Spatial prevalence and associated risk factors of childhood diarrhea: A cross-sectional study in rural Indian context
Diarrheal disease is the most prevalent health issue among children under the age of five, contributing to a staggering toll of approximately 525,000 deaths worldwide each year. Despite its devastating consequences, it is essential to note that this disease is both preventable and treatable. The present study aims to investigate the prevalence of childhood (under 5 years) diarrheal disease in rural parts of India and identify relevant factors associated with diarrheal disease, encompassing maternal, household, environmental, and individual-level characteristics. In addition, the study highlights the spatial distribution of diarrheal disease across India, identifying hot-spot and cold-spot regions, along with the associated risk factors. The study utilized secondary data extracted from the fifth round of the National Family Health Survey, conducted in India between 2019 and 2021 (N=161,368). Binary logistic regression analysis and spatial clustering techniques, specifically utilizing Global Moran’s I, were employed to achieve the study’s objectives. The findings revealed that diarrhea cases are more prevalent among the poor, rural, and children of Muslim families, as well as among those residing in environments lacking hygienic or adequate sanitation facilities and in households without floors, walls, or roofs built with concrete material. The highest prevalence is observed in the eastern and western parts of India. Necessary interventions are required to reduce diarrhea cases among children under the age of five in rural Indian areas. Given the vector-borne nature of this disease, public awareness of the importance of maintaining fresh and clean drinking water facilities is imperative.
Agegnehu, M.D., Bewket Zeleke, L., Goshu, Y.A., Ortibo, Y.L., & Mehretie Adinew, Y. (2019). Diarrhea prevention practice and associated factors among caregivers of under-five children in Enemay District, Northwest Ethiopia. Journal of Environmental and Public Health, 2019:5490716. https://doi.org/10.1155/2019/5490716
Agmas, Y.A., & Asmare, A.A. (2022). Trends and determinants of Anemia among under-five children in Gambia, evidence from 2013-2019/2020 Gambian demographic and health survey; multilevel binary logistic regression and multivariate decomposition analysis. Journal of Nutrition, 8:1-20. https://doi.org/10.17303/jfn.2022.8.102
Asfaha, K.F., Tesfamichael, F.A., Fisseha, G.K., Misgina, K.H., Weldu, M.G., Welehaweria, N.B., et al. (2018). Determinants of childhood diarrhea in Medebay Zana District, Northwest Tigray, Ethiopia: A community based unmatched case-control study. BMC Pediatrics, 18(1):120. https://doi.org/10.1186/s12887-018-1098-7
Atnafu, A., Sisay, M.M., Demissie, G.D., & Tessema, Z.T. (2020). Geographical disparities and determinants of childhood diarrheal illness in Ethiopia: Further analysis of 2016 Ethiopian demographic and health survey. Tropical Medicine and Health, 48:64. https://doi.org/10.1186/s41182-020-00252-5
Azage, M., Kumie, A., Worku, A., Bagtzoglou, A.C., & Anagnostou, E. (2017). Effect of climatic variability on childhood diarrhea and its high risk periods in northwestern parts of Ethiopia. PLoS One, 12(10):e0186933. https://doi.org/10.1371/journal.pone.0186933
Bado, A.R., Susuman, A.S., & Nebie, E.I. (2016). Trends and risk factors for childhood diarrhea in Sub-Saharan countries (1990-2013): Assessing the neighborhood inequalities. Global Health Action, 9(1):30166. https://doi.org/10.3402/gha.v9.30166
Badowski, N., Castro, C.M., Montgomery, M., Pickering, A.J., Mamuya, S., & Davis, J. (2011). Understanding household behavioral risk factors for diarrheal disease in Dar es Salaam: A photovoice community assessment. Journal of Environmental and Public Health, 2011:130467. https://doi.org/10.1155/2011/130467
Bah, D., Gebru, G., Hakizimana, J.L., Ogbonna, U., Sesay, B., Bah, B., et al. (2022). Prevalence and risk factors of diarrheal diseases in Sierra Leone, 2019: A cross-sectional study. The Pan African Medical Journal, 41:3. https://doi.org/10.11604/pamj.2022.41.3.32403
Bakir, H., Hadi, M., & Jurdi, M. (2017). Towards a renewed public health regulatory and surveillance role in water, sanitation and hygiene. Eastern Mediterranean Health Journal, 23(8):525-526.
Behera, D.K., & Mishra, S. (2022). The burden of diarrhea, etiologies, and risk factors in India from 1990 to 2019: Evidence from the global burden of disease study. BMC Public Health, 22(1):92. https://doi.org/10.1186/s12889-022-12515-3
Bowen, A., Agboatwalla, M., Luby, S., Tobery, T., Ayers, T., & Hoekstra, R.M. (2012). Association between intensive handwashing promotion and child development in Karachi, Pakistan: A cluster randomized controlled trial. Archives of Pediatrics and Adolescent Medicine, 166(11):1037-1044. https://doi.org/10.1001/archpediatrics.2012.1181
Chopra, M., Binkin, N.J., Mason, E., & Wolfheim, C. (2012). Integrated management of childhood illness: What have we learned and how can it be improved? Archives of Disease in Childhood, 97(4):350-354. https://doi.org/10.1136/archdischild-2011-301191
Colombara, D.V., Hernández, B., McNellan, C.R., Desai, S.S., Gagnier, M.C., Haakenstad, A., et al. (2016). Diarrhea prevalence, care, and risk factors among poor children under 5 years of age in Mesoamerica. The American Journal of Tropical Medicine and Hygiene, 94(3):544. https://doi.org/10.4269%2Fajtmh.15-0750
Dev, A., Taywade, M., Mishra, A., & Behera, B.K. (2022). Time to revamp existing integrated child development services logo contextual with 21st century. MRIMS Journal of Health Sciences, 10(2):32. https://doi.org/10.4103/mjhs.mjhs_50_21
Didcock, E., & Polnay, L. (2001). Pioneers, paediatricians and public health: The evolution of community child health services, Clifton, Nottingham 1983-1999. Public Health, 115(6):412-417. https://doi.org/10.1038/sj.ph.1900789
Diouf, K., Tabatabai, P., Rudolph, J., & Marx, M. (2014). Diarrhea prevalence in children under five years of age in rural Burundi: An assessment of social and behavioural factors at the household level. Global Health Action, 7(1):24895. https://doi.org/10.3402/gha.v7.24895
Egbewale, B.E., Karlsson, O., & Sudfeld, C.R. (2022). Childhood diarrhea prevalence and uptake of oral rehydration solution and zinc treatment in Nigeria. Children (Basel), 9(11):1722. https://doi.org/10.3390/children9111722
Escobar, A.L., Coimbra, C.E. Jr., Welch, J.R., Horta, B.L., Santos, R.V., & Cardoso, A.M. (2015). Diarrhea and health inequity among Indigenous children in Brazil: Results from the first national survey of indigenous people’s health and nutrition. BMC Public Health, 15(1):191. https://doi.org/10.1186/s12889-015-1534-7
Fagbamigbe, A.F., Oyinlola, F.F., Morakinyo, O.M., Adebowale, A.S., Fagbamigbe, O.S., & Uthman, A.O. (2021). Mind the gap: What explains the rural-nonrural inequality in diarrhea among under-five children in low and medium-income countries? A decomposition analysis. BMC Public Health, 21(1):575. https://doi.org/10.1186/s12889-021-10615-0
Getachew, A., Tadie, A., Hiwot, M.G., Guadu, T., Haile, D., Cherkos, T.G., et al. (2018). Environmental factors of diarrhea prevalence among under five children in rural area of North Gondar zone, Ethiopia. Italian Journal of Pediatrics, 44(1):95. https://doi.org/10.1186/s13052-018-0540-7
Ghosh, K., Chakraborty, A.S., & Mog, M. (2021). Prevalence of diarrhoea among under five children in India and its contextual determinants: A geo-spatial analysis. Clinical Epidemiology and Global Health, 12:100813. https://doi.org/10.1016/j.cegh.2021.100813
Ghosh, K., Chakraborty, A.S., & Sen Gupta, S. (2023). Identifying spatial clustering of diarrhoea among children under 5 years across 707 districts in India: A cross sectional study. BMC Pediatrics, 23(1):272. https://doi.org/10.1186/s12887-023-04073-3
Hodge, J., Chang, H.H., Boisson, S., Collin, S.M., Peletz, R., & Clasen, T. (2016). Assessing the association between thermotolerant coliforms in drinking water and diarrhea: An analysis of individual-level data from multiple studies. Environmental Health Perspectives, 124(10):1560-1567. https://doi.org/10.1289/EHP156
Hussein, H. (2017). Prevalence of Diarrhea and Associated Risk Factors in children under five Years of Age in Northern Nigeria: A Secondary Data Analysis of Nigeria Demographic and Health Survey 2013. Unpublished Degree Project. Sweden: Uppsala Universitet.
International Institute for Population Science, (1956). Available from: https://www.iipsindia.ac.in/content/nfhs-project. 2019-2021 [Last accessed on 2024 May 20].
International Classification of Functioning, (1980). Available from: https://www.cdc.gov/nchs/icd/icf.htm#:~:text=After%20 ten%20years%20of%20international,in%201980%20 (and%20then%20called [Last accessed on 2024 May 20].
Kamath, A., Shetty, K., Unnikrishnan, B., Kaushik, S., & Rai, S.N. (2018). Prevalence, patterns, and predictors of diarrhea: A spatial-temporal comprehensive evaluation in India. BMC Public Health, 18:1288. https://doi.org/10.1186/s12889-018-6213-z
Kapwata, T., Mathee, A., Le Roux, W.J., & Wright, C.Y. (2018). Diarrheal disease in relation to possible household risk factors in South African villages. International Journal of Environmental Research and Public Health, 15(8):1665. https://doi.org/10.3390/ijerph15081665
Kattula, D., Francis, M.R., Kulinkina, A., Sarkar, R., Mohan, V.R., Babji, S., et al. (2015). Environmental predictors of diarrheal infection for rural and urban communities in south India in children and adults. Epidemiology and Infection, 143(14):3036-3047. https://doi.org/10.1017/S0950268814003562
Khan, A.M., & Chhabra, P. (2021) Strategies to improve maternal, infant and young child nutrition under POSHAN Abhiyaan by involvement of community medicine departments of medical colleges in India. Healthline. 2021;12(3):3-6. https://doi.org/10.51957/healthline_278_2021
Lakshminarayanan, S., & Jayalakshmy, R. (2015). Diarrheal diseases among children in India: Current scenario and future perspectives. Journal of Natural Science, Biology, and Medicine, 6(1):24-28. https://doi.org/10.4103%2F0976-9668.149073
Machava, N.E., Mulaudzi, F.M., & Salvador, E.M. (2022). Household factors of foodborne diarrhea in children under five in two districts of maputo, mozambique. International Journal of Environmental Research and Public Health, 19(23):15600. https://doi.org/10.3390/ijerph192315600
Mbugua, S., Musikoyo, E., Ndungi, F., Sang, R., Kamau- Mbuthia, E., & Ngotho, D. (2014). Determinants of diarrhea among young children under the age of five in Kenya, evidence from KDHS 2008-09. African Population Studies, 28:1046-1056. https://doi.org/10.11564/28-0-556
Melese, B., Paulos, W., Astawesegn, F.H., & Gelgelu, T.B. (2019). Prevalence of diarrheal diseases and associated factors among under-five children in Dale District, Sidama zone, Southern Ethiopia: A cross-sectional study. BMC Public Health, 19(1):1235. https://doi.org/10.1186/s12889-019-7579-2
Mohammed, S., & Tamiru, D. (2014). The burden of diarrheal diseases among children under five years of age in Arba Minch District, southern Ethiopia, and associated risk factors: A cross-sectional study. International Scholarly Research Notices, 2014:654901. https://doi.org/10.1155/2014/654901
Moon, J., Choi, J.W., Oh, J., & Kim, K. (2019). Risk factors of diarrhea of children under five in Malawi: Based on Malawi demographic and health survey. Journal of Global Health Science. 1(2):e45. https://doi.org/10.35500/jghs.2019.1.e45
Mosisa, D., Aboma, M., Girma, T., & Shibru, A. (2021). Determinants of diarrheal diseases among under five children in Jimma Geneti District, Oromia region, Ethiopia, 2020: A case-control study. BMC Pediatrics, 21(1):532. https://doi.org/10.1186/s12887-021-03022-2
Nasir, W.A., Saw, Y.M., Jawid, S., Kariya, T., Yamamoto, E., & Hamajima, N. (2020). Determinants of diarrhea in children under the age of five in Afghanistan: A secondary analysis of the Afghanistan demographic and health survey 2015. Nagoya Journal of Medical Science, 82(3):545. https://doi.org/10.18999%2Fnagjms.82.3.545
Nhampossa, T., Mandomando, I., Acacio, S., Quintó, L., Vubil, D., Ruiz, J., et al. (2015). Diarrheal disease in rural Mozambique: Burden, risk factors and etiology of diarrheal disease among children aged 0-59 months seeking care at health facilities. PLoS One, 10(5):e0119824. https://doi.org/10.1371/journal.pone.0119824
Niehaus, M.D., Moore, S.R., Patrick, P.D., Derr, L.L., Lorntz, B., Lima, A.A., et al. (2002). Early childhood diarrhea is associated with diminished cognitive function 4 to 7 years later in children in a Northeast Brazilian shantytown. The American Journal of Tropical Medicine and Hygiene, 66(5):590-593. https://doi.org/10.4269/ajtmh.2002.66.590
Pahmi, L., & Endah, W.C. (2019). Household risk factors on the event of diarrhea disease: In children under five years old in Indonesia (Secondary Data Analysis’ 2017 Idhs). Jurnal Ilmu Kesehatan Masyarakat, 10(1):50-58. https://doi.org/10.26553/jikm.2019.10.1.50-58
Paul, P. (2020). Socio-demographic and environmental factors associated with diarrhoeal disease among children under five in India. BMC Public Health, 20(1):1886. https://doi.org/10.1186/s12889-020-09981-y
Saha, J., Mondal, S., Chouhan, P., Hussain, M., Yang, J., & Bibi, A. (2022). Occurrence of diarrheal disease among under-five children and associated sociodemographic and household environmental factors: An investigation based on national family health survey-4 in rural India. Children (Basel), 9(5):658. https://doi.org/10.3390/children9050658
Sinmegn Mihrete, T., Asres Alemie, G., & Shimeka Teferra, A. (2014). Determinants of childhood diarrhea among underfive children in Benishangul Gumuz regional state, north West Ethiopia. BMC Pediatrics, 14:102. https://doi.org/10.1186/1471-2431-14-102
Siziya, S., Muula, A.S., & Rudatsikira, E. (2009). Diarrhoea and acute respiratory infections prevalence and risk factors among under-five children in Iraq in 2000. Italian Journal of Pediatrics, 35(1):8. https://doi.org/10.1186/1824-7288-35-8
Srivastava, S., Banerjee, S., Debbarma, S., Kumar, P., & Sinha, D. (2022). Rural-urban differentials in the prevalence of diarrhoea among older adults in India: Evidence from longitudinal ageing study in India, 2017-18. PLos One, 17(3):e0265040. https://doi.org/10.1371/journal.pone.0265040
Tesfaye, T.S., Magarsa, A.U., & Zeleke, T.M. (2020). Moderate to severe diarrhea and associated factors among under-five children in Wonago District, South Ethiopia: A cross-sectional study. Pediatric Health, Medicine and Therapeutics, 11:437-443. https://doi.org/10.2147/PHMT.S266828
Troeger, C., Blacker, B.F., Khalil, I.A., Rao, P.C., Cao, S., Zimsen, S.R., et al. (2018). Estimates of the global, regional, and national morbidity, mortality, and aetiologies of diarrhea in 195 countries: A systematic analysis for the global burden of disease study 2016. The Lancet Infectious Diseases, 18(11):1211-1228. https://doi.org/10.1016/S1473-3099(18)30362-1
Unicef, & WHO. (2024). Diarrhea. Why Children are Still Dying and What can be Done. Available from: https://apps.who. int/iris/bitstream/10665/44174/1/9789241598415_eng.pdf
UNICEF. (2005). The State of the World’s Children 2006: Excluded and Invisible. United States: UNICEF.
WHO. (2020). WHO and the Maternal and Child Epidemiology Estimation Group (MCEE) Estimates. Switzerland: WHO.
WHO/UNICEF Joint Water Supply, Sanitation Monitoring Programme, World Health Organization, WHO/UNICEF Joint Monitoring Programme for Water Supply, & UNICEF. (2005). Water for Life: Making it Happen. Switzerland: World Health Organization.
Workie, G.Y., Akalu, T.Y., & Baraki, A.G. (2019). Environmental factors affecting childhood diarrheal disease among under-five children in Jamma district, South Wello zone, Northeast Ethiopia. BMC Infectious Diseases, 19:804. https://doi.org/10.1186/s12879-019-4445-x
World Health Organization. (2021). Diarrhea: Why Children are Still Dying and what can be Done. 2009. Geneva: UNICEF/ WHO.
Zedie, F.B., & Kassa, D.H. (2018). Socio-economic, behavioral and environmental factors associated with diarrhea among under five children in health development and non-health development army member mothers in Wondogenet, south Ethiopia. Health Education and Care, 3(3):1-8.