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Prevalence of diarrhoea and related risk factors among children aged under 5
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ORIGINAL RESEARCH ARTICLE
Prevalence of diarrhoea and related risk factors among
children aged under 5 years in Sana’a, Yemen
Mabrook Aidah Bin Mohanna and Naijla Al-Sonboli
Department of Paediatrics, Faculty of Medicine and Health Sciences, Sana’a University, Yemen
Abstract
Diarrhoeal disease is one of the most common problems affecting children
across the world. This study assessed the prevalence of diarrhoea and
related risk factors among children aged <5 years. A cross-sectional study
was conducted over 8 months at Sam Specialized Paediatric Centre and
Al-Mamoon Diagnostic Medical Centre, Yemen, involving 1570 children
aged <5 years with diarrhoea. Detailed data regarding age, sex, diarrhoeal
episodes, family size, education level of mother or female caregiver,
breastfeeding and weight were collected. Of 5400 patients seen for
different causes, 1570 patients were children aged <5 years presenting
with diarrhoea, giving a prevalence of 29.07%. A total of 850 children were
boys and 720 were girls, with ages ranging from 6 to 60 months. There
were 1325 children aged <12 months, 160 aged 1–2 years and 85 aged
3–5 years. There were 700 (44.59%) children from small families and
870 (55.41%) from large families. A total of 922 (58.73%) children were
malnourished and 648 (41.27%) were not. There were 1125 (71.66%)
children whose mothers or female caregivers had no or low-level formal
education and 445 (28.34%) whose mothers or female caregivers had
secondary or high-level education. A total of 651 (41.46%) children were
breastfed, 735 (46.82%) were mixed fed and 184 (11.72%) were bottle
fed. The prevalence of diarrhoea in children was high; it was highest in
those who were aged <12 months, from a large family, malnourished and
not exclusively breastfed, and in those whose mother or female caregiver
had no or low-level education. It is important to encourage family
planning, a balanced diet, exclusive breastfeeding and maternal education,
and to strengthen health intervention programmes, in order to reduce the
incidence of diarrhoea.
Introduction
Diarrhoeal disease is the principal cause of mortality
and morbidity in children aged <5 years in developing
countries. It is the second leading cause of death in
developing countries where it is responsible for
1.7 million child morbidities and 760000 child
Correspondence: Mabrook Aidah Bin Mohanna, Department of
Paediatrics, Faculty of Medicine and Health Sciences, Sana’a
University, Yemen. Email: mabrookmohanna@yahoo.com
© 2017 The Author(s)
Journal Compilation © 2017 Sheikh Hamdan Bin Rashid Al Maktoum Award for Medical Sciences
Hamdan Medical Journal 2017 (http://dx.doi.org/10.7707/hmj.711)
mortalities every year.1,2 Diarrhoeal disease is one of
the most common problems affecting children in
the world. It can cause malnutrition, stunted growth
and reduced well-being. It can affect intellectual
development, leading to significantly lower than
average scores in intelligence tests in children aged
<5 years, and creates a considerable demand for
health services.3–5
Diarrhoea is defined as the passage of three or more
loose or liquid stools per day, or more stools than is
normal for the individual.6 Diarrhoea results from
infection of the intestinal tract by any of a variety of
viruses, bacteria or parasites; it is often acquired
directly from another infected person or from food
or water that has been contaminated by stools.2
In Yemen, intestinal parasite diseases are a serious
health problem, with a prevalence ranging from
18% to 27%.7 Promotion of better eating practices,
vaccination against rotavirus, and vitamin A and/or
zinc supplementation are effective in reducing the
incidence of diarrhoea. Exclusive breastfeeding for at
least the first 6 months of an infant’s life protects
against diarrhoeal disease. Clinical health professionals,
public health professionals and communities must
work together to develop diagnostic, treatment and
prevention methods to reduce diarrhoeal morbidity
and mortality.8–12 Oral rehydration solutions of
sodium, potassium and glucose should be taken for
rehydration if patients can consume the required
volumes; if not, appropriate intravenous fluids should
be used.13 The aim of the study was to assess the
prevalence of diarrhoeal disease and related risk
factors among children aged <5 years presenting at
Sam Specialized Paediatric Centre and Al-Mamoon
Diagnostic Medical Centre, Sana’a, Yemen.
1
Hamdan Medical Journal 2017 (http://dx.doi.org/10.7707/hmj.711)

ORIGINAL RESEARCH ARTICLE

Method Exclusion criteria

A cross-sectional study was carried out at Sam Patients on antibiotics or with insufficient information
Specialized Paediatric Centre and Al-Mamoon were excluded.
Diagnostic Medical Centre from 1 January to
31 August 2015. The centres offer services to the Ethics approval and consent
community through outpatient clinics and receive The study was approved by the Medical Corporation
patients from Sana’a, neighbouring areas and of Sam Specialized Paediatric Centre and Al-Mamoon
occasionally from other governorates, including Diagnostic Medical Centre. Verbal consent was
referred cases from private clinics. obtained from the parents and caregivers of children
who participated in the study.
Sample size and collection
The sample comprised 1570 children of both sexes
Statistical methods
aged <5 years presenting with diarrhoea. All mothers
The collected data were processed manually using
or female caregivers whose children presented with
diarrhoea were interviewed. Detailed information a chi-squared test to determine the significance
regarding age, sex, weight, episodes of diarrhoea, of differences between variables, which were
considered statistically significant at a P-value of
family size, educational status of mother or female
caregiver and breastfeeding was collected. <0.05. The results were recorded in tables as
frequencies and percentages.
Inclusion criteria
All children aged <5 years presenting with diarrhoea Results
were included in this study. The children were divided Over an 8-month period, 5400 patients were seen
into three age groups (<12 months, 1–2 years and for different reasons; of these, 1570 were children
3–5 years) for assessment of the prevalence of aged <5 years presenting with diarrhoea, giving a
diarrhoeal disease in each group. Diarrhoeal disease prevalence of 29.07%. A total of 850 were boys and
was defined as a passage of three or more loose 720 were girls, with ages ranging from 6 to 60 months.
or watery stools per day. The ages of the children There were 1325 children aged <12 months, 160 aged
were obtained from their caregivers, birth certificates, 1–2 years and 85 aged 3–5 years (Table 1). There were
immunization cards and other available medical 700 (44.59%) children from small families and 870
records. Large families were defined as families (55.41%) from large families. A total of 922 (58.73%)
including five or more dependent children; small children were malnourished and 648 (41.27%) were
families had fewer than five dependent children. not. There were 1125 (71.66%) children whose
Mothers or female caregivers with no or low-level mothers or female caregivers had no or low-level
formal education were those who had no education formal education and 445 (28.34%) whose mothers
or had not completed primary school; those with or female caregivers had secondary or high-level
secondary or high-level education were educated to education. A total of 651 (41.46%) children were
secondary school level or above. Children who were
breastfed were those who were fed exclusively on
TABLE 1 The prevalence of diarrhoea by sex and age in
breast milk from birth to 6 months of age; children
children aged <5 years in Sana’a (N=1570)
who were mixed fed were those fed on both breast
milk and milk formula from birth; bottle-fed children Characteristic na % P-valueb
were those fed exclusively on milk formula from birth.
Prevalence of diarrhoea 1570 29.07
Weight was measured with the child wearing minimal
Sex <0.0003
clothing and in bare feet using an RGZ-20 infant
weighing scale (Hangzhou Tianheng Technology Co. Male 850 54.14
Ltd, Hangzhou, China) for children aged <2 years Female 720 45.86
and an RGZ health scale (Shanghei Maney Medical Age <0.0001
Technology Co. Ltd, Shanghei, China) for children <12 months 1325 84.4
aged ≥2 years. Nutritional status was evaluated on the 1–2 years 160 10.19
basis of expected weight by age: children were 3–5 years 85 5.41
considered malnourished when their weight was a
The total number of patients seen for different causes was 5400.
below the normal range for their age (<80%).14
b
The result is significant at P<0.05.

2 © 2017 The Author(s)

Journal Compilation © 2017 Sheikh Hamdan Bin Rashid Al Maktoum Award for Medical Sciences

exclusively breastfed, 735 (46.82%) were mixed fed
and 184 (11.72%) were bottle fed. Episodes of
diarrhoea were seen to be significantly associated with
children who were aged <12 months, from a large
family, malnourished, not exclusively breastfed, and
with those whose mother or female caregiver had no
or low-level education (Table 2).
Discussion
Diarrhoeal disease is still one of the most significant
causes of morbidity and mortality in developing
countries.1,2 In this study, the prevalence of diarrhoeal
disease among children aged <5 years was 29.07%.
This is higher than in many studies; for example,
Yilgwan et al.15 reported a prevalence of 2.7%, Yilgwan
et al.16 a prevalence of 10.3% and Bezatu Mengistie17
a prevalence of 22.5% and the prevalence rates
observed in studies carried out in Sudan18 and India
were also lower.19 However, the prevalence we found
is still lower than that reported by Diouf et al.20 (32.6%)
and Mohammed and Tamiru21 (30.5%). These
differences in the prevalence of diarrhoea could be
attributed to many factors. For example, diarrhoeal
diseases are more common in low-income countries
than in middle- and high-income countries. In
developing countries, including Yemen, mortality and
morbidity rates from diarrhoeal diseases in children
aged <5 years are high and represent a public health
problem.1,2,15,22 Diarrhoea can be caused by many types
TABLE 2 Relationship between prevalence of diarrhoea
and related risk factors (family size, nutritional status,
education level of mother or female caregiver and
breastfeeding) in children aged <5 years in Sana’a (N=1570)
Variable n %
Family size
Five or more dependants 870
(large family)
Fewer dependants (small family) 700
Nutritional status
Normal 648
Malnourished 922
Education of mother or female caregiver
No or low-level formal education 1125
Secondary and high-level education 445
Feeding
Breastfed 651
Mixed fed 735
Bottle fed 184
The result is significant at P<0.05.
a
© 2017 The Author(s)
Journal Compilation © 2017 Sheikh Hamdan Bin Rashid Al Maktoum Award for Medical Sciences
Hamdan Medical Journal 2017 (http://dx.doi.org/10.7707/hmj.711)
ORIGINAL RESEARCH ARTICLE
of virus, bacteria and parasites, and infection is often
acquired directly by contact with another infected
individual or by consuming food or water that has
been contaminated by stools.2 Yemen depends
entirely on ground and rain water, and only 25% of
the population have easy access to safe water.7
In this study, 54.14% of children found to have
diarrhoeal disease were boys and 45.86% were girls,
which is a similar result to the results of studies carried
out by Bahartha and AlEzzi22 and Yilgwan et al.,16 but
differs from the results of studies by Kolahi et al.23 in
Iran, Shah et al.19 in Pakistan and Gascón et al.24 in
Tanzania. There is no current explanation for this,
although it was noted that several families in Yemen
prefer boys to girls, which could affect caregiving.
In this study, the prevalence of diarrhoea decreased
with increasing age: children aged <12 months
(n=1325) formed the largest group presenting
with diarrhoea, followed by those aged 1–3 years
(n=160) and then those aged 3–5 years (n=85). This
is similar to a number of other studies that found
that the prevalence of diarrhoea was greater in
children aged <12 months than in children of other
age groups.17,18,22,25 This could be because a large
proportion of children with diarrhoea in this
age group (<12 months) were not exclusively
breastfed or were introduced at an early stage to
complementary feeds, increasing the likelihood of
diarrhoea. Exclusive breastfeeding for at least the
first 6 months of an infant’s life protects against
diarrhoeal diseases because maternally acquired
antibodies enhance children’s physiological
resistance to diseases.21 The early introduction of
complementary feeds may increase the risk of
P-valuea diarrhoea because of the potential contamination
<0.0001 of feeds.18 Among children aged 1–2 years and
55.41 3–5 years, the most common causes of diarrhoea
are likely to be consumption of contaminated feed
44.59 or water and inadequate personal hygiene or
<0.0001 sanitation.22 In this study, 922 (58.73%) children
41.27 with diarrhoea were malnourished and below the
58.73 expected weight for their age, and 648 (41.27%)
<0.0001 were not malnourished. The consequences of
71.66 malnourishment in children are many, including
28.34
increased vulnerability to infection and diarrhoea,
impaired development, increased mortality and
<0.0001
reduced well-being.4,26 Malnourished children have
41.46
low immunity and are more susceptible to infection,
46.82
including diarrhoeal disease. Recurrent or chronic
11.72
diarrhoeal disease can result in malnutrition and,
in children under 2 years of age, can lead to
3
Hamdan Medical Journal 2017 (http://dx.doi.org/10.7707/hmj.711)
ORIGINAL RESEARCH ARTICLE
permanent impairment of physical and mental
development, including stunted growth and
delayed intellectual development.27,28 Breastfeeding
exclusively until the age of at least 6 months, then
introducing feed in addition to breast milk between
6 months and 2 years, improves outcomes by
decreasing rates of malnutrition and mortality.2,29
This study found that diarrhoea was more common
in children whose mothers or female caregivers
had no or low-level education. This is in agreement
with many studies: Dikassa et al.30 in the Congo,
Ekanem et al.31 in Lagos, Nigeria, and Mohammed
and Tamiru21 in Ethiopia. Therefore, it is essential to
educate mothers or female caregivers in hygiene,
the care for sick children and when to seek medical
assistance.11,12,16,17,32 For example, in some areas in
Yemen, many illiterate mothers resort to traditional
treatments in an attempt to stop diarrhoea, including
abdominal cautery or tying a piece of cloth around
the abdomen. In Sudan, illiterate mothers resort to
traditional remedies such as gum cautery.17
This study found that diarrhoea was more common
among children from large families (five or more
dependent children) than among children from
small families (fewer than five dependent children).
This may be because infective diarrhoeal agents are
more likely to be transmitted from person to person
in large families. Mothers in large families may also
face more difficulties when caregiving, particularly
in the areas of hygiene and meeting their children’s
daily food requirements, increasing the risk of
malnutrition and diarrhoea in their children.
This study found that diarrhoea was more common
among children who were not exclusively breastfed.
Breastfeeding is the ideal method of infant feeding.
The American Academy of Pediatrics recommends
exclusive breastfeeding for about 6 months, followed
by continued breastfeeding and complementary
foods for ≥1 year.33
Conclusion
Evaluation of the nutritional status of participants
was based only on expected weight for age, rather
than weight for age, height for age, or similar.
However, expected weight for age is frequently
used as a measure of nutritional status and has the
advantage of being somewhat more practical, given
the ease of weighing a child. Assessing malnutrition
grades, Ghai et al.14 reported that malnourished
4 © 2017 The Author(s)
Journal Compilation © 2017 Sheikh Hamdan Bin Rashid Al Maktoum Award for Medical Sciences
children weighed <80% of their expected weight for
age. The results of this study promote exclusive
breastfeeding, maternal education and family
planning as means to reduce diarrhoeal disease. This
study should encourage further research in this area,
and encourage planners and programme managers
in Yemen to improve infrastructure and the health
care system.
The prevalence of diarrhoea in children is high;
it is highest among those aged <12 months, from
a large family, malnourished, not exclusively
breastfed, and whose mother or female caregiver
has no or low-level education. It is important to
encourage exclusive breastfeeding, a balanced diet,
maternal education and family planning, and to
strengthen health intervention programmes, in
order to reduce the incidence of diarrhoea.
Acknowledgements
We would like to thank all the children, their
caregivers, the data collectors and the laboratory
technicians who participated in and contributed to
this study. We would like also to thank Dr Afrah Al
Gadri for her valuable participation in this study.
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