Discussion
In this study, we investigated socioeconomic and knowledge risk factors for childhood diarrheal disease in peri-urban communities in Cochabamba, Bolivia. Because this study was nested within a cluster RCT, we had the opportunity to evaluate how risk factors change within a population with the implementation of a water, sanitation, and hygiene intervention in comparison to a control group. Because the intervention study only observed a significant impact of the water filter arms of the study, we stratified the study population to the non-filter and filter group.
The findings from this study showed that caregiver lack of awareness of practices related to personal and food hygiene for diarrhea prevention were a significant risk factors for diarrheal disease in this cohort of children < 5 years of age in Cochabamba, Bolivia. Although in this study we did not have a measure of actual household hygiene and food preparation practices, these findings suggest that these two knowledge factors are important in childhood diarrhea prevalence for this population. This is consistent with recent findings from Sima and others,47 which found a significant association between food and household hygiene and childhood diarrhea prevalence. There was also a significant protective relationship in this study between knowledge of proper disposal of feces to prevent diarrhea and diarrhea prevalence. These finding are consistent with Dikassa and others and Bertrand and others,30,31 which found that children of mothers that were less aware of the importance of child caretaker cleanliness and proper sanitary practices were at significantly higher risk of severe diarrheal disease. Intriguingly, the association between knowledge of proper feces disposal and reduced diarrhea prevalence was only found in the filter group, perhaps suggesting that once exposure through microbial contamination of drinking water is removed the transmission route through direct fecal oral contamination becomes more important.