Prevalence of diarrhoea and associated risk factors among children under five years old in Pader District, northern Uganda

Background Diarrhoea remains a major cause of morbidity and mortality in children under 5 years in sub-Saharan Africa. Of the three East African countries, Uganda has the worst mortality rate in children < 5 years, with 22% of these deaths attributed to diarrhoea. For proper planning and implementation of control, an understanding of the prevalence and determinants of the disease is crucial. This study assessed the prevalence of diarrhoea and related risk factors among children < 5 years in Pajule Subcounty, Pader District in northern Uganda. Methods A cross-sectional survey was conducted in April 2018, covering 244 randomly selected households having children < 5 years old in the study area. A semi-structured questionnaire was used to interview the households about diarrhoeal history in their children in the last 2 weeks preceding the survey, and on the risk factors predisposing children to diarrhoeal infections. Bivariate and multivariate logistic regression analyses with a 95% confidence interval and p < 0.05 was used to identify the risk factors associated with childhood diarrhoeal disease. Results We found a prevalence of diarrhoea of 29.1% [95% CI (23.7–35.0)] among children < 5 years in Pajule Subcounty during the 2 weeks preceding the survey. Use of unprotected water sources, age of child caretaker, child weaning time and family size had significant associations with diarrhoeal morbidity. Conclusion The prevalence of childhood diarrhoea among children < 5 years of age in rural settings of Pajule Subcounty was higher than the Ugandan national average. Use of unprotected water sources, age of child caretaker, child weaning time and family size were identified as predictors of diarrhoeal occurrence. These findings underscore the need for improving access to clean water and providing community health education as the best methods for fighting childhood diarrhoea in the study area.


Background
Diarrhoea, defined as having unusually loose or watery stool that occur more frequently than usual within 24 h [1], remain among the most common causes of mortality and morbidity in children, particularly in low and middle-income countries. Worldwide, diarrhoea accounts for an estimated 3.6% of the global burden of disease, as expressed in disability-adjusted life years [2], and it is the leading killer, accounting for approximately 8% of all deaths among children < 5 years despite the availability of simple effective treatments [3]. Although the global mortality from diarrhoea has been declining over the past 25 years, the disease is still a major cause of mortality in children < 5 years of age in developing countries, contributing up to 21% of deaths [4].
In Uganda, diarrhoea is among the top four causes of morbidity in infants and young children [5]. The Uganda Demographic and Health Survey of 2016 reported that the prevalence of diarrhoea among children < 5 years in Uganda was 20% [6]. In 2017, diarrhoeal disease deaths reached 6.41% of total deaths, making the country to be ranked 27th worldwide [7]. Presently, diarrhoea still remains among the top ten causes of morbidity in the country, with rotavirus being responsible for about 40% of all diarrhoeal cases [8].
Pader District in northern Uganda was affected by the civil war between the Lord's Resistance Army (LRA) and the Uganda People's Defense Forces (UPDF) that plagued the region between the1980's and 2008. This resulted in the creation of internally displaced persons' camps (IDPs), disrupting social services delivery [9,10]. Currently, the district lags behind the rest of the country in terms of the human development indices and is characterized by high levels of poverty [11]. Infant mortality rate [IMR] in the district is standing at a staggering 180+ per 1000 live births, with acute diarrhoea accounting for 8% of such deaths [12]. Sanitation remains a challenge with only 30% of the households having unimproved toilet facilities, and about 600,000 households do not have any toilet facility at all [13]. Despite these statistics, accurate information on prevalence and factors associated with diarrhoea in the district remain virtually unknown. The current study determined the prevalence of diarrhoea and risk factors among children < 5 years old with the view to provide information that could be useful in planning interventions to reduce the burden of the disease in the district.

Study area
The study was conducted in Pajule Subcounty (2 0 56′ 23″ N and 32 0 56′ 38″ E) located in Aruu North constituency, Pader District in northern Uganda [ Fig. 1]. Pajule Subcounty consists of six parishes and has a population of 22,713, with 4050 of these being children below 5 years [11]. Like in other parts of northern Uganda, poverty level is higher than the national average, due to a combination of factors like the prolonged civil war that affected the entire northern region, cattle rustling by the Karimojong, and marginalisation that dates back to the colonial era [9]. The majority of the households derive their livelihood from subsistence farming; only 27% depend on earned income [13]. Water coverage has reduced from 57% when the population was in camps to only 38% as the communities returned to their homes [14].

Study design and data collection
A cross-sectional survey was conducted in April 2018 in four randomly selected parishes out of the six parishes in Pajule Subcounty. According to the 2014 National Housing and Population Census, Pajule Subcounty has approximately 4000 households, and so a sample size of 351 households was estimated using the Krejcie and Morgan table [15]. However, due to logistical constraints, non-response or unavailability of targeted respondents at the time of survey, we only sampled a total of 244 households. The number of households in each parish was determined using probability proportional to size, and from each parish, at least two villages were randomly selected using a random number. The list of households in each village was obtained from the respective Local Council chairpersons. Only individuals from households where the mother or caregiver was present and had a child < 5 years old were interviewed. In cases, where there were more than one child < 5 years in the same household, index child was selected by lottery method. Trained research assistants administered semistructured questionnaires based on the World Health Organization (WHO) guidelines [16]. The dependent or outcome variable was the presence of diarrhoea among children aged < 5 years within the 14 days before the survey. This was evaluated by asking the mother or caregiver if the child involved in the study had suffered from diarrhoea within 14 days before the study. Independent variables included socio-demographic, socio-economic, environmental and behavioural factors. Socio-demographic and economic characteristics included age of the child, number of children under the age of five in the household, family size, age of the child's caregiver, sex of the child, the income status of the family, and the mother's or caregiver's education level. Environmental factors included type of water source, availability of animals in the homestead, presence of animals' houses, child's stool disposal practice, availability of latrines, ownership of latrine, hand washing practices, availability of kitchen, household's environmental cleanliness, and presence of utensils' drying racks. The behavioral characteristics included source of drinking water, boiling of water before consumption, frequency of warming cold food, weaning age, and age of food supplementation.

Data analyses
Descriptive analyses using frequency and percentages were used to summarize the independent and dependent variables. To obtain the associations between diarrhoea among children and risk factors, we used multivariable logistic regression. The adjusted odd ratios [AORs] of having diarrhoea with 95% confidence interval [CIs] and P value < 0.05 were used to describe associations. First, we conducted univariate analyses to determine the associations between diarrhoea and other associated factors using chi-square and binary logistic regression. Eight variables with p-values less than 0.05 in bivariate analyses were included in the final multivariable logistic regression. All analyses were done using IBM SPSS for windows version 25.

General characteristics of study households
Of the 244 households surveyed, 11.1% of the respondents were mothers or caretakers with no formal education while the majority (68%) had primary level education (Table 1), and 20.9% had secondary education. In terms of latrine coverage, 79.9% of the households had latrines in their homesteads while 68.9% reported sharing of latrines with other nearby households. For those who had latrines, only 14.3% had hand-washing facilities erected near the latrines. The practice of disposal of children's stool was fairly well addressed with 80.7% of the respondents properly disposing of children's stool as opposed to 19.3% who disposed of tools unsafely. According to the World Health Organization [17], a child's stool is considered to be disposed of safely when he/she uses either the toilet or latrine and puts or buries the faeces in the toilet/latrine. Furthermore, majority (83.2%) of the households gave food supplements to children when aged > 6 months, and 49.2% weaned their children at the age of > 1 year. Majority (45.5%) of the respondents had a family size less than five individuals and only 63.5% of mothers/caretakers completed their immunization schedules as required ( Table 1).

Prevalence of diarrhoea and associated risk factors among children
Overall, from a total of 224 households surveyed, 29.1% [95% CI (23.7-35.0)] reported episodes of diarrhoea in children < 5 years in the two-week period prior to data collection. The diarrhoeal prevalence in males, 52% [95% CI (48.5-58.3)] and females, 48.0% [95% CI (41.7-54.2)] did not differ significantly. Age group 13-24 months appeared most vulnerable, followed by 0-12 months, and the lowest prevalence was in category 37-48 months (  (Table 1) and univariable binary logistic regression analysis ( Table  2), age of child caretaker, family size, nature of protection of drinking water source, availability of separate kitchen, child weaning time, warming of cold food, sharing of houses with domestic animals and mothers not washing hands at critical times had a p-value less than 0.05 and were further analyzed by multivariable logistic regression ( Table 2). The multiple logistic regression revealed that the only factors significantly associated to diarrhoeal morbidity among children below 5 years in Pajule Subcounty    (Table 2). Finally, children exclusively breastfed had 85% lower chance [AOR: 0.1542, 95%CI (0.034-0.595)] of diarrhoea than children who were weaned early (< 1 year).

Discussion
We assessed the prevalence and risk factors of diarrhoea among children under 5 years old in Pajule Subcounty in Pader District, northern Uganda. Overall, the mothers or caretakers reported a prevalence of diarrhoea of 29.1%, which is lower than the 40.8% reported in neighboring Agago District [18], and elsewhere in Uganda; 41.3% in Adjumani Refugee Camp in West Nile [19] and 40.3% in Sembabule District [20]. However, the reported prevalence is higher than the 20% reported for the same age group in the Uganda Demographic and Health Survey of 2016 [6]. The high prevalence of diarrhoea in Pajule Subcounty than the national average could be due to the fact that the area suffered a prolonged conflict which disrupted social services like education and health, infrastructural development, and the overall economic fabric of the society [9]. For example, 11.1% of the mothers or caretakers had no formal education, and the majority (68.0%) had stopped in the lower primary (Primary one to four). Although this was not significant in our analyses, the role of formal education cannot be under-rated, as less educated people are less likely to take their hygiene and sanitation seriously, as well as those of their children.
Our results showed that family size, the age of child caretaker, child-weaning time, nature of protection of water source had significant associations with diarrhoeal morbidity. Children whose households had 10-15 children had seven times higher odds of diarrhoea than children whose households had one child. High number of individuals in a household potentially compromises hygiene and sanitation, making children more prone to contact with diarrhoeal pathogens. In Pajule, house sizes are mostly small temporary huts where humans, and sometimes pets, occupy the limited space, further reducing cleanliness in the household.
The present study also showed that exclusively breastfed children had 85% lower chance of diarrhoea than children who were weaned early (at less than 1 year). Given the poor hand washing practices and general unhygienic conditions observed in this study, preparations of weaning foods have the potential of spreading diarrhoeal causing germs to the infants. Weaning foods prepared under unhygienic conditions are frequently heavily contaminated with pathogens and are thus a major factor in the cause of diarrhoeal diseases and associated malnutrition [21]. Our results are consistent with many previous studies that have indicated that the addition of early food supplements to infants fed under prevailing environmental conditions in developing countries lead to their increased diarrhoeal attacks and associated reduced food intake [22].
Children whose caretakers were older had 12-14 times higher odds of diarrhoea than caretakers aged less than 15 years. This finding is surprising because previous studies have shown that young mothers are associated with a higher odds of diarrhoea than older mothers [23]. This is because, older caretakers tend to have experience in taking care of children compared to their younger counterparts and hence reducing childhood diarrhoeal incidences. Our results could however be explained by the fact that the majority of mothers were in teenage age (age 16-30) ( Table 1).
Our study also showed that the risk of developing diarrhoea in children whose households use protected water sources was 68% lower compared to their counterparts who use unprotected water sources. This finding is similar with a study by [24] in Kenya who found that sources of drinking water was one of the household characteristics that had significant influence on childhood diarrhoea. However, a study conducted in southwest Ethiopia by [25] did not find any significant association of diarrhoeal occurrence and drinking water sources. Nevertheless, unprotected water sources have higher chances of fetching germs from the intruding animals or from running water carrying waste matters. In Pajule, like the rest of northern Uganda, access to safe water is a major challenge due to inadequate funding for construction of clean water sources and/or inadequate training of users in water source maintenance [26]. Due to lack of access to safe water, communities are forced to utilize unsafe sources such as streams, which requires boiling to make it safe.

Conclusions
In the current study, prevalence of diarrhoea among under-five children in the rural setting of Pajule Subcounty in Pader was found to be high (29.1%). The use of unprotected water sources, age of child caretaker, child weaning time and family size had significant associations with diarrhoeal occurrence. These are mainly household level factors that can be mitigated by provision of access to clean water and community health education to fight childhood diarrhoea in the study area.

Study limitations
Our study is prone to recall bias since it was based on respondents' recalling of diarrhoeal history in their children within the last 2 weeks preceding the survey. However, we asked the mothers to report on the diarrhoea episode within 2 weeks from the time of the interview to reduce on recall bias. Additionally, diarrhoea prevalence was based on self-reported screening and was not further confirmed. Also, being cross-sectional in design did not take into account seasonal variation in the prevalence; data was collected in April 2018, which is the beginning of the wet season in northern Uganda. Follow up studies should cater for seasonal variation as well as stool and water analysis for the diarrhoeal causal agents and contaminations.