ENVIRONMENTAL HEALTH, CHILD HEALTH AND DIARRHOEA

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CHAPTER 3 THEORETICAL FRAMEWORK OF THE RESEARCH

INTRODUCTION

This chapter presents the concept of paradigm and the paradigmatic assumptions of the study. The chapter discusses the ontological, epistemological and methodological assumptions which are explained from a positivist approach. The chapter also gives detail on the F-diagram model of faecal-oral disease transmission which provides the conceptual framework of the study.

PARADIGM

A paradigm is defined by Polit and Beck (2010:14) as a worldview, a general perspective on the complexities of the real world. According to Grove et al (2013:702), paradigm refers to a particular way of viewing a phenomenon in the world. It is a way of looking at natural phenomena that encompasses a set of philosophical assumptions and guides one’s approach to inquiry (Polit & Beck 2010:562).
Quantitative research methodology was employed in this research and the outcomes obtained from the quantitative data are numeric and quantifiable. Polit and Beck (2010:565) define quantitative research as the investigation of phenomena that lend themselves to precise measurement and quantification, often involving a rigorous and controlled design. Quantitative research is associated with the positivist paradigm (Polit & Beck 2010:564). This study is, therefore, opted to use quantitative research within a positivistic paradigm with the aim of explaining the relationship between the household environmental health factors associated with the occurrence of diarrhoea in children under-five years.
The quantitative paradigm is based on positivism, which takes scientific explanation to be nomothetic (i.e. based on universal laws). Its main aims are to measure the social world objectively, test hypotheses and predict and control human behaviour (De Vos, Strydom, Fouche & Delport 2002:79). Positivism emphasises scientific method.
Scientific method is a set of orderly, systematic, controlled procedures for acquiring dependable, empirical – and typically quantitative–information; which is the methodological approach associated with positivist approach (Polit & Beck 2010:567).
According to Polit and Beck (2010:14), positivists believe that reality exists and can therefore be studied. In the positivist paradigm, the researcher is independent from those being researched. Positivism maintains that values and biases are to be held in check. Objectivity is sought and has utmost importance. The best methods for obtaining evidence in the positivist-directed research are deductive processes; emphasis on discrete, specific concepts; focus on objective and quantifiable; fixed, pre-specified design; outsider knowledge – the researcher as external; control over context; measured, quantitative information; statistical analysis and seeks generalisations (Polit & Beck 2010:15).
Evidence that this study was rooted in the positivist paradigm includes:
The use of a quantitative research design (see section 4.2.1)
The fact that the research process used was systematic and followed a logical step-wise approach (see section 4.3)
The use of mechanisms to control the study so that biases are minimised (see section 4.4)
The researcher took the position of an interested outsider in that the information given by respondents was all treated with utmost respect (see section 4.3.4.6)
 Careful construction and pre-testing of the interview schedule ensured objectivity (see section 4.3.4.2 and section 4.3.4.4)
The gathering of empirical evidence through data collection processes (see section 4.3.4.5)
The evidence were measured and analysed statistically (see section 4.3.5)

PARADIGMATIC ASSUMPTIONS

Assumption is a principle that is believed to be true without proof or verification (Polit & Beck 2010:14). According to Grove et al (2013:41), assumptions are statements that are taken for granted or are considered true, even though they have not been scientifically tested. Sources of assumptions include universally accepted truths, theories and previous research (Grove et al 2013:41).
Assumptions of the positivist paradigm will apply to this study since the reality to be described is environmental health factors at household level in relation to childhood diarrhoea. This reality can be observed and measured by means of a fixed design that will provide quantitative information. The quantitative approach to scientific inquiry emerged from a branch of philosophy called logical positivism, which operates on strict rules of logic, truth, laws, axioms, and predictions. Quantitative researchers hold the position that truth is absolute and that there is a single reality that one could define by careful measurement (Grove et al 2013:24).
According to Polit and Beck (2010:14), a fundamental assumption of positivists is that reality exists. In the positivist paradigm, nature is basically ordered and regular and an objective reality exists independent of human observation. The related assumption of determinism refers to the positivists’ belief that phenomena (observable facts and events) are not haphazard or random, but rather have antecedent causes. Thus, positivists seek to be objective because of their belief in an objective reality. Their approach involves the use of orderly and disciplined procedures with tight controls over the research situation to test hunches about the nature of phenomena being studied and relationships among them (Polit & Beck 2010:15).
According to Creswell (2007:74), a research paradigm is based on assumptions that relate to the nature of reality or existence (ontology), the relationship between the researcher and what is being researched or how knowledge is developed (epistemology) and the manner or process of best obtaining research evidence (methodology).
The ontological, epistemological and methodological assumptions used in the present study in assessing and exploring the relationship between the environmental health factors associated with childhood diarrhoea among the households of Sebeta town in Ethiopia are listed below.
Ontological assumptions
The ontological assumptions regarding reality underlying this study are as follows:
People take health related actions on the basis of information on the identified environmental health risk factors of childhood diarrhoea from the study communities and the study can be used to educate the community about good environmental health practices for prevention of childhood diarrhoea.
Adequate knowledge and understanding of the magnitude of environmental health risks from the study contributes to the prevention and control of childhood diarrhoea.
There are many environmental sanitation interventions that can help to prevent diarrhoeal and other infectious diseases. The environmental health interventions dealing to control diarrhoeal diseases involve measures that communities and households can implement (Murphy et al 1997:11).
Epistemological assumptions
The epistemological assumptions underlying this study are as follows:
The F-diagram model of faecal-oral disease transmission can provide the conceptual structure through which the empirical data of the study can be organised.
Strategies recommended from this study would provide insight into the prevention of household environmental health factors associated with the occurrence of childhood diarrhoea and would also provide useful input that will enhance the effective implementation of environmental health programmes in order to prevent and reduce the prevalence of morbidity due to childhood diarrhoea.
Methodological assumptions
The methodological assumptions of this study are that:
The emphasis is on discrete, specific concepts as delineated in the structured interview schedule which was used to collect data (see Annexure B).
The focus is on the objective and quantifiable data which is obtained from the data collection tool (interview schedule) (see Chapter 5).
A quantitative research design ensured that empirical data were used, statistical analyses were performed and the study results can be generalised to the study population (see Chapter 4).

THE CONCEPTUAL FRAMEWORK: THE F-DIAGRAM MODEL OF FAECAL-ORAL DISEASE TRANSMISSION

According to LoBiondo-Wood and Haber (2010:57), a research’s conceptual framework or theoretical framework is a structure of concepts and/or theories pulled together as a map for the study that provides rationale for the development of research questions or hypotheses. This study was based on the F-diagram model of faecal-oral disease transmission which provides the conceptual framework of the research.
The F-diagram model of faecal-oral disease transmission (Figure 3.1) described by Wagner and Lanoix in 1958 is a useful model to explain the principal routes of transmission of infectious diarrhoeal disease (Hunt 2001:5; UN-Water 2008). Accordingly, this model provided the conceptual framework for this study. Diarrhoeal diseases are mostly spread by disease-causing organisms (pathogens) which are found in human and/or animal excreta. Most common transmission mechanism of these pathogens from excreta to a susceptible host is through faecal-oral transmission (WaterAid 2012:15).
The major transmission routes are through ‘the five Fs’ (Figure 3.1): fingers, fluids (e.g. water), flies, fields and food. Excreta pathogens can spread to a new ‘susceptible host’ and be ingested through any of these transmission routes. For instance, they can contaminate a water supply and contaminated water can be used for drinking or in food preparation. Flies that have had contact with human waste matter can carry pathogens to places where food is being prepared and/or eaten. Soil with excreta material can be transmitted into the home by humans or animals and unknowingly carried to places where food is prepared or children play (WaterAid 2012:15).
Diarrhoeal disease can spread through the following five paths (‘the five Fs’) (Kleinau & Pyle 2004:25; Environmental Health Project 2004:6):
1. Fluids — carry disease through contaminated water
2. Fields — become contaminated by outdoor defecation
3. Flies — carry and transmit diseases
4. Fingers — become contaminated by bacteria that transmit disease
5. Food — becomes infected by fluids, flies, or fingers and then ingested (Kleinau & Pyle 2004:25).
The exposure of children to diarrhoeal disease pathogens is effectively reduced by blocking several of these paths (Environmental Health Project 2004:7). All of the transmission routes shown in the F-diagram (Figure 3.1) can be blocked by changes in domestic hygiene practice. Improved infrastructure, such as water and excreta disposal facilities, can also contribute to the prevention of transmission. However, public infrastructure can only be fully effective if employed in conjunction with safe hygiene practices in the home (Curtis et al 2000:25).
The F-diagram of disease transmission prevention and control shown in Figure 3.2 allows in differentiating between primary barriers and secondary barriers that prevent and control the spread of diarrhoeal disease causing pathogens in the environment (Curtis et al 2000:25). The most effective method of reducing disease transmission is by implementing ‘primary barriers’ and ‘secondary barriers’ that prevent the spread of pathogens in the environment or being carried onto susceptible hosts (WaterAid 2012:15).
The primary barriers prevent infectious disease-causing organisms found in excreta from entering the environment, by using the following methods:
The containment and disposal of human excreta in such a way that it gets isolated or separated from human contact (by the use of latrines, septic tank, sewers, etc.).
The removal of traces of faecal matter from hands after contact with excreta (i.e. washing hands with soap after defecation or after cleaning up children post-defecation) (WaterAid 2012:15).
Secondary barriers are hygiene practices that stop excreta pathogens that would have spread into the environment in stool or on hands from multiplying and reaching new susceptible hosts. The secondary barriers include:
Hand-washing before preparing food or eating.
Preparing, cooking, storing and re-heating food in such a way as to prevent pathogen survival and multiplication.
Protecting water supplies from faecal contamination, and utilising water treatments such as boiling or chlorination.
Keeping domestic environment free of faecal matters (WaterAid 2012:16).
The F-diagram indicates useful implications. Firstly, it indicates that diarrhoeal pathogens originate in stool. Secondly, it suggests that if primary barriers to the transmission of faecal pathogens are in place, then secondary barriers will be less important. Interventions to encourage the safe disposal of stool and adequate hand-washing after stool contact should thus pay greater advantage than those that concentrate on the secondary barriers (Curtis et al 2000:25).
The following points review the specific practices related to the primary and secondary barriers, such as safe stool disposal, hand-washing, protecting water, fly control and food hygiene in the light of this hypothesis.
i) Safe stool disposal
The association between stool disposal and child diarrhoea has been investigated in a number of epidemiological studies. Indiscriminate defecation near the home or in living areas was found to be associated with an increased incidence of diarrhoea. A further source of evidence for the importance of safe stool disposal is the literature on the impact of sanitation programmes in developing countries. If the construction of latrines reduces diarrhoeal disease then the effect is presumably due to the safe disposal of stools. Thus, the studies indicates that human stool in the domestic environment are a source of diarrhoeal infection for small children, and evidence shows that the safe disposal of stool should be one of the key measures to prevent diarrhoeal diseases (Curtis et al 2000:26). Sanitation facilities that are not properly working can set up further potential disease transmission pathways and these conditions can lead to the pollution of the environment. Selection of the right technologies, good design, appropriate use and proper management are required to protect against these additional risks (Water Supply and Sanitation Collaborative Council & World Health Organization 2005:10).
ii) Hand washing
Hand washing can interrupt several of the transmission routes in the F-diagram (Figure 3.2). Hand washing can interrupt pathogen transmission as a primary barrier (removing faecal matter after contact with stools) and hand-washing as a secondary barrier (before preparing food, handling fluids, feeding and eating). To prevent stool pathogens from gaining access to the domestic environment, efforts should concentrate on hand-washing after stool contact, especially after defecation or after cleaning up a child (Curtis et al 2000:26).
iii) Preventing transmission through water
The F-diagram shows how diarrhoeal pathogens use water as a route to reach new hosts. Primary barriers to this transmission route include preventing contamination of water by faecal material, both at source and in transit. Secondary barriers remove pathogens once get into water supplies, and include methods of purification both at source and in the home. Fluids can also become contaminated by a failure of other barriers, via unwashed fingers, for example. Preventing transmission through water thus requires action in both the public domain and in the sphere of domestic hygiene. Keeping water supplies free of faecal contamination at source and in transit is important for preventing diarrhoeal disease. However, the best way to do this may be to ensure that faecal material is not released into the environment and so does not get into water. This again requires safe stool disposal and effective hand-washing after stool contact (Curtis et al 2000:27).
iv) Flies
Flies are commonly thought of as a source of diarrhoeal disease. Flies have been shown to carry pathogens on their feet, in their faeces and in the digestive juices which they regurgitate onto foods. A number of studies have linked flies to diarrhoea incidence. Though fly control might be desirable in settings where flies form a major nuisance and where there is substantial faecal contamination of the environment, it is not yet achievable. The logic of the F-diagram again leads to the conclusion that the primary need is to prevent flies gaining access to stools in the first place. Safe stool disposal in latrines, sewers, or by burying thus has two benefits. It reduces opportunities for flies to breed and it removes the source of fly transported pathogens (Curtis et al 2000:28).
v) Food-borne transmission of diarrhoeal diseases
The F-diagram shows food as a possible link in the chain of transmission of diarrhoeal pathogens from stool to new host. Potential interventions to break this chain include the secondary barriers of hand-washing before food preparation and handling, safe food storage, avoidance of contaminated foods, adequate cooking and reheating, cleaning kitchens, surfaces and utensils, and hand washing before eating or feeding children. Food is potentially important for disease transmission because pathogens on food have an easy route into the digestive system, and some gastro-enteric pathogens can multiply in food and thereby increase the dose ingested. The risk practices that should be targeted in the efforts to prevent diarrhoeal disease are: first, in the public domain foods should be protected from contamination before they come into the home, especially from food handlers’ stools. Second, since food contamination with diarrhoeal pathogens in the domestic domain can only result from an inadequate disposal of stool, or if hands are inadequately washed after stool contact, then hand washing and stool disposal are key to diarrhoea prevention (Curtis et al 2000:28).
Multiple routes of infection
A number of studies have concluded that several interventions at a time are more effective than one alone. Alam and colleagues in 1989 demonstrated that a combination of clean water, absence of faeces in the yard and hand-washing resulted in 40% less diarrhoea than when one practice alone was observed. Haggerty and colleagues in 1994 reported an 11% reduction in diarrhoea reporting in villages where hand washing and the disposal of human and animal faeces were promoted. Thus, the source of the diarrhoeal pathogens is removed by a correct disposal of human stool from the domestic environment and hand-washing after stool contact. Households may still be at risk from contaminated materials that are brought into the household from outside and need to adopt a variety of hygiene practices (Curtis et al 2000:29).
To achieve full health benefits and in the interest of human dignity, other sources of contamination and disease also need to be managed. These include:
Sullage (dirty water that has been used for washing people, cloths, pots, pans, etc)
Drainage (natural water that falls as rain or snow)
Solid waste (also called garbage, refuse or rubbish) (Water Supply and Sanitation Collaborative Council & World Health Organization 2005:10)
Although several factors are responsible for the survival of children under the age of five in developing countries, studies reveal that some childhood diseases that often result in mortality can be explained by well-known health hazards within the child’s household environment. Indeed, environmental health hazards are threats to the health of millions of people in the settings where they live. Studies have shown that sanitation, water supply, and hygiene are generally poor in developing countries (Fayehun 2010:2).
According to several studies priority environmental health interventions for prevention of diarrhoeal disease typically includes:
Disposing of human excreta appropriately through improved sanitation
Improving water quality
Providing sufficient water quantity and access
Promoting hand-washing with soap (Clasen et al 2010:5; Kleinau & Pyle 2004:25)
All these sources of contamination and disease must be managed in all the locations where they are produced. Thus, a full-scale programme to improve hygiene would need to address the management of excreta, wastewater (sullage and drainage) and solid waste handling at households (both formal and informal); schools; semi-public places; and public places (such as markets, and other areas) (Water Supply and Sanitation Collaborative Council & World Health Organization 2005:11).
Though the research focus was on the F-diagram model of faecal-oral disease transmission for the study of the environmental health determinants in relation to childhood diarrhoea, the study included other sources of contamination based on the aforementioned premises. Thus, the environmental risk factors included in the study are: water supply, sanitation facilities, disposal of solid waste and wastewater and hygiene practices as well as the study gathered data on household characteristics. Within this context, the concept of faecal-oral transmission of diarrhoeal pathogens provides the conceptual framework for this research’s focus regarding the environmental health risk factors for childhood diarrhoea at household level.

CONCLUSION

The chapter presented the concept of paradigm and the paradigmatic assumptions. It discussed the ontological, epistemological and methodological assumptions underpinning the study from a positivist approach. The chapter also described the F-diagram model of faecal-oral disease transmission which provided the conceptual framework of the study within which to focus on the consideration of environmental health risk factors for childhood diarrhoea.
The following chapter will present the research design and methods used in the current study.

TABLE OF CONTENTS
DECLARATION
ACKNOWLEDEMENTS
ABSTRACT
TABLE OF CONTENTS
LIST OF TABLES
LIST OF FIGURES
LIST OF ABBREVIATIONS
LIST OF ANNEXURES
CHAPTER 1 ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKROUND INFORMATION ABOUT THE RESEARCH PROBLEM
1.3 STATEMENT OF THE RESEARCH PROBLEM
1.4 AIM OF THE STUDY
1.5 SIGNIFICANCE OF THE STUDY
1.6 DEFINITION OF KEY CONCEPTS
1.7 THEORETICAL FOUNDATIONS OF THE STUDY
1.8 RESEARCH DESIGN AND METHOD
1.9 SCOPE OF THE STUDY
1.10 STRUCTURE OF THE THESIS
1.11 CONCLUSION
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION
2.2 ENVIRONMENTAL HEALTH, CHILD HEALTH AND DIARRHOEA
2.3 THE GLOBAL PROBLEM OF DIARRHOEAL DISEASE AMONG CHILDREN
2.4 PUBLIC HEALTH SIGNIFICANCE OF DIARRHOEAL DISEASES AMONG CHILDREN
2.5 ENVIRONMENTAL HEALTH FACTORS FOR CHILDHOOD DIARRHOEA
2.6 MAJOR ENVIRONMENTAL HEALTH DETERMINANTS OF CHILDHOOD DIARRHOEA
2.7 THE HEALTH SYSTEM OF ETHIOPIA
2.8 CONCLUSION
CHAPTER 3 THEORETICAL FRAMEWORK OF THE RESEARCH
3.1 INTRODUCTION
3.2 PARADIGM
3.3 PARADIGMATIC ASSUMPTIONS
3.4 THE CONCEPTUAL FRAMEWORK: THE F-DIAGRAM MODEL OF FAECAL-ORAL DISEASE TRANSMISSION
3.5 CONCLUSION
CHAPTER 4 RESEARCH DESIGN AND METHOD
4.1 INTRODUCTION
4.2 RESEARCH DESIGN
4.3 RESEARCH METHOD
4.4 VALIDITY AND RELIABILITY
4.5 CONCLUSION
CHAPTER 5 ANALYSIS, PRESENTATION AND DISCUSSION OF THE RESEARCH FINDINGS
5.1 INTRODUCTION
5.2 DATA COLLECTION, RESPONSE RATE AND RESPONDENTS
5.3 DATA MANAGEMENT AND ANALYSIS
5.4 RESEARCH RESULTS
5.5 DISCUSSION ON THE FINDINGS OF THE STUDY
5.6 CONCLUSION
CHAPTER 6 SUMMARY, CONCLUSIONS, RECOMMENDATIONS, CONTRIBUTIONS AND LIMITATIONS OF THE STUDY
6.1 INTRODUCTION
6.2 SUMMARY OF THE STUDY FINDINGS
6.3 CONCLUSIONS
6.4 RECOMMENDATIONS
6.5 CONTRIBUTIONS OF THE STUDY
6.6 LIMITATIONS OF THE STUDY
6.7 CONCLUDING REMARKS
CHAPTER 7 DEVELOPMENT OF ENVIRONMENTAL HEALTH STRATEGIES FOR PREVENTION OF CHILDHOOD DIARRHOEA
7.1 INTRODUCTION
7.2 URBAN ENVIRONMENTAL HEALTH STRATEGIES FOR THE PREVENTION OF CHILDHOOD DIARRHOEA
7.3 CONCLUSIONS
LIST OF REFERENCES
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