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Predictors of diarrhea episodes and treatment-seeking behavior in under-five children: a longitudinal study from rural communities in Zambia

Introduction globally, diarrhea is the second leading cause of mortality in children aged below five years, and is responsible for killing about 760 000 children every year. Poor treatment-seeking behavior among caretakers remains a major challenge in low-income countries. The current study aimed to determine the predictors of diarrhea episodes and treatment-seeking behavior among under-five children of Chivuna and Magoye in Zambia. Methods we conducted a community-based longitudinal study among 1216 children aged 12-59 months between July 2006 and June 2007. A structured interviewer-administered questionnaire was used to collect data on demographic factors, diarrhea episodes and treatment-seeking behavior from caretakers. Chi-square, one-sample test of proportions and logistic regression were the statistical methods used in this study. Results of the 1216 children who participated in the study, 698 (57%) were from Chivuna and 518 (43%) from Magoye. Factors associated with diarrhea episodes were location (children in Chivuna had increased episodes of diarrhea; aOR 1.32; 95%CI 1.15, 1.52) and age distribution (children aged 37-59 months vs. 12-36 months had reduced episodes of diarrheal aOR 0.81; 95%CI 0.72, 0.91). Fifty two percent (52%) of the diarrhea cases had their treatment sought within 24 hours of onset (early treatment). Thirty one percent (31%) of the diarrhea cases had their early treatment at a health facility. Female children (52%) had the majority of their diarrhea episodes treated within 24 hours of onset. The higher proportion of diarrhea episodes had their treatment at home (52%). Children who did not have home treatment had a significantly reduced chance of having early treatment (aOR 0.62; 95%CI 0.47, 0.82). Conclusion this study revealed that diarrhea episodes and treatment seeking behavior in under-5 children is of public health concern. There is need to re-enforce the preventative and control measures aimed at reducing diarrhea in under-5 children, and interventions should take into account the different predictors of diarrhea and treatment seeking behavior in different settings, like the ones highlighted in this study.


Introduction
Globally, diarrhea is the second leading cause of mortality in children aged below five years, after pneumonia, and is responsible for about 760 000 child deaths, or 1 in 9, every year [1]. Diarrhea is defined as passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). Most deaths from diarrhea are due to severe fluid loss and dehydration. Children who are malnourished and those with impaired immunity are at highest risk for life-threatening diarrhea [2]. Diarrheal diseases are more prevalent in low-and middle-income countries, largely as a result of lack of safe drinking water, sanitation and hygiene, as well as poorer overall health and nutritional status [3]. Moreover, most people living in rural areas prefer home management of diarrhea and those who go to the clinic are often inadequately treated [4,5], due largely to lack of high quality health facilities and poverty [6]. However, diarrheal diseases are preventable by safe water and improved hygiene and sanitation [2]. Additional primary control strategies for diarrhea morbidity that have proven to be more cost effective and efficacious are timely administration of oral rehydration salt (ORS), and Zinc tablets [7].
A decrease in child mortality due to diarrheal diseases is imperative in attaining the aims of Sustainable Development Goal (SDG) 3 (target 3.2) which targets to end preventable deaths in newborn and under-five children by 2030 [8]. Therefore, information on disease predictors and the health-seeking behavior of households is important in designing mechanisms aimed at reducing the burden of the disease.
Diarrhea is the third largest killer of children aged less than five in Zambia and it is estimated that every year 15 000 die as a result of the disease [9]. The burden of the disease in Zambia is intensified by the weak health system infrastructure and lack of human and financial capacity. The rationale for performing the analysis is to aid interventions to improve diarrhea outcomes. Hence, the current study sought to investigate the predictors of diarrhea episodes and treatment-seeking behavior among caretakers of under-five children in Chivuna and Magoye rural parts of Zambia.  were informed that participation in the survey was not compulsory but voluntary and that they were free to withdraw from the study any time. They were also informed that their identity and that of their children would be kept confidential.

Results
Basic characteristics of the study participants: a total of 1,216 children aged between 12 and 59 months participated in the study.

Relationship of diarrhea episodes with independent
variables: the overall prevalence of diarrhea episodes was 22% and the monthly one ranged from 13% to 32%. A significant proportion of diarrhea episodes were reported in Chivuna (25% vs 20%, p < 0.001) and among children aged 12 to 36 months (23% vs 21%, p = 0.007).
Overall, 23% of male children, compared to 21% of female children, had diarrhea. Among those with episode of diarrhea, there were significantly (p < 0.0001) high proportion of them being treated away from home (63%) in comparison to those treated at home (37%). The proportion of diarrhea cases which were treated by community health workers were 68% and by health facility it was 32%, a statistically significant difference p = 0.0471. The majority of the diarrhea episodes were treated after 24 hours of onset (53% vs 47%, p < 0.0001). Most of the children were significantly given more water (42%) than usual (32%) when they had diarrhea by their caretakers, p < 0.0001 (Table 2). In multivariable analysis (

Discussion
The study revealed that diarrheal episodes and early treatment (within 24 hrs) was still of great public health concern among caretakers of under-5 children in Chivuna and Magoye rural communities. In most rural communities of resource limited settings, diarrhea and treatment seeking behaviors still remain a major challenge [11][12][13]. As evidenced by this study, a good proportion of diarrhea cases had their treatment sought after 24 hours of onset (delayed) and mostly treated at home and by community health workers. The study had limitations as it depended on how much caretakers could remember regarding what transpired to their children in the past one month. Hence, the study was subject to recall bias. The project did not also comprehensively take into consideration, caretakers´ socio-demographic factors which are of paramount importance in explaining the factors associated with diarrheal episodes and treatment-seeking behaviors in under-5 children, and thereby in coming up with best predictors´ models. This is largely because the study utilized the data of another study whose primary aim was different. However, the information generated in the study is good enough to shape the policy and programs aimed at reducing morbidity and mortality due to diarrhea in children aged below the age of five.
The study revealed that catchment area (location) and age of the child was a significant predictor of diarrheal disease. This is similar to the study conducted in rural Malawi, where it was found that morbidity was associated with a child´s area of residence [13]. A child in Chivuna was more likely to have an episode of diarrhea than one from Magoye. This can be as a result of lower accessibility to preventative measures in Chivuna considering that it is more remote as compared to Magoye. Magoye is near the main road (great north road), which might have given it more advantage in receiving adequate and timely preventative measures for diarrhea. In addition, Magoye has high access to latrines and improved water supply. In a study conducted in Ethiopia [14], it was revealed that lack of latrine ownership and improved water sources was significantly associated with diarrheal disease. In Chivuna, there are also many streams, which could be a risk factor for diarrheal disease. The project further ascertained that many children in Magoye had their treatment of diarrhea within 24 hours of onset. The discrepancy could have been due to the fact that many households in Chivuna are far away from the health facility as compared to the ones in Magoye. A study in Tanzania [15], found that children who lived more than 1 km from the health facility were more likely to receive delayed treatment, home care and/or no care at all.
In another study, distance to a health facility was revealed as a barrier to seeking treatment [16]. The above reasons could also explain why most children in Magoye and Chivuna had their treatment at a health facility and home, respectively.
The prevalence (22%) of diarrhea revealed in this project is comparable with that of earlier studies [14,15,17]. However, lower [13,18] and higher [11,19] proportions were observed from previous studies. The episodes of diarrhea were more in male children as compared to their female counterparts. This is in line with previous observation from other studies [15,20]. Male children are more physically active compared to females [21] and this may make them wander off more in unsanitary surroundings than female children.
Hence putting them at a higher risk of having diarrhea. In Hong Kong, at a pediatric hospital admission, it was revealed that a higher proportion of males were consistently admitted in almost all illnesses [22]. This entails that male children are more vulnerable to diseases than females. Our results also showed that the youngest children (< 3yrs) had more episodes of diarrhea compared to the older children (≥ 3yrs). Similar findings were reported by other studies [23,24] where it was shown that younger children were at an increased risk of having an episode of diarrhea. Epidemiologically, the prevalence of rotavirus which is the commonest cause of diarrhea is high in children aged below the age of 24 months [25]. The lower prevalence in the older children may be as a result of developed acquired immunity. Further, the project was able to reveal that age distribution is a predictor of diarrheal episodes in children aged below the age of five.
Various studies have shown that there is still a good proportion of childhood diarrheal cases being managed at home [10,26] and a lot of these cases are poorly managed [21,27]. In the current study, similar results were found. Less than 1% of the caregivers in Nigeria were found to be knowledgeable about home management of diarrheal diseases [28]. A study conducted in rural Gambia is not in agreement with our findings, as they found that the majority (81.5%) of the caregivers sought treatment outside home [19]. When mothers/caretakers have given a child a home remedy, it makes them reluctant in seeking outside treatment. As it was observed in Sierra Leone that the use of traditional medicine was associated with not seeking outside care for diarrhea [11]. This is a probable explanation as to why most children in our study did not receive outside treatment.
Less than half of the children in the two areas of focus were more likely to be given more water than usual. These findings are in line with that of Forsberg et al. (2007), which revealed that in low-and middle-income countries very few children with diarrheal diseases get increased amount of fluids [29]. It is therefore important that caretakers are educated on the importance of giving more fluids to their children when they have diarrhea in order to prevent it from being complicated (i.e. severe dehydration and death). It was also shown that older children were more likely to receive home and early treatment than the younger ones. Gender and age were not significant predictors of early treatment, which means that caregivers offer equal treatment skills across all age groups and gender. These results are comparable with a study conducted in Burundi [30], where it was revealed that there was no gender differences in diarrhea treatment for under-5 children by the caretakers.
Most of the diarrhea cases were treated by the community health workers as compared to the health facility. This is contrary to a study which was conducted in Bangladesh [31], where the majority of diarrhea cases got treated at a health facility. In our project, less than 50% of the diarrhea cases were treated at a health facility. This was in line with an earlier study [19]. The picture portrays how ineffective diarrheal diseases are managed in rural settings. Usually caretakers at home may lack the technical know-how with regards to management or rather treatment of diarrheal diseases. In Ethiopia, it was shown that caregivers had inadequate knowledge in the prevention and management of childhood diarrheal diseases [23]. Basically caretakers of under-5 children in rural areas have challenges in seeking appropriate and early treatment of childhood illnesses [32]. This might be a contributing factor to morbidity and mortality in under-5 children.
There is need for strong health education programs aimed at educating caretakers on the importance of seeking treatment from health centers and reducing on the use of home remedies for diarrhea without prescription from qualified health personnel to ensure correct and timely treatment of the disease.

Conclusion
The study was able to reveal a number of issues surrounding childhood diarrhea. Suffice to say that, in the study areas diarrhea in  The study has shown that in this setting majority of mothers sought care from outside the home; of those who sought care outside the home, majority relied on community health workers, which shows that community health workers are still an important source of care in low resource settings.