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Contents lists available at ScienceDirect

Journal of Infection and Public Health

journal homepage: http://www.elsevier.com/locate/jiph

Association of water handling and child feeding practice with

childhood diarrhoea in rural community of Southern Nepal
Dilaram Acharya a, , Jitendra Kumar Singh b,g, , Mandira Adhikari c , Salila Gautam d ,
Pragya Pandey e , Vinita Dayal f
a
Department of Community Medicine, Kathmandu University, Devdaha Medical College and Research Institute, Devdaha Municipality-10, Rupandehi,
Nepal
b
Department of Community Medicine & Public Health, Tribhuvan University, Janaki Medical College, Janakpur, Nepal
c
Nepal Development Society, Bharatpur, Nepal
d
Department of Public Health, Purbanchal University, Sanjeevani College of Medical Sciences, Butwal, Rupandehi, Nepal
e
Faculty of Nursing, Janaki Medical College, Tribhuvan University, Janakpur, Nepal
f
Population Services International, New Delhi, India
g
Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, India

a r t i c l e i n f o a b s t r a c t

Article history: Diarrhoea is a major cause of childhood morbidity and mortality globally. While the childhood diarrhoea
Received 15 October 2016 and its association with child feeding, and hygiene, hand washing and water treatment are studied else-
Received in revised form 15 March 2017 where, the association of water handling and child feeding with childhood diarrhoea is an understudied
Accepted 28 April 2017
area in Nepal. This study aimed to investigate the association of water handling and child feeding practice
with childhood diarrhoea among children of one to ve years of age in Southern, Nepal. A cross-sectional
Keywords:
study was conducted in the Dhanusha district of Southern Nepal in 2013. A total of 284 motherchild
Childhood diarrhoea
pairs were selected using systemic random sampling. A four-week prevalence of childhood diarrhoea was
Child feeding practices
Water handling practices
reported using frequency distribution. The association of childhood diarrhoea with water handling and
Nepal child feeding practices was ascertained using multiple logistic regressions after adjusting for potential
confounders. The result of the study demonstrated that the four-week prevalence of childhood diarrhoea
was 36.6%. Our nding showed that unsafe water handling practices were associated independently with
childhood diarrhoea: untreated water (aOR 3.55; 95% CI: 1.1311.10), uncovered water (aOR 2.14; 95%
CI: 1.094.19). Similarly, partial breast feeding (aOR 4.35; 95% CI: 1.8710.12) was also associated with
higher odds of childhood diarrhoea. One third of children in Southern Nepal still had diarrhoea within the
four weeks preceding the survey. As poor water handling and sub optimal infant feeding practice were
major risk factors contributing to such a high burden of the disease, health promotion strategies such as
promotion of safe water handling, improved hygiene and child feeding practices are recommended for
the prevention of childhood diarrhoea in Southern Terai of Nepal.
2017 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University
for Health Sciences. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction responsible for the deaths of approximately 760,000 children every

Diarrhea is a major cause of childhood morbidity and mortality.
The World Health Organization (WHO) has reported that nearly
1.7 billion cases of diarrhea occur globally. Diarrhea is the second
leading cause of death in children below ve years of age and is
Corresponding author.
E-mail addresses: dilaramacharya123@gmail.com
(D. Acharya), jsingdj@gmail.com (J.K. Singh),
adhikarimandira2013@gmail.com (M. Adhikari), salu but@yahoo.com (S. Gautam),
pragyatuku@gmial.com (P. Pandey), vinita.dayal@gmail.com (V. Dayal).
year [1,2]. As a result of the higher incidence and multiple episodes
of childhood diarrhea in low- and middle-income countries, there
is need for further efforts to reverse the situation.
The Nepal Demographic and Health Survey (2011) reported that
14% of children under the age of ve years had diarrhea [3]. The
trend of diarrhea incidence in Nepal has signicantly increased
over the past three years from 528 to 629 per 1000 children, with
36 per 1000 deaths of under children under ve years of age dur-
ing 2013/2014 [4]. Diarrhea is transmitted through the feco-oral
route mainly by biological agents [5]. Contaminated food and uids

http://dx.doi.org/10.1016/j.jiph.2017.04.007
1876-0341/ 2017 The Authors. Published by Elsevier Limited on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the
CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Acharya D, et al. Association of water handling and child feeding practice with childhood diarrhoea
in rural community of Southern Nepal. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2017.04.007
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2 D. Acharya et al. / Journal of Infection and Public Health xxx (2017) xxxxxx
as well as improper personal hygiene, waste disposal and feeding
practices facilitate pathogen transmission [69].
One of the major causes may be inadequate sanitation prac-
tices. For instance, only 60.1% of households in Nepal have access
to improved sanitation facilities [10].
Improper sanitation, poor personal hygiene, a limited water
supply, and water quality were risk factors for the incremental
childhood diarrhea prevalence in Pakistani and Nepalese studies
[11,12]. A review on diarrhea reported that most of the inter-
ventions related to hygiene and water quality were effective in
reducing childhood diarrhea [13]. However, aspects of water han-
dling at the household level are the most important risk factors.
The majority of household water sources in the Terai region of
Nepal are contaminated with diarrheal pathogens that need proper
treatment before they are t for human consumption. For example,
Atreya et al. [14] reported that 61% of the household water sources
in the Terai region of Nepal were contaminated with total coliforms.
Some previous studies on diarrheal disease prevention in Nepal
highlighted the importance of water treatment [11], hand washing
[15], and combined school-led total sanitation and global public pri-
vate partnership for hand washing [16] to reduce diarrheal disease
in the country. However, few previous studies have explored water
handling practices and their effects on the incidence of diarrheal
diseases.
Child feeding practices play important roles in nutrition and
the health status of children. The WHO recommends exclusive
breastfeeding for six months, followed by the initiation of com-
plementary feeding with breastfeeding [17]. A number of studies in
developing countries have demonstrated a protective effect of early
initiation and exclusive breastfeeding against diarrhea [1823]. For
instance, studies in Vietnam and Uganda revealed a strong pro-
tective effect of early initiation of breastfeeding against childhood
diarrhea occurrences [18,22]. This nding was equally true for all
children who were exclusively breastfed compared to partially or
non-breastfed children [23,24]. Some studies have shown that two-
thirds of Nepalese mothers exclusively breastfeed their children for
less than or equal to ve months and initiate breastfeeding within
the rst hour of childbirth [25,26]. Although international studies
have provided evidence of the benecial effects of breastfeeding,
the relationship of sub-optimal breastfeeding with childhood diar-
rhea has been rarely studied in Nepal. Therefore, the aim of this
study was to report the association of childhood diarrhea with
water handling and child feeding practices in a rural community
in the Dhanusha district of southern Nepal
Methods
Study setting
This study was conducted in the LaxmipurBageba village
development committee of Dhanusha district, Nepal. The village
development committee is the lowest administrative unit in rural
Nepal. This district is located in a rural area in southern Nepal
that is 12 km from the district headquarter Janakpur. The area was
selected purposively as a part of a community health diagnostic
eld practice. The study area included 1333 households with a
population of approximately 8147 individuals. The total number
of children under ve years of age in Dhanusha district was 81,464,
and the annual food and waterborne disease prevalence rate in
children under ve years of age was 21.29% [27].
Ethics
The research proposal was approved by the Ethics Committee
for Health Research of Janaki Medical College and Teaching Hos-
Please cite this article in press as: Acharya D, et al. Association of water handling and child feeding practice with childhood diarrhoea
in rural community of Southern Nepal. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2017.04.007
pital, Tribhuvan University, Nepal. A written approval letter was
obtained from the District Health Ofce, Janakpur. Mothers pro-
vided written consent for themselves and their children. Personal
identiers were removed prior to the data analysis.
Study design and sampling
This cross-sectional study was conducted in a rural community
of Nepal. Information on the number of households and the popu-
lation in each ward of the village was obtained from the village
development committee ofce. Households were selected using
systematic random sampling from the list. Mothers with children
15 years of age in the selected households were considered as
respondents. For each family within the household, a mother and
child pair (youngest child) was taken into consideration when more
than one child was suffering from diarrhea. If a child 15 years of age
was not found, a subsequent household was recruited until the eli-
gible participant requirement was met. Children below 12 months
and above ve years of age were excluded from the study. A sam-
ple size of 258 was calculated assuming a prevalence of waterborne
disease of 21% and an allowable error rate of 5% [28]. We inated
the sample size to 284 to account for possible missing data.
Data collection
Data were collected between September 2013 and October 2013
in Laxmipur Bageba village development committee of Dhanusha
district, Nepal. Face-to-face interviews were conducted using a
structured questionnaire adapted from the Nepal Demographic and
Health Survey 2011 [3]. Four female research assistants who had
a college degree in health sciences were involved in data collec-
tion. The outcome variable of the study was childhood diarrhea
in the past four weeks and was recorded based on the mothers
recall. Diarrhea was ascertained using maternal recall from the
response to the question: Did your children get sick in the past four
weeks? If yes, what was the illness? The answers to this question
included acute respiratory infection (ARI), diarrhea, worm infesta-
tion, malaria and others (common cold, measles and skin diseases).
The child was assumed to have diarrhea if the mother reported
the passage of loose, liquid, or watery stool usually more than
three times a day. The major independent variables of interest were
water handling and child practices. The water handling technique
included storage methods (covered/uncovered), holding methods
(dipping a water glass into water along with ngers/holding from
outside), type of water consumed (plain/raw or boiled/treated) and
water source (piped, tap or hand pump or ground water from the
well) [3]. Child feeding practices were categorized as child breastfed
(partial or exclusive) and complementary feeding given to the child
(before 6 months and after 6 months). A number of other signi-
cant variables were included based on the literature. The maternal
age was categorized as 19 years, 2035 years and 36 years. Eth-
nicity was based on the caste system in Nepal and was divided
into four major groups based on available literature and similarities
between the caste/ethnic groups as disadvantaged/dalit (Dushadh,
Dhobi, Doom and Sonar), disadvantaged/aadibasi/janajati (Newar,
Rai andGurung), non-dalitterai caste (Yadav, Teli, Koiri, Haluwai
and Thakur) and advantaged/upper caste (Brahmin and Chhetri)
[29]. Maternal education was recorded as no education (illiterate),
primary education (15 years of schooling), and secondary edu-
cation and above (10 or more years of schooling). The maternal
occupation was coded as working in agriculture/livestock, daily
wage labor and business/service [3]. The Standard of Living Index
(SLI) was calculated based on the house type, availability of house-
hold goods (radio, television set, wall clock, refrigerator, bicycle,
motorcycle, motorcar, and foam mattress), and possession of land
and animals (cultivated land, cattle, and goats/sheep). A score was
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Table 1 Table 2
Distribution of household asset/amenity scores by factor. Demographic characteristics and morbidity proles of children under ve years of
age.
Assets/amenities Factor score
Characteristic Number Percentage
Yes No (N = 284)
Household Goods Age of child, months (mean SD) 37.16 11.68
Electricity 1 0
Radio 1 0 Gender of child
Television set 1 0 Male 130 45.8
Mobile phone 1 0 Female 154 54.2
Sewing machine 1 0
Health problems of children in the past 4 weeksa
Solar power 1 0
ARI 118 48.2
Wall clock 1 0
Diarrhea 77 36.6
Refrigerator 1 0
Worm infestation 37 26.7
Bicycle 1 0
Malaria 29 6.7
Motorcycle 1 0
Others (common cold, measles, and skin diseases) 19 6.7
Tempo 1 0
Episodes of diarrhea (median, range) 3 (15)
Animal-drawn cart 1 0
Table 1 0 a
Multiple responses.
Chair 1 0
Bed 1 0
Sofa 1 0
Fan 1 0 Factors associated with childhood diarrhea
Dhiki/janto 1 0
Toilet 1 0 A number of factors related to childhood diarrhea, such as water
Cultivated land 1 0
storage methods, water holding methods, type of water consump-
Livestock (i.e., cattle, goat/sheep, buffalo, cow) 1 0
tion, breast feeding and duration of complementary feeding, were
Types of Houses signicantly associated with childhood diarrhea in the univariate
Concrete 1 0
analysis (Table 4).
Others (mud, bamboo) 1 0
The nal results of the multiple logistic regression analysis are
Types of materials used in houses shown in Table 5. Adjusting for the socio-demographic characteris-
Floor (concrete) 1 0
Wall (concrete) 1 0
tics, water storage methods, holding water methods, types of water
Ceiling (concrete) 1 0 consumed, and child breastfeeding and child complementary feed-
ing approaches modied the association. Children whose mothers
Fuel used for cooking
Smokeless 1 0 used untreated water [adjusted odds ratio (AOR) 3.55 (95% CI:
Other (rewood, cow dung) 1 0 1.1311.10)] and uncovered water [(AOR 2.14; 95% CI: 1.094.19)]
Total 28 0 were more likely to have diarrhea. Furthermore, partially breastfed
[(AOR 4.35; 95% CI: 1.8710.12)] children were more likely to have
diarrhea than their exclusively breastfed counterparts. The water
assigned for each factor, and the sum of the scores for all factors holding methods and time of initiating complementary feeding
was categorized as low (less than nine), medium (920), and high were not signicant in the nal model.
(more than 20) [30] (Table 1).
Discussion
Statistical analysis
This study found that slightly more than one-third of the chil-
Water handling practices were reported as percentages. The dren had suffered from diarrhea during the four weeks prior to
four-week prevalence of diarrhea was also reported as a percent- the study. The rate was relatively high compared with the Nepal
age. The association of diarrhea with independent variables was Demographic and Population Health Survey data, which reported
rst tested using the Chi-square (2 ) test and then ascertained that 14% of all children under ve years of age had diarrhea in the
using multivariable logistic regression models. A P-value 0.05 was two weeks preceding the survey [3]. This high burden of childhood
considered signicant. The statistical analysis was performed using diarrhea warrants further attention and prevention efforts in this
Statistical Package for Social Science, Advanced statistics, Release community in southern Nepal.
20.0 with add-on package (SPSS for windows, SPSS Inc., Chicago, IL, The current study also demonstrated that children whose moth-
USA). ers used untreated water more commonly suffered from diarrhea
than children whose mothers used treated water. The ndings of
our study are consistent with many other studies [13,3134]. This
Results study also found that children whose mothers used uncovered
water at the household suffered diarrhea more frequently than
Characteristics of the participants their counterparts whose mothers did not use uncovered water.
This nding is consistent with the ndings of a south Ethiopian
The average age of the children was 37.16 months (standard study [35]. Poor water quality, inconvenient water-point locations
deviation 11.68 months). Slightly more than one-third of the and weak institutional capacity are some of the major issues related
children (36.6%) had diarrheal episodes (median: 3; range: 13) to drinking water in Nepal [36]. Because even safe water has the
(Table 2). The majority of the children (73.2%) were born to mothers potential to become contaminated with feces during collection,
in the 2035-year-old age group. More than half of the moth- transport, storage and drawing in households [37], health promo-
ers (56.7%) had no formal education. Nearly three-quarters of the tion intervention should target mothers or caregivers to introduce
mothers (73.2%) were engaged in agriculture/livestock. Slightly a hygienic method for the storage, treatment, and serving method
more than half of the children born to the mothers (53.9%) had for water at the household level to reduce childhood diarrhea mor-
a middle standard of living (SLI) (Table 2) (Table 3). bidity.

Please cite this article in press as: Acharya D, et al. Association of water handling and child feeding practice with childhood diarrhoea
in rural community of Southern Nepal. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2017.04.007
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Table 3
Socio-demographic characteristics and prevalence of diarrheal episodes in the children studied (N = 284).

Characteristic Number N = 284 (%) Diarrhea in children Crude OR (95% CI) P-value

Present n = 77 (%) Absent n = 207 (%)

Age of mother
19 years 52 (18.3) 15 (28.8) 37 (71.2) 1.2 (0.403.6) 0.934
2035 years 208 (73.2) 56 (26.9) 152 (73.1) 1.1 (0562.1)
36 years 24 (8.5) 6 (25.0) 18 (75.0) 1.00

Family size
<5 113 (39.8) 27 (23.9) 86 (76.1) 0.76 (0.441.38)) 0.322
5 171 (60.2) 50 (29.2) 121 (70.8) 1.00

Ethnicity
Dalit 20 (7.0) 7 (35.0) 13 (65.0) 2.94 (0.988.77) 0.003
Adibasi/Janjati 62 (21.8) 27 (43.5) 35 (56.5) 1.57 (0.574.32)
Non Dalit Terai Caste 118 (41.6) 30 (25.4) 88 (74.6) 0.69 (0.241.98)
Upper caste 84 (29.6) 13 (15.5) 71 (84.5) 1.00

Educational status
No education 161 (56.7) 60 (37.3) 101 (62.7) 4.35 (2.029.37) 0.000
Primary 48 (16.9) 8 (16.7) 40 (83.3) 2.97 (1.306.76)
Secondary & above 75 (26.4) 9 (12.0) 66 (88.0) 1.00

Occupation
Agriculture/livestock 208 (73.2) 59 (28.4) 149 (71.6) 0.69 (0.271.7) 0.208
Daily wage labor 22 (7.7) 8 (36.4) 14 (63.6) 1.74 (0.823.6)
Service/business 54 (19.0) 10 (18.5) 44 (81.5) 1.00

Standard of living index (SLI)

Low 77 (27.1) 30 (39.0) 47 (61.0) 2.8 (1.206.41) 0.017
Middle 153 (53.9) 37 (24.2) 116 (75.8) 2.00 (1.113.60)
High 54 (19.0) 10 (18.5) 44 (81.5) 1.00
Total 284 77 207

Table 4
Association of water handling and child feeding practices of mothers with children 15 years of age associated with childhood diarrhea.

Factor Category Number N = 284 (%) Childhood diarrhea Crude OR (95% CI) P-value

Present n = 77 (%) Absent n = 207 (%)

Water handling characters

Water storage method Uncovered 109 (38.4) 44 (40.4) 65 (59.6) 2.9 (1.704.99) 0.000
Covered 175 (61.6) 33 (18.9) 142 (81.1) 1.00

Water holding method Dipping glass with ngers 160 (56.3) 54 (33.8) 106 (66.2) 2.23 (1.273.91) 0.005
Holding from outside 124 (43.7) 23 (18.5) 101 (81.5) 1.00

Type of water Plain/raw (untreated) 231 (81.3) 73 (31.6) 158 (68.4) 5.66 (1.9616.27) 0.001
consumption Boiled (treated) 53 (18.7) 4 (7.5) 49 (92.5) 1.00

Source of drinking Piped water (tap/hand pump) 192 (67.6) 53 (27.6) 139 (72.4) 1.08 (0.611.89) 0.788
water Ground water (well) 92 (32.4) 24 (26.1) 68 (73.9) 1.00

Child feeding practices

Child breast fed Partial 98 (34.5) 43 (43.9) 55 (56.1) 3.49 (2.026.03) 0.000
Exclusive 186 (65.5) 34 (18.3) 152 (81.7) 1.00

Child complementary Before 6 months 106 (37.3) 31 (29.2) 75 (70.8) 2.38 (1.334.25) 0.003
feeding At or after 6 months 178 (62.7) 46 (25.8) 132 (74.2) 1.00

Child complementary Cold 111 (39.1) 35 (31.5) 76 (68.5) 1.43 (0.842.44) 0.181
feeding, warm or cold Warm 173 (60.9) 42 (24.3) 131 (75.7) 1.00

Our study found that exclusive breastfeeding practices reduced
the diarrhea prevalence. This nding is supported by several other
studies [18,22,24,38,39]. Breastfeeding promotion strategies are
needed and should incorporate a diarrheal disease control program.
The ndings of this study will help develop sound childhood
diarrhea prevention programs in Nepal. However, there are some
potential limitations. Firstly, the main outcome variable (onset
of diarrhea) and other variables were self-reported based on the
respondents perceptions of symptoms of illness. Inquiry on diar-
rhea among mothers for the four weeks prior to the interview may
have led to potential recall bias [40]. Secondly, we did not test
the quality of the water used in the households and the sources
of water from where they were drawn and the adequacy of breast-
feeding. Further studies examining water quality concomitant with
water handling behavior are necessary. Furthermore, the methods
used in this study could not rule out potential confounders, such
as age of the child, breastfeeding practices, housing, availability of
basic sanitation facilities, and measures such as bathing and clean-
ing utensils. Finally, this cross-sectional study was conned to a
small area of southern Nepal, which limited the generalizability of
the study results.
Conclusion
This study found that one-third of children suffered diarrhea
in southern Nepal and that poor water handling and suboptimal
infant feeding practices were the major risk factors contributing
to the high burden of the disease. To reduce the burden of child-

Please cite this article in press as: Acharya D, et al. Association of water handling and child feeding practice with childhood diarrhoea
in rural community of Southern Nepal. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2017.04.007
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Table 5
Childhood diarrhea associated with water handling and child feeding practices of mothers with children 15 years of age using logistic regression models.
Factor Category
Water storage method Uncovered/covered
Type of water consumption Raw (untreated)/boiled (treated)
Child breast fed Partial/exclusive
Variables entered included socio-demographic characteristics, water storage methods, holding water methods, types of water consumed, child breast fed and child comple-
mentary feeding given at 6 months.
hood diarrhea in Nepal, more effective prevention strategies are
required. These strategies should focus on the promotion of safe
water handling, improved hygiene and child feeding practices.
Competing interests
The authors declare that they have no competing interests.
Authors contributions
JKS and DA participated in the design of the study. JKS and DA
performed the statistical analysis. DA and JKS wrote the manuscript
with signicant contributions from MA and SG. MA, SG, VD, and PP
contributed to the analysis, interpretation of the results, literature
review, and revision of the manuscript. All authors contributed to
the revision and agreed on the nal manuscript.
Acknowledgments
Our special thanks go to our research assistants and all of the
respondents who participated in this study. We are grateful to
Vishnu Khanal (PhD, Curtin University, Australia) for a nal English
check and editing of our manuscript.
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Please cite this article in press as: Acharya D, et al. Association of water handling and child feeding practice with childhood diarrhoea
in rural community of Southern Nepal. J Infect Public Health (2017), http://dx.doi.org/10.1016/j.jiph.2017.04.007