Abstract

Background: Diarrhea is a very common condition in pediatrics. Indeed, it is one of the leading causes of infant mortality, accounting for around 8% of all deaths of children under five worldwide in 2017. Low-income countries are the most affected. However, the prevalence of diarrhea and the factors associated with it are not homogeneous. They vary from one region to another depending on the socio-economic context and even certain cultural practices. The main objective of this study is to determine the prevalence and factors associated with acute diarrhea in children aged 0 to 59 months seen in a rural university hospital.

Method: Analytical cross-sectional study conducted among 230 parents with children aged 0-59 months randomly selected from different sectors of the pediatrics department from May 1 to 31, 2022. Data were collected from guided face-to-face interviews by a structured questionnaire in Haitian Creole. They were analyzed using Jamovi 2.3.9 software at a 95% confidence interval. Descriptive analysis and binary logistic regression were performed.

Results: For a total of 230 parents interviewed, 56.52% reported having had diarrhea in the last two preceding the survey, 12% had received a natural purgative in the 48 hours preceding the diarrheal episode, 77% had access to drinking water, 89.13% of households had latrines (59.5% improved) 30% of homes consisted of a single room with more than 5 inhabitants in 62.6% of cases. 52.17% of habitats with hand washing points. Diarrhea was significantly associated with education level (p<0.025), vaccination status (p<0.001) latrine type (p<0.039) and use of natural purgative (p<0.039). Logistic regression also showed a significantly high relationship with having a cell phone (p<0.029) and a lower relationship with having electricity (p<0.035).

Conclusion: Our survey revealed a high prevalence of diarrhea in children under 5 years old seen in consultation or hospitalized at the Mirebalais University Hospital. The factors associated with this high prevalence are the level of education of the parents, access to information and the use of natural purgatives. Health education campaigns on ways to prevent diarrhea in children could prove useful in the strategy to reduce this phenomenon.

Keywords: Childhood diarrhea, risk factors, epidemiology, prevalence, Haiti.

Introduction

Diarrhea is a very common clinical situation in pediatrics. However, there are several definitions of acute pediatric diarrhea which imply notable differences in morbidity and mortality estimates. (4) The definition most often used is that of the World Health Organization which considers diarrhea as: "passage from least three loose or watery stools per day or more frequent bowel movements than normal for the individual.”(4,5)

Generally, acute diarrhea in young children is of infectious origin, particularly in developing countries due to the lack of sanitation and access to drinking water. (6–9)

Much effort has been made over the past three decades to counteract child mortality due to diarrheal disease worldwide. (10,11) However, it still remains a public health problem, as each year approximately 1, 7 billion cases of diarrhea are recorded in children worldwide with more than 520,000 deaths. (2) Children under 5 years old are the most vulnerable with an average of three episodes of diarrhea per year, especially in low-income countries. (1–3) Globally, diarrhea remains the second leading cause of death in this age group despite being both a preventable and treatable disease. (2) However, the prevalence of diarrhea is not homogeneous, and the factors associated with it are multiple. They can be divided into individual factors directly linked to the characteristics of the child and environmental factors.(12) The childhood factors most often incriminated in the literature are: young age, (13) non-breastfed children,(14,15) incomplete vaccination,(12,13) nutritional status,(18) and limited access to health care.(12) Environmental factors are considered as the characteristics of the family and household, they include: the level of education maternal,(19) maternal employment,(20) lack of sanitation, (21–23) non-traditional family structures and young age of mothers,(24) poverty,(14) rural residence (18) and overcrowded households.(25)

Haiti is the poorest country in Latin America, with growing socio-political instability which puts the entire population in a situation of alarming vulnerability. (15) The last prevalence survey in Haiti, dating from 2016, revealed that one in five children was affected by diarrhea, the centrer department would be the third department most affected by diarrheal disease in children, or 22.5% of all cases. (16)

A study carried out in 2016 at the Mirebalais University Hospital in children under 5 years of age hospitalized with acute gastroenteritis over a period of 3 years showed a prevalence of 12.7%, seasonal variation was addressed but not the factors associated with the pathology.(17) The main objective of our study is therefore to determine the prevalence of diarrhea in children under 5 years of age seen at the Mirebalais University Hospital as well as the factors associated with it.

Such data would provide a solid basis for planning, implementing interventions and targeted prevention strategies aimed at reducing morbidity due to diarrhea at the community level.

Materials and methods

Setting and period of the study

This is a transversal analytical study which took place in Haiti from May 1 to 31, 2022 at the Mirebalais University Hospital (HUM), a tertiary, mixed establishment, opened in March 2013 in the department of Center by Zanmi Lasante/Partners in Health in partnership with the Ministry of Public Health. The hospital provides primary care services to approximately 185,000 people in Mirebalais and also to other neighboring communities and more remote departments in the country.(18)

The pediatric department includes around a hundred beds with 6 sectors distributed as follows: The outpatient clinic, the emergency room, two hospitalization rooms, the neonatal intensive care unit, neonatology and Kangaroo Care.

                                                                                                                                                                           

Population and Sampling

The study population consists of children aged 0-59 months seen in an outpatient clinic or hospitalized in one of the different pediatric sectors of HUM whose parents have consented to participate in the study.

The sample size was calculated from Open-Epi with a 95% CI, a risk ? agreed at the significance level of 0.05, a prevalence of diarrhea in children aged 0 to 5 years of 10.49%, and an accuracy of 5%. It is calculated with N= 6863 (n being the number of children aged 0-59 months who were seen during the last year) for a power of 80%, increased by 10% in anticipation of possible problems linked to the data collection. A total of 230 parents of children aged 0 to 5 years seen in an outpatient clinic or hospitalized in the pediatric department for the period were included in the study. Excluded are parents of seriously ill children or children with mental health problems, hearing disorders and children with chronic digestive pathologies or other systemic pathologies responsible for diarrhea such as celiac disease, malabsorption syndrome, HIV, etc.

Procedures / Data collection

Our dependent variable was the occurrence of diarrhea in the last two weeks preceding the survey.

The collection team was made up of residents and nurses from the pediatric department who benefited from a training session on the use of the questionnaire before the start of the collection. As a tool, we used a structured electronic questionnaire in Haitian Creole adapted from the latest Morbidity, Mortality and Use of Services Survey (EMMUS) previously tested. The interviews were conducted face to face after obtaining informed and signed consent from randomly selected guardians during the period from May 1 to 31, 2022.

 

Statistical analyzes

The dependent variable was the occurrence of diarrhea in the two weeks preceding the survey. The data were entered into Excel then processed and analyzed with Jamovi 2.3.9 software. Prevalences were compared in each group by the overall Chi-square test and multivariate analysis by logistic regression with a 95% confidence interval (CI). The level of significance was set at 0.05. Some variables with a non-significant p-value (≥0.05) were excluded in the logistic regression.

 

Ethics approval

The study was validated by the ethics committee of the Mirebalais University Hospital.

 

Results

Sociodemographic characteristics of parents

In this study, we interviewed 230 parents of children aged 0 to 59 months, 89.5% of whom were female, and the majority came from the Center department, i.e. 79.5%. The largest age group was 25-34 years old with 45.2% of parents. 43.47% were cohabiting compared to 32.17% married and 24.34% single. Among 61 parents, 3% have completed primary school compared to 13% who have not been to school. 51.7% were self-employed, 64% claimed to have knowledge on methods of preventing diarrhea and its transmission.

 

Environmental characteristics

In the overall population, 77% reported having access to drinking water. Among those who did not have it, 85% used home water treatment via chlorination. 89.13% had latrines, of which 59.5% of these latrines would be improved. We considered an improved sanitation facility in the context of our study to be one corresponding to the definition proposed by UNESCO: “pit latrine with slab or ventilated improved latrine, or flush latrine or a composting toilet”. 19) 30% of habitats consisted of a single room with more than 5 inhabitants in 62.6% of cases. 52.17% of homes would have a hand washing point, and 30% did not have electricity.

 

Characteristics of children

67% of the children were infants aged between 1 and 24 months, the majority of whom were male. 80% of children would have an up-to-date vaccination status in relation to the expanded vaccination program (EPI), however 88.5% of vaccinated children presented with diarrhea in the two weeks preceding the survey. 41% of children benefited from exclusive breastfeeding during the first 6 months of life, 53% received their first dose of vitamin A in accordance with the Ministry of Health schedule. About 12% of children who developed diarrhea had received a natural purgative at least in the 48 hours before the diarrhea episode.

67.2% of children who presented with diarrhea experienced more than 5 liquid stools per day for more than 5 days. In 72% of cases, signs associated with diarrhea were reported, such as abdominal pain, fever and vomiting. Only 38% of children with diarrhea benefited from the administration of oral serum at home.

 

Table 1: Socio-demographic characteristics of parents

 

Discussion

The main objective of our work was to determine the prevalence of diarrhea as well as associated factors in children aged 0-59 months seen as outpatients or hospitalized at the Mirebalais University Hospital. As part of this study, 130 parents, or 56.52%, reported that their children had diarrhea in the last two weeks preceding the survey. This prevalence seems high compared to the 12.7% found during the study which was carried out in 2016 in the same hospital.(20) However, their lower prevalence than ours could be explained by the fact that they had included in their study only hospitalized children, unlike the rest of us who also considered children seen in outpatient consultations. As another hypothesis to explain this high prevalence, we can blame the socio-political unrest plaguing the country, particularly in the capital, which has caused an influx to hospitals in the outskirts. Studies carried out over the last three years in several countries on the African continent, some of which with a socio-economic context close to ours, have revealed prevalences ranging from 14.5% to 35.8%.(21–24) Another study carried out in 40 developing countries found an overall prevalence of diarrhea of 14%.(25) It is important to remember that all of these above-mentioned studies were carried out at the community level unlike ours. which is institutional. Obviously our higher prevalence could be explained by the fact that children with diarrhea are more likely to present to the hospital.

 

Environmental factors linked to diarrhea

The prevalence of diarrhea was higher among young mothers in our study. Although we did not find sufficient statistical evidence to categorize it as an associated factor in the context of our work, other authors have already reported this association. According to a multinational study that was conducted in 40 developing countries, children of young mothers are more likely to develop diarrhea, and more than half of them were in the 25 to 34 age group. (21) Another recent study carried out in Africa as well as others carried out in other regions of the globe also made the same observation. (22,23) The plausible explanation for this phenomenon would be that young mothers are less experienced in childcare.

We found that parental education level was associated with the prevalence of diarrhea; (Table 1) children of uneducated parents compared to those of educated parents would be more likely to develop diarrhea. This finding aligns with data from the literature. Indeed, the mother's education level plays a very important role in diarrheal disease in children. (26)A recent study carried out in sub-Saharan Africa in around thirty countries also corroborated this fact.(27) However, the level of education does not always imply possession of knowledge on the means of transmission and methods of diarrhea in children. In our sample, two thirds of the people questioned declared having this knowledge, paradoxically only a third of the children received oral serum at home following the diarrhea episode.

In the analysis of environmental characteristics, the type of latrine was found to be a factor associated with the prevalence of diarrhea (Table 3), which corroborates the literature data because the fecal-oral peril is the one of the very important factors in the transmission of diarrhea. It has already been shown that the presence of even an unimproved latrine has a positive correlation on the health of the community in general and would help prevent acute diarrhea in children. (28) We have also identified the availability of electricity as a protective factor for the occurrence of acute diarrhea.

Bauleth et al, as well as Sarker, made similar observations in the context of their work. (27,29) This could be explained by the fact that residents with electricity at home would probably also have telecommunications devices ( radio, television) which would allow them to be more exposed to information from health campaigns. It should also be noted that the availability of electricity also reflects the economic status of the household, because people living in the most remote and disadvantaged municipal sections are more likely not to have it.

Table 2: Characteristics of children

Childhood factors linked to diarrhea

Overall, children under 5 years of age are more affected by diarrheal disease.(8,26) However, certain age subgroups have attracted attention with a higher risk. A recent study carried out in Rwanda identified the 12 to 23 month age group as being at greater risk of developing diarrhea.(26) While another study carried out 3 years earlier in northern Ethiopia had identified the group infants aged 36 to 47 months were at higher risk for diarrheal disease.(30) In our study 59% of children who developed diarrhea were infants aged 1 to 24 months, but we did not find evidence statistics to incriminate the age of children as a factor associated with the prevalence of diarrhea.

Some studies have also identified the male sex as a risk factor associated with diarrheal disease.(28)While others agree that the female sex is most affected by the phenomenon.(7) We have not did not find any significant difference regarding sex between children who had diarrhea or not.

The benefits of breastfeeding have already been well documented since the end of the 20th century. “It is one of the most effective means of ensuring the health and survival of the child” according to the World Health Organization. (31) It makes it possible to reduce morbidity and mortality linked to several diseases in children, including acute diarrhea. (32–34) Only 41% of the children in our study benefited from exclusive breastfeeding during the first 6 months of life. Although we did not find statistical significance, 62.5% of non-breastfed children developed diarrhea. The observation made at HUM is no different from that of the rest of the country, since the last EMMUS report demonstrated that the proportion of mothers breastfeeding their infants during the first six years of life is only 40%. (16).

According to literature data, diarrhea is strongly associated with incomplete vaccination.(12,13) The effectiveness of vaccination against rotavirus has reduced hospitalizations as well as deaths linked to acute diarrhea in children. over the last decade.(13) Paradoxically we found contradictory evidence in the context of our study. According to our results, vaccination would be a risk factor for developing diarrhea. (Table 3) This finding remains questionable because we have not found an explanation for this phenomenon. It could be that another factor not taken into account in this study but linked to the population of those vaccinated in the study could explain this finding which is discordant with the literature.

An interesting finding in our study was the association between the occurrence of acute diarrhea and the intake of natural purgative. The administration of natural purgatives to children is very common in rural Haiti; they are generally composed of decoctions of various plants mixed with vegetable oils. According to the general concept, they are used in children either to induce diarrhea in constipated children, as dewormers or purifiers. To date, we have not found any other studies that have investigated this association.

Table 3:  Characteristics of children

Table 4: Multivariate Analysis (reduced model)

(Please click here to view all tables)

Limitations

We are aware of certain limitations of our study which otherwise did not hinder the achievement of our objectives. However, it must be emphasized that the prevalence of diarrhea took into account only the perception of the guardian and was not verified by the investigators, as were certain characteristics of the environment. Given the cross-sectional nature of the study and the fact that we only included children seen in consultation or hospitalized, we cannot extrapolate our findings to the community.

Conclusion

Diarrheal disease in children remains a challenge in rural areas. Our survey revealed a high prevalence of diarrhea among children under 5 years old seen as outpatients or hospitalized at the Mirebalais University Hospital. The factors associated with this high prevalence are the education level of guardians, access to information and the use of natural purgatives. Health education campaigns on ways to prevent diarrhea in children could prove useful in the strategy to reduce this phenomenon.

Funding: none.

Conflict of Interest: The authors declare that they have no conflict of interest.

 

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