Natural catastrophes have a profound impact on the health of children, particularly in low and middle-income countries such as South and Southeast Asia.Reference Rodriguez, Vos and Below 1 , Reference Watts, Amann and Arnell 2 Floods are one of the most common natural hazards in the world, posing a significant threat to the health of children.Reference Noji 3 , Reference Ahern, Kovats and Wilkinson 4 It is predicted that the magnitude and frequency of floods will gradually increase in the future as a result of global warming.Reference Vitousek, Barnard and Fletcher 5 -Reference Apurv, Mehrotra and Sharma 7 By the end of this century, approximately 1.2% of the global population is expected to be affected by floods. Reference Hirabayashi, Mahendran and Koirala 8 In India, about 23 million people were affected by floods in 2018.Reference Dimitrova and Bora 9
In addition to the financial loss and infrastructure and property damage, floods have wide-ranging negative impacts on various aspects of human well-being, including crop production, economic activities, livelihood, and mental health.Reference Watts, Amann and Arnell 2 Furthermore, floods can contribute to the incidence of infectious diseases, including diarrhea, leptospirosis, and cholera.Reference Ahern, Kovats and Wilkinson 4 , Reference Ivers and Ryan 10 -Reference Shokri, Sabzevari and Hashemi 13 The post-flood period may also lead to an increase in vector-borne diseases such as malaria, dengue, hemorrhagic fever, and West Nile Fever due to the proliferation of mosquitoes in stagnant water.Reference Garziera, Pedrosa and de Souza 14 -Reference Bhan, Thomas and Singh 16 Bacterial causes of diarrhea are more common in the summer season, whereas viral diarrhea is more prevalent during the winter season.Reference Abuzerr, Nasseri, Yunesian, Hadi, Mahvi, Nabizadeh and Mustafa 17 -Reference Levy, Hubbard and Eisenberg 20 In lower and middle income countries, infectious diseases remain a significant cause of death, and floods can pose a serious hazard to public health, with a substantial impact on childhood diarrhea.Reference Wang, Asare and Pitzer 21
In India, the leading causes of mortality among children under the age of five remain a critical issue. Pneumonia, a respiratory infection (in 2015, there were an estimated 192,000 pneumonia deaths in children younger than 5 years), and diarrheal diseases, linked to inadequate clean water and sanitation, are significant contributors.Reference Walker, Rudan and Liu 22 , Reference Wahl, Knoll and Shet 23 Malnutrition weakens children’s immune systems, heightening susceptibility to various diseases, accounting for 68.2% of the total deaths among children below five years of age. 24 Preterm birth complications, occurring before 37 weeks of gestation, and childbirth-related issues like birth asphyxia and trauma, also contribute to health complications and under-five mortality.Reference Beck, Wojdyla and Say 25
Diarrhea remains a significant public health challenge in low- and middle-income countries, contributing to increased morbidity and mortality rates among children.Reference Walker, Rudan and Liu 22 It ranks as the second leading cause of illness and death among children under the age of five.Reference Walker, Rudan and Liu 22 Each year, approximately 17 million children are affected by diarrhea, and an estimated 52,500 children die from the disease, with the majority of cases occurring in children under the age of two. 26 According to the World Health Organization (WHO), diarrheal disease is characterized by three or more loose or liquid stools per day. 27 It is primarily caused by waterborne bacteria, protozoa, and viruses. Poor sanitation, unhygienic food practices, and unfavorable environmental conditions further contribute to the burden of childhood diarrhea.Reference Hasan, Pathela and Alam 28 Various studies have indicated that socio-economic, demographic, environmental conditions and household characteristics play a significant role in the occurrence of childhood diarrhea.Reference Paul 29 , Reference Ghosh, Chakraborty and Mog 30 , Reference Manun’ebo, Haggerty and Gaie 31 Moreover, geographical factors have been found to influence the spatial distribution of diarrheal diseases, including factors such as geographical location, place of residence, and the rural-urban composition.Reference Paul 29 , Reference Ghosh, Chakraborty and Mog 30 , Reference Nilima, Shetty and Unnikrishnan 33 -Reference Chaurasia, Srivastava and Singh 36 Sanitation facilities and hygiene conditions have a significant impact on childhood diarrhea, including factors such as the absence of toilet facilities, poor household conditions, improper child stool disposal, and lack of access to improved drinking water.Reference Ghosh, Chakraborty and Mog 30 Additionally, behavioral factors such as breastfeeding practices, eating habits, food consumption patterns, and hand-washing practices are also closely associated with childhood diarrhea.Reference Zedie and Kassa 37 -Reference Gupta, Sarker and Rout 39 In lower-income countries, sanitation facilities, water quality, and the causative agents of diarrhea (such as bacteria and pathogens) differ from those in higher-income countries, leading to poor health outcomes following floods, including cholera, rotavirus diarrhea, cryptosporidiosis, and non-specific diarrhea. Reference Khan, Abimbola and Kyobutungi 40 -Reference Mondal, Biswas and Manna 45 A rigorous study conducted in Bangladesh revealed that a flood-induced diarrheal epidemic was primarily driven by cholera.Reference Schwartz, Harris and Khan 46 Furthermore, climatic and weather variations also play a significant role in influencing the occurrence of childhood diarrhea. The seasonal variation of climatic events can have a direct impact on the prevalence and incidence childhood diarrhea, which remains a major concern for the overall well-being of children.Reference Mondal, Biswas and Manna 45 , Reference Ballester, Michelozzi and Iñiguez 47 While many studies have focused on micro-level or regional perspectives, there is a limited amount of large-scale research on flood and childhood diarrhea in rural India. Therefore, this study sought to explore the association of floods with diarrhea among under-five children in rural India. This study aims to contribute to the scarce existing evidence on the association between childhood diarrhea and flood exposure in rural India.
Methods
Data Source
The study utilized data from the latest round of the National Family Health Survey (NFHS-5), conducted in 2019-21. The NFHS-5 is a nationally representative large-scale sample survey that collected data from 636,699 households, 724,115 ever-married women aged 15-49 years, and 101,839 men aged 15-54 years. The survey was carried out across all 28 states and 8 union territories in the country. A stratified two-stage sampling design was used for the selection of samples. The purpose of this survey was to gather updated and reliable information on a wide range of population and health indicators such as maternal and child health, fertility, childhood morbidity and mortality, family planning, immunization services, nutritional status of women and children, family planning, non-communicable diseases, disability, access to a toilet facility, etc. up to the district level. A detailed description of the sampling design and procedures of the survey is provided in the national report NFHS-5. 48
Study Design
To assess the relationship between childhood diarrhea and floods, a cross-sectional study design was employed using data from the fifth round of the National Family Health Survey (NFHS-5) data. The study focused on children under the age of five residing in rural areas, with a total of 178,334 children whose information were collected in the NFHS-5 survey. These children were included as study subjects to explore the association between childhood diarrhea and flood occurrences.
Outcome variable
The outcome variable of this study is diarrheal disease among children under five years of age. Diarrhea is defined as having three or more loose or watery stools in 24 hours as reported by the mother or caregiver of the children in the last two weeks of the survey. Reference Paul 29 In the NFHS survey, data on children’s experiences with diarrhea were gathered by interviewing mothers of children under the age of five in the selected households. Mothers were asked whether her child/children had suffered from diarrheal diseases in the last two weeks preceding the survey, and their responses were recorded as ’0’ for ’no’ and ’1’ for ’yes.’
Predictor variable
In this study, non-flood-affected areas and flood-affected areas were considered as the explanatory variable. At first, we categorized the districts into flood and non-flood-affected districts using the Central Water Commission annual reports of 2018-19, 2019-20, and 2020-21. This study included only those districts severely affected by floods. Those districts affected by floods for three consecutive years (2018-20) were termed as “three times affected” and if a flood occurred one or two times between the years 2018 and 2020, they were assigned as “one and two times”. To conduct this study, only participants residing in rural areas were included. Of the total, 39 districts were included in the flood-affected area and 659 districts were included in the non-flood-affected area.
Confounders
Apart from the main predictor variable, several socio-demographic and environmental characteristics of households were incorporated into the analysis as confounding factors that could significantly influence the prevalence of childhood diarrhea. The selected variables included the age of the children (0-11, 12-23, 24-35, 36-47, 48-59 months), sex of child (male and female), birth order (1, 2-3, and 4+), birth weight (< 2.5 kg [low birth weight] and ≥ 2.5 kg [normal]), maternal age (15-24, 25-34, and 35-49 years), maternal education (no education, primary, secondary, and higher), caste (Scheduled Castes [SC], Scheduled Tribes [ST], Other Backward Classes [OBC], and none of them [forward caste]), religion (Hindu, Muslim, and other religions), household size (0-4, 5-6, and 6+), wealth quintile (poorest, poorer, middle, richer, and richest), the availability of toilet facility (no/yes), type of house (kutcha and pucca), child stool disposal (not safe and safe), sources of drinking water (unimproved and improved), and perceived distance to the health facility (no problem, not a big problem, and big problem).
The caste system in India is a hierarchical social structure traditionally based on the division of labor and hereditary occupations, with individuals categorized into distinct groups known as castes. Despite efforts to address economic and social deprivation, the caste system has persisted, influencing social interactions and opportunities for individuals within the Indian society. According to the 2011 census, about 16.6% of India’s population belongs to the Scheduled Castes (SCs), often residing in rural areas and working as landless agricultural laborers. Another marginalized group, the Scheduled Tribes (STs) or Adivasis, makes up around 8.6% of the population, having faced historical discrimination. In contrast, Other Backward Classes (OBCs) and general castes together make up 71% of India’s total population.Reference Bango and Ghosh 49 It is important to mention that the wealth quintile is used as a proxy measure of standard of living which is calculated using the household’s ownership of selected assets (e.g., television, bicycle, types of access to water and sanitation facilities, etc.). Likewise, we grouped the type of house into two categories i.e., houses made from mud, thatch, sand, dung, or other low-quality materials are termed as kutcha houses, and houses made with bricks, cement, wood, or high-quality materials throughout, including floor, roof, and exterior walls, are termed as pucca houses. Availability of toilet facilities was dichotomized into two groups “yes” (improved, unimproved, and shared latrine facility) and “no” (households using open defecation). The children’s stools were considered to be disposed of safely if the child used a toilet or latrine, or rinsed into a toilet or latrine, or the stools were buried. Sources of drinking water were classified as improved and unimproved sources. Improved sources of drinking water comprised piped water, public taps, standpipes, tube wells, boreholes, protected dug wells and springs, rainwater, tanker truck, cart with a small tanks, bottled water, and community reverse osmosis (RO) plants, whereas unimproved sources of drinking water included unprotected dug well, unprotected spring, tanker/cart with a small tank, and surface water. The perceived distance to health facility was assessed by asking women regarding the difficulty they faced in travelling a certain distance to the health facility when they were sick and seeking medical advice or treatment.
Data Analysis
Descriptive statistical analyses were carried out to describe the distribution of study subjects. To assess the prevalence of the diarrheal disease among children, bivariate percentage distribution was estimated using selected predictors and confounding variables. Pearson’s chi-square statistic was later tested and variables with P < 0.05 were considered statistically significant. Bivariate and multivariate logistic regression models were employed to examine the associations between exposure to flood and diarrhea among children. The regression results were presented by unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) and the results were considered to be statistically significant at P < 0.05. All statistical analyses were performed using STATA version 16.0 (StataCorp LP, College Station, TX, USA).
Ethics Declarations
This study used secondary data drawn from the National Family Health Survey 2019-21, which is available in the public domain. The ethical approval for NFHS-5 (2019–21) was obtained from the International Institute for Population Sciences (IIPS) in Mumbai. Furthermore, the ICF International Review Board (IRB) conducted a review of the survey and granted ethical approval. The datasets are publicly available with no identifiable information about the survey participants and the datasets are freely available from the Demographic Health Survey (DHS) program at https://dhsprogram.com/data/. Therefore, no separate ethical approval was required for conducting this study.
Results
A total of 177,978 samples from children under the age of five were included in the analysis. In non-flood affected areas, of the total number of children, 9,690 were reported to have experienced diarrhea. In regions affected by floods once or twice, 1,335 children were found to have suffered from diarrhea. Additionally, in areas affected by floods three times, 1,472 children were reported to have experienced diarrhea. These findings are summarized in Table 1, which outlines the characteristics of the study sample.
Table 1. Background characteristics of living children aged 0-59 months in rural India, NFHS-5 (2019-21)
Prevalence of Diarrheal Disease by Background Characteristics of Under-five Children in India
The occurrence of diarrhea was higher in children aged 12-23 months (9.78%), 0-11 months (9.6%), and male children (7.27%). A significantly higher proportion of diarrheal diseases were found among children affiliated to the Muslim religion (7.25%). The prevalence of diarrheal diseases was substantially higher among children with low birth weight (8.09 %) and birth order above three (7.45 %). Furthermore, the prevalence of diarrheal diseases was higher among children of mothers aged 15-24 years (8.47%) than those children of mothers aged 35-49 years (6.02%). Mother’s education was found to be significantly correlated with the occurrence of diarrhea among children. Childhood diarrhea was comparatively higher among those participants whose mothers had the primary level of education (7.63 %) as compared to those mothers who had a higher level of education (6.01%). Similarly, the occurrence of diarrheal diseases in children decreases from the poorest to the richest wealth quintile. The proportion of children experiencing diarrheal diseases were found to be significantly higher in children living in households without a toilet facility (8.02%) compared to those whose households had a toilet facility. The occurrences of diarrheal diseases were higher when the stool was not disposed of safely (7.25%). The prevalence of diarrhea is higher among the children living in kutcha house (7.31%) as compared to those living in pucca house (6.46%).
Table 2 also presents the association of under-five children experiencing diarrhea with the background characteristics across “non-flood affected area”, “one and two times flood affected area,” and “three times flood affected area.” The results show that except caste and sources of drinking water of children, other variables were significantly associated with childhood diarrhea. Birth weight, household size, and child stool disposal were found to be significantly associated with diarrhea in the non-flood affected area and one and two times flood affected area but not significantly associated with under-five children experiencing diarrhea in the three times flood affected area.
Table 2. Prevalence of diarrhea among under-five children by background characteristics of respondents in rural India, NFHS-5 (2019-21)
Notes: P value: significance level of Pearson’s chi-square statistic.
Figure 1 depicts the close correlation between the flood occurrence patterns and the prevalence of diarrhea among under-five children. The distribution of flood occurrences in India reveals that regions experiencing one to two instances and three instances of flooding are concentrated in the Ganga and Brahmaputra River basins, primarily across northern districts of Bihar, some parts of West Bengal, and select areas of Assam. Coastal districts of Orissa have also reported occurrences of one to two floods (Figure 1A). Furthermore, regions experiencing a heightened frequency of severe flooding exceeding two instances in the past three years align with high prevalence rates of childhood diarrhea (Figure 1B). Thus, it is evident that floods are directly associated with an increased prevalence of childhood diarrhea.
Figure 1 Spatial distribution of flood occurrence from 2018-21 (A) and prevalence of diarrhea among under five children from 2019-21 in rural India (B).
Association Between Recurrent Floods on Diarrheal Diseases among Under-five Children in Flood-prone Areas
Table 3 illustrates the results of crude and adjusted logistic regression models for assessing the impact of floods on childhood diarrhea. The crude logistic regression model revealed that children exposed to flood three times between the years 2018-19 to 2020-21 were associated with a 32% higher likelihood of experiencing diarrhea among children (COR: 1.32, 95% CI: 1.22-1.43) than those children exposed to flood one or two times.
Table 3. Bivariate and multivariate logistic regression analysis assessing the association between flood and diarrhea among under-five children in rural India, NFHS-5 (2019-21)
Notes: Significance level: **P < 0.01; **P < 0.05; ref.: reference category; COR: crude odds ratio; AOR: adjusted odds ratio; CI: confidence interval.
In the adjusted analyses we found that children exposed to flood three times between the years 2018-19 to 2020-21 were associated with a 34% higher likelihood of developing diarrhea among children (AOR: 1.34, 95% CI: 1.20-1.50) than those children exposed to flood one or two times. The present study identified several socio-demographic characteristics of households significantly associated with diarrhea. It is observed that the children aged 12-23 months (AOR: 1.09, 95% CI: 0.97-1.23) had a higher likelihood of experiencing diarrhea as compared to children aged 0-11 months. However, children aged 24-35 months (AOR: 0.64, 95% CI: 0.51-0.79), 36-47 months (AOR: 0.38, 95% CI: 0.30-0.48), and 48-59 months (AOR: 0.36, 95% CI: 0.28-0.46) were less likely to experience diarrhea compared to children aged 0-11 months. Female children had a lower risk of the experiencing diarrhea compared to male children (AOR: 0.89, 95% CI: 0.80-1.00). Children suffering from diarrhea were more common among those in fourth or higher birth order (AOR: 1.31, CI: 1.07-1.60) compared to first-born children. Additionally, children with a normal birth weight had a slightly lower risk of diarrhea compared to those with a low birth weight (AOR: 0.86, 95% CI: 0.74-0.99). The likelihood of childhood diarrhea decreases with an increase in maternal age. Children of mothers aged 35-49 years were associated with a 36% decreased odds of diarrhea (AOR: 0.64, 95% CI: 0.49-0.85) compared to those whose mothers were aged 15-24 years. Children belonging to religions other than Hindu and Muslim (AOR: 0.41, 95% CI: 0.25-0.67) were less likely to experience diarrhea as compared to Hindu children. Household size was found to be significantly associated with childhood diarrhea, with a lower likelihood among children in houses with more than five persons (AOR: 0.77, 95% CI: 0.62-0.95) than those with 1-3 household members. The results revealed that the odds of experiencing diarrhea among children in the richer wealth quintile decreased by 26% (AOR: 0.74, 95% CI: 0.56-0.98) compared to those in the poorest wealth quintile. Surprisingly, there was an increased likelihood of childhood diarrhea observed among children with an improved source of drinking water (AOR: 1.58, 95% CI:.16-2.15).
Discussion
It is the first study conducted in India that examines the association between flood and diarrhea among under-five children and flood using a large-scale representative dataset. The study findings reveal that the prevalence of diarrhea was significantly higher (10.85 %) among children who were exposed to three consecutive floods during the period of 2019-21 than among children who were not affected by floods. This finding is in line with a previous study conducted in Uttar Pradesh, which also reported a high prevalence of diarrhea among children exposed to floods.Reference Joshi, Kaushal and Aribam 32 , Reference Mondal, Biswas and Manna 45 This could be because floods create favorable environmental conditions that facilitate the proliferation of various pathogens, which can then be transmitted through contaminated food or water sources. Moreover, the damage inflicted upon sewage systems during flooding events can contribute to the spread of diarrheal diseases after sewage water mixes with floodwater and spills onto the ground surface.Reference Ding, Zhang and Gao 50
The results of the study reveal that children who are exposed to floods for three consecutive years have a higher likelihood of developing diarrhea compared to children who experience floods one or two times. This result is consistent with a study conducted in China.Reference Ding, Zhang and Gao 50 Furthermore, the present study identifies several socio-demographic characteristics of households that are significantly associated with childhood diarrhea in addition to flood exposure. The risk of childhood diarrhea reduces with increasing age of the children. This finding is in line with other studies conducted in Uganda and Ethiopia.Reference Bbaale 51 -Reference Mosisa, Aboma and Girma 54 This trend may be attributed to the fact that children in this age range begin to crawl and walk, exposing themselves to a wider range of environmental factors such as dirt or contaminated objects that they may put in their mouths, leading to an increased risk of diarrheal illnesses.Reference Kamal, Tewabe and Tsheten 55 Another plausible reason could be that breastfeeding and complementary feeding practices for children were adversely affected during flooding.Reference Goudet, Griffiths and Bogin 56 Consequently, inadequate breastfeeding coupled with the provision of poor complementary feeding practices, whether in the form of cooked meals prepared with contaminated water or packaged food that is difficult for children to digest, may contribute to an increased likelihood of childhood diarrhea.Reference Arikpo, Edet and Chibuzor 57 The study highlighted that female children were less likely to experience diarrhea compared to male children. This finding is in line with other studies.Reference Kombat, Kushitor and Sutherland 58 -Reference Siziya, Muula and Rudatsikira 60 The higher likelihood of diarrhea among young males compared to young females might be attributed to the tendency of young males to wander in unhygienic environments as opposed to their female counterparts. This tendency is particularly pronounced during periods of flood-induced damage to water supply and sewage systems, leading to compromised hygiene standards and poor sanitation, thereby exacerbating the risk of diarrhea among males.Reference Chowdhury, Khan and Patel 61 Additionally, children born with a normal birth weight exhibited a slightly reduced risk of diarrhea when compared to those with a low birth weight. The study is consistent with previous studies conducted in India and Brazil.Reference Paul 29 , Reference Lira, Ashworth and Morris 62 Moreover, the results indicate that children in the birth order of three or higher have a higher risk of developing diarrhea compared to those with birth orders below three. The odds of having diarrhea were 31% higher in children with a fourth or higher birth order. This finding is congruent with a study conducted in Ethiopia.Reference Ali, Asfaw and Beyene 63 It suggests that the mothers’ ability to pay attention and care for a larger number of children may be compromised, resulting in a potential risk of increased exposure to germs and infections, making these children more susceptible to diarrhea.Reference Mihrete, Alemie and Teferra 52 , Reference Hashi, Kumie and Gasana 64 In consistent with previous studies conducted in Indonesia and Sub-Saharan Africa, the present study identified that children with relatively young mothers had a higher likelihood of experiencing diarrhea compared to older mothers.Reference Rohmawati, Panza and Lertmaharit 65 -Reference Finlay, Özaltin and Canning 68 It might be due to young mothers lacking skills and experience in childcare practices, unhygienic food practices, and poor knowledge of diarrheal disease transmission.Reference Demissie, Yeshaw and Aleminew 66 This finding of the current study is similar to studies conducted in Malawi, Bangladesh, and Ethiopia.Reference Moon, Choi and Oh 67 , Reference Ferede 69 , Reference Rahman and Hossain 70 The result of this study finding demonstrated that children belonging to other religious communities were less likely to experience diarrhea as compared to Hindu children. However, a study by Joshi et al. (2011) conducted in a flood-affected area of Uttar Pradesh, India, found no significant association between diarrhea and religion.Reference Joshi, Kaushal and Aribam 32 The size of the household was also found to be a significant factor associated with childhood diarrhea. These results are consistent with studies conducted in Bangladesh and Ethiopia that have emphasized that households with fewer individuals face a notably higher risk of childhood diarrhea compared to those with six or more members.Reference Chowdhury, Khan and Patel 61 , Reference Getachew, Guadu and Tadie 71 One possible reason could be the larger size of households, which may include grandparents. Grandparents are often considered a source of knowledge and advice for parents of children, such as advising mothers to continue breastfeeding during diarrhea episodes and suggesting giving children plenty of fluids when they have diarrhea.Reference Jonasi 72 This study also revealed that under-five children from the middle wealth quintile had a lower chance of developing diarrhea compared to children from the poorest wealth quintile. The findings of the present study also confirmed the results found in different contexts.Reference Vijayan and Ramanathan 73 -Reference Mulatya and Ochieng 75 It is a well-known fact that increasing household incomes are associated with decreased under-five mortality as well as a decrease in number of children. The improvement of socio-economic situation of the vulnerable population is the ultimate preventative measures in many communities. Repeating floods may deteriorate the household income and will increase the difficulties of accessing healthcare.Reference Saha 76 Another possible explanation is that access to basic water and sanitation services is intrinsically linked with household income. Thus, children in the poorest quintile are more prone to utilize unsafe water sources and have poor sanitation practices, making them more vulnerable to diseases like diarrhea. Nonetheless, numerous studies have emphasized that the intensity of floods can independently act as a risk factor, leading to an increased prevalence of diarrhea regardless of the presence of improved sanitation facilities.Reference Wang, Asare and Pitzer 21 , Reference Kikuchi 77 The findings of this study align with this notion, indicating that a higher frequency of floods is correlated with an elevated risk of diarrhea, and improved sanitation may not necessarily contribute to the prevention of diarrhea. Moreover, our study suggests that in addition to focusing on increasing access to improved sources of drinking water to prevent diarrhea, it is necessary to ensure access to safe drinking water for all. Future strategies need to prioritize thorough monitoring and testing of water quality across all categories of water sources, including those classified as ’improved.’ Moreover, it is imperative to integrate community engagement and educational campaigns aimed at increasing awareness about water quality indicators and effective treatment techniques in the flood affected area.
Notably, the present study did not find a significant association between childhood diarrhea, mother education, caste, type of house, availability of toilet facility, child stool disposal, and perceived distance to health facility. The results of the present study should be interpreted with caution due to some limitations. First, the dataset lacks information on the type, frequency, and intensity of floods, which are potential predictors of childhood diarrhea but were not included in the analysis. Second, the cross-sectional nature of our study design prevents us from establishing causality between predictor and outcome variables (i.e., childhood diarrhea). Third, our study relied on self-reported retrospective data, introducing the possibility of recall bias. Fourth, we have considered districts affected by floods, but due to the district-level data collection, it is not possible to determine whether individual households were affected. Fifth, the inclusion of some potentially mediating factors between exposure and outcome in the multivariate analysis might have led to over adjustment in the estimate of association. However, despite these limitations, our study holds significant implications for reducing diarrhea morbidity among children under the age of five residing in flood-prone areas. The findings offer valuable insights for policymakers to identify preventive measures, especially for the groups highlighted in this study as significantly associated with childhood diarrhea in flood-affected regions.
Conclusion
This study indicates that repeated experiences of floods have the adverse risk of diarrheal diseases among under-five children. Several other socio-demographic factors that were associated with diarrhea among children were the age of children, child sex, birth order, birth weight, maternal age, religion, household size, wealth quintile, and sources of drinking water. Based on the results of the present study, it is suggested that public health initiatives focus on areas affected by recurrent flooding with persistently high diarrhea prevalence, and necessary preventive steps should be undertaken to reduce both the frequency and severity of childhood diarrhea. The young infants were identified as more susceptible to childhood diarrhea, it is imperative to provide special support to lactating mothers. This support should include the provision of breastfeeding counseling to promote optimal breastfeeding practices, particularly during floods. Mothers belonging to the poor wealth quintile, young mothers, and mother with young infants and more children should be targeted to receive child health related counseling by community health workers like ASHA (Accredited Social Health Activist) and Anganwadi workers to mitigate childhood diarrhea in flood-affected areas. Additionally, emphasizing a study conducted by Debsarma (2022), we recommend that rural unqualified healthcare providers (RUHPs) in flood-prone areas of rural India or other low- and middle-income countries can be trained and upskilled in the prevention and management of childhood diarrhea at the household level.Reference Debsarma 78 If these strategies are implemented, there is possibility of preventing childhood diarrhea in the flood prone areas of India. Lastly, we recommend that there is the need to conduct a longitudinal study to understand the underlying factors contributing to the elevated risk of diarrhea in flood-affected areas.
Author contribution
Conception and design: JS, DH, and DD. Data management and analysis: JS. Interpretation of the results: JS. Drafting of the article: JS, DH, and DD. Review and editing: JS, DH, and DD. All authors read and approved the final version.
Competing interest
The authors have no conflicts of interest to declare.
Ethical standard
Secondary data available in the public domain were used; therefore, obtaining ethical approval was not required for conducting this study.
