Introduction: Childhood diarrhoeal diseases and stunting are major health problems in low- and middle-income countries (LMICs). Poor water supply, sanitation services and hygiene, frequently encountered in resource-poor settings, contribute to childhood diarrhoea and stunting.
Methods: Data on demographic characteristics, hygiene practices, sanitation and human-animal interactions (predictors) and child height-for-age z-scores (HAZ) (outcome) were collected once, while diarrhoea incidences were collected fortnightly for 24 months (outcome).
Results: Drinking water from public taps (OR = 0.51, 95% CI. 0.44 - 0.61; p < 0.001) and open wells (OR = 0.46, 95% CI. 0.39 - 0.54; p < 0.001) and older age of children (OR = 0.43, 95% CI. 0.27 - 0.67; p < 0.001) were protective against diarrhoea. Inappropriate disposal of children’s faeces (OR = 1.15, 95% CI. 1.02 - 1.31; p = 0.025), sharing water sources with animals in the dry season (OR = 1.48, 95% CI. 1.29 - 1.70; p < 0.001), over- night sharing of houses with cats (OR = 1.35, 95% CI. 1.16 - 1.57; p < 0.001) and keeping chickens inside the house overnight regardless of room (OR = 1.39, 95% CI. 1.20 - 1.60; p < 0.001) increased the risk of diarrhoea. The Sukuma language group (p = 0.005), washing hands in running water (p = 0.007), access of chickens to unwashed kitchen utensils (p = 0.030) and over- night sharing of the house with sheep (p = 0.020) were associated with higher HAZ in children.
Conclusions: Until a more precise understanding of the key risk factors is available, these findings suggest efforts towards control of diarrhoea and improved linear growth in these areas should be directed to increased access to clean and safe water, hand- washing, sanitation, and improved animal husbandry practices.
1. Troeger C, Forouzanfar M, Rao P C, Khalil I, Brown A, Reiner RC, Fullman N, Thompson RL, Abajobir A, Ahmed M, Alemayohu MA, Alvis-Guzman N, Amare AT, Antonio CA, Asayesh H, Avokpaho E, Awasthi A, Bacha U, Barac A, Betsue BD, Beyene AS, Boneya DJ, Malta DC, Dandona L, Dandona R, Dubey M, Eshrati B, Fitchett JRA, Gebrehiwot TT, Hailu GB, Horino M, Hotez PJ, Jibat T, Jonas JB, Kasaeian A, Kissoon N, Kotloff K, Koyanagi A, Kumar GA, Rai RK, Lal A, El Razek HA, Mengistie MA, Moe C, Patton G, Platts-Mills JA, Qorbani M, Ram U, Roba HS, Sanabria J, Sartorius B, Sawhney M, Shigematsu M, Sreeramareddy C, Swaminathan S, Tedla B, Jagiellonian RT, Ukwaja K, Werdecker A, Widdowson M, Yonemoto N, El Sayed Zaki M, Lim, SS, Naghavi M, Vos T, Hay SI, Murray CJL, Mokdad AH.Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet Infectious Diseases 2017; 17: 909-48. doi: 10.1016/S1473-3099(17)30276-1
2. UNICEF WHO World Bank. Monitoring the situation of children and women. UNICEF, WHO, World Bank: Joint Child Malnutrition Estimates. 2018 [cited 2019 28/3]; Available from: https://data.unicef.org/topic/nutrition/malnutrition/
3. MoHCDGEC MoH NBS OCGS and ICF. Tanzania Demographic and Health Survey and Malaria Indicator Survey (TDHS-MIS) 2015-16. Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC) [Tanzania Mainland], Ministry of Health (MoH) [Zanzibar], National Bureau of Statistics (NBS), Office of the Chief Government Statistician (OCGS), and ICF. 2016. Dar es Salaam, Tanzania, and Rockville, Maryland, USA. Dar es Salaam: MoHCDGEC 2016:630. https://dhsprogram.com/pubs/pdf/FR321/FR321.pdf
4. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham McGregor S, Katz J, Martorell R, Uauy R. Maternal and child undernutrition and overweight in low-income and middle-income countries. The Lancet 2013; 382: 427-51. 10.1016/S0140-6736(13)60937-X.
5. Leroy JL, Frongillo EA. Perspective: What Does Stunting Really Mean? A Critical Review of the Evidence. Advances in Nutrition 2019; 10: 196-204. doi: 10.1093/advances/nmy101
6. Humphrey JH. Child undernutrition, tropical enteropathy, toilets, and handwashing. Lancet 2009; 374: 1032-35. doi: https://doi.org/10.1016/S0140-6736(09)60950-8
7. El Samani EFZ, Willett WC, Ware JH. Association of malnutrition and diarrhea in children aged under five years: A prospective follow-up study in a rural Sudanese community. American Journal of Epidemiology 1988; 128: 93-105. doi: 10.1093/oxfordjournals.aje.a114963
8. Rahman AE, Moinuddin M, Molla M, Worku A, Hurt L, Kirkwood B, Mohan SB, Mazumder S, Bhutta Z, Raza F, Mrema S, Masanja H, Kadobera D, Waiswa P, Bahl R, Zangenberg M, Muhe L. Childhood diarrhoeal deaths in seven low- and middle-income countries. Bulletin of the World Health Organization 2014; 92: 664-71. doi: 10.2471/BLT.13.134809
9. Danaei G, Andrews KG, Sudfeld CR, Fink G, McCoy DC, Peet E, Sania A, Smith F, Mary C, Ezzati M, Fawzi WW. Risk factors for childhood stunting in 137 developing countries: A comparative risk assessment analysis at global, regional, and country levels. PLoS medicine 2016; 13: e1002164-e. doi: 10.1371/journal.pmed.1002164
10. Oloruntoba EO, Folarin TB, Ayede AI. Hygiene and sanitation risk factors of diarrhoeal disease among under-five children in Ibadan, Nigeria. African Health Sciences 2014; 14 1001-2. doi: 10.4314/ahs.v14i4.32
11. Zambrano LD, Levy K, Menezes NP, Freeman MC. Human diarrhea infections associated with domestic animal husbandry: a systematic review and meta-analysis. Transactions of the Royal Society of Tropical Medicine and Hygiene 2014; 108: 313-25. doi: 10.1093/trstmh/tru056
12. Conan A, O’Reilly CE, Ogola E, Ochieng JB, Blackstock AJ, Omore R, Ochieng L, Moke F, Parsons MB, Xiao L, Roellig D, Farag TH, Nataro JP, Kotloff KL, Levine MM, Mintz ED, Breiman RF, Cleaveland S, Knobel DL. Animal-related factors associated with moderate-to-severe diarrhea in children younger than five years in western Kenya: A matched case-control study. PLOS Neglected Tropical Diseases 2017; 11: e0005795. doi: 10.1371/journal.pntd.0005795
13. de Bruyn J, Thomson PC, Darnton-Hill I Bagnol B, Maulaga W, Alders Robyn RG. Does Village Chicken-Keeping Contribute to Young Children's Diets and Growth? A Longitudinal Observational Study in Rural Tanzania. Nutrients 2018; 10: 1799. DOI: 10.3390/nu10111799
14. Oberhelman RA, Gilman RH, Sheen P, Cordova J, Zimic M, Cabrera L, Meza R, Perez J. An intervention-control study of corralling of free-ranging chickens to control Campylobacter infections among children in a Peruvian periurban Shantytown. American Journal of Tropical Medicine and Hygiene 2006; 74: 1054-9. doi: https://doi.org/10.4269/ajtmh.2006.74.1054
15. Alders R, Aongola A, Bagnol B, de Bruyn J, Kimboka S, Kock R, Li M, Maulaga W, McChonchie R, Mor. S, Msami H, Mulenga F, Mwale M, Mwale S, Pengely B, Rushton J, Simpson J, Victor R, Yongolo C, Young M. Using a one health approach to promote food and nutrition security in Tanzania and Zambia. Planet@Risk 2014; 2: 187-90. doi: https://planet-risk.org/index.php/pr/article/view/67
16. Lema MA, Majule AE. Impacts of climate change, variability and adaptation strategies on agriculture in semi-arid areas of Tanzania: The case of Manyoni District in Singida Region, Tanzania. African Journal of Environmental Science and Technology 2009; 3: 206-18. doi: 10.5897/AJEST09.099
17. de Bruyn J, Thomson PC, Bagnol B, Maulaga W, Rukambile E, Alders RG. The chicken or the egg? Exploring bi-directional associations between Newcastle disease vaccination and village chicken flock size in rural Tanzania. PLOS ONE 2017; 12: e0188230. doi: 10.1371/journal.pone.0188230
18. WHO. Diarrhoeal disease (Fact sheet No. 330). 2013 [cited 2018 1/10]; Available from: http://www.who.int/mediacentre/factsheets/fs330/en/.
19. WHO. World Health Organisation Multicentre Growth Reference Study Group. WHO Child Growth Standards: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and development. Geneva: World Health Organization 2006 ed. Geneva: WHO 2006:312. https://www.who.int/childgrowth/standards/technical_report/en/
20. StataCorp. Stata Statistical Software: Release 14. College Station, TX: StataCorp LP. 14. 2 ed. Texas, USA: StataCorp 2015. http://www.stata.com
21. R Core Team. R: A language and environment for statistical computing. R Foundation for Statistical Computing. 2019 [cited 2019 10/05]; Available from: https://www.R-project.org/.
22. Kang Y, Aguayo VM, Campbell RK, Dzed L, Joshi V, Waid JL, Gupta SD Haselow NJ, West Jr. KP. Nutritional status and risk factors for stunting in preschool children in Bhutan. Maternal & Child Nutrition 2018; 14: e12653. doi: 10.1111/mcn.12653
23. Nshimyiryo A, Hedt-Gauthier B, Mutaganzwa C, Kirk CM, Beck K, Ndayisaba A, Mubiligi J, Kateera F, El-Khatib Z. Risk factors for stunting among children under five years: a cross-sectional population-based study in Rwanda using the 2015 Demographic and Health Survey. BMC Public Health 2019; 19: 175. doi: 10.1186/s12889-019-6504-z
24. Hong R, Banta JE, Betancourt JA. Relationship between household wealth inequality and chronic childhood under-nutrition in Bangladesh. Int J Equity Health 2006; 5: 15-.doi: 10.1186/1475-9276-5-15
25. Faye CM, Fonn S, Levin J. Factors associated with recovery from stunting among under-five children in two Nairobi informal settlements. PLoS One 2019; 14: 1-17. doi: 10.1371/journal.pone.0215488
26. Bbaale E. Determinants of diarrhoea and acute respiratory infection among under-fives in Uganda. The Australasian Medical Journal 2011; 4: 400-9. doi: 10.4066/AMJ.2011.723
27. Ahmed SF, Farheen A, Muzaffar A, Mattoo GM. Prevalence of diarrhoeal disease, its seasonal and age variation in under- fives in Kashmir, India. International journal of health sciences 2008; 2: 126-33. doi: https://www.ncbi.nlm.nih.gov/pubmed/21475494
28. Bessong PO, Odiyo JO, Musekene JN, Tessema A. Spatial distribution of diarrhoea and microbial quality of domestic water during anoutbreak of diarrhoea in the Tshikuwi Community in Venda, South Africa. Journal of Health, Population and Nutrition 2009; 27: 652-9. doi: 10.3329/jhpn.v27i5.3642
29. Diouf K, Tabatabai P, Rudolph J, Marx M. Diarrhoea prevalence in children under five years of age in rural Burundi: an assessment of social and behavioural factors at the household level. Glob Health Action 2014; 7: 24895. doi: 10.3402/gha.v7.24895
30. Mengistie B, Berhane Y, Worku A. Household water chlorination reduces incidence of diarrhea among under-five children in rural Ethiopia: A cluster randomized controlled trial. PLOS ONE 2013; 8: e77887. doi: 10.1371/journal.pone.0077887
31. Acharyaa D, Singhb JK, Adhikaric M, Gautamd S, Pandeye P, Dayalfa V. Association of water handling and child feeding practice with childhood diarrhoea in rural community of Southern Nepal. Journal of Infection and Public Health 2018; 11: 69-74.doi: 10.1016/j.jiph.2017.04.007.
32. Kabinga FM, Mbewe A, Banda J. Environmental health factors associated with diarrhoea in the under five children in Mtendere, Lusaka, Zambia. International Journal of Infectious Diseases 2016; 53: 69. doi: 10.1016/j.ijid.2016.11.173
33. Kapwata T, Mathee A, le Roux WJ, Wright CY. Diarrhoeal disease in relation to possible household risk factors in South African villages. International journal of environmental research and public health 2018; 15: 1665. doi: 10.3390/ijerph15081665
34. Siziya S, Muula AS, Rudatsikira E. Diarrhoea and acute respiratory infections prevalence and risk factors among under-five children in Iraq in 2000. Italian Journal of Pediatrics 2009; 35: 8-. doi: 10.1186/1824-7288-35-8
35. Hadley C. Ethnic expansions and between-group differences in children’s health: A case study from the Rukwa Valley, Tanzania. American Journal of Physical Anthropology 2005; 128: 682-92. doi: 10.1002/ajpa.20056
36. Hadley C, Mulder MB, Fitzherbert E. Seasonal food insecurity and perceived social support in rural Tanzania. Public Health Nutrition 2007; 10: 544-51. doi: 10.1017/S1368980007246725
37. Islam MM, Sanin KI, Mahfuz M, Ahmed AMS, Mondal D, Haque R, Ahmed T. Risk factors of stunting among children living in an urban slum of Bangladesh: findings of a prospective cohort study. BMC public health 2018; 18: 197-. doi: 10.1186/s12889-018-5101-x
38. Angdembe MR, Dulal BP, Bhattarai K, Karn S. Trends and predictors of inequality in childhood stunting in Nepal from 1996 to 2016. Int J Equity Health 2019; 18: 42-. doi: 10.1186/s12939-019-0944-z
39. Gatica-Domínguez G, Victora C, Barros AJD. Ethnic inequalities and trends in stunting prevalence among Guatemalan children: an analysis using national health surveys 1995–2014. Int J Equity Health 2019; 18: 110. doi: 10.1186/s12939-019-1016-0
40. Kabhele S, New-Aaron M, Kibusi SM, Gesase AP. Prevalence and factors associated with diarrhoea among children between 6 and 59 months of age in Mwanza City Tanzania. Journal of Tropical Pediatrics 2018; 64: 523-30. doi: 10.1093/tropej/fmx109
41. Wasihun AG, Dejene TA, Teferi M, Marugán J, Negash L, Yemane D, McGuigan KG. Risk factors for diarrhoea and malnutrition among children under the age of 5 years in the Tigray Region of Northern Ethiopia. PLOS ONE 2018; 13: e0207743. doi: https://doi.org/10.1371/journal.pone.0207743
42. Demirchyan A, Petrosyan V. Hand hygiene predicts stunting among rural children in Armenia: Anahit Demirchyan. European Journal of Public Health 2017; 27. doi: 10.1093/eurpub/ckx186.287
43. Mbuya MN, Humphrey JH. Preventing environmental enteric dysfunction through improved water, sanitation and hygiene: an opportunity for stunting reduction in developing countries. Maternal and Child Nutrition 2016; 12 Suppl 1: 106-20. doi: 10.1111/mcn.12220
44. Maponga BA, Chirundu D, Gombe NT, Tshimanga M, Shambira G, Takundwa L. Risk factors for contracting watery diarrhoea in Kadoma City, Zimbabwe, 2011: a case control study. BMC Infectious Diseases 2013; 13: 567. doi: 10.1186/1471-2334-13-567
45. Hoque BA. Handwashing practices and challenges in Bangladesh. International Journal of Environmental Health Research 2003; 13: S81-S7. doi: 10.1080/0960312031000102831
46. Luby SP, Rahman M, Arnold BF, Unicomb L, Ashraf S, Winch PJ, Stewart CP, Begum F, Hussain F, Benjamin-Chung J, Leontsini E, Naser AM, Parvez SM, Hubbard AE, Lin A, Nizame FA, Jannat K, Ercumen A, Ram PK, Das KK, Abedin J, Clasen TF, Dewey KG, Fernald LC, Null C, diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial. The Lancet Global Health 2018; 6: e302-e15. doi: https://doi.org/10.1016/S2214-109X(17)30490-4
47. Pickering AJ, Djebbari H, Lopez C, Coulibaly M, Alzua ML. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial. The Lancet Global Health 2015; 3: e701-e11. doi: https://doi.org/10.1016/S2214-109X(15)00144-8
48. Gebreegziabher T, Regassa N. Ethiopia's high childhood undernutrition explained: analysis of the prevalence and key correlates based on recent nationally representative data. Public Health Nutrition 2019; 22: 2099-109. doi: 10.1017/s1368980019000569
49. Chattopadhyay A, Sethi V, Nagargoje VP, Saraswat A, Surani N, Agarwal N, Bhatia V, Ruikar M, Bhattacharjee S, Parhi RN, Dar S, Daniel A, Sachdev HPS, Singh CM, Gope R, Nath V, Sareen N, De Wagt A, Unisa S. WASH practices and its association with nutritional status of adolescent girls in poverty pockets of eastern India. BMC Women's Health 2019; 19: N.PAG-N.PAG. doi: 10.1186/s12905-019-0787-1
50. Behravesh CB, Brinson D, Hopkins BA, Gomez TM. Backyard poultry flocks and salmonellosis: A recurring, yet preventable public health challenge. Clinical Infectious Diseases 2014; 58: 1432-8. doi: 10.1093/cid/ciu067
51. Gómara I, Miren, Kang G, Mammen A, Jana AK, Abraham M, Desselberger U, Brown D, Gray J. Characterization of G10P Rotaviruses causing acute gastroenteritis in neonates and infants in Vellore, India. Journal of Clinical Microbiology 2004; 42: 2541. doi: 10.1128/JCM.42.6.2541-2547.2004
52. Luchs A, Timenetsky MTS. Unexpected detection of bovine G10 rotavirus in a Brazilian child with diarrhea. Journal of Clinical Virology 2014; 59: 74-6. doi: 10.1016/j.jcv.2013.11.001
53. Dione MM, Ikumapayi UN, Saha D, Mohammed NI, Geerts S, Ieven M, Adegbola RA, Antonio M. Clonal differences between non-typhoidal Salmonella (NTS) recovered from children and animals living in close contact in The Gambia. PLoS Neglected Tropical Diseases 2011; 5: e1148. doi: 10.1371/journal.pntd.0001148
54. Tun HM, Konya T, Takaro TK,. Brook JR, Chari R, Field CJ, Guttman DS, Becker AB, Mandhane PJ, Turvey SE, Subbarao P, Sears MR, Scott JA, Kozyrskyj AL, Sears MR, Subbarao P, Anand SS, Azad M, Becker AB, Befus AD, Brauer M, Brook JR, Chen E, Cyr M, Daley D, Dell S, Denburg JA, Duan Q, Eiwegger T, Grasemann H, HayGlass K, Hegele R, Holness DL, Hystad P, Kobor MS, Kollmann TR, Kozyrskyj AL, Laprise C, Lou WYW, Macri J, Mandhane PM,Miller G, Moraes T, Paré PD, Ramsey C, Ratjen F, Sandford A, Scott JA, Scott J, Silverman F, Simons E, Takaro T, Tebbutt S, To T. Turvey SE. Exposure to household furry pets influences the gut microbiota of infants at 3–4 months following various birth scenarios. Microbiome 2017; 5: 40. doi: 10.1186/s40168-017-0254-x
55. Passarelli s, Ambikapathi R, Gunaratna N, Madzorera I, Canavan C, Noor RA, Worku A, Berhane Y, Sibanda S, Sudfeld C, McConnell M, Fawzi W. Effects of chicken production on child nutrition and health outcomes Ethiopia. Annual Agriculture, Nutrition and Health (ANH) Academy Week. Hyderabad, India 2019.
56. Contzen N, Meili IH, Mosler H-J. Changing handwashing behaviour in southern Ethiopia: A longitudinal study on infrastructural and commitment interventions. Social Science & Medicine 2015; 124: 103-14. doi: 10.1016/j.socscimed.2014.11.006
57. Water Aid. wateraid Nepal's field experience in community-based resources management. field work paper. Kathmandu, Nepal: Water Aid 2008:28. https://www.wateraid.org/uk/search/wasearch