This document outlines a logic model for reducing diarrheal morbidity and mortality in children under 5 years old in Nigeria. It involves training community health workers, teachers, and healthcare providers to promote behaviors like exclusive breastfeeding, handwashing, and water treatment/storage. Evaluating the impact on knowledge, behaviors, and health outcomes will help reduce missed school/work days and the overall burden of diarrhea.

1. REDUCING DIARRHEAL MORBIDITY AND MORTALITY IN CHILDREN BELOW AGE 5 YEARS IN NIGERIA
University of Iowa
Omotoyosi Soniyi
INPUTS OUTPUTS OUTCOMES
- Time
- Resources
- Money
-Community health
workers (CHWs)
- Research, expert opinion
- Program staff
-Recruit and train CHWs
- Train teachers
-Train nurses, primary care
providers
- Provide soap in
sanitation facilities
-Social media and
television adverts to
promote hand washing
- Conduct teachings in the
local governments
-CHWs
-Nurses, primary care
physicians
-Children below age 5
years and older children
-Breastfeeding mothers
and mothers, caregivers
-Teachers
-Local communities and
Organizations
-Mothers increase
knowledge on breastfeeding
practices
-Caregivers/mothers increase
knowledge on sanitation and
household treatment of water
-Improved hand washing
practices in children
-Improved community
awareness on diarrheal
disease, prevention, and care
-Mother behavior increase
to practicing exclusive
breastfeeding in the first 6
months of baby life.
-Children improve
behavior to hand washing
-Mother/caregiver skill
increases in the treatment
and storage of water
-Reduced missed school
days associated with
diarrheal disease
-Reduce morbidity and
mortality associated with
diarrhea in children
below age 5 years
-Improved productivity
and quality of life in
children.
Short Medium LongActivities Participation
LOGIC MODEL
-Globally, diarrhea kills more children than AIDS,
malaria, and measles combined.
-Diarrhea accounts for over 15% of under five child
deaths in Nigeria.
-Approximately one million children in Nigeria die
each year before their 5th birthday
-Diarrhea can lead to a 10 IQ point decrease in
children by the time they reach 7-9years of age
-Children who do not die experience long term effects
of impaired development and do not reach full
potential.
-Children miss school for an average of two days
during diarrheal episodes.
-Parents/guardians spend an average of two hours
daily caring for children with diarrhea.
-Studies suggest that children with repeated bouts of
diarrhea, whose growth become stunted are at
increased risk of obesity and associated health effects.
BACKGROUND RISK FACTORS/DETERMINANTS
Modifiable
- Vaccination, poor hygiene, HIV infected children
- Exclusive breastfeeding, knowledge of mothers, poor hygiene
- Poor housing and living conditions
- Low SES
- Inadequate health infrastructure
- Contaminated weaning food
Non modifiable
- Low birth weight
- Age
GOALS
-Reduce missed school days, morbidity and mortality
associated with diarrhea in children under five.
-Improve hand washing and personal hygiene
behavior in children under five.
OBJECTIVES
PROCESS;
-By 6 months, recruit and train 200 community
health workers to provide continuous counseling to
mothers on exclusive breastfeeding
-By 1 year, train teachers in 10 schools per state to
educate young children and older school children on
hand washing.
-By the end of 2017, conduct teachings in each local
government (community) on point of use water
treatment and storage.
IMPACT;
-By the end of 2016, the amount of schools in Nigeria
that carry out a hand-washing program will increase
by 20%
-Increase in a year the amount of mothers who have
been educated on exclusive breastfeeding by 10%
OUTCOME;
-By 2020, the rate of missed school days in children
below age 5 years in school will have decreased by
25%
TARGET BEHAVIOR AND REVIEW OF
LITERATURE
Target behavior: Personal hygiene and hand washing, point of use water treatment, exclusive
breastfeeding.
Literature review:
- Breastfeeding interventions are cost effective, studies show that interventions that promote
exclusive breastfeeding and continue to train/counsel mothers after birth reduce diarrheal
prevalence by almost 15%.
- Studies show that interventions to promote hand washing behavior in schools, provide soaps and
use peer monitors significantly reduce missed schools days and morbidity associated with
diarrhea. Children were also more likely to practice the behaviors at home and teach their friends,
siblings, and parents.
- Interventions that teach mothers/caregivers on point of use water treatment and storage have been
found to prevent diarrheal disease by as much as 43%.
INTERVENTION STRATEGIES AND ACTIVITIES
 Interpersonal level - Education on exclusive breastfeeding for mothers
Activities; Primary care providers, nurses and community health workers will be trained
During prenatal care, knowledge on exclusive breastfeeding is assessed
Mothers will receive education on the importance of breastfeeding and brochures that match language skills
Community health workers will then continue the visits at 3 months and at 6 months.
 Community level - Education on household treatment of water with chlorine and storage
Activities; Community health workers will be trained to carry out this intervention
Community assessment to determine those who do not have access to water and those who have access to water.
Conduct trainings in local governments and household on water treatment and storage.
 Institution/Organizational level - School-based programs on hand washing and hygiene
Activities; Teachers will be trained to deliver hand washing program
Teachers will hold sessions that educate children on hygiene and hand washing before eating and after toilet use
Soaps will be provided and facilities will be improved to facilitate the intervention
Senior students will also go through the program and serve as mentors to younger children in schools
Hand washing images on toilet and bathroom doors, and give posters to children to put on toilet/bathroom doors in their homes.
EVALUATION
Process, Impact and Outcome evaluation
• Pre intervention baseline survey
• Post intervention survey
• Process evaluation using program records, in depth
interviews at 6 months, year 1 and year 2.
• Impact evaluation using short questionnaires on hand
washing practices, caregiver survey on knowledge on
household treatment and storage of water at baseline
and annually.
• Outcome evaluation using interviews, surveys, school
attendance records, and hospital records at baseline,
annually, and at the end of program.
Data collection: Quantitative and Qualitative methods
Limitations: Contamination, Participants dropping out of
program, Interference of multiple treatments.
Assumptions; Mothers will go to the hospital for prenatal care, funds will be available for the provision of soaps,
schools will include hand washing program in curriculum, children will teach peers and family hand washing.
External factors; Health infrastructure and insurance, priorities in schools and communities, religious
beliefs to seeking care
ANTICIPATED CHALLENGES
AND REMEDIES
- Funding and Resources (NGOs, organizations,
government)
- Time (provide compensation to participants)
- Access to water (policy level)
- Religious, Cultural beliefs (Education and training to
improve knowledge)
REFERENCES
-Bhandari, N., Bahl, R., Mazumdar, S., Martines, J., Black, R. E., & Bhan, M. K.
(2003). Effect of community-based promotion of exclusive breastfeeding on
diarrhoeal illness and growth: a cluster randomised controlled trial. Lancet,
361(9367), 1418-1423. doi: 10.1016/s0140-6736(03)13134-0
-Bowen, A., Ma, H., Ou, J., Billhimer, W., Long, T., Mintz, E., . . . Luby, S.
(2007). A cluster-randomized controlled trial evaluating the effect of a
handwashing-promotion program in Chinese primary schools. Am J Trop Med
Hyg, 76(6), 1166-1173
-GLORIA VILLAREAL, L. A. L., KATHERINE JIMÉNEZ, KARINA
MARTÍNEZ, ETILVIA MARTÍNEZ, CAROLINA OJEDA, . (2011). Educational
intervention for the prevention of diarrheal diseases in the Mano de Dios
neighborhood, Sincelejo, Colombia: A success experience. Colombia Médica, 42,
8.
-O'Reilly, C. E., Freeman, M. C., Ravani, M., Migele, J., Mwaki, A., Ayalo, M., . .
. Quick, R. (2008). The impact of a school-based safe water and hygiene
programme on knowledge and practices of students and their parents: Nyanza
Province, western Kenya, 2006. Epidemiol Infect, 136(1), 80-91. doi:
10.1017/s0950268807008060
--Organization, W. H. (March, 2004). Water, Sanitation and Hygiene Links to
Health FACTS AND FIGURES. from
http://www.who.int/water_sanitation_health/en/factsfigures04.pdf?ua=1
--Sobsey, M. D., Handzel, T., & Venczel, L. (2003). Chlorination and safe storage
of household drinking water in developing countries to reduce waterborne disease.
Water Sci Technol, 47(3), 221-228