Skip to main content
NCBI home page
Preventive Medicine Reports logoLink to Preventive Medicine Reports
. 2024 Feb 23;40:102666. doi: 10.1016/j.pmedr.2024.102666

Factors associated with acute watery diarrhea among children aged 0–59 months in Obongi District, Uganda, April 2022: A case–control study

Edirisa Juniour Nsubuga a,⁎, Jireh Kirabo b, Andrew Kwiringira a, Linus Andaku c, Saharu Magona Nerima b, Fred Nsubuga d, Rashida Nakazzi e, Benon Kwesiga a, Lilian Bulage a, Daniel Kadobera a, Paul Edward Okello a, Alex Riolexus Ario a
PMCID: PMC10904186  PMID: 38435417

Highlights

  • •

    Poor caregiver hand hygiene linked to acute watery diarrhea in children.

  • •

    Source of water in a home was associated with acute watery diarrhea in children.

  • •

    Rotavirus vaccination only, not enough to prevent acute watery diarrhea in children.

  • •

    Educate communities on handwashing at critical times, using clean water & soap.

  • •

    Stresses need for treated pipped/tap water in every household.

Keywords: Case–control study, Acute watery diarrhea, Children 0–59 months, Associated factors, Comorbidity, Obongi District, Uganda

Abstract

Background

Diarrheal diseases, are major concerns for Ugandan children; persistent in Obongi District despite high rotavirus vaccination rates (2019–2021). The district recorded the country's highest annual acute watery diarrhea (AWD) incidence from 2017 to 2021. Our study, conducted in April 2022, assessed AWD risk factors among 0–59-month-old children in Obongi.

Methods

We conducted a 1:2 (193:386) unmatched case–control study. A case was a child (0–59 months) with ≥ 3 loose/liquid stools/day, negative malaria/pneumonia tests, residing in Itula/Parolinya subcounty from 1 to 30 April 2022. Medical records from 10 facilities were reviewed. Simple random sampling identified cases, who were interviewed, and controls were randomly chosen from non-AWD neighboring households. Child health cards provided vaccination details. We used logistic regression to identify factors associated with AWD.

Results

Among 193 cases and 386 controls, 104 (54 %) cases and 183 (47 %) controls were male, 58 (30 %) cases and 127 (33 %) controls were aged 12–23 months, 187 (97 %) cases and 369 (96 %) controls had received at least one dose of rotavirus vaccine, 58 (30 %) cases and 120 (34 %) controls treated drinking water. Comorbidity presence (undernutrition, diabetes, HIV) (AOR = 12; CI: 2.5–53), caregiver's unwashed hands post-toilet (AOR = 3.9; CI: 1.2–13), and borehole vs. piped water (AOR = 4.0; CI: 1.7–9.6) linked to AWD.

Conclusion

Modifiable factors, including failure of caregivers to wash their hands with soap after visiting toilets and use of borehole water were associated with AWD, suggesting that community sensitization on handwashing at critical times, using clean water and soap, and expanded use of piped water could reduce AWD incidence in this area.

1. Background

Acute watery diarrhea (AWD) is the abrupt onset of three or more loose stools per day that can last up to two weeks (Drugs and Diseases: Pediatrics: General Medicine: Diarrhea [Internet]. Medscape., 2020). It is the second-leading cause of mortality among children aged 0–59 months worldwide, causing an estimated 525,000 deaths and 1.7 billion child cases annually (Diarrhoeal disease Fact Sheet [Internet]. World Health Organisation (WHO)., 2017). AWD can be caused by bacteria, viruses, or parasites spread through the fecal oral route (Diarrhoeal disease Fact Sheet [Internet]. World Health Organisation (WHO)., 2017). In Uganda, AWD is among the top ten causes of morbidity in children aged 0–59 months, accounting for up to 8 % of all outpatient visits (MoH, 2022).

The World Health Organization (WHO) recommends the use of the rotavirus vaccine, in addition to treatment packages and preventive strategies such as oral rehydration salt solution, zinc supplements, intravenous fluid rehydration (for severe dehydration or shock), early (within one hour), exclusive (for the first 180 days), and continuous breastfeeding, hand-washing, supply of clean and safe water and sanitation, and provision of nutrient-rich foods, as part of a comprehensive strategy to control AWD (Information Sheet: Observed Rate of Vaccine Reactions: Rotavirus Vaccine [Internet]. World Health Organization (WHO)., 2014, Government launches new Rotavirus vaccine to protect children in Uganda from diarrhea [Internet]. World Health Organisation (WHO)., 2018). Ninety percent of children who receive the rotavirus vaccine are protected from severe rotavirus diarrhea, and approximately 70 % are protected from all forms (severe and mild) of rotavirus disease (MOH, 2024). Before the introduction of the rotavirus vaccine in 2018, rotavirus diarrhea was responsible for nearly 40 % of all AWD cases and caused approximately 11,000 deaths among children under 5 years of age in Uganda annually (Government launches new Rotavirus vaccine to protect children in Uganda from diarrhea [Internet]. World Health Organisation (WHO)., 2018, Uganda Rolls out Rotavirus Vaccine into the Routine Immunization Schedule [Internet]. Ministry of Health, Uganda., 2018). In addition to the WHO-recommended treatment packages and preventive strategies for AWD already in use (MOH, 2016), in June 2018, the government of Uganda through the Ministry of Health (MoH) introduced the rotavirus vaccine into the Uganda National Expanded Program on Immunization to protect children from AWD (Government launches new Rotavirus vaccine to protect children in Uganda from diarrhea [Internet]. World Health Organisation (WHO)., 2018, Uganda Rolls out Rotavirus Vaccine into the Routine Immunization Schedule [Internet]. Ministry of Health, Uganda., 2018). The rotavirus vaccine is free and available in health facilities and through community vaccination outreaches throughout the country (MoH, 2022). Uganda immunizes its children at 6 and 10 weeks of age with an interval of at least 4 weeks between doses (MoH, 2022).

Despite having a 2-dose rotavirus vaccination coverage of > 95 % from 2019 to 2022, Obongi District, located in the West Nile Region, consistently reported the highest incidence rates of AWD in Uganda, with > 45 cases/100 children aged 0–59 months each year from 2017 to 2021 (E.N., unpublished data). We evaluated factors associated with AWD among children aged 0–59 months in Obongi District in April 2022 to guide Ministry of Health efforts to reduce AWD in children.

2. Methods

2.1. Study setting

Obongi District is in the West Nile Region of Uganda and comprises six subcounties (Aliba, Ewafa, Gimara, Itula, Obongi Town Council, and Parolinya) (Ministry of Local Government, 2021). Itula and Parolinya contributed more than 75 % of the AWD cases among children aged 0–59 months in the district (MOH, 2024). Obongi District is a refugee-hosting district, primarily hosting refugees from South Sudan. Its refugee population was estimated at 128,500 persons in January 2022 (UNHCR, 2022), outnumbering the host community population, estimated at 50,000 people (UBOS, 2002). As of September 2022, the safe water coverage of Itula and Parolinya subcounties was 95 %, and the household latrine coverage was 93 % (MWE, 2022, UBOS, 2017).

2.2. AWD surveillance in Uganda

AWD among children aged 0–59 months is a notifiable disease in Uganda (MoH, 2021). AWD surveillance is passive as part of the national integrated disease surveillance and response system (MoH, 2021). When an AWD case is diagnosed at a health facility, information about that patient is filled into the health facility outpatient or inpatient register, depending on where the patient was treated (MoH, 2021, MoH, 2019a, MoH, 2019bb). At the end of every month, the total number of AWD cases at the health facility are reported to the district and the MoH through the health unit outpatient monthly report and the health unit inpatient monthly report (MoH, 2021, MoH, 2019a, MoH, 2019bb). These reports are then uploaded into the electronic district health information system version 2, where they are easily accessed by MoH policymakers and other stakeholders (MOH, 2024, MoH, 2021).

2.3. Study design and population

We conducted an unmatched case–control study in Itula and Parolinya subcounties to assess factors associated with AWD among children aged 0–59 months. The study participants were caregivers of children living in Itula and Parolinya subcounties of Obongi District in Uganda. We defined a case of AWD as the passage of ≥ 3 loose or liquid stools per day with negative malaria and pneumonia tests in a child aged 0–59 months residing in Itula or Parolinya subcounties, Obongi District, from 1 to 30 April 2022. A control was a child aged 0–59 months who did not suffer from AWD from 1 to 30 April 2022 and was from households that had no case in them residing in Itula or Parolinya Subcounties, Obongi District, from 1 to 30 April 2022. We defined a household as a collection of one or more people living either under one roof or more than one roof in the same compound, but sharing meals and having one household head. Overall, we studied children aged 0–59 months residing in Itula and Parolinya subcounties, Obongi District, from 1 to 30 April 2022. We define 0 months as age of a child from birth to less than one month (i.e. less than 28 days).

2.4. Sample size

The required sample size was calculated using the Fleiss formula in Epi Info software version 7 with an assumed prevalence of childhood diarrhea of 18 % of controls and 34 % of cases (Asfaha et al., 2018). We used untreated drinking water as one of the determinant factors of AWD, a 1:2 ratio of case to control, a 95 % confidence level, a 5 % margin of error and 80 % power to generate a sample size of 549. The final sample size for this study after considering a nonresponse rate of 5 % was 579 (193 cases and 386 controls).

2.5. Case finding, sampling procedures, and exclusion criteria

We line listed 298 AWD cases among children aged 0–59 months documented in April 2022 in the 10 health facilities of Itula and Parolinya subcounties, which contributed more than 75 % of the AWD cases in the district. Two hundred forty-one (81 %) of the line listed case-patients were refugees from South Sudan.

The line list included the child’s name, village and subcounty of residence, nationality status, next of kin, age, date of visit to the health facility, diagnosis at discharge, and laboratory results. After listing all the cases from the outpatient and inpatient registers of the 10 health facilities, we selected 193 cases from the line list by simple random sampling.

Controls were children aged 0–59 months from households with at least one child aged 0–59 months and without any case during the study period (1–30 April 2022). One control was randomly selected from eligible children in each control household. Cases and controls whose caregivers did not verbally consent to participate in the study and those whose caregivers were not available after two follow-up visits were excluded from the study.

2.6. Study variables and data collection

Using a pretested electronic questionnaire, we interviewed the mothers or caregivers of the cases and controls. Variables considered for the case–control study were identified after extensive literature review and included sociodemographic characteristics, receipt of rotavirus and measles vaccines and vitamin A, breastfeeding practices, caregiver and family members’ history of diarrhea, and water, sanitation, and household and individual hygiene characteristics and practices, presence of diabetes mellitus (DM), malaria, and malnutrition (Asfaha et al., 2018, Gashaw and Walie, 2019, Getachew et al., 2018, Getachew et al., 2018, Gunsa et al., 2018, Kasye et al., 2018, Melese et al., 2019, Musonda et al., 2017, Angesom, 2015, Sinmegn Mihrete et al., 2014, Tamiso et al., 2014). We created a new variable called comorbidity using data collected on undernutrition, diabetes, and HIV, where a child had a comorbidity if they had one or more of undernutrition, diabetes, and HIV. Information about the child’s rotavirus and measles vaccination history and the number of doses of each vaccine received was obtained from child health cards. “In cases where the child health cards were not available, we used self-reports, and calendar of local and national events”.

2.7. Data analysis

We extracted a Microsoft Excel dataset from the electronic database server and exported it to STATA version 14 for cleaning and subsequent descriptive and statistical analysis. The outcome variable was case status. Descriptive statistics were computed for the different variables. We conducted bivariate and multivariate logistic regression analyses to generate crude odds ratios (CORs) and adjusted odds ratios (AORs) with 95 % confidence intervals (CIs), respectively. A cutoff point of p ≤ 0.1 was used to consider variables for the multivariate logistic regression model using a backward stepwise method and controlling for possible confounders. Covariates with p < 0.05 were considered factors associated with the incidence of AWD among children aged 0–59 months in Obongi District. We tested the model using the Hosmer–Lemeshow goodness of fit test.

We conducted additional common reference group analysis for the factors that were statistically significantly associated with AWD among children aged 0–59 months in Obongi District using MedCalc software (Odds ratio calculator, 2022).

3. Results

A total of 193 cases and 386 controls with their respective mothers or caregivers were interviewed with a response rate of 100 %. Cases were generally younger than controls and more often came from small households than controls. Other minor but significant differences existed between cases and controls (Table 1).

Table 1.

Sociodemographic characteristics of respondents in a study assessing the factors associated with acute watery diarrhea among children aged 0–59 months, Obongi District, Uganda, April 2022.

Characteristic Cases (N = 193) Controls (N = 386) p-value
Frequency (n) Percent (%) n %
Nationality of household members
Nationals 16 8 51 13 0.08a
Refugee 177 92 335 87
Child sex
Female 89 46 203 53 0.14
Male 104 54 183 47
Child age (months)
0–5 25 13.0 46 11.9 0.704
6–11 73 37.8 69 17.9 <0.001a
12–23 58 30.0 127 32.9 0.481
24–35 28 14.5 81 21.0 0.060
36–47 3 1.6 38 9.8 <0.001a
48–59 6 3.1 25 6.5 0.087
Mean (range) 14 (0–59) 20 (0–59) <0.01a
Median (IQR) 11 (1–48) 18 (0–58)
Household in settlement
Yes 178 92 337 87 0.08
No 15 8 49 13
Subcounty
Itula 142 74 267 69 0.27
Parolinya 51 26 119 31
Caregiver category
Parent 173 90 363 94 0.06
Grandmother 15 8 19 5 0.16
Older siblings 5 2 4 1 0.14
Marital status of caregiver
Married/Cohabiting 165 86 358 93 0.01a
Single 14 7 19 5 0.24
Divorced/Separated 14 7 9 2 <0.01a
Caregiver age (yrs)
Mean (range) 27.5 (16–62) 29 (16–58) 0.02a
Median (IQR) 26 (17–56) 28.5 (17–56)
Highest education level caregiver
No formal education 26 13 55 14 0.82
Primary 142 74 263 68 0.17
Secondary 22 11 63 17 0.12
Tertiary/University 3 2 5 1 0.77
Sex household head
Male 117 61 243 63 0.58
Female 76 39 143 37
Occupation household head
Farmer 133 69 243 63 0.16
Unemployed 38 20 61 16 0.24
Business person 16 8 54 14 0.05
Others 6 3 28 7 0.04a
HH size
Small (2–4) 64 33 74 19 <0.01a
Large (5–9) 108 56 263 68 <0.01a
Very large (≥10) 21 11 49 13 0.53
No. of children < 5 years
One 40 21 130 34 <0.01
2–3 128 66 240 62 0.33
≥4 25 13 16 4 <0.01a
Child’s birth order
1st born 44 23 70 18 0.18
2nd–3rd born 79 41 148 38 0.55
≥4th born 70 36 168 44 0.10
Open in a new tab
a

Significant association at p < 0.05, IQR: interquartile range.

3.1. Child caring practices of respondents in a study assessing the factors associated with acute watery diarrhea among children aged 0–59 months, Obongi District, Uganda, April 2022

Rotavirus vaccine history and doses of rotavirus vaccine received were not different between cases and controls. Cases generally came from households in which other family members suffered from diarrhea during the study period compared to the controls. Other minor but noteworthy differences existed between cases and controls (Table 2).

Table 2.

Child caring practices of respondents in a study assessing the factors associated with acute watery diarrhea among children aged 0–59 months, Obongi District, Uganda, April 2022.

Characteristic Cases (N = 193) Controls (N = 386) p-value
Frequency (n) Percent (%) n %
Received rotavirus vaccine
Yes 187 97 369 96 0.45
No 6 3 17 4
Doses of rotavirus vaccine†
One 28 15 58 16 0.83
≥Two 159 85 311 84
Received measles vaccine
Yes 117 61 287 74 <0.01a
No 66 34 89 23 0.01a
Don’t know 10 5 10 3 0.11
Doses of measles vaccine‡
One 96 82 222 77 0.30
≥Two 21 18 65 23
Vitamin in previous 6 months
Yes 129 67 252 65 0.72
No 53 27 121 31 0.35
Don’t know 11 6 13 4 0.19
Duration of exclusive breastfeeding
<6 months 80 41 162 42 0.91
≥6 months 113 59 224 58
Age at start of weaning
<6 months 80 41 162 42 0.91
At 6 months 46 24 88 23 0.79
>6 months 67 35 136 35 0.91
Age stopped breastfeeding completely (month)
0–6 87 45 124 32 <0.01a
7–18 39 20 71 18 0.60
≥18 67 35 191 50 <0.01a
Caregiver suffered from diarrhea in April 2022
Yes 43 22 53 14 0.01a
No 150 78 333 86
Family member suffered from diarrhea in April 2022
Yes 85 44 89 23 <0.01a
No 108 56 297 77
Child had a comorbidity in April 2022§
Yes 31 16 9 2 <0.01a
No 162 84 377 98
Child had malnutrition
Yes 28 15 8 2 <0.01a
No 165 85 378 98
Child had diabetes mellitus (DM)
Yes 4 2 1 0.3 0.03a
No 189 98 385 97.3
Child had HIV
Yes 2 1 0 0 0.05
No 191 99 386 100
Open in a new tab
a

Significant association at p < 0.05, †Among 187 cases and 369 controls who received rotavirus vaccine, ‡Among 117 cases and 287 controls who received measles vaccine, §including malnutrition, DM, and HIV.

3.2. Water, sanitation, and hygiene characteristics of respondents in a study assessing the factors associated with acute watery diarrhea among children aged 0–59 months, Obongi District, Uganda, April 2022

All cases and controls came from households with a toilet facility. Cases were more often living in households that did not have a hand washing facility compared to controls. Other minor but significant differences existed between cases and controls (Table 3).

Table 3.

Water, sanitation, and hygiene characteristics of respondents in a study assessing the factors associated with acute watery diarrhea among children aged 0–59 months, Obongi District, Uganda, April 2022.

Characteristic Cases (N = 193) Controls (N = 386) p-value
Frequency (n) Percent (%) N %
Main source of water
Pipped 114 59 160 41 <0.01*
Borehole 79 41 226 59
Roundtrip distance to fetch water
≤30 min 98 51 200 52 0.82
>30 min 95 49 186 48
Home water treatment†
Yes 58 30 120 34 0.34
No 135 70 232 66
Separate container for drinking water
Yes 109 56 251 65 0.05
No 84 44 135 35
Toilet facility at home
Yes 193 100 386 100 –
No 0 0 0 0 –
Method of handwashing
Water only 129 67 218 57 0.02*
Water and soap 24 12 97 25 <0.01*
Don’t wash hands 40 21 71 18 0.51
Wash hands after visiting the toilet
Yes 87 45 141 37 0.05
No 106 55 245 63
Wash hands before feeding the child
Yes 161 83 317 82 0.70
No 32 17 69 18
Wash hands after cleaning child’s buttock
Yes 143 74 301 78 0.30
No 50 26 85 22
Wash hands after disposal of child’s stool/urine
Yes 149 77 303 78 0.72
No 44 23 83 22
Wash hands before preparing food
Yes 146 76 289 75 0.85
No 47 24 97 25
Hand washing facility at home
Yes 45 23 131 34 0.01*
No 148 77 255 66
Hand washing facility near toilet‡ (<2 m away)
Yes 23 51 45 34 0.05
No 22 49 86 66
Child stool disposal method
Toilet 170 88 350 91 0.33
Covered by soil 18 9 28 7 0.40
Open space 5 3 8 2 0.70
Child stool in compound
Yes 43 22 56 15 0.02*
No 150 78 330 85
Refuse in compound
Yes 61 32 90 23 0.03*
No 132 68 296 77
Open in a new tab

*Significant association at p < 0.05, †Among 352 controls who responded to home water treatment, ‡Among 45 cases and 131 controls who had a hand washing facility near the toilet (within 2 m).

3.3. Factors associated with acute watery diarrhea among children aged 0–59 months in Obongi District, Uganda, April 2022

Factors associated with AWD among children in bivariate analysis included living in households with 5–9 people (COR: 2.1; 95 % CI: 1.4–3.2) and > 10 people (COR: 2.0, 95 % CI: 1.1–3.7), suffering from a comorbidity (Human immunodeficiency virus (HIV), malnutrition, and/or DM) (COR: 8.0; CI: 3.7–17), living in households that had no hand washing facility near the toilet (COR: 2.0; CI: 1.1–4), living in households that had caregivers who did not wash their hands with soap after visiting the toilet (COR: 1.4; CI: 1.1–2.0), and living in households that used borehole water (COR: 2.1; CI: 1.4–2.9) (Table 4).

Table 4.

Bivariate and multivariate logistic regression analysis results of factors associated with acute watery diarrhea among children aged 0–59 months, Obongi District, Uganda, April 2022.

Characteristic Case (N = 193) Control (N = 386) COR (95 % CI) p-value AOR (95 % CI) p-value
n % n %
Nationality of HH members
Nationals 16 8 335 87 1.00 1.00
Refugee 177 92 51 13 0.6 (0.33–1.1) 0.084 1.4 (0.23–7.9) 0.736
Child’s birth order
1st born 44 23 70 18 1.00 1.00
2nd–3rd born 79 41 148 38 1.2 (0.74–1.9) 0.491 0.6 (0.17–1.9) 0.376
≥4th born 70 36 168 44 1.5 (0.94–2.4) 0.086 0.9 (0.26–2.9) 0.809
HH size
Small (2–4) 64 33 74 19 1.00 1.00
Large (5–9) 108 56 263 68 2.1 (1.4–3.2) <0.001* 1.3 (0.44–3.9) 0.639
Very large (≥10) 21 11 49 13 2.0 (1.1–3.7) 0.024* 0.9 (0.18–4.6) 0.899
Child sex
Female 89 46 203 53 1.00 1.00
Male 104 54 183 47 0.8 (0.55–1.1) 0.142 0.5 (0.22–1.2) 0.115
Child had a comorbidity
No 162 84 377 98 1.00 1.00 1.00
Yes 31 16 9 2 8.0 (3.7–17) <0.001* 12 (2.5–53) 0.002*
Household in settlement
No 15 8 49 13 1.00 1.00
Yes 178 92 337 87 0.6 (0.32–1.1) 0.078 0.3 (0.04–2.1) 0.218
Hand washing facility near toilet† (<2 m away)
Yes 23 51 45 34 1.00 1.00
No 22 49 86 66 2.0 (1.1–4) 0.048* 1.1 (0.48–2.7) 0.776
Wash hands with soap after visiting the toilet
Yes 87 45 141 37 1.00 1.00
No 106 55 245 63 1.4 (1.1–2.0) 0.048* 3.9 (1.2–13) 0.027*
Main source of water
Pipped 114 59 160 41 1.00 1.00
Borehole 79 41 226 59 2.1 (1.4–2.9) <0.001* 4.0 (1.7–9.6) 0.002*
Open in a new tab

*Significant association at p < 0.05, †Among 45 cases and 131 controls that received rotavirus vaccine.

In multivariate logistic regression, after controlling for the nationality of household members, child birth order, number of household occupants, child sex, whether the household was located in the refugee settlement, and presence of a hand washing facility near (less than 2 m from) the toilet, children suffering from a comorbidity (DM, malnutrition and/or HIV) (AOR: 12; CI: 2.5–53), children whose caregivers did not wash hands with soap and water after visiting the toilet (AOR: 3.9; CI: 1.2–13), and children living in households that used borehole water (AOR: 4.0; CI: 1.7–9.6) remained associated with AWD (Table 4).

4. Discussion

AWD is a major cause of morbidity and mortality among children 0–59 months in Uganda despite interventions to address it (MOH, 2016), including rotavirus vaccination since 26 June 2018 (Government launches new Rotavirus vaccine to protect children in Uganda from diarrhea [Internet]. World Health Organisation (WHO)., 2018, Uganda Rolls out Rotavirus Vaccine into the Routine Immunization Schedule [Internet]. Ministry of Health, Uganda., 2018). We set out to identify factors associated with AWD among children aged 0–59 months in the high-burden AWD Obongi District. The population had extremely high rates of rotavirus vaccine coverage. Studies in Ethiopia and Zambia showed that the use of unprotected water sources, lower age of child caregivers, child weaning time, family size, low maternal education, poor sanitation, contaminated water sources, shorter duration of breast feeding, failure to wash hands, absence of rotavirus vaccination, failure to dispose of feces hygienically, and adequate food hygiene were significant predictors of acute watery diarrhea among children aged 0–59 months (Gashaw and Walie, 2019, Getachew et al., 2018, Getachew et al., 2018, Gunsa et al., 2018, Kasye et al., 2018, Melese et al., 2019, Musonda et al., 2017). Other studies showed that child-related factors such as sex (Angesom, 2015), age (Sinmegn Mihrete et al., 2014), and malnutrition (Tamiso et al., 2014) were associated with childhood diarrhea. However, in the current study, comorbidities such as HIV, caregiver’s failure to wash hands with soap after visiting the toilet, and using borehole water were associated with acute watery diarrhea among children aged 0–59 months in Obongi District.

In this study, children suffering from a comorbidity such as HIV, malnutrition, and DM had higher odds of suffering from acute watery diarrhea than those who did not suffer from any comorbidity. These comorbidities lower the child’s immunity, and as a result, the child is predisposed to frequent infections such as AWD from agents and sources from which they would not have been infected (Mulholland, 2005). Our findings are similar to findings from other studies in Zambia, Ethiopia, and Sudan that showed that comorbidities such as HIV and malnutrition were associated with recurrent AWD among children aged 0–59 months (Musonda et al., 2017, Derseh et al., 2018, Netsereab and Xenos, 2017).

In this study, we also found that children whose caregivers did not wash their hands with clean water and soap after visiting the toilet had more odds of suffering from AWD than those whose caregivers washed their hands using clean water and soap after visiting the toilet. This is not surprising since hand washing using clean water and soap kills diarrhea-causing organisms and hence reduces their transmission from one person to the other (Datta et al., 2011). Dirty hands serve as gateways for carrying infectious pathogens to the child’s food during feeding of the child; thereby predisposing the child to diarrhea-causing agents (Datta et al., 2011). Similar findings were also reported in studies carried out in Ethiopia, Zambia, Botswana, Uganda, Tanzania, and Nepal, which also reported that caregivers’ hand washing habits, especially washing hands with clean water and soap at critical times, such as after visiting the toilet, were protective against AWD among children 0–59 months (Melese et al., 2019, Musonda et al., 2017, Nantege et al., 2022, Arvelo et al., 2010, Hashi et al., 2017, Budhathoki et al., 2016, Tesfaye et al., 2020, Kabhele et al., 2018). However, a study carried out in Ethiopia among children aged 0–59 months did not find any significant association between washing hands at critical times, such as after visiting the toilet, and AWD (Asfaha et al., 2018). This might be because that study was carried out among nationals of a fairly stable socioeconomic status compared to the current study; which was conducted primarily among refugees of a low socioeconomic status.

This study showed that children living in households that used borehole water had higher odds of suffering from AWD than those who lived in households that mainly used pipped water, which was chlorinated. The chlorine in pipped water disinfects (kills) or inactivates diarrhea-causing organisms, hence rendering it safe for home use (Centres for Disease Control and Prevention, 2020). Itula and Parolinya subcounties of Obongi District are bounded by the River Nile and have high water tables; implying that toilets in the settlements could have easily contaminated the borehole water since the boreholes are not so deep. A study in Tanzania reported that borehole water was contaminated by fecal material attributed to the entry of sewage (human wastes) into underground water and recommended the treatment or boiling of borehole water before consumption (Basamba et al., 2013). Although boreholes and other ground water sources are classified as improved and safe water sources (UN World Water Development Report, 2022), several microbiological studies of groundwater sources, including boreholes, have reported high rates of Escherichia coli, indicating fecal contamination of those sources (Richardson et al., 2009, Kanyerere et al., 2012, Howard et al., 2003). The high population densities in the settlements where these boreholes are located could have exposed them to contamination by children who touch the spouts (water outlets) when fetching water. A study conducted in Zimbabwe reported that although improved sources of water, such as boreholes, generally deliver ‘safe’ water, a proportion of those sources can easily be contaminated at the point of collection (Gundry et al., 2006). Findings from our study are similar to findings in another study carried out in Nigeria that showed that protected groundwater sources such as boreholes were associated with a high risk of contracting diarrhea (Hunter et al., 2013). However, our findings are contrary to findings in another study conducted in Uganda that showed that children from homes that mainly used borehole water were at reduced risk of AWD than those that mainly used piped water (Ssenyonga et al., 2009). The major difference between that study and the current study is that it was a cross-sectional study using the 2000/2001 Uganda Demographic and Health Survey dataset (Ssenyonga et al., 2009); yet ours is a case control study. That study never gave reasons why children aged 0–59 months from households that used borehole water were at a lower risk of contracting diarrhea compared to those who used pipped water.

5. Study limitations

This investigation had some limitations. Cases and controls were obtained for the month of April 2022; therefore, the seasonal variations in AWD during the year were not considered. Recall and social desirability bias might have influenced responses to some of the questions that were asked, as they depended on the respondent’s own memory, and findings from this study are based on self-reported data, although several measures, such as quality control and observation checks, were incorporated into the questionnaire to ensure the accuracy of the data collected. Additionally, there are difference between cases and controls on some variables such as nationality, child age, and household size, however measures were put in place to ensure collection of high-quality data during data collection.

6. Conclusion

Suffering from a long-term illness such as HIV, malnutrition, and DM, caregivers’ failure to wash their hands with soap after visiting toilets, and households using borehole water were associated with AWD among children aged 0–59 months in Obongi District. We recommended health facility management for all children with AWD. We also recommended education of communities on hand washing at critical times using clean water and soap and expanded use of boreholes and piped water.

Ethics approval and consent to participate

The Ministry of Health of Uganda gave the directive and approval to carry out this investigation. In agreement with the International Guidelines for Ethical Review of Epidemiological Studies by the Council for International Organizations of Medical Sciences (1991) and the Office of the Associate Director for Science, CDC/Uganda, it was determined that this activity was not human subject research and that its primary intent was public health practice or disease control activity (specifically, epidemic or endemic disease control activity). This activity was reviewed by the CDC and was conducted consistent with applicable federal law and CDC policy. All experimental protocols were approved by the US CDC human subjects review board (The National Institute for Occupational Safety and Health Institutional Review Board) and the Uganda Ministry of Health and were performed in accordance with the Declaration of Helsinki. Parental/legal guardian written informed consent was obtained on behalf of all the children before the start of each interview since they were aged less than 5 years. Written informed consent was also obtained from all study (caregivers/mothers) participants.

Funding source and disclaimer

This case control investigation was supported by the President’s Emergency Plan for AIDS Relief (PEPFAR) through US Centers for Disease Control and Prevention Cooperative Agreement number GH001353–01 through Makerere University School of Public Health to the Uganda Public Health Fellowship Program, Ministry of Health. The contents of this article are exclusively the responsibility of the authors and do not essentially represent the official views of the US Centers for Disease Control and Prevention, Makerere University School of Public Health, or the Ministry of Health, Uganda.

Authors’ contributions

EJN took the lead in conceptualizing the study idea, data collection, data analysis, writing, and editing of the manuscript. JK, LA, SMN, and RN were involved in data collection, data analysis, and writing of the manuscript. AK, FN, BK, LB, DK, PEO, and ARA were involved in the conceptualization of the study idea and the writing, editing, and reviewing of the manuscript. All authors read and approved the final manuscript.

CRediT authorship contribution statement

Edirisa Juniour Nsubuga: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Jireh Kirabo: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft, Writing – review & editing. Andrew Kwiringira: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Writing – original draft. Linus Andaku: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – original draft. Saharu Magona Nerima: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Software, Writing – original draft, Writing – review & editing. Fred Nsubuga: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Supervision, Writing – original draft, Writing – review & editing. Rashida Nakazzi: Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Software, Writing – original draft, Writing – review & editing. Benon Kwesiga: Funding acquisition, Investigation, Methodology, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Lilian Bulage: Funding acquisition, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Daniel Kadobera: Conceptualization, Funding acquisition, Resources, Supervision, Validation, Visualization, Writing – review & editing. Paul Edward Okello: Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Writing – original draft, Writing – review & editing. Alex Riolexus Ario: Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Software, Supervision, Writing – review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgments

The authors would like to thank the Obongi District leadership, including the District Health Team, the health facility in charges and records assistants of the 10 health facilities in Itula and Parolinya subcounties, and the seven research assistants (Hope Suzan, Charles Amanzuru, Jane Piyo, Denis Obulejo, Abiko Gertrude, Abdulmalik Mahad, and Marupia Dorothy) who helped in data collection.

References

  1. Vaccines and Preventable Diseases: Rotavirus Vaccination [Internet]. Centres for Disease and Prevention (CDC). [cited 03 October 2021]. Available from: https://www.cdc.gov/vaccines/vpd/rotavirus/index.html.
  2. Angesom T. Addis Ababa University; Ethiopia: 2015. Prevalence and associated factors of diarrhea among under-five children in laelay-Maychew District, Tigray region. [Google Scholar]
  3. Arvelo W., Kim A., Creek T., Legwaila K., Puhr N., Johnston S., et al. Case–control study to determine risk factors for diarrhea among children during a large outbreak in a country with a high prevalence of HIV infection. Int. J. Infect. Dis. 2010;14(11):e1002–e1007. doi: 10.1016/j.ijid.2010.06.014. [DOI] [PubMed] [Google Scholar]
  4. Asfaha K.F., Tesfamichael F.A., Fisseha G.K., Misgina K.H., Weldu M.G., Welehaweria N.B., et al. Determinants of childhood diarrhea in medebay Zana District, Northwest Tigray, Ethiopia: a community based unmatched case–control study. BMC Pediatr. 2018;18(1):1–9. doi: 10.1186/s12887-018-1098-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Basamba T.A., Sekabira K., Kayombo C.M., Ssegawa P. Application of factor and cluster analyses in the assessment of sources of contaminants in borehole water in Tanzania. Pol. J. Environ. Stud. 2013;22(2):337–346. [Google Scholar]
  6. Budhathoki S.S., Bhattachan M., Yadav A.K., Upadhyaya P., Pokharel P.K. Eco-social and behavioural determinants of diarrhoea in under-five children of Nepal: a framework analysis of the existing literature. Tropical Medicine and Health. 2016;44(1):1–7. doi: 10.1186/s41182-016-0006-9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Water Disinfection with Chlorine and Chloramine: Chlorine and chloramine are the major disinfectants used in public water systems [Internet]. Centres for Disease Control and Prevention (CDC). 2020 [cited August 11, 2022]. Available from: https://www.cdc.gov/healthywater/drinking/public/water_disinfection.html.
  8. Datta S., Singh Z., Boratne A., Senthilvel V., Bazroy J., Dimri D. Knowledge and practice of handwashing among mothers of under five children in rural coastal South India. International Journal of Medicine and Public Health. 2011;1(1) [Google Scholar]
  9. Derseh B., Mruts K., Demie T., Gebremariam T. Co-morbidity, treatment outcomes and factors affecting the recovery rate of under -five children with severe acute malnutrition admitted in selected hospitals from Ethiopia: retrospective follow up study. Nutr. J. 2018;17(1):116. doi: 10.1186/s12937-018-0423-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Diarrhoeal disease Fact Sheet [Internet]. World Health Organisation (WHO). 2017 [cited 3 October 2021]. Available from: https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease.
  11. Drugs and Diseases: Pediatrics: General Medicine: Diarrhea [Internet]. Medscape. 2020 [cited 7 November 2022]. Available from: https://emedicine.medscape.com/article/928598-overview.
  12. Gashaw T.A., Walie Y.M. Prevalence and determinate factors of diarrhea morbidity among under five children in shake zone, Southwest Ethiopia, a community based cross-sectional study. Archives of Community Medicine and Public Health. 2019;5(1):008–014. [Google Scholar]
  13. Getachew A., Guadu T., Tadie A., Gizaw Z., Gebrehiwot M., Cherkos D.H., et al. Diarrhea prevalence and sociodemographic factors among under-five children in rural areas of North Gondar zone, Northwest Ethiopia. Int. J. Pediatr. 2018;2018 doi: 10.1155/2018/6031594. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Getachew B., Mengistie B., Mesfin F., Argaw R. Factors associated with acute diarrhea among children aged 0–59 months in Harar town, eastern Ethiopia. East African Journal of Health and Biomedical Sciences. 2018;2(1):26–35. [Google Scholar]
  15. Government launches new Rotavirus vaccine to protect children in Uganda from diarrhea [Internet]. World Health Organisation (WHO). 2018 [cited 03 September 2021]. Available from: https://www.afro.who.int/news/government-launches-new-rotavirus-vaccine-protect-children-uganda-diarrhea.
  16. Gundry S.W., Wright J.A., Conroy R., Du Preez M., Genthe B., Moyo S., et al. Contamination of drinking water between source and point-of-use in rural households of South Africa and Zimbabwe: implications for monitoring the millennium development goal for water. Water Practice and Technology. 2006;1(2) [Google Scholar]
  17. Gunsa G.G., Rodamo K.M., Dangiso D.D. Determinants of acute diarrhoea among children aged 6–59 months in Chiffre District, southern Ethiopia: unmatched case-control study. J Gynecol Obstet. 2018;6(2):15–25. [Google Scholar]
  18. Hashi A., Kumie A., Gasana J. Hand washing with soap and WASH educational intervention reduces under-five childhood diarrhoea incidence in Jigjiga District, eastern Ethiopia: a community-based cluster randomized controlled trial. Prev. Med. Rep. 2017;6:361–368. doi: 10.1016/j.pmedr.2017.04.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Howard G., Pedley S., Barrett M., Nalubega M., Johal K. Risk factors contributing to microbiological contamination of shallow groundwater in Kampala. Uganda. Water Research. 2003;37(14):3421–3429. doi: 10.1016/S0043-1354(03)00235-5. [DOI] [PubMed] [Google Scholar]
  20. Hunter P.R., Risebro H., Yen M., Lefebvre H., Lo C., Hartemann P., et al. Water source and diarrhoeal disease risk in children under 5 years old in Cambodia: a prospective diary based study. BMC Public Health. 2013;13(1):1–9. doi: 10.1186/1471-2458-13-1145. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Information Sheet: Observed Rate of Vaccine Reactions: Rotavirus Vaccine [Internet]. World Health Organization (WHO). 2014 [cited 03 October 2021]. Available from: https://www.who.int/vaccine_safety/initiative/tools/Rotavirus_vaccine__rates_information_sheet.pdf?ua=1.
  22. Kabhele S., New-Aaron M., Kibusi S.M., Gesase A.P. Prevalence and factors associated with diarrhoea among children between 6 and 59 months of age in Mwanza city Tanzania. J. Trop. Pediatr. 2018;64(6):523–530. doi: 10.1093/tropej/fmx109. [DOI] [PubMed] [Google Scholar]
  23. Kanyerere T., Levy J., Xu Y., Saka J. Assessment of microbial contamination of groundwater in upper Limphasa River catchment, located in a rural area of northern Malawi. Water SA. 2012;38(4):581–596. [Google Scholar]
  24. Kasye D.G., Garoma N.H., Kassa M.A. Assessment of the prevalence of diarrheal disease under-five children serbo town, Jimma zone south West Ethiopia. Clin Mother Child Health. 2018;15(281):2. [Google Scholar]
  25. Melese B., Paulos W., Astawesegn F.H., Gelgelu T.B. 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. 2019;19(1):1–10. doi: 10.1186/s12889-019-7579-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Obongi District Investment Profile [Internet]. Ministry of Local Government, Obongi District. 2021. Available from: https://www.ugandainvest.go.ug/wp-content/uploads/2021/08/Obongi-2021.pdf.
  27. MoH National Technical Guidelines for integrated disease surveillance and response. third ed: ministry of. Health. 2021 [Google Scholar]
  28. MoH Immunization in practice and the new routine immunization schedule: a training guide for operational level health workers. Ministry of Health (MoH), the Republic of Uganda. 2022 [Google Scholar]
  29. Uganda Clinical Guidelines 2016: National Guidelines for Management of Common Conditions [Internet]. Ministry of Health, Government of Uganda. 2016. Available from: https://health.go.ug/sites/default/files/Uganda%20Clinical%20Guidelines%202016_FINAL.pdf.
  30. Health Unit Outpatient Monthly Report (HMIS Form 105) [Internet]. Ministry of Health (MoH), Government of Uganda. 2019 [cited 20 October 2022]. Available from: https://www.malariaconsortium.org/gallery-file/06081045-69-hmis105healthunitoutpatientmonthlyreport.pdf.
  31. MoH. Health Unit Inpatient Monthly Report (HMIS Form 108). Kampala, Uganda: Ministry of Health (MoH), Uganda; 2019.
  32. MoH. Annual Health Sector Performance Report Financial Year 2020/21. www.health.go.ug: Ministry of Health (MoH), Uganda; 2022.
  33. Uganda eHMISUganda's Electronic Health Information System: DHIS2 [Internet]. Ministry of Health. Available from: https://hmis.health.go.ug/dhis-web-commons/security/login.action.
  34. Mulholland K. Commentary: comorbidity as a factor in child health and child survival in developing countries. Int. J. Epidemiol. 2005;34(2):375–377. doi: 10.1093/ije/dyi028. [DOI] [PubMed] [Google Scholar]
  35. Musonda C., Siziya S., Kwangu M., Mulenga D. Factors associated with diarrheal diseases in under-five children: a case control study at Arthur Davison children’s hospital in Ndola, Zambia. Asian Pac J Health Sci. 2017;4(3):228–234. [Google Scholar]
  36. Obongi District [Internet]. Directorate of Water Development, Ministry of Water and Environment (MWE), Republic of Uganda. 2022 [cited September 4, 2022]. Available from: http://wsdb.mwe.go.ug/index.php/reports/district/146.
  37. Nantege R., Kajoba D., Ddamulira C., Ndoboli F., Ndungutse D. Wakiso District; Uganda: 2022. Prevalence and factors associated with diarrheal diseases among children below five years in selected slum settlements in Entebbe municipality. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Netsereab T.B., Xenos P. Factors associated with diarrhea among children less than 5 years old in Sudan. Journal of Health Research. 2017;31(Suppl. 2):S209–S215. [Google Scholar]
  39. Odds ratio calculator [Internet]. 2022. Available from: https://www.medcalc.org/calc/odds_ratio.php.
  40. Richardson H.Y., Nichols G., Lane C., Lake I.R., Hunter P.R. Microbiological surveillance of private water supplies in England-the impact of environmental and climate factors on water quality. Water Res. 2009;43(8):2159–2168. doi: 10.1016/j.watres.2009.02.035. [DOI] [PubMed] [Google Scholar]
  41. Sinmegn Mihrete T., Asres Alemie G., Shimeka T.A. Determinants of childhood diarrhea among underfive children in benishangul gumuz regional state, north West Ethiopia. BMC Pediatr. 2014;14(1):1–9. doi: 10.1186/1471-2431-14-102. [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Ssenyonga R., Muwonge R., Twebaze F., Mutyabule R. Determinants of acute diarrhoea in children aged 0–5 years in Uganda. East Afr. Med. J. 2009;86(11):513–519. [Google Scholar]
  43. Tamiso A., Yitayal M., Awoke A. Prevalence and determinants of childhood diarrhoea among graduated households, in rural area of shebedino district, southern Ethiopia, 2013. Science. 2014;2(3):243–251. [Google Scholar]
  44. Tesfaye T.S., Magarsa A.U., Zeleke T.M. 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. 2020;11:437. doi: 10.2147/PHMT.S266828. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. UBOS . Uganda Bureau of Statistics (UBOS); Kampala: 2017. National Population and Housing Census 2014: Area specific profiles-Moyo District. [Google Scholar]
  46. Population & Censuses: Census Population counts (2002 and 2014) by Region, District and Mid Year Population projections (2015-2021) [Internet]. Uganda Bureau of Statistics (UBOS). 2022 [cited 02 March 2022]. Available from: https://www.ubos.org/explore-statistics/20/.
  47. Uganda Rolls out Rotavirus Vaccine into the Routine Immunization Schedule [Internet]. Ministry of Health, Uganda. 2018 [cited 03 September 2021]. Available from: https://www.health.go.ug/2019/12/02/uganda-rolls-out-rotavirus-vaccine-into-the-routine-immunization-schedule/.
  48. UN World Water Development Report 2022 ‘Groundwater: Making the invisible visible’: New report : Is the solution to water crises hiding right under our feet? [Internet]. United Nations (UN). 2022 [cited 11 August, 2022]. Available from: https://www.unwater.org/un-world-water-development-report-2022/#:∼:text=Groundwater%20presently%20provides%20half%20of,all%20water%20used%20for%20irrigation.
  49. Uganda - Refugee Statistics January 2022 - Palorinya [Internet]. United Nations High Commission for Refugees (UNHCR). 2022. Available from: file:///C:/Users/HP/Downloads/Palorinya%20Settlement%20Profile_31Jan2022%20(1).pdf.

Articles from Preventive Medicine Reports are provided here courtesy of Elsevier

RESOURCES