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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 3  |  Page : 114-120

Knowledge and prevalence of diarrheal disease in a suburban community in north western Nigeria


1 Department of Community Medicine, Kaduna State University, Kaduna, Nigeria
2 Sight Savers International, Kaduna, Nigeria
3 Department of Paediatrics, Kaduna State University, Kaduna, Nigeria
4 Department of Community Medicine and Epidemiology, Benue State University, Makurdi, Benue State, Nigeria
5 Department of Community Medicine, Ahmadu Bello University, Zaria, Kaduna State, Nigeria

Date of Submission12-Sep-2018
Date of Acceptance22-Jul-2019
Date of Web Publication26-Sep-2019

Correspondence Address:
Dr. Victoria Nanben Omole
Department of Community Medicine, Faculty of Clinical Sciences, College of Medicine, Kaduna State University, PMB 2339, Kaduna
Nigeria
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DOI: 10.4103/smj.smj_50_18

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  Abstract 


Background: Diarrheal disease is the second leading cause of under-five mortality, accounting for 700,000–800,000 preventable deaths, globally. Most of these occur in rural and suburban areas of developing countries. Correct knowledge about the dynamics of the disease is crucial in arresting and reversing its prevalence. Objective: The objective of the study was to determine the prevalence of diarrheal disease in a suburban community and explore the knowledge of the disease among mothers of children <5 years of age therein. Materials and Methods: A cross-sectional, descriptive study was conducted among 350 mothers of under-fives in a suburban community. Respondents were selected by multistage sampling method and interviewed using interviewer-administered, closed-ended questionnaires. Results: About 89.4% of the respondents had correct perception of the definition of diarrhea. Over 60% of them had correct knowledge of the cause (s) of diarrheal disease, and none was ignorant of the potential complications. Both point and period prevalences for the disease were 13.14% and 30.29%, respectively, and these were relatively higher than local, regional, and national values. Conclusion: The good knowledge of diarrheal disease observed among respondents was not reflected in the unacceptably high prevalence and frequency of the disease. This may be attributable to the challenges of poor water sources and insanitary environmental conditions. Public health interventions are recommended with particular attention to environmental sanitation and water supply in suburban and rural communities.

Keywords: Diarrheal disease, knowledge, prevalence, suburban, under-five children


How to cite this article:
Omole VN, Wamyil-Mshelia TM, Aliyu-Zubair R, Audu O, Gobir AA, Nwankwo B. Knowledge and prevalence of diarrheal disease in a suburban community in north western Nigeria. Sahel Med J 2019;22:114-20

How to cite this URL:
Omole VN, Wamyil-Mshelia TM, Aliyu-Zubair R, Audu O, Gobir AA, Nwankwo B. Knowledge and prevalence of diarrheal disease in a suburban community in north western Nigeria. Sahel Med J [serial online] 2019 [cited 2019 Oct 13];22:114-20. Available from: http://www.smjonline.org/text.asp?2019/22/3/114/267899




  Introduction Top


The World Health Organization (WHO) defines diarrhea as “the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual).”[1] The condition, if persistent and/or without intervention, may lead to several complications and even death, particularly among infants and children under the age of 5 years.[1],[2],[3] Morbidities and mortalities associated with diarrheal disease arise largely due to the depletion of fluids and electrolytes essential for normal body function and survival, thus resulting in severe dehydration, electrolyte imbalances, malnutrition, and a host of other detrimental long-term sequelae such as stunting, impaired physical fitness, cognitive retardation, and poor academic performance in the long run.[1],[4] Diarrhea in most parts of the developing world is often infectious in etiology.[1],[4] Most cases are often viral in origin, with rotaviruses being majorly implicated.[1],[5]

Globally, it is estimated that about 1.7 billion episodes of childhood diarrheal disease occur annually, and over 700,000–800,000 of these cases result in preventable deaths.[1],[2],[5] Diarrheal disease is reported to be the second leading cause of deaths among children under the age of 5 years, after acute respiratory infections, particularly pneumonia; others include malaria, malnutrition, and measles.[1],[2],[4],[5],[6] Almost three-quarters of these mortalities occur in the first 2 years of life.[4],[5],[7] Thus, it constitutes a public health concern. This burden is significantly high in many parts of Asia and sub-Saharan Africa,[7] including Nigeria as compared to most parts of the world. High prevalence rates have been reported across different parts of these regions, reaching to as high as 35%, with both seasonal fluctuations and spatial variations observed. In Nigeria, north-south regional variations have been reported in the prevalence of diarrheal disease, with northern Nigeria being more severely affected.[8] The estimated childhood mortality secondary to diarrhea in Nigeria is about 151, 700–175,000 annually.[4],[9]

Most diarrhea-associated morbidities and mortalities occur in low- and medium-income countries, usually in rural areas as well as in the suburbs and slums of urban areas.[2],[3] In these settings, the incidence is further fueled by the vicious cycles of poverty, ignorance, malnutrition, and endemic and infectious diseases. Obviously, issues directly or remotely connected to socio-environmental factors such as sanitation and quality of water, unhygienic feeding practices (including hand hygiene), suboptimum breastfeeding, zinc deficiency, and barriers to appropriate and affordable health care [1],[2],[3],[5] exist as catalysts of the diarrheal disease burden among under-fives in these parts of the world.

Evidence demonstrates that globally, mortality from diarrhea has declined considerably in the last two decades.[3],[5],[6] On the contrary, both morbidity and mortality from diarrhea in sub-Saharan Africa have not,[10] as risk factors remain unacceptably high.[3] Adequate and appropriate knowledge as well as a good understanding of the underlying etiological factors and dynamics involved in the occurrence of diarrheal disease and its progression to diverse severe outcomes, complications, and mortalities are essential to its prevention.[2] The WHO recognizes health education about how diarrheal infections spread as a key component of preventive measures for both diarrhea and its complications.[1] This borders on ensuring the dissemination of adequate and appropriate knowledge of the disease among caregivers and health workers at community levels. The right knowledge has been recognized to positively impact on child survival strategies.[4] Mothers, in particular, remain the conventional, traditional, and biological primary (or first line) caregivers of young children in most sociocultural contexts, especially in the developing world. The right knowledge about the disease among this category of stakeholders in the society is pivotal in attaining a sustained decline in its burden among under-fives. This study sought to determine the prevalence of diarrheal disease in a suburban area in north western Nigeria and explore the knowledge of the disease among mothers of children <5 years of age in that community.


  Materials and Methods Top


Study area

The study was conducted in Samaru, a suburban community, in Sabon Gari Local Government Area (LGA) of Kaduna State, North western Nigeria. Based on the 2006 census, the LGA had an estimated population of 291,358 (projected to 393,300), while Samaru had an estimated population of 45,897.[11],[12] Women within the reproductive age group and under-fives represent 18.2%–22% and 17.1% of the LGA's population, respectively.[12],[13] The LGA is divided into six districts, namely Basawa, Muchiya, Samaru, Bomo, Hanwa, and Sabon Gari. Samaru is one of the several suburban areas within Zaria metropolis. It falls within the guinea savannah region and has evolved over time from a little farming settlement to a fairly large, suburban community opposite the main campus of Ahmadu Bello University (ABU), Zaria,[12] thus earning the community the epithet “university village.” Samaru falls within parts of urban and peri-urban Zaria referred to as “critical areas,” with regard to potable, pipe-borne water supply.[14] These areas experience dry water taps for many years in a row and as such are compelled to depend on alternative sources of water supply such as wells, boreholes, and purchased water from local water vendors (popularly known as “mairuwa”). The quality of such water may not be guaranteed. Insanitary environmental conditions have also been reported in the study area.[15]

Study design

This was a cross-sectional, descriptive, community-based study.

Study population

Consenting mothers of children <5 years of age resident in the study area were included.

Sample size

The sample size was calculated using the formula:



where

n = the desired sample size

z = the standard normal deviate which corresponds to 95% confidence interval (normally set at 1.96)

p = the prevalence of diarrhea as obtained from a similar study [16] =38.4% (i.e. 0.384).

q = 1 − p = 61.6% (i.e. 0.616)

d = degree of precision (0.05).



n = 363.

The response rate was 350 (96.42%).

Sampling method

Multistage sampling method was employed. The study area was stratified according to its existing 15 wards (sub-areas); a minimum of 24 households were selected by stratified random sampling method from each ward in the first stage. In each selected household, one mother of an under-five child was selected by simple random sampling technique using balloting (the second stage of sampling).

Inclusion criteria

Mothers of under-five children resident in the study area, who consented to participating in the study, were eligible.

Exclusion criteria

Nulliparous women, women who do not have any under-five children, and women outside the reproductive age group were excluded from the study.

Data management

Data collection was achieved by the aid of interviewer-administered, closed-ended, questionnaires and thereafter cleaned for errors and analyzed using Microsoft Excel software. The WHO's definition of diarrhea was adopted as the working definition. Results were presented in the form of frequency tables and charts.

Ethical considerations

Informed consent was obtained from both the respondents and their spouses, in keeping with cultural norms. Permission was also obtained from the various ward heads and the local government authorities. Ethical clearance dated 28th March 2008 was obtained from the Health Research Committee of ABU Teaching Hospital, Shika, Zaria (ABUTH/HREC/UG/6), in keeping with the principles of the Helsinki Declaration.


  Results Top


Almost half of the respondents (44.3%) were within the 25–34 years' age group; women over the age of 44 years were the least in proportion (2.9%). Less than one-third of the respondents (29.7%) had post-secondary level of education and 40% were full-time homemakers. Respondents from the Hausa ethnic group constituted about two-thirds (65.1%) of the studied population [Table 1]. Majority of the respondents (89.43%) defined diarrhea as the passage of loose and watery stools [Table 2], whereas a small minority defined it as the passage of well-formed stools (1.43%) and the passage of no stools (0.86%). Over 60% of the respondents attributed diarrheal diseases to infections (32.86%) and contaminated foods (28.86%). Teething was mentioned by a quarter (25.43%) of them as a cause of diarrheal disease; weaning (8.57%) and supernatural factors (3.71%) were cited by a few [Table 2]. No respondent thought that diarrheal diseases have no detrimental effects on children [Table 2]. Consequences mentioned include: weakness (38%), dehydration (24.57%), fever (12%), and death (25.43%). The point prevalence obtained was 13.14% [Figure 1], while the period prevalence (over the immediate past 3-month period) was 30.29% [Figure 2]. In terms of frequency, a total of 106 children had experienced at least one episode of diarrhea within the 3-month period preceding the study. More than three-quarters (77.35%) of these children had experienced 1–3 episodes of diarrheal disease, diarrheal disease, while about 9.44% of them had experienced over 6 episodes within 3 months [Table 3].
Table 1: Sociodemographic profile of respondents (n=350)

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Table 2: Knowledge of the definition, cause (s), and consequences of diarrhea among respondents (n=350)

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Figure 1: Point prevalence of diarrhea among under-five children of respondents (n = 350)

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Figure 2: Period prevalence of diarrhea among under-five children of respondents (n = 350)

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Table 3: Frequency of diarrhea among under-five children of respondents over the preceding 3 months (prior to interview) (n=106)

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  Discussion Top


This study aimed at exploring the knowledge of mothers of under-five children in a suburban community in north western Nigeria on their perception of the definition, causes (or determinants), and consequences (or outcomes) of diarrheal disease among children and relates the same to the prevalence of diarrheal disease in that community. A correct knowledge of these factors and the dynamics involved in the disease entity is likely to guarantee informed and improved health-seeking behavior among mothers and other caregivers.[17] It is also likely to positively influence the institution of primary and secondary levels of prevention, particularly with regard to early detection and prompt and appropriate treatment.[18]

Majority of the respondents in this study (89.43%) were able to correctly define diarrhea as the passage of loose and watery stools (even though the frequency dimension of “three or more stools per day” was omitted by them). Only a small proportion (2.29%) gave definitions that were completely “off target” such as the “passage of no stools or well-formed stools.” This is similar to findings from a study in a semi-urban community in Sokoto, north western Nigeria,[19] where 93.8% of caregivers “thought that diarrhea was characterized by the passage of frequent loose stools.” However, it significantly differs from findings of a study in a rural community in north central Nigeria,[17] where less than half of the respondents (42.7%) correctly defined diarrhea. This disparity in the knowledge of the correct definition of diarrhea may be due to differences in location of study, as the urban-rural variation of knowledge and literacy levels are recognized factors in Nigeria,[13] with urban and suburban areas being at an advantage. Studies from Ethiopia reported levels relatively lower than that obtained in this study, ranging between 63.6% and 65.4% of mothers having good knowledge.[20],[21] A review of some Indian studies also revealed proportions ranging between 47% and 72% for correct definition of diarrhea among caregivers.[22],[23]

With regard to the cause of diarrhea, almost two-thirds (about 62.29%) of the respondents attributed diarrheal disease to infective or unhygienic causes, either directly (32.86%) or indirectly (29.43%) with responses such as “bad” (contaminated) food and water. A study in three north western Nigerian states of Katsina, Kebbi, and Zamfara [24] corroborated this finding, reporting that “59% of caregivers associated diarrhea with suboptimal hygienic conditions and contaminated food and water” and an additional “10% linked diarrhea with various infections.” The earlier cited study in north central Nigeria [17] reports that a cumulative 65.7% of respondents identified germs and contaminated food and water as causes of diarrheal disease. However, this is in contrast with findings from south eastern Nigeria, where a higher proportion of respondents (between 87.9% and 93.7%) affirmed the disease to be caused by contaminated food as well as inadequate sanitation and hygiene.[25],[26] This higher rate was attributed to urban residence, age of respondents, and higher level of education, which is relatively lower among females in our study area compared to their counterparts in the southern part of the country.[4],[19] This calls for the need to address the issue of female health education in this region of the country.

About 25.43% and 8.57% of the respondents attributed diarrheal disease to teething and weaning, respectively. The phenomenon of teething has been reportedly implicated as a perceived “cause” of diarrheal disease in many other studies around the country.[16],[17],[24],[25],[26] Furthermore, teething has been widely but erroneously “accepted” among mothers and caregivers in many sociocultural circles as a “harmless” and self-limiting cause of diarrhea among infants (a “developmental” milestone of some sort).[26],[27] However, this perception has been documented to be both unfounded and untrue; rather, it is only an apparent association stemming from poor hygiene and insanitary conditions.[17],[26] Interestingly, certain unscientific misconceptions such as supernatural causes were expressed by a few (3.71%) respondents in this study. A similar phenomenon was reported by Asiegbu et al. in south eastern Nigeria,[25] where over two-thirds (69.70%) of the respondents strongly believed that diarrheal disease was caused by witchcraft, although these were mainly from rural-based respondents with little or no formal education. This further underscores the place and relevance of appropriate health education and enlightenment, especially among mothers and other caregivers.

Furthermore, weaning on its own (as expressed by 8.57% of the respondents) should not constitute a cause for concern (as a cause of diarrhea). It is only a natural intervention that arises as the demands of infant growth and development eventually exceed the nutritional supplies of breast milk and other alternatives around the ages of 4–6 months. Thus, making the introduction of complementary foods not only necessary, but also inevitable. As long as the food preparation processes and handling of cooking and feeding utensils are kept at optimal hygienic standards, and food and water contamination has been eliminated; weaning should go uneventful. However, a previous study [28] reported an association between weaning time (in terms of infant age) and type of milk diet given prior to weaning and the occurrence of diarrhea. This study observed a higher incidence of diarrhea among infants weaned before 4 months and those fed on a combination of breast milk with animal and commercial milk. Furthermore, a phenomenon coined “weaning diarrhea,” recognized and documented by Gordon et al.[29] as far back as in 1963, may also unravel or explain away some cases of diarrhea observed during the weaning period. Characterized by a wide range of severity, from mild discomfort to severe and even life-threatening manifestations, weaning diarrhea is described as diarrhea that occurs with the transition of breastfed infants to a mixed diet.[30] However, its occurrence is not commonplace.

With regard to the frequency of diarrhea within the 3-month period prior to the survey, over three-quarters (77.35%) of the respondents reported in the affirmative to the occurrence of 1–3 episodes of diarrhea among their children. This corresponds with the report of an earlier study [16] in south eastern Nigeria, where about 76.43% of respondents' children had <3 episodes of diarrhea within the preceding 6 months. Frequent bouts of diarrhea progressively debilitate children, as each successive episode moves children further away from their normal weight-for-age, thereby greatly increasing their risk of malnutrition and impaired development.[4] In a yearlong, prospective study in two urban slums in Brazil,[31] an average of 2.8 episodes per child per year, ranging from 1 to 18 episodes per child per year, was reported. About 75% of the children presented with at least one episode of diarrhea during the whole observation period. The average number of children affected per month was 5.0 (5.9%).

On the consequences or outcomes associated with diarrheal disease, none of the respondents thought that diarrhea occurs without any potential danger. Consequences enumerated include weakness (38%), dehydration (24.57%), fever (12%), and death (25.43%). This reflects a high level of awareness of the potential dangers associated with the condition and is a good omen for prompt and positive intervention in the event of its occurrence. This finding is consistent with those from a study in an Ethiopian community, where majority (83.5%) of the respondents acknowledged the impact of diarrheal disease on children being diverse forms of morbidities as well as mortality (as reported by 63.5% of respondents) and growth retardation (by 20% of respondents).[21] Studies from other parts of Nigeria also reflect similar high levels of knowledge of the consequences of diarrheal disease.[18],[25]

The point prevalence (on the day of interview) and period prevalence (over the 3-month period preceding the interview) obtained in this study were 13.14% and 30.29%, respectively. This is significantly higher than the estimated figures of 13.5% and 9.2% reported by the Nigerian Demographic and Health Survey (NDHS) for Kaduna State and the north western region, where the study community is located, respectively.[13] The NDHS estimates the national prevalence for diarrhea at 10%.[13],[32] The period prevalence reported in this study clearly triples the national prevalence and calls for urgent attention and intervention by stakeholders and local health authorities. A similar study conducted in selected villages of Kashmir, India,[33] reports point prevalence and period prevalence of 9.3% and 25.2%, respectively. Findings from other parts of Nigeria vary significantly as follows: Jos, north central Nigeria [34] (2.7%); Kaduna North, north western Nigeria [4] (21.1%); and Abakaliki, south eastern Nigeria [16] (38.4%). However, it should be noted that the Jos study, reporting a very low prevalence of 2.7% (unlike ours and others), is facility based. The prevalence observed in this study is corroborated by findings reported in a rural, agrarian community in Ethiopia (30.5%).[2] Another study from Senegal [3] reported a prevalence of 26%, with a higher figure (44.8%) in peri-urban areas relative to urban areas (36.3%). The foregoing findings further buttress the spatial and regional variation and disparities in the knowledge and prevalence of diarrheal disease, with rural and suburban areas as well as urban slums being worst affected.[3],[4],[35] The suburban nature of the community surveyed in this study coupled with many pockets of slum-like habitats existing therein may account for the high prevalence and frequent episodes of diarrheal disease reported.[14],[15]


  Conclusion Top


Despite the good knowledge of diarrheal disease observed among respondents in this study, the prevalence and frequency of the disease still remain unacceptably high. This may be attributable to the challenges of poor water sources and insanitary environmental conditions. Public health interventions, including environmental sanitation and potable water supply, are required to reduce the burden of this disease in the study population.

Limitations

The practice of preventive measures by respondents against the disease as well as personal hygiene was not ascertained. Also, the source (s) of information about diarrheal disease among respondents and possible environmental factors contributing to the phenomenon were not enquired. Furthermore, the possibility of non-response was not factored in calculating the sample size (which is another acknowledged limitation of this study). These gaps in the scope of this study create lacunae for further research, which may avail the missing puzzle pieces in deciphering the high prevalence and frequency of the disease, despite a good knowledge of it among mothers of under-five children.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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