Prevalence and Treatment of Diarrhea Among Children in India, 2016-2021.

Importance: The World Health Organization recommends the use of oral rehydration solution (ORS) for the treatment of child diarrhea. In India, adherence to these guidelines remains far less than complete. Objective: To elucidate geographic variations in ORS treatment for child diarrhea between and within India's 720 districts. Design, Setting, and Participants: This repeated cross-sectional study used data from 2 rounds of India's National Family Health Survey from 2016 and 2021. Complete diarrhea data were available from 246 695 children in 2016 and 223 785 children in 2021 from all 720 districts in both waves. Data on ORS treatment were available for 22 413 children in 2016 and 15 302 children in 2021. These children lived in 716 of India's 720 districts in 2016 and in 718 districts in 2021. The data were analyzed in October 2024. Main Outcomes and Measures: The primary outcome was the district-level percentage of children who received ORS treatment if they had diarrhea in the past 2 weeks. The prevalence of diarrhea was also estimated. These values were estimated for both outcomes in 2016 and 2021 so that change over time could be estimated. The SD of the community-level prevalence of children who received ORS treatment by each district as a measure of the within-district inequality was also estimated for 2016 and 2021. Results: The study included 246 695 children younger than 5 years (mean [SD] age, 2.0 [1.4] years; 128 098 boys and 118 597 girls) for diarrhea prevalence and 22 413 children younger than 5 years (mean [SD] age, 1.5 [1.3] years; 12 050 boys and 10 363 girls) for ORS treatment in 2016. The study also included 223 785 children younger than 5 years (mean [SD] age, 2.0 [1.4] years; 115 632 boys and 108 153 girls) for diarrhea prevalence and 15 302 children younger than 5 years (mean [SD] age, 1.6 [1.4] years; 8160 boys and 7142 girls) for ORS treatment in 2021. Of the 9.2% (95% CI, 9.1%-9.3%) of children who had diarrhea in the 2 weeks prior to the survey in 2016, 50.6% (95% CI, 50.0%-51.3%) were treated with ORS. In 2021, 7.3% (95% CI, 7.2%-7.4%) of children had diarrhea, of whom 60.7% (95% CI, 59.9%-61.5%) were treated with ORS. There was considerable between-district variation in the prevalence of ORS treatment for child diarrhea (as of 2021, the state or Union Territory with the lowest district-level prevalence of ORS treatment was Haryana [49.0%]; the state or Union Territory with the highest district-level prevalence of ORS treatment was Jammu and Kashmir [83.4%]). The prevalence of ORS treatment decreased by more than 2.49 percentage points in 185 districts between 2016 and 2021 even though, nationally, the prevalence of ORS treatment increased over the same period, from a median of 57.5% (IQR, 47.2%-66.5%) to a median of 62.4% (IQR, 56.9%-72.5%). Finally, many districts with high prevalence of child diarrhea had low prevalence of ORS treatment. And in 71 districts, the prevalence of child diarrhea increased while the prevalence of ORS treatment decreased between 2016 and 2021. Conclusions and Relevance: This cross-sectional study of the prevalence of child diarrhea and its treatment with ORS in India found that the prevalence of ORS treatment for child diarrhea increased at a national level between 2016 and 2021, but this increase was not even between or within India's 720 districts. The findings suggest that efforts aimed at promoting ORS treatment for child diarrhea in India must address the place-based factors that might be associated with underuse of this treatment.