published in Global HealthLink
(issue 111, September 9, 2001), a publication of the Global Health
Reproduced with permission.
A Framework for Action
Child Diarrhea Prevention
By Massee Bateman, MD
Director, Environmental Health Project
and Chris McGahey, PhD
Coordinator of Community-Based Programs,
Environmental Health Project
Diarrhea is the second most serious killer of children under five,
accounting for nearly one-fifth of child deaths—an estimated 1.9 million
deaths annually 5. Not only is diarrhea a life threatening disease, it is
also one of the most frequent childhood illnesses. For example, in some
studies in Latin America, young children have an average of more than 10
episodes of diarrhea each year. While the death rate from diarrhea has come
down during the course of the child survival revolution, the frequency of
illness has changed little, if at all, in many settings. This burden of
diarrhea has an impact on the health system, the household and the
nutritional status of the child. The means to prevent diarrhea are
understood, but significant challenges must be addressed to do so at scale.
The Hygiene Improvement Framework helps us understand the means to prevent
diarrhea and the obstacles that must be overcome to do so.
The Problem: Frequent Diarrhea
One of the most widely recognized achievements of the child survival
revolution has been the successful introduction of oral rehydration solution
(ORS) and oral rehydration therapy (ORT), which have halved childhood deaths
due to diarrhea. Nonetheless, the application of this therapy has its costs.
Frequent consultations and hospitalizations for diarrhea are a strain on
overburdened health services. In the home, direct and indirect costs of
diarrhea in children include expenses of treatment, lost wages for parents
or missed school for older siblings who must stay home to care for the sick
child, additional strain on overburdened mothers, etc. In addition, it is
well documented that diarrhea, especially frequent and prolonged episodes
and dysentery, is an important contributor to malnutrition 4,1 and even mild
malnutrition is associated with increased risk of death from a variety of
childhood illnesses 6.
Diarrhea is a Preventable Disease
The means to prevent diarrhea via water supply, sanitation and hygiene have
been demonstrated in numerous field locations and have been well documented.
Esrey et al. 19912 and Hutley et al. 19973 reviewed all relevant field
studies addressing diarrheal prevention. Figure 1 summarizes what these
studies revealed about the effectiveness of various interventions.
Figure I (Click on image to enlarge).
First, improved water quality and quantity effectively prevent diarrheal
diseases, but excreta disposal and hand washing also have a significant
impact on diarrheal disease. Second, interventions aimed at improving
hygiene, such as hand washing, can lead to a significant reduction in
diarrheal diseases as hardware improvement.
Hygiene Improvement Framework
Based upon these results and the experience of a wide range of global
partners, the Environmental Health Project (EHP) advocates the Hygiene
Improvement Framework—an integrated approach which links hardware and
hygiene promotion and an enabling environment with strong organizational
structures to prevent diarrheal disease. This framework is based on the
recognition that behaviors—especially drinking safe water, sanitary
disposal of feces, and washing hands with good technique at appropriate
times—are the key determinants of diarrhea risk. In order to prevent
diarrhea these behaviors—“hygiene improvement” in the diagram—must
be supported by hardware and materials, “software” or promotion of the
behaviors, and an enabling institutional and policy environment to achieve
these improvements at scale and in a sustainable fashion. EHP believes that
each component should be viewed as a necessary part of the Hygiene
Improvement Framework shown in figure 2.
Figure 2 (Click on image to enlarge).
Reducing the Burden of Diarrheal Disease
Challenge 1: Continue practices already found in child health programs—and
increase their coverage. This includes ORT, exclusive breastfeeding,
micronutrient supplementation, complementary feeding and measles
Challenge 2: Develop effective hygiene promotion strategies and programs. In
recognition of the importance of diarrhea prevention and the role of the
health sector, sanitary disposal of feces and handwashing are included among
the 16 key practices of household and community IMCI. Hygiene behaviors are
typically deeply rooted in local culture and social values and may require
different skills from those commonly available for behavior promotion
programs if hygiene promotion is likely to be appropriate and effective.
Challenge 3: Work in Partnership. Rarely can one program or agent address
all features of the Hygiene Improvement Framework effectively. The elements
represented do not exist in one sector, and may be subject to many
influences. To be truly effective in bringing down the burden of diarrheal
disease, inter-sectoral, inter-agency and inter-institutional collaboration
and coordination will be needed. These partnership efforts will deserve
special attention for documentation, both for advocacy and to provide
guidance to others through lessons learned.
Diarrhea is an important cause of death of children under five and a
burdensome disease in many regards. It can be prevented. We know what to do.
As public health programming becomes more sophisticated in efforts to work
in complex partnerships, this burden can be reduced.
(1) Alam D.S., G.C. Marks, A.H. Baqui, M. Yunus, and G.J. Fuchs (2000).
“Association Between Clinical Type of Diarrhea and Growth of Children
Under 5 Years in Rural Bangladesh” International Journal of Epidemiology
(2) Esrey S.A., J.B. Potash, L. Roberts, and C. Shiff (1991). “Effects of
Improved Water Supply and Sanitation on Ascariasis, Diarrhoea,
Dracunculiasis, Hookworm Infection, Schistosomiasis, and Trachoma”
Bulletin of the World Health Organization 69(5):609-21.
(3) Hutley S.R.A., S.S. Morris, and V. Pisani (1997). “Prevention of
Diarrhoea in Young Children in Developing Countries” Bulletin of the World
Health Organization 75:163-74.
(4) Martorell R., C. Yarbrough, A. Lechtig, J.P. Habicht, and R.E. Klein
(1975). “Diarrheal Diseases and Growth Retardation in Pre-school
Guatemalan Children” American Journal of Physical Anthropology 43:341-6.
(5) Murray C., and A. Lopez, eds. (1996). Global Health Statistics: Volume
2. World Health Organization, World Bank and Harvard School of Public
(6) Pelletier D.L., E.A. Frongillo Jr, D.G. Schroeder, and J.P. Habicht
(1995). “The Effects of Malnutrition on Child Mortality in Developing
Countries” Bulletin of the World Health Organization 73(4):443-8.
For more information, contact: [email protected]
or [email protected]ehproject.org.