Prevalence and determinants of diarrhoea among infants in selected primary health centres in Kaduna north local government area, Nigeria

Introduction Despite efforts toward the prevention and management of diarrhoea, associated mortality among infants has remained high in Northern Nigeria. This study was designed to determine the prevalence and identify determinants of diarrhoea among infants in Kaduna North Local Government Area (KNLGA), Nigeria. Methods In a cross-sectional survey 630 mothers of infants attending three primary health care centers were interviewed. Data was collected on socio-demo graphic characteristics, infant care practices, infant diarrhoea history and mothers knowledge of causes, symptoms and management of diarrhea. Data were analyzed using descriptive statistics, Chi-square, and logistic regression tests at 5% level of significance. Results Mothers' mean age was 27±5.5 years and 46.1% had secondary education. Infants' mean age was 22.4± 12.8 weeks and 50% were females. Prevalence of diarrhoea in the two weeks preceding the study was 21.1%. Only 11.7% of mothers had poor knowledge of diarrhoea. About 76.3% of mothers always washed their hands with soap after cleaning infants' perineum. Majority of infants (84.6%) completed age appropriate immunization while 31.6% were exclusively breastfed. Infants whose mothers sometimes (OR=2.32; 95% CI: 1.4-3.87) or never washed (OR=2.64; 95% CI: 1.19-5.82) their hands with soap after cleaning the infants perineumand those with incomplete age appropriate immunization (OR=1.87, 95% CI: 1.2-2.896) were more likely to have diarrhoea. Conclusion Promotion of hygiene and nutrition education for mothers particularly on proper infant feeding practices, hand washing practices and complete immunization of infants is needed to address the diarrhea determinants.


Introduction
Diarrhoea is defined as passage of loose or watery stools at least three times per day, or more frequently than normal for an individual. Frequent passing of formed stools is not diarrhoea [1].
Babies fed only breast milk often pass loose, "pasty" stools; this also is not diarrhoea. Mothers can usually determine when their children have diarrhoea [2]. Each year, an estimated 2.5 billion cases of diarrhoea occur among children under five years of age, and estimates suggest that overall incidence has remained relatively stable over the past two decades, more than half of these cases are in Africa and South Asia, where bouts of diarrhoea are more likely to result in death or other severe outcomes [3,4]. Diarrhoea due to infection is widespread throughout the developing world. According to WHO, in Southeast Asia and Africa, diarrhoea is responsible for as much as 8.5% and 7.7% of all deaths respectively. In Africa, it has been estimated that every child has five episodes of diarrhoea per year and that 800,000 children die each year from diarrhoea and dehydration. Diarrhoea is the second biggest killer of children in Nigeria, responsible for about 16% of child's death every year.
Nigeria was estimated to have a total number of annual child deaths due to diarrhoea to be 151,700 (WHO, 2009). Diarrhoea was the most commonly reported cases of waterborne infection in the three towns in North Western Nigeria. In Nigeria, contaminations of drinking water with pathogens have also been reported in several towns [4,5]. The infectious agents that cause diarrhoea are present or are sporadically introduced throughout the world. Although, diarrhoea is a rare occurrence for most people who live in developed countries where sanitation is widely available, access to safe water is high, personal and domestic hygiene is relatively good.
Diarrhoea due to infection continues to be widespread throughout the developing world. Incidence of diarrhoea is highest in the first two years of life and declines as a child grows older. Diarrhoeal disease mostly affects children under two years of age, and may be life-threatening, particularly in those who are malnourished or have impaired immunity [6,7]. These causative pathogens of diarrhoea are found in faecal matter and are transmitted from the stool of one individual to the mouth of another (faecal-oral transmission ) which may be spread through contaminated water, food, hands, eating and drinking utensils, flies, and dirt under fingernails [8]. Apart from causing significant mortality and morbidity, diarrhoea is also a leading cause of malnutrition in children under-five years old due to its association with poor nutrient absorption and appetite loss.
Frequent bouts of acute diarrhoea seriously debilitate children. With each successive episode, a child moves further away from his or her normal weight for age thereby greatly increasing the risk of malnutrition and impaired child development.
Diarrhoea is an immediate health threat to children; it also has longterm negative effects on the country socio-economic development [9]. Infant diarrhoeal infections have sequelae which impact on children lives. Several studies have quantified these long-term effects of early childhood diarrhoea and parasitic infections during the critical, formative first two years of life. The long-term effects include growth shortfalls, substantially impaired physical fitness, diminished cognitive capacity and delayed achievement at school [10]. Diarrhoea indirectly, has adverse effect on health, educational performance and school attendance of these children. Thus it can be stated that diarrhoea affects key areas of development such as heath, economy and education. In Nigeria, there is a regional discrepancy in the distribution of diarrhoea. There is an increasing   (Table 1).

Socio-demographic characteristics of infants:
The age of the infants ranges from 1to11 months with mean 5.6±3.2 months and 50.5% were females. The birth order of the infants ranged from 1 to 11 (Table 1).
Infant care practices of mothers/care giver: Infant feeding practices of mothers/care giver: Table   2 Shows also the various feeding practices of the mothers among the infants surveyed. About 99.0% of infants were still breast feeding at the time data was collected. Initiation of breastfeeding commenced in most (82.9%) of the infants within 12 hours of delivery. Only 31.6% of the infants were exclusively breast fed and 11.3% of EBF infants were fed with breast milk only for six months as at the time of interview. In total 30.5% infants were predominantly and 37.9% of the infants were partially breast fed.
Less than half (43.5%) of the six hundred and thirty infants were pre-lacteally fed with honey (16.1%), glucose water(15.3%), combination of zam-zam (holy water from Saudi Arabia) and date fruit (10.6%) after birth. Culture/ traditional practice (33.9%) were the reason why mothers pre-lacteally fed their infants' and 62.2% of infants were given breast milk within three days of birth.

Knowledge of diarrhoea of mothers:
The mean knowledge score was 7.6±1.0 out of 9 points, with many (88.3%) of the respondent scoring above 7 points. These respondents were classified as having a good knowledge on diarrhoea. were significantly associated with diarrhoea among infants.

Determinants of infant diarrhoea: multivariable result
Diarrhoea is also significantly associated with infants whose Mothers/care giver had poor knowledge of causes of diarrhoea (OR=3.3, CI = 1.9 ' 5.7) ( Table 3).

Discussion
The two weeks period prevalence of diarrhoea was 21.1%.
However, the prevalence of diarrhoea in this study was lower than the prevalence of diarrhoea in Jos North central Nigeria which is 27% [12], but higher than the prevalence in in Ondo state, a predominantly agrarian state in the high rainfall region of south western Nigeria where the prevalence of diarrhoea was 8.1%, [12] further confirming regional variation in the prevalence of diarrhoea [13]. The observation that mothers with at most primary education had higher probability of having diarrhoea than those with at least secondary education corroborate findings of a study conducted in Guinea Bissau in which education was significantly associated maternal morbidity [13]. The result from the logistic regression analysis of predictors of diarrhoea shows significant association with washing hands with soap after cleaning infants' perineum. Infants whose mother sometimes and never wash their hands with soap after cleaning infants perineum were more likely to have diarrhoea than infants whose mother always wash their hands with soap after cleaning their infants perineum (OR =2.32; 95% CI: 1.40 -3.87) and (OR=2.64; 95% CI: 1.19-5.82) respectively. Findings from this study corroborate with finding of Curtis and Cairncross that there are clear scientific evidence that support the practice of hand washing, stating that hand washing reduces diarrhea risk by 47% [14]. According to the WHO, Immunizations help reduce deaths from diarrhoea in two ways: by directly preventing infections that cause diarrhoea (such as rotavirus) and by preventing infections that can lead to diarrhoea as a complication of an illness (such as measles). The impact of immunization status on the prevalence of diarrhoea is corroborated by findings from this study. In this study infants whose immunization status was not up to date for their age were found more likely to experience diarrhoea than infants whose immunization status was up to date for age. The WHO recommends exclusive breast feeding for the first six months of life and continued breastfeeding until the age of two years. Predominantly and partially breast fed infants were significantly more likely to have reported diarrhoea than exclusively breast fed infants Similarly, in this study, infants who started on complementary foods at any period between two and six months were significantly more likely to have reported diarrhoea than infants who had never being fed with complementary foods. The observation that mothers knowledge of diarrhoea symptoms, causes and prevention of diarrhoea was associated with lower prevalence of diarrhoea among their infants are in agreement with findings of a study conducted in Ibadan in which knowledge was significantly associated practice of child survival strategy [15].

Conclusion
The findings of this study demonstrated that diarrhoea is a common experience among infants in KNLGA and that a large proportion of infants have experienced diarrhoea in the last two weeks. The findings from the study also show that the factors associated with Page number not for citation purposes 5 the occurrence of diarrhoea among infants in KNLGA were modifiable maternal factors (poor maternal education, partial breast feeding, and predominant breast feeding and poor maternal knowledge of diarrrhoea). It is therefore strongly recommended that diarrhoea prevention programmes should focus on these modifiable factors.
What is known about this topic  The findings from this study suggests that control of diarrhoea among infants will benefit greatly from intervention at maternal level with particular focus onhand-washing before feeding infants and also after cleaning up infants.

Competing interests
Author's declare no competing interest.

Authors' contributions
MDD and IFT conceived the study, did the literature review and designed the study instrument. IFT collected the data. MDD and IFT analysed the data while MDD, IFT and ATS wrote the manuscript.
All authors reviewed and approved the manuscript