Association between moderate-to-severe diarrhea in young children in the global enteric multicenter study (GEMS) and types of handwashing materials used by caretakers in Mirzapur, Bangladesh

Associations between Shared Sanitation, Stunting and Diarrhoea in Low-Income, High Density Urban Neighbourhoods of Maputo, Mozambique - a Cross-Sectional Study

INTRODUCTION

Shared sanitation facilities are used by over 500 million people around the world. Most research evidence indicates that shared sanitation conveys higher risk than household sanitation for many adverse health outcomes. However, studies often fail to account for variation between different types of shared facilities. As informal housing development outpaces sanitation infrastructure, it is imperative to understand which components of shared facilities may mitigate the health risks of shared sanitation use.

METHODS

This cross-sectional study determines whether sanitation improvement or compound hygiene were associated with stunting or diarrhoeal prevalence in children under five living in Maputo, Mozambique who rely on shared sanitation facilities. The study uses logistic and linear multivariable regression analysis to search for associations and control for potential confounding factors.

RESULTS

346 children (43.9%) in the study population were stunted. Each unit increase in sanitation score was associated with an approximate decrease of 22% in the odds of stunting (OR: 0.78, CI: 0.66, 0.92), and an increase in height of 0.23 height-for-age z-scores (CI: 0.10, 0.36). There was no evidence that the compound hygiene score was associated with height as measured by stunting (OR: 1.05, CI: 0.87, 1.26) or z-score (-0.06, CI: -0.21, 0.09). Neither sanitation nor compound hygiene score were associated with diarrhoea in the population.

CONCLUSIONS

Use of an improved shared latrine is associated with decreased odds of stunting. There is no evidence of an association between latrine improvement and diarrhoea. Further investigation is necessary to isolate attributes of shared sanitation facilities that may reduce health risks.

Diarrhea Prevalence and Associated Factors among Children in Azezo Sub-City, Northwest Ethiopia: A Community-Based Cross-Sectional Study

Globally, diarrheal disease continues to be a major cause of morbidity and mortality among children under 5 years of age, especially in low-income countries such as Ethiopia. However, there is still limited evidence in the study area quantifying the burden of diarrheal disease among children under 5 years. A community-based cross-sectional study was conducted in April 2019 to estimate the prevalence of childhood diarrhea and to identify its associated factors in Azezo sub-city, northwest Ethiopia. A simple random sampling technique was applied to recruit the eligible cluster villages with children under 5 years. Data were collected by interviewing mothers or guardians using structured questionnaires. The completed data were entered into EpiInfo version 7 and exported to SPSS version 20 for analysis. Binary logistic regression model was used to identify factors associated with diarrheal disease. Adjusted odds ratio (AOR) with 95% CI was used to measure the strength of association between the dependent and independent variable. The period prevalence of diarrheal disease among children under 5 years was 24.9% (95% CI: 20.4-29.7%). Age group between 1 and 12 months [AOR: 9.22, 95% CI: (2.93-29.04)] and 13 and 24 months [AOR: 4.44, 95% CI: (1.87-10.56)], as well as low monthly income (AOR: 3.68, 95% CI: (1.81-7.51)] and poor handwashing practice [AOR: 8.37, 95% CI: (3.12-22.52), were significantly associated with high risk of childhood diarrhea. In contrast, small family size [AOR: 0.32, 95% CI: (0.16-0.65)], and immediate consumption of prepared meals [AOR: 0.39, 95% CI: (0.19-0.81)] were significantly associated with low risk of childhood diarrhea. Diarrheal diseases were a common health problem among children under 5 years of age in Azezo sub-city. Therefore, an appropriate hygiene intervention program through health education is recommended with a focus on identified risk factors to reduce the burden of diarrheal diseases.

Handwashing among caregivers of young children in a protracted and complex refugee and immigration context: a mixed methods study on the Thai-Myanmar border

Introduction

Protracted refugee situations create complex contexts that present significant health risks for young children. Effective hand hygiene practices by caregivers can reduce respiratory infections and diarrhoeal disease, the two largest contributors to mortality among children between 1 month and 5 years of age. This study documented handwashing patterns and access to water, sanitation and hygiene (WASH) infrastructure among caregivers of young children living along the Thai-Myanmar border, one of the world's most protracted and complex refugee and immigration contexts. It also examined the association between handwashing and socio-demographic variables and captured participants' explanations for when and how hands are washed. The study broadened the scope of previous research by also including the large number of caregivers living outside formal camps.

Methods

Caregivers of children attending 11 preschools in Tak province, Thailand participated in a mixed-methods cross-sectional study. Quantitative questionnaire data (n = 384) were supplemented by a thematic analysis of data from in-depth interviews (n = 9).

Results

Fewer than half the caregivers reported routinely washing their hands before preparing meals or after using the latrine/toilet. Fewer than one-in-five routinely used soap in these situations. Interviewees explained that handwashing was only necessary when a substance could be felt or seen, in which case wiping with a cloth or a rinsing with water were sufficient to clean hands. However, their explanations also suggested some potential avenues for culturally appropriate and feasible interventions to improve hand hygiene.

Conclusion

The results confirmed previous research on the multi-dimensional barriers to good hand hygiene in protracted refugee situations and other low-resource settings. Additional investment to overcome shortages in the infrastructure necessary to support good hand hygiene and creative means of drawing on and developing human capital will be necessary to realize the potential hand hygiene holds for reducing ill-health and mortality among young children living in these contexts.

Anderson C, B. Boehm A, Wolfe MK. Quantifying the Viral Reduction Achieved Using Ash and Sand as Handwashing Agents

The WHO recommends handwashing with soap and water for 20-40 seconds. In settings where soap is not available, ash or sand is used for handwashing, yet their efficacy as handwashing materials is underresearched. The purpose of this study was to quantify the removal of viruses using ash and sand as handwashing agents, and compare their efficacy to commonly recommended handwashing methods. We performed a volunteer study to estimate the log reduction value (LRV) of model viruses Phi6 and MS2 on hands after six handwashing conditions: two handwashing agents (ash and water, and sand and water) with two time points (5 and 20 seconds), and two handwashing agents (soap and water, and water only) with one time point (20 seconds). Plaque assays were used to measure infectious virus reduction. Handwashing with any of the handwashing agents for 20 seconds resulted in a greater LRV than the 2-log reduction U.S. Food and Drug Administration criteria for both viruses. Soap and water resulted in a significantly greater LRV (2.7-4.8) than washing with ash and water (2.0-2.8) or sand and water (1.8-2.7) for 5 seconds for both viruses, and water only resulted in a significantly higher LRV (2.8) than all ash (2.0-2.6) and sand (1.8-2.4) conditions for MS2 only. These results suggest that using ash or sand as handwashing agents can be efficacious in reducing viruses but may be less efficacious than soap, especially when used for shorter durations. Further research should investigate the use of ash and sand as handwashing agents in real-world settings.

Hand cleaning with ash for reducing the spread of viral and bacterial infections: a rapid review

BACKGROUND

Handwashing is important to reduce the spread and transmission of infectious disease. Ash, the residue from stoves and fires, is a material used for cleaning hands in settings where soap is not widely available.

OBJECTIVES

To assess the benefits and harms of hand cleaning with ash compared with hand cleaning using soap or other materials for reducing the spread of viral and bacterial infections.

SEARCH METHODS

On 26 March 2020 we searched CENTRAL, MEDLINE, Embase, WHO Global Index Medicus, and the WHO International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included all types of studies, in any population, that examined hand cleaning with ash compared to hand cleaning with any other material.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and full texts, and one review author extracted outcome data and assessed risk of bias, which another review author double-checked. We used the ROBINS-I tool for observational studies, we used RoB 2.0 for three interventional studies, and we used GRADE to assess the certainty of the evidence. We planned to synthesise data with random-effects meta-analyses. Our prespecified outcome measures were overall mortality, number of cases of infections (as defined in the individual studies), severity of infectious disease, harms (as reported in the individual studies), and adherence.

MAIN RESULTS

We included 14 studies described in 19 records using eight different study designs, but only one randomised trial. The studies were primarily conducted in rural settings in low- and lower-middle-income countries. Six studies reported outcome data relevant to our review. A retrospective case-control study and a cohort study assessed diarrhoea in children under the age of five years and self-reported reproductive tract symptoms in women, respectively. It was very uncertain whether the rate of hospital contacts for moderate-to-severe diarrhoea in children differed between households that cleaned hands using ash compared with households cleaning hands using soap (RR 0.97, 95% CI 0.84 to 1.11; very low-certainty evidence). Similarly, it was very uncertain whether the rate of women experiencing symptoms of reproductive tract infection differed between women cleaning hands with ash compared with cleaning hands using soap (RR 0.48, 95% CI 0.12 to 1.86; very low-certainty evidence) or when compared with handwashing with water only or not washing hands (RR 0.50, 95% CI 0.13 to 1.96; very low-certainty evidence). Four studies reported on bacteriological counts after hand wash. We rated all four studies at high risk of bias, and we did not synthesise data due to methodological heterogeneity and unclear outcome reporting.

AUTHORS' CONCLUSIONS

Based on the available evidence, the benefits and harms of hand cleaning with ash compared with soap or other materials for reducing the spread of viral or bacterial infections are uncertain.

Viral Pathogen-Specific Clinical and Demographic Characteristics of Children with Moderate-to-Severe Diarrhea in Rural Bangladesh

Diarrheal disease is a leading cause of childhood morbidity and mortality worldwide, but particularly in low-income countries in sub-Saharan Africa and South Asia. The Global Enteric Multicenter Study (GEMS) examined the infectious etiologies as well as associated demographics, socioeconomic markers, health-care-seeking behaviors, and handwashing practices of the households of children with diarrhea and their age- and gender-matched controls in seven countries over a 3-year period (December 2007-December 2010). Stool studies to determine diarrheal etiologies and anthropometry were performed at baseline and at 60-day follow-up visits, along with surveys to record demographics and living conditions of the children. We performed secondary analyses of the GEMS data derived from the Bangladesh portion of the study in children with diarrhea associated with viral enteropathogens and explored pathogen-specific features of disease burden. Rotavirus and norovirus were the most prevalent pathogens (39.3% and 35%, respectively). Disease due to rotavirus and adenovirus was more common in infants than in older children (P < 0.001 and P = 0.001, respectively). Height for age decreased from baseline to follow-up in children with diarrhea associated with rotavirus, norovirus, and adenovirus (P < 0.001). Based on these analyses, preventive measures targeted at rotavirus, norovirus, and adenovirus will be expected to have meaningful clinical impact. Cost of treatment was highest for rotavirus as well, making it an obvious target for intervention. Association of specific viruses with stunting is particularly notable, as stunting is an attributable risk factor for poor cognitive development and future productivity and economic potential.

Sanitization During and After COVID-19 Pandemic: A Short Review

Sanitization is a preventive and strategic method to contain the spread of SARS-CoV2. Since there is no foolproof method to tackle the present COVID-19 pandemic, sanitization has a central role to play. The present article briefly reviews various methods of sanitization for individuals, surfaces and ambience. The article reviews different approaches toward sanitization and examines the historicity of the methods employed.

Diarrheal correlates associated with enteric bacterial infections among children below five years in Murang'a County, Kenya

INTRODUCTION

The burden of childhood diarrheal disease has resulted in massive mortality and morbidity globally. Children below 5 years in sub-Saharan Africa are most implicated by diarrheal illnesses resulting in numerous medical consultations, admissions, and deaths despite the disease being easy to prevent and control. The study aimed to determine the correlates of enteric bacterial infection causing diarrhea.

METHODS

During the months of April-October 2017, 163 children below five years presenting with diarrhea were randomly selected in Murang'a and Muriranja's hospitals. Bacterial agents were identified and correlates of diarrhea determined. The study used a hospital-based cross-sectional study design. A standardized questionnaire was used to collect information from the guardian. Statistical analyses were performed using STATA v. 13.

RESULTS

Forty-nine children were infected with enteric pathogenic bacteria (Enterotoxigenic Escherichia coli, Enteropathogenic Escherichia coli, Enteroaggregative Escherichia coli, Salmonella, Shigella, and Vibrio species). Factors associated with infection by these bacteria among the 49 children were evaluated. Children between 0-12 months (OR 0.3, 95% CI 0.1-0.8), those fed exclusively on breast milk (OR 0.3, 95% CI 0.09-0.9) and children weighing 1-5 kilograms (OR 0.2, 95% CI 0.04-0.9) were less likely to be infected with these enteric pathogenic bacteria. Female participants (OR 1.8, 95% CI 1.1-3.4) were nearly twice likely to be infected with enteric pathogenic bacteria. Children who presented with watery stool (OR 0.4, 95% CI 0.2-0.9) or mucoid stool (OR 0.3, 95% CI 0.2-0.7) remained associated with enteric pathogenic bacterial infection but less likely to be infected compared to those who presented with watery-blood stained stools. Piped water (OR 0.01, 95% CI 0.01-0.4) was less associated with enteric bacterial infection than water stored in jerry-cans while storing water without a lid (OR 1.9, 95% CI 1.1-3.7) was more likely to lead to bacterial infection. Hand washing after toilet use (OR 1.6, 95% CI 1.1-2.7) was associated with enteric bacterial infection compared to hand washing before meal preparation.

CONCLUSION

Sanitation, hygiene, nutritional and clinical factors were associated with enteric bacterial infections causing diarrhea among children below five years in the study area. Childhood diarrhea in Murang'a County is a major public health problem.

Risk factors for diarrhoea and malnutrition among children under the age of 5 years in the Tigray Region of Northern Ethiopia

BACKGROUND

Diarrhoea and malnutrition are the leading cause of morbidity and mortality among children in areas with poor access to clean water, improved sanitation, and with low socioeconomic status. This study was designed to determine the prevalence of diarrhoea, malnutrition and risk factors among children aged 6-59 months in the Tigray Region of Northern Ethiopia.

METHODS

A community based cross-sectional study design was conducted from June to August 2017 to assess the magnitude and factors associated with diarrhoea and malnutrition among children. A standardized questionnaire was used to collect data on diarrhoea, environmental, demographic and behavioural factors from 610 mother-child pairs. Anthropometric measurements were collected from the children. SPSS ver.21 statistical software was used for analysis. Factors associated with diarrhoea and nutritional status were identified using bivariate and multivariate logistic regression. A p-value ≤ 0.05 was considered statistically significant.

RESULTS

Of the 610 children monitored in this study, the incidence of diarrhoea among 6-59 month-old children in the two weeks preceding the day of the interview day was 27.2% (95% CI: 23.6-31%). Specifically, 35.9%, 9.7%, and 1.8% had 1-2, 3-4 and 5-6 times of diarrhoea episodes in a one year of time, respectively. The prevalence of stunting, underweight, wasting, and acute under-nutrition were 36.1% (95% CI: 31-38.6%), 37% (95% CI: 32-39.6%), 7.9% (95% CI: 5.5-9.7%), and 5.4% (95% CI: 3.8-7.4%), respectively. In a multivariate logistic regression analysis, type of drinking water source [AOR = 3.69; 95% CI: 2.03-6.71], mothers not hand washing at critical times [AOR = 15.42; 95% CI: 2.02-117.78], improper solid waste disposal [AOR = 12.81; 95% CI: 2.50-65.62], and child age (36-47 months) [AOR = 2.57; 95% CI: 1.45-4.55] were found to be predictors of diarrhoea. Being within the age range of 12-23 months was a predictor for wasting [AOR = 4.38; 95% CI: 1.61-11.90] and being underweight [AOR = 4.4; 95% CI: 1.7-11.2]. Similarly, the age range of 36-47 months was associated with wasting [AOR = 2.3; 95% CI: 1.45-3.85] and stunting [AOR = 1.7; 95% CI: 1.03-2.67]. Family size (less than 4) [AOR = 0.56; 95% CI: 0.368-0.959] was inversely associated for wasting.

CONCLUSIONS

Our study revealed that the problem of diarrhoea and malnutrition amongst 6-59 months children in the study area was significant. Access to clean water was the main problem in the study area. Hence, improving access to clean water and providing health education to mothers on personal and environmental hygiene, and proper waste disposal could improve diarrhoea in the study area. Intervention on children's nutrition should also be implemented to minimize the problem of malnutrition.

Acceptability and Feasibility of Sharing a Soapy Water System for Handwashing in a Low-Income Urban Community in Dhaka, Bangladesh: A Qualitative Study

Handwashing with soap at key times is an effective means of reducing pathogen transmission. In a low-income community in urban Dhaka, we piloted and evaluated the acceptability and feasibility of a shared handwashing intervention. This included promotion by community health promoters of a homemade solution of detergent powder mixed with water and stored in a 1.5-L reclaimed mineral water bottle. Community health promoters encouraged sharing of the recurrent detergent cost among compound members. Of 152 participating compounds, fieldworkers randomly selected 60 for qualitative assessment. Fieldworkers conducted 30 in-depth interviews and five focus group discussions among purposively selected compound members. The reclaimed bottles served as an easily accessible dispenser for the soapy water, which could feasibly be retained next to the toilet and kitchen areas for communal use. Bottles functioned as a positive reminder for handwashing at recommended key times. Most compounds (45/60, 75%) shared a common soapy water system and its associated costs. There was reluctance to prepare soapy water for shared use in the remaining 25%. Soapy water was an acceptable hand cleaning agent, with the bottle as a feasible dispenser. It was simple in design, cost-effective, replicable, popular with intervention recipient, and neighboring nonrecipients, and commonly shared among nonrelated households. The need to share expenses and product preparation served as a barrier. Developing a sustainable maintenance system, therefore, is critical to ensuring the public health benefits of handwashing with soap.

Behavioral antecedents for handwashing in a low-income urban setting in Bangladesh: an exploratory study

BACKGROUND

Health programs commonly promote handwashing by drawing attention to potential fecal contamination in the environment. The underlying assumption is that the thought of fecal contamination will result in disgust, and motivate people to wash their hands with soap. However, this has not proven sufficient to achieve high rates of handwashing with soap at key times. We argue that handwashing with soap is influenced by broader range of antecedents, many unrelated to fecal contamination, that indicate to people when and where to wash their hands. This exploratory study aimed to identify and characterize this broader range of handwashing antecedents for use in future handwashing promotion efforts.

METHODS

First, an initial list of behavioral antecedents was elicited through unstructured interviews, focus group discussions and observation with residents, from a low-income community in Dhaka, Bangladesh, who were also recipients of a handwashing intervention. Then, photographs representing three categories of behavioral antecedents were taken: activities of daily living, visual or tactile sensations, and handwashing-related hardware and activities. Finally, the research team conducted ranking exercises with a new set of participants, from the same area, to assess the perceived importance of each antecedent illustrated by the photographs. The research team probed about perceptions regarding how and why that particular antecedent, represented by the photograph, influences handwashing behavior.

RESULTS

After coming out of the bathroom and dirt (moyla) on hands were the two antecedents that ranked highest. In all the categories, intervention-related antecedents (three key times for handwashing which included handwashing after coming out of the bathroom, after cleaning a child's anus and before food preparation; intervention provided items that included handwashing station, soapy water bottle, handwashing reminders from posters and community health provider visits) that were being promoted actively in this community were perceived favorably in the qualitative responses, but did not consistently rank higher than non-intervention items. However, many other antecedents were reported to influence when and where people wash their hands: cutting greasy fish, starting a meal, contact with oil and fat stuck to dishes, oil and lice from hair, sweat, unwashed vegetables, reminders from son and daughter or observing others wash hands, and observing the sunset.

CONCLUSIONS

Beyond well-recognized antecedents related to fecal contact and dirt on hands, we identified a broader set of antecedents not reported in the literature. Adopting a handwashing promotional strategy to highlight existing antecedents that people themselves have identified as important can help inform the content of an intervention that is more relatable and effective in increasing handwashing practices.

Prevalence and determinants of acute diarrhea among children younger than five years old in Jabithennan District, Northwest Ethiopia, 2014

Background

Despite the global decline in death rates of children younger than five years old, the risk of a child dying before turning five years of age remains highest in the WHO African Region. The problem of child death in Ethiopia is worse, with an Ethiopian child being 30 times more likely to die by his/her fifth birthday than a child in Western Europe. Therefore, the aim of this study was to assess the prevalence and factors associated with diarrhea among children younger than five years old.

Methods

A community-based, cross-sectional study was conducted with mothers who had children younger than five years old from April to June 2014. A multistage sampling procedure was used to select eligible women. The data were coded, entered, cleaned and analyzed with the SPSS software package, version 16.

Results

he data of 775 mothers were included in the analysis, and 21.5% of the children had diarrhea in the two weeks before the survey. The main factors affecting the occurrence of diarrhea were residence (Odds ratio (AOR) = 11.29, 95% Confidence interval (CI): 3.49-36.52), sex (AOR = 2.52, 95% CI:1.28-4.93), methods of complementary feeding (AOR = 50.88, 95% CI: 23.85- 108.54), types of water storage equipment (AOR = 19.50, 95% CI: 8.11-46.90), and cleansing materials used to wash hands (AOR = 5.53, 95% CI: 2.19-13.99).

Conclusion

Approximately one-fifth of the children included in the study reported diarrheal disease. Residence, sex of the child, type of water storage container, methods of complementary feeding, and cleansing materials to wash the hands were the most important variables that affected the occurrence of diarrhea in children. Therefore, families, the government and nongovernmental organizations working in the area must cooperate in interventions and prevention to minimize the risk of disease.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4021-5) contains supplementary material, which is available to authorized users.

Early-life enteric infections: relation between chronic systemic inflammation and poor cognition in children

The intestinal microbiota undergoes active remodeling in the first 6 to 18 months of life, during which time the characteristics of the adult microbiota are developed. This process is strongly influenced by the early diet and enteric pathogens. Enteric infections and malnutrition early in life may favor microbiota dysbiosis and small intestinal bacterial overgrowth, resulting in intestinal barrier dysfunction and translocation of intestinal bacterial products, ultimately leading to low-grade, chronic, subclinical systemic inflammation. The leaky gut-derived low-grade systemic inflammation may have profound consequences on the gut-liver-brain axis, compromising normal growth, metabolism, and cognitive development. This review examines recent data suggesting that early-life enteric infections that lead to intestinal barrier disruption may shift the intestinal microbiota toward chronic systemic inflammation and subsequent impaired cognitive development.

Determinants of undernutrition among children aged 6 to 59 months in rural Zambézia Province, Mozambique: Results of two population-based serial cross-sectional surveys

BACKGROUND

While many countries are transitioning from epidemics of undernutrition to overnutrition, Mozambique's very high 44% prevalence of stunting in children under age 5 years is cause for serious concern.

METHODS

We conducted two population-based cross-sectional surveys of ~4000 female heads of households each in Zambézia Province, Mozambique from August-September 2010 (Baseline) and April-May 2014 (Endline) as part of the USAID funded Strengthening Communities through Integrated Programs (SCIP) grant. Anthropometric measurements were collected on 560 children aged 6-59 months at Baseline and 912 children at Endline and classified as: "stunted," a height-for-age z-score less than -2; "wasted," weight-for-height z-score less than -2; and "underweight," weight-for-age z-score less than -2. Descriptive statistics and logistic regression using Stata 13.1 were used to examine factors associated with undernutrition.

RESULTS

Of children under age five years, 43% were undernourished in 2010 and 55% in 2014. The most common form of undernutrition was stunting (39% in 2010, 51% in 2014), followed by underweight (13% in both 2010 and 2014), and wasting (7% in 2010, 5% in 2014). Child's age was found to have a non-linear association with stunting. Vitamin A supplementation was associated with a 31% (p=0.04) decreased odds of stunting. Children who were exclusively breastfed for at least six months had an 80% (p=0.02) lower odds of wasting in 2014 and 57% (p=0.05) decreased odds of being underweight in 2014. Introducing other foods after age six months was associated with a five-fold increased odds of wasting in 2014 (p=0.02); household food insecurity was associated with wasting (OR=2.08; p=0.03) and underweight in 2010 (OR=2.31; p=0.05). Children whose mother washed her hands with a cleaning agent had a 40% (p=0.05) decreased odds of being underweight. Surprisingly, per point increase in household dietary diversity score, children had 12% greater odds of being stunted in 2010 (p=0.01) but 9% decreased odds of being underweight in 2014 (p=0.02).

CONCLUSIONS

A combination of household and individual level factors was associated with undernutrition. As such, employment of multidimensional interventions should be considered to decrease undernutrition in children under five years old.

Observed practices and perceived advantages of different hand cleansing agents in rural Bangladesh: ash, soil, and soap

Bangladeshi communities have historically used ash and soil as handwashing agents. A structured observation study and qualitative interviews on the use of ash/soil and soap as handwashing agents were conducted in rural Bangladesh to help develop a handwashing promotion intervention. The observations were conducted among 1,000 randomly selected households from 36 districts. Fieldworkers observed people using ash/soil to wash their hand(s) on 13% of occasions after defecation and on 10% after cleaning a child's anus. This compares with 19% of people who used soap after defecation and 27% after cleaning a child who defecated. Using ash/soil or soap was rarely (< 1%) observed at other times recommended for handwashing. The qualitative study enrolled 24 households from three observation villages, where high usage of ash/soil for handwashing was detected. Most informants reported that ash/soil was used only for handwashing after fecal contact, and that ash/soil could clean hands as effectively as soap.

Prevalence, one week incidence and knowledge on causes of diarrhea: household survey of under-fives and adults in Mkuranga district, Tanzania

Background

Diarrhea is known to be the major cause of mortality in children aged less than five years old. Although mortality from diarrheal disease is decreasing globally, morbidity is not. The objectives of this study were to determine the prevalence of diarrhea among under-fives and assess knowledge on causes of diarrhea among adults in Mkuranga district Tanzania.

Methods

Interviews with heads of households and observations were the methods of data collection employed by this study.

Results

The prevalence of diarrhea in children below the age of five years as reported by heads of households was 6.1% and most affected were children in age groups 12 – 17 and 18 – 23 months (11.6% and 15.8% respectively; p – value 0.001). The rate of diarrhea incidence was 1 episode per 10 children per week. The mean duration of diarrhea illness was 1.7 days. Most under-fives had diarrhea for one (38.1%) or two (24%) days. Respondents in the 4th least poor quintile were more likely to have comprehensive knowledge on causes of diarrhea compared to respondents in the 1st poorest quintile. Male respondents were two times more likely to have comprehensive knowledge than female respondents. Respondents with comprehensive knowledge on causes of diarrhea were less likely to have poor hand-washing practice and more likely to have received water, hygiene and sanitation education. Under-fives in age group 12 – 17 months and those from households with reported poor hand washing practice were more likely to experience diarrhea episodes.

Conclusion

Although prevalence of diarrhea reported in this study is low, the one week incidence is moderately high but less severe. Majority of household respondents had inadequate knowledge on causes of diarrhea and poor hand-washing practice. There is a need to provide WASH education to improve their knowledge on causes of diarrhea and hand washing practice.