Volume 91, Issue 6
  • ISSN: 0002-9637
  • E-ISSN: 1476-1645



This study examined the relationship between childhood diarrhea prevalence and caregiver knowledge of the causes and prevention of diarrhea in a prospective cohort of 952 children < 5 years of age in Cochabamba, Bolivia. The survey of caregiver knowledge found that more than 80% of caregivers were unaware that hand washing with soap could prevent childhood diarrhea. Furthermore, when asked how to keep food safe for children to eat only 17% of caregivers reported hand washing before cooking and feeding a child. Lack of caregiver awareness of the importance of practices related to hygiene and sanitation for diarrhea prevention were significant risk factors for diarrheal disease in this cohort. The knowledge findings from this study suggest that health promotion in these communities should put further emphasis on increasing knowledge of how water treatment, hand washing with soap, proper disposal of child feces, and food preparation relate to childhood diarrhea prevention.


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  1. Liu L, Johnson HL, Cousens S, Perin J, Scott S, Lawn JE, Rudan I, Campbell H, Cibulskis R, Li M, Mathers C, Black RE, Child Health Epidemiology Reference Group of WHO and UNICEF; , 2012. Global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. Lancet 379: 21512161.[Crossref] [Google Scholar]
  2. Coa RO, , 2009. Encuesta Nacional de Demografía y Salud. La Paz, Bolivia: Ministerio de Salud y Deportes. [Google Scholar]
  3. Pathela P, Zahid Hasan K, Roy E, Huq F, Kasem Siddique A, Bradley Sack R, , 2006. Diarrheal illness in a cohort of children 0–2 years of age in rural Bangladesh. I. Incidence and risk factors. Acta Paediatr 95: 430437.[Crossref] [Google Scholar]
  4. Quick R, Venczel L, Mintz ED, Soleto L, Aparicio J, Gironaz M, Hutwagner L, Greene K, Bopp C, Maloney K, Chavez D, Sobsey M, Tauxe RV, , 1999. Diarrhea prevention in Bolivia through point-of-use water treatment and safe storage: a promising new strategy. Epidemiol Infect 122: 8390.[Crossref] [Google Scholar]
  5. Mølbak K, Jensen H, Aaby P, , 1997. Risk factors for diarrheal disease incidence in early childhood: a community cohort study from Guinea-Bissau. Am J Epidemiol 146: 273282.[Crossref] [Google Scholar]
  6. VanDerslice J, Popkin B, Briscoe J, , 1994. Drinking-water quality, sanitation, and breast-feeding: their interactive effects on infant health. Bull World Health Organ 72: 589. [Google Scholar]
  7. Guerrant RL, Kirchhoff LV, Shields DS, Nations MK, Leslie J, de Sousa MA, Araujo JG, Correia LL, Sauer KT, McClelland KE, , 1983. Prospective study of diarrheal illnesses in northeastern Brazil: patterns of disease, nutritional impact, etiologies, and risk factors. J Infect Dis 148: 986997.[Crossref] [Google Scholar]
  8. Blake PA, Ramos S, MacDonald KL, Rassi V, Gomes TA, Ivey C, Bean NH, Trabulsi LR, , 1993. Pathogen-specific risk factors and protective factors for acute diarrheal disease in urban Brazilian infants. J Infect Dis 167: 627632.[Crossref] [Google Scholar]
  9. Kosek M, Yori PP, Pan WK, Olortegui MP, Gilman RH, Perez J, Chavez CB, Sanchez GM, Burga R, Hall E, , 2008. Epidemiology of highly endemic multiply antibiotic-resistant shigellosis in children in the Peruvian Amazon. Pediatrics 122: e541e9.[Crossref] [Google Scholar]
  10. Dargent-Molina P, James SA, Strogatz DS, Savitz DA, , 1994. Association between maternal education and infant diarrhea in different household and community environments of Cebu, Philippines. Soc Sci Med 38: 343350.[Crossref] [Google Scholar]
  11. Genser B, Strina A, Teles CA, Prado MS, Barreto ML, , 2006. Risk factors for childhood diarrhea incidence: dynamic analysis of a longitudinal study. Epidemiology 17: 658667.[Crossref] [Google Scholar]
  12. Lee G, Pan W, Yori P, Paredes Olortegui M, Tilley D, Gregory M, Oberhelman R, Burga R, Chavez CB, Kosek M, , 2013. Symptomatic and asymptomatic Campylobacter infections associated with reduced growth in Peruvian children. PLoS Negl Trop Dis 7: e2036.[Crossref] [Google Scholar]
  13. Tornheim JA, Morland KB, Landrigan PJ, Cifuentes E, , 2009. Water privatization, water source, and pediatric diarrhea in Bolivia: epidemiologic analysis of a social experiment. Int J Occup Environ Health 15: 241248.[Crossref] [Google Scholar]
  14. Checkley W, Gilman RH, Black RE, Epstein LD, Cabrera L, Sterling CR, Moulton LH, , 2004. Effect of water and sanitation on childhood health in a poor Peruvian peri-urban community. Lancet 363: 112118.[Crossref] [Google Scholar]
  15. Maponga BA, Chirundu D, Gombe NT, Tshimanga M, Shambira G, Takundwa L, , 2013. Risk factors for contracting watery diarrhea in Kadoma City, Zimbabwe, 2011: a case control study. BMC Infect Dis 13: 567.[Crossref] [Google Scholar]
  16. D'Souza RM, , 1997. Housing and environmental factors and their effects on the health of children in the slums of Karachi, Pakistan. J Biosoc Sci 29: 271281.[Crossref] [Google Scholar]
  17. Ghosh S, Sengupta P, Mondal S, Banu M, Gupta D, Sircar B, , 1997. Risk behavioral practices of rural mothers as determinants of childhood diarrhea. J Commun Dis 29: 714. [Google Scholar]
  18. Saha D, , 2013. Acute Diarrhea in Children in Rural Gambia: Knowledge, Attitude and Practice, Aetiology, Risk Factors and Consequences among Children Less Than Five Years of Age. Dunedin, New Zealand: University of Otago. [Google Scholar]
  19. Bushen OY, Davenport JA, Lima AB, Piscitelli SC, Uzgiris AJ, Silva TM, Leite R, Kosek M, Dillingham RA, Girao A, Lima AA, Guerrant RL, , 2004. Diarrhea and reduced levels of antiretroviral drugs: improvement with glutamine or alanyl-glutamine in a randomized controlled trial in northeast Brazil. Clin Infect Dis 38: 17641770.[Crossref] [Google Scholar]
  20. Sobel J, Gomes T, Ramos RT, Hoekstra M, Rodrigue D, Rassi V, Griffin PM, , 2004. Pathogen-specific risk factors and protective factors for acute diarrheal illness in children aged 12–59 months in Sao Paulo, Brazil. Clin Infect Dis 38: 15451551.[Crossref] [Google Scholar]
  21. Esrey SA, , 1996. Water, waste, and well-being: a multicountry study. Am J Epidemiol 143: 608623.[Crossref] [Google Scholar]
  22. Kotloff KL, Nataro JP, Blackwelder WC, Nasrin D, Farag TH, Panchalingam S, Wu Y, Sow SO, Sur D, Breiman RF, Faruque AS, Zaidi AK, Saha D, Alonso PL, Tamboura B, Sanogo D, Onwuchekwa U, Manna B, Ramamurthy T, Kanungo S, Ochieng JB, Omore R, Oundo JO, Hossain A, Das SK, Ahmed S, Qureshi S, Quadri F, Adegbola RA, Antonio M, Hossain MJ, Akinsola A, Mandomando I, Nhampossa T, Acácio S, Biswas K, O'Reilly CE, Mintz ED, Berkeley LY, Muhsen K, Sommerfelt H, Robins-Browne RM, Levine MM, , 2013. Burden and aetiology of diarrheal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study. Lancet 382: 209222.[Crossref] [Google Scholar]
  23. Figueroa ME, Kincaid DL, , 2007. Social, cultural and behavioral correlates of household water treatment and storage. Household Water Treatment and Safe Storage. Geneva: World Health Organization. [Google Scholar]
  24. Goldman N, Pebley AR, Beckett M, , 2001. Diffusion of ideas about personal hygiene and contamination in poor countries: evidence from Guatemala. Soc Sci Med 52: 5369.[Crossref] [Google Scholar]
  25. Nichter M, , 1985. Drink boiled water: a cultural analysis of a health education message. Soc Sci Med 21: 667669.[Crossref] [Google Scholar]
  26. Folasade Iyun B, Adewale Oke E, , 2000. Ecological and cultural barriers to treatment of childhood diarrhea in riverine areas of Ondo State, Nigeria. Soc Sci Med 50: 953964.[Crossref] [Google Scholar]
  27. McLennan JD, , 1998. Knowledge and practices of preventing diarrhea in malnourished children. J Diarrhoeal Dis Res 16: 235240. [Google Scholar]
  28. Nielsen M, Hoogvorst A, Konradsen F, Mudasser M, van der Hoek W, , 2003. Causes of childhood diarrhea as perceived by mothers in the Punjab, Pakistan. Southeast Asian J Trop Med Public Health 34: 343351. [Google Scholar]
  29. Elegbe I, Juba A, , 1988. Partnership with nursing mothers: an interim strategy for combating childhood enteric diseases in Nigeria. Child Care Health Dev 14: 5158.[Crossref] [Google Scholar]
  30. Dikassa L, Mock N, Magnani R, Rice J, Abdoh A, Mercer D, Bertrand W, , 1993. Maternal behavioral risk factors for severe childhood diarrheal disease in Kinshasa, Zaire. Int J Epidemiol 22: 327333.[Crossref] [Google Scholar]
  31. Bertrand WE, Walmus BF, , 1983. Maternal knowledge, attitudes and practice as predictors of diarrheal disease in young children. Int J Epidemiol 12: 205210.[Crossref] [Google Scholar]
  32. Dreibelbis R, Winch PJ, Leontsini E, Hulland KR, Ram PK, Unicomb L, Luby SP, , 2013. The integrated behavioral model for water, sanitation, and hygiene: a systematic review of behavioral models and a framework for designing and evaluating behavior change interventions in infrastructure-restricted settings. BMC Public Health 13: 1015.[Crossref] [Google Scholar]
  33. Curtis VA, Danquah LO, Aunger RV, , 2009. Planned, motivated and habitual hygiene behavior: an eleven country review. Health Educ Res 24: 655673.[Crossref] [Google Scholar]
  34. Curtis V, Schmidt W, Luby S, Florez R, Touré O, Biran A, , 2011. Hygiene: new hopes, new horizons. Lancet Infect Dis 11: 312321.[Crossref] [Google Scholar]
  35. Mosler H-J, , 2012. A systematic approach to behavior change interventions for the water and sanitation sector in developing countries: a conceptual model, a review, and a guideline. Int J Environ Health Res 22: 431449.[Crossref] [Google Scholar]
  36. Aunger R, Schmidt W-P, Ranpura A, Coombes Y, Maina PM, Matiko CN, Curtis V, , 2010. Three kinds of psychological determinants for hand-washing behavior in Kenya. Soc Sci Med 70: 383391.[Crossref] [Google Scholar]
  37. Clasen T, Schmidt W-P, Rabie T, Roberts I, Cairncross S, , 2007. Interventions to improve water quality for preventing diarrhea: systematic review and meta-analysis. BMJ 334: 782.[Crossref] [Google Scholar]
  38. Fewtrell L, Kaufmann RB, Kay D, Enanoria W, Haller L, Colford JM, Jr, 2005. Water, sanitation, and hygiene interventions to reduce diarrhea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis 5: 4252.[Crossref] [Google Scholar]
  39. Curtis V, Cairncross S, , 2003. Effect of washing hands with soap on diarrhea risk in the community: a systematic review. Lancet Infect Dis 3: 275281.[Crossref] [Google Scholar]
  40. Sima LC, Desai MM, McCarty KM, Elimelech M, , 2012. Relationship between use of water from community-scale water treatment refill kiosks and childhood diarrhea in Jakarta. Am J Trop Med Hyg 87: 979.[Crossref] [Google Scholar]
  41. Aposhian HV, Arroyo A, Cebrian ME, del Razo LM, Hurlbut KM, Dart RC, Gonzalez-Ramirez D, Kreppel H, Speisky H, Smith A, Gonsebatt ME, Ostrosky-Wegman P, Aposhian MM, , 1997. DMPS-arsenic challenge test. I: increased urinary excretion of monomethylarsonic acid in humans given dimercaptopropane sulfonate. J Pharmacol Exp Ther 282: 192200. [Google Scholar]
  42. Lindquist ED, George CM, Perin J, Neiswender de Calani KJ, Norman WR, Davis TP, Jr Perry H, , 2014. A cluster randomized controlled trial to reduce childhood diarrhea using hollow fiber water filter and/or hygiene-sanitation educational interventions. Am J Trop Med Hyg 91: 190197.[Crossref] [Google Scholar]
  43. Liang K-Y, Zeger SL, , 1986. Longitudinal data analysis using generalized linear models. Biometrika 73: 1322.[Crossref] [Google Scholar]
  44. Davison AC, Hinkley DV, Young GA, , 2003. Recent developments in bootstrap methodology. Stat Sci 18: 141157.[Crossref] [Google Scholar]
  45. Efron B, , 2003. Second thoughts on the bootstrap. Stat Sci 18: 135140.[Crossref] [Google Scholar]
  46. Hall P, Wilson SR, , 1991. Two guidelines for bootstrap hypothesis testing. Biometrics 47: 757762.[Crossref] [Google Scholar]
  47. Sima LC, Ng R, Elimelech M, , 2013. Modeling risk categories to predict the longitudinal prevalence of childhood diarrhea in Indonesia. Am J Trop Med Hyg 89: 884891.[Crossref] [Google Scholar]
  48. Clasen TF, Brown J, Collin SM, , 2006. Preventing diarrhea with household ceramic water filters: assessment of a pilot project in Bolivia. Int J Environ Health Res 16: 231239.[Crossref] [Google Scholar]
  49. Nielsen M, Hoogvorst A, Konradsen F, Mudasser M, van der Hoek W, , 2003. Causes of childhood diarrhea as perceived by mothers in the Punjab, Pakistan. Southeast Asian J Trop Med Public Health 34: 343351. [Google Scholar]
  50. Weiss MG, , 1988. Cultural models of diarrheal illness: conceptual framework and review. Soc Sci Med 27: 516.[Crossref] [Google Scholar]
  51. Pebley A, Hurtado E, Goldman N, , 1999. Beliefs about children's illness. J Biosoc Sci 31: 195219.[Crossref] [Google Scholar]
  52. Kirchhoff LV, McClelland KE, Do Carmo Pinho M, Araujo JG, De Sousa MA, Guerrant RL, , 1985. Feasibility and efficacy of in-home water chlorination in rural north-eastern Brazil. J Hyg (Lond) 94: 173180.[Crossref] [Google Scholar]
  53. Nichter M, , 1991. Use of social science research to improve epidemiologic studies of and interventions for diarrhea and dysentery. Rev Infect Dis 13: S265S271.[Crossref] [Google Scholar]
  54. Smith ER, Rowlinson EE, Iniguez V, Etienne KA, Rivera R, Mamani N, Rheingans R, Patzi M, Halkyer P, Leon JS, , 2011. Cost-effectiveness of rotavirus vaccination in Bolivia from the state perspective. Vaccine 29: 67046711.[Crossref] [Google Scholar]
  55. Rivera R, Forney K, Castro MR, Rebolledo PA, Mamani N, Patzi M, Halkyer P, Leon JS, Iñiguez V, , 2013. Rotavirus genotype distribution during the pre-vaccine period in Bolivia: 2007–2008. Int J Infect Dis 17: e762e767.[Crossref] [Google Scholar]
  56. Desai R, Oliveira LH, Parashar UD, Lopman B, Tate JE, Patel MM, , 2011. Reduction in morbidity and mortality from childhood diarrheal disease after species A rotavirus vaccine introduction in Latin America: a review. Mem Inst Oswaldo Cruz 106: 907911.[Crossref] [Google Scholar]

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  • Received : 25 Jan 2014
  • Accepted : 18 Aug 2014
  • Published online : 03 Dec 2014

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