This study investigates trends and inequalities in using ORT with continued feeding for treating childhood diarrhoea in Sierra Leone between 2008, 2013 and 2019. While national coverage for ORT with continued feeding remained relatively stagnant, there was a concerning widening of inequalities in access across different groups.
The study reveals a modest increase in the percentage of children under five years old with diarrhoea receiving oral rehydration therapy and continued feeding, rising from 56.5% in 2008 to 59.7% in 2019. This increase is a positive indicator of progress in addressing childhood diarrhoea, a leading cause of morbidity and mortality in young children worldwide. Several factors may have contributed to this increase in ORT coverage. Enhanced public health campaigns, community health education, and increased availability of ORT solutions at health facilities could play pivotal roles [19]. For instance, initiatives to educate mothers about the importance of ORT and continued feeding during diarrhoea episodes can lead to improved health-seeking behaviours [7, 20]. Additionally, the increase aligns with broader efforts to strengthen health systems in Sierra Leone, particularly following the Ebola outbreak, which emphasised the need for robust healthcare infrastructure [11]. Investments in maternal and child health programmes may also have contributed to this positive trend [11]. Our finding is closely linked to Sustainable Development Goals (SDGs) 3 target 3.2, which aims to end preventable deaths of newborns and children under five years of age, which is directly supported by effective treatment of diarrhoea through ORT. As Sierra Leone continues to work towards achieving the SDGs, particularly those related to health, this finding highlights both progress made and the challenges in improving child health outcomes. Mothers aged 20–49 had higher rates of ORT with continued feeding for their children with diarrhoea in Sierra Leone. This finding is consistent with the previous studies [4, 21]. Mothers aged 20–49 might have greater awareness about ORT and continued feeding due to living longer and potentially having more experience caring for children [22]. Mothers in the 20–49 age range might be more likely to have had access to healthcare information or attended prenatal care visits where they could have learned about ORT and continued feeding compared to younger mothers [23]. Younger mothers (15–19) might face more social or economic challenges, making it harder to access healthcare facilities or follow treatment recommendations. This could be due to a lack of transportation, childcare for other children, or feeling less comfortable navigating the healthcare system [24].
Our study revealed that children of wealthy and more educated mothers show a decrease in coverage of ORT with continued feeding with time compared to the poor and the lowly educated in Sierra Leone. This finding suggests that while overall access to interventions may improve, the benefits are not equally distributed [25]. Wealthier families, who might have greater access to information and resources, may be less reliant on public health initiatives or may prioritising different health practices, potentially leading to a decline in the uptake of essential interventions like ORT. In contrast, poorer and less educated families, who often face more significant barriers to healthcare access, may increasingly rely on these critical interventions as they become more aware of their importance in managing diarrhoea [26]. This disparity raises essential questions about the effectiveness of health education and outreach programmes in reaching all population segments. It underscores the need for targeted strategies that specifically address the needs of wealthier and more educated families, ensuring they remain engaged with public health initiatives [27]. Additionally, it highlights the necessity of fostering community-level support and education to reinforce the importance of ORT and continued feeding, particularly in urban areas where the decline is most pronounced [28,29,30]. These findings are closely linked to SDG 3 (Good Health and Well-Being) and SDG 10 (Reduced Inequality). The observed decrease in coverage among wealthier populations indicates a potential setback in achieving SDG 3, as equitable access to health interventions is crucial for reducing child mortality rates. Moreover, the disparities highlighted in our study resonate with SDG 10, which seeks to reduce inequality within and among countries. The findings suggest that without targeted interventions, health inequities may persist or even widen, particularly between different socioeconomic groups. Addressing these disparities is essential for improving child health outcomes, fostering social equity and ensuring that all children, regardless of socioeconomic status, have access to life-saving interventions.
Our study revealed that male children gained more access to ORT and continued feeding treatment than female children in Sierra Leone. This finding aligns with the previous study [4]. In some cultures, with a son preference, boys might receive more attention and resources for healthcare compared to girls. This could make girls with diarrhoea less likely to receive ORT and continued feeding [31]. Traditionally, healthcare decisions for children might lie with fathers or male heads of households. These individuals might hold different beliefs about treatment priorities for sons versus daughters, impacting access to ORT and continued feeding [32]. Further investigation is needed to understand the specific reasons behind the widening gender gap in ORT and continued feeding access.
Our study reveals a troubling trend as children of mothers in urban areas of Sierra Leone exhibit a decrease in coverage of oral rehydration therapy with continued feeding over time, in contrast to their rural counterparts. This finding suggests that despite the perception that urban areas may have better access to healthcare resources, this is not translating into improved health outcomes for children suffering from diarrhoea. Several factors may contribute to this decline. Urban families might experience a shift in health-seeking behaviour, potentially relying more on private healthcare options or alternative remedies rather than public health interventions [33]. Additionally, rapid urbanisation and associated lifestyle changes may lead to increased stress and less emphasis on traditional health practices, impacting the uptake of essential interventions like ORT [34]. The decrease in ORT coverage among urban populations also raises concerns about the effectiveness of health education and outreach programmes in these areas. It highlights the necessity for tailored interventions that address the unique challenges faced by urban families, such as misinformation about health practices or a lack of engagement with public health initiatives. Moreover, as urban settings often experience higher rates of migration and diversity, targeted community-based programmes that emphasise the importance of ORT and continued feeding are essential to ensure that all families, regardless of their background, understand and utilise these critical health interventions. These findings are closely aligned with SDG 3 and SDG 11. The observed decline in ORT coverage among urban populations indicates a potential barrier to achieving SDG 3, emphasising the need for equitable access to health interventions across different living environments. Furthermore, our findings relate to SDG 11, which focuses on making cities and human settlements inclusive, safe, resilient, and sustainable. As urban areas grow, ensuring that health services are accessible and effective becomes increasingly critical. Addressing the decline in ORT coverage in urban settings is essential for fostering healthier communities and reducing health disparities.
The regional disparities in ORT and continued feeding for childhood diarrhoea remained high in Sierra Leone despite a slight downward trend. Although the overall picture might be improving, there could be a persistent gap in the distribution of healthcare facilities, trained personnel, and ORT supplies across different regions [35]. Remote or underserved areas might still have limited access to these resources, hindering proper treatment for diarrhoea. Poor infrastructure in certain regions, like limited transportation networks, could make it difficult for families to reach healthcare facilities, especially during emergencies or for follow-up care, impacting their ability to consistently adhere to ORT and continued feeding practices [36]. Addressing these potential reasons requires a multi-pronged approach. Investing in infrastructure development, ensuring equitable distribution of healthcare resources, and tailoring public health interventions to address regional needs are crucial steps. Engaging with communities and promoting health literacy can further bridge the gap and ensure all children in Sierra Leone have access to effective treatment for diarrhoea.
Policy and practice implications
Our study on children under five with diarrhoea receiving oral rehydration therapy and continued feeding in Sierra Leone in 2008, 2013, and 2019 reveals the need for policy and healthcare practices adjustments. Policies promoting ORT and continued feeding should prioritise addressing identified inequalities. This could involve targeted campaigns, resource allocation based on need, and collaboration with local community leaders. Develop age-appropriate education materials and outreach programmes to ensure caregivers understand the specific needs of different age groups during diarrhoea episodes. Explore policy solutions like subsidies for ORT or financial assistance programmes to improve access for underprivileged communities. Integrate diarrhoea treatment best practices into existing educational programmes for mothers and caregivers. This could involve collaborating with the Ministry of Education or incorporating these topics into antenatal care services. Further research is needed to understand the reasons behind the widening sex disparity. Policy interventions could then address these specific cultural or social barriers. Allocate resources and healthcare worker training based on identified regional inequality. Consider implementing pilot programmes in high-burden regions to test and refine targeted interventions. Regularly collect treatment coverage and inequalities data to track progress and identify areas where policies and practices need further refinement. By implementing these policy and practice changes, Sierra Leone can work towards achieving equitable access to effective diarrhoea treatment for all children under 5, regardless of age, economic background, education level, residence, sex, or region.
Strengths and limitations
The SLDHS provide nationally representative data, allowing for generalisable conclusions about trends and inequalities across the country. SLDHS likely include variables on childhood diarrhoea, ORT use, continued feeding practices, child age, economic status, maternal education, place of residence, child’s sex, and region. These are all directly relevant to the research question. WHO Heat is specifically designed to analyse and visualise health survey data. This can be a strength as it simplifies data analysis, creates publication-quality visualisations, and facilitates the calculation of concentration indices and population-attributable fractions used to assess inequality. While SLDHS follow standardised protocols, recall or social desirability bias in survey responses can still affect data quality. SLDHS data may not capture all the nuances of care practices. For instance, they may not differentiate between types of ORT used or provide details on how continued feeding was practised. Ecological fallacy is a potential concern since the data are collected at the household level. This means conclusions drawn about individuals may not be accurate.
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