Diarrhoeal diseases and its associated factors among ...

The Health Agenda, Volume 3. Issue 3. July, 2015

ORIGINAL ARTICLE: Online Ahead of Publication

Diarrhoeal diseases and its associated factors among children 1-5 years of age
in a rural area of Jammu

Authors: Shivali Suri and Dinesh Kumar

Corresponding author: Dr. Shivali Suri, Senior Resident
Department of Community Medicine
Lady Hardinge Medical College & Associated Hospitals
New Delhi 110001
Mail ID: [email protected]

ABSTRACT

Background: Mortality due to diarrhoea has declined in the recent years; still, it is the second leading
cause of death in children under five years of age, leading to 13% of deaths in this age-group. Objectives:
To study the burden of diarrhoeal diseases among children 1-5 years of age, and to study its association
with socio-demographic and dietary factors. Methodology: 750 children from 15 clusters comprising of
50 subjects from each cluster were selected using multi-stage random sampling technique. Mothers
(or care-giver) of the eligible children were interviewed to obtain information whether their children had
diarrhoea in the last 2 weeks preceding date of interview and factors like age, gender, socio-economic
status of the family, breast-feeding and complementary feeding practices, Vit-A prophylaxis received,
along with the nutritional status of the child. Results: The prevalence of diarrhoea in the sample studied
was 21.2%. Diarrhoea was found to be significantly associated with age of the child (p value <0.001) and
socio-economic status of the family (p value 0.01). The prevalence of diarrhoea was found to be high
(22.6%) among children who started weaning after the age of 12 months. There was a negative
association between prevalence of diarrhoea with Vit-A supplementation (p value 0.01) and nutritional
status (p value 0.01). Conclusion: Diarrhoea continues to be burdensome morbidity among under-fives.
Effective implementation of factors considered as essential components of various child care programmes
like nutrition education, growth monitoring, appropriate age of weaning, Vit-A supplementation along
with improvement of nutritional status of the children needs emphasis.

Key words: Diarrhoeal diseases, Under five Children, Weaning

INTRODUCTION The diarrhoeal diseases cause huge economic
burden on the health services. For children
Diarrhoeal diseases have long been a major under 5 years, 3-5 episodes of diarrhoea occur
public health concern of low-income countries per child-year which is similar to that reported
leading to high morbidity and mortality among in the previous decades. (4) Research to identify
under-five children. WHO initiated Diarrhoeal new preventive and treatment recommend-
Diseases Control Programme in 1980, and since dations for diarrhoea should continue for better
then, total number of deaths due to diarrhoea in understanding of the factors which lead to high
children aged less than five years has declined child mortality and morbidity attributable to
globally. In spite of this, diarrhoeal disease diarrhoea. While diarrhoeal diseases have been
continues to be the second leading cause of controlled to a greater extent, the relative
death in children under five years old, and is burden in under-five morbidity and mortality
responsible for killing around 7,60,000 children continues to be high.
every year. (1) Reports suggest that as many as
13% of death in this age-group (3 lakh children OBJECTIVES
per year) occur due to diarrhoea. (2) In India, as
per WHO 2012 estimates, diarrhoeal diseases In view of this, need was felt to conduct a study
were responsible for 11% of child mortality in with objectives, to study the burden of diarrhoea
age group of 1- 5 years. (3) among children 1-5 years of age, and to study its
association with socio-demographic and dietary
factors.

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The Health Agenda, Online ISSN No: 2320-3749

Suri S, Kumar D: Diarrhoeal diseases and its associated factors among children

METHODOLOGY The questionnaire used was pre-tested and then
modified based on difficulties in understanding
The present community based cross-sectional or interpretation that were encountered. The
study was conducted in Block R. S. Pura, a rural questionnaire written in English was translated
field practice area of Postgraduate Department to local language (Dogri) and again translated
of Community Medicine, Government Medical back to English to ensure its accuracy. The data
College, Jammu; located at a distance of 23 Kms were analysed using SPSS software for windows
from GMC Jammu. The population of the block (version 11.5). Chi-square test was used to
was 1,80,560 as per census 2001, spread over determine the statistical significance of
198 villages. (5) The block is divided into eight difference in prevalence of under-nutrition with
zones for the purpose of administration. The various risk factors. A probability of less than
study was conducted between Jan-Dec 2011 0.5 was considered statistically significant.
after obtaining approval from the Institutional
Ethics Committee of Government Medical RESULTS
College and Hospital, Jammu.
Table 1 depicts the salient characteristics of
Multi-stage random sampling technique was study population. Of the total 750 children
used, wherein zones formed the 1st stage units, studied in 15 villages of Block R. S. Pura, Jammu,
villages 2nd stage units and eligible children two-third (65.5%) were in the age group of 1-3
formed the 3rd stage unit. Two villages from each years and the mean age of children was
of the first seven zones were picked up 33.45±12.7 months. 58.4% of the children were
randomly, while only one village was picked up boys. Majority (84.5%) of children belonged to
from the last remaining eighth zone thus middle SES (upper middle 24.3%, middle 44.1%
providing all the 15 clusters needed for the and lower middle 16.1%) families as per
study. A total of 750 subjects were studied with modified Uday-Pareek Scale.
50 subjects drawn from each of the 15 clusters.
In case a sample of 50 households with children The association of diarrhoea with socio-
1-5 years was not available in that village, demographic characteristics has been shown in
remaining children were taken from next Table 1. Majority (72.3%) of the children with
geographically closest village. diarrhoea were in younger age group (47.8% in
1-2 years; 24.5% in 2-3 years). Prevalence of
Mothers (or another responsible care-giver) of diarrhoea was found to be significantly
the eligible children were interviewed at their associated with age of the child (p value <0.001),
place of residence. Mothers were inquired about and decreasing with advancing age. Though the
history of diarrhoea in their children within 14 diarrhoeal episodes were found to have no
days prior to the day of interview. The significant association with gender of the child
operational definition that was used for (p value 0.26), majority of the subjects with
diagnosing diarrhoea was passage of loose, diarrhoea were boys (62.2%). Socio-economic
liquid or watery stools passed more than three status also showed significant association with
times a day. prevalence of diarrhoea (p value 0.008).

The mothers were also asked about history of Table 2 shows 46.4% children had history of
other characteristics like age and gender of the exclusive breastfeeding for six months, but it
child, socio-economic status of the family was not found to be significantly associated with
(determined using modified Uday-Pareek Scale) diarrhoea (p value 0.34). The duration of breast
(6), breast-feeding and complementary feeding feeding was also found to have no significant
(weaning) practices adopted, number of doses association with presence of under-nutrition (p
of Vitamin A prophylaxis received in the last six value 0.32). 66.7% of the children started
months along with the nutritional status of the weaning around 6-8 months and the age at
child. The nutritional status was assessed by which weaning was initiated was found to have
anthropometric examinations recording the significant association with prevalence of
mid-upper-arm circumference (MUAC) to the diarrhoea. The prevalence of diarrhoea was
nearest 0.1 cm. (7) found to be high (22.6%) in the subjects who
started weaning after the age of 12 months.

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The Health Agenda, Volume 3. Issue 3. July, 2015

Table 1: Socio-demographic characteristics of study children

Characteristics Present [159] Diarrhoea Total [750] p value
N (%) Absent [591] N (%) < 0.001
Age (in months)
12-24 N (%) 251(33.5) 0.26
25-36 241(32.1) 0.008
37-48 76 (47.8) 175 (29.6) 177(23.6)
49-60 39 (24.5) 202 (34.2) 81(10.8)
Gender 34 (21.4) 143 (24.2)
Boys 10 (6.3) 71 (12.0) 438(58.4)
Girls 312(41.6)
Socio-economic status 99 (62.3) 339 (57.4)
Upper 60 (37.7) 252 (42.6) 74(9.9)
Upper-middle 182(24.3)
Middle 16 (10.1) 58 (9.8) 331(44.1)
Lower-middle 31 (19.5) 151 (25.5) 121(16.1)
Lower and BPL 61 (38.4) 270 (45.7) 42 (5.6)
39 (24.5) 82 (13.9)
12 (7.5)
30 (5.1)

Table 2: Factors associated with diarrhoea among children 1-5 years of age

Characteristics Present [159] Diarrhoea Total [750] p value
Absent [591] N (%) 0.34
N (%) 0.32
N (%) 348 (46.4)
Exclusive breastfeeding 402 (53.6) 0.001
269 (45.5) 0.002
Present 79 (49.7) 322 (54.5) 59 (7.9) 0.01
171 (22.8)
Absent 80 (50.3) 42 (7.1) 140 (18.7)
140 (23.7) 262 (34.9)
Duration of breastfeeding (months) 106 (17.9) 118 (15.7)
206 (34.9)
None 17 (10.7) 97 (16.4) 91 (12.1)
500 (66.7)
1-6 31 (19.5) 77 (13)
396 (67.0) 48 (6.4)
7-12 34 (21.4) 6 (0.8)
44 (7.4) 105 (14.0)
13-24 56 (35.2) 5 (0.8)
69 (11.7) 96 (14.9)
> 24 21 (13.2) 546 (85.1)
65 (12.8)
Age at weaning (months) 443 (87.2) 213 (28.4)
537 (71.6)
< 6 months 14 (8.8) 155 (26.2)
436 (73.8)
6-8 months 104(65.4)

8-10 months 4 (2.5)

10-12 months 1 (0.6)

> 12 months 36 (22.6)

Vitamin A supplementation*

Received 31 (23.1)

Not received 103(76.9)

Nutritional status

Under-nutrition 58 (36.5)

Normal 101(63.5)

(*Percentage calculated out of 642 children. For rest of the 108 children, documented evidence of having received Vit A
was not available.)

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Suri S, Kumar D: Diarrhoeal diseases and its associated factors among children

Table 3: Prevalence of diarrhoea among DISCUSSION
children aged 1-5 years in rural area of
Jammu The present study had majority of children in
younger age-group (12-36 months). As the age
Under-five children of children increased in the study population,
lesser children were available for the study
Sr. Village with H/O diarrhoea possibly because the older children were
No. (50 from each village) attending schools during the study hours.
Majority of the surveyed children comprised of
N (%) boys (58.4%), which is in accordance with the
skewed sex ratio of our country revealed by
1 Maralia 21 (42) census 2011. (8) 44.1% of the surveyed children
belonged to middle socio-economic status as
2 Tanda, Mahlowal 19 (38) classified by the Modified Uday-Pareek Scale.

3 Chakrohi 14 (28) In the present study, it was observed that
younger children had higher prevalence of
4 Kadarpur 14 (28) diarrhoea. Nearly three-fourth of children
(72.3%) with diarrhoea were in the age group of
5 Sidhra 12 (24) 1-3 years. The results obtained in our study are
concordant to those reported by NFHS-3 which
6 Hara Pir 11 (22) states that diarrhoea is more common in
younger children. (9) Lakshminarayanan and
7 Dablehar 11 (22) Singh et al also observed that younger aged
children were at higher risk of diarrhoea. (2,10)
8 Jasore 10 (20) Ahmed et al and Mengistie et al also observed
that the prevalence of diarrhoea decreased
9 Simbal 9 (18) significantly with increasing age. (11,12) Kanungo
et al and Patel et al also reported similar
10 Krishna Nagar 8 (16) findings in their studies. (13,14) This pattern may
be due to the fact that increased exposure to
11 Rangpur 7 (14) contaminated foods occurs in younger age group
coupled with lower immunity in such age.
12 Nanuwali, Mana 6 (12)
No gender differentials in the propensity to have
13 Karan Basti 6 (12) diarrhoeal episodes were observed in the
present study. Our findings are in conformity to
14 Chakbala 6 (12) those made by Jha et al who conducted a study
in Pune in 2014 among children aged 1-4 years
15 Dher Camp, Fagle 5 (10) and found that gender was not associated with
prevalence of diarrhoea in children. (15) The
Total 159 (21.2) findings of the present study are similar to those
reported by Mengistie et al and Kanungo et al.
The propensity to take supplementary doses of (12,13) Studies conducted by other authors
Vitamin A was found to be very meagre in the including Singh et al and Ahmed et al, also
study population with only 14.9% children suggested similar findings. (10,11)
receiving a dose of Vitamin A in the last six
months. There was a significant association of Socio-economic status (SES) has been found to
Vitamin A supplementation with the prevalence be significantly associated with increased risk of
of diarrhoea in the study children (p value 0.01), diarrhoea in the children. The findings of our
suggesting that Vitamin A supplementation study are similar to those reported by
acted as a protective factor against the Lakshminarayanan et al who observed that the
development of diarrhoea in them. difference in prevalence of diarrhoea was

Significant association was seen between the Page | 4
nutritional status and prevalence of diarrhoea in
the study children (p value 0.01). The
prevalence of under-nutrition in the study
subjects was 28.4%. Out of the total children
with diarrhoea, 36.5% had poor nutritional
status as measured by their mid-upper-arm
circumference using the cut-offs suggested by
WHO.

Table 3 shows the overall prevalence of
diarrhoea in the children in the 15 study
villages. 21.2% of the study children had history
of diarrhoea in last two weeks. The prevalence
in the study villages of R. S. Pura block ranges
from 42% in Maralia, 38% in Tanda and
Mahlowal to 10% in Dher camp and Fagle.

The Health Agenda, Volume 3. Issue 3. July, 2015

statistically significant among lower socio- In the present study it was observed that the
economic groups than higher SES. (2) Kanungo et overall prevalence of diarrhoea in the study
al also observed that the children living in lower children was high with almost one-fifth (21.2%)
socio-economic status were significantly of them suffering from it in the past 14 days. The
associated with higher prevalence of diarrhoea high prevalence of diarrhoea in our study
in them. (13) corroborates with the findings of Ahmed et al
who conducted a study in Kashmir and found
The present study revealed that breastfeeding the prevalence of 25.2% in under-five children.
had no significant impact on the prevalence of (11) According to NFHS-3 survey, the prevalence
diarrhoea in children. The findings of the of diarrhoea in children less than one year of age
present study are similar to those reported by was 9%. (9) Bandyopadhyay et al found a higher
Mengistie et al, who found that diarrhoea was prevalence of 31.6% among under-five children
not significantly associated with duration of in Kolkata. (16) The prevalence of diarrhoea has
breastfeeding.(12) Bandyopadhyay et al also been reported to range from 22.5% by Mengistie
observed similar findings in their study. (16) et al, 51% by Shah et al and 63.5% by Alaa et al.

We found that age at which the children started (12,20,21)
complementary feeding (weaning) was
significantly associated with the prevalence of Many other factors have been linked with
diarrhoea in them. Rasania et al observed that at diarrhoea among under-five children including
the optimum age of 4-6 months, 42.9% children parents’ education, occupation, family type,
started weaning and had a lower prevalence of family size, use of toilet, source of water etc.
under-nutrition. (17) These factors have been studied in detail by a
number of authors in their studies but were not
Diarrhoea dehydrates the body, weakens the included in the present study due to constraint
immune system and impedes body’s ability to of time and resources.
absorb nutrients from the diet. These events
lead to a vicious circle, wherein children become CONCLUSION
malnourished, which further enhances their
susceptibility to infections. Study revealed that The present study reiterates the fact that
36.5% of the children with diarrhoea had diarrhoeal diseases exist as a public health
presence of under-nutrition. These findings are problem in the study area. Multi-pronged
very close to those reported by Gupta A who approaches like maternal and child health care,
conducted a study in under-fives in Punjab and nutrition education, growth monitoring,
found 46% children with diarrhoea were improvement of socio-economic status,
suffering from under-nutrition (p value <0.001). appropriate age of weaning, Vitamin A
(18) Jha et al in 2014 had similarly found that supplementation along with improvement of
children with under-nutrition were at 2.4 times nutritional status of the children need to be
higher risk of diarrhoea than normal children. encouraged to combat the morbidity and
(15) Lakshminarayanan et al also found that mortality caused due to diarrhoeal diseases.
diarrhoea was more common in children with
malnutrition. (2) Rice et al (2000) concluded that Acknowledgement
there is a consistent relationship between
malnutrition and increased risk of death due to The authors thank faculty and students of
diarrhoea. (19) Patel et al and Shah et al also Department of Community Medicine,
found a high prevalence of diarrhoea among Government Medical College, Jammu for their
children with malnutrition. (14,20) constant support and encouragement during the
research period.

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Suri S, Kumar D: Diarrhoeal diseases and its associated factors among children

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Particulars of contributors: Source of funding: Nil
1. Dr. Shivali Suri, Senior Resident Conflict of interest: None
Date of Submission: 7 May 2015
Dept. of Community Medicine Date of Acceptance: 2 June 2015
Lady Hardinge Medical College & Associated Hospitals Date of Publishing:

2. Dr. Dinesh Kumar, Associate Professor and Head Page | 6
Dept. of Community Medicine
Govt. Medical College & Associated Hospital, Jammu