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Socioeconomic Variables and Rates of Diarrhoeal Disease in Urban Bangladesh
Socioeconomic Variables and Rates of Diarrhoeal Disease in Urban Bangladesh
TRAN~.KTION~
OF THE ROYAI.SOCETYOF TROPICAL.
MEDICINEAND HYGIENE (1987) 81, 278-282
Abstract
Sociodemographic factors including low maternal education, low economic status, inferior quality
of housing, diminished accessto water and sanitation facilities, and crowding in the household are
associatedwith increased diarrhoea in the rural setting of many developing countries. To assessthe
relationship of these variables with diarrhoea rates in children in an urban setting we monitored the
episodesof diarrhoea of children <6 years of agefrom 1921 families living in 51 clusters throughout
Dhaka city, Bangladesh, for 3% months. Comparing incidence density ratios, we found that, of the
factors listed above, only low family income and living in a one-room house were statistically
associated with increased diarrhoea and that none of these variables was associated with a
meaningfully increased risk of diarrhoea. We conclude that the risk factors for increased episodesof
diarrhoea in the urban setting appear to be different from those of the rural setting.
Bangladesh populations which elicited information about Table l-Socioeconomic stahts of 1921 households shldicd
owner&u of houses. land and valuable wrsonal items.
accessto-plumbing and electricity, house construction ani Median household income/month* 1000 TK
stated income of the household in the previous month. This One room only in house 1324 (69%)
questionnaire had previously been tested on a population House constructed of pucca 643 (33%)
with a similar so&cultural background to our study Household owns one or more radios 564 (29%)
population. These forms required approximately 45 min to Household owns one or more watches 810 (42%)
process. Head of household owns house 514 (27%)
We analyzed both maternal and paternal education, Head of household owns land 1083 (56%)
accepting as years of school any formal academic or religious Electricity in home 1011 (53%)
training and recording the highest grade completed. For Tap or tubewell water in compound** 401 (21%)
economic status we used one direct measure (income in the Compound or house has sanitary latrine** 473 (25%)
previous month) and 3 indirect measures(possessionof 1 or Compound or house has other latrine** 406 (21%)
more radios, of 1 or more watches and of a ‘pucca’ (cement l US$l.OO = 27 taka (TK)
or brick) home). We defined ‘accessto clean water’ as havine: **Within bari enclosure or provided and maintained by landlord to
a tap or tubewell available for free use in the compound or ai renters as part of rental agreement.
having free accessto the landlord’s tap or mbewell as part of
the rental agreement. Similarly, ‘accessto sanitary disposal’ Table Z-Episodes of diarrhoea by age and sex
was defined as access to a sanitary, pit or hanging latrine
provided by the landlord as part of the rental agreement or Diarrhoea episodehger 100 child-weeks
constructed and maintained by the community dwellers. Age in months Female Total
‘Crowding’ was determined by number of people in a
household, number of rooms in a house and number of 0 - 11 11.6 10.6 Il.0
people per room. 12 - 23 11.1 8.8
24 - 35 7.8 10.2 ;:;
2. Diarrhoea mmitming 36 - 47 5.8 7.5
After the enumeration, 7 contiguous rounds of a 2-week 48 - 59 ;:: ;:; 6.0
recall of diarrhoea of all children <6 years of age were 60 - 71 6.8 6.3
obtained from the mothers bv the interviewers. The
accuracy of the 2 week retail was augmented by a
home-maintained ‘health calendar’ for each child and thrice
weekly visits to each household by a volunteer to discussany ‘fee-for-service’ positions (rickshaw drivers and boat
problems with the mother. Diarrhoea was defined as >3 taxies), and 8% were domestic servants.
loose stools in any 24 h period. To avoid identifying as ‘new’ Table 1 presents the socioeconomic status of the
an episode of diarrhoea that was a continuation or exacerba- families. The median income was onlv $37 ner familv
tion of a pre-existing episode, we defined diarrhoea of any per month. Only one-third of homes ieke c&structea
duration during a given 2-week round as one episode. bf “pucca” (cement or brick); the remainder were
Episodes of diarrhoea beginning in an earlier round and made of bamboo. thatch and scrao. Onlv 7% of
lasting into the next round were not counted as a separate
episode in the new round. The 7 rounds were completed houses had 4 or more rooms (inclu*ding ai outside
between 7 October 1984and 15 January 1985,corresponding unenclosed verandah.) Possessionsof value were few;
with 1 month of the wet and 2% monthsof the dry season. less than half of famiiies owned one or more watched
Information obtained from these rounds formed the basis for and less than one-third owned a radio. While half the
a subsequent intervention trial. families did own land, this was usuallv ioint own-
ership with other family members of a &all plot in
C. Data analysis their rural villages. Facilities were meagre with only
To evaluate the effect of sociodemoaraphic risk factors on half the homeshavine electricitv. less than half having
diarrhoea rates, we analysed direct measures or proxies of
the more commonly implicated factors. Each analysis was accessto a latrine ana only o&-&h having accesst;
initially performed with one year age groups but we have water. The remaining families relied on ad hoc
summarized data which were homogenousacrossage strata. sanitary facilities (rental of a neighbour’s latrine,
Subjects in different categories of the risk factors were construction of a temporary hanging latrine jointly
compared for diarrhoea rates using incidence density ratios. with several other families, or defaecation in gutters).
Statisticalsignificanceof the ratios was assessed
using the Water could be purchased from neighbours or
Mantel-Haenszel x2 test. Statistical tests were interpreted in obtained from the occasional street taps installed by
a two-tailed fashion. An incidence density ratio of <l the municipality.
connoteda negativerisk, 1 correspondedto no increased
risk, and > 1 denotedan mcreasein risk (KLEINBAUM et al.,
1982). Diarrhoea rates
Diarrhoea rates during this 3% month interval
Results ranged from 6 episodes per 100 child-weeks in 4-and
Socio-demographic characteristics Syear-old children to 11 episodesper 100child-weeks
Our population included 11 176 people, 51% of in children 0 to 11 months (Table 2). Girls tended to
whom were male, living in 1921 households. The have higher rates in the first 2 years of life than boys,
median number of persons in each household was 6. but subsequently had slightly lower rates. The mean
19% of the population (2128) were less than 6 vears of number of episodes for all children <6 years of age
age and an additional 24% (2632) were under 13 years. was 8.2 per 100 weeks.
The education level obtained was low, with 1990 The analyses of the relationship between sociode-
(66%) women and 1604(44%) men older than 10 years mographic factors and diarrhoea -rates are shown in
having had no formal education. Only 56% (17% of Table 3. Because detailed analvses bv one vear
women and 92% of men1 of the 5339 ‘emnlovable’ subgroups appeared to be consist& th; results-are
persons (>12 years of age, not a student and not summarized over the age strata.
disabled) had remunerative work. 9% of these were Decreased family income was associated with a
employed only on a daily basis, 26% were in statistically significant increase in diarrhoea episodes
280 SOCIODEMOGRAPHIC FACTORS IN DIARRHOEAL DISEASE IN BANGLADESH
Paternal educationt
At or below median 0.98 0.91 - 1.05
Above median - -
Monthly income**
At or below median l-19 1.08 - 1.30
Above median - -
ow?lerseipof item
Yes 1.01 o-90 - 1.13
No - -
Access to
Latrine: Yes 1.05 0.94 - 1.18
No - -
Indications of crowding
Number of people in household++
At or below median 8.36 1.09 0.96 - 1.24
Above median 7.72 - -
The duration of the study presented here is short, The fact that socioeconomic variables associated
3% months, because the data were gathered in with diarrhoea rates in rural Bangladesh do not appear
preparation for an intervention which began in to have a substantial impact on diarrhoea rates in the
March, 1985. However, becausewe were reporting on urban area illustrates the basic difference between
2100 children, the total number of child-weeks of these settings and underscores the importance of not
observation is quite large. It is unlikely that seasonal- extrapolating from rural to urban areas.A next step in
ity per sewould have changed our results, as this 3% formulating diarrhoeal control recommendations for
month interval covered one month of the wet and 2% the urban area will be to determine if hygienic
months of dry seasons. practices between families with high and low rates of
Inadequate or poorly conceived research question- diarrhoea differ.
naires may result in poor data. Our research tools Acknowledgements
were all extensively field-tested before use. The We thank the urban volunteers,the researchteam,Mrs
censusenumeration record was adapted from a system TaikeraKhair and Mrs KhoclezaKhatun for their help; Dr
which has been in use for over 2 years in Bangladesh. BogdanWojtyniak for his adviceon the statistical analysis;
Similarly, the socioeconomic record was compiled and Mr Jatindra Nath Sarker and Mr Sontosh Daniel
Ascension for their aid in preparing the manuscript.
from tools used extensivelv bv scientists at ICDDR,B ICDDR, B is supportedby countriesand agencieswhich
in 2 other areasof Banglades-h.The diarrhoea recall, share its concern ab& the impact of diarrh&a disease on
which utilized a 2-week period, was augmented by the developing world. Funds for this particular study were
thrice weekly home visits by a community health provided by the UNDP, Arab Gulf Fund, UNICEF and the
worker and by a home-maintained health calendar. Belgian Government.
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ANNOUNCEMENT
II LATIN-AMERICAN AND V COLOMBIAN CONGRESS OF PARASITOLOGY
AND TROPICAL MEDICINE - BOGOTA, COLOMBIA, 25-29 MAY 1987
Submission of one or more papers is invited; they should be sent to the President of the Organizing
Committee, Dr August0 Corredor, at the Institute National de Mud, Apartado A&e0 92305, Bogok,
D.E., Colombia, from whom further information can be obtained.