|ORIGINAL RESEARCH ARTICLE
|Year : 2018 | Volume
| Issue : 1 | Page : 29-33
Prevalence of diarrhoea and related risk factors among children aged under 5 years in Sana'a, Yemen
Mabrook Aidah Bin Mohanna, Naijla Al-Sonboli
Department of Paediatrics, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a, Yemen
|Date of Web Publication||29-Mar-2018|
Asso. Prof. Mabrook Aidah Bin Mohanna
Department of Paediatrics, Faculty of Medicine and Health Sciences, Sana'a University, Sana'a
Source of Support: None, Conflict of Interest: None
Background: Diarrhoeal disease is one of the most common problems affecting children across the world. This study assessed the prevalence of diarrhoea and related risk factors among children aged <5 years. Methods and Material: A cross-sectional study was conducted over 8 months at Sam Specialized Paediatric Centre and Al-Mamoon Diagnostic Medical Centre, Yemen, involving 1570 children aged <5 years with diarrhoea. Detailed data regarding age, sex, diarrhoeal episodes, family size, education level of mother or female caregiver, breastfeeding and weight were collected. Results: Of 5400 patients seen for different causes, 1570 patients were children aged <5 years presenting with diarrhoea, giving a prevalence of 29.07%. A total of 850 children were boys and 720 were girls, with ages ranging from 6 to 60 months. There were 1325 children aged <12 months, 160 aged 1–2 years and 85 aged 3–5 years. There were 700 (44.59%) children from small families and 870 (55.41%) from large families. A total of 922 (58.73%) children were malnourished and 648 (41.27%) were not. There were 1125 (71.66%) children whose mothers or female caregivers had no or low-level formal education and 445 (28.34%) whose mothers or female caregivers had secondary or high-level education. A total of 651 (41.46%) children were breastfed, 735 (46.82%) were mixed fed and 184 (11.72%) were bottle-fed. Conclusion: The prevalence of diarrhoea in children was high; it was highest in those who were aged <12 months, from a large family, malnourished and not exclusively breastfed, and in those whose mother or female caregiver had no or low-level education. It is important to encourage family planning, a balanced diet, exclusive breastfeeding and maternal education, and to strengthen health intervention programmes, in order to reduce the incidence of diarrhoea.
Keywords: Children below 5 years, diarrheal disease, risk factors, Yemen
|How to cite this article:|
Bin Mohanna MA, Al-Sonboli N. Prevalence of diarrhoea and related risk factors among children aged under 5 years in Sana'a, Yemen. Hamdan Med J 2018;11:29-33
|How to cite this URL:|
Bin Mohanna MA, Al-Sonboli N. Prevalence of diarrhoea and related risk factors among children aged under 5 years in Sana'a, Yemen. Hamdan Med J [serial online] 2018 [cited 2019 Jun 26];11:29-33. Available from: http://www.hamdanjournal.org/text.asp?2018/11/1/29/228861
| Introduction|| |
Diarrhoeal disease is the principal cause of mortality and morbidity in children aged <5 years in developing countries. It is the second leading cause of death in developing countries where it is responsible for 1.7 million child morbidities and 760,000 child mortalities every year., Diarrhoeal disease is one of the most common problems affecting children in the world. It can cause malnutrition, stunted growth and reduced well-being. It can affect intellectual development, leading to significantly lower than average scores in intelligence tests in children aged <5 years and creates a considerable demand for health services.,,
Diarrhoea is defined as the passage of three or more loose or liquid stools per day, or more stools than is normal for the individual. Diarrhoea results from infection of the intestinal tract by any of a variety of viruses, bacteria, or parasites; it is often acquired directly from another infected person or from food or water that has been contaminated by stools.
In Yemen, intestinal parasite diseases are a serious health problem, with a prevalence ranging from 18% to 27%. Promotion of better eating practices, vaccination against rotavirus and Vitamin A and/or zinc supplementation are effective in reducing the incidence of diarrhoea. Exclusive breastfeeding for at least the first 6 months of an infant's life protects against diarrhoeal disease. Clinical health professionals, public health professionals and communities must work together to develop diagnostic, treatment and prevention methods to reduce diarrhoeal morbidity and mortality.,,,, Oral rehydration solutions of sodium, potassium and glucose should be taken for rehydration if patients can consume the required volumes; if not, appropriate intravenous fluids should be used. The aim of the study was to assess the prevalence of diarrhoeal disease and related risk factors among children aged <5 years presenting at Sam Specialized Paediatric Centre and Al-Mamoon Diagnostic Medical Centre, Sana'a, Yemen.
| Methods|| |
A cross-sectional study was carried out at Sam Specialized Paediatric Centre and Al-Mamoon Diagnostic Medical Centre from 1st January to 31st August 2015. The centres offer services to the community through outpatient clinics and receive patients from Sana'a, neighbouring areas and occasionally from other governorates, including referred cases from private clinics.
Sample size and collection
The sample comprised 1570 children of both sexes aged <5 years presenting with diarrhoea. All mothers or female caregivers whose children presented with diarrhoea were interviewed. Detailed information regarding age, sex, weight, episodes of diarrhoea, family size, educational status of mother or female caregiver and breastfeeding was collected.
All children aged <5 years presenting with diarrhoea were included in this study. The children were divided into three age groups (<12 months, 1–2 years and 3–5 years) for assessment of the prevalence of diarrhoeal disease in each group. Diarrhoeal disease was defined as a passage of three or more loose or watery stools per day. The ages of the children were obtained from their caregivers, birth certificates, immunisation cards and other available medical records. Large families were defined as families including five or more dependent children and small families had fewer than five dependent children. Mothers or female caregivers with no or low-level formal education were those who had no education or had not completed primary school and those with secondary or high-level education were educated to secondary school level or above. Children who were breastfed were those who were fed exclusively on breast milk from birth to 6 months of age; children who were mixed fed were those fed on both breast milk and milk formula from birth and bottle-fed children were those fed exclusively on milk formula from birth. Weight was measured with the child wearing minimal clothing and in bare feet using an RGZ-20 infant weighing scale (Hangzhou Tianheng Technology Co. Ltd, Hangzhou, China) for children aged <2 years and an RGZ health scale (Shanghai Maney Medical Technology Co. Ltd, Shanghai, China) for children aged ≥2 years. Nutritional status was evaluated on the basis of expected weight by age: children were considered malnourished when their weight was below the normal range for their age (<80%).
Patients on antibiotics or with insufficient information were excluded.
Ethics approval and consent
The study was approved by the Medical Corporation of Sam Specialized Paediatric Centre and Al-Mamoon Diagnostic Medical Centre. Verbal consent was obtained from the parents and caregivers of children who participated in the study.
The collected data were processed manually using a Chi-squared test to determine the significance of differences between variables, which were considered statistically significant at P < 0.05. The results were recorded in tables as frequencies and percentages.
| Results|| |
Over an 8-month period, 5400 patients were seen for different reasons; of these, 1570 were children aged <5 years presenting with diarrhoea, giving a prevalence of 29.07%. A total of 850 were boys and 720 were girls, with ages ranging from 6 to 60 months. There were 1325 children aged <12 months, 160 aged 1–2 years and 85 aged 3–5 years [Table 1]. There were 700 (44.59%) children from small families and 870 (55.41%) from large families. A total of 922 (58.73%) children were malnourished and 648 (41.27%) were not. There were 1125 (71.66%) children whose mothers or female caregivers had no or low-level formal education and 445 (28.34%) whose mothers or female caregivers had secondary or high-level education. A total of 651 (41.46%) children were exclusively breastfed, 735 (46.82%) were mixed fed, and 184 (11.72%) were bottle-fed. Episodes of diarrhoea were seen to be significantly associated with children who were aged <12 months, from a large family, malnourished, not exclusively breastfed and with those whose mother or female caregiver had no or low-level education [Table 2].
|Table 1: The prevalence of diarrhoea by sex and age in children aged <5 years in Sana'a (n=1570)|
Click here to view
|Table 2: Relationship between prevalence of diarrhoea and related risk factors (family size, nutritional status, education level of mother or female caregiver and breastfeeding) in children aged <5 years in Sana'a (n=1570)|
Click here to view
| Discussion|| |
Diarrhoeal disease is still one of the most significant causes of morbidity and mortality in developing countries., In this study, the prevalence of diarrhoeal disease among children aged <5 years was 29.07%. This is higher than in many studies; for example, Yilgwan and Okolo. reported a prevalence of 2.7%, Yilgwan and Okolo  reported a prevalence of 10.3% and Bezatu Mengistie  reported a prevalence of 22.5%, and the prevalence rates observed in studies carried out in Sudan  and India were also lower. However, the prevalence we found is still lower than that reported by Diouf et al. (32.6%) and Mohammed and Tamiru  (30.5%). These differences in the prevalence of diarrhoea could be attributed to many factors. For example, diarrhoeal diseases are more common in low-income countries than in middle- and high-income countries. In developing countries, including Yemen, mortality and morbidity rates from diarrhoeal diseases in children aged <5 years are high and represent a public health problem.,,, Diarrhoea can be caused by many types of virus, bacteria and parasites, and infection is often acquired directly by contact with another infected individual or by consuming food or water that has been contaminated by stools. Yemen depends entirely on ground and rain water, and only 25% of the population have easy access to safe water.
In this study, 54.14% of children found to have diarrhoeal disease were boys and 45.86% were girls, which is a similar result to the results of studies carried out by Bahartha and AlEzzi  and Yilgwan and Okolo, but differs from the results of studies by Kolahi et al. in Iran, Shah et al. in Pakistan and Gascón et al. in Tanzania. There is no current explanation for this, although it was noted that several families in Yemen prefer boys to girls, which could affect caregiving.
In this study, the prevalence of diarrhoea decreased with increasing age: children aged <12 months (n = 1325) formed the largest group presenting with diarrhoea, followed by those aged 1–3 years (n = 160) and then those aged 3–5 years (n = 85). This is similar to a number of other studies that found that the prevalence of diarrhoea was greater in children aged <12 months than in children of other age groups.,,, This could be because a large proportion of children with diarrhoea in this age group (<12 months) were not exclusively breastfed or were introduced at an early stage to complementary feeds, increasing the likelihood of diarrhoea. Exclusive breastfeeding for at least the first 6 months of an infant's life protects against diarrhoeal diseases because maternally acquired antibodies enhance children's physiological resistance to diseases. The early introduction of complementary feeds may increase the risk of diarrhoea because of the potential contamination of feeds. Among children aged 1–2 years and 3–5 years, the most common causes of diarrhoea are likely to be consumption of contaminated feed or water and inadequate personal hygiene or sanitation. In this study, 922 (58.73%) children with diarrhoea were malnourished and below the expected weight for their age and 648 (41.27%) were not malnourished. The consequences of malnourishment in children are many including increased vulnerability to infection and diarrhoea, impaired development, increased mortality and reduced well-being., Malnourished children have low immunity and are more susceptible to infection, including diarrhoeal disease. Recurrent or chronic diarrhoeal disease can result in malnutrition and, in children under 2 years of age, can lead to permanent impairment of physical and mental development, including stunted growth and delayed intellectual development., Breastfeeding exclusively until the age of at least 6 months, then introducing feed in addition to breast milk between 6 months and 2 years, improves outcomes by decreasing rates of malnutrition and mortality.,
This study found that diarrhoea was more common in children whose mothers or female caregivers had no or low-level education. This is in agreement with many studies: Dikassa et al. in Congo, Ekanem et al. in Lagos, Nigeria, and Mohammed and Tamiru  in Ethiopia. Therefore, it is essential to educate mothers or female caregivers in hygiene, the care for sick children and when to seek medical assistance.,,,, For example, in some areas in Yemen, many illiterate mothers resort to traditional treatments in an attempt to stop diarrhoea, including abdominal cautery or tying a piece of cloth around the abdomen. In Sudan, illiterate mothers resort to traditional remedies such as gum cautery.
This study found that diarrhoea was more common among children from large families (five or more dependent children) than among children from small families (fewer than five dependent children). This may be because infective diarrhoeal agents are more likely to be transmitted from person to person in large families. Mothers in large families may also face more difficulties when caregiving, particularly in the areas of hygiene and meeting their children's daily food requirements, increasing the risk of malnutrition and diarrhoea in their children.
This study found that diarrhoea was more common among children who were not exclusively breastfed. Breastfeeding is the ideal method of infant feeding. The American Academy of Pediatrics recommends exclusive breastfeeding for about 6 months, followed by continued breastfeeding and complementary foods for ≥1 year.
| Conclusion|| |
Evaluation of the nutritional status of participants was based only on expected weight for age, rather than weight for age, height for age, or similar. However, expected weight for age is frequently used as a measure of nutritional status and has the advantage of being somewhat more practical, given the ease of weighing a child. Assessing malnutrition grades, Ghai et al. reported that malnourished children weighed <80% of their expected weight for age. The results of this study promote exclusive breastfeeding, maternal education and family planning as means to reduce diarrhoeal disease. This study should encourage further research in this area and encourage planners and programme managers in Yemen to improve infrastructure and the health care system.
The prevalence of diarrhoea in children is high; it is highest among those aged <12 months, from a large family, malnourished, not exclusively breastfed and whose mother or female caregiver has no or low-level education. It is important to encourage exclusive breastfeeding, a balanced diet, maternal education and family planning and to strengthen health intervention programmes, in order to reduce the incidence of diarrhoea.
We would like to thank all the children, their caregivers, the data collectors and the laboratory technicians who participated in and contributed to this study. We would also like to thank Dr. Afrah Al Gadri for her valuable participation in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gebru T, Taha M, Kassahun W. Risk factors of diarrhoeal disease in under-five children among health extension model and non-model families in Sheko district rural community, Southwest Ethiopia: Comparative cross-sectional study. BMC Public Health 2014;14:395.
Bowen A, Agboatwalla M, Luby S, Tobery T, Ayers T, Hoekstra RM, et al.
Association between intensive handwashing promotion and child development in Karachi, Pakistan: A cluster randomized controlled trial. Arch Pediatr Adolesc Med 2012;166:1037-44.
Rodríguez L, Cervantes E, Ortiz R. Malnutrition and gastrointestinal and respiratory infections in children: A public health problem. Int J Environ Res Public Health 2011;8:1174-205.
Grantham-McGregor SM, Walker SP, Chang S. Nutritional deficiencies and later behavioural development. Proc Nutr Soc 2000;59:47-54.
Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev 2012;(8):CD003517. doi: 10.1002/14651858.CD003517.pub2.
Black RE. Zinc deficiency, infectious disease and mortality in the developing world. J Nutr 2003;133 Suppl 5:1485-9.
Bhutta ZA, Black RE, Brown KH, Gardner JM, Gore S, Hidayat A, et al.
Prevention of diarrhea and pneumonia by zinc supplementation in children in developing countries: Pooled analysis of randomized controlled trials. Zinc Investigators' Collaborative Group. J Pediatr 1999;135:689-97.
Mayo-Wilson E, Imdad A, Herzer K, Yakoob MY, Bhutta ZA. Vitamin A supplements for preventing mortality, illness, and blindness in children aged under 5: Systematic review and meta-analysis. BMJ 2011;343:d5094.
Chhagan MK, Van den Broeck J, Luabeya KK, Mpontshane N, Bennish ML. Cost of childhood diarrhoea in rural South Africa: Exploring cost-effectiveness of universal zinc supplementation. Public Health Nutr 2014;17:2138-45.
Wittenberg DF. Management guidelines for acute infective diarrhoea/gastroenteritis in infants. S Afr Med J 2012;102:104-7.
Ghai OP, Gupta P, Paul VK, editors. Nutrition and macronutrient disorders. In: Essential Pediatrics. 6th
ed. New Delhi: CBS; 2005. p. 93-118.
Yilgwan CS, Okolo SN. Prevalence of diarrhea disease and risk factors in Jos University Teaching Hospital, Nigeria. Ann Afr Med 2012;11:217-21.
] [Full text]
Mengistie B, Berhane Y, Worku A. Prevalence of diarrhea and associated risk factors among children under-five years of age in Eastern Ethiopia: A cross-sectional study. Open J Prev Med 2013;3:446-53.
Ahmed IS, Eltom AR, Karrar ZA, Gibril AR. Knowledge, attitudes and practices of mothers regarding diarrhoea among children in a Sudanese rural community. East Afr Med J 1994;71:716-9.
Shah SM, Yousafzai M, Lakhani NB, Chotani RA, Nowshad G. Prevalence and correlates of diarrhea. Indian J Pediatr 2003;70:207-11.
Diouf K, Tabatabai P, Rudolph J, Marx M. Diarrhoea prevalence in children under five years of age in rural Burundi: An assessment of social and behavioural factors at the household level. Glob Health Action 2014;7:24895.
Mohammed S, Tamiru D. The burden of diarrheal diseases among children under five years of age in Arba Minch district, Southern Ethiopia, and associated risk factors: A cross-sectional study. Int Sch Res Notices 2014;2014:654901.
Bahartha AS, AlEzzi JI. Risk factors of diarrhea in children under 5 years in Al-Mukalla, Yemen. Saudi Med J 2015;36:720-4.
Kolahi AA, Nabavi M, Sohrabi MR. Epidemiology of acute diarrheal diseases among children under 5 years of age in Tehran, Iran. Iran J Clin Infect Dis 2008;3:193-8.
Gascón J, Vargas M, Schellenberg D, Urassa H, Casals C, Kahigwa E, et al.
Diarrhea in children under 5 years of age from Ifakara, Tanzania: A case-control study. J Clin Microbiol 2000;38:4459-62.
Dessalegn M, Kumie A, Tefera W. Predictors of under-five childhood diarrhea: Mecha District, West Gojam, Ethiopia. Ethiop J Health Dev 2012;25:192-200.
Asfaw M, Wondaferash M, Taha M, Dube L. Prevalence of undernutrition and associated factors among children aged between six to fifty nine months in Bule Hora district, South Ethiopia. BMC Public Health 2015;15:41.
Schlossberg D. Clinical Infectious Disease. Cambridge: Cambridge University Press; 2008.
Guerrant RL, Schorling JB, McAuliffe JF, de Souza MA. Diarrhea as a cause and an effect of malnutrition: Diarrhea prevents catch-up growth and malnutrition increases diarrhea frequency and duration. Am J Trop Med Hyg 1992;47:28-35.
Bhutta ZA, Das JK, Rizvi A, Gaffey MF, Walker N, Horton S, et al.
Evidence-based interventions for improvement of maternal and child nutrition: What can be done and at what cost? Lancet 2013;382:452-77.
Dikassa L, Mock N, Magnani R, Rice J, Abdoh A, Mercer D, et al.
Maternal behavioural risk factors for severe childhood diarrhoeal disease in Kinshasa, Zaire. Int J Epidemiol 1993;22:327-33.
Ekanem EE, Akitoye CO, Adedeji OT. Food hygiene behaviour and childhood diarrhoea in Lagos, Nigeria: A case-control study. J Diarrhoeal Dis Res 1991;9:219-26.
Levine OS, Levine MM. Houseflies (Musca domestica
) as mechanical vectors of shigellosis. Rev Infect Dis 1991;13:688-96.
Anonymous. Breastfeeding and the use of human milk. Pediatrics 2012;129:e827-41.
[Table 1], [Table 2]