Table of Contents  

Mohanna and Al-Sonboli: Prevalence of diarrhoea and related risk factors among children aged under 5 years in Sana’a, Yemen

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.1,2 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.35

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.6 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.2

In Yemen, intestinal parasite diseases are a serious health problem, with a prevalence ranging from 18% to 27%.7 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.812 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.13 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.

Method

A cross-sectional study was carried out at Sam Specialized Paediatric Centre and Al-Mamoon Diagnostic Medical Centre from 1 January to 31 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.

Inclusion criteria

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, immunization cards and other available medical records. Large families were defined as families including five or more dependent children; 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; 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; 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 (Shanghei Maney Medical Technology Co. Ltd, Shanghei, 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%).14

Exclusion criteria

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.

Statistical methods

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 a P-value of < 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)

Characteristic na % P-valueb
Prevalence of diarrhoea 1570 29.07
Sex < 0.0003
 Male 850 54.14
 Female 720 45.86
Age < 0.0001
 < 12 months 1325 84.4
 1–2 years 160 10.19
 3–5 years 85 5.41

a The total number of patients seen for different causes was 5400.

b The result is significant at P < 0.05.

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)

Variable n % P-valuea
Family size < 0.0001
 Five or more dependants (large family) 870 55.41
 Fewer dependants (small family) 700 44.59
Nutritional status < 0.0001
 Normal 648 41.27
 Malnourished 922 58.73
Education of mother or female caregiver < 0.0001
 No or low-level formal education 1125 71.66
 Secondary and high-level education 445 28.34
Feeding < 0.0001
 Breastfed 651 41.46
 Mixed fed 735 46.82
 Bottle fed 184 11.72

a The result is significant at P < 0.05.

Discussion

Diarrhoeal disease is still one of the most significant causes of morbidity and mortality in developing countries.1,2 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 et al.15 reported a prevalence of 2.7%, Yilgwan et al.16 a prevalence of 10.3% and Bezatu Mengistie17 a prevalence of 22.5% and the prevalence rates observed in studies carried out in Sudan18 and India were also lower.19 However, the prevalence we found is still lower than that reported by Diouf et al.20 (32.6%) and Mohammed and Tamiru21 (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.1,2,15,22 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.2 Yemen depends entirely on ground and rain water, and only 25% of the population have easy access to safe water.7

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 AlEzzi22 and Yilgwan et al.,16 but differs from the results of studies by Kolahi et al.23 in Iran, Shah et al.19 in Pakistan and Gascón et al.24 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.17,18,22,25 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.21 The early introduction of complementary feeds may increase the risk of diarrhoea because of the potential contamination of feeds.18 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.22 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.4,26 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.27,28 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.2,29

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.30 in the Congo, Ekanem et al.31 in Lagos, Nigeria, and Mohammed and Tamiru21 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.11,12,16,17,32 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.17

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.33

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.14 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.

Acknowledgements

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 like also to thank Dr Afrah Al Gadri for her valuable participation in this study.

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