Prevalence of and factors associated with diarrhoeal diseases among children under five in Malaysia: a cross-sectional study 2016

Diarrhoeal disease is among the leading causes of mortality and morbidity among children under 5 years. WHO estimates that, worldwide, 525,000 children under five years die due to diarrhoeal diseases each year with 1.7 billion cases of diarrhoeal disease every year [1]. In developing countries, children under three years’ experience on average three episodes of diarrhoea every year. Each episode contributes to significant nutrition deprivation which is necessary for child growth [2].

The prevalence of diarrhoea in young children is linked to socioeconomic status. In North Sudan, a study found that 28% of children below five years had diarrhoea [3]. Another study done in Eastern Ethiopia revealed a diarrhoea prevalence of 21.5% [4]. Both these countries fall under the low-income group according to the World Bank [5]. In middle income countries, the prevalence is lower, a study done in 2016 for Thailand reported a prevalence of 4.9% while Vietnam reported 8.6% in 2014 [6, 7].

Based on the 2006 National Health and Morbidity Survey (NHMS), the overall prevalence of diarrhoea in children below 5 years old in Malaysia was 4.5% [8]. Detailed analysis of the NHMS done in year 2011 found that children below 5 years old were 33% higher compared to 5–9 years old aged group [9]. Although Malaysia enjoys a high coverage of treated water, diarrhoea episodes among children are still reported. We found a scarcity of published data on acute gastroenteritis (AGE) prevalence in Malaysia among children. Information on the risk factors of diarrhoea in children will benefit intervention strategies to halt this problem. As such, this study aims to determine factors associated with diarrhoea in children aged less than 5 years in Malaysia.

Numerous factors associated with increased risk in diarrhoea among children under five have been identified. In the present study, we found significant differences in diarrhoea prevalence by ethnicity, parents’ education and occupation, household income, water supply, sanitation and waste disposal. The differences were all expected based on what is known regarding the risk factors for diarrhoeal diseases. Our findings correlate with a study in India which reported that prevalence of diarrhoea was positively associated with occupation and education of mother, source of water and toilet facility [11]. The same study also identified storage of water, lack of hand washing, feeding habits, immunization and rural residence, factors which were not included in our study [12]. Meanwhile, a study done in Baghdad showed that children were more at risk when the mother is unemployed and has lower education, and mother and father have poor nutritional knowledge [14].

The present overall prevalence of diarrhoea among children under five was 4.4%. In NHMS 2006, prevalence of diarrhoea was reported at 4.5% [8]. Although the rate is not high, our study demonstrates that diarrhoea prevalence among children less than five years has not shown any improvement in the past 10 years. Although Malaysia has rapidly improved its health and sanitation facilities, and there is now wider access to clean water and proper education, this condition may be contributed by the influx of immigrants to our country recently as NHMS targeted all residents in Malaysia irrespective of the nationality status. For comparison, a study done in 2013 using the same MICS survey tool in Bangladesh and Mongolia reported that prevalence of diarrhoea among children under five was 3.9 and 8.2%, respectively [14].

Highest prevalence was seen in Other Bumiputeras (8.8%), Indians (5.3%), others (5%) and the least was among Chinese children (3.3%). The previous study done (NHMS 2006) showed the Other Bumiputeras also recorded the highest level of prevalence of diarrhoea of 5.8% compared to other major ethnic groups, with the Chinese least likely to report acute diarrhoea. The reasons for such differences are not well understood, however the finding could be attributed to genetic or sociocultural differences between the ethnicities, which may be related to dietary and culinary practices or risk of acquiring gastrointestinal infections [9].

Prevalence of diarrhoea in Malaysia using untreated water was 13.4%. This is clearly supported by a study done in neighbouring Indonesia where they found a significant association between children with diarrhoea and unsafe drinking water source [15]. Meanwhile, a study done in Ibadan, Nigeria showed an increased risk of diarrhoea among children whose caregivers/mothers collected drinking water from a storage container by dipping into it with any other container [16]. Contaminated water may carry diarrhoea causing pathogens that may lead diarrhoea.

By education level, children of parents with lower education levels were more prone to have diarrhoea compared to parents with tertiary education levels. A similar study in India found a 13% lower risk of diarrhoea among educated mothers versus uneducated mothers [12]. Another study done in Ghana, stated that the prevalence of diarrhoea varied according to education of mother, being significantly lower among children with educated mothers (secondary and higher) than among children of mothers with no or primary level education [17]. In Malta, the majority of cases were found to have lower education [18]. Education provides knowledge of hygiene, good feeding and weaning practises, early recognition of symptoms and, thus, timeliness in responding to childhood illnesses [19]. Be that as it may, with regards to diarrhoea prevention, parents and caregivers can be informed and trained on hygienic practices and disease control regardless of their low education level. This is the aim and function of public health strategies – to develop programmes suited to the capabilities of the target communities.

Our survey observed that the poorest with prevalence of 5.8% were the most vulnerable to diarrhoea among the various household income groups. A study done in Thailand showed identical results with a diarrhoea prevalence rate of 9.8% [20]. A study conducted in Malawi mentioned that the father’s job or poor income of a head of the household is also a risk factor for diarrhoea in children [21]. In Bangladesh, a study showed the effect of maternal education and family income on diarrhoea, where they found high family income was associated with more than 40% of risk reduction [22]. This could be explained by children living in poorer households having higher diarrhoea rates than their wealthier counterparts due to sanitary facilities, unsanitary environments in the home and poor child hygiene.

Our study concluded that children from homes with unsanitary latrines and/or waste disposal were more likely to have diarrhoea compared to those with sanitary latrines and/or waste disposal. This is not surprising. Prevalence of diarrhoea for unsanitary waste disposal was 6.8% while for unsanitary latrines it stood at 6.3%. A recent study done in Banten, Indonesia, discovered that mothers who defecated at latrines have fewer children with diarrhoea than mothers who defecated at other places [15]. Improved access to sanitation reduces the risk of contracting diarrhoea by 2.2 percentage points, as shown by a study done in India [23]. An earlier study done in Burkina Fasso, found that children whose mothers regularly disposed of feces in the latrines had an approximate 40% reduction in diarrhoea rate [24]. In India, another study showed that, children from households in which the toilet facilities were not available within the house were more likely to develop diarrhoea compared with children from households with toilet facilities [12]. The presence of latrines increases the chance of safe disposal of faeces, reduces the risk of contact between the causative organisms of diarrhoea and the host. Similarly, with regards to proper waste disposal, unsafe refuse disposal showed a statistically significant relationship with childhood diarrhoea in Atwima Nwabiagya District in Ghana. Children who lived in households where unsafe refuse disposal was practised were two times more likely to suffer diarrhoea [25]. This result was consistent with studies conducted In Ethiopia which also found that improper refuse disposal was associated with a higher risk of childhood diarrhoea [26].

Finally, after controlling for various factors, multivariate analysis showed that only the associations with ethnicity and untreated water remained significantly associated with diarrhoea among children under five years old.

The strength of this study is the analysis based on a large nationally representative sample that allowed for a reliable inference to Malaysian children within a similar age-group. This survey used robust standard WHO MICS questionnaire, which is advantageous for international comparison.

Causal relationship between identified factors and diarrhoea was unable to be identified due to cross-sectional nature of this study. In addition, we only did face and content validity of the questionnaire used in this study.

Diarrhoea prevalence was based on self-reported screening and was not further confirmed.

Diarrhoea among children is a very important issue that needs to be addressed. From this study, we have found that diarrhoea in Malaysia was higher in Indian and Other Bumiputeras by ethnicity and usage of untreated water. Thus, healthcare strategy and campaign should be focused on specific ethnicity and universal treated water must be available among all residents of Malaysia.