Hindawi

Advances in Public Health

Volume 2019, Article ID 4313759, 12 pages
https://doi.org/10.1155/2019/4313759

Research Article
Hygiene and Sanitation Practices and the Risk of Morbidity
among Children 6–23 Months of Age in Kumbungu District,
Ghana

Fusta Azupogo,1 Fadilatu Abdul-Rahaman,1 Beatrice Gyanteh,1 and Ambrose Atosona 2

1
Department of Family and Consumer Sciences, Faculty of Agriculture, University for Development Studies, Tamale, Ghana
2
Department of Nutritional Sciences, School of Allied Health Sciences, University for Development Studies, Tamale, Ghana

Correspondence should be addressed to Ambrose Atosona; [email protected]

Received 11 August 2019; Accepted 19 October 2019; Published 12 December 2019

Academic Editor: Jennifer L. Freeman

Copyright © 2019 Fusta Azupogo et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background. Poor hygiene and sanitation (WASH) practices are characterised by the manifestation of disease and infections, notably
diarrhoea and respiratory tract infections (RTIs) among children. This study aimed to assess the influence of WASH practices on
the occurrence of diarrhoea and RTIs among children 6–23 months of age. Methods. An analytical cross-sectional study design was
conducted in June 2017. Systematic random sampling technique was used to select 300 mothers/caregivers with children aged 6–23
months from 9 communities in the Kumbungu District. We assessed the WASH practices, socio-demographic characteristics of
the households and the occurrence of diarrhoea and RTIs among the children with a semi-structured questionnaire. The Hygiene
Improvement Framework observational guide was adapted for household sanitation. Backward binary multiple logistic regression
was used to determine the WASH practices that significantly predicted morbidity. Results. About 53% and 55.3% of the children
reportedly experienced diarrhoea and RTIs, respectively, two weeks before the survey. Caregiver handwashing with soap after
defecation [OR = 0.32 (95% C.I: 0.19, 0.52)] and before feeding [OR = 0.50 (95% C.I: 0.30, 0.84)] as well as washing the child’s hands
with or without soap before feeding [OR = 0.21 (95% C.I: 0.04, 1.01)] were associated with lower odds of diarrhoea morbidity. The
main determinants of RTI morbidity included caregiver handwashing with or without soap after defecation [OR = 0.29 (95% C.I:
0.10, 0.81)] and washing of the child’s hands with soap before feeding [OR = 0.60 (95% C.I: 0.37, 0.99)] However, we found no
association between household sanitation and diarrhoea as well as RTI among the children. Conclusion. About a half each of the
children had diarrhoea and RTI 2 weeks before the survey. The results emphasise the need for urgent targeting of handwashing and
waste disposal programmes to avert the high burden of diarrhoea and RTIs among children.

1. Introduction Upper Respiratory Tract Infections (URTIs) refers to infec-

tions in the respiratory tract down to the larynx and include
Globally, diseases such as diarrhoea and respiratory tract common cold, pharyngitis, tonsillitis, otitis media and exter-
infections (RTIs) have been identified as major threats to child nal, sinusitis, stomatitis etc. [5]. Lower Respiratory Tract
survival. Diarrhoea, defined as the passage of three or more Infections (LRTIs) refer to infections below the larynx and
loose/liquid stools per day, is one of the leading causes of mor- include pneumonia, bronchitis, bronchiolitis, empyema, lung
bidity and mortality in children under five years [1–3]. abscess etc. [5]. These conditions are responsible for between
According to the WHO [3], an estimated 1.7 billion cases of 1.9 million and 2.2 million childhood deaths [4]. According
diarrhoea disease occur annually worldwide, with approxi- to Williams et al. [4], it is further documented that 42% of
mately 525 000 children dying from the disease. Diarrhoea is RTIs associated deaths occur in Africa [4]. In most cases, RTIs
currently the second most important cause of child morbidity can also be as a result of diarrhoea over an extended period
and mortality after malaria. [6].
Similarly, acute respiratory tract infections are a significant Underlying reasons for the spread of these diseases are
cause of death among children under five years of age [4]. found in poor hygiene and sanitation, limited access to safe
2 Advances in Public Health

drinking water as well as inadequate education of health care Number 1, 2 and 3, Cheshegu, Kpalga, Garizegu, Kpachi and
providers and recipients [7]. According to the UNICEF con- Nyoring) in the Kumbungu District. The District is made up
ceptual framework of malnutrition, poor hygiene and sanita- of 5 area councils namely, Gupanerigu, Gbullung, Zangbalung,
tion are one of the underlying determinants of malnutrition Dalun and Voggu area councils. The Gbullung area council
among children with the resultant effect of growth retardation, was randomly chosen and the 9 communities selected from
poor cognitive development, low productivity and death. this area council based on population size. Participants were
Mothers and children in low socioeconomic areas with limited selected from the communities through systematic random
hygiene and sanitation facilities tend to have poor hygiene sampling. Where a household did not meet the inclusion cri-
practices such as using dirty cooking or eating utensils for teria, the next household was selected. In a house with several
their children. households with eligible children, only one child aged 6–23
While poor hygiene practices, especially in food prepara- months was randomly selected from the different households
tion and feeding practices, may increase the risk of having through a simple lottery. None of the respondents selected
diarrhoea and other infections; up to 70% of diarrhoea epi- declined to participate in the study. Eligibility included per-
sodes are caused by water and food contaminated with path- manent residence in the survey community, having a child
ogens [6]. Sanitation includes the provision and use of facilities aged 6–23 months and willingness of the mother/caregiver to
and services that safely dispose of human urine and faeces, participate.
thereby preventing contamination of the environment while The sample size was determined using the formula:
hygiene relates to the practice of handwashing with soap after
defecation and disposal of child faeces, prior to preparing and 𝑧2 𝑝(1 − 𝑝)
handling food, before eating, and in healthcare facilities, 𝑁= , (1)
𝑀.𝐸2
before and after examining patients and conducting medical
procedures [8]. [17] where: 𝑁 is the sample size; 𝑧 is the abscissa of the normal
Ghana achieved the Millennium Development Goal target curve that cut-off an area at the tail (1.96); M.E is the desired
of 78% of the population using improved drinking water in level of precision (5% = 0.05); 𝑝 is the estimated proportion of
2011 [9]. Furthermore, many hygiene and sanitation improve- an attribute (Diarrhoea/RTIs) that is present in the study pop-
ment programmes have been implemented in northern Ghana, ulation. The prevalence of diarrhoea and RTIs are 16% and
yet diarrhoea and RTIs are still prevalent. According to the 5% respectively [10]. The prevalence of diarrhoea (16%) was
2014 Ghana Demographic Health Survey, about 16% of chil- used in computing the sample size as it is higher than that of
dren under-five in the Northern Region had diarrhoea, and RTIs (5%). A sample size of 220 was obtained. Considering a
approximately 3.5% had RTI [10]. Improving the level of nonresponse rate and or incomplete data of 20%, the sample
hygiene practices may be highly effective in reducing diar- size was rounded to 300 child-mother pairs.
rhoea [11] and RTI [12] morbidity among children. A pre-tested semi-structured questionnaire was used to
Nevertheless, the effectiveness of water, hygiene and sanitation collect data on respondents’ socio-demographic characteristics
(WASH) programmes may be context-specific as social and (mother/caregiver’s sex, age, occupation, educational level,
cultural factors may also have a reinforcing or restraining religion, number of children and ethnicity and child’s sex and
influence. age) and prevalence of diarrhoea and RTIs. A structured
A few studies have examined the influence of WASH prac- questionnaire was used to document the mother’s and child’s
tices on morbidity among children in Ghana. However, these hand washing, food preparation, cleanliness of utensils, water
studies were limited in scope; focussing mostly on diarrhoea source and safe drinking water, child’s bottle-feeding hygiene
[13, 14] and a few determinants. Moreover, data on handwash- as well as housing and environmental condition. Schmidt et
ing is lacking. A more recent study assessed how household al. [18] recommended using a recall period of 7–14 days in
wealth status, coupled with the type of place of residence, cor- diarrhoea morbidity studies for improving the precision and
relates with the prevalence of childhood diarrhoea in Ghana power; thus a 14-day (2 weeks) recall period was used in
using nationally representative data [15]. To the best of our capturing the prevalence of diarrhoea and RTI among the
knowledge, the only study that examined the effect of WASH children. Diarrhoea was defined as passage of any watery/
practices on diarrhoea among children in Northern Ghana loose stool at least 3 times in a day [3] while RTI was defined
was limited to the Tamale Metropolitan area [16]. The objec- as any flue/cough, wheezing and/or chest in-drawing and
tive of the present study was to assess the influence of hygiene difficulty in breathing [5]. The period prevalence of diarrhoea
and sanitation practices on the occurrence of diarrhoea and and RTI was estimated as the percentage of children who had
RTIs among children 6–23 months of age in the Kumbungu diarrhoea or RTI 14 days prior to the survey. A caregiver was
District to provide evidence for policy formulation and pro- defined in the present study as a person who provides direct
gramme planning. care for a child.
An adopted observational guide from the Hygiene
Improvement Framework [19] was also employed for the assess-
2. Materials and Methods ment of household sanitation. The observational guide is an
18-item questionnaire on the physical and environmental
Analytical cross-sectional study design was employed and hygiene and sanitation conditions as observed in the household.
involved 300 mothers/caregivers with children aged 6–23 Adherence to each item in the questionnaire was scored 1 else
months selected from 9 communities (Zoolan Yili, Cheyohi 0; resulting in a maximum attainable score of 18. Households
Advances in Public Health 3

were subsequently ranked into terciles of hygiene and sanitation Table 1:  Socio-demographic characteristics of the children and
score as poor (≤9), good (10–13) and very good (>13). their mothers.
Lastly, the questionnaire included information on the
Variable Frequency (%)
dietary diversity of the children using a single qualitative
24-hour recall (24 hR). In the 24 hR, mothers/caregivers were Sex of child
asked to mention all the foods and beverages the child ate Female 166 (55.3)
24-hours preceding (from wake-up to wake-up) the survey Age of child
from home and outside of the home. She was next probed for <12 months 90 (30.0)
likely forgotten foods and then asked to give a detailed 12–24 months 210 (70.0)
description of foods and beverages consumed, including Ethnicity
ingredients for mixed dishes. The 24 hR was used to complete Dagomba 298 (99.3)
the WHO (2010) 7 food group score for children younger than Other 2 (0.7)
24 months of aged namely: (1) staple foods, (2) dairy products, Religion
(3) animal source foods, (4) vitamin-A rich fruits and Islam 287 (95.6)
vegetables, (5) other fruits and vegetables, (6) legumes and Christianity 11 (3.7)
nuts and (7) eggs. A score of 1 was assigned when a child Other 2 (0.7)
consumed at least one food item from a particular food group Age of mother
else 0. The individual dietary diversity score was then 15–25 years 107 (35.9)
determined by summing the scores of all the food groups 26–35 years 147 (49.3)
consumed by the child. The score ranged from a minimum of ≥36 years 44 (14.8)
0 to a maximum of 7. Since the recall was qualitative, the Educational status of mother
scoring did not consider a minimum intake (in grammes) for 242 (80.7)
Nonliterate
the food groups. The minimum dietary diversity score
Literate 58 (19.3)
(MDDS) [20] for children younger than 24 months of age was
Occupation of mother
subsequently defined as DDS ≥ 4.
Unemployed 64 (21.3)
2.1. Statistical Analysis. Data entry and analysis was done using Farmer 169 (56.3)
SAS 9.3 (SAS Institute Inc., Cary NC.). Bivariate binary logistic Petty trader 67 (22.3)
regression analysis was done using the PROC LOGISTIC Parity of mother
PROCEDURE [21]. Variables with 𝑃-values ≤0.25 from the ≤5 children 40 (13.3)
bivariate analyses were included in backward stepwise multiple >5 children 260 (86.7)
logistic regression models to determine the prevalence odds
ratios (POR) of the significant determinants of diarrhoea, RTIs
and co-morbidity in the sample. We entered interaction terms religion. About a half (49.3) of the mothers were aged 26–35
to explore potential nonlinearities, but none was significant. years; about 36% were aged under 25 years and only 14.8%
𝑃 < 0.05 was considered significant at two-tailed tests. older than 36 years of age. Only a fifth of the mothers was
literate and were predominantly farmers (56.3%) with the rest
2.2. Ethical Considerations. Approval to conduct the study was petty traders (22.3%) and unemployed (21.3%). Most (86.6%)
given by the Joint Ethical Review Committee of the School of the mothers had given birth to more than 5 children. Table 1
of Allied Health Sciences and the School of Medicine and shows the socio-demographic characteristics of the children
Health Sciences, University for Development Studies (Protocol and their mothers.
Number 11-2017). The rationale of the study was explained to
the mothers/caregivers of the children and written informed 3.1.2. Household Hygiene and Sanitation Conditions. Table 2
consent obtained before the interview. Concerning participants shows the hygiene and sanitation conditions in the households
who were less than 18 years of age, written informed consent of the children. Rubbish was generally thrown into a dug pit
was obtained from their parents. Participants were also assured (91.3%) close to the house, and the pits were regularly burned.
of the confidentiality of the information provided. Permission The rubbish sites were usually about 50 m (89.7%) from the
was also obtained from the opinion leaders of each survey household. Most (85.9%) of the households swept their
community. rooms or compounds at least twice daily but less than a half
(42%) had soak way drainage systems in their households.
Generally, less than a fifth of the households used a latrine,
3. Results and Discussion public toilet or water closet (WC) with most (83.7%) of them
practising open defecation. Similarly, the young children in
3.1. Results the household commonly defecated in the compound (40.7%)
3.1.1. Socio-Demographic Characteristics of the Children and or surroundings bushes (12%) with about 47.3% of them
Their Mothers/Caregivers. The study revealed that about 55.3% defecating in a chamber pot. When using the observation guide
of the children were females and most (70%) of them were to rate household sanitation, only 23.3% of the households
aged 12–24 months and were generally Dogombas in ethnic scored very good with about 39% and 37.7% scoring good
origin; their households were mostly adherents of the Islamic and poor respectively.
4 Advances in Public Health

Table 2: Household hygiene and sanitation conditions. Table 3: Water and food hygiene practices in the households of the
children.
Variable Frequency (%)
Garbage disposal Variable Frequency (%)
   Dug pit/burn 274 (91.3) Water safety and hygiene
   Otherwise 26 (8.7) Household water source
How far garbage disposal is from the house    Pipe/borehole 287 (95.7)
   0–50 m from house 269 (89.7)    Other 13 (4.3)
   50–100 m from house 31 (10.3) How water is treated before use
Sewage channel    Treated (filtration, boiling or chlorine tablets) 102 (34.00)
   Soak away 126 (42.0)    No treatment 198 (66.0)
   Otherwise 174 (58.0) How frequently water storage container is cleaned
Frequency of cleaning room/compound    Anytime storage container is being filled 275 (94.5)
   At least once daily 42 (14.1)    Otherwise 16 (5.5)
   At least twice daily 256 (85.9) Food hygiene practices
Where child defecates Utensils are washed with soap before cooking
   Chamber pot 142 (47.3)    Yes 275 (91.7)
   In the compound 122 (40.7)    No 25 (8.3)
   Other (surrounding bush) 36 (12) Treatment of fruits and vegetables before eating/cooking
Household toilet facility    Water and salt (saline) 35 (11.7)
   Public toilet, latrine or WC 49 (16.3)    Otherwise 265 (88.3)
   None (opened defecation) 251 (83.7) Leftover food is covered
Household sanitation condition based on observational guide    Yes 285 (95.3)
   Poor 113 (37.7)    No 14 (4.7)
   Good 117 (39) Leftover food is heated before consumption
   Very good 70 (23.3)    Yes 296 (98.7)
   No 4 (1.3)

3.1.3. Water and Food Hygiene Practices in the Households 3.1.5. Prevalence of Diarrhoea and RTI among the
of the Children. Nearly all (95.7%) of the households had Children.  Figure 1 shows that about half of the children had
access to improved water supply either from the piped water diarrhoea and RTI respectively, 2 weeks prior to the survey.
or borehole, but a few others (4.3%) had their household water Furthermore, about a third of the children had both diarrhoea
supply from wells, rivers or dams. The majority (94.5%) of and RTI (simultaneous occurrence) while about 78% of them
mothers reported cleaning their water containers any time had either diarrhoea or RTI (at least 1 of the conditions) 2
they were being filled. Similarly, utensils were commonly weeks prior to the survey. The sex of the child did not influence
washed with soap before cooking, and leftover foods were the prevalence of morbidity.
mostly covered. Furthermore, leftover food was typically
heated before consumption. Lastly, only a few (11.7%) of the 3.1.6. Univariate Determinants of Diarrhoea and RTI Morbidity
mothers reported washing fruits and or vegetables in saline among the Children.  Compared to throwing rubbish around
before consumption or cooking (Table 3). the house or on a rubbish dump, using a dug-out pit with
regular burning was associated with a 60% lower odds of
3.1.4. Child Feeding Practices and Hygiene among the diarrhoea and RTI co-morbidity [OR = 0.40 (95% C.I: 0.18,
Mothers/Caregivers of the Children.  The mothers (84.7%) 0.90)] (Table 5). Furthermore, the odds of diarrhoea and
were responsible for feeding the children. Furthermore, or RTI among the children were consistently higher for
most (92%) of the mothers reported washing their hands households using open defecation in the bush compared to
after defecating, but only a little over a half (52.7%) reported those who used a latrine or public toilet, but the association
washing their hands with soap after defecating. Additionally, was only significant for the presence of either diarrhoea or
almost all (96.7%) the mothers reported washing their hands RTI (Table 5).
before feeding; but 65% of them reported washing with soap. The results in Table 5 also showed that caregiver hand-
Similarly, most (95.7%) of the children had their hands washing with soap after defecating was consistently associated
washed before feeding, but about 62.3% of them had their with lower odds of diarrhoea [OR = 0.51 (95% C.I: 0.31, 0.83)],
hands washed with soap before feeding. About four-fifths co-morbidity of diarrhoea and RTI [OR = 0.38 (95% C.I: 0.23,
of the children were still breastfeeding and about a quarter 0.64)] and the prevalence of either diarrhoea or RTI [OR = 0.40
were bottle-fed. The mean dietary diversity score of the (95% C.I: 0.22, 0.72)] among the children. Although not sta-
children was 2.0 ± 1.8 with less than a third of the children tistically significant, a lower odds of diarrhoea and or RTI
meeting the minimum dietary diversity score (DDS ≥ 4) morbidity was observed for caregiver handwashing with or
(Table 4). without soap after defecating. Additionally, among caregivers
Advances in Public Health 5

Table 4: Child feeding and hygiene practices among the mothers/ Furthermore, the primary determinants of RTI prevalence
caregivers of the children. among the children were caregiver handwashing with or with-
out soap after defecating [OR = 0.29 (95% C.I: 0.10, 0.81)] and
Variable Frequency (%)
washing of the child’s hands with soap before feeding
Person who feeds the child [OR = 0.60 (95% C.I: 0.37, 0.99)]. Additionally, compared to
Mother 254 (84.7) open defecation in the surrounding bushes, use of a latrine or
Other 46 (15.3) public toilet was somewhat associated with a 48% lower odds
Caregiver washes hands with or without soap after defecating of RTI among the children [OR = 0.52 (95% C.I: 0.27, 1.02)]
Yes 276 (92) (Table 6).
No 24 (8) The results also showed that caregiver handwashing with
Caregiver washes hands with soap after defecating soap after defecating was associated with a 61% lower odds of
Yes 158 (52.7) diarrhoea and RTI co-morbidity [OR = 0.39 (95% C.I: 0.23,
No 142 (47.3) 0.67)]. Moreover, the odds of diarrhoea and RTI co-morbidity
Caregiver washes hands with or without soap before feeding child was 2.68 times higher among children those households
Yes 290 (96.7) dumped rubbish in the surrounding bushes or a rubbish dump
No 8 (2.7) site close to the house compared to children whose households
Caregiver washes hands with soap before feeding use a dugout out pit with regular burning [OR = 2.68 (95% C.I:
Yes 195 (65) 1.10, 6.53)]. The caregiver handwashing with soap before feed-
No 105 (35) ing also seemed relevant in reducing the odds of diarrhoea
Child’s hands washed with or without soap before feeding among the children.
Yes 287 (95.7) When modelling the prevalence of either diarrhoea or RTI,
13 (4.3)
the significant multivariate determinants included: caregiver
No
handwashing with soap before feeding [OR = 0.39 (95% C.I:
Child’s hands are washed with soap before feeding
0.21, 0.72)], the place where the child defecates (𝑃-trend = 0.03)
Yes 187 (62.3)
and treatment of fruit and vegetables before eating/cooking
No 113 (37.7)
[OR = 0.4.07 (95% C.I: 1.15, 14.18)].
Is child bottle fed?
Yes 72 (24.0) 3.2. Discussion. Diarrhoea and RTIs are major causes of
No 228 (76.0) morbidity and mortality among infants and young children
Is child still breastfeeding? globally. Hence the present study investigated the influence of
Yes 244 (81.6) WASH practices on the period prevalence of diarrhoea and
No 55 (18.4) RTIs among children 6–23 months.
Child dietary intake meets minimum dietary diversity (DDS ≥ 4) Regarding diarrhoea, the study revealed that about 53%
Yes 85 (28.3) of the children experienced diarrhoea 2 weeks preceding the
No 215 (71.7) study and this may be attributable to the consumption of food
Dietary diversity score (mean ± SD) 2.0 ± 1.8 or water which has been contaminated with human waste
through open defecation and improper dumping of rubbish,
as a majority of the households practised open defecation and
disposed waste in a dumpsite/pit close to the households.
who washed their hands with soap before feeding, the odds of Similarly, the odds of diarrhoea was higher when children
diarrhoea was 49% lower among their children compared to defecated outside the compound or the surrounding bushes
caregivers who did not do same [OR = 0.51 (95% C.I: 0.31, compared to defecating in chamber pot. The frequent open
0.83)]. Lastly, compared to children whose hands were not defecation may be related to unavailability and poor access to
washed before feeding, those whose hands were washed with toilet facilities in the district. This can also be a contributing
or without soap had an 81% lower odds of diarrhoea [OR = 0.19 factor to the spread of diseases as rainwater coupled with poor
(95% C.I: 0.04, 0.89)] (Table 5). drainage may carry all faecal matter to water bodies which
may be used for household consumption without proper
3.1.7. Multivariate Determinants of Diarrhoea and RTI treatment.
Morbidity among the Children. In the backward multiple A single gram of human faeces can hold up to 10 million
logistic regression (Table 6), the odds of diarrhoea among viruses, and 1 million bacteria and infant faeces are particular
the children was 68% lower for caregivers who washed their pathogenic [22], hence the need for proper disposal. Diarrhoea
hands with soap after defecating compared to those who did results in malnutrition and dehydration, increasing mortality
not [OR = 0.32 (95% C.I: 0.19, 0.52)]. Likewise, caregiver risk while regarding morbidity results in long-term burdens
handwashing with soap before feeding was significantly such as impaired growth and cognitive function [23]. As estab-
associated with a 50% lower odds of diarrhoea among the lished by the WHO, [24], diarrhoea is mainly caused by the
children [OR = 0.50 (95% C.I: 0.30, 0.84)]. Washing of the intake of pathogens from faeces improperly disposed or from
child’s hand with or without soap also seemed to be relevant in poor hygiene and sanitation, thus stopping open defecation
reducing the odds of diarrhoea among the children [OR = 0.21 through the use of toilet facilities, access to safe and clean
(95% C.I: 0.04, 1.01)]. drinking water as well as good hygiene and sanitation practices
6 Advances in Public Health

90
P = 0.89
80
78.4 77.7 78
70
P = 0.79
60 P = 0.82
Prevalence rate
50 53.7 52.4 53 54.5 56 55.3

40 P = 0.87

30
29.9 30.7 30.3
20

10

0
Diarrhoea RTI Morbidity (either diarrhoea Co-morbidity (both
or RTI) diarrhoea & RTI)
Male Total
Female

Figure 1: Prevalence of diarrhoea and respiratory tract infections (RTIs) among the 6–23 months old children 2 weeks prior to the survey.

can immensely curtail diarrhoea frequency among young of RTIs, in that, diarrhoea increases the risk of RTIs in children
children. [24, 34]. Diarrhoea causes micronutrient loss, immune system
Generally, socio-demographic factors did not appear to stress and dehydration, thereby increasing the risk of RTIs and
have much influence on diarrhoea and RTI prevalence, which this may partly account for the corresponding rise in RTIs
may in part be related to the homogeneity of the sample. prevalence. Washing of child’s hands with soap before feeding
Nonetheless, the present study emphasises the importance of was independently associated with decreased RTI risk in the
behavioural factors in diarrhoea causation. It was also revealed present study which is similar to the findings of studies by
in the present study that majority of the mothers (86.7%) had Luby et al. [28] and Rabie & Curtis [12]. Hands are known to
more than 5 children. This finding is in consonance with the be a vehicle for bacterial and viral pathogens transmission
finding of a previous study [10] in Northern region of Ghana, [35]; hence, proper handwashing with soap before feeding can
where the average number of children per woman was reported prevent RTIs in children. Caregiver handwashing with or with-
to be 6.6. Moreover, majority (70%) of the children were aged out soap after defecating was significantly associated with
12–24 months in the present study. This finding is also com- decreased risk of RTIs. Washing hands after defecation may
parable to the findings of other studies [25–27] in Ghana. reduce diarrhoea risk resulting in lower risk of RTIs since
Mother/caregiver handwashing with soap and water after diarrhoea increases childrens vulnerability to RTI.
defecation was significantly associated with a decreased occur- We found no association between household sanitation
rence of diarrhoea among the studied children. When mod- and diarrhoea and RTI morbidity. The lack of association may
elling diarrhoea and RTI co-morbidity as well as the occurrence be partly due to the method used for data collection or the
of either, mother/caregiver handwashing with soap and water study design. We relied on an observational guide to evaluate
after defecation remained a significant determinant. Similarly, the sanitation conditions of households, but it is possible some
several other studies have shown that caregiver’s handwashing of the observations at the time of visit may not be the usual
with soap after defecation is independently linked with a low pertaining conditions in the household; repeated observations
prevalence of diarrhoea among children [16, 28–30]. Caregiver could probably have captured the usual pertaining
handwashing with soap before feeding was also significantly conditions.
associated with decreased occurrence of diarrhoea among the Surprisingly, we found a reverse causation for treatment
children (Table 6). This finding agrees with that of Curtis & of fruits or vegetables with saline before consumption or cook-
Cairncross [31] who revealed that handwashing with soap ing as children from households where mothers/caregivers
before feeding reduces diarrhoea risk. Similarly, Mattioli et al. treated fruits/vegetables with saline before consumption and
[32], Danquah et al. [13] and Motarjemi et al. [33] also indi- or cooking were 4 times significantly more likely to have diar-
cated that handwashing with soap reduces the risk of diar- rhoea compared to those in households where mothers did
rhoea. Washing of hands with soap before feeding rids off not treat fruits and/or vegetables with saline. It was also
diarrhoea-causing pathogens thereby preventing faecal-oral observed that majority (60%) of mothers/caregivers who
transmission of these pathogens. Likewise, children who had treated fruits/vegetables with saline before consumption and
their hands washed with or without soap before feeding had or cooking lived in households with poor sanitation based on
a lower odds of diarrhoea. the observational guide. This could partly explain the high
Furthermore, it was revealed in the present study that the prevalence of diarrhoea among their children as poor house-
prevalence of RTIs was 55.3% 2 weeks preceding the study. As hold sanitation can result in the contamination of water and
the prevalence of diarrhoea increases, so does the prevalence food with pathogens [24].
Advances in Public Health 7

Table 5: Univariate determinants of diarrhoea and RTI morbidity and co-morbidity among the 6–23 months old children.

Respiratory tract infection

Diarrhoea Both diarrhoea and RTI Either diarrhoea or RTI
(RTI)
Variable
Odds ratio Odds ratio Odds ratio Odds ratio
𝑃-value 𝑃-value 𝑃-value 𝑃-value
(95% C.I) (95% C.I) (95% C.I) (95% C.I)
Demographics
Sex of child
(ref = female)
Male 1.05 (0.67, 1.66) 0.82 0.94 (0.59, 1.49) 0.79 0.96 (0.59, 1.58) 0.87 1.04 (0.60, 1.80) 0.89
Age of child (ref = 12–24 months)
<12 months 0.90 (0.55, 1.47) 0.67 1.08 (0.66, 1.78) 0.76 1.34 (0.67, 1.93) 0.64 0.82 (0.46, 1.47) 0.50
12–23 months (ref) 1 1 1 1
Age of mother 0.60 0.46 0.62 0.76
15–25 years (ref) 1 1 1 1
26–35 years 1.25 (0.76, 2.06) 0.74 (0.45, 1.22) 0.80 (0.46, 1.37) 1.19 (0.65, 2.17)
≥36 years 1.34 (0.66, 2.72) 0.74 (0.36, 1.49) 1.06 (0.51, 2.24) 0.92 (0.40, 2.07)
Parity of mother
≤5 children (ref) 1 1 1 1
>5 children 0.91 (0.47, 1.78) 0.79 1.02 (0.52, 1.98) 0.96 0.78 (0.39, 1.58) 0.49 1.21 (0.56, 2.63) 0.62
Occupation of mother 0.46 0.44 0.71 0.14
Unemployed 0.72 (0.36, 1.44) 0.99 (0.49, 1.98) 1.00 (0.48, 2.07) 0.55 (0.22, 1.39)
Farmer 0.70 (0.39, 1.24) 0.73 (0.41, 1.30) 0.81 (0.44, 1.49) 0.46 (0.21, 1.00)
Petty trader (ref) 1 1 1 1
Educational status of mother
Nonliterate 0.69 (0.39, 1.24) 0.22 0.85 (0.47, 1.51) 0.58 0.79 (0.43, 1.45) 0.44 0.60 (0.28, 1.29) 0.19
Literate (ref) 1 1 1 1
Household sanitation
Household sanitation
condition based on 0.56 0.26 0.13 0.71
observational guide
Poor (ref) 1 1 1 1
Good 0.75 (0.45, 1.27) 1.23 (0.73, 2.06) 1.09 (0.61, 1.94) 0.81 (0.43, 1.52)
Very good 0.86 (0.47, 1.56) 1.66 (0.90, 3.06) 1.85 (0.98, 3.48) 0.75 (0.37, 1.55)
How garbage is disposed
∗
Dug pit/burn (ref) 0.57 (0.25, 1.32) 0.19 0.76 (0.33, 1.73) 0.51 0.40 ( 0.18, 0.90) 0.03 1.07 (0.41, 2.78) 0.89
Otherwise1 1 1 1 1
How far garbage disposal is from the house
50–100 m from
1 1 1 1
house (ref)
0–50 m from house 1.23 (0.58, 2.59) 0.59 0.65 (0.30, 1.42) 0.28 0.66 (0.31, 1.42) 0.29 1.27 (0.54, 2.98) 0.59
Sewage channel
Soak away 1 1 1 1
Otherwise2 1.23 (0.78, 1.95) 0.38 1.23 (0.78, 1.95) 0.38 1.32 (0.80, 2.18) 0.28 1.30 (0.75, 2.25) 0.36
Number of times compound is cleaned
At least once daily 1.72 (0.87, 3.38) 0.12 1.07 (0.55, 2.07) 0.84 1.16 (0.58, 2.33) 0.67 2.27 (0.85, 6.02) 0.10
At least twice daily
1 1 1 1
(ref)
Toilet facility in household
Latrine/pubic toilet
1 1 1 1
or WC (ref)
None (open ∗
1.49 (0.81, 2.76) 0.20 1.64 (0.89, 3.05) 0.11 1.61 (0.78, 3.32) 0.19 1.97 (1.04, 3.86)) 0.049
defecation)
Where child shits 0.95 0.26 0.99 0.066
Chamber pot (ref) 1 1 1 1
Outside the
1.08 (0.67, 1.76) 1.31 (0.80, 2.13) 1.00 (0.59, 1.70) 1.63 (0.91, 2.92)
compound
Other3 1.03 (0.49, 2.14) 1.94 (0.90, 4.19) 1.03 (0.46, 2.24) 3.03 (1.01, 9.13)
8 Advances in Public Health

Table 5: Continued.

Respiratory tract infection

Diarrhoea Both diarrhoea and RTI Either diarrhoea or RTI
(RTI)
Variable
Odds ratio Odds ratio Odds ratio Odds ratio
𝑃-value 𝑃-value 𝑃-value 𝑃-value
(95% C.I) (95% C.I) (95% C.I) (95% C.I)
Water and food hygiene practices
Washing of utensils with soap before cooking
Yes (ref) 1 1 1 1
No 0.96 (0.42, 2.17) 0.92 0.72 (0.32, 1.64) 0.44 0.88 (0.36, 2.20) 0.79 0.70 (0.28, 1.76) 0.45
Frequency of cleaning water container before use
Any time container
1 1 1 1
is being filled
Otherwise 2.09 (0.71, 6.18) 0.18 0.77 (0.28, 2.12) 0.62 1.05 (0.35, 3.12) 0.93 2.04 (0.45, 9.21) 0.36
Frequently used water
source
Pipe/borehole (ref) 1 1 1 1
Other4 1.04 (0.34, 3.16) 0.95 0.94 (0.31, 2.86) 0.91 0.68 (0.18, 2.53) 0.56 1.58 (0.34, 7.31) 0.56
Treatment of fruits and vegetables
Washed with saline 1.58 (0.76, 3.27) 0.22 1.26 (0.61, 2.58) 0.53 1.25 (0.59, 2.63) 0.56 2.36 (0.80, 6.96) 0.12
Otherwise (ref)5 1 1 1 1
Leftover food is covered
Yes (ref) 1 1 1 1
No 1.20 (0.41, 3.55) 0.74 1.49 (0.49, 4.55) 0.49 1.80 (0.60, 5.33) 0.29 1.04 (0.28, 3.84) 0.95
Child feeding practices
Caregiver washes hands with or without soap after defecation
Yes 0.79 (0.34, 1.84) 0.59 0.39 (0.15, 1.00) 0.05 0.48 (0.21, 1.12) 0.09 0.48 (0.14, 1.67) 0.25
No (ref) 1 1 1 1
Caregiver washes hands with soap after defecation
∗ ∗
Yes 0.28 (0.18, 0.46) <.0001* 0.83 (0.53, 1.31) 0.43 0.38 (0.23, 0.64) 0.0002 0.40 (0.22, 0.72) 0.002
No (ref) 1 1 1 1
Caregiver washes hand with soap before feeding
Yes 0.51 (0.31, 0.83) 0.006∗ 1.01 (0.62, 1.62) 0.98 0.62 (0.37, 1.02) 0.06 0.70 (0.38, 1.26) 0.23
No (ref) 1 1 1 1
Child’s hands washed with or without soap before feeding
∗
Yes 0.19 (0.04, 0.89) 0.03 1.07 (0.35, 3.25) 0.91 0.49 (0.16, 1.50) 0.21 0.70 (0.38, 1.26) 0.23
No (ref) 1 1 1 1
Child’s hands washed with soap before feeding
Yes 0.89 (0.56, 1.42) 0.62 0.65 (0.40, 1.04) 0.07 0.64 (0.39, 1.06) 0.08 0.79 (0.44, 1.40) 0.41
No (ref) 1 1 1 1
Child is bottle fed
Yes 0.71 (0.39, 1.29) 0.26 0.70 (0.41, 1.19) 0.19 0.71 (0.39, 1.29) 0.26 0.72 (0.39, 1.34) 0.30
No (ref) 1 1 1 1
Person who feeds the child
Mother (ref) 1 1 1 1
Other 0.96 (0.51, 1.80) 0.90 1.06 (0.56, 1.99) 0.86 0.89 (0.44, 1.78) 0.74 1.19 (0.54, 2.61) 0.67
DDS 0.95 (0.84, 1.08) 0.43 0.94 (0.83, 1.07) 0.36 0.95 (0.83, 1.09) 0.46 0.91 (0.78, 1.06) 0.22
Breastfeeding status of child
Yes 0.70 (0.39, 1.27) 0.24 0.86 (0.48, 1.56) 0.62 0.78 (0.42, 1.45) 0.43 0.64 (0.30, 1.39) 0.26
No (ref) 1 1 1 1
Values are odds ratios and 95% confidence interval; 1inlcudes rubbish dump site and surrounding bush; 2gutter and no drainage; 3surrounding bush; 4includes
∗
well, river and dam; 5washing with only water; statistically significant at 5% level of significance.
Our study was conducted in the rainy season (June) which overestimation of diarrhoea prevalence because there is a strong
was assumed to be the peak of diarrhoea prevalence as described link between diarrhoeal morbidity and seasonality [38]; this
in a previous study [36]. In Ghana, the highest peak diarrhoea may partially explain our results. However, some studies in
occurred in the rainy season from May to August [37]. Hence, developing context also observed high diarrhoea prevalence in
performing the study in a rainy season may lead to an dry seasons [39]. Although the prevalence of diarrhoea in the
Advances in Public Health 9

Table 6: Backward multivariate binary logistic regression of the determinants of diarrhoea and RTI morbidity among the 6–23 months
children.

Respiratory tract infection

Diarrhoea Both diarrhoea and RTI Either diarrhoea or RTI
(RTI)
Variable
Odds ratio Odds ratio Odds ratio Odds ratio
𝑃-value 𝑃-value 𝑃-value 𝑃-value
(95% C.I) (95% C.I) (95% C.I) (95% C.I)
Caregiver washes hands
with or without soap after
defecating (ref = No)
∗ 0.43
Yes 0.29 (0.10, 0.81) 0.02 0.06
(0.17, 1.05)
Caregiver washes hands
with soap after defecating
(ref = No)
0.32 ∗ 0.39 ∗ 0.39 ∗
Yes <.0001 0.0006 0.004
(0.19, 0.52) (0.23, 0.67) (0.21, 0.72)
Caregiver washes hands
with soap before feeding
(ref = No)
0.50 ∗ 0.61 (0.35, 0.07
Yes 0.009
(0.30, 0.84) 1.04)
Child’s hands washed with
or without soap before
feeding (ref = No)
0.21 ∗
Yes 0.052
(0.04, 1.01)
Child’s hands are washed
with soap before feeding
(ref = No)
∗
Yes 0.60 (0.37, 0.99) 0.047
Household toilet facility
Public toilet, latrine or 0.50 (0.24,1.07) 0.07
0.52 (0.27, 1.02) 0.058
WC
Otherwise (surrounding 1
1
bush)
How garbage is disposed
Dug pit/burn 1 1
∗
2.68 0.03
Otherwise1
(1.10, 6.53)
Where child defecates 0.03∗

Chamber pot 1
1.78
Outside the compound
(0.93, 3.39)
4.07
Other2
(1.15, 14.38)
Treatment of fruits and
vegetables
4.07 0.03∗
Water and salt (saline)
(1.15, 14.18)
Otherwise3 1

Model fit statistics

∗
Log likelihood ratio 35.61 <.0001 12.84 0.005 25.54 <.0001 24.40 0.0002
∗
Wald test 30.42 <.0001 12.19 0.007 25.52 <.0001 23.69 0.0007
2 0.12 0.13
Nagelkerke’s 𝑅 0.16 0.06
Values are odds ratios and 95% confidence interval; ref = reference group; 1inlcudes rubbish dump site and surrounding bush; 2inside compound, surrounding
∗
bush; 3includes washing with only water; statistically significant at 5% level of significance.
10 Advances in Public Health

present study was higher compared to estimates (16%) by the Notwithstanding the limitations, this study has thrown
GDHS, the prevalence was even lower compared to estimates more light on WASH practices in the rural Northern context
by Casals et al. [39] in rural Tanzania (71%) but similar to esti- of Ghana and the determinants of diarrhoea and RTI preva-
mates (6–56%) by Kiulia et al. [40] in Kenya. Osumanu [16] lence among children 6–23 months. To the best of our knowl-
also found a similar prevalence rate (57.5%) of diarrhoea among edge, this study was the first to examine the effect of WASH
under-five years children from indigenous residential areas in practices on the prevalence of diarrhoea as well as RTI among
the Tamale Metropolis of Ghana. Most recently, in the Volta 6–23 months children in the rural northern Ghanaian
Region of Ghana, diarrhoea prevalence rate of 44.7–59.2% was context.
reported for intervention and control groups in a randomised
trial [41]. It is worth noting that our sample was younger than
the GDHS sample and younger children are more vulnerable 4. Conclusions
to infections and poor health, which may also be related to poor
care and dietary inadequacies and may also partly explain the The study showed a high prevalence of diarrhoea and RTI
high diarrhoea prevalence. among children aged 6–23 months in the Kumbungu District
Early childhood diarrhoea is independently associated of Ghana. Caregiver’s handwashing with soap after defecation
with substantial linear growth retardation that continues even and before feeding as well as hand washing of the child with
beyond age 6 years and targeted interventions for controlling or without soap before feeding were predictive of diarrhoea
it may have profound and lasting growth benefits for children prevalence while caregiver handwashing with or without soap
[23]. According to Rah et al. [32], improved WASH practices after defecation and washing of the child’s hands with soap
are associated with reduced prevalence of stunting in rural before feeding were predictive of RTI prevalence among the
settings. Although not the focus of the present study, our find- children. Caregiver handwashing with soap after defecation
ings may somewhat explain why the northern Region is worst- and household garbage disposal were also predictors of diar-
off in stunting prevalence (33%) among children under-five rhoea and RTI co-morbidity. Moreover, the place where the
in Ghana [10]. Unpublished data from the study area among child defecates, caregiver handwashing with soap after defe-
children under five also showed that more than half of children cation and treatment of fruits and vegetables before eating/
under-five are stunted [43]. cooking were the determining factors of diarrhoea or RTI
The findings of the present study emphasise the importance prevalence. Interventions geared towards improving hand-
of handwashing and waste disposal practices in addressing diar- washing and waste disposal should be implemented to avert
rhoea and RTI morbidity among young children. Policies and the high burden of diarrhoea and RTI among the children in
programmes aimed at addressing morbidity and malnutrition Kumbungu District of Ghana.
among young children need to consider hand washing and waste
disposal practices; thus, shifting the emphasis from nutri-
Data Availability
tion-specific to nutrition-sensitive programming.
Our findings should be interpreted with caution because The data used to support the findings of this study are available
diarrhoea and RTI prevalence were based on the mother/car- from the corresponding author upon request.
egiver's recall which may be influenced by recall bias related
to the reliance on the memory of the respondents. Moreover,
there may be misclassification of cases if the mother/caregiver Conflicts of Interest
wrongly assumes diarrhoea/RTI prevalence during the recall
time; nevertheless, to minimise recall bias and misclassifica- The authors declare that they have no conflicts of interest.
tion, research assistants were trained to probe further.
Although there can be a potential bias in any recall method,
this way of data collection is less expensive and relatively fast Funding
and is still considered. Mothers/caregivers may also report
socially desirable practices which in reality they do not prac- We did not obtain any external funding for this study.
tice; however, we observed that mothers in our study were
very motivated and freely answered the questions without
hesitancy or intrusions from other people. Acknowledgments
A major limitation of our present study is its cross-sec- The authors would like to thank the women who willingly
tional design as the inference of possible causality is specula- agreed to participate in this survey with their children. We also
tive since it is not possible to determine if any of the WASH wish to acknowledge and thank all the community leaders for
practices preceded the diarrhoea and or RTI occurrence. As their support during the survey.
a prospective design would be better equipped to address this
problem, we limit the interpretation of our findings to describ-
ing associations. Our study population was also limited to 9 References
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