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Socio-Economic, Environmental, and Behavioural Factors Associated with the Occurrence of Diarrhoeal Disease Among Under-Five

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Socio-Economic, Environmental, and Behavioural Factors Associated with the Occurrence of Diarrhoeal Disease Among Under-Five SOCIO-ECONOMIC, ENVIRONMENTAL, AND BEHAVIOURAL FACTORS ASSOCIATED WITH THE OCCURRENCE OF DIARRHOEAL DISEASE AMONG UNDER-FIVE CHILDREN, MESKANENA MAREKO WOREDA, SOUTHERN ETHIOPIA. BY TEKLU MULUGETA (B.Sc.) A THESIS SUBMITTED TO THE SCHOOL OF GRADUATE STUDIES OF ADDIS ABABA UNIVERSITY IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTERS OF PUBLIC HEALTH IN THE DEPARTMENT OF COMMUNITY HEALTH MAY 2003 ADDIS ABABA DEDICATION This work is dedicated to my beloved wife Tigist Bogale whose encouragement and help gave me strength to successfully finish this MPH course. I would like also to dedicate this thesis to our son Mussie Teklu who is only two, and also to all under-five children in the study area. ACKNOWLEDGEMENTS The financial and material support for the study was obtained from Addis Ababa University, Medical Faculty, Community Health Department. I am very grateful to my advisors Drs. Abera Kumie and Nigussie Deyessa. The advice, encouragement and guidance of my advisors was so helpful to this study. Special thanks also go to Professor Yemane Berhane for his valuable comments from the initial stage of this project. The unlimited assistance of Sr. Mitike Molla, Research assistant, Butajira Rural Health Program, and W/ro. Shewbeza Yusuf, field coordinator, is very much appreciated. The enumerators and supervisors of the Butajira Rural Health Program also deserve special thanks. The hospitality and cooperation of the population of the study site in general, and the study subjects in particular are highly appreciated. My heartfelt thanks also go to Ato Wondwossen Bekele for his unreserved assistance in the process of data collection and analysis. I extend my thanks to the staff of Medical Faculty main library, Department of Community Health library and the library of World Health Organization, Ethiopia for their help in searching for relevant literatures. i TABLE OF CONTENTS Page Acknowledgements i Table of contents ii List of tables iii List of figures iv List of annex v Abstract vi Introduction 1 Literature Review 3 Objectives 15 Methods and Materials 16 Study design 16 Study area 16 Source and study population 18 Sample size determination 18 Sampling procedure 19 Data collection 20 Data quality 23 Data management and analyses 25 Operational definitions 25 Ethical consideration 26 Results 27 Discussion 50 Conclusion 58 Recommendations 59 References 60 ii LIST OF TABLES Page Table 1. Socio-economic characteristics of the study households by place of residence, Meskanena Mareko Woreda, Jan. 2003. 29 Table 2. Environmental conditions of the study households by place of residence, Meskanena Mareko Woreda, Jan. 2003. 32 Table 3. Maternal childcare and health practices by place of residence, Meskanena Mareko Woreda, Jan. 2003. 36 Table 4. Demographic and health characteristics of the index children, by place of residence, Meskanena Mareko Woreda, Jan. 2003. 37 Table 5. Households' selected socio-economic factors in relation to childhood diarrhoeal morbidity by place of residence, Meskanena Mareko Woreda, Jan. 2003. 40 Table 6. Households' environmental conditions in relation to childhood Diarrhoeal morbidity by place of residence, Meskanena Mareko Woreda, Jan. 2003. 42 Table 7. Maternal childcare and health practices in relation to childhood diarrhoeal morbidity by place of residence, Meskanena Mareko Woreda, Jan. 2003. 45 Table 8. Child demographic and health factors in relation to childhood diarrhoeal morbidity by place of residence, Meskanena Mareko Woreda, Jan. 2003. 46 Table 9. Summary of the stepwise logistic regression analysis of the relative effect of socioeconomic, environmental and behavioural factors on the prevalence of childhood diarrhoea . Meskanena Mareko Woreda, Jan. 2003. 49 iii LIST OF FIGURES Page Figure 1. Conceptual framework of potential determinants of childhood diarrhoeal morbidity. 14 Figure 2. Schematic representation of data collection process. 21 Figure 3. Distribution of childhood diarrhoeal morbidity by age group, Meskanena Mareko Woreda, Jan. 2003. 38 iv LIST OF ANNEX Page Annex 1. Map of Meskanena Mareko Woreda indicating the study sites. 64 Annex 2. Schematic representation of the sampling procedure. 65 Annex 3. The English version of the questionnaire. 66 Annex 4. The Amharic version of the questionnaire. 71 v ABSTRACT Diarrhoeal diseases are still the major cause of morbidity and mortality among children in many developing countries, including Ethiopia. There is a general agreement that the cause of child mortality and morbidity in developing countries is multi-factorial. Interaction of socio- economic, biological, behavioural and environmental factors influences the survival of children. This comparative cross-sectional study was carried out to examine the effects of socio-economic, environmental and behavioural factors that were associated with childhood diarrhoea in Meskanena Mareko Woreda, between December 2002 and January 2003. A total of 987 households that had at least one under-five child were randomly selected from the nine peasant associations and one urban kebele that are found in the Butajira Rural Health Program catchments. Information on the households' socio-economic, environmental and behavioural characteristics was collected using structured, pre-tested questionnaire. Diarrhoeal morbidity occurred in the under-five children at the time of the interview, and the subsequent 15-days was registered to determine prevalence and incidence. The findings of this study showed that the overall two-week period prevalence of diarrhoea in under-fives was 51.4%, and that of incidence 12.9 percent. The point prevalence was found to be 38.5 percent. Significant variation was observed in prevalence of diarrhoea between urban and rural areas. Children in the age group 12 – 23 were highly affected. A logistic regression analysis showed that rural children had more than five times higher odds of having diarrhoea than their urban counterparts. The odds of having diarrhoea in children who lived in households where there were two or more children were two times higher than the odds in children who lived in households where there was only one child. Also, households that vi disposed refuse indiscriminately had children who had about two times higher odds of getting diarrhoea than households that burned or disposed the refuse in a pit. Maternal diarrhoeal morbidity and current breast-feeding were also found to be significant predictors of diarrhoeal morbidity in children. From the study it is concluded that the prevalence of diarrhoea in under-five children is very high in Meskanena Mareko Woreda, especially in children who reside in rural areas, and who are younger than two years of age. Poverty, crowding and poor environmental conditions are associated with the occurrence of diarrhoea in children. Even though these problems may be alleviated by sustainable socio-economic development through integrated effort of different sectors in the long run, recommendations are forwarded considering short-term solutions. vii I. INTRODUCTION Diarrhoeal disease remains a leading cause of mortality and morbidity in children of the developing world. In developing countries, the average annual incidence rate of diarrhoea in under-fives is estimated to be 2.6 episodes. It is also estimated that there are 1000 million episodes and 3.3 million deaths occurring each year among children of under-five years of age (1). In Africa, a child experiences five episodes of diarrhoea per year, and 800,000 children die each year from diarrhoea and dehydration (2). Diarrhoea is also responsible for 25 to 75% of all childhood diseases and account for about 14% of outpatient visits, 16% hospital admissions (3). In addition to the excess mortality and morbidity, diarrhoea predisposes children to malnutrition, which makes children highly susceptible to other infections (4). In Ethiopia, morbidity reports and community-based studies have shown that diarrhoeal disease is a major public health problem that causes excess morbidity and mortality in children (4,5,6,7). Morbidity-Mortality-and Treatment (MMT) surveys conducted in Ethiopia at different times revealed five diarrhoeal episodes per child/year; and the two-week incidence rate to be 16%. The diarrhoea associated mortality rate is about 10/1000 under-five population (4,7). Studies conducted in central rural Ethiopia revealed that diarrhoea is one of the common causes of under-five mortality, accounting for about 8.4 to 27% of all deaths (8,9). Recent estimates indicate that the two-week period prevalence of diarrhoea in under-five children in Ethiopia is about 24 percent. (6). Children's health is affected by environmental conditions as well as by their family's socioeconomic status (10). Socioeconomic factors do not directly affect the risk of diarrhoea; 1 rather influence family behavior, which alter the child's exposure to pathogens and susceptibility to infection (11). Maternal practices related to hygiene, breastfeeding, sanitary food preparation and appropriate weaning practices are also potentially important determinants in the occurrence of diarrhoea in children. On the other hand, the relationship between childhood diarrhoea and parental socioeconomic, behavioral and household environmental factors was not consistent (2,10,11,12,13,14). There is a general agreement that the cause of child mortality and morbidity in developing countries is multi-factorial. The child's survival depends on the interaction of socioeconomic, biological, behavioral and environmental
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