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FACTORS INFLUENCING PERSISTENT INCREASE IN DIARRHOEA DISEASES AMONG UNDER FIVE CHILDREN IN NYUNGWE, KARONGA MALAWI

THESIS

SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE DEGREE OF BACHELOR OF SCIENCE IN PUBLIC HEALTH (BSc.PH)

DEPARTMENT OF PUBLIC HEALTH FACULTY OF APPLIED SCIENCES UNIVERSITY OF LIVINGSTONIA - LAWS CAMPUS

ENOCK MVULA (BPH/01/72/15)

MAY 2019

DEDICATION

I dedicate this thesis to my father Fridwell Dula Mvula and my mother Christina Jere for their encouragement and support in the success of my academic career.

DECLARATION

I, Enock Mvula, declare and affirm that this thesis is my own work. I followed ethical principles in gathering data, analysis and completion of this thesis. All work of other scholars and literature used in this thesis has been duly acknowledged.

This thesis is submitted in partial fulfilments for the Degree of Bachelor of Science in Public Health (BSc. PH) at the University of Livingstonia (Laws Campus). I solemnly declare that this thesis has not been submitted to any other institution anywhere for the award of any academic degree, diploma or certificate.

___________________________________________________________________ Enock Mvula – Candidate

Date

APPROVAL

This thesis of Enock Mvula has been submitted with my approval

Professor Bernard C.G. Kamanga. Supervisor and College Principal

_______________________________________________ Date ACKNOWLEDGEMENTS

I would like to express my sincere gratitude to my sponsor Cyd Hutton who have been providing financial support towards my university education. Cyd, receive my heartfelt thanks for the financial support that enabled me to finish the work.

Special gratitude goes to my supervisor Professor B.C.G. Kamanga, for his mentorship and massive contribution in supervising this work and not only that also he worked tirelessly for editing and reframing the work. The guidance and support he rendered are greatly appreciated. I have learnt a lot of things from him including being patient when I am doing things and time management. Time is one of the most valuable resources in one’s life time, knowing how to manage it is a prerequisite to successful life. I respect him for being a man who desires quality work rather than the quantity. Be blessed.

I thank all lecturers in the department of Public Health who worked tirelessly for us to reach this far. These were Mr John L.Z. Nyirenda, Mr Joseph Wu, Mr Erasmo Mbemba, Miss Margret Soko and other lecturers from other departments that taught us. I also thank Mrs Mary Sibande Kumwanje and Mrs Mary Tifiness Kamanga for their mentorship and encouragement to me to excel in my academic levels. God bless you all.

I would like to thank Nyungwe Health Centre staff members, in particular, Mr Mzembe (HMIS officer), Mr Banda (clinician) and all HSA’s who helped me when I was correcting data. I would like also to extend special thanks to Mr and Mrs Mvula, my parents and my sister Martha Mvula, my brother Yowoyani Mvula,, Aaron Mfune, aunt Roselyn Jere, uncle Humphrey Jere, aunt Paulina Msukwa and all my siblings who provided support, encouragement and happy moments in my life. I also thank my lovely fiancée Juliet Kaundama who was there for me during the period of this work and she provided her endless support in all aspects.

I thank the entire Public Health 2019 class and the following people for their active contribution to my general welfare and academic life: Dennis Gift Mkandawire, Atusaye Mzota Mkandawire., Dael Davie Nkundika, Davie Mlowoka, Uchindami Chekani, Blessings Tano, Peter Kapenda, Adams Kasambala, Lindizga Nyirenda, Clara Silungwe, Lucy Mwale, Annie Nyasulu, Chipiliro Chathinya, Chisomo Moyo and Wezzie Botha.

Above all, I thank the almighty God for giving me life, strength and ability to undertake this work. Oh Lord, you have been my ever present help in times of need. Thank you! TABLE OF CONTENTS DEDICATION	i DECLARATION	ii APPROVAL	iii ACKNOWLEDGEMENTS	iv TABLE OF CONTENTS	vi LIST OF TABLES	x LIST OF PLATES	xi ACRONYMS	xii ABSTRACT	xiii Chapter 1. Introduction	14 1.1.	Background	14 1.2.	Statement of the problem	16 1.3.	Justification of the study	17 1.4.	Research questions	17 1.5.	Objectives	18 1.5.1.	Broad objectives of the study	18 1.5.2.	Specific Objective	18 chapter 2. Literature review	19 2.1. Introduction	19 2.2. Causes and transmission routes of diarrhoea	19 2.3. Epidemiology of diarrhoeal disease in Malawi	19 2.4. Risk factors of diarrhoeal	20 2.5. Impact of Diarrhoea	21 2.6. Diarrhoea prevention and management	21 Chapter 3. MethodOLOGY	22 3.1	Introduction	22 3.2	Type of research study	22 3.3	Study site	22 3.4	Study population	23 3.5	Sample size	24 3.6	 Information collection	24 3.7	Data management and analysis	25 3.8	Study limitations	25 3.9	Ethical Considerations	25 CHAPTER 4. RESULTS	26 4.1. Introduction	26 4.2 Socio economics characteristics	26 4.2.1. Age distribution	26 4.2.2. Marital status of mothers	27 4.2.3. Ethnicity of mothers	27 4.2.4. Religion of mothers	28 4.2.5. Level of education	28 4.2.6. Occupation of mothers	29 4.2.7. Household economic status	30 4.3. Environmental and behavioural factors influencing diarrhoea	32 4.3.1. Water related practices	32 4.3.1.1. Water sources in the study	32 4.3.1.2. Distance from water source	32 4.3.1.3. Utensils used to carry water from the source	32 4.3.1.4. Utensils used to store domestic water	33 4.3.1.5. Water handling in the household	33 4.3.1.6. Household water treatment in the study area	33 4.3.2. Household hygiene practices	34 4.3.3. Environmental sanitation and health	36 4.3.4. Personal hygiene practices	38 4.3.5 Food hygiene practices	40 4.4. Knowledge and perception on diarrhoea causes and prevention	43 4.4.1. Knowledge of diarrhoea causes and mode of transmission	44 4.4.2. Knowledge of diarrhoea prevention	45 Chapter 5: Discussion	47 5.1. Introduction	47 5.2. Socio economic factors associated with diarrhoea	47 5.2.1 Mothers’ age	47 5.2.2. Marital status of the mothers	48 5.2.3 Mothers’ education	48 5.2.4 Maternal occupation	48 5.2.5. Economic status of mothers	49 5.3. Environmental factors influencing the increase in diarrhoea	49 5.3.1. Water related practices	49 5.3.1.1. Water source in the study	49 5.3.1.2. Distance from water source	50 5.3.1.3. Utensils used to carry water from the source	51 5.3.1.4. Utensils used to store domestic water	51 4.3.1.5. Household water treatment	52 5.3.2. Environmental sanitation and health	52 5.3.3 Household hygiene practices	53 5.3.4. Personal hygiene practices	53 5.3.5. Food hygiene practices that related to occurrence of diarrhoea	54 5.4. Knowledge of parents about diarrhoea causes and prevention	55 5.4.1. Knowledge of causes and routes transmission of diarrhoea	55 5.4.2. Knowledge of diarrhoea prevention and management	55 CHAPTER 6. CONCLUSION AND RECOMMENDATIONS	56 61. Introduction	56 6. 2.Conclusion	56 6.3. Recommendations	57 6.3.1. Recommendation of the study	57 63.2. Policy recommendations	58 63.3. Further study recommendations	58 BIBLIOGRAPHY	59 APPENDICES	65 Appendix 1. Questionnaire	65

LIST OF TABLES Table 1. Demographic characteristics of respondents in Nyungwe community in Karonga district in 2019	31 Table 2. Water related practices, Nyungwe community, June 2019	34 Table 3. Type of households, cleaning and poultry rearing by respondents in Nyungwe community in Karonga  in 2019	36 Table 4. Sanitation and health of the respondents in Nyungwe community in Karonga district in 2019	38 Table 5. Personal hygiene practices of the respondents in Nyungwe community in Karonga in 2019	40 Table 6. Food related hygiene practices of the study household, Nyungwe community in Karonga in 2019	42 Table 7. Type of foods and fruits mothers buy for their children from the street vendors in Nyungwe Community in Karonga in 2019	43 Table 8. Knowledge of diarrhoea by respondents in Nyungwe Community in Karonga in 2019	45 Table 9. Knowledge of diarrhoea prevention of the respondents, in Nyungwe community in Karonga in 2019	46

LIST OF PLATES Plate 1. Map of Malawi showing Nyungwe area in Karonga	23

ACRONYMS

AIDS			Acquire Immune Deficiency Syndrome CDC			Centre of Disease Control CLTS			Community Led Total Sanitation HMIS			Health Management Information System HSAs			Health Surveillance Assistance HW			Hand washing HWWS		Hand Wash with Soap MCH			Maternal Child Health MDHS			Malawi Demographic Health Survey MoH			Ministry of Health REC			Research Ethic Committee SDGs			Sustainable Development Goals SPSS			Statistical Packages for Social Sciences TA			Traditional Authority UNICEF		United Nation International Children Emergency Fund UNILIA		University of Livingstonia WASH			Water Sanitation and Hygiene WHO			World Health Organisation ABSTRACT

The study was carried out to identify factors influencing persistent increase in diarrhoea among children under-five years in Nyungwe, Karonga. A cross-sectional study was conducted with a sample of 40 respondents. The questionnaire of the study focused on three key areas about the increase of diarrhoea among the under-five children: (a) Environmental factors (b) Socioeconomic factors and (c) Knowledge and awareness levels of respondents. An interview questionnaire was used to collect data. Quantitative data was analysed using Statistical Package for Social Science version 20, where descriptive statistics were generated.

The results show that the prevalence of the diarrhoea among the under five children was high. The study found that socio-economic factors were the positive predictors of the persist increase of diarrhoea. The independent variations that influenced the increase of diarrhoea was maternal education, age of mothers, economic status and occupation. The majority of respondents were poor and aged between 15 to 24 years. It was also found out that lack of knowledge about hand washing and clean breast before breastfeeding had exposed their children to the disease.

Keywords: Diarrhoea, children, environment, socioeconomics, Nyungwe.

Chapter 1. Introduction

This chapter describes the background about the problem of the statement, justification of the study and research objectives.

Background Diarrhoea is defined as having loose or watery stool for three or more times during a 24–hour period, and remains a leading cause of morbidity and mortality in developing countries, killing nearly two million children every year (WHO, 2009). Diarrhoea is caused by a virus known as rotavirus and bacteria and is transmitted through consumption of contaminated food and water (Masangwi et al., 2009). The frequency and severity of diarrhoea occurred by lack of access to sufficient clean water and sanitary disposal of human waste, improper feeding practices and hand washing, poor housing conditions(Masangwi et al., 2010).

Diarrhoeal disease contributed to 15% of all under-five deaths globally each year (Thiam et al., 2017b). According to the World Health Organization, globally, there are nearly 1.7 billion cases of diarrhoea every year among children under five. Diarrhoea is the second-leading cause of death in children under five and is responsible for killing around 760,000 children every year (WHO, 2018). Diarrhoea kills more children than AIDS, malaria and measles combined; diarrhoea is a leading cause of malnutrition and stunting in children (TRANG et al., 2015). Mortality from diarrhoea has declined over the past decade from an estimated 2.5 million deaths per year among children under five (WHO, 2009).

In Africa especially Sub-Saharan Africa, diarrhoeal disease is the main cause of mortality and morbidity due to dehydration, which accounts for over 19% of deaths in children under five years (Gidudu et al., 2011). It has been estimated that every child has five incidences of diarrhoea per year and that 800,000 children die each year from diarrhoea (Farthing et al., 2013). Sub-Saharan Africa remains the region with the highest under five mortality rate in the world, with 1 child in 13 dying before reaching 5 years old with diarrhoea diseases. The under-five mortality rate in low-income countries was 73.1 deaths per 1000 live births, nearly 14 times the average rate in high-income countries approximately 5.3 deaths per 1000 live births (Munjita, 2015).‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬

Diarrhoea is one of the major causes of death in young children in Malawi. The prevalence of diarrhoea among children of age below 5 in Malawi was reported at 22% in 2015, according to the Malawi Demographic and Health Survey   More than 1 in 5 children under five had diarrhoea in the two weeks before the survey and  diarrhoea was most common among children age 6-11 months (41%)(MDHS, 2016). Furthermore, the Malawi Demographic and Health Survey showed a higher percentage of cases without access to improved drinking water and sanitation. More than half of under-five child deaths are attributable to diseases that are easily preventable and treatable through simple, cost effective, and affordable interventions. Strengthening health systems to provide such interventions to all children will potentially save many young lives (Morse & Simpson, 2014).

In 2015, the United Nation adopted the Sustainable Development Goals (SDGs) to reduce child mortality and to promote well-being for all children. The SDG goal number 3 Target 3.2 aims at ending preventable deaths of new-borns and under-five children by 2030(WHO, 2017). Similarly, the Malawi Government also implemented various strategies such as the rotavirus vaccination, hygiene and sanitation, Health promotion Program, to prevent and control infectious diseases like diarrhoea(MoH, 2016).

Childhood diarrhoea was still being a concern in Karonga district, specifically in Nyungwe community traditional authority Mwilang’ombe. The diseases had many consequences that include high morbidity and mortality especially among under five children. Table below shows the under five children with new diarrhoea cases in the past four years

Year 2015 2016 2017 2018

Diarrhoea Cases 898 842 786 566 (Jan-Oct)

Source: HMIS- Nyungwe Health Centre

The information above indicates that the diarrhoeal cases among under five children were going down. This could be attributable to the efforts made by World Vision and Malawi Red Cross Society which implemented some interventions such as Community Led Total Sanitation and hand washing in order to prevent and control infectious diseases like diarrhoea. However, the numbers were still not acceptable. This study therefore, sought to identify the factors that contributed to increase of diarrhoea in Nyungwe community.

Statement of the problem Childhood diarrhoea is a leading cause of morbidity and mortality in Karonga district. In spite of department of environment health through the ministry of health with the other stakeholders in the health sector efforts of developing health education and awareness and other environmental health programmes to prevent the situation, the disease continues to devastate many children below the age of five.

In action many childhood cases in Karonga district are associated with environmental behaviour and socio economic status. Diarrhoea remains one of the most important childhood environmental health problem. The report from Malawi World Bank, (2012) transmission of diarrhoea and water related diseases are directly linked to inadequate access to water and hygiene practices. Poor access to improved Water, Sanitation and Hygiene (WASH) leads to a variety of waterborne diseases.

The prevalence of childhood diarrhoea in Karonga district was sixteen percent (MDHS, 2016), and the study conducted by Hendrix et al., (2017) found out that childhood diarrhoea is increasing (17%) in Karonga district. In addition, diarrhoeal disease leads to malnutrition which harms children’s growth. This diarrhoea leads to malnutrition which leads to growth retardation, including stunting and wasting. This is a serious problem in Karonga where is 28 percent of children under the age of five are stunted (MDHS, 2016)

According to the health records obtained from Nyungwe Health Centre, 2018, diarrhoea-related morbidity among children under five were the most commonly reported in the 2015-17 period in Nyungwe community, T/A Mwilang’ombe, with children having the highest diarrhoea cases. However, the factor that contributed to the diarrhoea increase in the study area is not documented. This research therefore, sought to identify the factors that contributed to increase of diarrhoea among under five children in Nyungwe community

Justification of the study For the effective prevention of diarrhoeal, it was necessary to understand risk factors associated with the disease. The study assessed the level of knowledge, the attitudes and perceptions about diarrhoea. This information would help to explore factors that influenced the increase of diarrhoea cases among the under five children. The results would help decision makers to come up with suitable strategies of addressing diarrhoea among under five children. Furthermore, the findings would help health professionals to design targeted interventions to tackle morbidity and mortality related to diarrhoea among children.

Research questions What were the socio-economic factors that influence a persistent increase in diarrhoeal cases among under-five children? What were the environmental factors that influence a persistent increase in diarrhoeal cases among under-five children? What Knowledge did parents and caregivers have about diarrhoeal in under-five children?

Objectives

Broad objectives of the study The main purpose of this research was to identify the factors influencing high prevalence of diarrhoeal among under five children in Nyungwe community in Karonga district.

Specific Objective To identify the socio-economic factors that influence the persistent increase in diarrhoea among under-five children To identify environmental factors that influence the persistent increase in diarrhoea among under-five children To assess the knowledge and perceptions of parents and caregivers about diarrhoea in under-five children

chapter 2. Literature review

2.1. Introduction In Africa, diarrhoeal contributes to approximately 19% of deaths in children under the age of five (Kakulu, 2012). In Malawi, it has also been well recorded that one of the main cause of death in children under the age of five alongside malaria and acute respiratory infection is diarrhoea( Ministry of Health Malawi, 2012).

2.2. Causes and transmission routes of diarrhoea Diarrhoea is caused by bacterial, parasitic; viral infections or the non-infectious causes of childhood diarrhoea( Agustina et al., 2013). Viral gastroenteritis is the main causes of diarrhoea. Among those causes, the rotavirus is the most leading cause of severe complication of dehydration especially in developing countries where there is drinking of unimproved water and poor sanitation(Liu et al., 2012). Diarrhoea infection is acquired through faecal-oral transmission that includes consumption of contaminated water or food, direct contact with person-to-person or direct contact with faecal matter(Services, 2015).

2.3. Epidemiology of diarrhoeal disease in Malawi The overall prevalence of diarrhoea in Malawi in 2015 was 18%, ranging from 15% in the Northern Region to 20% in the Central Region(UNICEF, 2015). Children of women with improved drinking water source and improved unshared toilet facilities, and children of women with more than a secondary school education had the lowest prevalence of diarrhoea(MDHS, 2016). The 57% of children with diarrhoea in the Central Region were taken to a health care provider for advice on treatment, compared to 66% in the Southern Region and 71% in the Northern Region(Innocent, 2015). Although some research has been conducted on diarrhoea in Malawi, statistics and specific information remain limited. The studies showed that many guardians do not attend health facilities with under-fives when they are suffering from diarrhoea(MDHS, 2016).

2.4. Risk factors of diarrhoeal Demographic factors: several studies have documented that the diarrhoea prevalence is increased in younger children especially in children between 6-11months (Di ouf, Tabatabai, Rudolph, & Marx, 2014). Several findings showed that the diarrhoea rate is greater in boys than girls. Other demographic factors like low level of mother's education, mothers’ younger age, birth order, and high number of siblings were notably associated with diarrhoea in children below five years (Agustina et al., 2013).

Environmental factors: Contaminated drinking water, poor hygiene practices, lack of sanitation and poor food hygiene are all documented sources of diarrhoeal in Malawi (Morse, 2006). In addition, literature has described specific risk factors which also contribute to the presence of diarrhoea in households including zoonotic transmission from domesticated animals to people, educational and employment status of the head of the household, maternal age, economic status of the household and the size of the household (Masangwi et al., 2010; ,Woldu, Bitew, Bikes, & Gizaw, 2016). Particularly, diarrhoea occurrence is more associated with unsafe or unprotected water sources for example wells, rivers, lakes (Regassa & Lemma, 2016). Other environmental risk factors of childhood diarrhoea include unimproved sanitation, hand washing facilities, poor knowledge on diarrhoea diarrhoeal cases and unimproved latrine.

To minimize the magnitude of childhood diarrhoea designing and implementing various prevention strategies, such as health education, child care, personal hygiene, and household sanitation, in integration with the existing national health extension program is recommended(Connell, Quinn, & Scheuerman, 2017).

2.5. Impact of Diarrhoea The global impact of diarrhoeal on children under five years is high mortality and morbidity rates. Diarrhoeal diseases have been classified as the second cause of morbidity and mortality in children. Globally, there are nearly 1.7 billion cases of diarrhoea every year among children under five (WHO, 2018). Diarrhoea is the second-leading cause of death in children under five and is responsible for killing around 760,000 children every year (WHO, 2018). Diarrhoeal result in dehydration, malnutrition, stunting and cognitive impairment (Walker et al., 2013).

2.6. Diarrhoea prevention and management The prevention of diarrhoeal is based on access to safe drinking-water, use of improved sanitation, hand-washing with soap, personal and food hygiene (Bonkoungou et al., 2013). All major cases of diarrhoeal in children under five years of age can be prevented by proper household practices of water, sanitation and hygiene (Mbakaya, Kalembo, & Zgambo, 2019).

Chapter 3. MethodOLOGY

3.1	Introduction This chapter explains how information was collected, processed and analysed. It also describes the type of research study, study place, study population, sample size, collection, data and management, study limitations and ethical consideration.

3.2	Type of research study The study was a descriptive cross sectional study was quantitative research. This type of research was selected because it was cost-effective, time-efficient and easily accessible for collecting information from the target population. The study used both the qualitative and quantitative methods. However, mainly the study was quantitative research method

3.3	Study site The study was conducted in southern parts of Karonga district, Nyungwe community in traditional authority (T/A) Mwilang’ombe which is found in the northern region of Malawi. Its geographical coordinates are 10˚17’43”S and 34˚4’30”E. There are two main dominated tribes that is the Nkhonde and Tumbuka. The common language is Chitumbuka. Many people in Nyungwe earn their living through fishing and small businesses.

Plate 1. Map of Malawi showing Nyungwe area in Karonga . 3.4	Study population The study population comprised mothers and caregivers who had children of age below five years. From this population, a sample was taken. This study used simple random sampling technique for the data collection. Random sampling is a procedure for sampling from a population in which the selection of a sample unit is based on chance and every element of the population has a known, non-zero probability of being selected. In this technique, each member of the population has an equal chance of being selected as subject. The entire process of sampling was done in a single step with each subject selected independently of the other members of the population. The most simple and mechanical method was the lottery method. Each member of the population was assigned a unique number. Each number was placed in a box and mixed thoroughly. The blind-folded researcher then picked numbered tags from the box. All the individuals bared the numbers picked by the researcher were the subjects for the study.

3.5	Sample size A study sample was 40 respondents from the targeted population. The study used a simple sample size formula to calculate the sample size (Viechtbauer et al. 2015). This study used the formula below because the purpose of study was to identify the prevalence and also the actual population was unknown so the formula was easy to find the probability sample size.

N= = 58.4-18=40 Where P is the probability that a subject has the problem of interest (P=0.05). C is the probability of the confidence level that result of study will swim in (C=0.95) Problems with a prevalence of 5% were almost certainly identified with 95% confidence in the study that included 40 respondents.

3.6	 Information collection The research collected the primary data through using of a questionnaire. The secondary data was collected from records at the Nyungwe Health Centre Hospital. The data that was collected at Nyungwe Health Centre, consisted of new diarrhoea incidence cases for under five children

3.7	Data management and analysis Data analysis involved, establishment of categories, coding of data, tabulation and drawing statistical inferences. Statistical Package for Social Science software (SPSS v 20) was used to analyse the data collected. Descriptive statistics were generated. Data was presented in tables and written statements for easy understood and interpretation

3.8	Study limitations During data collection there were some limitations as some eligible participants refused to participate after being told about the study although explanations were made that this was a school project they did not believe but rather giving false answers and some chose not to participate. Misunderstanding of the questions arose as some of the participants could not grasp some questions which led to time consuming as they were explaining things that were not in line with the questions asked. Also some respondents were not eager to participate voluntary.

3.9	Ethical Considerations Ethical approval for the study was obtained from UNILIA Research Ethics Committee (Unilia-REC) and tradition authority (TA) Mwilang’ombe. The purpose and benefits of the study were explained to the respondents and asked them for their permission to answer the questions. Participation in the study was voluntary. Even those who initially accepted to participate were free to withdrawn in the course of the study if they did not wish to continue. CHAPTER 4. RESULTS

4.1. Introduction This chapter presents the findings of the study from Nyungwe community in T/A Mwilang’ombe in Karonga district. It presents findings of the demographic and socio-economic information associated with diarrhoea among under-five children. It further presents results of environmental and behavioural factors influencing the persistent increase in diarrhoea diseases among under-five children. It ends with the general knowledge of mothers and caregivers about diarrhoea.

4.2 Socio economics characteristics The Table 1 presents the information of the demographic characteristics of the respondents in Nyungwe community. It comprised age distribution, marital status, religion, ethnicity, level of education, occupation of mothers and economic status at household level. The respondents were all mothers or care givers of the under five children.

4.2.1. Age distribution Age is a determinant of knowledge achievement and decision making in the family or society. Age may be one of the factors influencing the occurrence of diarrhoea in under five children in young mothers. Age may influence the prevention behaviour of diseases like diarrhoea especially on the adult mothers. Samwel et al., (2014) indicated that 27.52% of the teenager mothers had the highest risk of experiencing childhood diarrhoeal diseases and mothers aged 40 to 44 years had the lowest risk of their children suffering from diarrhoea. Table 1 shows the age group of the mothers of the under five children in the study area. They were ranging from 15 to 44 years of age. The study found out that the majority of the respondents were young mothers aged 15-24 years (55%), followed by average mothers aged 25-34 years and age group of 35-44 years old. This study suggested that the mothers whose ages were less than 24 years could be associated with the occurrence of childhood diarrhoea, possibly due to lack of prior experience and care of nursing children. Immaturity may lead to poor sanitation and personal hygiene practices.

4.2.2. Marital status of mothers Marital status reveals a person’s relationship with others. It is the indicator of stability and maturity of the person. Examples are married, single, divorced and widow of such status and sometimes may be a source of judgement. Furthermost, married people are stable and behave maturely when they have responsibilities including taking care of their families and children compared to single mothers. The marital status of mothers is linked to the occurrence and preventive knowledge of diarrhoea among the under five children. The results of the study indicated that the majority of the respondents were married mothers, seconded by 16% that were single mothers and 2% included both widows and divorced (Table 1). The results suggest that most respondents had knowledge about causes and prevention of diarrhoea among the under five children in a study area. It may explain that there were mothers that had knowledge on the causes of the childhood diarrhoea but they failed to implement that due to attitude and cultural belief.

4.2.3. Ethnicity of mothers An ethnicity is a category of people who identify with each other, usually on the basis of acknowledged common language or culture. The study comprised Nkhonde, Tumbuka, Lambya, Chewa and Tonga people. The study’s results show that the majority of the respondents (67%) were Tumbuka, followed by Nkhonde and Chewa both average of10%. The least group of mothers belonged to 8% and 5% Lambya and Tonga respectively. The study showed that more children that had diarrhoea were of mothers from Tumbuka ethnic group seconded by Nkhonde and Chewa ethnic group.

The information was used for understanding and interpreting the cultural belief systems regarding specific hygiene behaviours and diarrhoea, with emphasis on hand washing. Hand washing was said to occur for three main reasons: to remove contamination, for social reasons, and for comfort reasons. The study identified that people in Nyungwe believed in defecating in the water alongside lake shore, despite having toilet facilities. The Tumbuka and Chewa might believe that diarrhoea was caused by teething and bad weather in an area.

Sources of dirt on the hands included human blood and faeces. Many perceived that causes of diarrhoea were identified, including dehydration associated with sunken anterior fontanel. Traditional perceptions regarding the treatment and prevention of diarrhoea were also identified (Ansari, Izham, Ibrahim, & Ravi, 2012).

4.2.4. Religion of mothers The religion is associated with the mother’s beliefs that treatment of illness requires traditional healers rather than modern curative treatments. Religion may also be associated with the occurrence of diarrhoea among children under five years of age due to their belief. The respondents thought that diarrhoea among under five children was occurred by teething. However, this study could not give much evidence of the relationship of religion and diarrhoea. The results in Table 1 indicate that the majority of the respondents were Christians (95%) and the 5% were Muslims. The results of this study had no enough evidence of these causes because it found other factors that influenced the occurrence of diarrhoea among the under five children in the study area.

4.2.5. Level of education Level of education determines how much one understands things and having the ability to relate them to current situation. An increased level of education can lead to increase in general knowledge of diarrhoeal causes and preventive measures. The study shows that majority of respondents attended school, however some of them never attended school. Table 1 shows the equal percentage of respondents who attended primary and secondary school. The rest of respondents were reported to have no formal education and tertiary education.

Other studies found out that mother educational status was associated with the occurrence of childhood diarrhoea. The children whose mothers had attended primary or secondary education school were less prospective to develop diarrhoea compared to children whose mothers had not attended formal education(Woldu, Bitew, & Gizaw, 2016). Education may likely help enhancing household health and sanitation practices. In addition, education can increase awareness about the transmission and prevention methods of diarrhoea. Awareness also encouraged changes in behaviours at the household level.

4.2.6. Occupation of mothers An occupation is a person’s role in society, more specifically is an activity usually performed in exchange for imbursement. A person can inaugurate a job by becoming an employee, volunteering, starting a business or becoming a parent. Occupation may determine the access to good health services for the members of the family. This study found out that the primary occupation of the respondents was being a housewife (53%) followed by the 25% and 20% for business women and unemployment respectively and only 2% was formally employed by government of Malawi (Table 1).

The results may suggest the category of mothers who influences the occurrence of the diarrhoea diseases in under five children. These findings were similar with other studies that found out that parental occupation influence under-five diarrhoea occurrence. The risk of diarrhoea was associated to be high with housewife compared to those working in the private or public sector (Thiam et al., 2017a).

4.2.7. Household economic status Households and individuals of lower socio-economic status are more likely to suffer from healthy problems and have fewer resources to safeguard themselves against the negative effects of poor health (Leonard & Pruitt, 2018). As a result, unexpected adverse health events can be particularly overwhelming for low-income households because they can affect employment, create new household economic needs such as healthcare costs, and increase household workloads. Despite the known challenges for low-income families when household members fall into poor health, relatively little is known about household coping strategies. The socio-economic status of households in the rural setting is an important phenomenon because it gives an indication of the well-being of the members of the households. The study found that 57% of the respondents in the study area had poor economic status and 43% of the respondent were of medium income. This information might reflect the influences of poor health in the area.

Table 1. Demographic characteristics of respondents in Nyungwe community in Karonga district in 2019

4.3. Environmental and behavioural factors influencing diarrhoea This section presents the findings of the environmental and behavioural factors that attributed an impact to the occurrence of under five children diarrhoea. It comprises an environmental characteristics, the water related practices, sanitation and personal hygiene. 4.3.1. Water related practices Table 2 presents information of the water related practices in the study area. The poor water related practices might influence occurrence of water related diseases like diarrhoea, typhoid fever, dysentery.

4.3.1.1. Water sources in the study The study findings indicate that all respondents in the study obtained their drinking water from borehole that were less contamination. This signify that 100% of respondents used improved and protected water sources in their household for cooking and drinking. The study suggest that source of water might cause diarrhoea However, water may be contaminated in the household by the way people use the water. Children mostly remain dirty through their playing habits and when they touch water with dirty hands it might be contaminated.

4.3.1.2. Distance from water source The study found out that distance to water source was shorter than before. This had eased the time spent by the water users within the study area with most of the respondents walking not more than 1 kilometre while others walked as far as half kilometre to fetch water. The results varied with 45% being highest and lowest was 12% for above 2 kilometres (Table 2).

4.3.1.3. Utensils used to carry water from the source The household economic status determines the kitchen utensil the family use to fetch and water storage. This study found out that 55% and 45% of the respondents used plastic buckets with lids and plastic buckets without lids respectively (Table 2) to carry water from the water source to their various households.

4.3.1.4. Utensils used to store domestic water The study extended the findings on how the respondents store domestic water. Table 2 shows that 68% of the respondents used the plastic containers with lids and 32% stored their water in containers without lids. This was on the basis of affordability in the market and provision of an option for safe water at household level. The results suggest that the respondents who used plastic buckets without lids for carrying water from the source and storage water might  have high risk of the water related disease like diarrhoea because the water they used at the household level was not safe and easily to be contaminated.

4.3.1.5. Water handling in the household According to this study, the drinking water storage containers were cleaned before replacing with fresh water. The observed results during the study found that majority of the households in the study area cleaned their drinking containers for water storage before replacing with fresh water. On average, 73% of the respondents used soap and water, 23% just drained the old water and cleaned their containers using water only and 4% just replaced with fresh water without washing or cleaning the water storage containers (Table 2). The respondents cleaned the storage containers as one way of making water safe to drink. 4.3.1.6. Household water treatment in the study area Table 2 presents that 75% of the respondents in the study area just covered the storage of drinking water without applying any treatment. This was explained to be the way of preventing water from physical contaminants like dust particles in order to make water safe to drink. On average, 13% of the respondents were drinking water without any treatment and not covered the water storages, 10% and 2% of the respondents in the study area used water guard and chlorine respectively to treat their drinking water as a way of killing the pathogens like microbial contaminants in drinking water.

Table 2. Water related practices, Nyungwe community, June 2019

4.3.2. Household hygiene practices Hygiene is a set of practices performed to preserve the health of people. According to the World Health Organisation hygiene was defined as “conditions and practices that help to maintain health and prevent the spread of diseases”. Home hygiene pertains to the hygiene practices that prevent or minimise the spread of disease at household and other everyday settings. Preventing diarrhoea in children required to understand the good hygiene at household level. Table 3 comprises the variables of type of household, time of cleaning and domestic poultry. First variable was the type of household 53% of the respondents were of the extended or composite households, consisting of parents like father, mother and their children, aunts, uncles, grandparents and cousins, all livings in the same household. Forty percent and 7% of the respondents were of nuclear family with children and nuclear single parent respectively (Table 3). The study suggested that the extended families may be associated with the occurrence of childhood diarrhoea because there may be a possibility of compromising hygiene.

Second variable was the frequency of cleaning the house surroundings. On average 68% of the respondents reported to clean the surroundings everyday especially in the morning. Thirty percent of the respondents cleaned the house surroundings when it became dirty. Only 2% of the respondents cleaned their surrounding 1 to 2 times a week.

Last variable was whether the respondents had domestic poultry. Table 3 shows average of 63% of the respondents were keeping the domestic poultry and 37% of the respondents were not keeping the domestic poultry. The study suggested that the domestic poultry was a risk factor for diarrhoea illness for humans.

Diarrhoeal diseases are caused by transmission of bacteria, parasites or viral enteric organisms to humans through the contamination of water or food sources by faeces. Environmental contamination from human faeces is the main risk factor for human diarrhoea, but zoonotic sources can also be responsible for transmission of diarrhoea disease pathogens to humans. Animal faeces can contribute to human diarrhoea incidence by introducing new zoonotic pathogens that cause diarrhoea illness(Zambrano, Levy, Menezes, & Freeman, 2014).

These conditions increase the potential for faecal contamination by poultry within the household environment. In particular, poultry like ducks had been implicated as a source of faecal contamination of soil. This was particularly problematic among young children, in whom faecal-oral transmission may be more common during play.

Table 3. Type of households, cleaning and poultry rearing by respondents in Nyungwe community in Karonga  in 2019

4.3.3. Environmental sanitation and health Sanitation generally refers to the provision of facilities and services for the safe disposal of human urine and faeces. The word 'sanitation' also refers to the maintenance of hygienic conditions, through services such as garbage collection and wastewater disposal (WHO, 2018).

Sanitation systems aim to protect human health by providing a clean environment that can stop the transmission of disease, especially through the faecal–oral route (WaterAid, 2012). For example, diarrhoea, a main cause of malnutrition and stunted growth in children, can be reduced through use of improved sanitation. There are many other diseases which are easily transmitted in communities that have low levels of sanitation, such as ascariasis, cholera, hepatitis, polio, schistosomiasis, trachoma, to name just a few (Mohammed, Elmanssury, Ahmed, & Dafaalla, 2018).

Table 4 presents environmental sanitation information in the study area. Almost 77% of the respondents had a toilet facility at home while the remaining 23% of households had no access to sanitation facilities. On average, 65% of the respondents had privately owned latrine facility and 35% of the respondents had shared pit latrine facility. Out of those who had pit latrine facility, 63% and 37% of the respondents had simple pit latrine and basic improved pit latrine facilities respectively (Table 4). Households with pit latrine facility had their latrine holes covered (70%) and only 30% of the respondents had not covered their pit latrine holes.

Poor sanitation is believed to be the main predisposing factor of under five children diarrhoea. Water treatment, sanitation and hygiene could prevent the death of children aged under 5 years each year. The study found that 12%, of the respondents cleaned their toilets every time if spoiled, 53% of the respondents cleaned their toilets every day in the morning, 20% of the respondents cleaned the toilet 1 or 2 times a week and 15% of the respondents did not clean the toilet even a single day. The majority of the respondents (68%) constructed their toilet facility near houses (within distance of 5 to 10) While 28% of the respondents had toilets within 10 to 15 metres away from house and only 4% of the respondents did not know the exact distance.

Table 4. Sanitation and health of the respondents in Nyungwe community in Karonga district in 2019

4.3.4. Personal hygiene practices According to the World Health Organization (WHO), "hygiene refers to conditions and practices that help to maintain health and prevent the spread of diseases." Personal hygiene refers to maintaining cleanliness of one's body and clothing to preserve overall health and well-being. It includes a number of different activities related to the following general areas of self-care: washing or bathing, including cleaning oneself after using the toilet. Personal hygiene is associated of preventive measure of the diarrhoea disease. The person who fails to take care of himself hygienically is highly risk to suffer from diarrhoea.

Table 5 shows findings from the study that 90% of the respondents washed their hands after handling children faeces with only 3% of the respondents not washing hands after handling children faeces. Ninety percent of the respondents washed their hands after visiting the toilet and reported to have been trained by the Health Surveillance Assistance (HSA) at the Nyungwe Health Centre.

On critical time of washing hands, 75% of respondents washed their hands before preparing food. On the other hand, 47% of the mothers did not wash their hands before breastfeeding their children. The study suggest that there may be more women who never wash hand before breastfeeding. Only 38% of the mothers washed hands before breastfeeding.

Table 5. Personal hygiene practices of the respondents in Nyungwe community in Karonga in 2019

4.3.5 Food hygiene practices Food hygiene are the conditions and measures necessary to ensure the safety of food from production to consumption. Food can become contaminated at any point during slaughtering or harvesting, processing, storage, distribution, transportation and preparation. Lack of adequate food hygiene can lead to foodborne diseases and death of the consumer(WHO, 2017). Food hygiene also play great role for preventing foodborne diseases like diarrhoea.

In most studies reviewed, the level of contamination is higher in preventing foods than in drinking water. Since there is a need to reach critical level of contamination before illness can occur after the ingestion of an enteropathogen, it is assumed that preventing foods is probably more important than drinking water for transmission of diarrhoeal diseases (Lanata, 2003). People who utilise street food, had been reported to suffer from food borne diseases like diarrhoea, cholera, typhoid fever and food poisoning.

Table 6 shows the findings of the study on hygiene. Almost 93% of the respondents covered cooked foods before eating for managing food hygiene and safety and only 7% of the respondents just leaved cooked food open before eating. Fifty two percent of the respondents consumed cooked food that stayed longer than six (6) hours while 25% of the respondents discarded food that stayed longer than 6 hours after cooking with only 23% of the respondents re-cooked (heat/warm) food before consumed if stayed longer than 6 hours. The study results further indicates that 85% of the mothers bought food from the street vendors for their children and only 15% of the mothers in the study area did not buy food from the street vendors for children. This study suggest that food sold by street vendors may be one of the factors influencing high occurrence of diarrhoea diseases in under five children in the study area because most of the foods were not covered, exposing them to flies and dust, which may harbour foodborne pathogens. Also the children ate foods that stayed more than 6 hours without recooking or heating it, which may influence the occurrences of diarrhoea.

The other studies reported that food handling was unsanitary especially among street vendors. The vendors can be carriers of pathogens like Escherichia coli, Salmonella, Shigella, Campylobacter and S. aureus which eventually transfer to consumers (Rane, 2011). Table 6. Food related hygiene practices of the study household, Nyungwe community in Karonga in 2019

In Table 7, the types of food and fruits that mothers bought for their children from the street vendors were shown. Nineteen percent of the respondents were likely to buy fritters (mandasi) and baobab freezes (malambe freezes) for their children, puff (kamba), fritters and puffs, fritters, freezes and puff, fritters, freezes and puff, fruits, fritters and puff, fruits and fritters, fritters, fruits and freezes (Table 7). Forty one percent of the mothers gave bananas to their children, 31% of the mothers had given their children bananas and oranges with only 13% gave oranges to their children. The study result further indicates that 56% of the respondents washed the fruits before giving their children, and 41% of the mothers did not wash the fruits before giving to children. The study suggested that without washing the fruits before giving children to eat could be one of the factors to influence persistent increase in diarrhoea in under five children in the study area. Fruits can harbour the microbial organisms which can cause diarrhoea diseases, in addition to the hands of the mothers which can contaminate the fruits. Some food that the respondents carried home from the markets were in small plastic bags (92%) and only 8% of the respondents carried their food without proper carriers.

Table 7. Type of foods and fruits mothers buy for their children from the street vendors in Nyungwe Community in Karonga in 2019

4.4. Knowledge and perception on diarrhoea causes and prevention This section presents the knowledge of the mothers and caregivers about the causes, spread and prevention of diarrhoea in under five children. Knowledge of the parents and caregivers correlated with reducing the occurrence of diarrhoea in children under five years. As primary caregivers to under five children in study area, mothers’ knowledge, and perception were important to minimise the effects of morbidity and mortality associated with diarrhoeal diseases.

4.4.1. Knowledge of diarrhoea causes and mode of transmission Table 8, presents information of the knowledge and perception of mothers about causes and transmission of diarrhoea. The 57.5% of mothers with under five children had their children with diarrhoea in period of 3 months and (42.5%) had not diarrhoea in period of 3 months. Comparing the children which had diarrhoea and had no diarrhoea in past 3 months, it showed that the prevalence was still high. However, the majority of the respondents understood that diarrhoea was caused by poor sanitation and unhygienic, and almost 33% didn’t know what caused diarrhoea. The other 13% of the respondents thought that diarrhoea was caused by teething.

Eighty three percent of the respondents believed that lack of toilets could lead to diarrhoea and only 17% of the respondents did not believe and they did not know that lack of toilets could cause diarrhoea. Ninety three percent of the respondents had knowledge about uncleanliness that might influence occurrence of the diarrhoea. The study results further indicate that 53% of the respondents knew how the diarrhoea spread and 47% did not know. Table 8. Knowledge of diarrhoea by respondents in Nyungwe Community in Karonga in 2019

4.4.2. Knowledge of diarrhoea prevention Table 9 presents findings of preventing diarrhoea. Seventy two percent of respondents had good knowledge towards home-based management and prevention of diarrhoea among under-five children. Despite having good knowledge of prevention of diarrhoea, 15% of the respondents knew more methods of the prevention of diarrhoea. The study results further indicates that some of the ways of preventing diarrhoea improved sanitation (23%), good personal and food hygiene (13%), hand washing with soap (10%) and rotavirus vaccination (15%). Table 9. Knowledge of diarrhoea prevention of the respondents, in Nyungwe community in Karonga in 2019

Chapter 5: Discussion

5.1. Introduction This study aimed to identify the socioeconomic and environmental factors that influence persistent increase in diarrhoea diseases among children aged less than five years old in Nyungwe community in Karonga district T/A Mwilang’ombe. The study aimed also at assessing the general knowledge of the parents and caregivers of children about diarrhoea causes and prevention.

This study showed that the prevalence of childhood diarrhoea among under-five children hat had diarrhoea in past 3 months  was high in Nyungwe community T/A Mwilang’ombe. This could be due to the difference in socio-economics status and basic environmental and behavioural characteristics of caretakers that might have affected practices that influence occurrence of diarrhoea.

5.2. Socio economic factors associated with diarrhoea This study provided exhaustive information about the significant risk factors that were associated with the persistent increase in diarrhoea among children under five years of age. The findings of study included mother’s age, education, work status and their marital status.

5.2.1 Mothers’ age This study found that the age of mothers was an influencing factor of persistent diarrhoea among children under five years of age. This was in line with a cross sectional study to determine the risk factors associated with diarrhoea morbidity among under five children in Kenya by Samwel et al.(2014). Younger mothers could be less experienced with child care and have less understanding and knowledge about mode of transmission and pathogens spread of diarrhoeal disease in the household environment compared to older mothers. From Table 1, younger mothers might have failed their duty of taking care of children because they had limited knowledge on personal and household hygiene.

5.2.2. Marital status of the mothers The high number of respondents being married might have increased responsibilities as parents taking care of children. The single and divorced mothers had less knowledge of causes of diarrhoea as compared to those mothers who were married probably because of the fact that mothers who were married might have the opportunity to share knowledge and practices from their husband. The study generalised that single and divorced mothers could influence persistence of diarrhoea in under five children in terms of education and knowledge levels.

5.2.3 Mothers’ education The findings of the present study highlight that the higher the level of education of the mother the more the reduction of the risks of the under-five child to experience diarrhoeal diseases. This agrees with a study that was conducted by Mihrete et al., (2014) to identify the determinants of childhood diarrhoea among under five children in northwest Ethiopia which found that mothers education was significantly associated with child diarrhoea. The findings were also similar to a study done in Nigeria by Adeyimika et al., (2017) which found out that children whose mothers cannot read and write were more likely to have diarrhoea. This study found out that mothers who had dropped out at junior level of secondary school exhibited same more knowledge than those mothers who had dropped out in primary school.

5.2.4 Maternal occupation Maternal occupation was found to be significant in childhood diarrhoea. The findings of this study suggested that children of mothers whose occupation was housewife and small business had a higher risk of diarrhoea compared with children whose mothers were working or formally employed. The result was in line with a case control study in India by Bawankule et al., (2017) and a study in Thailand  by Wilunda et al.,(2009) which showed that children whose mothers were not working had a significantly higher frequency of diarrhoea. In Table 1 the higher figures of the respondents might be due to the fact that a housewife lacked knowledge on preventive measures of the diarrhoea and let children to play freely on the soil which might increase the risk of the child to have diarrhoea. Working mothers spend more time at work and they hire nanny who looking after child as a result reducing the child risk of experiencing diarrhoea.

5.2.5. Economic status of mothers Children whose families were poor economically had higher odds of developing diarrhoea compared with their counterparts. This might be due to the fact that rich families might have greater opportunity to use soap for hand washing and water-guard at their houses to protect microbial contamination in water. These households could easily construct toilets. This study took place in a mainly poor area where the average family income was lower, reflecting that economic status was associated with childhood diarrhoea.

5.3. Environmental factors influencing the increase in diarrhoea This section presents findings of the environmental and behavioural factors that increased childhood diarrhoea in Nyungwe community. The high prevalence of the diarrhoea was associated with socio-economics and environmental factors.

5.3.1. Water related practices

5.3.1.1. Water source in the study Water source is part of the hygiene and correct handling of drinking water is an important factor to prevent any contamination. Thus, purifying techniques prior to drinking should be a part of implementation programs for households since even if water came from a protected source it could be under high risk of contamination due to in hygiene

Chapter 4 found out that the respondents of this study used the protected water sources. The respondents were reported that their domestic water was from the borehole which means there were less risk of drinking contaminated water. This study did not find an association between water source and childhood diarrhoea

5.3.1.2. Distance from water source Findings from this study indicated that respondents spent less time in accessing water in Nyungwe community. within the range of the recommended distance by SDGs, (2015) that population access to safe drinking water is an important metric for development. The World Health Organisation Joint Monitoring Program on water and sanitation states that “Access to drinking water means that the source is less than 1 kilometre away from their place of use and that it is possible access to basic drinking water is proposed to be defined as “using an improved source with a total fetching time of 30 minutes or less which is equivalent less than 1 kilometre for a round-trip including queuing.

The present study found no association between the time to the reach drinking water source and diarrhoea. This negative association could be explained by the fact that although when walking for a long time to fetch water, the water would be more exposed to contamination before reaching the household. If the water source was not protected in the first place the risk of contamination would not be related to the distance regardless of the time needed. This finding agreed with a randomized control trial conducted by Mohammed et al., (2018) in Sudan to study the effect of water supply on diarrhoea prevalence among children under 5 which found that the prevalence of diarrhoea decreased among children under 5 in households that went to neighbouring areas which were benefiting from borehole drilling to take benefit of the improved water supply.

5.3.1.3. Utensils used to carry water from the source In table 3, showed more than half (55%) of the respondents in the study were used plastic pails with lid to carry water from the source. 45% of the respondents were used pails without covers to use for fetching domestic water. The households that used pails without lids to carry water were highly at risk associated with the water related diseases like diarrhoea.

5.3.1.4. Utensils used to store domestic water In terms of household water storage, the study findings are similar to those of Mohammed et al., (2018) who found out that most respondents 74.4% in Dukem town used plastic bucket container to store drinking water. Safe water storage at the household level helps in preventing microbial water contamination causing water related diseases at the household level. This study finding contrasts with that of a study done in Kakamega that found out that respondents stored their water in different places in the house to make it cool for drinking (Azry et al., 2018).

Covering of drinking water storage containers provided a safer way of preventing household drinking water from the risk of microbial contamination. An average of 68% the households stored their drinking water in plastic containers with lid and 32% of the respondents stored water in containers without lid. The containers were tilted to pour water, preventing contamination and was regarded a safer way of accessing drinking water. This study suggested that the water can get contaminated within household if someone fetch water from the drinking water storage containers this may allowed the household members to place hands and or cups into the stored drinking water increasing the risk of faecal contamination of drinking water.

4.3.1.5. Household water treatment The study found that almost 75% of the respondents were just covering the domestic water as the way to make it safe to drink, only 10% of the respondents were used water guard for treating the drinking water. Household water treatment is significant in the reduction of water related diseases such as diarrhoea. Furthermore, the study found that, household practices water treatment especially there is cholera outbreak occurred due to this is the reason why the prevalence of the diarrhoea cases were not significantly reduced.

5.3.2. Environmental sanitation and health Sanitation systems aim to protect human health by providing a clean environment that stops the transmission of disease, especially through the faecal–oral route (WaterAid, 2012) For example, diarrhoea, a main cause of malnutrition and stunted growth in children, can be reduced through use improved sanitation.

Table 4 presents environmental sanitation information in the study area, which was positive significant to diarrhoea occurrence in under five children. The findings are in line with the study done in Tigray Region of Ethiopia on childhood morbidity (Gebru et al., 2014). The type of toilet facility and stool disposal schemes might shade light on the concepts of household sanitary conditions and as such on the possibility of the transmission of diarrhoea pathogens through faecal contamination(El-Mohammady et al., 2012).

A higher risk of diarrhoea was seen in children in a higher birth order and in households without improved toilet facilities. Lack of toilet facility was also a risk factor for childhood diarrhoea. The study findings indicates that 35% of the respondents were use shared toilet facility which means theses households were at high risk of the childhood diarrhoea. However, the findings shows that majority of the respondents having toilet facility but simple pit latrines 77% and 63% respectively. Study discovered that 30% of the respondents’ households were not covered toilet hole, which significant factors that influence increases of the prevalence of the diarrhoea cases in under five children.

5.3.3 Household hygiene practices The study’s findings indicates that household hygiene was another factor influences high prevalence of the under five children, this study was in line by Okou et al.,( 2012) he found that household's cleanliness including toilet and kitchen had a highly significant association with diarrhoea occurrence. This study found that in table 3, 68% respondents were clean at their premises every day in the morning and 30% cleaned when it dirty. The household cleanliness supposed to take account more had domestic poultry like ducks and chickens. This study found that, poultry like ducks have been connected to source of faecal contamination of soil. This is particularly problematic among young children, in whom faecal-oral transmission may be more common during play. This study found that 63% of the respondents had domestics’ poultry that were highly associated with diarrhoea prevalence increased.

5.3.4. Personal hygiene practices This study found that the personal and food hygiene were significantly associated with prevalence of the childhood diarrhoea. The practices of washing hands after visiting the toilet and before preparing food plays great role on reducing prevalence of the diarrhoea. The study found that 90% of the respondents washed their hands after visited toilet and handling the children faeces. On this the study had evidence that majority of the respondents minimised the risk of the diarrhoea occurrence by washing hands with soap, this was supported by similar studies performed in, Eastern Ethiopia, and Southwest Ethiopia by Godana et al.,( 2013), where found that mothers’ who practicing hand washing behaviours prevented the occurrence of diarrhoeal disease among their children. Since mothers were the main care givers for their children they should wash their hand in order to prevent diarrhoea and occurrence of other hygiene related disease respondents washed hands before preparing food, also food hygiene influence to prevent childhood diarrhoea. This study found that majority of the 47% mothers’ did not washed hands before breastfeeding their children. A mothers those who does not washed hands and clean her breast when breastfeeding was significantly associated with the occurrence of diarrhoea in children. This explained that the mother touched her breast with dirty hands and child put dirty breast into the mouth, this way of transmitted bacteria’s from mothers to child. This findings was in lined with the study done in Kenya by Samwel et al., (2014) who found that the bottle feeding in children also increase the chances of contracting diarrhoea among children due to the possibilities of contamination of the feeding bottle as a result of poor handling by the mother. A mother who observes proper hygiene when breast feeding is more likely to protect her young one from diarrhoeal diseases than one who doesn’t clean her breast when breast feeding.

5.3.5. Food hygiene practices that related to occurrence of diarrhoea This study indicates that food hygiene is another positive factor associated with persistence increase in diarrhoea cases. The majority of 93% the respondents were covered their food before eating as the way of managing hygiene and safety. Table 6, more than half (52%) of the mothers just eat the food that stays longer than 6 hours from time was it cooked. The study has strongly believed that eating food without recooked which stayed more than 6 hours was positive significant predictors of the occurrence of the childhood diarrhoea because the level of contamination is higher in foods than in drinking water. The mothers believed that recooked food had declines the tasty such as rice.

In terms of the street vendors’ food, although people enjoy food from these vendors, in many cases the food is of poor quality and it represents a serious health risk. In this study indicates that majority of 85% of the mothers bought food from the street vendors for their children. Street vendors’ food were highly associated with the occurrence of the diarrhoea diseases. This study agreed with a study in one African city done by Howard et al., (2002),who found that 98% of the street vendors had faecal contamination on their hands and food, a situation that is likely to be the same for food vendors in other cities and villages.

5.4. Knowledge of parents about diarrhoea causes and prevention Diarrhoea was more common among the children of younger mothers aged 15 - 24 years, probably due to lack of prior experience. Children of the mothers who were either not educated or less educated and involved in business or housewives suffered more from diarrhoea(Ansari et al, 2012).

5.4.1. Knowledge of causes and routes transmission of diarrhoea The low knowledge of causes of diarrhoea among respondents might be due to low education levels. This was the reason most respondents did not bother to follow hygiene practices at their homes, plus beliefs on traditional aspects such as teething as causes of diarrhoea. The results agrees with those by Ansari et al., (2012) who found out that more parents believed that age group of the children was 12 - 23 months had diarrhoea due to teething. Furthermore, the study found that the mothers had knowledge on how diarrhoea was transmitted. Fewer respondents knew that lack of toilets and uncleanliness could lead to occurrence of diarrhoea.

5.4.2. Knowledge of diarrhoea prevention and management . The high level of knowledge on prevention of diarrhoea and its management among the respondents was due to the high level of the maternal education which helped parents to know the diarrhoea preventive measures. This was taught at the health centres when attending health sessions. CHAPTER 6. CONCLUSION AND RECOMMENDATIONS

61. Introduction This study was conducted to identify the factors that influencing persistent increase in diarrhoea diseases among under-five children in Nyungwe community, T/A Mwilang’ombe in Karonga. To find answers, this study focused on factors such as socioeconomic, environmental and knowledge or awareness of parents of children of diarrhoea occurrence and prevention.

6. 2.Conclusion The study showed a high prevalence of diarrhoea among under five children in Nyungwe community in Karonga. This study was focused on three specific objectives, socio-economic status, an environmental factors, and knowledge of parents about diarrhoea in under five children.

The first specific objective of the study was to identify the socio economic factors that influences persistent increase in diarrhoea among under five children in Nyungwe, Karonga. The study showed the following independent variables: age of mother, maternal education, economic status, marital status and maternal occupation. The findings of results suggested that the age of the mother was associated with child diarrhoea in study area. The older the mother the lesser the probability of the under-five child to have diarrhoea. Young mothers aged 15 to 24 had more risk of diarrhoea. Level of mother education was also associated with the occurrence of diarrhoea among children under five years of age where the higher the education of the mother the lesser the odds of the child to experience diarrhoea incidences. Study identified that socio economic factors were associated with persistence increase in childhood diarrhoea in area.

The second specific objective of the study was to assess the environmental factors on causes of diarrhoea among under five children. Water source was not an issue because all households used borehole water. Poor household surroundings harbour microorganism that cause diarrhoea particularly when one has domestic poultry whose droppings contaminate the ground where children often play.

Personal and food hygiene are required in order to prevent diarrhoea. The study found that participants were washing their hands after visiting and handling children faeces. This study discovered that majority of the respondents in the study were not washing their hands and cleaning the breast before breastfeeding their children. Another factor associated diarrhoea increase was the behaviour of eating food without heating or recooked which stayed longer than 6 hours from time it was cooked

The last specific objectives of the study was to assess knowledge of parents about diarrhoea in under five children. They aim of this objective was to understand the perceptions of the mothers about diarrhoea prevention and management. The study found out that the majority of the mothers had knowledge on how diarrhoea was caused and spread. But fewer respondents believed that diarrhoea was caused by teething and poor sanitation. Some mothers knew the ways of preventing diarrhoea.

This study concluded that the prevalence of diarrhoea is high and was influenced by socio economic and environmental factors among under five children in the study area diarrhoea.

6.3. Recommendations

6.3.1. Recommendation of the study Ministry of Health through Nyungwe Health Centre should conduct more surveys in this area, so that can help the health workers and the community members to improve hygiene at house level Non-governmental organisations need to work more in the areas with people so that they can share information on diarrhoea prevention and management.

63.2. Policy recommendations In general, the findings of this study have important policy implications for health intervention programs Expansion of family planning services so that they are accessible to the entire population in the region will be helpful for controlling teenager pregnancies. Promotion of girls’ education levels as they may have a significant importance on child health and survival in Malawi. Provision of continuous information improves the environmental conditions at household levels Setting bylaws in maternal child health facilities would allow mothers to attend maternal and antenatal health where they can learn more about diarrhoea. There is need for health workers to further educate mothers on hand washing and breast cleaning before breastfeeding so that diarrhoea morbidity is reduced. in children

63.3. Further study recommendations Research need to be done on evaluation of effectiveness of rotavirus vaccine against severe rotavirus diarrhoea Another research also needed on effects of malnutrition on maternal child health. BIBLIOGRAPHY Adeyimika, D. T., M., O. M., Yetunde, J.-A. O., Opeyemi, O., & Adebowale, A. S. (2017). Maternal Education and Diarrhea among Children aged 0-24 Months in Nigeria Study area, 21(September), 27–36. Agustina, R., Sari, T. P., Satroamidjojo, S., Bovee-Oudenhoven, I. M., Feskens, E. J., & Kok, F. J. (2013). Association of food-hygiene practices and diarrhea prevalence among Indonesian young children from low socioeconomic urban areas. BMC Public Health, 13(1). https://doi.org/10.1186/1471-2458-13-977 Ansari, M., Izham, M., Ibrahim, M., & Ravi, P. (2012). Mothers ’ Knowledge, Attitude and Practice Regarding Diarrhea and its Management in Morang Nepal : An Interventional Study, 11(July), 847–854. Azry, F., Aziz, A., Ahmad, N. A., Aznuddin, M., Razak, A., Omar, M., … Ying, C. Y. (2018). Prevalence of and factors associated with diarrhoeal diseases among children under five in Malaysia : a cross-sectional study 2016, 1–8. Bawankule, R., Singh, A., Kumar, K., & Pedgaonkar, S. (2017). Disposal of children ’ s stools and its association with childhood diarrhea in India. BMC Public Health, 1–9. https://doi.org/10.1186/s12889-016-3948-2 Bonkoungou, I. J. O., Haukka, K., Österblad, M., Hakanen, A. J., Traoré, A. S., Barro, N., & Siitonen, A. (2013). Bacterial and viral etiology of childhood diarrhea in Ouagadougou, Burkina Faso. BMC Pediatrics, 13(1), 36. https://doi.org/10.1186/1471-2431-13-36 Connell, B. J. O., Quinn, M. A., & Scheuerman, P. (2017). GLOBAL JOURNAL OF MEDICINE AND PUBLIC HEALTH 1 www Risk factors of diarrheal disease among children in the East African countries of Burundi, Rwanda and Tanzania. gjmedph.com (Vol. 6). Retrieved from www.gjmedph.com Diouf, K., Tabatabai, P., Rudolph, J., & Marx, M. (2014). Diarrhoea prevalence in children under five years of age in rural Burundi: An assessment of social and behavioural factors at the household level. Global Health Action, 7(1). https://doi.org/10.3402/gha.v7.24895 El-Mohammady, H., Mansour, A., Shaheen, H. I., Henien, N. H., Motawea, M. S., Raafat, I., … Klena, J. D. (2012). Increase in the detection rate of viral and parasitic enteric pathogens among Egyptian children with acute diarrhea. The Journal of Infection in Developing Countries, 6(11). https://doi.org/10.3855/jidc.2349 Farthing, M., Salam, M. A., Lindberg, G., Dite, P., Khalif, I., Salazar-Lindo, E., … LeMair, A. (2013). Acute Diarrhea in Adults and Children. Journal of Clinical Gastroenterology, 47(1), 12–20. https://doi.org/10.1097/MCG.0b013e31826df662 Gebru, T., Taha, M., & Kassahun, W. (2014). Risk factors of diarrhoeal disease in under-five children among health extension model and non-model families in Sheko district rural community, Southwest Ethiopia: comparative cross-sectional study. BMC Public Health, 14(1), 385. https://doi.org/10.1186/1471-2458-14-395 Gidudu, J., Sack, D. A., Pina, M., Hudson, M. J., Kohl, K. S., Bishop, P., … Zaman, K. (2011). Diarrhea: Case definition and guidelines for collection, analysis, and presentation of immunization safety data. Vaccine, 29(5), 1053–1071. https://doi.org/10.1016/J.VACCINE.2010.11.065 Godana, W., & Mengiste, B. (2013). Environmental factors associated with acute diarrhea among children under five years of age in derashe district, Southern Ethiopia, 1(3), 119–124. https://doi.org/10.11648/j.sjph.20130103.12 Howard, G., Bogh, C., Prüss, A., & Goldstein, G. (2002). Healthy Villages A guide for communities and community health workers. Innocent, M. (2015). Integrated Service Delivery in Malawi A Case Study Integrated Service Delivery in Malawi A Case Study, (August). Kakulu. (2012). DIARRHOEA AMONG UNDERFIVE CHILDREN AND HOUSEHOLD WATER TREATMENT AND SAFE STORAGE FACTORS IN MKURANGA DISTRICT, TANZANIA. Lanata, C. F. (2003). Studies of food hygiene and diarrhoeal disease, 183(June), 175–183. https://doi.org/10.1080/0960312031000102921 Leonard, T., & Pruitt, S. L. (2018). with health shocks : An analysis of multi-sector linked data, 669(1), 125–145. https://doi.org/10.1177/0002716216680989.Understanding Liu, L., Johnson, H. L., Cousens, S., Perin, J., Scott, S., Lawn, J. E., … Black, R. E. (2012). Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. The Lancet, 379(9832), 2151–2161. https://doi.org/10.1016/S0140-6736(12)60560-1 Masangwi, S. J., Ferguson, N. S., Grimason, A. M., Morse, T. D., Zawdie, G., & Kazembe, L. N. (2010). Household and community variations and nested risk factors for diarrhoea prevalence in southern Malawi: A binary logistic multi-level analysis. International Journal of Environmental Health Research, 20(2), 141–158. https://doi.org/10.1080/09603120903403143 Masangwi, S. J., Morse, T. D., Ferguson, N. S., Zawdie, G., Grimason, A. M., & Namangale, J. J. (2009). Behavioural and environmental determinants of childhood diarrhoea in Chikwawa, Malawi. Desalination, 248(1–3), 684–691. https://doi.org/10.1016/j.desal.2008.05.120 Mbakaya, B. C., Kalembo, F. W., & Zgambo, M. (2019). Community-based interventions for preventing diarrhoea in people living with HIV in sub-Sahara Africa : A systematic review, 31(March), 86–94. MDHS. (2016). 2015-16 Demographic and Health Survey Key Findings Malawi. Retrieved from www.DHSprogram.com Mihrete, T. S., Alemie, G. A., & Teferra, A. S. (2014). Determinants of childhood diarrhea among underfive children in Benishangul Gumuz Regional State, North West Ethiopia. Ministry of Health Malawi. (2012). Malawi: Health Sector Strategic Plan, (July), 170. MoH. (2016). Malawi Health Sector Strategic Plan. Mohammed, E., Elmanssury, A., Ahmed, E. A., & Dafaalla, S. A. E. (2018). Environmental and Behavioral Factors Associated With Diarrhea Disease among Children Under Five Years Old in Mayo in Khartoum State, 8(November), 238–244. Morse. (2006). Reducing morbidity and mortality in Malawi through an integrated Environmental Health approach to improving water quality and health. https://doi.org/10.1080/09603120903403143 Morse, T., & Simpson, E. (2014). Charting the course for integrated diarrhea control in Malawi, (November). Munjita, S. M. (2015). Current Status of Norovirus Infections in Children in Sub-Saharan Africa. Journal of Tropical Medicine, 2015, 1–7. https://doi.org/10.1155/2015/309648 Okour, A., Al-ghazawi, Z., & Gharaibeh, M. (2012). Diarrhea Among Children and the Household Conditions in a Low-Income Rural Community in the Jordan Valley. Rane, S. (2011). Street Vended Food in Developing World : Hazard Analyses, 51(1), 100–106. https://doi.org/10.1007/s12088-011-0154-x Regassa, W., & Lemma, S. (2016). Assessment of Diarrheal Disease Prevalence and Associated Risk Factors in Children of 6-59 Months Old at Adama District Rural Kebeles, Eastern Ethiopia, January/2015. Ethiopian Journal of Health Sciences, 26(6), 581–588. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/28450775 Samwel, M., Eddison, M., Faith, N., Richard, S., Elizabeth, M., & Douglas, N. (2014). Determinants of diarrhea among young children under the age of five in Kenya, evidence from KDHS 2008-09, 28(2). SDGs. (2015). The Sustainable Development Goals for Water and Sanitation Services. Services. (2015). Diarrhea : Common Illness, Global Killer. World Health Organisation, 1–4. Thiam, S., Diène, A. N., Fuhrimann, S., Winkler, M. S., Sy, I., Ndione, J. A., … Cissé, G. (2017a). Prevalence of diarrhoea and risk factors among children under five years old in Mbour, Senegal: a cross-sectional study. https://doi.org/10.1186/s40249-017-0323-1 Thiam, S., Diène, A. N., Fuhrimann, S., Winkler, M. S., Sy, I., Ndione, J. A., … Cissé, G. (2017b). Prevalence of diarrhoea and risk factors among children under five years old in Mbour, Senegal : a cross-sectional study, 1–12. https://doi.org/10.1186/s40249-017-0323-1 TRANG, N. V., CHOISY, M., NAKAGOMI, T., CHINH, N. T. M., DOAN, Y. H., YAMASHIRO, T., ANH, D. D. (2015). Determination of cut-off cycle threshold values in routine RT–PCR assays to assist differential diagnosis of norovirus in children hospitalized for acute gastroenteritis. Epidemiology and Infection, 143(15), 3292–3299. https://doi.org/10.1017/S095026881500059X UNICEF. (2015). Charting the course for integrated diarrhea control in Malawi. Retrieved from https://www.defeatdd.org/sites/default/files/Malawi fact sheet.pdf Walker, C. L. F., Rudan, I., Liu, L., Nair, H., Theodoratou, E., Bhutta, Z. A., … Black, R. E. (2013). Global burden of childhood pneumonia and diarrhoea. Lancet (London, England), 381(9875), 1405–1416. https://doi.org/10.1016/S0140-6736(13)60222-6 WaterAid. (2012). Hygiene framework. WaterAid, London, UK. WHO. (2009). Diarrhoea : why children are still dying and what can be done. United Nations Children’s Fund. WHO. (2017). World Health Organization: Children: reducing mortality fact sheet. Retrieved September 24, 2018, from http://www.who.int/en/news-room/fact-sheets/detail/children-reducing-mortality WHO. (2018). WHO | World Health Organization: Global Health Observatory (GHO) data under-five mortality Under-five mortality. WHO. Retrieved from http://www.who.int/gho/child_health/mortality/mortality_under_five_text/en/ Wilunda, C., & Panza, A. (2009). FACTORS ASSOCIATED WITH DIARRHEA AMONG CHILDREN LESS THAN 5 YEARS OLD IN THAILAND : A SECONDARY ANALYSIS OF THAILAND MULTIPLE INDICATOR CLUSTER SURVEY 2006, 23, 17–22. Woldu, W., Bitew, B. D., & Gizaw, Z. (2016). Socioeconomic factors associated with diarrheal diseases among under-five children of the nomadic population in northeast Ethiopia. Tropical Medicine and Health, 7–14. https://doi.org/10.1186/s41182-016-0040-7 Woldu, W., Bitew, D., Bikes, & Gizaw, Z. (2016). Socioeconomic factors associated with diarrheal diseases among under-five children of the nomadic population in northeast Ethiopia. Tropical Medicine and Health, (December). https://doi.org/10.1186/s41182-016-0040-7 Zambrano, L. D., Levy, K., Menezes, N. P., & Freeman, M. C. (2014). Human diarrhea infections associated with domestic animal husbandry : a systematic review and meta-analysis, 313–325. https://doi.org/10.1093/trstmh/tru056

APPENDICES

Appendix 1. Questionnaire Questionnaire number…………………. FACTORS INFLUENCING PERSISTENT INCREASE IN DIARRHOEAL DISEASES AMONG UNDER FIVE CHILDREN IN NYUNGWE KARONGA I am ENOCK MVULA, a fourth year student at University of Livingstonia-Laws campus. I am doing this study as a partial fulfilment for the award to a bachelors of degree in public health. Humbly, I request you to participate this study by responding for the following questions with honest. The answers you will give will be used at academic purpose only and the information will be treated with confidentiality. District: Karonga Village/township: Nyungwe Traditional authority: Mwirang’ombe Name of the mothers or care givers……………………………………………. Date of interview…………………………………………………………………….

PART A. DEMOGRAPHIC AND SOCIO-ECONOMICS DATA 1. Age of the mothers or care givers 15-24 25-34 35-44 Above 45 2. Marital status of mothers Single Married Divorced Widow 3. Religion Christian Muslim Other………………………………………………… 4. Ethnic of mothers or care givers Nkhonde Tumbuka Lambya Chewa Other……………………………………………………………. 5. What is your highest educational qualification? No formal education Primary school education Secondary school education Tertiary education 6. Occupation status of mothers Formal employed Business Housewife Unemployed 7. Economic status of household Poor Medium Rich 8. Number of under-five children in the house One Two Three PART B. WATER RELATED PRACTICES 9. What is the main source of drinking water for members of this household? Piped water (NWB) Borehole Running water Surface water (rivers/lakes) 10. What do you use to bring the water to your household? Plastic bucket with lid Plastic bucket without lid Plastic Jerry-cans Others……………………………………………………………….. 11. How far is your water source from your house? Less than 0.5 kilometres 0.5-1 kilometres 1-2 kilometres Above 2 kilometres Others………………………………………………………………. 12. When it is in the household, how do you treat your water to make it safe to drink? No treatment Just cover it Heat the water before use Use water guard Use chlorine 13. What kind of utensils do you use to store water? Storage containers without lid Storage containers with lid Other…………………………. 14. What do you do to utensil before replacing with fresh water? Clean the utensils with soap Just drain the old water without cleaning without soap Just replacing fresh water Others……………………………………………………………. PART C. ENVIRONMENTAL AND BEHAVIOURAL FACTORS 15. What is the type of household you own? Nuclear single parent household Composite or extended household Nuclear with children household Others…………………………………………………………… 16. How often do you clean the surrounding of your household? Every time it is dirty Every day 1-2 times a week Not cleaned 17. Do you have domestic poultry? Having poultry Not having poultry 18. Do you have toilet facility? Available Not available 19. What type of toilet facility do you have? Flash toilet Simple pit latrine Basic improved pit latrine 20. Ownership of the toilet Shared toilet Private toilet 21. What is the distance of the toilet from house if it is not a flashing one? 5-10 metres 10-15 metres Don’t know the exactly distance 22. How often is the toilet cleaned? Every time it is spoiled Every day 1-2 times a week Not cleaned 23. Do you cover your toilet’s hole? Yes, it covered Not covered Sometimes 24. What do you do with your hands after cleaning faeces from your child? Wash with soap Wash without soap Sometimes wash hands Just rinse hands with wrapper Do nothing 25. What do you do with your hands after visiting the toilet? Wash with soap Wash without soap Sometimes wash hands Do nothing 26. How often do you wash your hands in this exercise? Soon after the toilet Any time after cleaning faeces from child Every time, when hand is dirty Every time wants to handle food and water Others………………………………………………………………….. 27. What do you do with your hands before preparing food and feeding your child? Wash with soap Wash without soap Sometimes wash hands Just rinse hands with wrap Do nothing 28. Do you wash hands and clean your breast before breastfeeding your child? Yes No 29. How often do you wash your hands in this exercise? Every time Every time before preparing food Every time before feeding child Not at all 30. What type of hand wash do you used after cleaning your child/toilet and before preparing food? Water only Water with soap Other…………………………………………….. 31. How do you manage your food after cooking and before eating? Cover it Leave it open Eat immediately after cooking Keep it in food warmers 32. If cooked food stays longer than 6 hours, what do you do to make it safe for re-use? Heat before eat Keep it in food warmers Keep it in refrigerator Just eat it without warming

33. Do you often buy food from street vendors for your child? Yes No 34. What type of food do you buy from street vendors for children? Fruits Fritters Freezes Puff (Kamba) Others 35. How do you carry the food to your children? Use small practice bags Use uncovered container Use covered container Carry in bare hands 36. What fruits do you often give your children? Bananas Oranges Mangoes 37. What do you do to the fruits before giving the children? Wash them with adequate clean water Just give them as they may be fresh PART D. GENERAL KNOWLEDGE OF DIARRHOEA CAUSE AND PREVENTION 38. Has the child had diarrhoea during the past 3 months? Yes No 39. What is the gender of the child? Male Female 40. What do you think causes diarrhoea in young children? Germ infection Poor sanitation and unhygienic Teething Water and food contamination Don’t know 41. Do you believe lack of toilets can cause diarrhoea? Yes, believe it Don’t believe it Don’t know 42. Do you believe that uncleanliness can result to diarrhoea causes? Yes, believe it Do not believe it Don’t know 43. Do you know how diarrhoea spreads/transmitted? Yes No 44. Do you know how to prevent diarrhoea especially among under 5 years? Yes No 45. What do you think are some of the ways of preventing diarrhoea? Access to safe drinking water Use of improved sanitation Hand washing with soap Good personal and food hygiene Rotavirus vaccination

………………THANK YOU……………