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In Ethiopia, evidence is lacking about maternal care-taking and environmental risk factors that contribute to acute diarrhoea and the case management of diarrhoea. The aim of this study was to identify the risk factors and to understand the management of acute diarrhoea. A pretested structured questionnaire was used for interviewing mothers of 440 children in a prospective, matched, case-control study at the University of Gondar Referral and Teaching Hospital in Gondar, Ethiopia. Results of multivariate analysis demonstrated that children who were breastfed and not completely weaned and mothers who were farmers were protective factors; risk factors for diarrhoea included sharing drinking-water and introducing supplemental foods. Children presented with acute diarrhoea for 3.9 days with 4.3 stools per day. Mothers usually did not increase breastmilk and other fluids during diarrhoea episodes and generally did not take children with diarrhoea to traditional healers. Incorporating messages about the prevention and treatment of acute diarrhoea into child-health interventions will help reduce morbidity and mortality associated with this disease. © International Centre for Diarrhoeal Disease Research, Bangladesh.
A prospective, matched, case-control study was conducted at the University of Gondar Referral and Teaching Hospital in the North Gondar Zone, Ethiopia, where the population is more than 2.9 million. Gondar is located approximately 700 km from Addis Ababa in the northwestern part of Ethiopia called the Amhara region. The average household has five members, often living in one room; many households have domestic animals; over 60% of the population has access to improved sources of drinking-water; and almost 40% of the population has access to a toilet or a latrine (7). In the Amhara region, 25% of females and 54% of males are literate (7). Three-fourths of health problems faced by children are due to communicable diseases, and at least half of all children aged less than five years experience symptoms of acute respiratory infections, malaria, and diarrhoea at any given point (7). Often, caretakers first take sick children to health posts or to health centres, and the district and zonal hospitals often are the last places where caregivers seek care for sick children. The University of Gondar Referral and Teaching Hospital provides care to approximately 10,000 children every year; 50 of the 350 beds in the hospital are allocated for children. The sample-size of 220 matched subjects was determined, using a confidence level of 95% and a power of 80% to detect a 50% difference between cases and controls (8). Four hundred and forty cases and controls were enrolled during July 2007–January 2008. Interviews with the mothers of children were completed after verbal informed consent was obtained. All children, aged less than five years, who came to the hospital for general treatment, were eligible for the study. Upon presentation, children were assessed at the outpatient department (OPD). If they did not have dehydration or complications, they were given prescriptions for medications and/or ORS and discharged. Children with moderate or severe dehydration and/or complications were referred to the inpatient paediatric ward, where they received appropriate drug and supportive therapy. All medical services were paid as out-of-pocket at the hospital, unless free papers were secured from peasant associations or local governments. Diarrhoea was defined as three or more liquid stools within a 24-hour period. Acute diarrhoea was defined as having diarrhoea for less than 14 days. Cases with acute diarrhoea were consecutively enrolled from the OPD and inpatient paediatric ward. Controls were selected from children who did not present with acute diarrhoea for at least 14 days before the date of interview. Controls from the OPD presented with a range of conditions, such as upper and lower respiratory tract infections, malaria, otitis media, and tonsillitis. Controls from the inpatient ward presented with upper and lower respiratory tract infections, malaria, malnutrition, paediatric HIV/AIDS, tuberculosis, and sepsis. Controls were selected to match the cases with 1:1 ratio by the following criteria: six-month age categories, sex, within two weeks from the date of the case visit, and the same ward. Children were excluded if they were aged five years or older, and children with acute diarrhoea were excluded if they did not meet the clinical definition of acute diarrhoea. Interviews with the mothers of children enrolled in the study were conducted in Amharic, the local language, by 10 interns who were working in the paediatrics department. All interviewers could read and write English. After the children were examined, data were collected using a pretested structured questionnaire that measured sociodemographic characteristics, nutritional factors, maternal and child hand-washing and disposal of faeces, water and latrine-use, disposal of wastes, and ORS-use. Additionally, the clinical presentation of illness, food and fluid intake, and treatment given by physicians were recorded for all the cases. The level of dehydration of all children was measured according to the criteria of the World Health Organization (WHO) for dehydration using four signs, such as mental status, eyes, thirst, and skin turgor (9). There was no attempt to make an aetiologic diagnosis for cases. Data were entered in Excel 2002 and analyzed using the Stata software (version 9.0) (StataCorp LP, College Station, TX, USA). A univariate analysis was conducted for all the variables from the questionnaire. Variables with p<0.10 were considered for inclusion in conditional logistic regression, along with variables that were known risk factors, such as income and maternal education (10, 11). Multivariate odds ratio (OR) and 95% confidence intervals (CIs) were calculated from the coefficients from the regression model. The final model was determined using forward step-wise logistic regression, which included variables significant at p<0.05, and the sensitivity of this model was checked by including maternal education and income variables in the socioeconomic status (SES)-adjusted model. Ethical clearance was obtained from the Research and Publications Office at the University of Gondar and the Committee on Human Research at the Johns Hopkins Bloomberg School of Public Health.
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