Risk Factors of Diarrhoea among Children Under Five Years in Southwest Nigeria

Diarrhoea is the passage of three or more loose or liquid stools per day or more frequent passage than is normal for an individual. Diarrhoea alters the microbiome, thus the immune system, and is a significant cause of morbidity and mortality in young children. This study evaluated the association between the risk factors and diarrhoea prevalence among children under five years in Lagos and Ogun States, located in Southwest Nigeria. Participants included 280 women aged 15–49 years and children aged 0–59 months. The study used quantitative data, which were assessed by a structured questionnaire. Data obtained were analyzed using the Statistical Package for the Social Sciences Software Version 25.0 and Microsoft Excel 2013. The relationships and/or association between variables were evaluated using Pearson's Chi Square and logistic regression tests. One hundred and eighteen (42%) of the children were male, and 162 (58%) were female. The majority of the children belonged to the age group 0–11 months (166). Age (p=0.113) and gender (p=0.366) showed no significant association with diarrhoea among the children. The majority of the mothers belonged to the age group 30–34. Multivariate analysis showed that the mother's level of education (95% CI for OR = 11.45; P=0.0001) and family income (95% CI for OR = 7.61, P=0.0001) were the most significant risk factors for diarrhoea among children. Mother's educational status, mother's employment, and family income were the factors significantly associated with diarrhoea in Southwest Nigeria. The study recommends that female education should be encouraged by the right government policy to enhance the achievement of the sustainable development goal three (SDG 3) for the possible reduction of neonates and infants' deaths in Nigeria.


Introduction
World Health Organisation defines diarrhoea as "the passage of three or more loose or liquid stools per day or more frequent passage than is normal for the individual" [1,2]. Diarrhoeal disease is the second leading cause of death in children under five years old and is responsible for killing around 525 000 children every year [2]. Childhood diarrhoea affecting children five years old and below accounts for approximately 63% of diarrhoea burden [3,4] and is the second significant cause of infant mortality in developing nations [2,[5][6][7], where poor sanitation and insufficient potable water are lacking [8,9]. In Southwest Nigeria, diarrhoea is one of the three most prevalent water-related diseases, the others being typhoid fever and cholera [10,11]. In Southwest Nigeria, most of the studies on childhood diarrhoea have focused on the molecular epidemiology of diarrhoeagenic agents [12][13][14][15]. Several other studies have reported the antimicrobial activities of indigenous medicinal plants on diarrhoea-causing agents [16][17][18]. However, there are insufficient reports on the associated risk factors of childhood diarrhoea in Southwest Nigeria [19,20]. erefore, this study aimed to determine the risk factors associated with diarrhoea prevalence among children under age 5 in Lagos and Ogun States, Nigeria.

Study Area.
e study was carried out in Lagos state (6 o 52ʹ44ʺ N, 3.37ʹ92ʺ E) and Ogun state (6°90ʹ 75ʺ N 3°58ʹ 13ʺ E), located in Southwest Nigeria (Figure 1). In Southwest Nigeria, three tiers of health care services are practiced, which are the tertiary, secondary, and primary healthcare systems [21]. ese hospitals provide subsidised health care services to the masses. Massey Street Children Hospital is a children's referral hospital owned by the Lagos State government [22]. Orile-Agege General Hospital has an excellent hospital-based record of paediatric cases and immunisation services. State Hospital Ota is proxy to the study centre. Federal Medical Centre Abeokuta is a federal governmentowned hospital with high patronage and also serves as a referral hospital in Ogun state [23,24].
e study was a cross-sectional case-control investigation involving four local government areas (LGAs) in Lagos and Ogun state, which were Lagos Island and Agege LGAs from Lagos state, Ado/Odo Ota, and Abeokuta South LGAs from Ogun state (Figure 1), respectively. Participants included a total of 280 children comprising 143 children with acute diarrhoea (cases) and 137 children who were not suffering from diarrhoea (controls) over 12 months. e diarrhoeic children were those that have been diagnosed by the medical personnel at the hospital for this study, and the control groups were children within the same age bracket that were not having diarrhoea and were attending the same healthcare facilities.

Inclusion Criteria
Under five children No acute diarrhoea Not on any antimicrobial treatment Informed written consent from the parents/guardians of children and assent from the subjects

Exclusion Criteria
Children whose parents did not consent

Inclusion Criteria
Under five children Acute diarrhoea (≥3 watery or loose stools with or without blood or mucus less than 14 days) Informed written consent from the parents/guardians of children and assent from the subjects

Exclusion Criteria
Children whose parents did not consent 3.3. Ethical Consideration. Participation was strictly voluntary. Parents/Caregivers received a thorough explanation of the aim, and objectives of the study were explained to the parents or caregivers. Each parent decided whether or not to participate or provide information about their children or wards. Participants were also enlightened about their freedom to withdraw in the course of the study without any consequences. e

Questionnaire Survey.
e authors developed a semistructured questionnaire. Mothers/caregivers responded through the assistance of hired research assistants. Communication was in English Language and local dialects where the respondents could not communicate effectively in the English Language. e questionnaires provided demographic, medical, nutritional, and environmental information about the children. Other information included the level of education and socioeconomic status of the mothers/ caregivers.

Data
Analysis. For quality control purposes, each completed questionnaire was proofed to avoid errors. e questionnaire data obtained were deposited in the SPSS Version 25 (IBM Corp., Armonk, NY, USA) program and Microsoft Excel 2013 for statistical analysis. Pearson's Chi square and t-test were used to determine the statistical significance in the relationships and or association between the dependent and independent variables. Comparisons were made between data derived from diarrhoeic and control subjects.
Logistic regression analysis was performed to assess the association of each predictor variable with the outcome variable. Measures of the relationship were expressed as crude odds ratios (CORs) for disease with 95% confidence intervals for variables.
Multivariable analysis was performed using all the significant variables obtained from the bivariate analysis. is provided the Adjusted Odds Ratios (AORs) at 95% confidence interval.

Results
Risk factors of diarrhoeal disease among children under five years of age in the study area. e risk factors of the occurrence of diarrhoea among children below the age of five were categorised into three, namely: age and gender of the child, demographic and socioeconomic status of the mother, and medical history and environment of the child (Tables 1-6 ). Table 1 shows the relationship between the age group and gender of the children and diarrhoea occurrence in the study area. ese two variables were similar in both case and control groups, and there was no significant relationship between the age (COR � 0.359, CI � 0.101 -1.274, p � 0.113) and gender (COR � 1.245, CI � 0.774 -2.003, p � 0.366) of the children with diarrhoea occurrence in the study area. Table 2 depicts the sociodemographic characteristics of caregivers or mothers for the case and control groups. All variables were significantly different between the case and control except for the age of the mothers. Results showed that there were significant relationships between diarrhoea occurrence and: mother's religion (OR � 0.185, p � 0.0001), mother's educational status (OR � 11.459, p � 0.0001), mother's employment status (OR � 2.082, p � 0.025), and family income (OR � 7.613, p � 0.0001).      Table 3 presents the medical history and environmental variables as risk factors for diarrhoea. ere were significant relationships between where the child was born (OR � 0.221. p � 0.009), mother's antenatal attendance (OR � 0.05, p � 0.0001), exclusive breastfeeding (OR � 0.25, p � 0.0001), reduced breastfeeding (OR � 4.3, p � 0.002), and crèche attendance (OR � 2.04, p � 0.011) and the occurrence of diarrhoea in this study. Children not exposed to drinking tap water (OR � 0.313, p � 0.011), borehole (OR � 0.538, p � 0.036), and sachets (OR � 0.214, p � 0.0001) were less likely to have diarrhoea, whereas those that drank bottled water (OR � 2.548, p � 0.001) were two times less likely to have diarrhoea (Table 3). Tables 4 and 5 showed the values of the adjusted odds ratio (AOR) of the variables. Some of the variables shown to be statistically significant using crude odds ratios were also significant after being adjusted. us, the results revealed that the mother's level of education (AOR � 10.282,  International Journal of Microbiology 5 p � 0.0001) and family income (AOR � 6.908, p � 0.001) have a significant relationship with diarrhoea occurrence in children under five years of age (Table 6).

Discussion
is study identified three significant risk factors that could predispose children under age five to diarrhoea occurrence. ese factors are: mother's educational status (OR � 11.46, P � 0.0001), mother's employment status (OR � 2.08, P � 0.025), and family income (OR � 7.61, P � 0.0001). Other factors are the mother's antenatal attendance, duration of breastfeeding, child's crèche attendance, and source of drinking water. e observation that children born by mothers with at most primary education is more likely to have diarrhoea  than a child of a more educated mother supports other studies conducted in Lagos (Akinyemi, 2019), Osun, and Oyo States [25]. Literacy has been earmarked consistently as a major determinant of health in any population, especially with regard to female education. Educated women have a better understanding of personal hygiene, nutrition and are more knowledgeable about accessing the healthcare system. [26], concluded in one of their studies that maternal education is the most important risk factor to diarrhoea prevalence among children under five years of age in Nigeria. Family income is a major risk factor of diarrhoea prevalence among children.
is study revealed that a child from a family with reduced income is more likely to have diarrhoea than a child from a financially comfortable home. is study agrees with the findings of [19], in which low monthly household income had a significant association with childhood diarrhoea in Southwest Nigeria. Reference [25] concluded that low socioeconomic status impedes the health of children under age five in Southwest Nigeria. Global reports highlight the impact of poverty on the burden of diarrhoea disease prevalence among children [27,28]. Reduced income subjects a family to poor living conditions such as lack of access to potable drinking water, improper sewage disposal, poor drainage system, and toilet facilities which have been identified as risk factors of childhood diarrhoea [29,30]. e observation that children of unemployed mothers are twice likely to have diarrhoea than children of employed mothers (Table 2) is similar to findings of [31], which further corroborates the impact of poverty on childhood diarrhoea incidence. is implies that mothers generate more income for the family, thereby providing basic household sanitary materials that ensure hygienic living conditions for the children.
Bivariate logistics regression identified the mother's antenatal attendance, breastfeeding, and source of drinking water as protective factors of diarrhoea prevalence in children. Lack of access to potable water is a key player in the transmission of diarrhoeal diseases because unclean water harbours diarrhoeagenic pathogens. Studies from Southwest Nigeria have implicated faecal contamination of the water used for domestic purposes [32][33][34][35]. e level of microbial contamination of the water used for domestic purposes is higher in Lagos State than Ogun state because of the high population, thus leading to poor management of wastes, which could lead to pollution of water aquifers [32,36]. is may be the reason for the high prevalence rate of diarrhoea in Lagos state (13.4%) than Ogun State (2%). Some of the drinking water (sachets) consumed in Lagos State are from unprotected sources [37,38].
Exclusive breastfeeding confers immunity against diarrhoea in children below the age of five.
is study revealed that children placed on exclusive breastfeeding were less likely to suffer from diarrhoeal diseases, while those fed with breastmilk for less than six months were more likely to have diarrhoea [39][40][41]. WHO and UNI-CEF recommend exclusive breastfeeding of infants for up to the first six months of life because of the nutritional and immunological value it provides to the child. Besides, breastfeeding helps to improve the cognitive and sensory development in infants. Besides, breastfeeding can protect a child against chronic and infectious diseases such as diarrhoea and pneumonia in children younger than five years of age. Breastfeeding has a huge impact on the health status of children. A significant correlation exists between breastfeeding and diarrhoea episodes [42,43]. Suboptimal breastfeeding increases the risk of developing diarrhoea because breast milk can confer the proper functioning of the gut immune system in infants, both for a short-and long-term duration [44,45]. Besides, breast milk contains antibodies, immunoglobulin A (IgA), which confer protection against pathogenic bacteria and harmonise the activity of white blood cells [46,47].

Conclusion
is study strongly supports the fact that socioeconomic factors are significant determinants of childhood diarrhoea. Female education should be encouraged by the right government policy to achieve child favourable health outcomes in the future.
us, the achievement of the sustainable development goal (SDG) 3 for a possible reduction of neonates and infants' deaths in Nigeria.
Data Availability e data supporting the results of this study are included in the manuscript.

Conflicts of Interest
e authors declare that they have no conflicts of interest.