Associations of Water Quality and Animal Ownership with Caregiver Reported Childhood Diarrhea in Rwanda: A Baseline Analysis Open Access

Wallace, Rachel (Spring 2022)

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Background/ Objective:

Despite the long history of diarrhea from identifying the disease, proposing and then identifying risk factors, continued research and interventions, diarrhea is still prevalent worldwide and has both high morbidity and mortality. The purpose of this study was to further investigate current risk factors associated with diarrhea in children < 60 months of age in Rwanda. Specifically, this study aimed to assess the association between number of E. coli Colony Forming Units per 100 mL of drinking water and caregiver reported diarrhea. This study also aimed to examine the association between animals (cows and/or chickens) observed in household compounds and caregiver reported diarrhea.


Logistic regression models were used for quantitative data analysis, using data collected from a randomized control trial in Rwanda. Independent variables were selected based on variables commonly identified and discussed in the literature regarding childhood diarrhea. All variables from the univariable analysis that had p-values less than 0.2 were included in a multivariable regression.


There was no association between water quality of household drinking water and caregiver reported diarrhea (adjusted odds ratio: 1.00; 95% CI: 1.00, 1.00; p=0.32) for children <60 months in Eastern Province, Rwanda. Categorizing the water quality variable based on WHO water quality risk factors produced similar results, with none of the categories being statistically significantly associated with caregiver-reported diarrhea. In the univariable regression, observed animals in the household compound appeared to have a slightly protective effect on caregiver reported diarrhea (OR: 0.74; 95% CI: 0.47, 1.12; p=0.16). The adjusted odds ratio for animals observed in the household compound at baseline was 0.70 (95% CI: 0.45, 1.08; p=0.12).


Current diarrhea risk factors can inform future research and programmatic endeavors to mitigate and address diarrhea in today’s world. This study found that when restricted to baseline, there was no association between drinking water quality and caregiver reported diarrhea among children in our study population. There was an inverse but not statistically significant relationship between chickens and cows observed in household compounds and caregiver reported diarrhea.

Table of Contents

Chapter 1: Introduction 1

       Problem Statement 2

       Research Goals & Research Questions 3

       Hypotheses 3

       Significance 4

Chapter 2: Literature Review 4

       Introduction to E. coli, diarrhea, and drinking water standards 4

       Risk factors for diarrhea: Water Quality 7

       Animal Ownership and Diarrhea 7

       Dose Response 8

       Diarrhea Research and Programmatic Challenges 10

                   Measurement 10

                   Use of proxy 11

                   Biological 11

                   Collection & Processing 12

                   Limited data collection 12

                   Recall & Reporting bias 12

Chapter 3: Methods 13

       Data Details: Population + Sample + Data Collection Methods 13

       Biostatistical Methods 17

                   Logistic Regression 17

       Ethics 20

       Limitations 20

Chapter 4: Results 21

       Introduction 21

       Findings 21

                   Descriptive Characteristics 21

                   Logistic Regressions 24

                   Univariable Regressions 25

                   Multivariable Regressions 26

                          Water Quality 26

                          Water Quality Categories 27

                          Observations of animals within household compounds 27

       Summary 28

Chapter 5: Discussion 29

       Introduction 29

       Discussion 29

       Strengths & Limitations 34

       Public Health Implication and Recommendations 35

       Conclusion 37

Bibliography 39

Appendix 44


Table of Figures

Figure 1:  Histogram of WQ Variable E. coli CFU/100mL at Baseline 16

Figure 2: Logistic Regression with Outcome Caregiver Reported Diarrhea 25

               and Independent Variable of Interest Water Quality.

Figure 3: Logistic Regression with Outcome Caregiver Reported Diarrhea 26

               and Independent Variable of Interest Water Quality, Categorized by

               WHO Water Quality Risk Groups

Figure 4: Logistic Regression with Outcome Caregiver Reported Diarrhea 28

               And Independent Variable of Interest Animals

               Observed in Household Compound

Table 1:  Descriptive Child, Respondent, and Household Characteristics 22

Table 2:  Water Quality Categories Descriptive Characteristics 23

Table 3:  Diarrhea Characteristics 24

Appendix Table 1: Variable Descriptions 44


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