Kumar V et al | DOI: 10.65188/nurexus.1022
Nurexus | Journal of MedVerse Research and Practice | Volume 3 | Issue – 05 | May 2025
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A Study on the Incidence of Diarrheal Conditions in Under-Five Children
Dr. Vishnu Kumar
1
, Dr. Johnson
2
Postgraduate, Professor
Department of Pediatrics, Government Medical College, Kerala
Email ID: vishnukumar92@gmail.com
Submission Date: 24.04.2025
Accepted Date: 22.05.2025
Published Date: 31.05.2025
DOI: 10.65188/nurexus.1022
Copyright © 2025. The author(s). Published by Journal of MedVerse Research and Practice. This is an open-access
article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.
Abstract
Introduction: Diarrhoeal diseases continue to pose a major threat to the health and survival of children under five
years of age, especially in developing countries. Despite being preventable and treatable, they remain a leading cause
of childhood morbidity. This study aimed to assess the incidence of diarrhoea and identify its associated risk factors
among under-five children in the Thiruvananthapuram district of Kerala.
Materials and Methods: A community-based cross-sectional study was conducted in the Department of Paediatrics,
Government Medical College, Thiruvananthapuram. A total of 300 children aged 0–59 months were selected using
multistage random sampling. Data were collected from caregivers through face-to-face interviews using a pre-tested,
semi-structured questionnaire. Information on demographic details, water sources, feeding practices, hygiene
behaviors, and diarrhoeal episodes in the preceding two weeks was gathered. Data analysis was performed using
SPSS version 26.0, with chi-square and multivariate logistic regression tests used to identify significant associations.
Results: The overall two-week incidence of diarrhoea was 23.3%. Children aged 12–23 months reported the highest
incidence (30.6%). Use of well water (33.3%) and borewell/handpump water (30.8%) was significantly associated
with increased risk compared to piped water (15.6%) (p = 0.002). Children who were not exclusively breastfed had a
higher incidence (35.0%) than those exclusively breastfed (17.5%) (p = 0.001). Poor maternal handwashing practices
were also linked to a higher occurrence of diarrhoea. Multivariate analysis identified age 12–23 months, unprotected
water source, lack of exclusive breastfeeding, and irregular maternal hand hygiene as independent predictors.
Conclusion: Diarrhoeal morbidity among under-five children in this region remains considerable. Key modifiable
risk factors include unsafe water, inadequate breastfeeding, and poor hygiene. Focused community interventions
promoting safe water access, exclusive breastfeeding, and proper hygiene practices are essential to reduce the burden
of diarrhoeal diseases.
Keywords: Diarrhoea, Under-five children, Breastfeeding, Water source, Hygiene, Child health
Introduction
Diarrhoea remains a major contributor to illness and death among children under five years of age globally,
particularly in resource-limited settings. Each year, millions of such cases are reported, with the disease
ranking as one of the top causes of child mortality despite being both preventable and manageable through
basic public health interventions
[1]. The underlying drivers often include contaminated drinking water,
poor sanitation infrastructure, inadequate hygiene practices, and childhood malnutrition
[2,3]. Although
extensive health campaigns and global partnerships have been initiated to reduce this burden, the incidence
remains troublingly high in many low- and middle-income countries (LMICs), where access to clean water
and health services is still limited
[4,5].
Kumar V et al | DOI: 10.65188/nurexus.1022
Nurexus | Journal of MedVerse Research and Practice | Volume 3 | Issue – 05 | May 2025
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In the Indian context, diarrhoea continues to pose a persistent threat to child health, especially among
underserved communities. According to the National Family Health Survey-5 (NFHS-5), 7.3% of Indian
children under five experienced diarrhoea in the two weeks before the survey, with disproportionately
higher rates in states such as Uttar Pradesh, Bihar, and Madhya Pradesh
[6]. This regional variability is
often linked to differences in water and sanitation coverage, maternal education levels, and accessibility of
healthcare services
[7,8]. Children raised in densely populated slum settings characterized by poor hygiene
and environmental pollution tend to bear the brunt of this preventable disease
[9,10].
To address this issue, the Government of India has introduced several public health programs, including the
Intensified diarrhoea Control Fortnight (IDCF), which aims to promote the use of oral rehydration salts
(ORS), zinc supplementation, and appropriate hydration strategies during diarrheal episodes
[11].
Nevertheless, significant barriers persist, including delays in care-seeking, limited community awareness,
and inconsistent program implementation across regions
[12,13]. Additionally, seasonal factors such as
monsoon rains and harmful weaning practices contribute to spikes in diarrhoea cases, especially during the
first two years of life
[14].
There is clear evidence that certain socio-demographic and behavioural factors elevate the risk of diarrheal
illness in children. Those born to mothers with lower educational attainment or living in economically
disadvantaged households tend to be at higher risk
[15]. Moreover, protective practices such as exclusive
breastfeeding, full immunization, and routine handwashing with soap have been shown to significantly
lower the occurrence of diarrheal episodes
[16,17]. Understanding the local prevalence and risk patterns is
essential for crafting region-specific strategies to address this pressing health concern.
This study seeks to examine the incidence of diarrheal conditions in under-five children residing in the
Thiruvananthapuram district of Kerala and to explore key demographic, environmental, and behavioural
factors contributing to this condition. The results of this research are expected to support locally relevant
health interventions and guide efforts aimed at meeting India’s child health goals through evidence-based
policy making.
Materials & Methods
This research was carried out as a community-based cross-sectional study in the Department of Pediatrics,
Government Medical College, Thiruvananthapuram, Kerala, to estimate the incidence of diarrheal
conditions among children below five years of age. The study population consisted of children aged
between 0 and 59 months who had been residing in both rural and urban areas of Thiruvananthapuram
district for a minimum of six months prior to the survey period. Children with diagnosed chronic
gastrointestinal disorders or other serious health conditions requiring long-term care were excluded to
minimize confounding variables.
The sample size was determined using the standard formula for cross-sectional studies, considering a
prevalence rate of 7.3% as reported by NFHS-5
[1], with a 95% confidence interval, 5% margin of error,
and an additional buffer for non-response. This yielded a final sample size of 300 children.
To ensure representativeness, a multistage random sampling method was adopted. Initially, several
panchayats and municipal wards were randomly selected from the district map. Within each selected area,
households were identified through systematic listing, and one eligible under-five child from each
household was included through simple random selection if more than one child was present.
Data collection was facilitated through face-to-face interviews using a semi-structured, pre-tested
questionnaire designed in the local language. The questionnaire was administered to the child's primary
caregiver, usually the mother. It included questions on household demographic information, maternal
Kumar V et al | DOI: 10.65188/nurexus.1022
Nurexus | Journal of MedVerse Research and Practice | Volume 3 | Issue – 05 | May 2025
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education, sanitation and hygiene practices, source of drinking water, immunization status, feeding
behavior, and history of diarrheal episodes within the preceding 14 days. Diarrhea was operationally
defined as the passage of three or more loose or watery stools in 24 hours, based on the World Health
Organization’s criteria
[11].
Collected data were systematically entered into Microsoft Excel and analyzed using IBM SPSS version
26.0. Descriptive statistics such as frequencies and percentages were used to summarize data. The Chi-
square test was employed to evaluate associations between diarrheal incidence and selected risk variables.
Furthermore, multivariate logistic regression analysis was performed to identify significant independent
predictors, with results presented as adjusted odds ratios (AOR) and 95% confidence intervals. A p-value
less than 0.05 was considered statistically significant.
Prior to the commencement of the study, ethical approval was obtained from the Institutional Ethics
Committee of Government Medical College, Thiruvananthapuram. Written informed consent was secured
from all participating parents or guardians. All information collected during the study was kept strictly
confidential and used solely for research purposes.
Institutional ethical clearance was obtained from the Ethics Committee of Government Medical College,
Kerala (Ref No: EC/GMC-KL/2023/73456). A detailed Participant Information Sheet was provided to the
participants, and written informed consent was obtained prior to their participation in the study.
Results
Table 1: Age-wise Distribution of Diarrhea among Under-Five Children (n = 300)
Age Group
(months)
Total Children
(n)
Children with Diarrhea
(n)
Percentage with Diarrhea
(%)
0–11
70
18
25.7%
12–23
85
26
30.6%
24–35
60
14
23.3%
36–47
45
7
15.6%
48–59
40
5
5.3%
Total
300
70
100%
The incidence of diarrhea was highest among children aged 12–23 months (30.6%), indicating increased
vulnerability during the weaning and early toddler stages.
Table 2: Association between Type of Drinking Water and Diarrhea (n = 300)
Age Group
(months)
Total Children
(n)
Children with Diarrhea
(n)
Percentage with Diarrhea
(%)
p-
value
0–11
70
18
25.7%
0.002
12–23
85
26
30.6%
24–35
60
14
23.3%
Children using untreated water sources had higher diarrhea rates 33.3% for well water and 30.8% for
borewell users compared to 15.6% among those using piped water. The association was statistically
significant (p = 0.002), indicating increased risk with unprotected water sources.
Table 3: Diarrhoea vs Exclusive Breastfeeding Status (n = 300)
Exclusive Breastfeeding (6
Total Children
Diarrhoea Cases
Percentage
p-
Kumar V et al | DOI: 10.65188/nurexus.1022
Nurexus | Journal of MedVerse Research and Practice | Volume 3 | Issue – 05 | May 2025
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months)
(n)
(n)
(%)
value
Yes
200
35
17.5%
0.001
No
100
35
35.0%
Children who were not exclusively breastfed had a significantly higher incidence of diarrhoea (35%)
compared to those who were exclusively breastfed (17.5%). The association was statistically significant (p
= 0.001), highlighting the protective effect of exclusive breastfeeding in reducing diarrheal risk.
Table 4: Handwashing Practices Among Mothers and Diarrhoea in Children (n = 300)
Handwashing with Soap After Toilet
Total (n)
Diarrhoea Cases (n)
Percentage (%)
p-value
Always
180
25
13.9%
<0.001
Sometimes
90
30
33.3%
Poor hand hygiene practices among mothers were strongly associated with higher diarrhoea rates in
children. Only 13.9% of children had diarrhoea when mothers always used soap, while the incidence was
50% when soap was never used (p < 0.001).
Table 5: Multivariate Logistic Regression for Predictors of Diarrhoea (n = 300)
Risk Factor
Adjusted Odds Ratio (AOR)
95% CI
p-value
Age 12–23 months
2.1
1.1 – 4.0
0.020
Use of well water
2.3
1.2 – 4.3
0.010
Not exclusively breastfed
2.6
1.4 – 4.8
0.003
Irregular handwashing
3.1
1.6 – 6.0
<0.001
Multivariate analysis identified four significant predictors of diarrheal episodes: children aged 12–23
months, use of well water, lack of exclusive breastfeeding, and poor maternal hand hygiene. Irregular
handwashing had the strongest association, with children having over 3 times the odds of developing
diarrhoea.
Discussion
The overall incidence of diarrhoea reported within the last two weeks among the 300 under-five children
was 23.3%. This is consistent with the National Family Health Survey (NFHS-5) [1], which reported a
diarrhoea prevalence of 7.3% in Kerala and 7.7% nationally in the same recall period, though our higher
estimate may be attributed to localized environmental conditions and seasonal factors at the time of data
collection.
A striking finding was that the highest incidence occurred among children aged 12–23 months (30.6%).
This trend is in line with studies by Patel et al [2] in Gujarat and Dairo et al [3] in Nigeria, both of which
identified the weaning period and early toddlerhood as critical risk windows for diarrheal illness. This can
be explained by increased mobility, oral exploratory behaviour, and introduction of semi-solid foods during
this age, which may be contaminated due to improper hygiene.
The water source was significantly associated with diarrheal incidence. Children using well and borewell
water had higher rates of diarrhoea (33.3% and 30.8%, respectively), compared to those using piped water
(15.6%). This observation is in agreement with Sharma et al [4] in Madhya Pradesh, where the use of
untreated groundwater significantly increased the odds of diarrheal episodes. Similar results were observed
by Ahmed et al [5] in rural Bangladesh, where contamination of shallow tube wells was associated with
high diarrhoea prevalence.
Kumar V et al | DOI: 10.65188/nurexus.1022
Nurexus | Journal of MedVerse Research and Practice | Volume 3 | Issue – 05 | May 2025
Page 30
Exclusive breastfeeding showed a clear protective effect. Children who were exclusively breastfed for six
months had a diarrheal incidence of 17.5%, compared to 35% among those who were not. This finding
aligns with Bhandari et al [6] in Nepal, who concluded that exclusive breastfeeding reduces exposure to
pathogens through contaminated food and water. Abera et al [7] in Ethiopia also highlighted the
immunological benefits of breastmilk in preventing enteric infections.
Hand hygiene emerged as a strong determinant. Children whose mothers never used soap for handwashing
had the highest diarrhoea incidence (50%), compared to just 13.9% among those who always practiced
proper handwashing. This confirms the WHO and UNICEF joint report [8], which emphasizes that
handwashing with soap can reduce diarrheal incidence by up to 40%. A similar Indian study by Ray et al
[9] in West Bengal found that inadequate maternal hygiene was a major contributor to paediatric diarrhoea.
The multivariable logistic regression model identified four independent predictors of diarrhoea: child’s age
(12–23 months), use of well water, lack of exclusive breastfeeding, and irregular maternal handwashing.
Notably, irregular handwashing was associated with a three-fold increase in diarrheal risk (AOR: 3.1),
which aligns with Singh et al [10] in rural Uttar Pradesh, reinforcing the critical importance of hygiene
practices in reducing disease burden.
Overall, this study corroborates global and national evidence on the modifiable risk factors of diarrheal
disease in children. Interventions focusing on safe water access, maternal hygiene education, and exclusive
breastfeeding promotion can significantly reduce the burden of diarrheal diseases in similar settings.
Conclusion
This study highlights that diarrhoeal diseases remain a significant health concern among children under five
years in the Thiruvananthapuram district of Kerala. The findings reveal that factors such as younger age
(particularly 12–23 months), consumption of water from unprotected sources like wells and handpumps,
lack of exclusive breastfeeding, and poor maternal hand hygiene practices are strongly associated with
increased incidence of diarrhoea. These results emphasize the urgent need for strengthening public health
interventions that promote safe water supply, breastfeeding awareness, and improved hygiene practices at
the household level. Targeted education for caregivers and continued community-based programmes could
play a vital role in reducing the burden of diarrhoeal diseases and achieving better child health outcomes.
Further research is recommended to explore seasonal variations and behavioral factors contributing to
diarrhoea in similar settings.
Conflict of Interest: Nil
Reference
1. International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5),
2019–21: India. Mumbai: IIPS; 2021.
2. Patel MM, et al. Risk factors for childhood diarrhea in semi-urban Gujarat. J Trop Pediatr. 2020;66(4):362–
368.
3. Dairo MD, Ibrahim TF, Salawu AT. Prevalence and determinants of diarrhea among infants in Nigeria. BMC
Pediatr. 2017;17:32.
4. Sharma P, Gaur KL, Gupta V. Water sources and diarrhea incidence in rural India: A cross-sectional study.
Indian J Public Health. 2022;66(1):21–25.
5. Ahmed T, et al. Drinking water contamination and diarrheal risk in Bangladesh. Trop Med Int Health.
2020;25(11):1342–1349.
6. Bhandari N, et al. Protective effect of exclusive breastfeeding against diarrhea in infants. J Nutr.
2018;148(11):1763–1768.
7. Abera M, et al. Breastfeeding and risk of diarrhea in Ethiopian children. Pediatr Health Med Ther.
2019;10:37–43.
Kumar V et al | DOI: 10.65188/nurexus.1022
Nurexus | Journal of MedVerse Research and Practice | Volume 3 | Issue – 05 | May 2025
Page 31
8. World Health Organization (WHO), United Nations Children’s Fund (UNICEF). Progress on Household
Drinking Water, Sanitation and Hygiene 2023. Geneva: WHO; 2023.
9. Ray SK, et al. Diarrhea in under-five children and associated hygiene practices: A study in rural West
Bengal. Indian J Community Med. 2021;46(2):258–263.
10. Singh R, Gupta S, Srivastava A. Role of maternal hand hygiene in childhood diarrhea: A study in rural Uttar
Pradesh. J Family Med Prim Care. 2021;10(3):1245–1249.
11. World Health Organization. Diarrhoeal disease. 2023 [cited 2025 April 20]. Available from:
https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease
12. Salam RA, Das JK, Lassi ZS, Bhutta ZA. Impact of water, sanitation and hygiene interventions on diarrhoea
morbidity in children. Nutrients. 2022;14(11):2184.
13. UNICEF. Progress on household drinking water, sanitation and hygiene 2000–2022. Geneva: WHO &
UNICEF; 2023.
14. Mengistu AG, Asmamaw DB, Alemayehu YK. Diarrheal morbidity among children in Ethiopia. Environ
Health Insights. 2023;17:11786302231174744.
15. Kamuli-Fox A, Phiri P, Price J. Socioeconomic disparities in diarrhea among children in Malawi. Trop Med
Int Health. 2024;29(3):273–83.
16. International Institute for Population Sciences (IIPS). National Family Health Survey (NFHS-5), 2019–21:
India. Mumbai: IIPS; 2021.
17. Dandona R, Kumar GA, Henry NJ. Mapping under-five diarrhea prevalence in India. Lancet Glob Health.
2020;8(8):e1030–e1039.
