Investigating Key Determinants of Childhood Diarrheal Incidence among Patients at Hoima Regional Referral Hospital, Western Uganda
Kateregga Joseph
Faculty of Clinical Medicine and Dentistry Kampala International University Western Campus Uganda.
ABSTRACT
This study aimed to analyze the determinants impacting diarrhea incidence among children under five at Hoima Regional Referral Hospital, Western Uganda. Through a cross-sectional investigation, quantitative data was collected via self-administered and investigator-led questionnaires utilizing digital tools such as Google Sheets for both online and offline data collection. From a randomized sample of 323 caregivers selected through convenience sampling, a diarrhea prevalence of 27.3% among children under five was observed at the time of data collection as reported by caregivers. Among the children studied, 136 (43.7%) were male, and 175 (56.3%) were female. The average age of the participants was 2 years with a standard deviation of 1.25 years. The analysis revealed higher rates of diarrhea among children aged 1 and 3 years, constituting 24 (28%) cases in each group, followed by 20 cases (24%) in the 2-year-old group. Additionally, 12 (14%) cases were reported in children aged 6-11 months, while only 5 (6%) cases were found in 4-year-olds out of the total 85 reported cases of diarrhea. Regarding breastfeeding practices, 11 (3.7%) children were breastfed 1-3 times a day, 77 (26.1%) were breastfed 3-5 times, 150 (50.8%) were breastfed 5-7 times, 34 (11.5%) were breastfed 7-9 times, and 23 (7.8%) were breastfed more than 9 times a day. The introduction of supplementary food varied with 25 (8.0%) initiated at 3-4 months, 80 (25.7%) at 5-6 months, and the majority, 181 (58.2%), introduced to supplementary food after 6 months. The study highlighted maternal occupation influencing weaning practices; 152 (48.9%) of mothers who weaned their children at 2 years were self-employed, followed by 56 (18.0%) engaged in casual labor and 36 (11.6%) in civil service. Merely 6 (1.9%) civil servant mothers, 47 (15.1%) self-employed, and 14 (4.5%) casual laborers practiced weaning at three years of age. The elevated prevalence of diarrhea (27.3%) was associated with factors such as health-seeking behavior, early introduction of supplementary foods, premature weaning, and breastfeeding frequency. Notably, exclusive breastfeeding practices were scarce, with mothers introducing other foods early and weaning their children prematurely.
Keywords: Diarrhoea, Children under five, Breastfeeding, Weaning, Supplementary foods.
INTRODUCTION
Conventionally diarrhoea is defined as frequent passage of loose or watery stool three or more times in twenty-four hours [1, 2]. Diarrhoea is commonly a sign of an infection in the intestinal tract that is caused by different bacteria, viruses, and parasitic entities. In low-resource areas, Rotavirus and Escherichia coli bacteria cause the highest incidents of diarrhea [3, 4]. Infection is more common when there is a shortage of adequate sanitation and hygiene and safe water for drinking, cooking, and cleaning [5, 6]. Acute diarrheal diseases are one of the main problems affecting children in the world, reducing their well-being and creating considerable demand for health services. Previous studies showed that diarrheal episodes cause the death of 700,000 under-five children [7]. Diarrhoea disease accounted for 4.6 Billion cases and 2.16 Million deaths worldwide in the year 2004 of which more than 50% were from low-income countries and most of the cases were children under five years [8]. In sub-Saharan Africa, diarrhoea is the primary cause of childhood morbidity and mortality [9]. Most deaths from diarrhoea occur among children less than 2 years of age living in South Asia and sub-Saharan Africa [10]. Diarrhoea causes death by depleting body fluids resulting in profound dehydration. Diarrhea can have an adverse impact on children’s growth and cognitive progress [11]. Many children’s lives can be saved through proper management of childhood diarrhea. Too many children do not receive adequate care because of the high prevalence of diarrhea in developing countries, and inadequate health infrastructures are partly responsible [10]. Diarrhoea devours micronutrients, especially minerals and vitamins. Minerals and vitamins contribute to the regulation of biological homeostasis by playing important functions [11-15]. Thus mineral and vitamin supplements are commonly added to anti-diarrhea medications.
Diarrheal disease is highly preventable, yet accounts for nine percent of all deaths among children under age five worldwide. In 2013, this translated into about 580,000 child deaths, or, on average, 1,600 children dying each day due to preventable diarrhoea. Most deaths from diarrhoea occur among children less than 2 years of age living in South Asia and sub-Saharan Africa [10]. The prevalence of diarrhoea in Uganda has remained above 20% in the past 10 years according to UDHS data. It was reported at 26% in 2006, 23% in 20ll and 20% in 2016 [17]. Children under five years are more susceptible to diarrhoea disease and the prevalence is high (43%) among children aged 6 – 11 months [5]. Studies on factors influencing diarrhoea in children under the age of five at Western Uganda are scanty. Therefore, this study was designed to determine factors influencing diarrhoea in children under the age of five attending Hoima Regional Referral Hospital Western Uganda.
Study Design
A cross-sectional study was conducted whereby quantitative data was acquired using participant self-administered questionnaires, investigator investigator-administered questionnaires.
Area of Study
This study was conducted within Hoima Regional Referral Hospital in Hoima District in Western Uganda.
Study Population
The study was focused on children below the age of five years of which their guardians were interviewed about diarrhea. The guardians in this included the children’s mothers, fathers, caretakers, or any other relative who has sufficient information on the child and the household.
Sample Size
The sample size was calculated using the formula.
Where:
n= Sample Size
p= Expected Prevalence of Diarrhea in Children Under Five (p=30%)
d= Margin of Error (d= 0.05)
z= Standard Normal deviation at 95% confidence level (1.96)
| 0.052 |
Therefore,
| 1.962x0.3(1-0.3) |
n =
n = 323
Inclusion and Exclusion Criteria
All caretakers to one or more children within the age range of 6 months to 4 years who had given informed consent were included in the study. All households found to be under the custody of elder children below the age of eighteen at the time of the study were excluded. All caretakers who did not give consent were excluded from the study.
Data collection tools.
The questionnaire used in this study was both interviewer and participant-guided to minimize bias and loss of data. The questionnaire focused on collecting demographic and descriptive data; and was divided into four main sections. Section 1 embraced an assessment of socio-demographic characteristics of both the caretaker and child which included age, sex, marital status, religious faith, tribe, level of education and occupation; Section 2 embraced respondents’ knowledge about diarrhoea; Section 3 embraced the prevalence of diarrhoea among children under five; Section 4 embraced factors associated with diarrhoea.
Training of Research Assistants
This study involved research assistants who were recruited and intensely trained prior to the study. Major criteria for recruitment included knowledge about diarrhoea and fluency in the Runyakitara language.
Pre-testing of the questionnaire.
The questionnaire used in this study was pre-tested to ensure the feasibility and acquaintance of research assistants with interview skills and questionnaire administration. Questionnaires were tested to check whether they generated the intended data and whether errors that were noted were corrected before the actual data.
Data Management
Properly filled questionnaires were checked for completeness at the end of each data collection day within the field so as to spot any missing data before leaving the field. At the end of each data collection day, all field questionnaires were handed over to the principal investigator for safe custody and all digital data collected was merged to the online database management system for saving.
Data Analysis
Data capture was done based on the dependent and independent variables of the study. The data field included the questionnaire codes in order to ensure excellent data entry. The data was entered; cleaned and analyzed using IBM Statistics SPSS 20 and graphics by Microsoft Excel.
Ethical Consideration
Informed consent was sought from participants after a thorough establishment of rapport and an explanation of the purpose of the study. This was backed up by an introductory letter from the administration of Kampala International University.
Social-demographic characteristics of the study population
A total of 323 children from the age of 6 months to 4 years were studied with a response rate of 96.3%. Table 1 below shows the distribution of the study population by demographic characteristics. The results based on the 311 respondents showed that about 136(43.7%) of the children studied were male and 175(56.3%) were female. The mean age of the study population was 2 years (with a standard deviation of 1.25 years).
Table 1: Distribution of the Study Population by Demographic Characteristics
| Characteristics | Frequency | Percentage (%) | 95% Confidence Interval | |
| Lower | Upper | |||
| Sex | ||||
| Male | 136 | 43.7 | 38.6 | 49.2 |
| Female | 175 | 56.3 | 50.8 | 61.4 |
| Age | ||||
| 6-11 Months | 55 | 17.7 | 13.5 | 22.2 |
| 1 Year | 89 | 28.6 | 23.1 | 33.8 |
| 2 Years | 60 | 19.3 | 15.0 | 23.5 |
| 3 Years | 80 | 25.7 | 20.6 | 30.9 |
| 4 Years | 27 | 8.7 | 5.5 | 12.0 |
Social Demographic characteristic of Respondents
Table 2 shows the Caretaker’s characteristics where the majority 249 (80.1%) were mothers, with a mean age of 31 years (with a standard deviation of 12 years), of which 188 mothers were married, 52 were single mothers and 9 were widowed mothers. Other caretakers included fathers who were 5(1.6%), uncles who were 6(1.9%), aunties who were 32(10.2%) others 19(6.1%) who included grandmothers and other guardians who were not close parents to the children of the study population.
Table 2: Distribution of respondents by their demographic characteristics
| Characteristics | Frequency | Percentage (%) | 95% Confidence Interval | |
| Lower | Upper | |||
| Caretaker’s Relationship to Child | ||||
| Mother | 249 | 80.1 | 75.2 | 84.6 |
| Father | 5 | 1.6 | 0.3 | 3.2 |
| Uncle | 6 | 1.9 | 0.6 | 3.9 |
| Auntie | 32 | 10.3 | 7.3 | 13.8 |
| Others | 19 | 6.1 | 3.2 | 9.0 |
| Caretaker’s Age Group | ||||
| 18-29 | 97 | 31.2 | 25.7 | 36.7 |
| 30-41 | 196 | 63.0 | 57.8 | 68.8 |
| 42-53 | 8 | 2.6 | 1.0 | 4.5 |
| 53-64 | 10 | 3.2 | 1.3 | 5.1 |
Education level and Occupation of the caretakers
The education level and occupation of the caretakers are represented below in Figure 1 and Figure 2 respectively showing that 40 caretakers attended primary school, 38 caretakers attended secondary school, 149 caretakers attended tertiary school and 84 caretakers attended university of which 70(23.0%) were casual labourers, 199(64.0%) were self-employed and 42(13.0%) being civil servants.
Breastfeeding Practice of Mothers.
Figure 3 shows the frequency of how mothers breastfeed their children per day in accordance with their education level. It is clearly shown in the figure that a total of 295 children were breastfeeding regularly with 11(3.7%) children breastfeeding for 1-3 times a day, 77(26.1%) breastfeeding for 3-5 times a day, 150(50.8%) breastfeeding for 5-7 times a day, 34(11.5%) breastfeeding for 7-9 times a day, and 23(7.8%) breastfeeding for more than 9 times a day.
Initiation of Supplementary Food to Children by Caretakers.
Figure 4 shows the number of children who are introduced to supplementary feeding at different months of age. It is depicted that 25(8.0%) children are initiated on supplementary food at the age of 3-4 months, 80(25.7%) at 5-6 months whereas 181(58.2%) who are the majority are initiated to supplementary food at above 6 months of age.
Weaning Practice of Mothers
Table 3 shows that mothers usually wean their children off breast milk at the ages of 2 and 3 years. It depicts that 244(78.5%) mothers wean their children at 2 years while 67(21.5%) mothers wean their children at 3 years of age.
Table 3: Weaning practice of mothers.
| Characteristics | Frequency | Percentage (%) | 95% Confidence Interval | |
| Lower | Upper | |||
| Weaning Age | ||||
| 2 Years | 244 | 78.5 | 74.0 | 83.0 |
| 3 Years | 67 | 21.5 | 17.0 | 26.0 |
Health Service Seeking Behavior of Respondents.
Table 4 shows the overall health service-seeking behaviour of the caretakers for their children regarding the treatment of diarrhoea. It is clearly shown that 296(95.2%) of the caretakers take their children to the health center when they develop diarrhoea whereas 15(4.8%) treat their children with local herbs at home.
Table 4: Health Service Seeking Behavior of Respondents.
| Characteristics | Frequency | Percentage (%) | 95% Confidence Interval | |
| Lower | Upper | |||
| I take him or her to the health center. | 296 | 95.2 | 92.6 | 97.4 |
| I treat him or her myself with local herbs at home. | 15 | 4.8 | 2.6 | 7.4 |
Domestic Handling of Water
Table 5 shows that the majority; 157(50.5%) of the caretakers fetch water for domestic use from the public taps supplying piped water, 124(39.9%) fetch water from the spring wells, and 30(9.6%) fetch water from the ponds; however, all the 311(100%) caretakers treat drinking by the method of boiling.
Table 5: Domestic handling of water
| Type of Water Source | Frequency | Percentage (%) | 95% Confidence Interval | |
| Lower | Upper | |||
| Pond | 30 | 9.6 | 6.4 | 12.9 |
| Spring Well | 124 | 39.9 | 34.7 | 44.8 |
| Public Tap | 157 | 50.5 | 45.7 | 55.9 |
| Do you treat water for drinking? | ||||
| Yes | 311 | 100.0 | 100.0 | 100.0 |
| If Yes. How? | ||||
| Boiling | 311 | 100.0 | 100.0 | 100.0 |
Latrine Coverage for the respondents according to different types
Figure 5 shows the distribution and possession of fecal waste disposal facilities among the respondents; 170(54.7%) had ventilated improved pit latrines,97(31.2%) had traditional pit latrines and 44(14.1%) had water-borne toilets.
Prevalence of Diarrhea.
Table 6 shows the prevalence of diarrhoea where out of the 311 children studied, 85(27.3%) children were reported to be having diarrhoea whereas 226(72.7%) children were reported not to have diarrhoea.
Table 6: Prevalence of reported diarrhoea in children under the age of five.
| Characteristic | Frequency | Percentage (%) | 95% Confidence Interval | |
| Lower | Upper | |||
| Does Your Child Pass Loose Stool? | ||||
| Yes | 85 | 27.3 | 22.4 | 31.8 |
| No | 226 | 72.7 | 68.2 | 77.6 |
Figure 6 shows the prevalence of diarrhoea in children under five with a total number of 85 children having diarrhoea accounting for 27.3% of the total study population of 311 children on which the research was conducted. With respect to different children’s ages, the figure shows that diarrhoea is mostly in children of 1 year and 3 years accounting for 24(28%) in each age group, this is followed by the age group of 2 years which has a number of 20(24%) of all children reported to have diarrhoea; Children aged 6-11months with diarrhoea are 12(14%) whereas those of 4 years were 5(6%) of the total number of children reported to have diarrhoea.
Multivariate Analysis
Table 7: Factors associated with diarrhoea in children under the age of five years.
| Predictors | Diarrhea | AOR | 95% Confidence Interval | P-Value | ||
| Yes | No | Lower | Upper | |||
| Care Taker’s Education | ||||||
| Primary | 8 | 32 | 1.000 | 0.257 | ||
| Secondary | 15 | 23 | 1.333 | 0.532 | 3.342 | 0.539 |
| Tertiary | 41 | 108 | 0.511 | 0.226 | 1.157 | 0.107 |
| University | 21 | 63 | 0.878 | 0.477 | 1.617 | 0.676 |
| Occupation | ||||||
| Casual Laborer | 18 | 52 | 1.000 | 0.830 | ||
| Self-Employed | 54 | 145 | 0.929 | 0.500 | 1.729 | 0.817 |
| Civil Servant | 13 | 29 | 0.772 | 0.331 | 1.799 | 0.549 |
| Child’s Age | ||||||
| 6-11 Months | 12 | 43 | 1.000 | 0.545 | ||
| 1 Year | 24 | 65 | 0.819 | 0.256 | 2.624 | 0.737 |
| 2 Years | 20 | 40 | 0.627 | 0.210 | 1.866 | 0.401 |
| 3 Years | 24 | 56 | 0.462 | 0.151 | 1.418 | 0.177 |
| 4 Years | 5 | 22 | 0.535 | 0.181 | 1.585 | 0.259 |
| Child’s Sex | ||||||
| Male | 39 | 97 | 1.000 | |||
| Female | 46 | 129 | 0.947 | 0.566 | 1.586 | 0.837 |
| Health Service Seeking | ||||||
| I treat him/her at home with local herbs | 8 | 7 | 1.000 | 0.796 | ||
| I take the child to the Health Centre | 77 | 219 | 3.250 | 1.141 | 9.262 | 0.027 |
| When do you normally Introduce Supplementary feeding to your children? | ||||||
| 3-4 Months | 12 | 13 | 0.536 | 0.211 | 1.363 | 0.191 |
| 5-6 Months | 29 | 51 | 0.290 | 0.120 | 0.700 | 0.006 |
| Above 6 months | 36 | 145 | 0.444 | 0.244 | 0.807 | 0.008 |
| Weaning Age | ||||||
| 2 Years | 67 | 177 | 2.570 | 0.267 | ||
| 3 Years | 18 | 49 | 0.857 | 0.452 | 1.624 | 0.636 |
DISCUSSION
Prevalence of Diarrhea
This study was a cross-sectional study that focused on the determination of factors influencing diarrhoea in children under the age of five attending Hoima Regional Referral Hospital. The study showed that the overall prevalence of diarrhoea among children under five was 27.3% at the instant of data collection based on the responses given by the children’s caretakers. This prevalence was shown to be significantly associated with a number of factors including health service-seeking behaviour, weaning age, breastfeeding practices, and initiation of supplementary feeding which showed the highest odds of influencing diarrhoea in children under the age of five. The significance of these variables was computed using Pearson’s correlation of with health service-seeking behaviour being significant with a value of 0.139*(P=0.021); frequency of breastfeeding being significant with a value of 0.286* (P=0.000); health service-seeking behaviour was shown to be significant with a value of 0.131*(P=0.021) with a 2 tailed test at 95% confidence level, P<0.05. The prevalence of diarrhoea among children under five in Agago district was 27.3% (CI: 0.353– 0.454). This is higher than the 23% diarrhoea prevalence in Uganda and the 24% prevalence in northern Uganda [17]. The high prevalence of diarrhoea within two weeks is comparable with studies carried out in Uganda by Bbaale [18] and Mbonye ([19]. These two studies also reported diarrhoea prevalence above the national rate at 32% and 40.3% respectively [5]. It is widely recognized that diarrhoea is a major cause of morbidity and mortality among children, especially children in developing countries. Low socio-economic status, limited education, poor environmental sanitation, and low hygienic practices pose a serious threat to people’s health, especially children’s health. The presence of other factors live HIV/AIDs, poor nutrition, malaria heighten the risk to diarrhea [20-25]. Risk factors for diarrhoea vary with the child’s age, the pathogens involved, and the local environment [26].
Maternal age is positively associated with diarrhea in children. The older the mother, the less likely children under 5 years old will have diarrhea. The mother’s education level is also positively related to the occurrence of diarrhea in children under 5 years old: the higher the mother’s education level, the higher the child’s risk of experiencing diarrheal episodes [27]. In this study, there was no significant difference in diarrhea incidence by child gender. This is in tandem with a similar finding study by Bernard [5].
CONCLUSION
The prevalence of diarrhoea in children under five is high (27.3%). Factors including health service-seeking behaviour, the introduction of supplementary foods to children at early ages, weaning children at early ages, and frequency of breastfeeding per day influence this prevalence. Mothers do not practice exclusive breastfeeding, however, they introduce their children to other foods at a very early age coupled with early weaning of children.
Recommendations
More efforts are needed to educate mothers about appropriate health services so that they seek specialized health care in properly equipped health facilities staffed by trained medical staff. All mothers need to be informed about the dangers of diarrhea and how to prevent it immediately after giving birth in a medical facility.
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CITE AS: Kateregga Joseph (2023). Investigating Key Determinants of Childhood Diarrheal Incidence among Patients at Hoima Regional Referral Hospital, Western Uganda. INOSR Experimental Sciences 12(3):1-14. https://doi.org/10.59298/INOSRES/2023/1.1.12322