Journal of Clinical Immunology and Allergy

Keywords

Acute Diarrhea, Diarrheal Disease, Under- Five Children, Galkayo, Somalia

Introduction

Although the world has made significant progress for the reduction of under-five child mortality, the risk of a child dying before his/her fifth birthday continues to be high in WHO African Region (76 per 1000 live births), approximately 8 times higher than that in the WHO European Region (9 per 1000 live births) (WHO, 2018). The under-five mortality rate in Somalia remains high, where 1 in 7 children die before the age of five years.

Diarrhea, which is referred as the passage of three or more loose or liquid stools per day, is a major public health concern, it contributes to significant childhood deaths. It is the second leading causes of under-five death, next to pneumonia, and account 8.6% global under-five child death (Liu et al., 2016). In Somalia, diarrhea remains to be the second primary cause that contributes to under five years of child mortality, which represents 19% death of children (SCI, 2018). The risk of childhood diarrhea diseases could be significantly prevented through water, sanitation, and hygienic interventions by 27% - 53% (Darvesh et al., 2017).

Different studies across the world have demonstrated that childhood diarrhea has been influenced by various socioeconomic, environmental, and behavioral factors (Alebel et al., 2018). In Somalia, the magnitude of under-five AWD remained high, 24%. Understanding the local context of factors associated with AWD is very crucial for the successful design and implementation of child health programs and policies that aim to reduce morbidity and mortality of childhood diarrhea. Therefore, this study aimed to find the magnitude of under-five child diarrhea and socio-economic, environmental, and behavioral factors that influence it.

Methods and materials

Study Area

This study was conducted in Galkayo district, Mudug region, Somalia. Galkayo is the capital city of the Mudug region, which contains two federal member state governments, namely Puntland in the north and Galmudug in the south. Galkayo city, which is the most centrally located city in Somalia, is 750 kilometers away from Mogadishu. The city geographically contains four main sub-villages, namely Israc, Garsor, Horumar, and Wadajir, with approximately 545,000 inhabitants.

Study design and Period

A community-based, cross-sectional study was carried out among under-five children living in Galkayo district, Somalia. Study data were collected two weeks from 7th to April 21st, 2018.

Study Population

The study populations were all households with mothers/ caregivers who have children less than five years living in Galkayo district. The study units were randomly selected houses with at least one under-five children.

Eligibility Criteria

Mothers/caregivers with under-five children and who were permanent residents in the study area were eligible to participate in the study. Households with children who was chronically ill and had persistent diarrhea for greater than two weeks and those with critically ill mothers/caregivers were excluded from the study.

Sample size and sampling procedure

The sample size was calculated considering the following parameters: Prevalence of diarrhea, 28% (UNICEF, 2016) in under-five children in Somalia, a confidence level of 95% (5% desired precision), and adding 10% of non-response rate making the final sample size 341 households. The study adopted a community-based cross-sectional, quantitative study to investigate the prevalence and determinants of AWD among under-five children. We used the non-probability sampling method (convenience followed by lottery). This method was used since Galkayo district does not have the list of houses “no sampling frame”. Two villages out of the four villages in Galkayo district were randomly selected. Then, convenience sampling of the 341 households were implemented. The sample size was equally split among the selected villages. If there are more than one under-five children in the same household, the lottery method was used to select the indexed child, and if the mother/ caregiver or the under-five child is not present in the selected household, the next household was chosen in the study data collection.

Data Collection

Data were collected using an interviewed-administered questionnaire and observational checklist from previously published similar articles through face-to-face data collection. A questionnaire comprising of a wide range of questions related to demographic, socio-economic, environmental, and behavioral variables were implemented in accordance with the WHO key features in diarrheal diseases. The questionnaire was prepared in English and was translated into Somali language by independent and qualified individuals. The Somali version was then translated back to English for cross-checking and consistency of the questions. We performed a pre-test of the questionnaire in villages that were not included in the study, and all necessary corrections to the data collection tools were made.

Ethical Approval

Ethical clearances were obtained from the institutional ethical committee (IEC) of Global Science University, Department of Public Health. Permission to conduct the study was obtained from Galkayo local government. The study data collectors thoroughly explained the aim of the study to the participants, and written consent was obtained from the mothers/caregivers of the indexed children.

Data Analysi

The data were entered into computer application and subsequently exported for STATA 13 for data management and analysis. Categorical data were summarized by using frequencies and percentages, while numerical variables were described by using means and standard deviation in the form of tables. In the bivariate analysis, variables significantly associated with AWD at the level of 0.2 were identified and then entered into the multivariate analysis. In the final model, the variable was considered to be significant if it had a p-value of less than 0.5.

Result

Demographic and socio-economic characteristics of the households

A total of 332 mothers of children younger than five years old, with a response rate of 97.4% (341/332), were enrolled in this study. The majority of the household family size was ≥5 (83.7%), whereas 78.62% of the households had two or more under-five children. Nearly half (50.6%) of the respondents were in the age group of 25-34 years, while one-third (31.93%) of the mothers/ caregivers were 35 or above years old. About 89.76% of the respondents were biological mothers, 72.89% were married, whereas a considerable part of the respondents (43.67%) were unable to read or write, and only 53 (15.96%) of the mothers/ caregivers attended university (see Table 1).

Table1 Demographic and socio-economic characteristics of the households in Galkayo town, April 2018

ENVIRONMENTAL CHARACTERISTICS OF THE HOUSEHOLDS

According to the findings of this study, one hundred ninety-six (59.04%) of the households had a cement floor, while ninetynine (29.82%) had mud-wall and floored compounds. The majority of the families (73.80%) were living in a house with three or more rooms. Only twenty-five households (7.53%) had domestic animals (Goats) living with them in the house.

The majority of the families (97.54%) had functioning latrine facilities, and 234 (72%) of the latrines were traditional pit latrines. According to the data, two hundred fifty-one (75.60%) of the households had a handwashing facility while 75 (23.08%) of the pit latrines were unclean or feces were seen around the hole, and only 64 (19.28%) of the households were seen feces around the compound. Regarding the method of waste disposal, 122 (36.7%) of the household burn their rubbish properly while only 18.67% dispose and throw their rubbish in the open fields. One hundred thirty-three (40.06%) of the household use proper pipeline water sources, and 190 (57.23%) do not treat water from any sources (see table 2).

Table 2. Environmental characteristics of the households in Galkayo town, April, 2018

BEHAVIORAL CHARACTERISTICS OF THE HOUSEHOLDS

The majority of the mothers/caregivers, 279 (84.04%), give supplementary foods to their child in addition to breastmilk, making powder milk 236 (71.08%) most fluid that was given to the children. More than half of the children (57.23 %) were bottle-fed, and approximately more than half of the caregivers (51.2%) wash their hands without soap or ashes. According to this study, 190 (57.23%) and 61 (18.37%) of the respondents fed their children with bottle and spoon, respectively, as a supplement to breast milk (see table 3).

Table 3. Behavioral characteristics of the respondents in Galkayo town, April 2018

Demographic and Health Characteristics of the Indexed Children

The majority of the children were male (53.31%) and aged less than 24 months (64.46%). Regarding breastfeeding initiation practice, most of the children 147 (47.12%) were breastfed within one hour after childbirth, and 165 (52.88%) had received breastmilk after one hour while 103 (33.01%) of the children were not given to colostrum milk.

Concerning other breastfeeding practices, only 11 (3.31%) of the children were exclusively breastfed, and approximately two in every three children (66.35%) were breastfed for less than 12 months. One-third of the children (31.64 %) did not receive measles vaccination. Regarding the time of complementary feeding initiation, 279 (88.57%) of the mothers started complementary feeding to their children before six months of age. The prevalence of Acute Watery Diarrhea “AWD” for the two weeks of this study period was 31.93% (See table 4).

Table 4. Demographic and health characteristics of the indexed children in Galkayo town, April 2018

ACTORS ASSOCIATED WITH ACUTE WATERY DIARRHEA

Variables that shown to be statistically associated with acute childhood watery diarrhea at p< 0.2 in the bivariate analysis were identified and included in multivariate analysis regression. Only hand washing facilities, method of a rubbish disposal, and home-based water treatment variables, as well as child feeding method and duration of breastfeeding variables, were statistically associated with acute childhood diarrhea (p<0.05) in the multivariate analysis (see table 5).

Children living in a household with no handwashing facilities were three times more likely to have diarrhea than those children living in the household with handwashing facilities [AOR=3.083 (1.351–7.030)]. Similarly, children living in the household who dispose of their rubbish through an open field were two times more likely to have diarrhea than those that dispose of through burning the rubbish [AOR=2.560 (1.101– 5.949)]. Besides, children who live in a household that did not use home-based water treatment had twice diarrheal events than their counterpart children [AOR=2.256 (1.064–4.783)]. Other types of food were found to be protective against diarrhea. Children who consumed other types of food were less likely to develop diarrhea than those who consumed powder milk [AOR=.340 (.125–.926)]. Concerning breastfeeding duration, children who were breastfed less than 12 months were two times more likely to develop than those children who were breastfed by more than 12 months [AOR=2.060 (1.111–3.821)]. Children fed with cups were less likely to have diarrhea than those fed with hand [AOR=.176 (.041–.751)].

Table 5: Multivariate analysis on the selected determinants of under-five diarrhea in Galkayo, Somalia, April 2018

Discussion

The prevalence of under-five watery diarrheal disease for the past two weeks in this study was 31.93%. The findings of this study are slightly higher than the result of Somali Region in Ethiopia, 27.3% (Hashi, Kumie, & Gasana, 2016), and UNICEF reported rate in Somalia, 28% (UNICEF, 2016), Uganda, 29.1% (Omona, Malinga, Opoke, Openy, & Opiro, 2020) and approximately similar with results from Arba-Minch in Ethiopia, 31% (Mohammed, Tilahun, & Tamiru, 2013) Burundi, 32.6% (Diouf, Tabatabai, Rudolph, & Marx, 2014).

The availability of a handwashing facility in the household is very crucial for the health of the family and particularly in children. In this study, children living in a household with no handwashing facilities were three times more likely to develop diarrhea. Similar results were also found in Ethiopia, where lack of handwashing facilities in the household was associated with the occurrence of AWD (Bizuneh, Getnet, Meressa, Tegene, & Worku, 2017; Dagnew et al., 2019; Degebasa, Weldemichael, & Marama, 2018). Lack of handwashing stand in the household could increase the contamination chance of food given to the children and subsequently could lead to diarrheal diseases.

Duration of breastfeeding is also another essential factor for child health. Children who were breastfed for less than 12 months were two times more likely to have diarrhea than their counterpart children. This could be due to the presence of bioactive molecules in human milk which prevents against diarrheal diseases. Besides, human milk is natural, safe, and free from contamination microbes that cause childhood diarrheal diseases (Ballard & Morrow, 2013).

Child feeding practice is an essential indicator of child health. Complimentary food and feeding method were also found to be a determinant factor for AWD. In this study, children who were fed with cups were less likely to have AWD than that given food with hand. This result was supported by a study in Ethiopia which found that children who were bottle-fed were having higher diarrheal diseases than cup-fed children (Anteneh, Andargie, & Tarekegn, 2017). The probable reason for this finding could be the lack of proper cleaning of bottles used for complementary feeding of the children. Besides to complementary feeding method, the type of food given to the children was also a significant predictor for AWD in this study. Children received other types of food (porridge with camel milk) had less diarrheal than those given to powder milk.

This study also found that children living in a household that did not employ home-based water treatment had twice the prevalence of acute childhood watery diarrhea than those that used it. This inconsistent with the study in Cameron, which also found the association between the occurrence of diarrhea and lack of treatment of drinking water (Thiam et al., 2017). Another study in Burundi also found a lower prevalence of diarrhea for households, which boils water prior to their use (Diouf et al., 2014). This could be because home-based water treatment improves the microbiological quality of household water and thereby reduce the prevalence of childhood AWD (Agrawal & Bhalwar, 2009).

The findings of this study should be used in light of several limitations. First, we cannot establish causality as we employed a cross-sectional study design that simultaneously measures both the determinant factors and the occurrence of diarrhea. Second, the hygienic practice was self-reported by the participants, and this could introduce bias that underestimated the prevalence of acute diarrheal diseases. Third, the occurrence of diarrhea was based on the mother or caregivers’ report, which could lead to recall bias.

CONCLUSIONS

In this current study, the prevalence of two weeks of diarrheal disease among under-five children in Galkayo was high (31.93%). Therefore, improvement of handwashing practice, employment of home-based treatment before the utilization of water, and appropriate disposal of rubbish, as well as the continuation of breastfeeding beyond 12 months, proper supplementary food, and feeding method, are highly recommended to reverse this high AWD.

DATA AVAILABILITY

The data that supported the findings of this study are available from the corresponding author on request.

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