Microsoft Word - GJPHM-2021- acute diarrhea.docx 429 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2021, VOL 3, ISSUE 2 gggggglo Original Research ACUTE DIARRHOEA AMONG UNDER FIVE YEARS OLD CHILDREN OF UNDERPRIVILEGED COMMUNITY IN KOTA KINABALU, SABAH Mohd Faizal Madrim1, Syed Sharizman Syed Abdul Rahim1, Hasanain Faisal Ghazi 2, Than Myint1, Khamisah Awang Lukman1, Kamruddin Ahmed3,4, Mohd Rohaizat Hassan5, Alabed Ali A. Alabed6 & Mohammad Saffree Jeffree1,2* 1 Department of Community and Family Medicine, Faculty of Medicine and Health Sciences, University Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia, 2 College of Nursing, Al-Bayan University, Baghdad, Iraq 3 Borneo Medical and Health Research Centre, University Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia, 4 Department of Pathobiology and Medical Diagnostics, Faculty of Medicine and Health Sciences, University Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia, 5 Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia. 6 Head of Community medicine department, Faculty of medicine, Lincoln University College, 47301, Petaling Jaya, Selangor, Malaysia *Corresponding author: saffree@ums.edu.my ABSTRACT The severity of childhood diarrhoea is linked with poor socioeconomic status, unhygienic living environment, and caregiver’s behaviour. This study is to determine the risk factors and economic burden associated with diarrhoea in children under 5 years of age. A case-control study using convenience sampling method with 105 cases and 105 controls was performed in Menggatal health clinic, Kota Kinabalu, Sabah between March-June 2017. Younger caregivers, without formal education, poor knowledge, practice handwashing with water only and stopped breastfeeding were associated with diarrhoea. Household with poor economic status, a family of five and more, crowded, with a pet, unsafe drinking water, no sanitary toilet, unsanitary garbage disposal and consuming street vendor food also associated with diarrhoea. The mean of total direct costs, total indirect costs and total incurred costs were (Ringgit Malaysia) RM 9.70, RM 59.40, and RM 14.30, respectively. As a conclusion, the risk factors for diarrhoea under 5 years of age still presents in Sabah. Environmental factors and hygienic practice are needed to control under 5 diarrhoea. Keywords: Diarrhoea; risk factors; household cost; children; underprivileged 430 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2021, VOL 3, ISSUE 2 gggggglo Introduction Diarrhoeal disease is responsible for 1.7 billion morbidity and 760, 000 mortality of children every year (World Health Organization 2017). Most of these deaths occur in developing countries. Lack of access to safe drinking water and sanitary toilets, improper hand washing, poor environmental condition of household and modest health care system can worsen the severity of diarrhoea (Godana and Mengistie 2013). Childhood and infant mortality rates are important components for the assessment of social development as well as health status assessment and the outcome of interactions of behavioural, socio- economic and environmental factors (Unicef 2012). Explorations of these factors are essential to obtain a better picture of childhood morbidity. Besides all these, diarrheal disease is an economic burden not only for the healthcare system, but also for patients’ families as well (Burke et al. 2014). Malaysia is a middle-income country in South East Asia. Despite tremendous progress in public health, the country still faces disparities among the population in different geographical locations. These are due to the inaccessibility of the places due to natural barriers such as dense tropical forests, mountains or remote islands. Diarrheal disease is a challenge for the health care system in these areas. Each year an estimated 16 outpatient clinic visits and 57 home-treated episodes per 1000 children under-5 with diarrhoea and costing about (Ringgit Malaysia) RM 10.8 million to the healthcare provider and about RM 15.8 million to society annually (Loganathan et al. 2016). The economic impacts of acute diarrhoea among children include high medical expenses, productivity loss, and childcare adjustment. The economic burden of family is highest among children aged less than two years old for acute diarrhoea (Diez-Domingo et al. 2011). Economically Sabah ranked the lowest among all the states in Malaysia (Jamil and Mat 2014). Evaluating the known risk factors and economic outcome associated with acute diarrhoea have important policy implications for health intervention programs that subsequently will improve child health care in the study area and in the country in general. Therefore, this study was done to determine the risk factors and household costs associated with acute diarrhoea of under five children visited a clinic serving underprivileged population in Kota Kinabalu, the capital of Sabah, East Malaysia. Methods This is a clinic-based case-control study. The study was conducted at a suburban area of Kota Kinabalu containing many undocumented immigrants. It contributes the highest number of under-five diarrheal cases among all the primary health clinics. The study was conducted from March to June 2017. All under-five patients with diarrhoea attending at Health Clinic were enrolled in this study. 431 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2021, VOL 3, ISSUE 2 gggggglo Written informed consents were obtained from caregivers who agreed to participate in this study. Children with acute diarrhoea were selected as cases and without diarrhoea as controls. Under-five children with food intolerance, adverse effects of medicine, irritable bowel syndrome and any other intestinal diseases were excluded. Sample size was calculated using the formula Parker and Bregman (Parker and Bregman 1986). Required minimum sample size was 210 among them; 105 cases and 105 matched controls. A questionnaire based face-to-face interviews were conducted to collect data in the present study. The questionnaire was adopted from the WHO and translated into Malay language. After that a pre-testing of questionnaires was conducted in urban area with 30 respondents which revealed good reliability - Chronbach’s Alpha 0.82. The questionnaire contains both open and close-ended questions, and it was divided into four sections: a section on demographic and socioeconomic information; a section on environmental factors; a section on behavioural factors of caregiver; and a section on household cost of family. Data were cleaned and analysed using IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. It was analysed descriptively to identify demographic and socioeconomic characteristics of study population, environmental and behavioural factors that are potential risk factors for diarrhoea among under-five children. The household cost of family among those under-five children with acute diarrhoea was also calculated. The study was reviewed and approved by the National Medical Research Registry (NMRR-16-2245- 32787) and the Medical Ethics Committee of Universiti Malaysia Sabah Medical Ethics Committee [JKEtika 1/17(1)]. All the consents for the study participants were collected from their parents. The parents were explained verbally and given a written guide by the assigned research assistant, parents were also asked to read the disclosure twice and asked if there were any uprising questions regarding the study prior to agreeing. Results A total of 210 under-five children, aged 30.1±16.6 (mean±SD) months, were enrolled in this study. Details of the demographic and social characteristics of the cases and controls are shown in Table 1. The caregivers were at the mean age of 31.1±7.1 (range 17 to 63) years old. The mean monthly household income was RM 1833.62±1617.71 (Range RM 300–11000). There is a statistically significant difference (p=0.02) of the monthly household income between the cases (1621.43±1374.21) and controls (2045.81±1811.00). Children from households with pets, clean drinking water, using sanitary toilets, dispose garbage sanitary way, practice hand washing with soap, practice hand washing in critical time, had statistically significant less diarrhoea than households without pet, clean drinking water, not use sanitary toilets, not dispose garbage sanitary way, practice hand washing with water only, and do not practice hand washing in critical time (Table 2). 432 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2021, VOL 3, ISSUE 2 gggggglo In the association test for knowledge, attitude and practice of diarrhoea related components of this study, knowledge was the only component that showed significant association to under-five diarrheal morbidity. The odds of having acute diarrhoea in children of caregivers who had poor knowledge of diarrhoea are 2.3 times compared to those children of caregivers who had better knowledge of the disease (OR=2.3; 95% CI 1.2 – 4.3; p<0.008). The total household costs of seeking care among under- five children with acute diarrhoea in this study are shown in Table 3. The mean transport time consumed was 14±11 minutes. The main cost items that family suffer are consultations and medications (combined) cost being RM 8.00 (1.86 USD) ± 19.80 (82.5% of total direct costs). We found out that the mean monthly food expenses are RM 471.33 (109.66 USD). The mean cost per diarrhoeal episode is RM 14.30 (3.33 USD) which almost consumes 3% of the mean monthly food expenses. The economic status of household was divided into poor and not poor, based on the classification of economic status by Economic Planning Unit of Malaysian Government. There were 57 families (61.3 %) in case group and 36 (38.7 %) in control group have poor household economic status (n=93). While 48 families (41.0 %) in case group and 69 (59.0 %) in control group have not poor household economic status (n=117). We found out that there is a statistically significant association between household economic status and under-five acute diarrhoea. The odds of having under-five acute diarrhoea among those with poor household economic status are 2.3 times compared to those with not poor household economic status (OR=2.3; 95%CI 1.3 – 4.0; p<0.0004). The main source of funding for household costs for diarrhoea episodes was by using savings from monthly income with 64.8%. The other common source was cutting down on other expenses (29.5%), borrowing (3.8%) and donation from friends/relatives (1.0%). Table 1: Socio-demographic characteristics of children and caregivers Variables Cases (n=105) Controls (n=105) Gender of children Male Female 63 (60.0%) 42 (40.0%) 63 (60%) 42 (40%) Age groups of children Mean age (months) Under 1 year 1-3 years 4-5 years 29.1 18 (17.1%) 51 (48.6%) 36 (34.3%) 31.2 17 (16.2%) 49 (46.7%) 39 (37.1%) Age groups of caregivers Under 20 years 20-40 years Above 40 years 3 (2.9%) 93 (88.6%) 9 (8.6%) - 95 (90.5%) 10 (9.5%) Household income per month (RM) RM5000 34 (32.4%) 61 (58.1%) 8 (7.6%) 2 (1.9%) 25 (23.8%) 66 (62.9%) 10 (9.5%) 4 (3.8%) 433 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2021, VOL 3, ISSUE 2 gggggglo Table 2: Associated risk factors between cases and controls Variables Cases (n=105) Control (n=105) X2 OR 95% CI Mean age 29.26 33.03 3.99 p<0.001* Education level of caregivers No formal education Formal education 27 (25.7%) 78 (74.3%) 12 (11.4%) 93 (88.6%) 7.09 2.7 (1.3, 5.6) Household economic status Poor Not poor 57 (54.3%) 48 (45.7%) 36 (34.3%) 69 (65.7%) 8.51 2.3 (1.3,4.0) Crowding index Overcrowded Not overcrowded 79 (75.2%) 26 (24.8%) 58 (55.2%) 47 (44.8%) 12.82 2.9 (1.6,5.2) Household size > 5 <5 87 (82.9%) 18 (17.1%) 65 (61.9%) 40 (38.1%) 11.53 3.0 (1.6,5.7) Pet in house Yes No 55 (52.4%) 50 (47.6%) 35 (33.3%) 70 (66.7%) 7.78 2.2 (1.3,3.8) Drinking water Unsafe Safe 29 (27.6%) 76 (72.4%) 12 (11.4%) 93 (88.6%) 8.76 3.0 (1.4,6.2) Sanitation facility Unimproved Improved 24 (22.8%) 81 (77.2%) 10 (9.5%) 95 (90.5%) 6.88 2.8 (1.3,6.2) Household garbage disposal Unsanitary Sanitary 50 (47.6%) 55 (52.4%) 30 (28.6%) 75 (71.4%) 8.08 2.3 (1.3,4.0) Knowledge on diarrhoea Poor Above poor 37 (35.2%) 68 (64.8%) 20 (19.0%) 85 (81.0%) 6.96 2.3 (1.2,4.3) Handwashing method Water only Water and soap 35 (33.3%) 70 (66.7%) 10 (9.5%) 95 (90.5%) 17.68 4.8 (2.2,10.2) Handwashing during all critical times Not full Full 32 (30.5%) 73 (69.5%) 13 (12.4%) 92 (87.6%) 10.21 3.1 (1.5,6.3) Breastfeeding No Yes 74 (70.5%) 31 (29.5%) 60 (57.1%) 45 (42.9%) 4.04 1.8 (1.0,3.2) Recent street vendor food consumption Yes No 32 (30.5%) 73 (69.5%) 15 (14.3%) 90 (85.7%) 7.92 2.6 (1.3,5.2) *p-value <0.05 is significant 434 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2021, VOL 3, ISSUE 2 gggggglo Table 3: Total household costs of seeking healthcare among case group Type of cost N Mean + SD Total Direct Cost (RM) 105 9.70 + 21.30 Indirect Costs (RM) 8 59.40 + 34.70 Total Incurred Costs (RM) 105 14.30 + 28.10 Discussion Diarrhoeal disease is a widely recognized major contributor of morbidity and mortality in children. Factors such as poor socio-economic status, low level of education, unsatisfactory environmental sanitation and poor hygienic practices account for a serious threat to human’s health, especially among children. In Malaysia, diarrhoeal disease accounts for 4.52 % and 4.82 % of hospitalization and mortality respectively in 2015 (Ministry of Health Malaysia 2016). Risk factors for acute diarrhoea are mainly varied with child’s age, local environmental condition and behaviour of caregivers. This study is a supplement to not much pre-existing research that have been conducted so far in Malaysia generally and Sabah specifically. The highest rates of diarrhoea occurrence were among children aged six to 11 months old. Diarrhoea occurrence rates maintained at a high level among the children aged one year old and reduced when children got older (Molbak 2000). In this study, the number of males was higher than females in all age groups. The reason for this difference is not clear. However, for older children, boys are more active compared to girls (Vale et al. 2010). The tendency of boys to move around and touch objects in the surrounding ground is higher than girls. Girls have more tendency to stay close to their caregivers and play with more hygienic toys (Arif and Naheed 2012; Eliot 2010; Kuitunen 2005; Yassin 2000). Children from a poor socioeconomic background have higher risk to get acute diarrhoea. This finding is in line with the studies conducted in Pakistan (Alnawajha, Bakry, and Aljeesh 2015; Arif and Naheed 2012; Dessalegn, Kumie, and Tefera 2011; Kuitunen 2005; Yassin 2000). Perhaps lower income levels not only equated to poorer food safety and quality, but also less consumption of healthier foods like fruits and vegetables. Furthermore, with poor economic status, there will be lack of resources such as availability of disinfectants in home cleaning and condition of the house surrounding. The caregivers with higher education have better chance of a child being spared of acute diarrhoea compared to lower education caregivers (Alnawajha, Bakry, and Aljeesh 2015; Dessalegn, Kumie, and Tefera 2011; Gebru, Taha, and Kassahun 2014; Sinmegn Mihrete, Asres Alemie, and Shimeka Teferra 2014; Siziya, Muula, and Rudatsikira 2013). Education provides not only basic but also important information about personal and environmental hygiene, weaning and feeding practices, and disease signs and symptoms which boosts timely action on childhood illness. 435 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2021, VOL 3, ISSUE 2 gggggglo Children from households with more than two crowding indexes were more likely to develop diarrhoea compared to children from households with lower crowding index (Siziya, Muula, and Rudatsikira 2013). Children who live in a household with pet was having higher risk to get diarrhoea compared to household without pet. This may indicate possible zoonotic infections or hygienic condition associated with pet rearing in our study population (Mamo and Hailu 2014; Seidu et al. 2013). Children from households with improved drinking water source were less vulnerable to diarrhoea compared to children from households who use unimproved water source as well as availability of proper sanitation facility (Dessalegn, Kumie, and Tefera 2011; Godana and Mengistie 2013). Children of caregivers with good knowledge on general idea, signs and symptoms, causes, complications and preventive measures of diarrhoea were less likely to develop acute diarrhoea compared to those with poor knowledge. Caregivers’ awareness of causes and general knowledge on how to prevent the disease are critical in the reduction of diarrhoea-related morbidity and mortality, which are, at present, unacceptably high (Ansari, Ibrahim, and Shankar 2011; Khalili et al. 2013; Ogunrinde et al. 2012; Wilson et al. 2012). Diarrhoea causes economic burdens for families. Even though the absolute number of household economic costs are relatively low for each childhood diarrhoea episode, but their cumulative impact is likely to be great. The small average costs also hide the continuous possibility that an episode will require more extensive and expensive care, resulting in not only indebtedness, but also selling of productive assets. Furthermore, all the costs and other barriers to care may create or accentuate disparities in adverse outcomes including mortality (Mendelsohn et al. 2008; Weraphong et al. 2013). Conclusion The risk factors for diarrhoea under 5 years of age still presents in Sabah especially among the underprivileged population. Environmental factors and hygienic practice are needed to control under 5 diarrhoea as it causes not only morbidity and mortality but detrimental effect on economy as well. Limitations of this study include method in selecting the controls and lack of observational component in the study. This study indicates that there is a need to focus on comprehensive diarrheal disease control strategies, including improvement of water quality, hygiene, and sanitation, together with regular awareness talk on breastfeeding. Acknowledgement We would like to thank the Director General of Health Malaysia for his permission to publish this article. The authors would also like to express our gratitude to the Sabah State Health Department. 436 GLOBAL JOURNAL OF PUBLIC HEALTH MEDICINE 2021, VOL 3, ISSUE 2 gggggglo Conflicts of Interest The author declares no conflicts of interest. 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