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Background: Diarrhea remains a major cause of morbidity and mortality among children in Tanzania. The purpose of this study was to explore associations between diarrheal disease and water, sanitation, and hygiene (WASH) related behaviors and determine care-seeking predictors for diarrheal disease. Methods: Data from 9996 female primary caregivers were collected as part of a larger integrated nutrition program. Logistic regression was used to measure associations between predictor and dependent variables and diarrheal and care-seeking outcomes. Results: Knowledge of the importance of handwashing after assisting a child who has defecated (OR 0.79, CI 0.72–0.87), before preparing food (OR 0.88, CI 0.80–0.97), and before feeding a child (OR 0.89, CI 0.81–0.99) were each associated with not having a child with diarrhea in the past two weeks. Fathers or male caregivers (OR 0.65, CI 0.48–0.89) were less likely to seek medical care for a child with diarrhea. No associations were found between WASH-related knowledge or behavior and seeking medical care for a child with diarrhea. Conclusions: Findings indicate that knowledge of handwashing importance was significant in washing hands after assisting a child who has defecated, before preparing food, and prior to feeding a child. These findings demonstrate the value of parental involvement to lower morbidity and mortality among children.
An evidence-based communication campaign was implemented between 2015 to 2020 in five regions of the Lake Zone in Tanzania. The purpose of the campaign was to prevent childhood stunting through the promotion of optimal health behaviors and knowledge regarding WASH and community nutritional practices. The communication campaign included support groups, mobile outreach clinics, home visits, WASH intervention training, and a media campaign that was broadcasted via radio and television between June 2017 and March 2020. This study does not report directly on the effects of the campaign or any of its related components, but instead opportunistically uses the cross-sectional data gathered for the campaign and examines associations between WASH-related knowledge and behaviors, as well as diarrheal outcomes. A survey was developed by the Addressing Stunting in Tanzania Early (ASTUTE) program to examine trends in key maternal and child health related behaviors. Eligibility for participation included households with children aged 0–23 months. Questions were directed to female caregivers. The survey contained 169 questions and took an average of 50–60 min to complete. The survey was written in English and translated to Kiswahili by Ipsos, a data collection firm. Pilot testing occurred prior to survey administration. Data were collected by a field team consisting of 10 supervisors and 50 enumerators. Data collection occurred digitally via smartphones and personal digital assistants (PDAs). The National Institute for Medical Research in Tanzania and relevant local government authorities authorized the research (NIMR/HQ/R.8a/Vol.IX/2344). Institutional Review Board (IRB) approval was obtained through an internal IRB at Developmental Medial International (DMI), a research and communications not-for-profit organization that implemented mass media activities. Quality checks were verified by 11 quality controllers and new interviews were conducted when the quality of a completed interview could not be validated. Prior to the intervention, villages were randomly selected (n = 243) from five regions (Geita, Kagera, Kigoma, Mwanza, and Shinyanga) of the Lake Zone. A stratified, multi-staged random sample design was used to select survey participants. Participants within each village were randomly sampled anew during each survey period. All participation was voluntary and required informed consent. Data was collected from 9996 households from 2017 through 2020. This study examined household and demographic information. All major variables used were dichotomous. Dependent variables included whether the child experienced diarrhea within the past 2 weeks and if the child received medical treatment for the diarrhea. Behavioral variables used were optimal stool disposal, access to a water source, how frequently the household washes hands with soup, if a handwashing station exists in the home, if there is soap or ash at the handwashing station, if there is water at the handwashing station, and if the household owns their own soap. Knowledge variables used were based upon knowledge of when it is important to wash one’s hands including after latrine use, after assisting child who has defecated, before preparing food, before eating food, and before feeding a child as well as knowledge on whether or not handwashing with water alone makes one’s hands clean. Sociodemographic-related predictor variables used included number of children, sex of the child, relationship to the child, mother’s education, household wealth, child’s age, and mother’s age. Optimal stool disposal was determined by whether the child used latrine, put stool into a latrine, or threw stool into the garbage. Poor stool disposal included putting it in a ditch, buried, left in the open, or unknown. The wealth index was constructed using a similar approach to wealth measurement used by Briceño [18]. In brief, the wealth index included access to safe drinking water sources, access to safe sanitation, as well as ownership of a radio, television, bicycle, motorcycle, automobile, mobile phone, boat, and/or animal-drawn cart. Relationship of the caregiver was re-coded into three variables denoting mother, father, and other (i.e., grandmother, grandfather, sibling, aunt/uncle). This decision-maker variable was composed of one’s self, partner, or both as equal decision makers. Logistic regression was used to examine the association between WASH practices and diarrhea and also the association between predictor variables and whether an individual sought out medical care for diarrheal disease. Adjusted models controlled for maternal age, maternal education level, and household wealth. Dependent variables included whether or not the child had diarrhea within the past 2 weeks and if the child received medical care for the diarrhea. Risk factors included WASH behaviors exhibited by the primary caregiver including handwashing techniques and method of stool disposal. Predictor variables (key indicators) included maternal age, child age, number of children, child gender, maternal education, maternal literacy, which parent stays home when the child is sick, and who makes decisions on healthcare. Odds ratios, p-values (a = 0.05) and 95% confidence intervals were used to assess the strength of the associations. Significant findings were determined by <0.05 p-value. Data were examined using SAS 9.4 software (SAS Institute, Cary, NC, USA). Hosmer and Lemeshow goodness of fit tests were computed for all models and only those models that met assumptions for fit were retained.
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