Socio-demographic and environmental factors of diarrhea among under-five children in India

DOI: https://doi.org/10.21203/rs.3.rs-22229/v2

Abstract

Background: Globally, diarrhea is the second leading cause of death in children under five years of age and is a major public health problem. Despite several health care initiatives taken by the government, a large proportion of under-five children still experience diarrheal diseases which cause high childhood mortality in India. This study aims to examine the socio-demographic and environmental factors of diarrhea in children under five years old in India.

Methods: A cross-sectional study was designed using the recent round of the National Family Health Survey (NFHS), conducted in 2015–16. A total of 247,743 living children below five years of age were included in the analysis. Bivariate and multivariate logistic regression models were carried out to assess the factors associated with childhood diarrheal disease.

Results: In India, about 9% of under-five children experience diarrheal disease in the past two weeks. Children living in rural areas (Adjusted odds ratio [aOR]: 1.05; 95% CI: 1.01, 1.09), belonged to scheduled tribe (aOR: 0.83; 95% CI: 0.79, 0.89) and other castes (aOR: 0.92; 95% CI: 0.88, 0.97), Muslim children (aOR: 1.18; 95% CI: 1.13, 1.24), and children resided in the central (aOR: 1.61; 95% CI: 1.52, 1.70) and west (aOR: 1.08; 95% CI: 1.01, 1.15) regions were significantly associated with higher likelihood of diarrhea in the past two weeks. Concerning environmental factors, child stool disposal (aOR: 1.06; 95% CI: 0.98, 1.09), floor materials (aOR: 1.08; 95% CI: 1.03, 1.12) and roof materials (aOR: 1.08; 95% CI: 1.04, 1.13) of the household were found to be significant factors of childhood diarrhea occurrence.

Conclusions: Diarrhea is common among rural, scheduled caste, Muslim and poor families’ children. Regarding environmental factors, stool disposal practices in the household, main floor and roof materials of the household unit are risk factors of diarrhea. Targeted approach should be initiated to mitigate the problem of poor health status of children by providing adequate health care. The policy-makers and stakeholders should address adverse environmental conditions by the provision of latrine and improved housing facilities.

Introduction

Childhood diarrhea is a major public health problem in low- and middle-income countries leading to high mortality in children under five. According to the World Health Organization (WHO), diarrheal disease is defined as the passage of three or more loose or liquid stools per day [1]. This preventable disease is the second leading cause of death in children under five. Each year, nearly 1.7 billion cases of childhood diarrheal diseases have been reported, killed around 525,000 under-five children, accounting for 8% of all deaths worldwide [1]. Most of the deaths from diarrhea occur in children below two years of age. Globally, the episodes of childhood diarrhea have been decreased by 60% between 2000 and 2017 [1, 2].

Diarrhoeal diseases have a detrimental impact on child growth and cognitive development [3]. Diarrheal diseases are associated with an increased risk of malnutrition in children [1]. Approximately 90% of diarrheal diseases occur in sub-Saharan and South Asian countries [4]. Although India has made considerable achievements in reducing infant and child mortality over the past 20 years, the episodes of preventable diseases like diarrhea and pneumonia remain high. According to the National Family Health Survey (NFHS)-4, about 9% of under-five children had diarrhea in the past two weeks preceding the survey during 2015-16 [5]. It is also notable that the prevalence of diarrhea significantly varies across geographic regions of the country from as high as 13.1% in the central to as low as 4.2% in the northeast region [5]. In India, pneumonia and diarrheal diseases accounted for 50% of all under-five deaths [6]. The government of India has initiated several interventions to reduce the burden of diarrheal diseases. In 1975, the Integrated Child Development Scheme (ICDS) was launched to reduce the incidence of childhood malnutrition, morbidity and mortality by providing supplementary nutrition and routine vaccination [7]. Besides, Water, Sanitation and Hygiene (WASH) trails, National Diarrhoeal Disease Control Program and policies for child health and nutritional programs have been initiated to control the incidence of diarrhea-related morbidity and mortality in children.

Many socio-demographic, environmental and behavioral factors are responsible for the occurrence of diarrheal disease among under-five children. Important socio-demographic factors include child’s age, place of residence, maternal education and the household economic condition [8–15]. Environmental factors such as drinking water, sanitation facilities, waste disposal and dwelling characteristics are associated with childhood diarrhea [11–13, 16, 17]. Furthermore, behavioral factors such as breastfeeding practices, eating habits and handwashing practices are found to be significant factors of diarrhea in children under five [12, 18, 19]. The Global Burden of Disease Study (2016) conducted in 195 countries yielded that child wasting, unsafe sanitation, low coverage of rehydration solution and unsafe water source are the leading risk factors of diarrheal disease in children under five worldwide [4]. A systematic review study in India indicated that diarrheal diseases in children occur due to a range of socio-economic factors including malnutrition, poor sanitation and hygienic practices [15]. Studies also highlighted that breastfeeding practices, birth weight and immunization coverage are significantly associated with childhood diarrheal diseases [15, 20, 21].

Despite high reported cases of diarrheal diseases, identifying the risk factors of childhood diarrhea is relatively scant in India as compared to other developing countries. Moreover, malnutrition and early childhood mortality are unacceptably high in India. Prevention of diarrhea is necessary to reduce the incidence of diarrhea-related morbidity and mortality in children. In a context where the burden of diarrhea-related mortality is high, it is imperative to investigate the factors associated with childhood diarrhea. Therefore, this study aims to examine the socio-demographic and environmental factors of diarrheal disease in children under five years old in India using a nationally representative sample survey.

Methods

Study design

This study used secondary data collected from the fourth round of the National Family Health Survey (NFHS-4), conducted in 2015–16. A cross-sectional study was designed.

Sample size and procedure

All living under-five children (n=247,743) who participated in the NFHS-4 were enrolled in the study. The NFHS-4 is a nationally representative large-scale sample survey carried out across all the states and union territories of India. The samples were selected using a two-stage stratified sampling design. In the first stage, the clusters were selected using the method of probability proportional to size.  In the second stage, complete household mapping and listing have done in the selected clusters and 22 households were randomly selected from each cluster. The sampling frame used in this survey was the 2011 Indian Population and Housing Census. A detailed description of the sampling design and survey procedure is provided in the NFHS-4 national report [5].

Outcome variable

The outcome variable of this study is diarrhea in under-five children. Diarrhea is defined as having three or more loose or watery stools in 24 hours, as reported by the mother/caregiver in the past two weeks preceding the survey.

Explanatory variables

Socio-demographic and environmental characteristics were included for explanatory variables in this study. Socio-demographic characteristics include place of residence (rural and urban), caste (scheduled caste/scheduled tribe, other backward classes and others), religion (Hindu, Muslim and others), maternal education (illiterate/primary and secondary/above) father’s education (illiterate/primary and secondary/above), maternal age (15–24, 25–34 and 35–49 years), maternal body mass index [BMI] (underweight, normal and obese), access to mass media (no and yes), household size (<6 and 6+), wealth quintile (poorest, poorer, middle, richer and richest), region (north, central, east, northeast, west and south), age of child (0–11, 12–23, 24–35, 36–47 and 48–59 months), sex of child (male and female), birth order (1, 1–3 and 4+) and birth weight (<2.5 kg [low birth weight] and ≥2.5 kg [normal]).

Environmental characteristics include the availability of toilet facility, sources of drinking water, child stool disposal, and main floor and roof materials of the household. Household toilet facility was a dichotomous variable, classified as households having a toilet facility and households without a toilet facility. Any improved, unimproved and shared latrine facility (flush or pit) were considered as households having a toilet facility, otherwise households using open defecation. Sources of drinking water were categorized as improved and unimproved sources. Improved sources of drinking water are protected from outside contamination, particularly from fecal matter [22]. Improved sources include piped water, public taps, standpipes, tube wells and boreholes, protected dug wells and springs, rainwater, and community reverse osmosis plants, while unimproved sources comprise unprotected dug well, unprotected spring, tanker/cart with small tank, surface water and bottled water. Child stool disposal was grouped into safe and unsafe disposal. Child’s stool was considered to be safely disposed, if a child used a toilet or latrine, or flushed into a toilet, or it was buried [5]. The main floor materials of the houses were categorized as dirt (e.g., mud/clay/earth, sand and dung) and non-dirt (e.g., raw wood planks, palm, bamboo, brick, stone, parquet or polished wood, vinyl or asphalt, ceramic tiles, cement, carpet and polished stone/marble/granite). Likewise, the main roof materials of the dwelling unit were grouped into thatch (e.g., thatch/palm leaf, mud, plastic/polythene, rustic mat, palm/bamboo, timber etc.) and metal/concrete (e.g., metal, wood, asbestos sheets, cement/concrete, tiles, slates, burnt bricks etc.).

Data analysis

Descriptive statistics were carried out to understand the distribution of socio-demographic and environmental characteristics for the study sample. The prevalence of diarrheal disease was estimated by selected explanatory variables. Pearson’s chi-square test was used and variables with p<0.05 were included for further analysis. The sample weight was used for the estimation of percentage distribution. Bivariate and multivariate logistic regression models were employed to assess the socio-demographic and environmental factors associated with diarrhea in children under five. The regression results are presented by unadjusted and adjusted odds ratio (OR) with 95% confidence interval (CI) and the results were considered to be statistically significant at p<0.05. All the statistical analyses were performed using STATA version 14.0 (StataCorp LP, College Station, TX, USA).

Results

Socio-demographic characteristics

A total of 247,743 living children aged 0–59 months were included in the analysis. The majority of children lived in rural areas (71.6%), affiliated to Hindu (78.6%), belonged to poor families (24.9% in the poorest wealth quintile and 21.8% in the poorer wealth quintile), and resided in the central and east regions of the country. About 43.5% of mothers had below the secondary level of education, while the corresponding figure for fathers was 31.6%. About 57.7% of mothers were in the age range of 25–34 years and one-fourth (24.8%) of them were underweight. Over one-third of mothers (34.3%) had no exposure to mass media. Respondents were almost equally distributed in all age groups. Among total children, 52.1% were male, 47.5% were in the birth order of 2–3, and 17.7% of children had low birth weight (Table 1).

Environmental condition of household

Around 46.5% of children living in the houses had no toilet facility. Only about 10% of children were drinking water from unimproved sources. About two-thirds (65.9%) of parents reported that their practice for child stool disposal was not safe. About 43.2% of children living in houses were made of dirt floor materials, and 14% of houses were made of thatch roof materials (Table 2).

Prevalence of childhood diarrhea by socio-demographic factors

The prevalence of diarrhea was significantly higher in children living in rural areas as compared to those living in urban (9.6 vs. 8.2%) (p= 0.001). Childhood diarrhea was common among scheduled caste (9.6%) and other backward classes (9.6%) and Muslim children (9.9%). Maternal education was found to be significantly correlated with children’s diarrhea occurrence (p<0.001). However, father’s education was not significantly associated with child diarrhea (p=0.950). The occurrence of diarrhea was substantially higher among those children whose mothers were in 15–24 years (10.7%), underweight (10.1%) and had no access to mass media (10.3%). Childhood diarrhea was also higher in children from the poorest households (10.2%) and those from the central region of the country (13.1%). Furthermore, the prevalence of diarrheal disease was common among children aged 0–11 months (14.0%) and 12–23 months (13.4%), male children (9.5%), birth order above three (10.4%) and children with low birth weight (10.2%) (Table 3).

Childhood diarrhea by environmental condition

The incidence of diarrhea was found to be considerably higher in children of households who had no toilet facility compared to those whose households had a toilet facility (10.0 vs. 8.3%). Surprisingly, the proportion of children’s diarrhea was higher in children of households consumed improved sources of drinking water than those children whose households consumed unimproved sources (9.2 vs. 8.0%). The prevalence of diarrhea was higher among households where child stool disposal practices were not safe (10.0%). The occurrence of diarrhea was substantially higher in children living in houses having dirt floor (10.3%) and thatch roof materials (10.4%) (Table 4).

Socio-demographic factors of diarrhea among under-five children

In bivariate analysis, it is found that all the selected socio-demographic factors were significantly associated with children’s diarrhea in the past two weeks. Multivariate analysis of this study revealed that children living in rural areas were associated with 5% higher likelihood of diarrheal disease (aOR: 1.05; 95% CI: 1.01, 1.09) as compared to living in urban. Children belonged to scheduled tribe (aOR: 0.83; 95% CI: 0.79, 0.89) and other castes (aOR: 0.92; 95% CI: 0.88, 0.97) were less likely to develop diarrhea as compared to scheduled caste children. The likelihood of childhood diarrhea was 18% higher among Muslim children (aOR: 1.18; 95% CI: 1.13, 1.24) as compared to children from Hindu religion. Participants whose mothers had the secondary and above level of education were associated with 9% decreased odds of diarrhea (cOR: 0.92; 95% CI: 0.88, 0.97) as compared to those mothers who had no formal education or had primary level of education in crude analysis. However, this association was not significant in the adjusted analysis.

Unadjusted analysis of this study also found that the likelihood of childhood diarrhea decreased with an increase in maternal age. Children of mothers aged 25–34 years (cOR: 0.77; 95% CI: 0.75, 0.80) and 35–49 years (cOR: 0.73; 95% CI: 0.69, 0.77) were less likely to suffer from the diarrheal disease than those children of mothers aged 15–24 years. Maternal BMI also had a significant association with children’s diarrhea occurrence in unadjusted analysis. Children of underweight women (cOR: 1.11; 95% CI: 1.08, 1.15) were 11% more likely and children of obese women (cOR: 0.87; 95% CI: 0.83, 0.91) were l3% less likely to develop diarrhea as compared to children of mothers who had normal BMI. The results also revealed that access to mass media of women was found to be a protective factor against childhood diarrhea. Children of women who had mass media exposure were associated with 18% decreased odds of diarrhea (cOR: 0.82; 95% CI: 0.80, 0.95) than those women who were not exposed to mass media. Wealth status of the household was found to have a strong association with childhood diarrhea. Children in the richest wealth quintile were 26% less likely to have diarrhea as compared to those children in the poorest wealth quintile (cOR: 0.74; 95% CI: 0.71, 0.78). The occurrence of diarrhea was also varied across geographical regions. After adjusting for socio-demographic and environmental characteristics, children from the central region (aOR: 1.61; 95% CI: 1.52, 1.70) and west (aOR: 1.08; 95% CI: 1.01, 1.15) regions were more likely and children from the northeast (aOR: 0.49, 95% CI: 0.43, 0.56) and south (aOR: 0.80, 95% CI: 0.75, 0.85) regions were less likely to experience diarrhea as compared to children from the north region of the country.

The risk of diarrhoea was decreased by 4–71% in children aged 12–23 months (aOR: 0.96; 95% CI: 0.92, 1.00), 24–35 months (aOR: 0.58; 95% CI: 0.55, 0.61), 36–47 months (aOR: 0.39; 95% CI: 0.37, 0.41) and 48–59 months (aOR: 0.29; 95% CI: 0.28, 0.31) as compared to those children aged 0–11 months. Female children were associated 8% decreased odds of diarrhea (aOR: 0.92; 95% CI: 0.89, 0.95) than male children. Birth order was found to be positively related to diarrheal disease in children. The odds of diarrhoeal disease increased by 22% in fourth or higher birth order children (cOR: 1.22; 95% CI: 1.17, 1.27) as compared to first birth order children. Low birth weight also increased the risk of diarrhea by 19% (cOR: 1.19; 95% CI: 1.15, 1.24) as compared to children with normal birth weight (Table 5).

Environmental factors of diarrhea among under-five children

Crude analysis demonstrated that children having a toilet facility in their houses had 18% less likely to have diarrheal diseases (cOR: 0.82; 95% CI: 0.80, 0.84) than those children who had no toilet facility in their houses. Surprisingly, children living in households having improved sources of drinking water were associated with higher odds of diarrhea (cOR: 1.17; 95% CI: 1.12, 1.24) compared to those households having unimproved sources of drinking water. Child unsafe stool disposal was associated with an elevated risk of diarrhea (aOR: 1.06; 95% CI: 1.02, 1.11) as compared to safe disposal of child stool. Children from households having dirt floor materials were associated with 8% higher likelihood of diarrhea (aOR: 1.08; 95% CI: 1.03, 1.12) compared to those whose households had non-dirt floor materials. Similarly, children living in houses having thatch roof materials were 8% more likely to experience diarrheal disease (aOR: 1.08; 95% CI: 1.04, 1.13) than those children from houses with metal or concrete roof materials (Table 5).

Discussion

The present study has examined the socio-demographic and environmental factors of diarrhea in children under five years old in India. Although the prevalence of childhood diarrhea has been reduced over recent periods, the burden of this preventable disease remains high. As per the NFHS-4, around 9% of under-five children suffered from diarrheal diseases [5].

The findings of this study revealed that children living in rural areas were more likely to experience diarrhea than those living in urban areas. This finding is in the line of previous studies conducted in India [13] and Jamma district of Ethiopia [17]. This could be due to limited access to healthcare and sanitation facilities in rural areas [17]. Caste and religion were significantly associated with childhood diarrheal disease. The present study found that children from scheduled tribes and other caste groups had a lower risk of diarrhea compared with those from scheduled castes. This finding is consistent with a study done in India [13]. Moreover, Muslim children were 18% more likely to develop the diarrhoeal disease compared to Hindu children. This might be due to scheduled caste and Muslim children have lower access to improved sources of drinking water and sanitation facilities than the other socio-religious groups of children.

Concerning maternal characteristics, maternal education and access to mass media were included in the multivariate analysis and none of these variables were found to be significant. However, crude analysis of this study showed that all maternal factors were significantly determined diarrhea in children. For instance, women’s secondary or higher level of education was associated with 9% reduced likelihood of diarrhea in children as compared to those who had no education or primary level of education. A similar finding is also reported in other studies conducted in Bangladesh [9] and different parts of Ethiopia [8, 11, 14]. This could be explained by hygiene practices, child feeding and caring practices, and improved living conditions of an educated mother [14]. Furthermore, this study also found that underweight mothers were associated with 11% increased risk of diarrhea in children. Children born to underweight women may also become malnourished and have a weak immune system. Therefore, malnourished are highly susceptible to infectious diseases including diarrhea. Mass media exposure of mothers was found to be a protective factor of childhood diarrhea. In unadjusted analysis, the study has found that children whose mothers had mass media access were less likely to have diarrhea.

Crude analysis of this study also indicated that wealth status of the household was significantly associated with children’s recent diarrhea occurrence. The present study revealed that the likelihood of diarrhea was reduced by 26% in children from the richest wealth quintile as compared to those from the poorest wealth quintile. A similar finding is also found in earlier studies conducted in India [13] and other developing countries [9, 23]. Wealth quintile variable was excluded from the multivariate analysis since household wealth was measured from a range of consumer items, drinking water and sanitation facilities including dwelling characteristics. Many of these characteristics were included in the multivariate analysis as environmental factors.

Geographical region also made significant variations in the prevalence of diarrhoeal diseases. The present study indicated that children from the central region were 61% and children resided in the western region were 8% more likely to experience diarrhea as compared to the southern region. In contrast, children from the northeast region were 51% and children from the south region were 20% less likely to develop diarrhea. Geographical differences in diarrheal disease also reported in a study conducted in India [24]. This could be due to unequal access to healthcare and inequity in the provisioning of drinking water and sanitation facilities [25].

This study found that the risk of diarrhea was decreased by 43–70% in children aged 24 to 59 months as compared to infants (children aged 0–11 months). An earlier study conducted in Kashmir (India) indicated maximum reported cases of diarrheal disease between the ages of 6 to 11 months [26]. Likewise, a study carried out in Jamma district of Ethiopia found that the likelihood of developing diarrhea was more than twice among children aged 6 to 23 months as compared to children aged two years or above [17]. A similar finding is also found in a study done in Bangladesh [9]. This is because, in the infant age, children are exposed to different contaminated agents leading to infectious diseases while crawling and walking [14]. Female children were found to have 8% reduced risk of diarrhea than male children. A study conducted in Bangladesh also revealed that male children had higher odds of diarrhea than female children [9]. A similar finding is also reported in a study carried out in rural parts of western Maharashtra [27]. The current study further demonstrated that children with low birth weight were more likely to have diarrhea as compared to those children with normal birth weight. A rural community-based study in south India indicated that low birth weight in children increased the risk of diarrheal disease by almost three-folds [21]. 

Among environmental factors, child stool disposal, floor and roof materials of the household unit were significantly associated with diarrhea in under-five children. In agreement with previous research [11], the current study also revealed that unsafe disposal of child stool was associated with 6% increased likelihood of diarrhea as compared to safe child stool disposal. This might be due to disposed child stool contaminated the water storage that may cause diarrheal diseases. The odds of having diarrhea were 8% higher among children living in houses with dirt floor materials as compared to those living in houses with non-dirt floor materials. This finding is consistent with several studies conducted in Ethiopia [8, 10, 11, 17]. Similarly, the risk of developing the diarrheal disease was 8% higher in children from households having thatch roof materials than those from households having metal or concrete roof materials. This finding is also in line with studies conducted in Ethiopia [16]. This could be because of the dirty floor and thatch roof materials of dwelling cause the transmission of pathogens, which may increase the risk of diarrheal diseases [8].

Limitations and strengths

The current study findings should be discussed in light of some limitations. Firstly, causality cannot be assumed from this analysis due to the cross-sectional nature of data. Further research is needed using longitudinal data to examine the potential pathways for the occurrence of diarrhea in children. Secondly, this study used self-reported retrospective information. Therefore, potential recall bias might be introduced in this study. Thirdly, since the study used secondary data, it was not possible to include all important factors of diarrheal disease, particularly behavioral factors in the analysis due to the paucity of information in the dataset.

Besides the above limitations, this study provides comprehensive evidence on the socio-demographic and environmental factors of diarrhoeal disease in children under five using a large-scale survey in India. The study sample size was large with nation-wide representation. This study is important for public health intervention to reduce the burden of diarrheal disease among children.

Conclusions

A number of socio-demographic such as rural-urban residence, caste, religion, region, child’s age and sex are associated with the risk of diarrhea among under-five children in India. Diarrhea is common among rural, scheduled caste, Muslim and poor families’ children. Concerning environmental factors, stool disposal practices in the household, main floor and roof materials of the household unit are risk factors of diarrhea. Interventions should be made in improving MCH to reduce the burden of diarrhea and diarrhea-related mortalities in children under five. Targeted approach should be initiated to mitigate the problem of poor health status of children by providing adequate health care among socio-economically disadvantaged women and children. The policy-makers and stakeholders should address adverse environmental conditions by the provision of latrine and improved housing facilities.

Abbreviations

BMI: Body mass index; CI: Confidence interval; ICDS: Integrated Child Development Scheme; MCH: Maternal and child health; NFHS: National Family Health Survey; OR: Odds ratio; WHO: World Health Organization

Declarations

Ethical approval and consent to participate

The present used secondary data which is available in public domain. The dataset has no identifiable information of the survey participants. Therefore, no ethical approval is required for conducting this study.

Consent for publication

Not applicable

Availability of data and materials

The dataset analysed during the current study are available in the Demographic Health Surveys (DHS) repository, https://dhsprogram.com/data/available-datasets.cfm.

Competing interests

The author declares no competing interests.

Funding

The author did not receive any financial assistance from any funding agency.

Authors’ contributions

PP conceptualized and designed the study, gathered and analysed the data and wrote the manuscript.

Acknowledgments

The author is grateful to the MEASURE Demographic Health Survey Survey (DHS) for providing the dataset in this study.

Authors’ information

The author is currently pursuing Ph.D. at the Centre for the Study of Regional Development, Jawaharlal Nehru University, New Delhi. His current research interests include child marriage, violence against women and public health issues. The author is currently investigating child marriage practice in West Bengal using socio-ecological framework. The author published research articles in various public health journals including PloS ONE, Journal of Public Health (Springer) and Midwifery (Elsevier). He received his M.A. and M.Phil. degrees in geography from Jawaharlal Nehru University, New Delhi.

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Tables

Table 1 Socio-demographic characteristics of living children aged 0–59 years in India, 2015–16

Variables

Frequency (n)

Percentage (%)

Place of residence

 

 

Urban

59,222

28.5

Rural

188,521

71.6

Caste

   

Scheduled caste

46,486

22.4

Scheduled tribe

49,804

11.0

Other backward classes

97,011

46.1

Others

43,329

20.5

Religion

   

Hindu

178,712

78.6

Muslim

39,004

16.6

Others

30,027

4.9

Maternal education

   

Illiterate/primary

112,129

43.5

Secondary and above

135,614

56.5

Father's education

   

Illiterate/primary

13,864

31.6

Secondary and above

29,151

68.4

Maternal age in years

   

15–24

80,714

34.9

25–34

142,212

56.7

35–49

24,817

8.4

Maternal BMI

   

Underweight

57,793

24.8

Normal

152,834

60.4

Obese

33,876

14.8

Access to mass media

   

No

91,357

34.3

Yes

156,386

65.7

Household size

   

<6

104,964

43.3

6+

142,779

56.8

Wealth quintile

   

Poorest

64,443

24.9

Poorer

58,294

21.8

Middle

49,588

19.9

Richer

41,472

18.4

Richest

33,946

15.1

Region

   

North

46,775

13.2

Central

70,915

26.5

East

51,507

25.4

Northeast

35,761

3.5

West

17,706

12.9

South

25,079

18.4

Age of child in months

   

0–11

48,295

19.3

12–23

49,284

20.0

24–35

49,084

19.8

36–47

51,497

20.9

48–59

49,583

20.0

Sex of child

   

Male

128,609

52.1

Female

119,134

47.9

Birth order

   

1

91,872

38.6

2–3

116,467

47.5

4+

39,404

13.9

Birth weight

   

Low birth weight

31,928

17.7

Normal

155,254

82.4

 

Table 2 Environmental characteristics of living children aged 0–59 years in India, 2015–16

Environmental characteristics

Frequency (n)

Percentage (%)

Availability of toilet facility

   

No facility

103,755

46.5

Facility

130,525

53.5

Sources of drinking water

   

Unimproved

29,084

10.0

Improved

205,107

90.0

Child stool disposal

   

Safe

83,545

34.1

Not safe

160,790

65.9

Main floor material

   

Dirt

107,786

43.2

Non-dirt

126,668

56.9

Main roof material

   

Thatch

32,407

14.0

Metal/concrete

193,533

86.0

 

Table 3 Prevalence of diarrheal disease by socio-economic and demographic characteristics of respondents in India, 2015–16

Socio-economic and demographic characteristics

Prevalence (%)

P-value

Place of residence

 

0.001

Urban

8.2

 

Rural

9.6

 

Caste

 

0.000

Scheduled caste

9.6

 

Scheduled tribe

8.1

 

Other backward classes

9.6

 

Others

8.8

 

Religion

 

0.000

Hindu

9.2

 

Muslim

9.9

 

Others

7.3

 

Maternal education

 

0.000

Illiterate/primary

9.6

 

Secondary and above

8.8

 

Father's education

 

0.950

Illiterate/primary

9.6

 

Secondary and above

9.2

 

Maternal age in years

 

0.000

15–24

10.7

 

25–34

8.5

 

35–49

8.0

 

Maternal BMI

 

0.000

Underweight

10.1

 

Normal

9.2

 

Obese

8.1

 

Access to mass media

 

0.000

No

10.3

 

Yes

8.6

 

Household size

 

0.519

<6

9.08

 

6+

9.28

 

Wealth quintile

 

0.000

Poorest

10.2

 

Poorer

9.5

 

Middle

9.3

 

Richer

8.5

 

Richest

7.8

 

Region

 

0.000

North

8.1

 

Central

13.1

 

East

8.7

 

Northeast

4.2

 

West

8.5

 

South

6.5

 

Age of child in months

 

0.000

0–11

14.0

 

12–23

13.4

 

24–35

8.5

 

36–47

5.8

 

48–59

4.6

 

Sex of child

 

0.000

Male

9.5

 

Female

8.9

 

Birth order

 

0.000

1

8.7

 

2–3

9.2

 

4+

10.4

 

Birth weight

 

0.000

Low birth weight

10.2

 

Normal

8.6

 

 

Table 4 Prevalence of diarrheal disease by environmental condition of respondents in India, 2015–16

Environmental characteristics

Prevalence (%)

P-value

Availability of toilet facility

 

0.000

No facility

10.0

 

Facility

8.3

 

Sources of drinking water

 

0.000

Unimproved

8.0

 

Improved

9.2

 

Child stool disposal

 

0.000

Safe

7.7

 

Not safe

10.0

 

Main floor material

 

0.000

Dirt

10.3

 

Non-dirt

8.2

 

Main roof material

 

0.000

Thatch

10.4

 

Metal/concrete

8.8

 

 

Table 5 Bivariate and multivariate logistic regression analysis of socio-demographic and environmental factors associated with childhood diarrhea in India, 2015–16

Characteristics

Crude OR

95% CI

 

Adjusted OR

95% CI

Socio-demographic

 

 

 

 

 

Place of residence

             

Urban

1.00

     

1.00

   

Rural

1.18*

1.14

1.22

 

1.05*

1.01

1.09

Caste

             

Scheduled caste

1.00

     

1.00

   

Scheduled tribe

0.83*

0.78

0.87

 

0.83*

0.79

0.89

Other backward classes

1.00

0.96

1.04

 

0.97

0.93

1.01

Others

0.91*

0.87

0.95

 

0.92*

0.88

0.97

Religion

             

Hindu

1.00

     

1.00

   

Muslim

1.09*

1.05

1.13

 

1.18*

1.13

1.24

Others

0.79*

0.73

0.85

 

1.07

0.99

1.16

Maternal education

             

Illiterate/primary

1.00

     

1.00

   

Secondary and above

0.91*

0.88

0.93

 

1.01

0.98

1.05

Maternal age in years

             

15–24

1.00

     

25–34

0.77*

0.75

0.80

 

35–49

0.73*

0.69

0.77

 

Maternal BMI

             

Underweight

1.11*

1.08

1.15

 

Normal

1.00

     

Obese

0.87*

0.83

0.91

 

Access to mass media

             

No

1.00

     

1.00

   

Yes

0.82*

0.80

0.85

 

0.98

0.94

1.02

Wealth quintile

             

Poorest

1.00

           

Poorer

0.92*

0.88

0.96

 

Middle

0.90*

0.86

0.93

 

Richer

0.82*

0.78

0.85

 

Richest

0.74*

0.71

0.78

 

Region

             

North

1.00

     

1.00

   

Central

1.71*

1.63

1.79

 

1.61*

1.52

1.70

East

1.09*

1.03

1.14

 

1.02

0.97

1.08

Northeast

0.49*

0.44

0.55

 

0.49*

0.43

0.56

West

1.05

0.99

1.11

 

1.08*

1.01

1.15

South

0.79*

0.75

0.83

 

0.80*

0.75

0.85

Age of child in months

             

0–11

1.00

     

1.00

   

12–23

0.95*

0.92

0.99

 

0.96*

0.92

1.00

24–35

0.57*

0.55

0.60

 

0.58*

0.55

0.61

36–47

0.38*

0.36

0.40

 

0.39*

0.37

0.41

48–59

0.30*

0.28

0.31

 

0.29*

0.28

0.31

Sex of child

             

Male

1.00

     

1.00

   

Female

0.93*

0.91

0.96

 

0.92*

0.89

0.95

Birth order

             

1

1.00

     

1.00

   

2–3

1.07*

1.03

1.10

 

1.01

0.98

1.05

4+

1.22*

1.17

1.27

 

1.02

0.97

1.07

Birth weight

             

Low birth weight

1.19*

1.15

1.24

 

Normal

1.00

     

Environmental

 

 

 

 

 

 

 

Availability of toilet facility

           

 

No facility

1.00

     

1.00

   

Facility

0.82*

0.80

0.84

 

0.97

0.94

1.02

Sources of drinking water

             

Unimproved

1.00

     

1.00

   

Improved

1.17*

1.12

1.24

 

1.03

0.98

1.09

Child stool disposal

             

Safe

1.00

     

1.00

   

Not safe

1.32*

1.28

1.36

 

1.06*

1.02

1.11

Main floor material

             

Dirt

1.28*

1.25

1.32

 

1.08*

1.03

1.12

Non-dirt

1.00

     

1.00

   

Main roof material

             

Thatch

1.21*

1.16

1.25

 

1.08*

1.04

1.13

Metal/ concrete

1.00

     

1.00

   

* p<0.05; OR= Odds ratio; CI= Confidence interval.