Evaluation of Wash Interventions and Risk Factors of Diarrhoea Among Children Under Five Years in Anloga District, Volta Region, Ghana.

Abstract

Introduction: Diarrhoea related to inadequate water, sanitation, and hygiene (WASH) practices account for about 58% of all diarrhoea deaths in low-middle-income-countries. Despite improved WASH interventions and rotavirus vaccination, the rate of decline in diarrhoea among children under-five years has been slower, threatening the achievement of Sustainable Development Goal 3, which aims to enhance health and well-being. In Ghana, improving WASH in communities through district assemblies and Non-Governmental Organisations (NGOs) and Rotavirus vaccination program for children are interventions to control diarrhoea. Yet, diarrhoea prevalence in children under-five years in Volta Region, increased from 6.9% in 2014 to 9.1% in 2022, suggesting the need for a comprehensive assessment of factors, including nutrition, health-seeking behaviours and pathogens. Objective: This study evaluated the implementation of WASH interventions and assessed the risk factors associated with diarrhoea among children under five years in the Anloga District of the Volta region, Ghana. Methods: The study was conducted from August 2022 to December 2023 in three phases using multiple study designs and mixed data collection methods. Analysis was done separately for each study and interpretation drawn from all studies. In phase one, a process evaluation of WASH interventions in the 2018-2021 Mid-term development plan for Anloga District was done using a cross-sectional approach. A desk review of all relevant documents was conducted, whiles interviews with district WASH committee members, and communities were done. Phase two employed a 1:1 case-control study among children under-five years. Cases were children under-five years in Anloga District presenting with diarrhoea in the health facility from November 2022 to December 2023, while controls were children under-five years from the same vicinity of the case but without diarrhoea in the past seven days prior to the interview. Interviews and anthropometric measurements were done. Phase three was a cross-sectional analysis of case-patients stool samples testing for rotavirus A using ELISA, and additional diarrhoea pathogens using TaqMan Array Card (TAC) PCR technology. ELISA was done for 80 samples and TAC for 38 samples. Desk reviewed data was used to develop a ten-step framework for assessment of the level of intervention implementation. Transcribed interviews and reports were used to explain the gaps identified in the implementation process. To determine factors associated with diarrhoea, binary logistic regression models was fitted through the generalized linear model with a logit link. Frequencies of pathogen types, pathogen co-infections and distribution by age and sex pathogens were generated. Diarrhoea severity was analysed descriptively by WASH interventions in the district and the pathogens present. Analysis was done with Stata version 17. All statistical tests were done at 5% significance level. Results: The process evaluation revealed that Anloga District achieved a reach of 72.5% and 49% for construction of water sources and toilet facilities respectively. Of the ten implementation steps outlined, the district fully followed four, and showed no evidence of implementing two steps, indicating significant gaps, particularly in community engagement, post-project support, and funding. The case-control study recruited 193 cases and 193 controls. Children using household toilets had reduced odds of diarrhoea (aOR: 0.48, 95%CI: 0.31-0.73), while underweight children had a threefold increased odds of diarrhoea (aOR: 3.06, 95%CI: 1.36-6.89). Health-seeking practices showed no significant association with diarrhoea. The other symptoms diarrhoea cases presented to the health facility with were fever (87.1%, 168/193), and mucus in stool (78.8%, 152/193). Severe cases were 7.8% (15/1939 and moderate 59% (114/193). For cases with improved water sources, 60% (114/190) had moderate diarrhoea. Majority of the case from households with improved toilet facilities were moderate diarrhoea cases (59.1%, 90/152). Of the rotavirus vaccinated children, 37.23% (70/188) had moderate diarrhoea. The prevalence of Rotavirus A among diarrhoea cases who were tested was low (2.5%, 2/80). Bacteria was found in 86.8% (33/38) of the samples. The most common pathogens were Enteroaggressive Escherichia coli (53%, 20/38) and norovirus (26%, 10/38). The rate of co- infections was high (68%: 26/38) with 36.8% (14/38) co-infected with four or more pathogens. Co-infection rates by age or sex were not significantly different. Cases with four of more pathogens identified in their stool reported more moderate-severe diarrhoea (53.4%, 7/13). More cases with virus-bacteria combination had moderate-severe diarrhoea (75.0%, 12/16) compared other co-infections. Conclusion: The WASH implementation process in Anloga District is suboptimal, with significant shortcomings in stakeholder engagement and post-implementation support. The study identified that household toilet use reduces the risk of diarrhoea, while being underweight significantly increases diarrhoea occurrence in children-under five years. The leading pathogens causing diarrhoea in children were Enteroaggressive Escherichia coli and norovirus, with rotavirus contributing the least. The prevalence of other diarrhoeal pathogens was high, with high rates of co-infection. The study recommends addressing community engagement gaps during implementation to increase acceptance and effectiveness of interventions. Also, collaboration between health workers and environmental health officers to intensify WASH activities can disrupt faecal-oral transmission pathways in the absence of other diarrhoea vaccines.