278

TRAN~.KTION~
OF THE ROYAI.SOCETYOF TROPICAL.
MEDICINEAND HYGIENE (1987) 81, 278-282

Socioeconomic variables and rates of diarrhoeal

disease in urban Bangladesh
BONITA F. STANTONAND J. D. CLEMENS
International Centre for Diarrhoeal Disease Research, Bangladesh (ZCDDR, B), GPO Box 128, Dhaka 2,
Bangladesh

Abstract
Sociodemographic factors including low maternal education, low economic status, inferior quality
of housing, diminished accessto water and sanitation facilities, and crowding in the household are
associatedwith increased diarrhoea in the rural setting of many developing countries. To assessthe
relationship of these variables with diarrhoea rates in children in an urban setting we monitored the
episodesof diarrhoea of children <6 years of agefrom 1921 families living in 51 clusters throughout
Dhaka city, Bangladesh, for 3% months. Comparing incidence density ratios, we found that, of the
factors listed above, only low family income and living in a one-room house were statistically
associated with increased diarrhoea and that none of these variables was associated with a
meaningfully increased risk of diarrhoea. We conclude that the risk factors for increased episodesof
diarrhoea in the urban setting appear to be different from those of the rural setting.

Introduction results indicate that socioeconomic factors are not

With the realization that by the year 2000 one half
of the world’s 6 billion people will be living in cities
(WITT, 1982), national and international policy mak-
ers hate beg& to focus attention on the urban &eas of
the develoDine world (UNITED NATIONS. 1967: 1968:
ISLAM, 1579x Policy decisions for f&ure health;
education, housing and sanitation development in
cities require a sound factual foundation. However,
the paucity of research in urban areas in most
developing countries, including Bangladesh, necessi-
tates the use of estimations and extrapolations from
rural data or of episodic descriptive surveys of the
urban areas (GOVERNMENTOF BANGLADESHet al.,
1979; CENTRE FOR URBAN STUDIES 1983; ISLAM,
1979).
Of the many health problems facing Bangladesh,
diarrhoea remains pre-eminent. Considerable data are
available on the incidence of diarrhoea in rural
Bangladesh (BLACK et al., 1983; RAHAMAN et al.,
1977), but not for urban Bangladesh. It is unknown if
diarrhoea rates in urban areasare associatedwith the
same socioeconomic risk factors as in rural areas.
These risk factors include lower maternal education
(VARAVITHYA et al., 1985; BETRAND & WALMUS,
1983), lower socioeconomic status (PIJAISANT et al.,
1985; BLUM & FEACHEM, 1983; MANDERSON, 1981),
inferior quality of housmg (STEWARTet al., 1955;
KOURNARY & VASGUEZ, 1969), less accessto water
and sanitation (RAHMAN et ai., 1985; BETRAND &
WALMUS. 1983: HENRY. 1981: TOMKINS et al., 1978:
MOORE 2 al., i969) and, crowding in the ho&ehold
(MOORE et al., 1965; RAHMAN, 1985).
In an attempt to provide the necessary data to
formulate realistic health and sanitation recommenda-
tions for urban Bangladesh, an urban diarrhoea
surveillance system was established by the Urban
Volunteer Program (UVP) of the International Centre
for Diarrhoeal Disease Research, Bangladesh
(ICDDR,B) (STANTON et al., 1985). We report here
an assessmentof the impact of socioeconomic vari-
ables on the diarrhoea rates of children <6 years. The
important determinants of diarrhoea in this urban
area; we suggestthat data about diarrhoea risk-factors
from rural areasmay have limited relevance to urban
areas.
Materials and Methods
A. Selection of sites
This study was conducted in 51 communities in the poor
and middle class areas of Dhaka, Bangladesh.Each com-
munity consisted of 38 contiguous households beginning 5
houses away from the home of an Urban Volunteer
(STANTON et al., 1985), a trained community health worker
acting as liaison between the community and our project.
‘Household’ was defined as all persons sharing a cooking pot.
The r&meters of 7 of the communities lav within % mile
(0.8 l&n) of the perimeter of the next closesi community and
3 of the communities were within sight of each other. The
remaining 41 communities were separated by up to 12 miles
(19 km). Most communities were about 100-200 vards
(loo-206m) long and wide; the largest community- was
approximately l/4 mile (0.4 km) long. Dwellings were
generally single storey and thatched, with walls shared by
the adjacent dwelling. Walkways were mud or dirt. The
communities included middle class single family homes and
apartment dwellings, small ‘backyard’ slums of wealthier
landlords, larger slums on municipal land, and illegal
‘squatter’ settlements.
B. Collecrion of infawmatim
Trained interviewers and field research officers gathered
all data. After obtaining baseline demographic and Gcioeco-
nomic data for each familv (seeCensus) a continuous record
of the diarrhoea experie&z of each ihild <16 years was
maintained (see “Diarrhoea monitoring”).
1. census
An enumeration form containing the address, name, sex,
age, relationship to the head of house, marital status,
employment status and educational level of each individual
was completed for each household from September to
October? 1984. The enumeration system and subsequent
monitonng system for demographic vital events was adapted
from a system developed at ICDDR,B for rural population
sampling (PHILLIPS & MAJUMDER, 1983). At the same
interview the researchteam completed a preceded household
socioeconomic form adapted from 2 forms used in rural
 B. F. STANTON AND J. D. CLEMENS 279

Bangladesh populations which elicited information about Table l-Socioeconomic stahts of 1921 households shldicd
owner&u of houses. land and valuable wrsonal items.
accessto-plumbing and electricity, house construction ani Median household income/month* 1000 TK
stated income of the household in the previous month. This One room only in house 1324 (69%)
questionnaire had previously been tested on a population House constructed of pucca 643 (33%)
with a similar so&cultural background to our study Household owns one or more radios 564 (29%)
population. These forms required approximately 45 min to Household owns one or more watches 810 (42%)
process. Head of household owns house 514 (27%)
We analyzed both maternal and paternal education, Head of household owns land 1083 (56%)
accepting as years of school any formal academic or religious Electricity in home 1011 (53%)
training and recording the highest grade completed. For Tap or tubewell water in compound** 401 (21%)
economic status we used one direct measure (income in the Compound or house has sanitary latrine** 473 (25%)
previous month) and 3 indirect measures(possessionof 1 or Compound or house has other latrine** 406 (21%)
more radios, of 1 or more watches and of a ‘pucca’ (cement l US$l.OO = 27 taka (TK)
or brick) home). We defined ‘accessto clean water’ as havine: **Within bari enclosure or provided and maintained by landlord to
a tap or tubewell available for free use in the compound or ai renters as part of rental agreement.
having free accessto the landlord’s tap or mbewell as part of
the rental agreement. Similarly, ‘accessto sanitary disposal’ Table Z-Episodes of diarrhoea by age and sex
was defined as access to a sanitary, pit or hanging latrine
provided by the landlord as part of the rental agreement or Diarrhoea episodehger 100 child-weeks
constructed and maintained by the community dwellers. Age in months Female Total
‘Crowding’ was determined by number of people in a
household, number of rooms in a house and number of 0 - 11 11.6 10.6 Il.0
people per room. 12 - 23 11.1 8.8
24 - 35 7.8 10.2 ;:;
2. Diarrhoea mmitming 36 - 47 5.8 7.5
After the enumeration, 7 contiguous rounds of a 2-week 48 - 59 ;:: ;:; 6.0
recall of diarrhoea of all children <6 years of age were 60 - 71 6.8 6.3
obtained from the mothers bv the interviewers. The
accuracy of the 2 week retail was augmented by a
home-maintained ‘health calendar’ for each child and thrice
weekly visits to each household by a volunteer to discussany ‘fee-for-service’ positions (rickshaw drivers and boat
problems with the mother. Diarrhoea was defined as >3 taxies), and 8% were domestic servants.
loose stools in any 24 h period. To avoid identifying as ‘new’ Table 1 presents the socioeconomic status of the
an episode of diarrhoea that was a continuation or exacerba- families. The median income was onlv $37 ner familv
tion of a pre-existing episode, we defined diarrhoea of any per month. Only one-third of homes ieke c&structea
duration during a given 2-week round as one episode. bf “pucca” (cement or brick); the remainder were
Episodes of diarrhoea beginning in an earlier round and made of bamboo. thatch and scrao. Onlv 7% of
lasting into the next round were not counted as a separate
episode in the new round. The 7 rounds were completed houses had 4 or more rooms (inclu*ding ai outside
between 7 October 1984and 15 January 1985,corresponding unenclosed verandah.) Possessionsof value were few;
with 1 month of the wet and 2% monthsof the dry season. less than half of famiiies owned one or more watched
Information obtained from these rounds formed the basis for and less than one-third owned a radio. While half the
a subsequent intervention trial. families did own land, this was usuallv ioint own-
ership with other family members of a &all plot in
C. Data analysis their rural villages. Facilities were meagre with only
To evaluate the effect of sociodemoaraphic risk factors on half the homeshavine electricitv. less than half having
diarrhoea rates, we analysed direct measures or proxies of
the more commonly implicated factors. Each analysis was accessto a latrine ana only o&-&h having accesst;
initially performed with one year age groups but we have water. The remaining families relied on ad hoc
summarized data which were homogenousacrossage strata. sanitary facilities (rental of a neighbour’s latrine,
Subjects in different categories of the risk factors were construction of a temporary hanging latrine jointly
compared for diarrhoea rates using incidence density ratios. with several other families, or defaecation in gutters).
Statisticalsignificanceof the ratios was assessed
using the Water could be purchased from neighbours or
Mantel-Haenszel x2 test. Statistical tests were interpreted in obtained from the occasional street taps installed by
a two-tailed fashion. An incidence density ratio of <l the municipality.
connoteda negativerisk, 1 correspondedto no increased
risk, and > 1 denotedan mcreasein risk (KLEINBAUM et al.,
1982). Diarrhoea rates
Diarrhoea rates during this 3% month interval
Results ranged from 6 episodes per 100 child-weeks in 4-and
Socio-demographic characteristics Syear-old children to 11 episodesper 100child-weeks
Our population included 11 176 people, 51% of in children 0 to 11 months (Table 2). Girls tended to
whom were male, living in 1921 households. The have higher rates in the first 2 years of life than boys,
median number of persons in each household was 6. but subsequently had slightly lower rates. The mean
19% of the population (2128) were less than 6 vears of number of episodes for all children <6 years of age
age and an additional 24% (2632) were under 13 years. was 8.2 per 100 weeks.
The education level obtained was low, with 1990 The analyses of the relationship between sociode-
(66%) women and 1604(44%) men older than 10 years mographic factors and diarrhoea -rates are shown in
having had no formal education. Only 56% (17% of Table 3. Because detailed analvses bv one vear
women and 92% of men1 of the 5339 ‘emnlovable’ subgroups appeared to be consist& th; results-are
persons (>12 years of age, not a student and not summarized over the age strata.
disabled) had remunerative work. 9% of these were Decreased family income was associated with a
employed only on a daily basis, 26% were in statistically significant increase in diarrhoea episodes
280 SOCIODEMOGRAPHIC FACTORS IN DIARRHOEAL DISEASE IN BANGLADESH

Table Uociodemographic variables and episodes of diacrhoea

Episodes of Mantel-Haenszel 95%
diarrhoea/lOO incidence density confidence
Factor childweeks ratio interval
Maternal education*
At or below median O-96 0.86 - 1.07
Above median - -

Paternal educationt
At or below median 0.98 0.91 - 1.05
Above median - -

Monthly income**
At or below median l-19 1.08 - 1.30
Above median - -

ow?lerseipof item
Yes 1.01 o-90 - 1.13
No - -

Radio: Yes 1.00 1.00

No - -

Pucca house: Yes 8.4 1.00 0.99 - 1.01

No 8.3 - -

Access to
Latrine: Yes 1.05 0.94 - 1.18
No - -

Drinking water: Yes 1.16 0.95 - 1.35

No - -

Indications of crowding
Number of people in household++
At or below median 8.36 1.09 0.96 - 1.24
Above median 7.72 - -

Number of rooms in house §

At or below median 8.66 1.14 0.98 - 1.33
Above median 7.5 - -

>6 people living in 1 room 1.04 0.98 - 1.10

<6 people living in 1 room
* Median = 0 years educationj+ + Median = 2 years education.
** Median = 1000 TWmonth; Median = 6 people; 5 Median = 1 room
(P<O*O5). The magnitude of this risk was small
(Mantell-Haenszel incidence density ratio (M-H
IDR) = 1.19).
Analysis of the other sociodemographic variables
did not reveal any meaningful association with
diarrhoea rates except that children living in homes
with only one room had statistically more episodesof
diarrhoea; however, the risk was small (M-H
IDR = l-14, O.OS<P<O*l).
Discussion
We found a notable lack of association between
so&demographic factors and childhood diarrhoea.
This result contrasts with the lindings of other,
primarily rural, studies on childhood diarrhoea mor-
bidity and mortality. Of the sociodemographic factors
which we examined, only low family income and
living in a one-room house were statistically associated
;:; - -
with higher rates of diarrhoea but in both situations
the relative risk associatedwith these factors was quite
low. Diarrhoea rates in urban Bangladeshi children
appear to be very high.
Limitations of the stuay
Because we deliberately avoided the upper class
areas, the sample is not strictly representative of
Dhaka city as a whole. However, it did include both
lower and middle class families. The overall percen-
tage of the upper class in Dhaka is estimated to be
quite small while the ‘lower class’ (our principal
focus) has been estimated to represent from 33% to
70% Dhaka (GOVERNMENT OF BANGLADESH et al.,
1979; CENTRE FOR URBAN STUDIES, 1983). Further,
the major health problems in cities of developing
countries in the future will not be in the upper class
areas but rather in the poorer areas.
 B. F. STANTON
The duration of the study presented here is short,
3% months, because the data were gathered in
preparation for an intervention which began in
March, 1985. However, becausewe were reporting on
2100 children, the total number of child-weeks of
observation is quite large. It is unlikely that seasonal-
ity per sewould have changed our results, as this 3%
month interval covered one month of the wet and 2%
months of dry seasons.
Inadequate or poorly conceived research question-
naires may result in poor data. Our research tools
were all extensively field-tested before use. The
censusenumeration record was adapted from a system
which has been in use for over 2 years in Bangladesh.
Similarly, the socioeconomic record was compiled
from tools used extensivelv bv scientists at ICDDR,B
in 2 other areasof Banglades-h.The diarrhoea recall,
which utilized a 2-week period, was augmented by
thrice weekly home visits by a community health
worker and by a home-maintained health calendar.
Findings of the study
If we assume that the rates observed during these
14 weeks remain constant throughout the year, the
annual diarrhoea rates in Dhaka city would be fully
50% higher than that reported for Jakarta (JOEet al.,
1966) and for rural Bangladesh (BLACK et al., 1982,
1983).
Becausematernal education has been shown to have
a profound impact on childhood mortality in and
outside Bangladesh (CALDWELL & MCDONALD,
1982; LINDENDAUM et al., 1985) and on diarrhoea
rates elsewhere (VARAVITHYA er aE., 1985), it was
surprising that the formal education of a mother had
no impact on the diarrhoea rates of her children. It is
possible that ‘hygienic practices’ taught in schools in
ihe rural area, from where many of our urban families
had mierated (ISLAM, 1979). or even in urban schools
using a’ curriculum developed for a primarily rural
population, are not applicable to the urban area.
Because facilities can result in differences in di-
arrhoea rates only if they are properly used, it is
nossible that the lack of association between accessto
iatrines or putatively clean water and diarrhoea rates
mav be due to subomimal use of these facilities. The
existing latrines and-water sources are generally quite
inadequate; although a family may have accessto a
latrine, usually it is shared by many families and is
commonly surrounded by excrement. The water
sources are also inadequate, with many families
sharing 1 tap that may or may not be sanitary and that
may produce water for only a few hours a day.
Unfortunately, even if the individuals or government
could provide the financial backing for single family
latrines and water taps.,the physical constraints of the
city would not perrmt this luxury. In the current
situation of single story dwellings with population
densities of 2000 people/acre (0.4 ha) (ISLAM, 1979),
there would not be sufficient spacefor these addition-
al amenities. The current municipal water system, the
capacity of which has already been exceeded by the
demand, would not support the added demand of taps
for each household (ISLAM, 1979). Thus, even though
single family latrines or water taps appear to offer
some improvement in childhood diarrhoea rates and
mortality in the rural settings (HENRY, 1981; RAH-
MAN et al., 1985), this approach does not appear to be
practicable in this urban setting.
AND J. D. CLEMENS 281
The fact that socioeconomic variables associated
with diarrhoea rates in rural Bangladesh do not appear
to have a substantial impact on diarrhoea rates in the
urban area illustrates the basic difference between
these settings and underscores the importance of not
extrapolating from rural to urban areas.A next step in
formulating diarrhoeal control recommendations for
the urban area will be to determine if hygienic
practices between families with high and low rates of
diarrhoea differ.
Acknowledgements
We thank the urban volunteers,the researchteam,Mrs
TaikeraKhair and Mrs KhoclezaKhatun for their help; Dr
BogdanWojtyniak for his adviceon the statistical analysis;
and Mr Jatindra Nath Sarker and Mr Sontosh Daniel
Ascension for their aid in preparing the manuscript.
ICDDR, B is supportedby countriesand agencieswhich
share its concern ab& the impact of diarrh&a disease on
the developing world. Funds for this particular study were
provided by the UNDP, Arab Gulf Fund, UNICEF and the
Belgian Government.
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II LATIN-AMERICAN AND V COLOMBIAN CONGRESS OF PARASITOLOGY
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