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The Long Term Association of Diarrhea with School Success

A case study from Pakistan

Jonathan MitchellCIES March 2008

Why Diarrhea?

Leading cause of infant mortality

Average of 3.3 episodes per child per year

Associated with PEM

Strongly associated with micronutrient deficiencies

ORS has reduced fatality rates, but not incidence or duration

ORS has increased diarrhea survivors

A link with developmental impairment would have profound policy implications

There is little to no research2

The Data

Location: Oshikhandas, Northern Areas Pakistan

Diarrhea information collected weekly

Weight and height every quarter

Parental income and education

End of year tests in Math, English and Urdu

Total of 107 children (39 girls and 66 boys)

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The Analysis

Ordered stepwise linear regression

Income, education and malnutrition variables entered first

Diarrhea variables entered last

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Math

VariableStandardized Coefficient

Change in R Squared P value

FI -Father's income 0.229 0.051 0.015

14PB2 - Episodes lasting more than 14 days before 2 -0.255 0.065 0.007

Total R Squared 0.116

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Variable Stand Coef P Value

14PB2 – Episodes lasting more than 14 days before 2* -0.255 0.007

TDURB2 – Total diarrhea days before 2* -0.214 0.025

14PA2 – Episodes lasting more than 14 days after 2 0.045 0.640

TDURA2 – Total diarrhea days after 2 -0.147 0.124

English

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VariableStandardized Coefficient

Change in R Squared P value

FI -Father's income 0.285 0.081 0.002

A2EP - After 2 episodes -0.260 0.067 0.005

Total R Squared 0.148

Variable Stand Coef P Value

A2EP - After 2 episodes * -0.260 0.005

TDURA2 - Total diarrhea days after 2 * -0.258 0.005

B2EP - Before 2 episodes -0.117 0.217

TDURB2 - Total diarrhea days before 2 -0.140 0.138

Urdu

Father’s Income and Education were together significant at the 5% level

FI and FE together accounted for 14.1% of variation

Height for Age at age 2 was nearly significant (p=0.07) and explained an additional 3.1%

No diarrhea variables approached statistical significance

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Discussion -- For this group of children:

All three subjects closely associated with FI

Malnutrition as measured by HA, WA and WH not associated with impairment in Math and English

FE and HA at age 2 positively associated with Urdu performance – why?

English and Math, but not Urdu, had a strong negative association with diarrhea, though vulnerable periods differ

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Conclusions and Policy Implications

Diarrhea, particularly of longer duration, is an important risk factor for impaired school performance

Findings consistent with hypothesis of causality through micronutrient or trace element deficiencies

Investment in diarrhea prevention and duration reduction may have significant long term payoffs in terms of reduced drop-out, improved promotion, and better learning

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