the bivariate analysis (p<0.05). Since the DHS survey used a two-stage stratified cluster sampling technique, the recommended sampling weight provided by the DHS was used in the analysis. The variance inflation factor test was employed to detect the multicollinearity in the regression model. All statistical analyses were performed using the statistical package STATA (V.16), and results were interpreted as statistically significant at a p value of <0.05.

Results

Basic background characteristics of mothers and children under 5-year old in South Asian countries

Table 1 represents the background characteristics of the mothers and children under 5-year old in South Asian countries. A total of 260 888 under-5 children were encompassed across the South Asian region. The majority of the study participants was from India (79.51%), followed by Afghanistan (10.37%). The distribution of children’s ages across age categories was nearly equal, and 51.77% of them were identified as male. The majority of the children was from rural areas, 188 625 (72.3%), and lived in households with more than five (76.45%) family members. The average age of the mothers was 27.34±5.21 years. More than 7 out of 10 mothers (71.17%) had attained education up to the higher level while 28.83% of these mothers had no education. The vast majority of the households had an improved source of drinking water (93.32%). Approximately 7 out of 10 (69.79%) of the households had access to improved toilet facilities (69.79%), while almost two-thirds of the (61.99%) participants had access to essential antimicrobial agents of handwashing present at their hand-washing place. On the other hand, considering the wealth quintile, almost a quarter (23.43%) of the study participants belonged to the poorest wealth quintile, while 16.7% of households belonged to the richest wealth quintile.

Table 1. List of background characteristics of mothers and children <5 years old in South Asian countries.

Characteristics	Weighted frequency n (%)	95% CI
Country’s name
Afghanistan	29 505 (11.31)	(10.37 to 12.32)
Bangladesh	7331 (2.81)	(2.62 to 3.01)
India	207 430 (79.51)	(78.61 to 80.38)
Maldives	2634 (1.01)	(0.9 to 1.14)
Nepal	4557 (1.75)	(1.58 to 1.93)
Pakistan	9430 (3.61)	(3.26 to 4.01)
Child’s age (in months)
<12	50 309 (19.28)	(19.08 to 19.49)
12–23	50 773 (19.46)	(19.26 to 19.66)
24–35	52 436 (20.10)	(19.90 to 20.30)
36–47	52 574 (20.15)	(19.93 to 20.37)
48–59	54 797 (21.00)	(20.8 to 21.21)
Sex of children
Male	135 055 (51.77)	(51.50 to 52.04)
Female	125 833 (48.23)	(47.96 to 48.50)
Mother’s age (in years)
Mean age (mean±SD, years)	27.34±5.21	(27.32 to 27.36)
<20	7328 (2.81)	(2.71 to 2.91)
20–34	225 726 (86.52)	(86.25 to 86.79)
Above 34	27 834 (10.67)	(10.42 to 10.93)
Mother’s education level
No education	75 205 (28.83)	(28.19 to 29.47)
Primary	33 623 (12.89)	(12.64 to 13.14)
Secondary	116 280 (44.57)	(44.06 to 45.09)
Higher	35 780 (13.71)	(13.38 to 14.06)
Number of children
<3	163 358 (62.62)	(62.11 to 63.12)
3 and above	97 530 (37.38)	(36.88 to 37.89)
Place of residence
Urban	72 263 (27.7)	(27.02 to 28.39)
Rural	188 625 (72.30)	(71.61 to 72.98)
Household size
1–4	61 455 (23.56)	(23.17 to 23.95)
5–15	193 108 (74.02)	(73.65 to 74.39)
>15	6326 (2.43)	(2.21 to 2.66)
Source of drinking water
Improved	243 459 (93.32)	(93.01 to 93.62)
Non-improved	17 429 (6.68)	(6.38 to 6.91)
Type of toilet facility
Improved	182 064 (69.79)	(69.19 to 70.38)
Unimproved	24 151 (9.26)	(8.67 to 9.88)
Open defecation	54 673 (20.96)	(20.51 to 21.41)
Handwashing with essential antimicrobial agent
Yes	161 720 (61.99)	(61.39 to 62.58)
No	99 169 (38.01)	(37.42 to 38.61)
Access to electronic media
Yes	169 211 (64.86)	(64.38 to 65.34)
No	91 678 (35.14)	(34.66 to 35.62)
Wealth status
Poorest	61 127 (23.43)	(22.98 to 23.89)
Poorer	55 304 (21.20)	(20.84 to 21.56)
Middle	51 515 (19.75)	(19.35 to 20.15)
Richer	49 370 (18.92)	(18.54 to 19.31)
Richest	43 572 (16.70)	(16.18 to 17.24)

Prevalence of childhood diarrhoea across South Asian countries

Figure 1 shows the pooled prevalence of diarrhoea, among children under the age of 5 across South Asia was 10.13% (95% CI 9.83 to 10.45). Afghanistan had the greatest prevalence of childhood diarrhoea in the South Asian region, with a rate of 29.15% (95% CI 28.01% to 30.31%). This was followed by Pakistan, which had a prevalence rate of 18.98%, and Nepal (10.36%). In contrast, the countries with the lowest prevalence rates were the Maldives (4.17%), Bangladesh (4.87%) and India (7.29%).

Figure 1. Prevalence of childhood diarrhoeal diseases across South Asian regions.

The prevalence of CDDs varied among different wealth quintiles, ranging from 3.2% to 30.9% across the South Asian region. Regarding the lowest wealth quintiles, the prevalence of CDDs is lowest in the Maldives (4%) and highest in Afghanistan (28.3%). The same pattern was also observed among the richest quintiles, lowest in the Maldives (3.3%) and highest in Afghanistan (30.9%). The disparities were visible among different wealth quintiles, with respondents in the poorest wealth quintile reporting a higher prevalence of CDDs than the richest wealth quintiles in Maldives (4% vs 3.3%), India (8.9% vs 4.9%) and Nepal (8.6% vs 7.1%) (online supplemental figure 1). However, the richest wealth quintiles reported a lower prevalence of CDDs than the poorest wealth quintiles in Bangladesh (5.1% vs 5%), Pakistan (17.6% vs 16.5%) and Afghanistan (30.9 vs 28.3%).

Childhood diarrhoeal disease across background characteristics

Across the background characteristics of study participants, the pooled diarrhoeal prevalence was higher among children aged 12–23 months (13.8%), male children (10.46%) and among the children who had youngest mother aged <20 years (14.31%) and had no education (15.37%). The prevalence was also higher among rural children (10.48%), those who belonged to the larger households (18.34%) and the poorest wealth quintiles (10.85%). The CDDs were also higher among the households with non-improved sources of drinking water (17.28%), unimproved toilet facilities (21.81%), and who had no access to electronic media (11.03%) and had no essential antimicrobial agents of handwashing (13.24%) (table 2).

Table 2. Prevalence of CDDs across background characteristics of study participants, % (95% CI).

Variables	Overall	Afghanistan	Bangladesh	India	Maldives	Nepal	Pakistan
Child’s age (in months)
<12	12.81	27.49	5.87	10.5	3.2	14.74	24.87
	(12.32, 13.32)	(24.98–30.15)	(4.65–7.39)	(10.08–10.93)	(1.70–5.93)	(11.56–18.61)	(22.26–27.68)
23-Dec	13.8	38.28	9.38	10.02	4.86	13.55	28.09
	(13.23, 14.40)	(35.81–40.80)	(7.81–11.22)	(9.61–10.45)	(3.29–7.12)	(10.98–16.6)	(25.38–30.97)
24–35	10.33	32.78	5.29	6.67	4.15	9.66	20.02
	(9.80, 10.89)	(30.61–35.03)	(4.14–6.73)	(6.35–7.00)	(2.52–6.77)	(7.63–12.16)	(17.36–22.97)
36–47	8.07	27.29	2.36	5.28	4.36	6.29	13.53
	(7.61, 8.55)	(24.48–30.3)	(1.65–3.36)	(4.99–5.58)	(2.40–7.8)	(4.69–8.39)	(11.56–15.76)
48–59	6.08	19.69	1.41	4.35	4.32	8.51	8.63
	(5.77, 6.40)	(17.75–21.77)	(0.91–2.18)	(4.09–4.62)	(2.58–7.13)	(6.57–10.95)	(7.03–10.56)
Sex of children
Male	10.46	30.06	5.21	7.55	3.6	10.31	20.09
	(10.10, 10.83)	(28.64–31.52)	(4.46–6.07)	(7.32–7.79)	(2.53–5.11)	(8.79–12.06)	(18.23–22.08)
Female	9.79	28.18	4.5	7	4.76	10.42	17.88
	(9.46, 10.12)	(26.92–29.48)	(3.79–5.33)	(6.76–7.24)	(3.52–6.41)	(8.64–12.51)	(16.37–19.5)
Mother’s age (in years)
<20	14.31	32.1	6.46	11.9	–	11.54	25
	(13.11, 15.61)	(26.68–38.04)	(4.86–8.55)	(10.73–13.19)		(7.78–16.77)	(18.93–32.24)
20–34	9.79	29.31	4.85	7.27	4.51	10.29	19.53
	(9.50, 10.10)	(28.06–30.59)	(4.26–5.52)	(7.09–7.47)	(3.37–6.02)	(8.87–11.90)	(17.99–21.16)
Above 34	11.8	28.16	2.84	6.1	3.09	10.45	15.99
	(11.03, 12.62)	(26.28–30.13)	(1.76–4.54)	(5.61–6.63)	(1.85–5.10)	(7.47–14.43)	(13.59–18.71)
Mother’s education level
No education	15.37	28.97	6.12	7.85	–	11.2	17.56
	(14.7, 16.07)	(27.73–30.24)	(4.06–9.14)	(7.47–8.24)		(8.61–14.44)	(16.02–19.22)
Primary	10.13	32.41	4.6	7.9	5.37	10.68	20.98
	(9.58, 10.72)	(28.3–36.82)	(3.75–5.65)	(7.44–8.38)	(3.36–8.46)	(8.94–12.70)	(17.90–24.44)
Secondary	8.06	30.08	4.83	7.51	4.27	9.85	21.05
	(7.80, 8.34)	(26.38–34.06)	(4.07–5.73)	(7.27–7.75)	(3.10–5.85)	(8.32–11.63)	(18.03–24.41)
Higher	5.87	17.69	4.85	5.3	3.17	7.88	18.36
	(5.51, 6.24)	(12.11–25.10)	(3.67–6.39)	(4.95–5.67)	(1.54–6.39)	(4.31–13.97)	(15.35–21.81)
Number of children
<3	8.92	30.47	5.28	7.39	3.77	10.85	22.46
	(8.67, 9.18)	(28.62–32.39)	(4.62–6.03)	(7.18–7.60)	(2.73–5.18)	(9.30–12.63)	(20.51–24.53)
3 and above	12.17	28.59	3.93	7.06	5.03	9.19	16.8
	(11.62, 12.73)	(27.31–29.91)	(3.16–4.89)	(6.75–7.38)	(3.06–8.16)	(7.40–11.34)	(15.33–18.37)
Place of residence
Urban	9.25	32.43	4.68	6.06	3.76	11.07	18.84
	(8.60, 9.94)	(29.87–35.10)	(3.74–5.83)	(5.73–6.41)	(1.92–7.25)	(9.23–13.22)	(16.31–21.64)
Rural	10.48	28.14	4.94	7.74	4.39	9.09	19.05
	(10.13, 10.83)	(26.91–29.41)	(4.31–5.66)	(7.53–7.96)	(3.46–5.56)	(7.67–10.74)	(17.57–20.63)
Household size
4-Jan	8.65	35.07	4.77	7.53	4.56	11.35	17.94
	(8.23, 9.08)	(30.36–40.09)	(3.90–5.81)	(7.19–7.88)	(2.63–7.80)	(9.45–13.57)	(15–21.31)
15-May	10.34	28.9	4.95	7.22	3.93	9.85	19.23
	(10.01, 10.68)	(27.72–30.12)	(4.30–5.69)	(7.01–7.43)	(2.85–5.39)	(8.29–11.66)	(17.69–20.87)
>15	18.34	26.92	2.63	5.82	6.97	9.59	17.84
	(16.35, 20.51)	(23.95–30.11)	(0.62–10.48)	(4.57–7.38)	(2.89–15.9)	(2.91–27.30)	(14.63–21.58)
Source of drinking water
Improved	9.62	29.56	4.9	7.27	4.18	10.5	19.05
	(9.31, 9.95)	(28.22–30.94)	(4.36–5.51)	(7.08–7.46)	(3.21–5.44)	(9.16–12)	(17.71–20.47)
Non improved	17.28	28.04	2.84	7.66	–	3.68	17.63
	(16.23, 18.38)	(26.24–29.91)	(1.10–7.16)	(7.01–8.36)		(1.05–12.07)	(14.15–21.74)
Type of toilet
Improved	8.49	29.33	4.9	6.82	4.18	10.29	19.39
	(8.22, 8.77)	(27.3–31.45)	(4.24–5.66)	(6.62–7.02)	(3.2–5.45)	(9.02–11.72)	(17.89–20.97)
Unimproved	21.81	28.7	4.83	7.85	3.5	16.53	19.1
	(20.45, 23.24)	(27.14–30.31)	(3.93–5.93)	(6.82–9.01)	(0.86–13.2)	(6.39–36.49)	(15.82–22.87)
Open defecation	10.46	30.55	4.1	8.7	–	10.66	16.56
	(9.99, 10.95)	(27.61–33.66)	(1.43–11.17)	(8.31–9.11)		(7.16–15.58)	(13.58–20.05)
Handwashing with essential antimicrobial agent
No	13.24	29.1	4.63	8.49	1.4	11.43	17.68
	(7.95, 8.51)	(27.84–31.43)	(3.98–5.37)	(8.17–8.82)	(0.35–5.40)	(9.30–13.98)	(15.94–19.55)
Yes	8.23	29.28	5.26	6.71	4.28	9.86	19.86
	(12.71, 13.80)	(27.21–30.39)	(4.38–6.31)	(6.5–6.91)	(3.28–5.58)	(8.44–11.48)	(18.12–21.73)
Access to electronic media
No	11.03	32.06	4.91	8.68	1.37	11.38	19.07
	(9.30, 10.01)	(30.05–34.15)	(4.22–5.72)	(8.34–9.02)	(0.18–9.75)	(9.74–13.27)	(17.24–21.05)
Yes	9.65	28.07	4.82	6.51	4.22	9.42	18.92
	(10.62, 11.45)	(26.83–29.34)	(4.05–5.72)	(6.32–6.72)	(3.23–5.49)	(7.83–11.28)	(17.14–20.85)
Wealth status
Poorest	10.85	28.26	5.03	8.94	4	8.57	16.53
	(10.41, 11.30)	(25.86–30.79)	(3.96–6.38)	(8.54–9.36)	(2.49–6.38)	(7.07–10.36)	(14.41–18.9)
Poorer	10.44	26.87	4.66	8.03	4.67	12	20.24
	(10.02, 10.86)	(25.03–28.80)	(3.61–5.99)	(7.67–8.4)	(3.33–6.50)	(9.55–14.96)	(17.51–23.27)
Middle	10.51	29.35	6.36	7.26	3.49	12.59	21.39
	(9.86, 11.19)	(26.88–31.94)	(4.87–8.26)	(6.9–7.63)	(2.11–5.74)	(9.91–15.88)	(18.94–24.06)
Richer	9.8	30.44	3.24	6.37	5.54	11.05	19.21
	(9.16, 10.47)	(28.17–32.82)	(2.41–4.36)	(6.01–6.75)	(3.09–9.74)	(8.81–13.78)	(16.53–22.20)
Richest	8.69	30.89	5.12	4.93	3.26	7.14	17.6
	(7.90, 9.56)	(28.08–33.84)	(4.01–6.52)	(4.59–5.3)	(1.01–10.05)	(4.95–10.19)	(14.41–21.31)
Total	10.13	29.15	4.87	7.29	4.17	10.36	18.98
	(9.83, 10.45)	(28.01–30.31)	(4.33–5.46)	(7.1–7.47)	(3.2–5.43)	(9.05–11.85)	(17.67–20.36)

CDDs, childhood diarrhoeal diseases.

Factors of CDDs in South Asian countries

Multivariable logistic regression analysis (table 3) showed that overall children with younger ages, male children, younger mother, mothers with lower and no education, larger households, households who had unimproved sources of drinking water, unimproved toilet facilities had no access to antimicrobial agents of handwashing, no access of electronic media and children belonged to the richest wealth quintiles were more likely to be suffer of childhood diarrhoeal diseases. The study observed that children aged <12 months were more likely to suffer CDDs in India (OR 2.56; 95% CI 2.42 to 2.71; p<0.001) and Nepal (OR 1.97; 95% CI 1.44 to 2.69; p<0.001) than any other ages. However, children aged 12–23 months had more likely to suffer diarrhoeal infections in Afghanistan (OR 2.53; 95% CI 2.33 to 2.76; p<0.001), Bangladesh (OR 7.15; 95% CI 4.48 to 11.41; p<0.001) and in Pakistan (OR 3.91; 95% CI 3.23 to 4.73; p<0.001). We found that male children were 1.09 (95% CI 1.05 to 1.15; p<0.001) more prone to diarrhoeal infections, whereas that was 1.11 times in Afghanistan (95% CI 1.05 to 1.17; p<0.001), 1.10 times in India (95% CI 1.06 to 1.13; p<0.001) and 1.15 times in Pakistan (95% CI 1.03 to 1.28; p<0.001) than female children.

Table 3. Associated factors of diarrhoea among children <5 years old in South Asian countries.

Adjusted OR (95 % CI)
Variables	Afghanistan	Bangladesh	India	Maldives	Nepal	Pakistan	Overall
Child’s age (in months)
<12	1.53*** (1.40 to 1.68)	4.26*** (2.61 to 6.93)	2.56*** (2.42 to 2.71)	0.70 (0.37 to 1.33)	1.97*** (1.44 to 2.69)	3.34*** (2.75 to 4.05)	2.40*** (2.25 to 2.56)
12–23	2.53*** (2.33 to 2.76)	7.15*** (4.48 to 11.41)	2.44*** (2.30 to 2.58)	1.12 (0.62 to 2.01)	1.74*** (1.28 to 2.36)	3.91*** (3.23 to 4.73)	2.64*** (2.48 to 2.81)
24–35	1.99*** (1.83 to 2.17)	3.80*** (2.33 to 6.19)	1.57*** (1.48 to 1.67)	0.92 (0.50 to 1.68)	1.13 (0.82 to 1.55)	2.56*** (2.10 to 3.12)	1.82*** (1.71 to 1.95)
36–47	1.53*** (1.40 to 1.67)	1.67 (0.96 to 2.89)	1.22*** (1.15 to 1.30)	0.99 (0.55 to 1.79)	0.73 (0.51 to 1.03)	1.62*** (1.31 to 1.99)	1.37*** (1.27 to 1.46)
48–59 (reference)	1	1	1	1	1	1	1
Sex of children
Male	1.11*** (1.05 to 1.17)	1.16 (0.93 to 1.44)	1.10*** (1.06 to 1.13)	0.74 (0.50 to 1.09)	1.00 (0.83 to 1.22)	1.15*** (1.03 to 1.28)	1.09*** (1.05 to 1.13)
Female (reference)	1	1	1	1	1	1	1
Mother’s age
<20	1.00 (0.86 to 1.18)	1.45 (0.79 to 2.66)	1.19*** (1.07 to 1.33)	–	0.61 (0.35 to 1.06)	0.95 (0.68 to 1.32)	1.18*** (1.04 to 1.33)
20–34	0.99 (0.93 to 1.06)	1.51 (0.90 to 2.52)	1.04 (0.97 to 1.11)	2.05** (1.16 to 3.63)	0.79 (0.56 to 1.13)	1.00 (0.86 to 1.16)	0.97 (0.91 to 1.04)
Above 34 (reference)	1	1	1	1	1	1	1
Mother’s education level
No education	2.13*** (1.67 to 2.73)	1.91** (1.16 to 3.17)	1.22*** (1.13 to 1.31)	–	1.33 (0.71 to 2.51)	0.90 (0.73 to 1.11)	2.51*** (2.31 to 2.74)
Primary	2.37*** (1.84 to 3.07)	1.16 (0.79 to 1.72)	1.27*** (1.18 to 1.37)	1.83 (0.91 to 3.68)	1.21 (0.66 to 2.21)	1.08 (0.87 to 1.34)	1.84*** (1.68 to 2.02)
Secondary	2.09*** (1.62 to 2.71)	1.11 (0.79 to 1.55)	1.26*** (1.19 to 1.34)	1.29 (0.74 to 2.24)	1.09 (0.61 to 1.96)	1.12 (0.93 to 1.36)	1.47*** (1.36 to 1.58)
Higher (reference)	1	1	1	1	1	1	1
Number of children
<3 (reference)	1	1	1	1	1	1	1
3 and above	1.05 (0.99 to 1.13)	0.75 (0.56 to 1.01)	0.95** (0.91 to 0.99)	1.48 (0.95 to 2.32)	0.78 (0.60 to 1.01)	0.78*** (0.69 to 0.88)	1.10*** (1.05 to 1.15)
Place of residence
Urban	1.28*** (1.17 to 1.40)	0.99 (0.75 to 1.31)	0.98 (0.94 to 1.03)	0.62 (0.30 to 1.28)	1.30** (1.04 to 1.61)	1.00 (0.87 to 1.14)	1.04 (0.98 to 1.09)
Rural (reference)	1	1	1	1	1	1	1
Household size
1–4 (reference)	1	1	1	1	1	1	1
5–15	0.81*** (0.73 to 0.90)	1.05 (0.83 to 1.35)	0.97 (0.93 to 1.01)	0.75 (0.44 to 1.28)	0.85 (0.69 to 1.05)	1.31*** (1.09 to 1.59)	1.03 (0.98 to 1.08)
>15	0.75*** (0.66 to 0.85)	0.49 (0.07 to 3.54)	0.81** (0.67 to 0.98)	1.36 (0.57 to 3.26)	0.62 (0.19 to 2.04)	1.17 (0.90 to 1.52)	1.33*** (1.17 to 1.50)
Source of drinking water
Improved (reference)	1	1	1	1	1	1	1
Non improved	0.95 (0.89 to 1.02)	0.58 (0.20 to 1.73)	0.88 (0.81 to 0.96)	–	0.29 (0.09 to 0.89)	0.94 (0.72 to 1.22)	1.26*** (1.18 to 1.35)
Type of toilet facility
Improved (reference)	1	1	1	1	1	1	1
Unimproved	1.05 (0.99 to 1.13)	0.92 (0.71 to 1.19)	1.03 (0.92 to 1.15)	0.85 (0.13 to 5.32)	1.59 (0.58 to 4.36)	1.04 (0.84 to 1.29)	1.95*** (1.82 to 2.08)
No facility	1.19*** (1.09 to 1.31)	0.87 (0.28 to 2.71)	1.07*** (1.03 to 1.12)	–	0.93 (0.66 to 1.32)	0.93 (0.76 to 1.14)	1.11*** (1.06 to 1.17)
Handwashing with essential antimicrobial agent
Yes (reference)	1	1	1	1	1	1	1
No	1.04 (0.98 to 1.12)	0.78 (0.60 to 1.02)	1.12*** (1.07 to 1.16)	0.39 (0.07 to 2.10)	1.26** (1.00 to 1.58)	0.90 (0.79 to 1.03)	1.28*** (1.23 to 1.35)
Access to electronic media
Yes (reference)	1	1	1	1	1	1	1
No	1.27*** (1.19 to 1.35)	0.98 (0.74 to 1.30)	1.12*** (1.07 to 1.17)	0.33 (0.02 to 4.99)	1.22 (0.98 to 1.52)	1.09 (0.95 to 1.24)	1.06** (1.01 to 1.12)
Wealth status
Poorest (reference)	1	1	1	1	1	1	1
Poorer	0.97 (0.89 to 1.05)	0.89 (0.63 to 1.25)	0.95** (0.90 to 1.00)	1.17 (0.65 to 2.11)	1.43** (1.06 to 1.93)	1.17 (0.97 to 1.41)	1.14*** (1.08 to 1.21)
Middle	1.12** (1.03 to 1.22)	1.13 (0.77 to 1.64)	0.90*** (0.85 to 0.96)	0.94 (0.50 to 1.76)	1.64*** (1.21 to 2.23)	1.11 (0.90 to 1.38)	1.30*** (1.22 to 1.39)
Richer	1.16*** (1.06 to 1.27)	0.54*** (0.34 to 0.86)	0.84*** (0.78 to 0.90)	1.88 (0.87 to 4.04)	1.38 (0.98 to 1.94)	0.96 (0.75 to 1.23)	1.39*** (1.29 to 1.51)
Richest	1.13 (0.99 to 1.28)	0.82 (0.49 to 1.38)	0.69*** (0.63 to 0.75)	1.43 (0.52 to 3.90)	0.91 (0.59 to 1.41)	0.79 (0.60 to 1.05)	1.53*** (1.39 to 1.69)

*p<0.1, **p<0.05, ***p<0.01.

We also observed that CDDs were significantly associated with mothers’ educational level. In Bangladesh and India, we observed that children with uneducated mother were more vulnerable to CDDs, while in Afghanistan (2.37 times), India (1.27 times) and the Maldives (1.83 times), there was a higher chance of CDDs among the children who had mothers with a primary level of education. Children from urban areas in Afghanistan (OR 1.28; 95% CI 1.17 to 1.40; p<0.001) and Nepal (OR 1.30; 95% CI 1.04 to 1.61; p<0.01) were more likely to suffer diarrhoeal infections; however, such relationship was not observed among rest of the South Asian countries. We observed that larger households (five and above) had a significantly lower odds of diarrhoeal diseases in Afghanistan and India but a higher prevalence in Pakistan. Alongside, non-availability of any toilet facility (open defecation) is significantly associated with the prevalence of diarrhoea in Afghanistan (OR, 1.19; 95% CI 1.09 to 1.31; p<0.001), India (OR, 1.07; 95% CI 1.03 to 1.12; p<0.001).

Our results indicated that the prevalence of diarrhoea was significantly higher among children who do not wash hands with essential microbial agents in India (OR, 1.12; 95% CI 1.07 to 1.16; p<0.001) and Nepal (OR, 1.26; 95% CI 1.00 to 1.58; p<0.005), such relationship was not observed in other South Asian countries. Similarly, access to electronic media had a significant role in India, Afghanistan and Nepal; however, such significance was not observed in other settings. To conclude with table 3, the wealth status of the households presents a very astounding result as diarrhoea prevalence is significantly higher in richer households in comparison to the poorest households. The results show that in all countries overall, the poorer wealth group has 1.14 times more prevalence (95% CI 1.08 to 1.21; p<0.001), the middle wealth group has 1.30 times more prevalence (95% CI 1.22 to 1.39; p<0.001), the richer group has 1.39 times more prevalence (95% CI 1.29 to 1.51; p<0.001) and the richest group has 1.53 times more prevalence (95% CI 1.39 to 1.69; p<0.001) than the poorest wealth group.

Discussion

Diarrhoeal infection remains a global public health concern and a leading cause of morbidity and mortality among under-5 children in low and middle-income countries. Although diarrhoeal infections are preventable and could be managed with low-cost interventions, the morbidity due to these infections remains stable in many South Asian settings.40,42 This study measures the prevalence of childhood diarrhoeal infections in South Asian countries using the most recent nationwide DHS dataset.

This study indicated that the overall pooled prevalence of CDDs in the South Asian region was about 10%, which was lower than in East African regions (14%) and sub-Saharan Africa (15.3%).^{26 43} This difference is possibly attributable to place of residence, inadequate sanitation facility, way of stool disposal, access to safe drinking water and availability of essential antimicrobial agent at the place of handwashing and overall economic conditions of this setting. Latest GBD 2021 data indicate that childhood diarrhoeal disease remains widespread in regions with inadequate socioeconomic and sanitary conditions, particularly in Eastern Sub-Saharan Africa, while the situation is comparatively better in South Asia.⁴⁴ The current study found that CDD is highly prevalent among the under-5 children in Afghanistan (29%), followed by Pakistan (19%). The similar high prevalence of childhood diarrhoeal infections is common in many South African Nations such as Ethiopia, Burundi and Malawi (14.5% to 24.80.1%).45,51 This might be because of the lack of improved water, sanitation and handwashing facilities, which are relatively better in many South Asian countries.47,51 The prevalence of CDDs is lowest in the Maldives (4%), followed by Bangladesh (5%), India (7%) and Nepal (10%). This finding is similar to other studies conducted in many Asian and African countries, where the overall prevalence of CDD ranges between 4% and 14%.^{40 50 52 53} Access to improved water, sanitation and handwashing facilities as well as different levels of knowledge regarding CDD, attitudes and habits towards diarrhoeal illness, may be contributing factors to these discrepancies.²⁶ Access to improved drinking water is nearly universal in Bangladesh (99%), and 80% of households utilise improved sanitation facilities.⁵⁴ These advancements have likely played a key role in the significant reduction of diarrhoea among children under 5. In contrast, countries such as Afghanistan, India and Pakistan face challenges with limited access to improved sanitation and the persistence of open defecation.^{33 36 37} This situation, compounded by lower levels of maternal education, often leads to delays in seeking treatment and poorer hygiene practices, contributing to a higher prevalence of diarrhoeal episodes in young children.^{55 56} Consequently, effective policy interventions to address diarrhoeal diseases will likely need to be tailored to the specific contexts of these nations. Therefore, prioritising these public health initiatives is essential to combating CDD and improving overall health outcomes in affected communities.

As expected, this study found that younger children <2 years old were at higher risk of CDDs, which is similar with many other East and Sub-Saharan African countries.^{26 40 42 43 53 57} At age 1–2, children often start to crawl and develop hand-to-mouth coordination and have weaker immune systems, which exposes them to various infectious diseases, including CDDs in many settings.4358,60 Furthermore, this could also be attributed to the interruption of exclusive breastfeeding in many South Asian nations, as breastfeeding provides protective benefits against the incidence and prevalence related to diarrhoea.^{61 62} Mother ages often appeared as a great role for tackling CDDs. Many studies indicated that children belonging to younger mothers aged <20 years were more prone to CDDs.^{19 26 43 53 63} The possible reason might be the greater experience of older women in child care and younger mothers might have less understanding and knowledge about diarrhoeal disease.^{26 64} However, this statement is not always reflected in many settings as the older mother often pays less attention to their child’s health due to larger family size.⁶⁵ Similarly, as expected, the educational qualification of the mother was highly associated with the prevalence of diarrhoea. This study found that the odds of having CDD was higher among children whose mothers had secondary education and below. This finding is similar to many other studies conducted across many countries as mothers having higher education may influence the practice of precautions regarding safe and properly treated water, proper stool disposal and safe sanitation.^{19 26 53 66} This indicates the importance of introducing basic health and child health education from an early period of education.⁶⁷

The relationship between drinking water quality, the type of toilet facility and diarrhoeal infections is significant, particularly in areas with poor sanitation and limited access to clean water.⁴¹ Like other studies, we also found that the probability of CDDs was significantly higher among households that had access to non-improved drinking water sources and no sanitation facility.^{19 41 57 68 69} Households of children under age 5 who had access to a handwashing facility with an essential antimicrobial agent were at lower odds of suffering from CDD. This finding is consistent with many other studies conducted in different regions.4557 70,72 So, governments’ efforts should be strengthened to promote and build handwashing facilities with essential antimicrobial agents to promote child health further. In line with other studies, we also found that CDDs are more common for all segments of the societies, although the poorest households are often more vulnerable. This study documented socioeconomic disparities in CDD prevalence across South Asia, with poorer quintiles more affected in the Maldives, India and Nepal, while wealthier quintiles exhibited slightly higher rates in Bangladesh, Pakistan and Afghanistan. These variations underscore the complex relationship between wealth and health, suggesting that targeted interventions should account for country-specific socioeconomic contexts. Indeed, children from those households that suffer from a lack of quality living standards, unfavourable environmental conditions, lack of nutritious food, dependence on junk foods and lack of awareness of child care are more prone to CDDs.^{73 74} Preventing diarrhoea across all tiers of society involves a multifaceted approach that considers the varying levels of resources, education and access to healthcare, which are limited in many South Asian countries.

This study had several strengths and limitations. The main strengths of this study are identifying factors associated with CDD among all children under age in South Asian countries using a pooled dataset. The finding of the study is based on large sample sizes and the most recent nationally representative datasets of six South Asian countries, which makes the findings applicable for the South Asian region. Unlike GBD 2021, which concentrated on mortality and DALYs in South Asian countries, our study highlights the prevalence and determinants of childhood diarrhoea using the DHS dataset, providing valuable evidence for preventive strategies. Despite all the strengths, this study is not without any limitations that need discussion. First, due to the nature of the study (cross-sectional), the observed association may not be a causal relationship between the studied variables and CDD. Second, recall and reporting errors and missing data may have overestimated or underestimated the findings of this study, as data regarding the outcome variable were obtained from mothers of children under 5 years. In this context, we excluded the observation from the sample if there was no information about diarrhoeal illness for under 5 children. Third, all the risk factors analysed in this study were constrained to variables collected by DHS. Few other related risk factors which could have been associated with CDD were not analysed. Fourth, DHS data do not contain information related to severity of illness, duration, recurrent episodes, need for hospitalisation, which limit the deep understand of the diarrhoeal burden which can be deemed as a limitation.

Conclusion

The study concluded that childhood diarrhoea prevalence in South Asia remains high despite improvements in water sanitation and vaccination. Factors such as child age, child gender, younger mothers, low maternal education, number of children in the household and inadequate access to clean water, proper sanitation, handwashing agents and electronic media were strongly linked to diarrhoea. To combat this, child health education and promotion interventions should be tailored for young, poor and less educated mothers or caretakers. Additionally, efforts to improve water sources are necessary. By reporting country-specific associated factors, this study aids policymakers in targeting interventions to reduce CDDs in the South Asian context. Although public health improvements are important for all countries, greater attention is needed in Afghanistan and Pakistan to prevent childhood diarrhoeal diseases.

Data availability statement

Datasets are publicly available at the Demographic and Health Survey (DHS) Program. https://dhsprogram.com/data