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REGIONAL INSTITUTE FOR POPULATION STUDIES 

 

HOUSING CONDITIONS AND THE INCIDENCE OF DIARRHOEA AMONG 

CHILDREN UNDER 5 YEARS IN GHANA 

 

 

BY 

 

 

PATRICK ADDO 

(10932994) 

 

 

THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, 

LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE 

AWARD OF MASTER OF ARTS IN POPULATION STUDIES DEGREE. 

 

 

JANUARY, 2023. 

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DECLARATION   

I, Patrick Addo, declare that this research work on the topic “Housing Conditions and the Incidence 

of Diarrhoea among Children Under 5 Years in Ghana” is the result of my original work produced 

under the supervision of Dr. Pearl Kyei. All ideas and information from other people’s work which 

are used in this project work have been duly acknowledged and cited.     

STUDENT   

PATRICK ADDO   

  

………………..   

DATE: 28th January 2023   

   

SUPERVISOR   

PEARL KYEI (PhD)   

   

 

DATE: 28th January 2023  

  

………………..       

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ACKNOWLEDGEMENTS   

First and foremost, I would like to recognize the efforts, time and inputs of my supervisor, Dr. Pearl 

Kyei, for her steadfast support, insightful, thorough reviews, critiques, and suggestions throughout 

my thesis writing. Special thanks go to Mr. Charles Asabere (PhD Candidate, RIPS),  Samuel 

Bosoka (MPhil Candidate, UHAS-SPH), Paul Obeng (MPhil Candidate, Health Education UCC) 

for assisting and guiding me through my data analysis.   

Profound gratitude goes to the Regional Institute for Population Studies (RIPS) for the 

immeasurable training and knowledge ingrained in me throughout the year of study. I am deeply 

honoured to be part of the RIPS alumni and I look forward to taking forward the legacy of RIPS.   

Thank you to my family for being there for me through the many highs and lows. Words cannot 

express my gratitude to my mother for a lifetime of unconditional love, assistance, support, and 

prayers. Thank you so much, dad, for your help and check-ups. I am honoured to call you, my 

father. To my brothers and our only sister, you are an amazing cheerleader and friend, not to 

mention a true inspiration for anyone aspiring to live a happy life.  

Special thanks to Dr. Biney for always opening your doors and allowing me to learn from you. You 

are, as I always say, a wonderful person. Also, to my nieces and children, I hope we can move past 

the stress of the MA and live a happy and fulfilling life together. I couldn't have made it without 

all of you.   

Last but not least, special mention to Mr. Philip Johnson (Colleague, RIPS) for giving me a room 

to lay my head and have a sound study. You have no idea how grateful I am to you. Additionally, 

thank you to all the great friends I made in class, Jeffery, Martin, Sansankroma, Alfred, Adwoa and 

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her sister, Janny, Tamba and everyone. I hope we get to meet someday to look back at our 

experience at RIPS and say, this is what made us today.   

Lastly, a very special mention to Ms. Perpetual Addo. I admire your support, jokes, motivation, 

and the love. If you are ready, then let us take off the tarmac.   

Thank you everyone, and I hope to see you all again soon.     

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ABSTRACT   

Globally, diarrhoea infection among children under five years has declined in the past three 

decades, yet it is still prevalent in developing countries. Almost two-thirds (63%) of diarrhoea 

incidence among children under 5 occurs in developing countries. Despite improvements made in 

adequate water provision and sanitation, diarrhoea remains endemic in Ghana, particularly among 

children under five years. The determinants of diarrhoea are inconclusive and inconsistent 

specifically with regards to how material made of housing structures can predispose children under 

five years to diarrhoea. This study therefore aims to contribute to knowledge by assessing the 

housing conditions and the incidence of diarrhoea among children under five years old in Ghana.   

This study examined the Ghana Multiple Indicator Cluster Survey (MICS) 2017-2018. The survey 

sample was then selected using a multi-stage, stratified cluster sampling approach. The study 

included 8,241 children under five in Ghana. The factors linked to diarrhoea were evaluated using 

multivariable logistic regression.   

The prevalence of diarrhoea was 17.1%. In the binary logistic regression model, place for cooking, 

presence of fixed facility in dwelling for handwashing, the age of a child, maternal education, 

household wealth quintile, and place of residence were statistically significantly associated with 

the incidence of diarrhoea among children under five years in Ghana. The study did not find any 

significant association between source of drinking water, sanitation, housing material and 

diarrhoea incidence among children under five years in Ghana.   

The prevalence of diarrhoea remains high among children under five years in Ghana. Place for 

cooking in household is a strong predictor of diarrhoea infection. This study recommends 

education should be given to mothers/caregivers to keep their place of cooking safe and clean.   

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CONTENTS  

DECLARATION ............................................................................................................................ ii 

ACKNOWLEDGEMENTS ........................................................................................................... iii 

ABSTRACT .................................................................................................................................... v 

CONTENTS ................................................................................................................................... vi 

LIST OF TABLES ......................................................................................................................... xi 

LIST OF FIGURES ...................................................................................................................... xii 

CHAPTER ONE ............................................................................................................................. 1 

1.0 INTRODUCTION .................................................................................................................... 1 

1.1 BACKGROUND TO THE STUDY ..................................................................................... 1 

1.2 STATEMENT OF THE PROBLEM ..................................................................................... 5 

1.3 RESEARCH QUESTIONS .................................................................................................. 8 

1.4 STUDY OBJECTIVES ......................................................................................................... 9 

1.4.1 GENERAL OBJECTIVE ............................................................................................... 9 

1.4.2 SPECIFIC OBJECTIVES .............................................................................................. 9 

1.5 RATIONALE ........................................................................................................................ 9 

1.6 ORGANIZATION OF THE STUDY ................................................................................. 12 

CHAPTER TWO .......................................................................................................................... 13 

2.0 LITERATURE REVIEW ........................................................................................................ 13 

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2.1 INTRODUCTION .............................................................................................................. 13 

2.2 DEFINITION OF DIARRHOEA ....................................................................................... 13 

2.3 PREDICTORS OF CHILDHOOD DIARRHOEA ............................................................. 14 

2.3.1 HOUSING CONDITIONS AND THE INCIDENCE OF DIARRHOEA INFECTION 

AMONG CHILDREN UNDER FIVE YEARS ................................................................... 15 

2.3.2 SOURCE OF DRINKING WATER ............................................................................ 16 

2.3.3 HOUSING SANITARY CONDITIONS ..................................................................... 17 

2.3.4 HOUSING MATERIAL (MAIN FLOOR, ROOF, AND EXTERIOR WALL 

MATERIALS) ...................................................................................................................... 18 

2.3.5 HOUSEHOLD WEALTH QUINTILE ........................................................................ 20 

2.3.6 PLACE FOR COOKING ............................................................................................. 21 

2.4 CHILD’S CHARACTERISTICS AND RISK OF DIARRHOEA INFECTION. .............. 22 

2.4.1 AGE ............................................................................................................................. 22 

2.5 MOTHER/CAREGIVER CHARACTERISTICS AND THE RISKS OF DIARRHOEA 

AMONG CHILDREN UNDER FIVE YEARS IN GHANA. .................................................. 25 

2.5.1 MATERNAL EDUCATION ........................................................................................ 25 

2.5.2 PLACE OF RESIDENCE ............................................................................................ 27 

2.5.3 HAND HYGIENE PRACTICES ................................................................................. 28 

2.5.4. MATERNAL AGE ...................................................................................................... 30 

2.6 THEORETICAL FRAMEWORK ...................................................................................... 31 

2.7 CONCEPTUAL FRAMEWORK ....................................................................................... 34 

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2.8 HYPOTHESES ................................................................................................................... 36 

CHAPTER THREE ...................................................................................................................... 37 

3.0 METHODOLOGY ................................................................................................................. 37 

3.1 INTRODUCTION .............................................................................................................. 37 

3.2 STUDY SITE DESCRIPTION ........................................................................................... 37 

3.3 DATA SOURCE.................................................................................................................. 39 

3.4 STUDY DESIGN ................................................................................................................ 39 

3.5 SAMPLING METHOD ...................................................................................................... 39 

3.6 DATA COLLECTION METHOD ...................................................................................... 40 

3.7 QUESTIONNAIRES .......................................................................................................... 41 

3.8 MEASUREMENT OF VARIABLES ................................................................................. 41 

3.8.1 DEPENDENT VARIABLE .......................................................................................... 41 

3.8.2 INDEPENDENT VARIABLES ................................................................................... 41 

3.9 DATA ANALYSIS .............................................................................................................. 51 

CHAPTER FOUR ......................................................................................................................... 52 

4.0 THE RESULTS OF THE STUDY .......................................................................................... 52 

4.1 INTRODUCTION .............................................................................................................. 52 

4.2.1. BIVARIATES ASSOCIATION BETWEEN THE INCIDENCE OF DIARRHOEA 

AND HOUSING CONDITIONS, MOTHER/CAREGIVER AND CHILD 

CHARACTERISTICS. ......................................................................................................... 58 

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4.2.3 MODEL 1. ASSOCIATION BETWEEN THE HOUSING CONDITIONS AND 

THE ....................................................................................................................................... 66 

4.2.4. MODEL 2. RELATIONSHIP BETWEEN THE SIGNIFICANT VARIABLES AND 

RISK OF DIARRHEA INCIDENCE AMONG CHILDREN UNDER FIVE YEARS IN .. 71 

CHAPTER FIVE .......................................................................................................................... 75 

5.0 DISCUSSION AND SUMMARY OF STUDY FINDINGS .................................................. 75 

5.1 INTRODUCTION .............................................................................................................. 75 

5.2 OVERVIEW OF THE RESULTS ....................................................................................... 75 

5.3 PREVALENCE OF DIARRHOEA AMONG CHILDREN UNDER FIVE YEARS IN 

GHANA ................................................................................................................................ 76 

5.4 HOUSING CONDITIONS ............................................................................................. 76 

5.5 MOTHER/CAREGIVER CHARACTERISTICS .............................................................. 78 

5.5.1 MATERNAL EDUCATIONAL LEVEL ..................................................................... 78 

5.5.2 HOUSEHOLD WEALTH QUINTILE ........................................................................ 78 

5.5.3 PLACE OF RESIDENCE ............................................................................................ 79 

5.6 CHILD CHARACTERISTICS ........................................................................................... 80 

5.6.1 AGE ............................................................................................................................. 80 

5.7 STRENGTHS AND LIMITATIONS OF THE STUDY ..................................................... 82 

CHAPTER SIX ............................................................................................................................. 84 

6.0 CONCLUSION AND RECOMMENDATION ...................................................................... 84 

6.1 INTRODUCTION .............................................................................................................. 84 

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6.2 CONCLUSIONS ................................................................................................................ 84 

6.3 RECOMMENDATIONS .................................................................................................... 85 

REFERENCES ............................................................................................................................. 86 

 

  

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LIST OF TABLES   

TABLE 3. 1 A TABLE SHOWING HOW THE VARIABLES WAS MEASURED. ................ 50  

TABLE 4. 1 THE BACKGROUND CHARACTERISTICS AND THE HOUSING CONDITIONS   

OF CHILDREN UNDER FIVE YEARS IN GHANA. ................................................................ 58   

TABLE 4. 3. MODEL 1. ASSOCIATION BETWEEN HOUSING CONDITIONS AND THE   

INCIDENCE OF DIARRHOEA AMONG CHILDREN UNDER FIVE YEARS IN GHANA….73   

TABLE 4.4.  MODEL 2. RELATIONSHIP BETWEEN THE SIGNIFICANT VARIABLES AND   

RISK OF DIARRHEA INCIDENCE AMONG CHILDREN UNDER FIVE YEARS IN   

GHANA…75   

    

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LIST OF FIGURES    

FIGURE 4. 1. PREVALENCE OF DIARRHOEA AMONG CHILDREN UNDER FIVE YEARS   

IN GHANA……62   

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CHAPTER ONE    

1.0 INTRODUCTION    

1.1 BACKGROUND TO THE STUDY   

Enabling children to reach their full potential is a human right that is critical for long-term 

development (World Health Organization [WHO], 2020). Over the last two decades, there has been 

a significant improvement in child health, survival, and nutrition. (Karambizi et al., 2021; Kyu et 

al., 2013). This progress has been associated with the delivery of effective, successful, and 

productive behavioural, biomedical and environmental interventions (National Research Council 

and Institute of Medicine, 2004; Victora et al., 2022). However, there is a significant distinction 

between developed and developing nations. (Victora et al., 2022). Several children and adolescents 

in resource-poor settings are not able to reach full optimal health (Kruk et al., 2022). This is mainly 

due to poor health systems, and inadequate access to healthcare and social systems (Kruk et al., 

2022).    

Diarrhoea could be defined as when an individual has three or more watery stools than usual in a 

day (WHO, 2017). Globally, the incidence of diarrhoea infection in children below five years has 

declined in the past three decades, yet it is still prevalent among children in developing countries 

(Behera & Mishra, 2022). Diarrhoea remains one of the leading causes of sickness and mortality 

in children below five years living in low resource environments (Das et al., 2014; Das & Bhutta, 

2016). Childhood diarrhoea makes a significant contribution to disability-adjusted life years 

(DALYs) associated diseases (Behera & Mishra, 2022; Karambizi et al., 2021). It contributes to 

early childhood mortality after the neonatal stage more than any other disease (Kyu et al., 2013; 

Troeger et al., 2018). The World Health Organization (WHO) estimates that 1.7 billion cases of 

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paediatric diarrhoeal illnesses are reported each year, and that they result in half a million (525,000) 

fatalities among children yearly (2017). In underdeveloped countries, children under 5 make up 

almost two-thirds (63%) of the diarrhoea incidence (Ugboko et al., 2020).    

Albeit the decline in diarrhoea cases globally, it is still prevalent amidst children under five years 

of age in Africa (Black et al., 2019). Over 50% of diarrhoea cases are concentrated in Africa and 

South Asia (Behera & Mishra 2022). The burden of the disease varies across the sub-region 

(Mihrete et al., 2014; Moon et al., 2019; Shine et al., 2020; Tambe et al., 2015). Several studies 

report a high prevalence of the disease among children in the region (Apanga & Kumbeni, 2021; 

Ndikubwimana, 2020; Nguyen et al., 2021). Cross sectional studies conducted in Benna Tsemay 

district, Ethiopia and Mathare informal settlement to determine the prevalence of diarrhoea among 

children below age five showed a total prevalence of 23.3% and 18.7% respectively (Alemayehu 

et al., 2020; Guillaume et al., 2020). Moreover, a cross-sectional study in Cape Town, South Africa 

also indicated a high (15.3%) prevailing of diarrhoea in children below age five. However, children 

living in informal settlements had a lower prevalence (13.4%) as compared to children living in 

formal settlements (21.2%) (Nguyen et al., 2021). In Jordan Valley, the total prevalence of child 

diarrhoea was 21.3%. Housing conditions variables that were shown to be related were adequacy 

of septic tanks, availability of tap water, adequate supply of drinking water, extended verses nuclear 

family, income, family size, toilet, kitchen cleanliness, and crowding index (Okour et al., 2012).      

Diarrhoea remains endemic in Ghana, particularly among children (Anyorikeya et al., 2016; 

Apanga & Kumbeni, 2021). It is one of the uppermost reasons of children’s hospitalization and 

death (Tetteh et al., 2018). More than 9 million cases of child diarrhoea are reported annually 

(Afitiri et al., 2020; Tetteh et al., 2018). An examination of the 2017/2018 Ghana Multiple Indicator 

Cluster Survey  (MICS) among 8879 children aged below five years showed a 17% prevalence of 

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diarrhoea among them (Apanga & Kumbeni, 2021; Ghana Statistical Service (GSS), 2018). This 

preventable disease kills approximately 14,000 children before age five annually (Asamoah et al., 

2016; Binka et al., 2011), contributing to one-fourth (25%) of all childhood mortalities in Ghana 

(Binka et al., 2011).    

Diarrhoea is caused by several environmental and behavioural factors (Adjei et al., 2004; 

Krumkamp et al., 2015; Workie et al., 2019), lack of toilet facility, inappropriate disposal of child 

stool (Ahmed et al., 2018; Binka et al., 2011). Low maternal education levels and having more 

than two children ever born are factors that increase the risk of child diarrhoea (Das et al., 2014; 

Das & Bhutta, 2016; WHO, 2020). In addition, children of uneducated mothers are more 

susceptible to diarrhoea than their counterparts, especially when there are no toilet facilities 

available at home (Apanga & Kumbeni, 2021; Danquah, 2015; Mølbak et al., 1997). Lack or 

inadequate access to water, sanitation, hygiene, undernutrition, poverty, education, poor feeding 

practices, overcrowding, and deprived household conditions contribute to the vulnerability of 

children to succumb to diarrhoea (Larbi et al., 2021; Songsore, 2008; Songsore & Mcgranahan, 

1993). Moreover, rising population growth and increasing movement to urban cities have led to 

the development of many informal settlements that present several health threats (Larbi et al., 2021; 

Nguyen et al., 2021). These exposure factors are prevalent in deprived settings, compounded by 

the unequal distribution of global healthcare resources, which renders children in these 

environments more susceptible to experiencing episodes of diarrhoea (Ameyaw et al., 2017; Larbi 

et al., 2021).   

Traditionally, housing conditions have strongly been linked to health outcomes (Tuthill, 2003). 

Diseases like the plague, typhoid fever, and diarrhoea broke out in the 18th century as a result of 

unsanitary housing, low accessibility to clean water, poor sanitation, and improper waste disposal  

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(British Columbia Medical Journal, 2020). Children residing in households without access to a 

toilet facility, where faeces are present around the compound, and with pit holes and thatched or 

leaking roofs (Ameyaw et al., 2017; Workie et al., 2019), are more prone to diarrhoea. In 

comparison, children living in households with secured or corrugated iron roofs, safe water 

facilities, proper handwashing practices, and effective waste management exhibit lower 

susceptibility to diarrhoea (Getachew et al., 2018; Ndikubwimana, 2020).    

The most prevalent types of dwelling units in Ghana are separate houses (detached) 63.3% and 

compound houses 20.9% (Ghana Statistical Service (GSS), 2021). Separate house (detached) is 

however more predominant in rural 76.6% than urban 53.8% areas (GSS, 2021). Compound house 

as described by (Asante & Ehwi, 2020) is a housing type in which inhabitants share basic facilities 

such as toilet facilities, kitchens, and electric meters. Though some researchers have documented 

shared toilet and sanitary facilities as unhygienic and unsafe because it does not prevent human 

contact and human faeces hence, encouraging the transmission of diarrhoea diseases, the situation 

still exists in a significant number of dwelling units in Ghana. These houses are characterized by 

obsolete, open or partially covered pit latrines, insufficient waste management and sanitation 

facilities, limited access to electricity and drinkable water, inadequate health and educational 

services, and inferior housing, especially in Ghana's rural villages (Adjei & Kyei, 2013).   

Children spend a significant amount of their time within the house (Harker, 2007). Physical 

housing and neighbourhood conditions predispose them to a high risk of injury and environmental 

toxins such as lead, mould, and dampness (World Health Organization (WHO), 2011). Children 

living in substandard houses experience ill health (Padgett, 2020; Unger, 2013). Poor housing 

conditions, such as insufficient access to water, sanitation, and hygiene, are linked to poor health 

outcomes (Chatindiara et al., 2022; Tustingi et al., 2020a). There is ample evidence on housing 

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conditions (like inadequate access to water, poor waste management, and sanitation facilities) and 

diarrhoea incidence among children, nonetheless, other variables like dwelling floor material, roof 

material, and exterior wall material have been shown to influence diarrhoea outcomes among 

children is less researched. This study examines the impact of housing conditions in Ghana, such 

as the type of material used to construct homes, on diarrhoea outcomes in young children. The 

study thus explores the relationship between housing conditions and the incidence of diarrhoea in 

children below five years in Ghana.   

1.2 STATEMENT OF THE PROBLEM   

Children under age five in underdeveloped countries still experience diarrhoea as one of the main 

causes of illness and mortality (Florez et al., 2020; Karambizi et al., 2021; Manetu et al., 2021). 

Every year, 1.7 billion diarrhoea episodes occur in children below five years around the world. 

(Shine et al., 2020; WHO, 2020). Children under the age of three (3) years have three or more 

episodes of diarrhoea per year (Alemayehu et al., 2020) causing one in five children’s deaths 

(Manetu et al., 2021). Diarrhoea accounts for more than half a million (525,000) deaths in children 

below the age of five years annually (Troeger et al., 2018). South Asian and SSA countries 

contribute to an estimated 88% of all diarrhoea illnesses and deaths due to inadequate access to 

safe and improved drinking water, sanitation, and hygiene (Manetu et al., 2021).    

Diarrhoea poses a greater public health threat in Ghana, and it is one of the leading causes of child 

hospitalization (Apanga & Kumbeni, 2021) and mortality (Afitiri et al., 2020; Tetteh et al., 2018). 

Children under 5 years are heavily burdened (Florez et al., 2020). It ranks among the top five 

national factors contributing to morbidity and mortality in children under five (Afrifa-Anane et al.,  

2022). In the year 2011, more than 113,786 children under five years diarrhoea cases were recorded 

in Ghana with 354 deaths in that same year, and 2,318 of those individuals apparently had severe 

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dehydration (Binka et al., 2011). Again, diarrhoea kills more than 14, 000 children under five years 

every year (Ameyaw et al., 2017). A facility-based trend analysis study of 17,740 children in 

Jasikan, Ghana, revealed a soaring widespread of diarrhoea in children under five, especially in 

girls (Tetteh et al., 2018). Children aged 12-24 months have greater probabilities of suffering from 

diarrhoea than children aged below 12 months. This was because children aged 12-24 months are 

introduced to complementary foods which could be contaminated with faecal matter,  water and 

prepared in an unclean environment (Amugsi et al., 2015).    

Diarrhoea has both immediate and long-term consequences for children, their families, and the 

country. For young children under five, it is a significant contributor to malnutrition, dehydration, 

and even death (Gebru et al., 2014). Furthermore, diarrhoea impairs physical and cognitive 

functioning in children under the age of five. Diarrhoea has an indirect cost because it causes 

women to miss work and spend days in hospitals providing for ill children (Aikins et al., 2010). In 

addition, the family's earnings are spent on drugs, lodging, and movement to and from the hospital 

(Aikins et al., 2010; Kumi-Kyereme & Amo-Adjei, 2016). The government has a significant cost 

burden in dealing with diarrhoea infections. An estimated US$33 million is spent each year in 

Ghana on the direct and indirect expenses of diarrhoeal illnesses (Aikins et al., 2010).    

According to earlier studies, children under the age of five in Ghana reported a prevalence of more 

than 19% burden of diarrhoea (Onda et al., 2012). About two decades ago, a household survey that 

randomly selected 489 children below six years in the Accra Metropolitan Area reported 19.2% 

diarrhoea in the two weeks preceding the study. Diarrhoea caused by dysentery was found to be 

29.8% and a negative correlation was observed between the incidence of childhood diarrhoea and 

household economic status and the mother’s education (Boadi & Kuitunen, 2005). Adjei et al. 

(2004) also reported 27.8% prevalence of childhood diarrhoea among children at the Korle-Bu 

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Teaching Hospital in Accra, Ghana. Cryptosporidium was found to be the commonest cause of 

diarrhoea among children aged 6-24 months but was exclusive in children aged below 6 months.   

Ghana has made significant strides in providing basic water services at the national level. However, 

just 36% of individuals use an improved source of water, and only 18% have access to at least 

minimal sanitization (United Nations Ghana, 2023). This puts 76% of families at threat of drinking 

water that is potentially polluted with faeces (United Nations Ghana, 2023). The increasing 

population presents a significant challenge in terms of maintaining and managing existing 

infrastructure. Additionally, the reduction of wetlands further exacerbates water scarcity, 

accelerates urbanization, and places additional strain on the availability of safe drinking water and 

sanitation in urban areas (United Nations Ghana, 2023). 

Several studies attribute the prevalence of childhood diarrhoea in Ghana to environmental and 

behavioural factors (Apanga & Kumbeni, 2021; Boadi & Kuitunen, 2005). The majority of these 

studies have found that the job and education of a mother, kind of toilet, place of abode, living 

conditions, poverty, handwashing, presence of human faeces in the household compound, and 

overcrowding all play a role (Bitew et al., 2017; Mihrete et al., 2014), children who live in 

households with poor personal and domestic hygiene conditions such as improper child stool 

disposal methods, inadequate water supply, and water quality are factors that influence child 

diarrhoea (Anyorikeya et al., 2016; Tampa-Naah et al., 2019; Tetteh et al., 2018).    

A substantial number of studies that have examined housing conditions and diarrhoea incidence in 

Ghana have predominantly employed a cross-sectional study design with a focus on a selected 

district in the country (Anyorikeya et al., 2016; Krumkamp et al., 2015; Tackie-ofosu et al., 2014). 

These sampled children used in the studies cannot be said to be a representation of all children less 

than five years in Ghana. The only study, to the best of my knowledge that used a nationally 

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representative survey, which could be said to be a good representation however did not investigate 

the association between housing conditions such as the primary outside wall material, the major 

roof material, and the main exterior floor material, and how these can cause a child to get diarrhoea 

(Apanga & Kumbeni, 2021). This study considered conditions such as toilet facility, sanitation, 

source of drinking water, water treatment, waste disposal, and the building material like the main 

material used for dwelling floor, roofing, and the main exterior wall of the building and how these 

can risk a child to diarrhoea.    

Even though several studies on the African continent have found a link between material made of 

housing structure (floor, roof and main exterior wall) and the risk of child diarrhoea, the findings 

have been inconclusive (Mihrete et al., 2014). Additionally, the extent to which  the material of 

which the structure is made can potentially predispose children under five years to diarrhoea is 

poorly understood particularly in the context of Ghana. This indicates a need to understand the 

various factors of diarrhoea that exist. Therefore, this study seeks to examine the relationship 

between characteristics of housing structures and the risk of incidence of diarrhoea among children 

under five years in Ghana.  

1.3 RESEARCH QUESTIONS   

The study seeks to answer the following intended questions:    

1. What is the prevalence of diarrhoea among children under the age of five in Ghana?   

2. What housing conditions are associated with the likelihood of a child before age five to 

experience episodes of diarrhoea in Ghana?   

3. What factors predict the occurrence of diarrhoea in children under the age of five in Ghana?   

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1.4 STUDY OBJECTIVES   

1.4.1 GENERAL OBJECTIVE   

The study's overarching goal was to investigate the relationship between housing conditions and 

the incidence of diarrhoea among children under five years in Ghana.   

1.4.2 SPECIFIC OBJECTIVES   

the specific objectives of the study are to: 

1. Ascertain the prevalence of diarrhoea in children under five years in Ghana.   

2. Examine the housing conditions associated with the risk of incidence of diarrhoea among 

children under five years in Ghana.   

3. Discuss predictors of diarrhoea incidence among children under five years in Ghana.   

   

1.5 RATIONALE    

Providing and improving maternal and child health is central to global public health objectives and 

priorities. The effort to improve child health has progressed beyond the Millennium Development 

Goals (MDGs) to now include Sustainable Development Goals (SDGs). Despite this, diarrhoea 

continues to be a major factor in hospital admissions and fatalities in Ghana, particularly among 

children age less than five years. This poses a greater threat to public health. Housing conditions 

(such as insufficient access to water, poor sanitation, poor hygiene, the presence of faeces in the 

compound, and so on) have been found to significantly contribute to diarrhoea, respiratory, 

communicable, and noncommunicable diseases, and injuries. Identifying and implementing 

effective and sustainable solutions to prevent diarrhoea, a potentially fatal infectious disease, is 

critical to meeting SDG three and improving child survival by 2030.   

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Again, the justification for conducting this study is rooted in the profound and persistent health 

challenges faced by children under the age of five in underdeveloped countries, particularly 

concerning the prevalence of diarrhoea. Despite advancements in healthcare and development, 

diarrhoea remains a major contributor to illness and death among young children (Florez et al., 

2020; Karambizi et al., 2021; Manetu et al., 2021). The alarming global statistic of 1.7 billion 

annual diarrhoea episodes in children below the age of five underscores the urgency of addressing 

this issue (Shine et al., 2020; WHO, 2020). Moreover, the fact that one in five child deaths is 

attributed to diarrhoea, along with over half a million annual deaths in children under five, 

highlights the immediate need for effective interventions (Manetu et al., 2021; Troeger et al., 

2018). 

Within this context, the situation is particularly dire in Ghana, where diarrhoea poses a significant 

public health threat, ranking among the leading causes of child hospitalization and mortality 

(Apanga & Kumbeni, 2021; Afitiri et al., 2020; Tetteh et al., 2018). The substantial burden faced 

by children under five years of age is evident, with significant morbidity and mortality 

consequences (Florez et al., 2020; Afrifa-Anane et al., 2022). The prevalence of diarrhoea in 

Ghana, as indicated by historical records, remains concerning, necessitating a deeper 

understanding of the contributing factors (Boadi & Kuitunen, 2005; Adjei et al., 2004). 

Furthermore, the broader implications of diarrhoea extend beyond immediate health consequences, 

affecting nutrition, cognitive development, economic productivity, and national healthcare costs 

(Gebru et al., 2014; Aikins et al., 2010; Kumi-Kyereme & Amo-Adjei, 2016). Given the 

multifaceted impact on families, communities, and the government, addressing diarrhoea is crucial 

not only for improving child health but also for promoting socio-economic development. 

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However, despite the recognition of environmental and behavioural factors contributing to 

diarrhoea prevalence in Ghana, the specific influence of housing structure characteristics remains 

less understood (Apanga & Kumbeni, 2021; Mihrete et al., 2014). Prior studies have yielded 

inconclusive results, emphasizing the need for a focused investigation in the Ghanaian context 

(Mihrete et al., 2014). This study aims to bridge this knowledge gap by examining the relationship 

between housing structure attributes and the risk of diarrhoea incidence among children under five 

years. As housing structure is a tangible and modifiable factor, understanding its role in diarrhoea 

incidence can provide actionable insights for targeted interventions and policy formulation. 

This study examined the relationship between housing conditions (specifically, the roofing, floor 

and main exterior wall material of the housing structure) and the incidence of childhood diarrhoea 

in Ghana. Furthermore, this study will add to a small but growing body of literature indicating a 

significant association between housing material and diarrhoea incidence in children under the age 

of five (Bitew et al., 2017; Ndikubwimana, 2020).   

Though previous studies report poor hygiene and sanitation as the major causes of diarrhoea, now, 

a growing but small body of literature indicates an association between building materials such as 

(materials used for dwelling floor, roof material, and main exterior wall material) and diarrhoea 

incidence among children (Getachew et al., 2018; Ndikubwimana, 2020; Tustingi et al., 2020b; 

Yaya et al., 2018). Identifying the conditions within the household and the characteristics of the 

housing unit and understanding how these conditions could predispose children to diarrhoea 

incidence is relevant. Additionally, this will help mothers/caretakers to put in place measures that 

will improve child health and child survival to prevent early childhood morbidity and mortality. It 

is therefore important for more research to be conducted to better understand the mechanisms 

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through which the disease-causative organisms of diarrhoea operate. This will help to put effective 

measures and targeted interventions to prevent diarrhoea incidence among children.   

1.6 ORGANIZATION OF THE STUDY   

There are six chapters in the study. The study's background, problem statement, research questions, 

study objectives, and justification are all included in the first chapter. The second chapter examined 

pertinent literature in the subject area. Additionally, the conceptual framework, theoretical 

framework and hypotheses are also discussed. The third chapter outlines the study's methodology, 

covering data source, study design, sampling of the study population, and the conceptualization, 

operationalization, and measurement of variables. The chapter also details the analysis process, 

statistical software used, before transitioning to Chapter 4's primary focus on results. This chapter 

is divided into three sections: univariate, bivariate, and multivariate. Univariate outlines study 

variables, while bivariate examines predictor variable links to the outcome (childhood diarrhoea). 

The multivariable analysis further explores predictor variables and the explanatory variable's 

relationship. The fifth chapter concentrates on the discussion of the results. The final chapter 

includes a summary of the study's findings, a conclusion, and policy recommendations based on 

the findings.  

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CHAPTER TWO    

2.0 LITERATURE REVIEW   

2.1 INTRODUCTION    

This chapter reviews the literature and describes the study's theoretical framework. The literature 

is reviewed according to the study objectives, as well as the variables suggested in previous studies 

to influence the incidence of diarrhoea in children less than five years. The final section includes 

a brief description of the conceptual framework developed to understand the interaction between 

the selected variables necessary to affect the child’s health (diarrhoea).   

2.2 DEFINITION OF DIARRHOEA    

Diarrhoea is defined as having three or more loose, watery stools per day (WHO, 2020). It is a sign 

of an intestinal infection brought about by many bacterial, viral, and parasite species, most of which 

are conveyed by water contaminated with faeces (Yaya et al., 2018). Diarrhoeal infections are more 

common when there is a lack of proper sanitation, hygiene, and safe water for drinking, cooking, 

and cleaning (Moon et al., 2019). Diarrhoea that normally lasts (1-2) days and resolves by itself. 

There are three types of diarrhoeas, Acute diarrhoea is a common form of diarrhoea that normally 

lasts one to two days before disappearing on its own. In most cases, persistent diarrhoea lasts for 

four weeks or longer (Podewils et al., 2004). And the third; is chronic diarrhoea. This kind of 

diarrhoea lasts for at least 4 weeks.   

Rotavirus and Escherichia coli are the two most common etiological agents of moderate-to-severe 

diarrhoea in low-income countries (Weldegebriel et al., 2018). Other pathogens, such as  

Cryptosporidium and Shigella, may also play a role (Carmo et al., 2011; Lamberti et al., 2016). 

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The causative organisms of diarrhoea can be transmitted in various ways. The bacteria which is 

more prevalent in developing countries are commonly spread through faecal-oral (Workie et al., 

2019). This is largely due to poor hygienic and sanitation conditions which are believed to be the 

mode of transmission (Behera & Mishra, 2022; Guillaume et al., 2020). Viral pathogens are also 

transmitted through contaminated food and drinking water that has come into contact with faecal-

oral matter and subsequently ingested. Nonetheless, other routes such as fomites and respiratory 

secretions could also be other alternatives routes through which they can be transmitted.   

The most important risk factors for diarrhoea in children are (age, birth weight), mother’s 

characteristics such as (education, occupation, poverty, and handwashing), household’s 

characteristics like (the type of toilet, the location, living conditions, the presence of human waste 

in the home compound, the quality of the housing material, and crowding) (Bitew et al., 2017; 

Mihrete et al., 2014). Children who live in households with poor personal and domestic hygiene 

conditions such as improper disposal methods of child stool, inadequate water supply, and poor 

water quality are at an increased risk of diarrhoea (Anyorikeya et al., 2016; Tampah-Naah et al., 

2019; Tetteh et al., 2018). Furthermore, rural children, children whose mothers had a 24 month or 

longer interval between births, and those houses' floors made of dung and mud materials are more 

likely to have diarrhoea episodes, whereas children from wealthy households, children with well-

educated mothers, are less likely to suffer diarrhoea morbidity and mortality (Larbi et al., 2021; 

Songsore, 2008).   

2.3 PREDICTORS OF CHILDHOOD DIARRHOEA   

The existing literature has identified several factors responsible for diarrhoea infection among 

children below the age of five years (Kassebaum et al., 2019; Ullah et al., 2019). These studies 

report behavioural, socioeconomic, and environmental factors as the main contributors to child 

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diarrhoea (Shine et al., 2020). The behavioural factors that influence child diarrhoea include poor 

hand hygiene, waste disposal, child breastfeeding, feeding with a bottle, and rotavirus vaccination 

of the child (Boadi & Kuitunen, 2005; Danquah, 2015). The availability of water, toilet facilities, 

presences of faeces in household compounds and housing conditions are all environmental factors 

that contribute to the incidence of diarrhoea in children under the age of five (Alemayehu et al., 

2020; Woldemicael, 2001). The socioeconomic factors which influence diarrhoea among children 

are mothers/primary caretaker’s educational level, income, place of residence (Asfaha et al., 2018). 

Sociodemographic characteristics such as maternal and child age also determine the occurrence of 

diarrhoea disease (Mohammed & Tamiru, 2014).   

2.3.1 HOUSING CONDITIONS AND THE INCIDENCE OF DIARRHOEA INFECTION 

AMONG CHILDREN UNDER FIVE YEARS   

Substantial literature on child diarrhoea infection has focused on environmental factors that 

contribute to diarrhoea infection in children under the age of five (Mohammed & Zungu, 2015; 

Paul, 2020). These studies suggest that a variety of environmental factors, including the source of 

children's food and drinking water, the availability of restrooms, sanitary conditions, inappropriate 

waste disposal, informal settlements, and many others, have an impact on children's diarrhoea 

(Ishimwe et al., 2020; Workie et al., 2019). In India, a cross-sectional study by Paul (2020), in 

which he analysed secondary data from the National Family Health Survey involving 247,743 

children under the age of 5, revealed concerning environmental conditions like child stool disposal, 

floor materials, and roof materials of the housing units were found to be significant predictors of 

the occurrence of childhood diarrhoea.    

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2.3.2 SOURCE OF DRINKING WATER    

Access to safe, protected and dependable drinking water is known to protect children under the 

age of five from childhood diarrhoea. Prior studies have shown that children without protected and 

safe drinking water source have higher odds of contracting diarrhoea as compared to children with 

safe and protected drinking water source (Workie, 2019; Moon et al. 2019). These findings have 

been corroborated by several studies (McClelland et al., 2022; Mshida et al., 2017). Children who 

have access to improved water sources, such as pipes or taps, are less likely to get diarrhoea than 

children who do not (river, stream) (Agegnehu et al., 2019). In low- and middle-income countries 

(LMICs), a systematic review and meta-analysis study indicated that providing an improved 

drinking water supply on premises with greater water quality reduced the risk of diarrhoea by 

(52%), compared to an unimproved source. (Wolf et al., 2022).    

The impact of the source of drinking water on the frequency of diarrhoea in children has also been 

highlighted by numerous other studies (Masangwi et al., 2009; Plate et al., 2004). These studies 

indicated the odds of diarrhoea are higher for children with access to unimproved water sources 

(McClelland et al., 2022). For instance, a community-based cross-sectional study revealed that 

children whose drinking water sources were unprotected had a 2.68 times higher risk of diarrhoea 

than those whose sources were protected (Workie et al., 2019). Similar to this, research by (Bitew 

et al., (2017) and Larbi et al., (2021) demonstrated a statistical association between childhood 

diarrhoea diseases and an unprotected source of drinking water. Additionally, a systematic analysis 

revealed that implementing WASH interventions aimed at improving water quality directly where 

it is used demonstrated a notable 40% reduction in the likelihood of experiencing diarrhoea and 

27% for encouraging handwashing with soap under running water. This reduction was specifically 

observed in relation to water filtration, showing a 31% decrease in risk, and in the context of water 

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disinfection  (Darvesh et al., 2017). Okour et al., (2012) also showed tap water availability, drinking 

water quantity, and frequency of water reservoir cleaning were also found to be significantly 

associated with a reduction in childhood diarrhoea.   

Nonetheless, a handful of studies report no association between access to improved water sources 

and a child’s chances of developing diarrhoea (Cronin et al., 2016). They argue that other 

behavioural factors such as handwashing practices could be the cause of diarrhoea in children 

(Begum et al., 2011). Furthermore, a case-control study conducted in Northeast Brazil showed that 

socioeconomic factors such as (wealth, access to improved sanitation and water, living condition, 

nutrition) contributed most to determining diarrhoea occurrence more than the source of drinking 

water (Genser et al., 2008). Similarly, Bennion et al. (2021) did not find a relationship between 

child diarrhoea and environmental factors, such as access to a water source. They also advocated 

for more research to better understand the environment in terms of distance to water sources and 

frequency of use in relation to diarrheal outcomes in Tanzanian children under the age of five. 

While the literature presents varying findings, it is clear that providing access to clean drinking 

water reduces the risk of diarrhoea in children under the age of five, particularly in regions where 

such resources (safe and clean water) are lacking. In order to effectively prevent diarrhoea and 

decrease the associated risks to children's health and well-being, it is imperative that safe drinking 

water becomes universally accessible to all. 

2.3.3 HOUSING SANITARY CONDITIONS    

Sanitation improvements minimize the propagation of bacteria that cause diarrhoea by preventing 

human faeces from contaminating the environment. In reviewed research, an estimated median 

reduction in the incidence of diarrhoea has been linked to improved sanitation facilities. 

Inadequate/lack of access to sanitation facilities coax the spread of solid and liquid waste within 

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place of abode playing a part in diarrhoea disease transmission especially among children under 

five years (Manetu & Karanja, 2021). Diarrhoea diseases are related to household sanitation 

(Beyene & Melku, 2018). Previous studies have established improved sanitation (presence of 

latrine with slab) is linked to decrease incidence of diarrhoea among children whereas unimproved 

sanitation is associated with increase odds for diarrhoea particularly in children (Gyimah, 2003).    

Lack of toilet facilities in homes is associated with a higher incidence of child diarrhoea than toilet 

facilities that do not isolate human excreta from human contact (Workie et al., 2019). Children 

living in households without toilets had a six-fold increased risk of developing diarrhoea compared 

to children living in houses with toilets (Mihrete et al., 2014). Furthermore, children living in 

households with presence of faeces on toilet facilities and in the compound have an increased risk 

of diarrhoea (Natnael et al., 2021). Tambe et al., (2015) found significance association between a 

child’s toilet facilities and diarrhoea. The Children who used the main toilet and other forms of 

place for convenience, such as the bush, diaper and streams were less likely to suffer from 

diarrhoea. Furthermore, children who use a flush toilet in the home had a 17% lower risk of 

contracting diarrhoea than those who defecate in the open (Yaya et al., 2018).    

2.3.4 HOUSING MATERIAL (MAIN FLOOR, ROOF, AND EXTERIOR WALL 

MATERIALS)    

A large number of published scientific studies that have established the relationship between 

housing and health (Clair & Hughes, 2019; Palacios et al., 2021; Spengler et al., 2004). Poor 

conditions in housing units are known to affect the health of occupants both positively and 

negatively (Kan et al., 2022). Building materials, poor ventilation, weak structures, overcrowding, 

poor indoor air quality, damp houses, lead poisoning, noise pollution, and many others have all 

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been linked to lower respiratory tract infections (LRTI), mental health diseases, and chronic 

diseases (Diaz & Siegel, 2018; Jensen et al., 2019; Spengler et al., 2004; Tang et al., 2022).    

In SSA, housing and health are major public health concerns. A cross-sectional survey among 

824,694 children in 33 countries showed an association between poor housing and child health 

such as, malaria, diarrhoea, acute respiratory infections (Tustingi et al., 2020b). A multi-level 

analysis of the relationship between the functional and sanitary state of housing infrastructure and 

caregiver reports of common childhood illnesses revealed a strong association between reported 

respiratory infections, skin infections, and housing condition. The results of the multivariate 

analysis revealed a robust independent link between the occurrence of respiratory infections and 

the overall functional state of the household. However, no significant correlation was found 

between the prevalence of other illnesses and either the overall functional state of the residence or 

the functionality of infrastructure necessary for specific healthy living practices. The hygienic 

condition of food preparation and storage areas was tied to cases of diarrhoea and vomiting (Bailie 

et al., 2010).   

   

A growing but small literature has shown the materials used to construct the main floor, roof, and 

external walls of homes to be significantly related with diarrhoea risk in children under the age of 

five (Ndikubwimana, 2020). A recent analysis of the Rwanda DHS among 7474 sampled under-

five children showed that having under-five children are less likely to be infected with diarrhoea 

if the main floor of their home is improved. Similar results were obtained in a community-based 

cross-sectional study of children under five in the rural North Gondar zone of Ethiopia, where it 

was discovered that the type of roof material was substantially related to diarrheal morbidity in 

this age group (Getachew et al., 2018).    

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The work of Tackie-Ofosu et al., (2014) further revealed that 79% of the homes had leaking roofs, 

a loud noise, a strong urine smell, an infestation of vermin, insects, and rats, dirty litter, insufficient 

lighting, fissures in the walls, poor ventilation, and leaking roofs. Lack of restrooms, kitchen 

facilities, adequate space, and poor ventilation in the rooms led to parents reporting an occurrence 

of at least one current health issue in their children, such as malaria, cough, asthma, or diarrhoea, 

which they linked to their living arrangements. Additionally, a pooled analysis of national 

representative datasets revealed that children with access to improved flooring were less likely to 

develop diarrhoea than children whose homes had unimproved flooring (soil, sand, clay, mud, or 

dung) (Tampah-Naah, 2019). Additionally, children who lived in homes with better floor materials 

had a lower risk of having comorbidity than their counterparts from homes with unimproved floor 

materials did (Afrifa-Anane et al., 2022).    

On the contrary, a population-based study conducted by Mihrete et al., (2014) that analysed 

childhood diarrhoea among under-five children in Benishangul Gumuz Regional State, North West 

Ethiopia using the demographic and health survey. A total of 925 children were included in the 

analysis. The results of the study did not find any association between childhood diarrhoea and 

household floor material despite all household environmental variables showing a significant 

association with child diarrhoea.    

   

2.3.5 HOUSEHOLD WEALTH QUINTILE   

Several studies have found a link between household wealth and the occurrence of diarrhoea in 

children. Children from wealthy households are protected of diarrhoea as compared to those from 

poor household. This conclusion has been substantiated through a study that analysed data from 

34 Sub-Saharan African demographic and health surveys together. The findings of the study 

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demonstrated that children hailing from households categorized as poorest, poorer, middle-poorest, 

and richer had an elevated likelihood of experiencing diarrhoea when compared to their 

counterparts from the richest households (Demissie et al., 2021). Similarly, other previous studies 

have shown that children belonging to the most affluent families exhibit a reduced susceptibility 

to diarrhoea. In accordance with a comprehensive examination of hospital records, it was observed 

that children from the wealthiest households faced a 42% lower risk of contracting diarrhoea in 

comparison to children from the least affluent households (Asamoah et al., 2016). 

On the contrary, a substantial number of literatures have not established the relationship household 

wealth and the risk of diarrhoea in children below five years. An examination of the Ghana 

Multiple Indicator Cluster Survey (2006) revealed an increased risk of diarrhoea among the rural 

poorer, middle, richer, and rural richest. The odds were higher in rural middle, richer and richest 

as compared to the rural poorer (Kumi-Kyereme & Amo-Adjei, 2016). Moon et al., (2019) also 

did not find an association between household wealth quintile and the occurrence of diarrhoea. The 

researchers did not provide any possible explanation as to why wealth index was not significant in 

the multivariate regression analysis despite showing an association in the simple regression 

analysis.   

2.3.6 PLACE FOR COOKING    

Microbes can contaminate food at any stage of the process, from production to sale to preparation 

to consumption (Kirk et al., 2017). These contaminants can come from the water used, cutlery or 

equipment, hands, methods of preparation or handling, ingredients, dishes, or storage containers 

as well as where the food is prepared (Donkor et al., 2009). Therefore, it is crucial to prepare and 

store food in a clean manner both at home and from vendors in order to lower the danger of 

contamination.   

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A substantial number of literatures have identified that from producing to preparing food under 

poor hygienic condition can contaminate and make the food unhealthy for consumption (Larbi et 

al., 2021). There is evidence that the location of cooking is related to the occurrence of diarrhoea 

in children (Ameme et al., 2016). According to research conducted in Turkey and Ghana, children 

whose homes lacked a kitchen were more likely to suffer from diarrhoea (Ameme et al., 2016; 

Etiler et al., 2004). Similarly, children in Nigeria who lived in households with a private kitchen 

had lower rates of diarrhoea than those who did not (Oni et al., 1991). Furthermore, children of 

households having cooking place inside the sleeping rooms had increased risk to experience 

diarrhoea resulting in stunting than those of households having separate cooking place (Das et al., 

2008). The cleanliness of the kitchen floor was found to be significantly related to the prevalence 

of diarrhoea among Nicaraguan children (Gorter et al., 1998). A case-control study in Myanmar 

found that children who ate food that had been left on the kitchen floor were significantly more 

likely to have persistent diarrhoea (Albert et al. 1999).   

2.4 CHILD’S CHARACTERISTICS AND RISK OF DIARRHOEA INFECTION   

2.4.1 AGE   

Diarrhoea disease remains a global public health threat (Mohammed & Tamiru, 2014). The disease 

is most common in children under the age of five, particularly in low- and middle-income 

countries. Several published works on child diarrhoea report an association between a child's 

characteristics such as age, gender, and birth order and diarrhoea morbidity (Moon et al., 2019;  

Shine et al., 2020). Importantly, diarrhoea is reported to be more common in children aged 6-11 

months and 12-24 months. At these ages, the chances of developing diarrhoea are twice as high as 

in children aged 0-5 months or more than 24 months.    

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Children aged 6-11 months and 12-24 months are more likely to develop diarrhoea, which has been 

linked to supplementary feeding and other developmental stages. Children of this age are fed other 

foods in addition to breast milk. The child's likelihood of acquiring diarrhoea is influenced by the 

primary caregivers' food handling and hand hygiene habits. Additionally, children between the ages 

of 6-11 months and 12-23 months are either crawling or walking and can readily choose dirt or 

other contaminated materials for playing with or eating. The work of Mihrete et al., (2014) found 

that the age of a child and birth order were significantly associated with childhood diarrhoea 

morbidity. When compared to age categories of 0-5 months, the risk of diarrhoea morbidity was 

higher at 6-11 months and 12-23 months, and reduced at 24 months and older.   

Similarly, a population-based cross-sectional study in Ghana revealed that children in the 6–11, 

12–23, and 24–59 months age groups had, respectively, 3.48, 4.57- and 1.93-times increased odds 

of getting diarrhoea infection compared to those in the youngest age category 0-5 months (Amugsi 

et al., 2015).    

Recent community-based cross sectional study designs also report higher risk of diarrhoea 

infection among children within the age bracket 6-11 and 12-24 months. In Ethiopia, children age 

6-23 months were 2.46 times higher odds of diarrhoea compared to children less than six months 

(Workie et al., 2019). Similar studies also show an increased risk of exposure of a child to diarrhoea 

after surviving the first six months of life (Bado et al., 2016; Tareke et al., 2022). The risk is further 

heightened at the age of 12-23 months (Tareke et al., 2022).  Children aged 6-11 months (7.48 

times), 12-23 months (11.64 times), and 24 months and older (8.97 times) had a significantly higher 

likelihood of developing diarrhoea compared to those younger than 6 months. (Asfaha et al., 2018).   

Other studies conducted do not report a child’s age as a factor associated to diarrhoea (Beyene & 

Melku, 2018; Gedamu et al., 2017). These studies report other factors such as maternal educational 

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level, poor waste disposal, water quality and others as significant association between a child and 

diarrhoea outcome (Demissie et al., 2021; Negesse et al., 2021). For instance, a cross-sectional 

survey conducted in Kaduna indicated infants whose mothers sometimes 2.32 times or never 

washed 2.64 times their hands with soap after cleaning the infant’s perineum and those with 

incomplete age-appropriate immunization 1.87 times were more likely to have diarrhoea (Dairo  

et al., 2017).    

In Ghana, the current age of a child is associated to the chances of a child developing diarrhoea. 

The odds of a child getting diarrhoea is higher among children aged between 6-11 and 12-23 

months as compared to those age 0-5 months. A study that analysed data from a national 

representative survey revealed in the multinomial analysis children aged between 6-11 months and 

12-23 months had 2.06 and 2.37 times more likely to be infected with diarrhoea respectively. 

Children aged below six months had lower odds (Apanga & Kumbeni, 2021). These findings have 

further been strengthened by (Afitiri et al., 2020; Afrifa-Anane et al., 2022). And this may be 

because, at that age, children age between 0-5 months are still breastfeeding and had not been 

introduced to street foods or feeding with bottles which could be a potential vehicle for diarrhoea-

disease causing microbes to transmit. Similarly, a review of hospital records of children below age 

five who attended War Memorial Hospital-Navrongo and were diagnosed of diarrhoea indicated 

the most affected age group of children with diarrhoeal diseases was between 0-11 months old than 

those aged 12-59 months (Anyorikeya et al., 2016). The possible reason why children in the age 

bracket 12-23 months did not have higher odds of developing diarrhoea could be due to how the 

age of children were categorized and analysed.    

Another characteristic of a child that protects him/her is rotavirus vaccination. Rotavirus 

vaccination has been proven to significantly reduce diarrheal hospitalizations (Enweronu-Laryea 

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et al., 2014; Patel et al., 2011) and deaths (Carmo et al., 2011; Enweronu-Laryea et al., 2014). 

Studies conducted in Africa on the impact of rotavirus vaccination on rotavirus diarrhoea show it 

is effective and efficacious in preventing rotavirus diarrhoea, severe rotavirus diarrhoea, and 

rotavirus hospitalizations among children below the age of five (Lamberti et al., 2016; 

Weldegebriel et al., 2018). An analysis of rotavirus-associated diarrhoea hospitalizations among 

children <5 years at three sentinel sites from 2009 through 2011 in South Africa showed that 

children less than five years testing positive for rotavirus decreased by 46%, 33%, and 29% in 

2009, 2010, and 2011 respectively. In terms of hospitalizations, there was a 61% and 69% reduction 

among infants for the period 2010 and 2011 respectively.   

In general, these studies have proven that the age of a child below five years is associated to 

diarrhoea outcomes. Children aged above five months are more likely to be infected with diarrhoea 

than those below six months. This is because unhygienic complementary feeding practices and the 

child’s life developmental stages are contributory factors.  

2.5 MOTHER/CAREGIVER CHARACTERISTICS AND THE RISKS OF DIARRHOEA 

AMONG CHILDREN UNDER FIVE YEARS IN GHANA  

2.5.1 MATERNAL EDUCATION    

The role of maternal education in child survivorship is well documented and established in many 

pieces of literature on health in developing countries (Desmennu et al., 2017; Guillaume et al., 

2020). These studies have found consistent findings and correlations between maternal education 

and the risks of child diarrhoea in children under the age of five (Mihrete et al., 2014; Nguyen et 

al., 2021; Victoria et al., 1992). Children belonging to educated mothers have a lower risk of 

diarrhoea than children belonging to mothers with low-level education (Asfaha et al., 2018). Also, 

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the risk of a child getting diarrhoea reduces as the mothers’ education level increases. Children of 

mothers with no education in SSA nations have higher odds of having diarrhoea, while those who 

are well-educated have fewer chances of getting diarrhoea (Demissie et al., 2021). Educated 

mothers are more likely to practice good hand hygiene, and manage and properly disposes of waste 

(Gyimah, 2003).   

Education empowers women to willingly decide to send their children to the hospital for healthcare 

services (Greenaway et al., 2012). Women who are educated have a greater advantage to have 

sources of income. Women without access to a source of income is a great challenge that impedes 

them to use health facilities specifically in developing countries (Essilfie et al., 2020). A mother’s 

education plays a vital role in a child’s health (Ugboko et al., 2020). Mothers with at least primary 

education can protect their children from diarrhoea in the instance of poor sanitary conditions at 

home and their surroundings (Mohammed & Tamiru, 2014). In Bangladesh, children under the age 

of five were twice as likely to have diarrhoea if their mothers were uneducated (Chowdhury et al., 

2016).   

On the other hand, some researches have contested the idea that maternal education and the risk of 

diarrhoea in young infants are related (Desai & Alva, 1998; Ward et al., 2021). While many 

academics argue that maternal education is a significant factor in determining a child's health 

(Desmennu et al., 2017; Victoria et al., 1992), other researchers argue that there is only a tenuous 

link between mother education and children's health (Buor, 2001; Desai & Alva, 1998; Ilma et al., 

2019). They contend that certain research may have overstated the relationship between maternal 

education and outcomes for children's health. Desai and Alva (1998) present an opposing 

viewpoint on the causal relationship between maternal education and improved child health. They 

argued that though there is a strong association between maternal and child health indicators such 

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as infant mortality, immunization, and child height-for-age, this relationship may be a result of a 

spurious relationship and not necessarily the education of the mother and improvement in the 

child’s health. After adjusting for individual socioeconomic characteristics and community effects, 

their findings from an analysis of demographic and health surveys from 22 developing countries 

revealed that the effect of maternal education on infant mortality and children's height-for-age was 

statistically significant in only a small number 7 of the countries. Hence, the claim that maternal 

education affects child health should be made with caution. Furthermore, a study that used Ghana 

Demographic and Health Survey data from 1998 and World Bank data from 2000 to examine the 

impact of mothers' education on childhood mortality in Ghana discovered that maternal education 

was inversely related to childhood mortality. Children born to mothers with high education had a 

low mortality rate. For neonatal deaths and infant deaths, children of mothers with primary 

education had more child death than those of no education (Buor, 2001).   

  

All these studies suggest there exists a strong positive association between maternal education and 

the incidence of child diarrhoea. Educated mothers practice good hygiene and better child feeding, 

which all contribute to a child's resistance to infectious diseases. Nonetheless, a handful of 

published literature reveals otherwise. Despite the mixed findings these works of literature show, 

the influence of maternal education on a child’s diarrhoea cannot be underestimated. Therefore, 

this literature review agrees to the hypothesis that a mother’s education influences the incidence 

of diarrhoea in children below the age of five years.    

2.5.2 PLACE OF RESIDENCE   

According to studies from Ghana, children who live in rural settings are less likely to contract 

diarrhoea than children who live in urban settings (Kumi-Kyereme & Amo-Adjei, 2016). This 

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discovery is similar to findings from other studies (Apanga & Kumbeni, 2021). The urban health 

penalty, which maintains that a disproportionate number of people with poor health live in cities 

where there is a concentration of the poor and unsafe conditions may help to explain the study's 

findings.    

The presence of diarrhoea has been linked to district cleanliness and sanitary conditions. In terms 

of hygienic conditions, children below five years in the Dembia district had a three times higher 

probability of experiencing diarrhoeal disease than those of Sanja region in the Northwest Ethiopia 

(Getachew et al., 2018). These study results highlight how the location of residence affects the 

likelihood of experiencing diarrhoea. The environment in which children reside (whether urban or 

rural) may predispose them to morbidity. Tampah-Naah et al. (2019) study revealed that the place 

of residence had a significant impact on diarrhoea. Children in rural regions carried a heavy burden 

when it comes to the prevalence of diarrhoea in terms of incidence (Wolf et al., 2014).   

Some factors, for example, are thought to contribute to the increased incidence of diarrhoea in rural 

areas, either individually or collectively. Among them are consuming tainted food, consuming 

unimproved water, poorly handling water, living in poverty, and maintaining inadequate sanitation 

and hygiene. Additionally, Kumi-Kyereme and Amo-Adjei (2016) noted that there is evidence to 

imply that residents of rural areas are less likely than those in urban areas to report diarrhoea, albeit 

insignificantly.   

2.5.3 HAND HYGIENE PRACTICES    

Previous studies have shown that encouraging handwashing among children contribute 

significantly to the reduction of the number of times a child have episodes of diarrhoea 

(Mohammed & Zungu, 2015). Recent review by Ejemot-Nwadiaro et al. (2021) and colleagues 

revealed that in high-income nations, boosting hand washing education programs and behaviour at 

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child day-care centres or schools prevented roughly one-third of diarrhoea occurrences. The review 

indicated that promotion of handwashing among children reduces child diarrhoea by 30%. Similar 

to this, Mbakaya (2017) systematic analysis of eight randomized control trials (RCT) emphasizes 

the importance of teaching children how to properly wash their hands to prevent diarrhoeal 

infections. The review discovered that good hand hygiene can lower the frequency of diarrhoea 

illnesses. Unlike Ejemot-Nwadiaro et al. (2021) and colleagues whose review places less emphasis 

on children in under-developed nations, where the morbidity and mortality from diarrhoea diseases 

in children is the largest and contributes to the majority of child fatalities, Mbakaya’s evaluation 

mostly focused on children in underdeveloped countries, even though the majority 75% of the 

studies that satisfied the inclusion criteria had methodological issues.   

Both Feleke et al. (2022) and Alebel et al. (2018) found a strong correlation between maternal 

handwashing habits and childhood diarrhoea. Feleke and colleagues’ community-based cross-

sectional study of children under the age of five between May 15 and May 29, 2021 in Bereh 

district indicated children whose mothers or caregivers washed their hands only with water during 

the five critical times had a higher risk of diarrhoea than children whose mothers or caregivers had 

to wash their hands with water and soap. Alebel and colleagues (2018) demonstrated that mothers 

who did not wash their hands after using the restroom were positively connected with childhood 

diarrhoea. Furthermore, children whose mothers practice poor hand washing (do not wash their 

hands after toilet, before preparing food, feeding a child, wash hands with soap under running 

water) are 2.33 times more likely to get diarrhoea (Mohammed & Tamiru, 2014). For example, a 

national survey study conducted in Tanzania among 9996 households and children aged (0-23) 

months showed a significant association between having WASH knowledge and childhood 

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diarrhoea. The study reported that, assisting a child to wash h/her hands after defecating before 

food, indicated a reduced incidence of child diarrhoea in the past two weeks (Bennion et al., 2021).   

Overall, these studies indicate that handwashing or hand hygiene are important predictors of 

childhood diarrhoea. The methods that the studies included in the reviewed can surely ascertain 

whether cause-effect relation exist between handwashing and diarrhoea in children.   

2.5.4. MATERNAL AGE 

A large body of literature have examined the link between mother’s age and child diarrhoea 

outcomes (Afitiri et al., 2020; Afrifa-Anane et al., 2022). These studies report a decline in 

likelihood of child’s diarrhoea as the mother’s age increases (Paul, 2022; Fagbamigbe et al., 2021). 

Children belonging to mothers age between 15 and 25 years are more likely to contract diarrhoea 

as compared to children of mothers age 25 years and above (Moon et al., 2019; Tampah-Naah, 

2019). The reason cited by most of these studies included financial capability of mothers age 

between 15 and 25 years (Paul, 2022; Fagbamigbe et al., 2021). They noted that most of these 

mothers are still teenagers and may not have the financial capacity and knowledge to raise healthy 

children. 

Nonetheless, a few studies report less likelihood of children belonging to mothers age 15-24 

contracting diarrhoea (Okafor et al. 2022). Kapti et al. (2022) revealed that infants with a history 

of LBW from mothers aged 20–24 years were 0.07 times less likely to develop diarrhoea as 

compared to those belonging to mothers of older age. Kapti further argues that mothers of 19-24 

age are young and considered older and are capable to raising healthy children. 

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2.6 THEORETICAL FRAMEWORK   

This study was premised on the framework for studying and analysing child survival in developing 

countries. This paradigm was established by W. Henry Mosley and Lincoln C. Chen in 1984 

(Mosley & Chen, 1984). The method makes it possible to measure morbidity and mortality in a 

single variable. The paradigm states that in order to have an effect on mortality, all social and 

economic factors that have a sizable impact on child mortality must pass through a common set of 

biological pathways or proximal determinants.  These components include; proximate, dependent 

and independent variables.   

Mosley and Chen grouped the proximate determinants into five broad categories. They are, 

maternal factors, environmental contamination, nutrient deficiency, injuries and personal illness 

control. 

Maternal factors: The maternal factors that Mosley and Chen argued affect the health of a child 

include age, the education of the mother/primary caretaker and the income.   

Environmental contamination: the framework maintained that in epidemiological studies the 

environment is one of the routes through which disease can spread. Given the routes of disease 

transmission, this may be measured directly by conducting a microbial examination of collected 

air samples, food, water, vectors, etc. example, a microscopic examination of E. coli bacteria from 

human faeces is measured in food or water. Children below the age of five who live in households 

with human excreta spread on the compound are highly at risk of diarrhoea infection. Additionally, 

children under five years whose source of drinking water is from unimproved sources are 

vulnerable to diarrhoea infection.   

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Nutrient deficiency: this maintained exposure to environmental factors could result in disease 

development in an individual, regarding nutrient deficiency, they posit the survival of a child is 

influenced by the child’s diet and nutrients present as well as the nutrient and diets of the mother. 

They believed that the mother’s diet and nutrients during pregnancy affect the child’s weight, and 

during breastfeeding, it influences the quantity and the quality and nutrients present in breast milk. 

Mothers who practice exclusive breastfeeding will protect children especially infants from 

diarrhoea diseases. Almost, they will boost the immune system of the children to fight any disease-

causing microbes.   

Injuries: With respect to this proxy determinant variable, Mosley and Chen assert the resultant 

effect of injury on children’s health outcomes (morbidity or mortality).  This variable attempt to 

measure the frequency of child’s injury within a short period of time and secondly, the total number 

of injuries that have harm the health of the child. This could be burns sustained or other accidental 

injuries. 

Personal illness control: Educated mothers are more likely to send their children to welfare clinic 

for rotavirus vaccination, zinc tablet supplement, severe diarrhoea treatment or management and 

finally, they are likely to initiate or give their children experiencing diarrhoea with oral rehydration 

solution. Again, mothers/caregivers with education will ensure the bottles used to feed children are 

well-cleaned and kept hygienically to prevent transmission of diseases like diarrhoea.   

The next variable the framework examines are the socioeconomic determinants (independent 

variables). Mosley and Chen contend that these variables work in conjunction with the proximate 

determinant to determine the degree of growth faltering and death. Individual productivity (fathers, 

mothers), traditions/norms/attitudes, and are three main categories of variables that make up the 

socioeconomic determinants and are frequently followed by individual-level variables. Income and 

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wealth variables at the household level. Ecology, politics, and the economics are community level 

variables, as is the health system.  

This study adapts four level variables from Mosley and  Chen’s analytical framework. These 

variables are (individual, community, health, and  environment). For the individual variables, the 

study includes maternal age, maternal education, child sex, and age of the child. The study 

considers the place of residence as the community-level variable. The environmental factors 

include the type of flooring, the type of roof, the type of main outer wall, the type of toilet, and the 

availability of handwashing facilities. The independent variables will be the individual and 

community levels, while the environmental factors or variables will be the proximal determinants 

of health.  

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2.7 CONCEPTUAL FRAMEWORK  

The figure below demonstrates the relationship and/or the interaction between selected variables 

at the different determinants as discussed in Mosley and Chen’s analytical framework in 1984 and 

how it influences child morbidity, specifically, the housing conditions and the incidence of 

diarrhoea among children under five years in Ghana. Using Mosley and Chen’s analytical child 

survival framework, this study included demographic (child’s age), socioeconomic (e.g., 

household wealth quintile), proximate determinants (maternal and child nutrition) variables. 

The mechanism in which these variables influence child’s health (morbidity/mortality) are shown 

in the figure below. An example is, the mother’s characteristics which is put under the broad 

proximate determinants can directly influence the child’s health outcome (diarrhoea or no 

diarrhoea). 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Figure 2.7.1 Conceptual Framework for Housing Conditions and the Incidence of Diarrhoea 

among Children Under Five Years in Ghana Integrating Mosley and Chen Analytical Child 

Survival Framework.  

 

 

  

  

  

  

  

  

  

  

  

  

  

  

  

Housing  Conditions   

Sanitation   

  Source of  drinking w ater     

Housing material index   

Presence of   handwashing  

facility   in dwelling   

Place for cooking   

Mother / Caregiver  

Characteristics   

A ge     

Maternal   educational level   

Household wealth income    

Place of residence   

Region    

      Child ’s   Characteristics   

Age of the  C hild   

  

Outcome variable   

( C hild   d iarrh o ea )   

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  2.8 HYPOTHESES    

This study hypothesized that;    

1. Children living in houses with unimproved housing materials are more likely to 

contract diarrhoea than children living in houses with improved housing materials.   

2. Children living in household without access to improved water are more likely to be 

infected with diarrhoea than children living in household with access to improved 

water.   

3. Children living in household without access to improved sanitation are more likely to 

contract diarrhoea than children living in household with access to improved sanitation. 

4. Mother’s educational level decreases the risk of a child’s diarrhoea infection.  

  

5. Children living in households with handwashing facilities are less likely to be infected 

with diarrhoea as compared to children living in households without handwashing 

facilities.  

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CHAPTER THREE   

3.0 METHODOLOGY 

3.1 INTRODUCTION 

This chapter describes the research approach that was employed to study the “Housing Conditions 

and the Incidence of Diarrhoea among Children Under Five (5) Years in Ghana. The chapter 

describes in brief the setting of the study, the source of data used for the study, the study design 

adopted. Additionally, this chapter describes the sampling procedure utilized, the method applied 

to gathering data from the study participants as well as the data collection tool used to gather data 

from the study’s participants. In furtherance, the chapter details how the variables employed for 

the study were measured and finally, the statistical analytical software package used and the 

various kinds of analysis utilized. 

3.2 STUDY SITE DESCRIPTION   

Ghana is located in the western part of the African continent. It is located along the Gulf of Guinea 

coastline. According to the recent population and housing census in 2021, there are 30,832,019 

people living there in total (Ghana Statistical Service [GSS], 2021). It covers a sizable area of 

238,535 km2 (92,099 sq. mi), comprising a diversity of biomes from tropical rainforests to coastal 

savannas. Ghana's capital city is Accra. Ghana's neighbours to the north, east, south and west are 

Burkina Faso, Togo, the Gulf of Guinea, and Côte d'Ivoire, respectively.   

Ghana was made up of 10 administrative regions. Currently it has sixteenth administrative regions. 

The Akan ethnic group is the major ethnic group in Ghana. Christians comprised about two-thirds 

of all religious divisions in the country. Rice, fufu (mashed cassava, plantain, or yam), kenkey, or 

banku (fermented maize meal) are common carbohydrate staples served with a sauce or stew in a 

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traditional Ghanaian dinner. Ghana has a diverse population that speaks more than 250 languages 

and dialects. The official language of the nation, English, is used most often in official and 

commercial transactions. Additionally, schools and colleges adopt it as their primary language.   

Ghana's economy has historically been based mostly on the export of cocoa, and it is currently one 

of the biggest cocoa exporters in the world. Nearly half of Ghanaians make their living from 

agriculture, which continues to be a significant economic sector. The country is rich in natural 

resources. Ghana is one of West Africa's wealthier countries due to its natural resources, which 

include oil, bauxite, manganese, gold, and diamonds. contamination of the water and deterioration.   

The majority of the nation's hospitals and clinics are run by the government and various Christian 

organizations. Examples of supplemental services include health facilities, pharmacies, and 

changing rooms (first-aid centres). Although there has been a tremendous improvement in the 

quantity and calibre of healthcare facilities and medical staff, the demand for resources is still being 

exceeded by the population expansion.   

Ghana has one of the most sophisticated educational systems in West Africa. Basic education 

consists of two years of kindergarten, six years of primary school, and three years of junior 

secondary school. Students then finish three years of senior secondary school, which includes 

courses and vocational training that prepare them for further study at the university or other third 

cycle coursework at highly regarded polytechnics and specialized institutes. Basic education is 

both free and required. In 2017, senior secondary education became free. The University of Ghana 

(founded 1948) has campuses in Legon and Accra, the Kwame Nkrumah University of Science 

and Technology in Kumasi (1951), the University of Cape Coast (1962), the University of 

Education in Winneba (1992), and the University for Development Studies in Tamale (1992).   

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3.3 DATA SOURCE   

The primary source of data is the Ghana Multiple Indicator Cluster Survey (MICS), 2017/2018. 

GSS collaborated with the Ghana Health Service (GHS), the Ministry of Health (MoH), the 

Ministry of Sanitation and Water Resources (MoSWR), the Ministry of Education (MoE), and the 

Ministry of Gender, Children, and Social Protection to conduct the study (MoGCSP). The World 

Bank, UNICEF, and other partners such as the Korea International Cooperation Agency (KOICA), 

the United Nations Development Program (UNDP), the United States Agency for International 

Development (USAID), and the Korea International Cooperation Agency (KOICA) provided 

technical and financial assistance through the Statistics for Results Facility-Catalytic Fund (SRF-

CF).    

The survey's objective was to gather information on indices of children's and women's well-being 

at the national, rural, and urban levels as well as for the ten administrative areas that existed at the 

time.   

3.4 STUDY DESIGN   

The MICS 2017/2018 used a cross-sectional sample design to collect data on several indicators 

regarding children, women, and men across the country, stratified into urban and rural areas as well 

as the ten geographical regions of Ghana at the time data was collected.   

3.5 SAMPLING METHOD    

The primary characteristics of the sampling technique utilized for the survey included; the target 

population, the sample frame, the sample allocation, the listing in chosen clusters, the selection of 

the area, the selection procedure, the stratification, and the computation of sample weights. The 

GMICS sample frame was based on the 2010 Population and Housing Census (PHC). The survey 

sample was then chosen using a multi-stage, stratified cluster sampling approach. The first stage 

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of sampling involved identifying households in enumeration areas (EAs) described for the 2010 

PHC enumeration. Then, in the second stage, a list of households was created in each sampled EA, 

and a representative of households was chosen.   

The smallest regions received at least 60 sample clusters (primary sampling units), with the Greater 

Accra Region receiving up to 86 sample clusters. Within each region, sample clusters were 

distributed between urban and rural strata in proportion to the size of the corresponding populations 

in the frame. Clusters (primary sampling units) were assigned to each region's urban and rural 

strata in proportion to the number of households in the census frame for that stratum. The number 

of households selected per cluster for the MICS Ghana 2017/18 was determined by a number of 

factors, including the design effect, the available budget, and the time required per team to 

complete one cluster. Women in their reproductive age between the ages of 15 and 49 were eligible 

to participate in the survey. A total of (13,202) households were sampled across the country's ten 

regions, with (8,879) mothers/caretakers and (8,902) children under the age of five eligible and 

recruited.   

3.6 DATA COLLECTION METHOD   

The survey used computer-assisted personal interviewing (CAPI) to collect information from 

participants (CAPI). The CSPro (Census and Survey Processing System) software, Version 6.3, 

was used, which included a MICS-specific data management platform. The survey adhered to the 

global MICS's standard program and procedures. This has been updated to reflect the MICS   

2017/2018 final questionnaires. The CAPI application was tested in the Central Region in August 

2017. Based on the results and issues identified, changes were made to the questionnaires and 

application.   

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3.7 QUESTIONNAIRES    

The 2017/2018 MICS collected information using questionnaires on: 1) all de jure household 

members (usual residents), the household, and the dwelling; 2) a water quality testing questionnaire 

administered in 5 households in each cluster of the sample; 3) a questionnaire for individual women 

administered in each household to all women aged 15-49 years; and 4) a questionnaire for 

individual men administered in each household to all men aged 15-49 years. The survey 

respondents' socio-demographic characteristics included age, gender, marital status, educational 

level, place of residence, occupation, religion, ethnicity, and child sex. The data collection spanned 

between September 2017 and January 2018.    

 

3.8 MEASUREMENT OF VARIABLES   

3.8.1 DEPENDENT VARIABLE   

The study's dependent variable is child diarrhoea. In the survey (GMICS), mothers and other 

caregivers of children under the age of five were questioned whether their "child has had diarrhoea" 

in the previous two weeks. The response was a “YES or NO”. A child was classified as having 

diarrhoea if the mother/caregiver responded “Yes” to the question “has the child had diarrhoea in 

the last two weeks preceding the survey”. A child was categorized as not having diarrhoea if the 

mother/caregiver responded “NO” to the question “has the child had diarrhoea in the past two 

weeks preceding the survey.”    

3.8.2 INDEPENDENT VARIABLES   

The independent variables included housing material index, source of drinking water, sanitation, 

presence of fixed facility for handwashing. A housing material index was computed. A housing 

material refers to the building materials used to construct the housing unit in which a child lived 

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in. This housing material index was categorized into improved and unimproved house. An 

improved house comprised of a house made of any of the main material of dwelling floor, roof and 

exterior wall classified as improved or finished by the Ghana Multiple Indicator Cluster Survey 

report (2017/2018). Parquet or polished wood, vinyl or asphalt strips, carpet, terrazzo, 

metal/tin/corrugated, iron sheet, wood, calamine/cement fibre, ceramic tiles, cement, roofing 

shingles, slate/asbestos, cement, stone with lime/cement, bricks, cement blocks, wood planks, and 

slates/asbestos are all components of an improved housing material while an unimproved housing 

material comprised of earth / sand, dung, wood planks, palm / bamboo, stone thatch / palm 

leaf/raffia, rustic mat, palm / bamboo, wood planks, cardboard/polythene sheet, mud/mud 

brick/earth, cane / palm / trunks, earth/mud/mud bricks, bamboo with mud, stone with mud, 

plywood, and cardboard.   

In furtherance, a place for cooking referred to the space within the building or structure in which a 

household cooks food. A place for cooking was grouped into three, mainly; children of households 

that cooked in separate room in the main building. Children of household that cooked in same 

room in the main building and lastly, children of household that cooked in the open space in the 

main building.   

Other housing features were access to clean water, sanitary conditions, and a wealth index. Five 

quintiles of household wealth were determined using principal component analysis (poorest, 

poorest, middle, richest, and richest). In addition, the participants' handwashing practices were 

categorized as either using a handwashing station at home or not. Both prior research and the 

relevant data that were present in the MICS data sets had an impact on our choice of variables.   

The WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation, and Hygiene 

classified drinking water sources as "improved" or "unimproved" (JMP). Drinking water from 

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piped water or tube wells, boreholes, protected dug wells, tanker trucks, protected springs, 

packaged water, and rainwater were all considered improved water sources whereas unimproved 

water includes water originating from streams, rivers, dams, lakes, ponds, irrigation and canal 

channels, unprotected springs, unprotected dug wells. In terms of sanitation, households that used 

bucket latrines, hanging latrines, or pit latrines without slabs or platforms, were unimproved whilst 

households that used pit latrines with slab, flush/pour flush toilets, ventilated improved latrines, 

and composting toilet were categorized as improved sanitation.    

Characteristics of the mother and the kid were also taken into account as independent variables.  

Based on information from earlier literature, it was determined that the age of mothers or 

caregivers, the location of the household, the level of education, and the age of the child might all 

have an effect on the likelihood of diarrhoea occurring among children under the age of five in 

Ghana. The literature has identified a number of variables as diarrhoea predictors. The mother's 

age, place of residence (urban, rural, or regional), and degree of education were among the maternal 

characteristics. The sex and age of the child were measured as categorical variables and were 

considered to be child-related characteristics.  

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TABLE 3. 1 A TABLE SHOWING HOW THE VARIABLES WERE MEASURED.   

Variables   Measurement   

Incidence of an episode of diarrhoea within the past 

weeks   

Yes   

No   

Housing material index    Improved    

Unimproved   

Water and Sanitation      

What is the major water source in your home that 

members of your family utilize for other activities like 

cooking and handwashing?   

Improved drinking water    

Piped water   

Piped into dwelling   

Pipe