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The determinants of childhood diarrhea and acute respiratory infection: testing the importance of community-level determinants in Eswatini.

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Background: It has been noted that regardless of the observed decline in childhood mortality in developing countries, the mortality rate is still extremely high. Approximately 30 countries in Africa and Asia need to triple their current standard of reduction of childhood mortality to realise the sustainable development goal (SDG) number 3 of ensuring healthy lives and wellbeing for all age groups. The study investigated the following research questions: 1. what is the prevalence of childhood diarrhoea and ARIs? 2. What are the individual, household and community-level factors associated with childhood diarrhoea and ARIs? 3. To what extent do community-level factors explain variations in childhood diarrhoea and ARIs? 4. Which clusters or communities have a higher burden of childhood diarrhoea and ARIs? Methodology: The study used a pooled secondary data analysis approach utilising data from the 2010 and 2014 Eswatini Multiple Indicator Cluster Surveys (MICS) that were cross-sectional. The study utilised 5340 children aged below five years as the unit of analysis. The outcome variables of the study were child diarrhoea and acute respiratory infection. The single-level multivariate logistic regression, multilevel multivariate logistic regression and Quantum GIS were used to answer the study questions. STATA 13 was used for the analyses. Results: The study found that the magnitude of diarrhoea in Eswatini was 16.2% among underfive children. In the multilevel model, child age, current height for age, toilet facility region of residence overall community diarrhoea, were found to be important variables. For instance, children aged 6-11 months and 12-23 months were 434% and 290% respectively, more likely to have diarrhoea relative to those aged less than 6 months. Children with a normal and above normal current height for age had 91% and 93% respectively increased odds of having diarrhoea compared to those with a growth deficit. Children from households with no toilet facility were 283% more likely to have diarrhoea compared to those from households with a flush toilet. Residents in the Hohho region were 159% more likely to have diarrhoea compared to children who resided in the Lubombo region. Children from communities that had medium and high overall community diarrhoea were 26% and 877% more likely to have diarrhoea compared to children from communities with low overall community diarrhoea. The results showed a substantial variation of diarrhoea across communities. The individual-level factors explained 5.6% of diarrhoea across communities; household factors explained 65.3% of the variation while community-level factors explained 85% of the variation even though it was not significant. The Mapping analysis revealed that the severity of diarrhoea was most pronounced in the Manzini region and the Shiselweni region when compared to the Hhohho region. A total of 31% of the constituencies had a high prevalence of diarrhoea between 18.4-28.1% in the Manzini region. A consideration of the Shiselweni region revealed that 50% of the communities had a high prevalence of diarrhoea of between 18.4-28.1% The study found that the magnitude of ARI in Eswatini was 20.9% among under-five children. In the multilevel model, maternal age, household wealth index, shared toilet with neighbours, and region of residence were important factors that explained the variation of ARI across communities. Individual factors explained about 76.05 % as shown by the PVC; household level factors explained about 94% of the variance, and community-level factors explained about 93.6% of the variation of child ARI across communities. The study mapped the prevalence of ARI across communities (clusters) and found that the Hhohho region had four constituencies with a high prevalence of ARI, Motshane, Mbabane South, Mbabane East, Nkhaba and Tiphisini. In the Manzini region, five constituencies had a higher burden of ARI, namely Lamgabhi, Kwaluseni, Ntontozi, Mafutseni and Ludzeludze. In the Shiswelweni region, the burden of diarrhoea was higher among five constituencies, namely Zombodze, Mbangweni, Kubuta, Ngudzeni and Sigwe. In the Lubombo region, the burden of ARI was higher at Lubulini, Hlane, and Mhlume. Conclusion: The study demonstrated that the prevalence of diarrhoea and ARI are still very high and a persistent public health problem in Eswatini. The causes of the high magnitude of diarrhoea and ARI vary by individual, household and community factors. Policies that aim to ensure reduction in child morbidity from diarrhoea and ARI in Eswatini include strategies and programmes that rectify characteristics of the community contexts which mainly in the socially and economically disadvantaged communities and regions of Eswatini.


Doctoral Degree. University of KwaZulu-Natal, Durban.