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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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