Keywords

Diarhhoea; Under fi ve; Sanitation; Ghana

Introduction

Diarrhoea is defined as passing loose or watery stools at least three times per day, or more frequently than normal for an individual [1].

Diarrhoea disease is the second leading cause of death in children under fi ve years old. It causes an annual mortality in 760 000 children [2].

In Ghana, it accounts for 25% of mortality in children under five years of age, with more than 9 million episodes occurring annually [3].

Although diarrhoea is common among children under fi ve years in Ghana, there is disparity between the prevalence in the urban (10.5%) and rural areas (12.8%) [4].

In Ghana, diarrhoea greatly affects children under fi ve years in specific risk groups with the highest prevalence occurring among children aged 12–23 months (16.8%). It is higher among males (13.1%) than in females (10.2%) [4]. In the middle or low income countries, diarrhoea is more common in the wet season [5,6].

Diarrhoea has a short and long term effect on children, their families and the nation. It is a major cause of malnutrition, dehydration and even death in children under fi ve years [2]. In addition diarrhoea affects the physical and cognitive functioning of children under fi ve years later in their development [7].

Diarrhoea creates an indirect cost in that mothers’ absence from work and stay in the hospital for days caring for sick children [8]. Moreover, the family income is spent on drugs, accommodation and transportation to the hospital [8,9].

There is a huge economic burden on the government in dealing with diarrhoea diseases. The direct and indirect costs to Ghana as a result of diarrhoea diseases is about US$33 million per annum [3,10].

Objective

The objective of this paper is to examine the different determinants that contribute to the occurrence, distribution and spread of diarrhoea among children below fi ve years of age in Ghana.

Methodology

Review of material

We searched published articles on the topic from Pub Med, Embase, Ghana Statistical Service databases, VU library, Ghana Health Service websites, Google Scholar, WHO Regional Databases and Hinari. Dahlgren and Whitehead [11] model which talks of the layers of influence on health was used to examine the different determinants of diarrhoea under fi ve years of age. They link the relationship between the individual, their environment and disease.

Inclusion criteria

Articles and documents on diarrhoea among children, mostly from Ghanaian and the African sub-region, written in the English language.

Findings

Age, Sex and Constitutional Factors

Age: Diarrhoea is least found in children between 0-6 months (5.6%) because they are usually exclusively breastfed, in the Ghanaian communities, so less exposed to contaminated food [4]. Older children between 6-23 months are at increased risk of having diarrhoea because of introduction of supplementary feeds and likely exposure to contamination [12]. Children aged between 6-23 months start to crawl, stand and walk and any contaminated thing they pick from the environment goes in to their mouth which predispose them to diarrhoea [2,4].

Sex: Diarrhoea occurs in both males and females but more common in males [2,4].

Gender: There is a disparity between prevalence of diarrhoea by sex. The prevalence of diarrhoea in males is 13.1% and 10.2% in females [4]. The rate at which males die and get ill is higher than females throughout life [13]. This is because males from infancy and childhood are susceptible to severe infectious diseases than females [13].

Constitutional factors: Biological factor such as food antigens found in cow’s milk, soya, egg, proteins and nuts are likely to cause allergic response in children which may cause diarrhoea [14]. Diarrhoea among children in their second year of life can also be caused by intestinal sensitivity to gluten found in wheat, barley, rye and oats [15].

Individual Lifestyle Factors

Mother’s lifestyle factor: At age six months, complementary foods are added to diet of children. Some mothers do not practice basic hygiene like washing of hands with soap after visiting the toilet, after changing the baby’s diaper and before preparing and feeding their babies [16]. Most often, babies feeding tools such as bowls, spoons and feeding bottles are usually left unwashed and houseflies settle and contaminate them. All these lifestyle factors of mothers predispose the children under fi ve to diarrhea [16,17].

Social and community networks: The Ghanaian community is such that children are also cared for by the extended family members. Mothers get support from in-laws, siblings, friends, cousins, parents and grandmothers. They do this to enable them carry on with their various occupations. Sometimes domestic helpers described as ‘house helps’ are often hired to care for children. The hygienic practices of these caregivers can be questionable, exposing the children to diarrhoea [17,18].

Moreover, people come together to perform many functions such as funerals, naming and marriage ceremonies. At these gatherings, people interact by shaking and holding hands. This practice leads to hand contamination. Some mothers take their children with them for such functions and have to feed them at regular intervals, at times, without proper hand washing. They are exposed to different types of food which are often contaminated and can lead to diarrhoea. Food preparation is done by different people mostly under unhygienic conditions. During such occasions, children are handled by other relatives who feed them with any available food which may be contaminated and hence predisposing them to diarrhoea.

Living and Working Conditions

Education: The educational level of a mother is particularly important in determining the health status of children. Children of mothers with no education have a high prevalence of diarrhoea diseases in Ghana [4]. It has been proven that educated mothers practice good hygiene and feed their babies well and appropriately which increases their immunity against infections such as diarrhea [19], malaria, pneumonia, urinary tract infections etc. Furthermore, education brings about health awareness among women who utilize the acquired knowledge to promote health of their children [20].

Employment: Education is linked to the employment status of the mother. Education prepares mothers for skillful employment [19-21]. This increases mothers’ accessibility to quality food, good housing and household amenities. Children will also have access to better hygiene and environment that will reduce their risk of getting diarrhea [19]. Prevalence of diarrhea is high among children from a low socioeconomic family [4,22].

Housing: Housing is another important health determinant. As discussed above, an unemployed mother may not be able to afford a house with facilities such as toilet, water and electricity supply. In Ghana 18% of the people practice open defecation [22,23]. Others sit on chamber pots to defecate which are often thrown into nearby drains, pits around the house or nearby refuse dumps. These activities put children at risk of contracting diarrhea when they play on contaminated grounds [9,19].

Work environment: The occupation of women and their work environment have an effect on the wellbeing of their children. Women who work as potters, cleaners or traders at open markers are likely to expose their children to dirty environment. Women who work at these places take their children with them. They buy food from vendors to feed their children. There are poor child defecation practices as well as mothers cleaning up practices. These factors contribute to the occurrence of diarrhea disease among children under fi ve years [24].

On the other hand, diarrhea is scarcely reported by mothers in the formal sector where they have cleaner environment to keep their children.

Agriculture and food production: The crops produced in Ghana are mainly cereals such as rice, maize, sorghum and millet [25]. Children are weaned with complementary foods after six months of age to support their growth [26]. Some children have biological factors which make their intestinal mucosa sensitive to cereals. When such foods are consumed by these children, it leads to diarrhoea [15].

Water and sanitation: In the Ghanaian community, some household practice unimproved sanitation by using pit latrine and others defecate and wash in water bodies. This practice leads to contamination of water bodies which are direct source of drinking water for many local communities and this contribute to the occurrence of diarrhea diseases [24,27]. Diarrhea also increases with lack of access to safe water. Due to intermittent flow of water in some parts of Ghana, water vendors store water for long periods to keep their business. This process contaminate the water which can cause diarrhea when used to prepare food [19] and for drinking.

Health care services: People access health care services if it is available, affordable, accessible and acceptable. In some situations, people cannot access health care when the cost of treatment is expensive [10]. In many rural settings, health care centers are situated at strategic points so that it can be accessible to a number of communities. This demotivates inhabitants from accessing health care because they have to travel long distances. Most of them are unable to afford cost of transportation. This leads to mothers lacking knowledge on preventive measures hence, increasing incidence of diarrhoea among children under five years [10].

General socioeconomic, cultural and environmental conditions

Socioeconomic: There is a disparity in the economic growth of Ghana and this has led to economic an inequality which has affected different sections of the society [28].

Prevalence of diarrhoea among children under fi ve years is high (14.1%) among households with low wealth quintile compared to children among households with high wealth quintile (6.8%) [2,4,8]. This implies that poverty is an important factor for diarrhoea among children. It is, therefore, not surprising those children from poor homes accounts for 86.2% of diarrhoea cases because of food contamination by flies [19]. Another factor is sharing of toilet facility among household [19,23,29].

Cultural: Cultural environment influences health seeking behaviors of parents especially in the rural areas to seek herbal medications instead of orthodox. People attribute diseases to spiritual cause and consult fetish priest or herbalist when they are ill [10]. In many rural communities in Africa, herbal medications are used in treatment of diarrhoea [30]. Breast feeding mothers are usually discouraged from exclusively breastfeeding their babies because grandmothers and mothers-in-law believe that breast milk is inadequate for the baby. Hence, mothers are made to stop exclusive breast feeding and introduce early complementary foods thus exposing the baby to diarrhoea when hygienic measures are compromised [31].

Environmental conditions: The climate of Ghana has seasonal variation. The prevalence of diarrhoea varies with seasons [4]. The southern part of Ghana is marked by two rainy seasons, from April to June and September to November. The North part is marked by one rainfall season which begins in May and last till September [4]. During rainy season, flooding occurs in many parts of Ghana as a result of poor drainage systems. There is stagnation of dirty water in gutters and spillage of septic tanks into main sources of drinking water. This process increases the occurrence of diarrhoea when the contaminated water is use for food preparation and drinking [27].

Conclusion

Diarrhoea is a common childhood diseases that causes high morbidity and mortality among children under fi ve years in Ghana. The most important determinants are maternal education, lifestyle, employment, water and sanitation. It can be prevented, in many cases by practicing personal hygiene.

Conflict of Interest

Authors report no conflict of interest.

Funding and Support

We did not receive funding from any institution.

Acknowledgement

Authors are grateful to Royal Tropical Institute (KIT), Netherlands.

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