ABSTRACT.
Diarrhea is highly prevalent in Nigeria and accounts for 16% of deaths among Nigerian children. The WHO classifies water source into two categories: improved and unimproved. This study aimed to examine the association between type of water source and the prevalence of diarrhea among members of a nationally representative sample of Nigerian households while controlling for key sociodemographic and household factors. This study used cross-sectional data from 22,571 households participating in the 2018 Water, Sanitation and Hygiene-National Outcome Routine Mapping survey. Data collectors visited and interviewed household members across all 36 states in the country. Logistic regression was used to assess associations between water source type and the odds of a family member reporting diarrhea, after controlling for financial status, availability of soap/detergent for handwashing, availability of a refrigerator in the home, toilet type, and urban/rural status. After controlling for explanatory variables in the adjusted model, having an unimproved water source was associated with greater odds of diarrhea among a family member (odds ratio, 1.59; 95% CI, 1.44–1.77). Not having a refrigerator and not having soap/detergent for handwashing were also associated with greater odds of diarrhea. In summary, this study found an association between water-source type and diarrhea prevalence among Nigerian households. This study is in line with prior studies in Nigeria and elsewhere, and the results call for greater commitment and action by stakeholders to improve water sources and, ultimately, reduce the prevalence of diarrhea in Nigeria.
INTRODUCTION
One of the most globally recognized health promotion campaigns is providing potable and safe water in developing countries.1 In 2017, an estimated 785 million people worldwide did not have access to a safe and uninterrupted water supply.2 Water-source quality can greatly influence the overall health status of a community.1 Water source has been linked to 4 billion cases of diarrhea and more than 5 million annual deaths globally.2 Goal 6 of the Sustainable Developmental Goals set by the United Nations is to reduce the number of people without access to improved water sources to improve sustainable access to safe water and basic sanitation by 2030.1,3 Unfortunately, a significant amount of the world’s population continues to lack access to adequate drinking water.
In Nigeria, more than 66 million people have inadequate access to drinking water from an improved source such as piped water or a protected dug well.4 This has resulted in many households using other water sources, which can be highly polluted or contaminated.4–6 Drinking contaminated water has been linked to the transmission of diseases such as cholera, diarrhea, dysentery, hepatitis A, typhoid, and polio.7 Water contamination can occur through the means of a physical, chemical, biologic, or radiological substance.5,6 Absent, inadequate, or inappropriately managed water exposes individuals to preventable health risks. Nigeria is the second-largest contributor to the worldwide under-five mortality rate from diarrhea, with more than 151,700 deaths annually.8 The absence of clean water, safely managed sanitation, and hygiene are responsible for almost 88% of the country’s disease burden.8
Previous studies have found that consuming water from a WHO-classified unimproved source such as a tanker truck or unprotected spring is associated with an increased risk of diarrhea.9–11 Improved sources are preferred because they are protected, which reduces risk of contamination from pathogens that produce diarrhea.12 Currently, there is a limited understanding of how the type of water source is related to diarrhea prevalence when accounting for pertinent sociodemographic (e.g., urban/rural status, financial status) and household variables (e.g., access to refrigeration, toilet type). Given recent efforts to improve drinking water in Nigeria,12,13 there is a need to perform new national assessments of the public health implications of consuming water from an unimproved water source to determine whether these initiatives have been effective. Thus, the overarching aim of this study is to evaluate the relationship between water-source type (improved versus unimproved) and diarrhea prevalence among a large, nationally representative sample of households in Nigeria. This study’s findings may inform future policy and decision-making regarding resource allocation and diarrhea prevention measures in Nigeria. It is hypothesized that households with an unimproved water source will have a greater prevalence of diarrhea than households with an improved water source after controlling for sociodemographic and household factors.
METHODS
Study design and data source.
This study involved a secondary analysis of the 2018 Water, Sanitation and Hygiene–National Outcome Routine Mapping (WASH-NORM) survey. The survey was commissioned by the Nigerian Federal Ministry of Health and led by the National Bureau of Statistics with support from the United Nations Children’s Fund (UNICEF).14 The sampling frame used for the survey was adapted from the National Population Council enumeration areas. The survey was carried out in all 36 states of the federation and the federal capital territory of Abuja in 2018. The survey focused broadly on two components: assessment of water, sanitation, and hygiene (WASH) levels within households and the evaluation of WASH facilities. The household component of the survey collected information on household characteristics, the demographics of household members, and the functionality of household features such as appliances.
A total of 23,029 households were interviewed for the survey. The selected households were weighted to ensure the sample reflected the country’s actual demographic distribution of the corresponding states. Data collectors interviewed the head of each household to obtain detailed data on the home and its occupants. The household head was a parent, in most cases. In households where no parent was available for the interview, the oldest person in the house was interviewed, regardless of gender. This approach was adopted to ensure the quality of data. The Nigerian Institute of Medical Research review board, in compliance with UNICEF, reviewed and approved the Nigeria 2018 WASH-NORM study. Interviewees were required to consent to participate in the survey orally. Additional details about this survey are available elsewhere.15 At the University of Illinois at Urbana-Champaign, the institutional review board approved this analysis and deemed it exempt research.
Variables.
Trained fieldworkers used paper-based questionnaires to collect data on key variables of interest. For our study, the primary explanatory variable was the household’s drinking water source. Water source is classified into two categories: improved and unimproved. As defined by the WHO16 and UNICEF, a description of both classifications of water sources is provided in Table 1. The response variable was a recent occurrence of diarrhea (yes versus no) among a member of the household. Household heads were explicitly asked, “Has any household member suffered from diarrhea in the past 2 weeks?” Thus, diarrhea status was self-reported by household heads and assessed at the household level. Other explanatory variables of interest include the following: urban/rural status, self-reported financial status (rich, average, or poor), availability of a refrigerator in the home (yes versus no), availability of soap/detergent for handwashing in the home (yes versus no), and toilet type (flush toilet versus pit latrine versus other). All variables, except for urban/rural status, were self-reported. WASH-NORM officials assessed and provided information on urban/rural status based on each household’s geographic location. “Other” toilet type includes bucket latrines, hanging toilets, and no available toilet facility (e.g., bush or field).
Table 1.
Description of drinking water source classes
| Source class | Description |
|---|---|
| Unimproved drinking water source | Unprotected dug well, unprotected spring, a cart with small tank or drum, surface water (e.g., dam, lake, pond, stream, canal, irrigation channel), and tanker truck water |
| Improved drinking water source | Piped water connection located inside the user’s dwelling, plot, or yard; public taps or standpipes; tube wells or boreholes; protected dug wells; protected springs; and rainwater collection |
Source: The WHO.16
Statistical analysis.
Data analyses were performed using Stata (version 15; StataCorp LLC, College Station, TX). Only households with available information on recent diarrhea occurrences among household members were included in this analysis. Thus, the analytical sample comprised 22,571 households (98.0% of the total sample). Descriptive statistics (i.e., means and frequencies) were calculated to summarize study variables. The χ2 test of independence was used to evaluate associations between all explanatory variables (i.e., water source, urban/rural status, financial status, soap/detergent availability for handwashing, toilet type, and refrigerator availability), and recent diarrhea among a member of included households. Unadjusted and multivariable-adjusted logistic regression models were used to determine the association between the type of drinking water source and odds of diarrhea among Nigerian households when controlling for other explanatory variables. Unadjusted models only include the variable of interest. The adjusted model included all explanatory variables of interest. The sampling weights were applied to all analyses using the SVY commands in Stata to account for the survey’s sampling scheme. The significance level was set at P < 0.05.
RESULTS
Table 2 displays descriptive statistics and differences in explanatory variables by household diarrhea status. Approximately 11% of the 22,571 households in the analytical sample reported that a household member experienced diarrhea during the past 2 weeks, and 26% of households reported having an unimproved water source. A large percentage of households were located in a rural area (90%), had average financial status (62%), and did not have a refrigerator in the home (81%). More than half the households (59%) did have soap/detergent for handwashing, and the most common toilet type reported by households was a pit latrine (42%).
Table 2.
Descriptive statistics of sociodemographic and environmental variables stratified by diarrhea status among Nigerian households in 2018
| Variable | All households (N = 22,571), n (%) | Reported diarrhea (n = 2,786, 10.55%), n (%) | Reported no diarrhea (n = 19,785, 89.45%), n (%) | P value* |
|---|---|---|---|---|
| Water source† | < 0.0001 | |||
| Unimproved water source | 6,721 (25.57) | 1,155 (40.35) | 5,566 (23.83) | – |
| Improved water source | 15,850 (74.43) | 1,631 (59.64) | 14,121 (76.17) | – |
| Urban/rural status | < 0.0001 | |||
| Urban | 2,786 (10.55) | 459 (18.86) | 6,481 (36.94) | – |
| Rural | 19,785 (89.45) | 2,327 (81.14) | 13,304 (63.06) | – |
| Financial status | < 0.0001 | |||
| Poor | 8,000 (35.44) | 1,222 (43.86) | 6,778 (34.25) | – |
| Average | 14,043 (62.22) | 1,503 (53.94) | 12,540 (63.38) | – |
| Rich | 528 (2.34) | 61 (2.18) | 467 (2.36) | – |
| Refrigerator | < 0.0001 | |||
| Yes | 4,302 (19.10) | 277 (11.51) | 4,025 (22.00) | – |
| No | 18,269 (80.94) | 2,509 (88.49) | 15,760 (88.00) | – |
| Soap/detergent for handwashing | < 0.0001 | |||
| Yes | 12,768 (58.83) | 1,098 (40.86) | 11,670 (60.95) | – |
| No | 9,803 (41.16) | 1,688 (59.14) | 8,115 (39.04) | – |
| Toilet type | < 0.0001 | |||
| Flush toilet | 6,113 (30.86) | 332 (14.38) | 5,781 (32.80) | – |
| Pit latrine | 9,909 (41.88) | 1,638 (59.72) | 8,271 (39.77) | – |
| Other | 6,549 (27.26) | 816 (25.88) | 5,733 (27.42) | – |
Sample sizes may not add up to the total because of missing observations for some variables.
P values calculated with a χ2 test of independence.
Examples of improved and unimproved water sources are provided in Table 1.
χ2 Tests revealed that all explanatory variables were associated significantly with diarrhea status among households, including water-source type. Among households that reported diarrhea, 40% had an unimproved water source, compared to only 24% among households that did not report diarrhea. A greater percentage of households that reported no diarrhea were located in urban areas (37%) than those reporting diarrhea (19%). A greater percentage of households that reported no diarrhea (22%) had a refrigerator than households that reported diarrhea (12%). A greater percentage of households that reported no diarrhea (61%) had soap/detergent for handwashing compared with 41% of households that reported diarrhea. Regarding toilet type, 60% of households that reported diarrhea used a pit latrine compared with 39.8% of households that reported no diarrhea.
Table 3 displays logistic regression models examining the relationship between water-source type and diarrhea status among participating households in Nigeria. After adjusting for all variables of interest, having an unimproved water source was associated significantly with greater odds of a household member reporting diarrhea (odds ratio [OR], 1.59; 95% CI, 1.44–1.77). The adjusted model revealed living in an urban area (OR, 0.60; 95% CI, 0.53–0.69) and having soap/detergent for handwashing (OR, 0.58; 95% CI, 0.52–0.64) were protective against diarrhea. Having a refrigerator was not significant in the adjusted model. Households with a poor and rich financial status had greater odds of diarrhea than households that reported an average financial status. In addition, households with pit latrines had greater odds of having diarrhea (OR, 2.10; 95% CI, 1.76–2.44) than households with a flush toilet.
Table 3.
Logistic regression models examining associations between variables of interest and diarrhea prevalence among Nigerian households in 2018 (N = 22,571)
| Variable | Unadjusted models | Adjusted Model* | ||||
|---|---|---|---|---|---|---|
| OR | 95% CI | P value | OR | 95% CI | P value | |
| Water source | ||||||
| Improved (ref.) | – | – | – | – | – | – |
| Unimproved | 2.16 | 1.96–2.38 | < 0.0001 | 1.59 | 1.44–1.77 | < 0.0001 |
| Urban/Rural status | ||||||
| Urban | 0.39 | 0.35–0.45 | < 0.0001 | 0.60 | 0.53–0.69 | < 0.0001 |
| Rural (ref.) | – | – | – | – | – | – |
| Financial status | ||||||
| Poor | 1.49 | 1.35–1.64 | < 0.0001 | 1.20 | 1.09–1.33 | < 0.0001 |
| Average (ref.) | – | – | – | – | – | – |
| Rich | 1.18 | 0.87–1.62 | 0.29 | 1.77 | 1.28–2.45 | 0.001 |
| Refrigerator | ||||||
| Yes | 0.46 | 0.39–0.54 | < 0.0001 | 0.97 | 0.81–1.16 | 0.74 |
| No (ref.) | – | – | – | – | – | – |
| Soap/detergent for handwashing | ||||||
| Yes | 0.44 | 0.40–0.49 | < 0.0001 | 0.58 | 0.52–0.64 | < 0.0001 |
| No (ref.) | – | – | – | – | – | – |
| Toilet type | ||||||
| Flush toilet (ref.) | – | – | – | – | – | – |
| Pit latrine | 3.43 | 2.96–3.96 | < 0.0001 | 2.10 | 1.76–2.44 | < 0.0001 |
| Other | 2.15 | 1.84–2.52 | < 0.0001 | 1.13 | 0.94–1.35 | 0.138 |
OR = odds ratio; ref. = reference.
The adjusted model includes all variables of interest.
DISCUSSION
The primary aim of this study was to examine the association between drinking water source and the prevalence of diarrhea among members of a large and nationally representative sample of Nigerian households surveyed in 2018. Furthermore, this study aimed to examine this relationship while accounting for factors such as financial status, availability of soap/detergent for handwashing, availability of a refrigerator in the home, toilet type, and urban/rural status. Factors associated with diarrhea prevalence in Nigeria are of great interest to public health officials considering the country’s under-five mortality rate resulting from diarrhea.13 Overall, findings from our study suggest a significant association between having an unimproved water source and the prevalence of diarrhea at the household level after controlling for all other explanatory variables. These results align with previous studies conducted in Nigeria, and other African countries on the relationship between water source and diarrhea.9–11,17–20 For example, a secondary analysis of data from the 2013 Nigerian Demographic and Health Survey reported that household drinking water source was associated with childhood diarrhea.10 Children living in households that used improved sources had 16% lower odds of experiencing diarrheal episodes.10 Studies from other African countries, including Ethiopia, have also found that diarrhea is associated significantly with unimproved water.17–19 Overall, these findings confirm that type of water source is still a strong predictor of diarrhea in Nigeria and other parts of Africa.
Most of the household variables (i.e., soap/detergent for handwashing, toilet type, refrigerator in the home) evaluated in our study were associated significantly with diarrhea among members of the Nigerian households. Having soap/detergent for handwashing was protective against diarrhea. Previous studies reported similar results.11,20,21 These data suggest that increasing the availability of soap and detergent to improve hygiene may reduce the risk of diarrhea in Nigeria. Programs or interventions that aim to promote handwashing with detergents in Nigeria have the potential to save millions of lives, because hands serve as vectors for transmitting pathogens to susceptible hosts, and handwashing can prevent viral and bacterial diarrhea.22
Study findings regarding toilet type emphasized that people from households with access to a pit latrine or toilet types other than a flush toilet experience a greater risk of having diarrhea. These findings are consistent with studies conducted in Nigeria, Ethiopia, Egypt, and Lesotho.10,23–26 Similar to water source, toilet type can be classified as improved and unimproved.10 According to the WHO and UNICEF, an unimproved toilet type does not separate human excreta properly from human contact, thereby increasing probability of transmitting pathogens that cause diarrhea.10 A recent systematic review of 31 studies conducted in Ethiopia reported that have an unimproved latrine is associated with twice of odds of diarrhea among under-five children.24 Thus, toilet type is vital to the overall health status of the household. A direct association was observed between owning a refrigerator and the prevalence of diarrhea in our study, which also mirrors other studies.23,27,28 Compared with households with a functional refrigerator, those with no refrigerator reported double the odds of diarrhea at the household level, implying that possessing a refrigerator may reduce the risk of diarrhea. A case–control study conducted in Zambia also reported a significant association.27 Researchers theorize that refrigerators preserve food and keep chlorine-treated water cool, which reduces the need to add a block of ice purchased in a marketplace that often carries environmental contaminants.29
Regarding sociodemographic variables, living in an urban area was protective against the prevalence of diarrhea among Nigerian households. Although prior study results have been mixed on this topic, most have reported that people living in rural areas are more likely to experience diarrhea.10,24,30 A possible explanation may be greater access to improved water sources in Nigeria’s urban settlements.10,24,30 Another explanation is differences in social determinants of health between urban and rural households.10,24,31–33 Having an improved water source has been shown to correlate with basic social amenities such as electricity, roads, sanitation facilities, improved housing, and access to health care.10,24,31 Furthermore, households in rural settlements tend to be poorer than those in urban areas, which affects educational attainment, hygiene practices, health-seeking behavior, and childbearing practices.32,33 Given this information, it is possible that households in urban areas have a lower prevalence of diarrhea. However, additional research is needed to describe more fully the social and environmental differences between urban and rural areas of Nigeria.
This study has strengths and limitations. The data source was a strength because it is a national survey conducted across all 36 states of Nigeria, allowing findings to be generalized to the entire population. In addition, the survey features a wide variety of variables collected from a large sample of households. Nevertheless, the survey is cross-sectional and provides only a snapshot of the country’s health at a specific time in a year. It does not consider the role of seasonality on the prevalence of diarrhea or permit the assessment of relationships over time. Longitudinal studies are the best design to provide observational data on the changing prevalence of diarrhea and the influence of household factors over time. Another limitation was the self-reported variables, which may be subject to recall and reporting errors. Self-reported variables, such as financial status, might have not captured fully the phenomenon they intended to measure, which may have resulted in residual confounding in the analyses. In addition, the quality of water was not measured to test properly for pathogens or fecal bacteria. Instead, the WHO classification of water source was adopted to represent type of water source (improved versus unimproved). Evaluating water quality would have strengthened the study results, because it is possible that the WHO classification does not capture water quality completely.
CONCLUSION
This study found an association between type of drinking water source and the prevalence of diarrhea among households in Nigeria. It also found a significant association between refrigerator availability, detergent availability, toilet type, urban/rural status, and diarrhea. This information is pertinent to the Nigerian government and UNICEF’s efforts to reduce diarrhea and other relevant diseases in Nigeria. It calls for 1) a closer evaluation of funded programs that aim to improve drinking water and 2) the development of long-term solutions to decrease morbidity from diarrhea. We conclude that investing in living conditions, water sources, and sanitation is critical to diarrhea prevention programs in Nigeria. Additional research is needed to describe more completely the relationship between unimproved water sources and the prevalence of diarrhea, especially identifying the types of unimproved sources that contribute the most to diarrhea prevalence.
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