THE PREVALENCE OF DIARRHOEA AMONG CHILDREN IN APO RESETTLEMENT

ABSTRACT

Introduction: Diarrhoea is the fourth leading cause of death among children under five in the world with the highest number of deaths in Sub-Saharan Africa. In Nigeria, diarrhoea is number six among the top ten causes of under five years’ morbidity and mortality. Apo resettlement has witnessed a constant increase in diarrhoea cases among under five in the last three years. It is therefore important to identify factors associated with the increasing number of diarrhoea cases to revert the trend.

Objectives: This study was set out to estimate diarrhoea prevalence and identify factors associated with the increasing cases of diarrhoea among children under five years in Apo resettlement.

Method: A cross sectional study was conducted with the aid of a structured questionnaire developed in English and translated in Luo language. A total of 812 mothers/caregivers were randomly sampled from the population within the district using multistage sampling technique. Modified Poisson Regression method with cluster robust standard errors for univariable and multivariable analysis was used. The outputs are stated in prevalence rate ratios (PRR), 95% confidence intervals (CI) and P-values. Variable Inflated Factor (VIF) was used to assess for multicollinearity among the factors at multivariable analysis.

Results: The prevalence of diarrhoea in Apo resettlement within two weeks prior to the survey was 40.8%. The study noted that 22.7% of the mothers did not give any liquid and 17.8% did not give food to their children with diarrhoea, an indication of a knowledge gap in diarrhoea management practices. The number of under five children in a household was statistically associated with diarrhoea. The prevalence of childhood diarrhoea was 17% less in households with one child compared to households with three or more children under five (P<0.008 CI:

0.046 – 0.312). Other factors associated with diarrhoea in children under five in Apo resettlement includes; open defecation, distance to water point and health education on diarrhoea management and prevention. Childhood diarrhoea was 33% less in households who defecates in latrines compared to households who defecates in open (P<0.001, CI 0.234 – 0.430) and children whose mothers received health education on diarrhoea management and prevention were 11% less likely to acquire diarrhoea compared to their counterparts (P<0.003 CI: 0.038 – 0.187). The study also noted that childhood diarrhoea prevalence was 11% less among households who moves less than 501 metres compared to households who moves more than one kilometres from home to the nearest water source (P<0.012 CI: 0.026 – 0.212)

Conclusion: The prevalence of diarrhoea in Agago was still high (40.8%) compared to the national prevalence rate (20%). This study underscores the importance of mothers’ knowledge on diarrhoea prevention and management, having few number of under five children in a household, proper disposal of faeces, and distance to water source as measures to prevent diarrhoea. Government and other stakeholders should therefore strengthen the provision of health education services, increase access to safe water sources by drilling more boreholes and implement Community Led Total Sanitation (CLTS) to revert the trend of diarrhoea in the district.

CHAPTER ONE

INTRODUCTION

BACKGROUND

Diarrhoea is one of the major public health concerns worldwide; the World Health Organisation (WHO) estimates that 2.5 billion cases of diarrhoea occur yearly among children under five years of age. The same report further indicates that nearly three quarters of child deaths are due to diarrhoea. In 2015, it was reported that 16,000 children under five die every day from mostly preventable causes such as pneumonia, diarrhoea and Malaria (MDG 2015), 80% of these cases are in Africa and South Asia (46% and 38% respectively). Nigeria was ranked number 9 among these countries with 29,000 deaths due to diarrhoea. According to AHSPR (2013), diarrhoea is number six among the top ten causes of under five years morbidity and mortality in Nigeria, its accounts for 3.4% of under five year mortality. AHSPR 2013 report further shows an increase in the trend from 1.84% in 2011 to 3.4% in 2013. Overall, these children experience an average of 3.2 episodes of diarrhoea per child per year.

Demographic and Health Survey (UDHS 2011) conducted by Nigeria Bureau of Statistics (UBOS) indicate that 23% of children under five years of age had diarrhoea in Nigeria. The prevalence was 20% in 2016 according UBOS. Northern region where Apo resettlement is located recording 24% prevalence, slightly above the national rate. Apo resettlement in particular has recorded the highest number of diarrhoea cases in the region in the year 2015. The trend in Agago shows a constant increase in the number of children under five years who had diarrhoea in the past three years. The cases increased from 10,962 cases in 2013 to 12,861 cases in 2014 and now to 16,663 cases in 2015. Almost half (750) of these cases were persistent diarrhoea (HIMS 2015). It is therefore necessary to identify associated factors leading to the increasing cases of diarrhoea in the district. The study was conducted to generate information and inform

the development of an appropriate programme with an aim of reducing the number of diarrhoea cases in the district.

Many studies (Anthony 2014, Lofgren 2012, Nakawesi 2010, Ssenyonga 2009 and Bbaale 2011) have been done in the country to investigate factors associated with diarrhoea and few were conducted in Agago during the time of insurgency when people were still living in the internally displaced people’s camp. The situation has greatly changed since most of the population have moved and are settled in their original homes. They live in different social, health and economic contexts from when they were in the internally displaced camps. There has been no study conducted on diarrhoea in children under five in the district under this new context. This study will help to determine the current diarrhoea prevalence, level of knowledge on diarrhoea management and prevention and identify associated factors associated with the increasing cases of diarrhoea among children under five years of age in Apo resettlement.

   : STATEMENT OF THE PROBLEM

Northern Nigeria is among the regions with the highest prevalence of diarrhoea in the country. Apo resettlement has recorded a persistent increase in cases of diarrhoea in the past three years from 10,962 in 2013 to 12,861 in 2014 and 16,663 in 2015 (HMIS). 750 of these cases were persistent diarrhoea an increase from 662 cases reported in 2014. The incidence varies greatly with seasons and a child’s age; highest in rainy season and among children aged 6-11 months (UDHS 2011). These children experience on average 3.2 episodes of diarrhoea within a year (AHSPR 2013). Studies conducted in Nigeria by Bbaale 2011, Mbonye 2004, Anthony 2014 and Ssenyonga 2009 pointed out that diarrhoea was associated with malnutrition, HIV/ADIS, water source and absence of latrine respectively. Other studies (Bezatu 2013 and Sinmegan 2014) outside Nigeria noted improper disposal of waste and lack of handwashing facility as factors associated with diarrhoea in children under five.

However, few studies have yet been conducted on knowledge of diarrhoea management in Nigeria (Lofgren 2012). It was noted that these few studies were majorly on knowledge, attitude, behaviour and practices and did not examine whether diarrhoea management practices were associated with diarrhoea which is intended to be address by this study. Poor diarrhoea management practices increase the risk of infection and its effect in children and in the community. It may lead to loss of functional days (miss work and miss school days), loss of income, considerable human suffering, increased burden on caregiver, weakening of general health, growth retardation weight loss in children, and eventually death (CDC 2015).

Government is focusing on ensuring access to improved water source and advocating for improved sanitation and hygiene practices, through the implementation of Demand Responsive

Approaches (DRA) to ensure sustainability of new water points and providing sanitation grant and support to NGOs for awareness creation on hygiene and sanitation in the community. This study will help to identify factors associated with the increasing cases of diarrhoea among children under five years of age in Apo resettlement. Identification of these factors will help the government and other stakeholders to develop more appropriate programmes that may lead to reduction of diarrhoea cases and ultimately contribute to reduction in child morbidity and mortality in the district and in the country.

   : STUDY JUSTIFICATION

Although factors associated with diarrhoea diseases has been widely studied in the country, no study has yet been conducted in Agago under the current context despite the constant increase in diarrhoea cases in the past three years. Factors leading to the increasing cases of diarrhoea in the district is still unknown. In addition, there are limited literatures on the level of knowledge of diarrhoea management among mothers of children under five in the district. This study will help to identify the associated factors that has led to the increasing cases of diarrhoea in the district and assess the knowledge gaps on diarrhoea management among mothers/caregivers. Identification of factors associated with diarrhoea will help the government and other stakeholders such as GOAL, UNICEF, AVSI and Mercy Corps who are working in this area, to develop more focused and appropriate programmes that shall lead to reduction of diarrhoea rate and ultimately contribute to sustainable development Goals (SDGs 2030) target 3.2 which aim at ending preventable deaths of new born and children under five 5 years of age. The findings from this study may provide ground for the formulation of policy and assist in lobbing for more resources that can be appropriately used with an aim of reducing diarrhoea cases in the district. It may also guide the allocation and prioritisation of available resources in the district.

   : CONCEPTUAL FRAME WORK

• : Description of Conceptual Frame work

Diarrhoea is associated with several factors what are interrelated. The discussion below shows the interrelatedness among the factors and how they may lead to diarrhoea in children under five. These factors are grouped under; health and demographic, water, sanitation and hygiene factors.

Social demographic factors such as education increases the caregivers’ awareness of diarrhoea preventive measures. A study conducted to assess the association between maternal education and infant diarrhoea in Cebu found that maternal education protects against diarrhoea in the more economically and socially advantage society (Molina 1994). Educated mothers are also most likely to maintain proper hygiene and sanitation at their homes, including taking their children for immunisation. WHO notes that immunisation can boost a child’s immunity, thereby enhancing the body’s ability to fight diarrhoea disease. While on the other hand, proper hygiene and sanitation practices helps reduce the spread of diarrhoea (Bezatu 2013 and Sinmegan 2014). A study by Agustina (2013) noted that children living in a house with less dirty sewage had significantly lower diarrhoea prevalence compared to those who did not. In addition, occupation and family size may grossly affect the mothers/caregivers time to attend to the needs of a child. A mother who spends 8 hours doing office works will miss the opportunity to adequately attend to her child. These mothers usually find it difficult to practise exclusive breastfeeding, hence missing out the benefits of breastfeeding on child development and growth. A systematic review on the benefits of breastfeeding on diarrhoea concluded that exclusive breastfeeding is protective against childhood diarrhoea (Bernardo 2013). Age of the mother is one of the factors associated with diarrhoea cases in children. The older women tend to have experience in caring and handing of children compared to young mothers/caregivers. There is usually less cases of diarrhoea in old and experienced mothers compared to young and inexperienced mothers. A study on knowledge of mother in management of diarrhoea noted

that the level of knowledge of mother on diarrhoea management had significant relationship with their age (Gasemi 2013). Marital status is likely to influence how decisions are made at home since married women are more likely to get support than those who are not married hence given more options to protect their children from any disease including diarrhoea.

Distance to the nearest health facility may influence an individual’s health seeking behaviours. It noted that those who visit the health centres receives health education from the health workers and are better informed on diarrhoea prevention and management than those who do not visit the health units. A study in Ethiopia by Okwaraji (2012) on effect of geographical access to health facilities on child mortality found that distance to a health centre had a marked influence on under five mortalities. A similar study in Kenya (Daniel R Feikin 2009) demonstrated that the rate of clinic visits decreases by distance. Some scholar urged that the spatial occurrence of diarrhoea disease is influenced by the concurrent presence of other infection. For instance, two studies by MacArthur (2012) and Bbaale (2011), indicates that diarrhoea is high among malnourished children and children with HIV/AIDS. It is therefore important to study the presence of any illness in children.

Sanitation and hygiene factors such as proper waste disposal, latrine use, and food hygiene may reduce contamination of food and water by diarrhoea pathogen. Maintenance of proper hygiene and practising good sanitation plays a big role in children’s health and contributes to reduction of diarrhoea among children under five years of age (Bezatu 2013 and Sinmegan 2014). Handwashing especially during critical times; before eating, after defecation/cleaning a child’s faeces, before breastfeeding a child, and after attending to animals reduces the risk of ingestion of diarrhoea disease causing pathogen by a child (Bezatu 2013).

In addition to sanitation and hygiene factors, source of drinking water and treatment of water are some of the risk factors for diarrhoea. Many scholars (Mbonye 2004, Ssenyonga 2009, Godana 2013) have noted that source of water is associated with diarrhoea. Water from unimproved or unprotected sources are prone to contamination with diarrhoea causing pathogens. Children are more likely to suffer from diarrhoea if water from these sources are used without treatment. Water can also be contaminated at various level; during collection, transportation and at storage point. To reduce on the level of contamination, water must be collected, transported and stored safely.

Community knowledge on diarrhoea prevention, causes and management is important for reduction of diarrhoea cases. Provision of more fluid and use of ORS can help prevent dehydration (WHO). In addition, WHO recommends that children with diarrhoea should drink more fluid and eat normally. Knowledge of preventive measures, causes, treatment and source of treatment is equally important in reducing the burden of diarrhoea. Mothers who are knowledgeable in these areas tend to take the right decision at the right time hence protecting their children from diarrhoea or reducing its impact on the child. A cohort study by christine (2014) on risk factors for diarrhoea in children under five in Bolivia noted that lack of caregiver awareness of the importance of practices related to hygiene and sanitation for diarrhoea prevention were significant risk factors for diarrheal disease.

   : STUDY OBJECTIVES

• : General objective

To determine the prevalence of diarrhoea and identify factors associated with the increasing number of diarrhoea cases among children under five years in Apo resettlement. Identification of these factors shall inform the development of appropriate interventions that may lead to reduction in the number of diarrhoeal cases among children under five in the district.

           : Specific objectives

• To estimate the prevalence of diarrhoea among children under five years of age in Apo resettlement
• To identify diarrhoea management factors associated with diarrhoea in children under five years of age in Apo resettlement.
• To examine water related factors associated with diarrhoea among children under five years of age in Apo resettlement.
• To measure sanitation and hygiene related factors associated with diarrhoea among children under five years of age in Apo resettlement.

           : Research Questions

What is the prevalence of diarrhoea in the past two weeks among children under five years of age in Apo resettlement?

What are the knowledge gaps on diarrhoea management practices in children under five years among mothers/caregivers in Apo resettlement?

What are the associated diarrhoea management, water, sanitation and hygiene factors associated with the increasing cases of diarrhoeal disease among children under five years of age in Apo resettlement?

THE PREVALENCE OF DIARRHOEA AMONG CHILDREN IN APO RESETTLEMENT