Gastrointestinal infections are among the most common causes of morbidity and mortality around the world. Most are caused by viruses and some are caused by bacteria or other organisms [1]. In underdeveloped and developing countries, acute gastroenteritis involving diarrhea is the leading cause of mortality in infants and children younger than 5years [1]. Diarrhea results in large losses of water and electrolytes, especially sodium and potassium and frequently is complicated by severe systemic acidosis [1].

Diarrhea is a condition of public health importance in many areas of the world. A 2015 Nigerian study by Ezeama NN et al. acknowledged that diarrhea was especially lethal when superimposed on malnutrition [2]. Diarrhea accounts for more deaths in early childhood after the neonatal period than any other etiology [3]. The disease is associated with an estimated 1.3million deaths annually [4], with most occurring in resource limited countries [5]; and up to 25% of deaths in young children living in Africa and south east Asia attributable to acute gastroenteritis [6]. The youngest children are most vulnerable with the incidence of severe gastroenteritis being highest in the first 2 years of life [7]. Morbidity due to diarrhea is further concentrated in marginalized communities within resource limited countries [8]. Despite improvements in standard of living, advances in sanitation, water treatment and food safety awareness, diarrheal diseases still account for significant economic and societal losses [9]. Perhaps, the improvement was not so significant, because bearing in mind that this socio demographic risk factors continue to play key roles in the occurrence of diarrhea disease in the under 5. Therefore, pointing out these associations followed by health education of the people will go a long way in reducing the morbidity and mortality among this vulnerable group.

The disease as a cause of childhood morbidity and mortality stems from a multifactorial etiology. Exposure to poor environmental, socio-economic and behavioral factors are responsible for the morbidity and mortality in under 5 children [10]. This morbidity depends on the interaction of socio-demographic, physical, behavioral and environmental factors [10]. Hence, to understand children’s morbidity, one has to examine the linkage and interactions among the aforementioned factors 

To effectively prevent diarrhea, it is imperative that the important risk factors associated with diarrhea be identified first in communities and in patients presenting to the hospital with diarrhea disease through research.

All over the world many studies have been conducted towards describing the epidemiology and microbial aetiology of diarrhea disease among children of less than 5years of age. However, the local epidemiology and socio-demographic predictors of diarrhea in most rural areas of Nigeria have not been researched on. In addition, most studies in Nigeria have focused on a specific pathogen rather than identify the socio-demographic factors that call these organisms into play.

Therefore, this study is aimed at determining the relationship between the socio-demographic predictors and occurrence of diarrhea disease among under 5 children presenting in NAUTH Nnewi, Nigeria. More specifically to: 

• Identify risk factors for diarrhea among under 5 children      presenting at NAUTH Nnewi Anambra state

• Ascertain the effects of selected environmental, socio-demographic and behavioural factors on diarrhea disease in the under 5

• Educate the masses on these identified risk factors and appropriate strategy to prevent diarrhea disease in their children

• Recommend suitable and effective measures to reduce morbidity and mortality resulting from diarrhea disease in the under 5

Study Area 

This case-control study was conducted at Nnamdi Azikiwe University Teaching Hospital (NAUTH) Nnewi, Anambra state, Nigeria. Located at the urban part of Nnewi town. NAUTH is a tertiary health-care institution. The major specialties include; Pediatrics (Nutrition and gastroenterology), Internal medicine, Surgery, Community medicine, Obstetrics and Gynecology. Nnewi is located in Anambra state in the southeastern part of Nigeria, east of River Niger and about 22km southeast part of Onitsha. Nnewi is the second largest city in Anambra state and occupies an area of approximately 1,076.9 square miles (2,789km²) with an estimate population of 391,227 [11].

Study Design and Study Population 

This is a case control study. The case study population were under 5 children diagnosed with diarrhea disease, while the control population consisted of under 5 children not diagnosed of diarrhea disease or similar gastrointestinal disease

Sample Size Determination 

X=U√[π1(1-π1) + π2(1-π2)] + √π(1-π)

(π1-π2)2

Where; u = 1.28 (where power is 90%), v = 1.96 (where significant level = 5%), π1 = Proportion of control exposed = 0.463,  π2 = Proportion of cases exposed = 0.061 [11, 12]

X=1.28√0.463(1-0.463)+0.061(1-0.061)+√0.2925(1-

0.2925)    =   11.35372

(0.463-0.061)²

0.161604

X=70, Minimum Sample size = 70

Sampling Technique 

For the cases, total population sampling was used and for the control, simple random sampling was used.

Data Collection 

Data was collected using a interviewer-administered questionnaire to the care givers of the under 5 children presenting in NAUTH. The questionnaires were distributed to consenting care givers and they were required to give the appropriate answers to the questions in the questionnaire.

Inclusion Criteria 

For the case group these included;

• Children diagnosed with diarrhea disease 

• Children under the age of 5years 

• Children with complete data on the risk factors under evaluation

For the control group, inclusion criteria were:

• Children free of diarrhea disease 

• Children of the same sex as the case study group 

• Children within the same age range as the case study group

Study limitations 

Mothers of the under 5 children used as case were not so receptive, which could be attributed to their children’s ill   health     and     the    stress      from     hospital     admission.

Ethical Considerations 

This research work received the approval and permission of Nnamdi Azikiwe University Teaching Hospital Ethics Committee (NAUTHEC) through the Head of department of Community medicine, Nnamdi Azikiwe University. The aim of the study was explained to the subjects and only those who gave their informed consent were interviewed. The caregivers were assured of utmost confidentiality to any information provided in the questionnaire and no names of the   respondents   were  recorded   in   the   questionnaires.

Data analysis 

Data obtained was analyzed using the statistical package for social sciences (SPSS). The association between the variables was calculated using appropriate risk analysis (odds ratio) and   the   test  of   significance   set  at   p<0.05.

Table 1 shows the socio-demographic characteristics of cases and control groups. Majority of the respondents live in Nnewi (67.1% of the cases and 78.6% of the control). Similarly, children 1-2 years were in the majority among the cases (94.3%) and controls (97.1%), but the gender distributions were similar. While majority of the mothers of the cases were unemployed (64.3%), the reverse was true for mothers of the control (32.9%).

Table 2 depicts sanitation practices; 96.5% and 55.7% of the cases practiced open dumping for diapers disposal and household rubbish respectively while 67.7% and 41.4% of controls   practiced   open   dumping   for   their   diapers    and household rubbish disposal respectively as well.

Table 3 shows the hygiene practices of mothers of under 5 children, evaluated from their children feeding practices and regular hand washing.

Table 4 shows that 61.4% of the cases had running water as their source of water supply,28.6% and 10% of the cases had well and rain water as the source of their water supply respectively while 74.3%, 11.4% and 14.3% of the control had running water, well and rain water as source of their water supply respectively. The table also shows that about 87.1% and 91.4% of the cases and control respectively breastfed their children.

Table 5 shows that at a confidence interval of 0.32-0.56, children whose mothers practiced poor hygiene and poor sanitation were 4 times and twice more likely to suffer diarrhea than their counterparts whose mothers practiced good hygiene (p = 0.001) and good sanitation (p = 0.002) respectively. Similarly, uneducated mothers were thrice more likely to have their children suffer diarrhea compared to the educated (p = 0.001). The same trend applied for wealth index (p = 0.002) Furthermore, older mothers were 27% more likely to have their children suffer the disease than the children of younger mothers. Also, while the practice of water chlorination for children’s use had 99% chance of protecting against childhood diarrhea (p = 0.002), children who took only filtered water were about twice more likely to come down with diarrhea when placed side by side with those who used properly treated water (p = 0.001). Again, breast fed babies had 40% higher protection against diarrhea than babies who were not breastfed (p = 0.002).

This study analyzed some common risk factors associated with diarrhea disease among the under 5 children. The risk factors included hygiene and effective hand washing practices, education of mother, wealth index of family, water related practices, sanitation, age of child and breastfeeding practices. 

Table 1: Socio-demographic characteristics of the cases and control groups

Table 2: Sanitation and refuse disposal

Table 3: Hygiene and hand washing practices

Table 4: Water-use related practices and breastfeeding

Table 5: Risk analysis for the identified common risk factors

Hygiene practice and effective hand washing were the leading associated risk factors, which was seen in 57.1% of the cases. This agreed with similar studies carried out by Nitaji et al. in Oghara Delta state and Asekun-Orimoloye et al. and Olorunda in Osun state Nigeria in which poor hand hygiene was associated with 47.5% and 81.6% respectively. The lower value obtained in the study by Nitaji et al. could be because their study was done in the urban part of the country where people were enlightened and tended to maintain a better hygiene practice than their rural counterpart. Moreover, Ifeadike et al. in two separate 2014 Nigerian cross-sectional surveys observed that food hygiene rested directly on the state of personal hygiene and habits of the food vendor and subsequently linked diarrhea disease to poor food hygiene [15,16]. This is a further indication that mothers/caregivers who do not maintain good personal hygiene while preparing their children’s meal are veritable reservoirs and sources of pathogens responsible for childhood diarrhea disease   Orimoloe et al. showed in a study that infection was caused largely by low knowledge on the role of hand washing (hygiene) leading to diarrhea infection. [17]. Also, another work by Asekun-Orimoloye et al. in Nigeria, showed a marked relationship between ineffective hand washing practices and diarrhea disease among mothers of under 5 children [14]. Some studies have revealed that  children not washing hands before meals or after defecation, mothers not washing hands before feeding children or preparing foods, children eating with their hands rather than with spoons  ,eating of cold leftovers  , dirty feeding bottles and utensils , unhygienic domestic places (kitchen, living room, yard) ,unsafe food storage, presence of animals inside the house, presence of flies inside the house were associated with risk of  diarrhea morbidity  in children [18,19].

In this study, education of mother was the second leading risk factor associated with diarrhea disease, as 57.1% of the mothers had no formal education while 42.9% had a formal education and this is similar to the findings of the study by Ntaji et al. with 46.2% of women being uneducated and 28.6% had formal education [13]. Another study in Ibadan, Nigeria in 2017 showed that there was a significant association between level of education and diarrhea status among children aged 0-24 months in Nigeria [20].  Also, the prevalence of diarrhea fell consistently as the level of maternal education increased.  It reduced from 15.5% among children of women who had no formal education to 6.4% among those whose mothers had tertiary education [20].  Also, another study done in Delta, Nigeria showed that over all, the prevalence of diarrhea among children decreased with increased level of education of their mothers [13]. By virtue of what they learnt in school, educated mothers possess more knowledge and skill about causes of diarrhea disease and what to do in order to prevent it in under 5 children.

Wealth index of the family is the third leading risk factor in this study. This result is similar to outcome of another study by Desmenuu et al. which showed a negative association between diarrhea disease and the wealth index of the family [20]. Wealth index was found to be related to the occurrence of diarrhea and more prevalent among children of women from poorer homes [20].

Water related practices is another strongly associated childhood diarrhea risk factor in this study. A statistically significant positive association was noted between diarrhea and filtration practice where this is the only means of water purification, However, for subjects who used water chlorination, the relationship was such that chlorination strongly protected against diarrhea among the children. Oloruntoba et al. and Chineke et al. in their respective Nigerian studies also showed similar relationships between water related practices and diarrhea disease [7,21]. These are pointers to the fact that filtration of water as the sole method of water purification for drinking, increases the risk of diarrhea disease while chlorination of water is protective. 

Poor sanitation practices were significantly associated with diarrhea disease in this study (p=0.002) (OR=1.76). This is similar to study done by Ntaji et al. [7] which found a positive association between poor sanitation practices (like open dumping) and diarrhea disease in children. Also, the work by Oloruntoba et al. showed that there was increased risk of diarrhea among children whose caregivers/mothers used community dumping method as against those using government waste management outfit. Also, there was increased risk of diarrhea among children with clogged drainage near or around their house with statistical association recorded between diarrhea among under 5 children and presence of breeding places for flies/insects and having animals near/around the house [7]. Sanitation obviously plays a key role in reducing diarrhea morbidity. Some sanitation factors, like indiscriminate or improper disposal of children's stool and household garbage, absence of latrine or unhygienic toilet, sharing of latrine or houses without sewage system, increase the risk for diarrhea in children [19,22,23].

Age of the child and breast-feeding practices were the other identified risk factors in this work. This study found that the children less than 24 months were significantly more likely have diarrhea than the older ones, (p=0.024) (OR=1.27). This is similar to the finding in another Nigerian study which observed that children aged 7-18 months had a higher occurrence of diarrhea disease than those below 7months and above 18months [20]. Also, Aseku-Orimoloye et al. found that all forms of diarrhea (acute watery diarrhea, acute bloody diarrhea and persistent diarrhea) were common among the under 5 aged children with incidence highest in the first 2 years of life [14]. A work done by Mumtaz et al. also showed an inverse relationship between diarrhea disease and the age of the child, that as the child’s age increased the incidence of diarrhea disease decreased [24]. This pattern could be explained by the fact that at this age, most children are exposed to contaminants through their surroundings as they crawled around. This is also the weaning period of the children and this its associated challenges. 

The result from the breastfeeding practices showed a protective relationship between diarrhea disease and breast feeding, a statistically significant value of (p=0.002) (OR=0.6) was obtained and the result is similar in the findings of works done by Morrow A.L et al. and Egenti N.B et al. which noted that the morbidity of diarrhea is lowest in exclusively breastfed children and highest in fully weaned children [19,25]. In addition, a particular risk of diarrhea is associated with bottle-feeding. The same study by Morrow et al. noted the strong protective effect of breast feeding and that high concentration of specific antibodies, cells and other mediators in breast milk reduced the risk of diarrhea following colonization with entero-pathogens [19].

The study has shown that a significant relationship exists between diarrhea disease among the under 5 and the following risk factors; Poor hygiene practices, maternal education, wealth index of the family, water related practices, sanitation, age of the child and breast-feeding practices. The respective ORs are indications of strength of association between diarrhea disease and the studied risk factors viz: that babies with poor hygiene related practices, uneducated mothers, low wealth index, the use of filtration as the only means of water treatment and poor sanitation practices, were between four-folds and two folds more likely to develop diarrhea disease than those without the risk factors, while breastfeeding appeared to be protective with OR of 0.6.

Recommendations

The following strategies are recommended in order to decrease the occurrence of diarrhea disease among under 5 children:

• Public enlightenment campaign should be carried out, emphasizing diarrhea disease as a major cause of under 5 morbidity and mortality. This will probably bring awakening of the masses to this fact and cause a positive response to reduce the risk.

• Female education should be encouraged and promoted to build the capacity of potential mothers in child care.

• Government and other stakeholders should provide adequate and proper means of refuse disposal. This will go a long way in reducing the indiscriminate use of open dumping of waste as currently practiced, thus improving sanitation and reducing the risk of diarrhea disease.

• Effective hand washing practices should be encouraged by proper sensitization of the masses via media, hospitals, schools, churches etc and its health implications, hence the need to put them into proper use.

• Women should be educated on the health importance of breastfeeding, which ranges from its benefit to the mother, the baby, the family, the society and to the world at large.

• Provision of clean water to the society, this will go a long way in the prevention of diarrhea disease in the under 5.

Further Research

The area for further research is: ‘Exploring the link between poverty and disease among children less than 5 years of age in Nigeria.

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