Water, Sanitation, and Burden of Water-Related Diseases among Under-Five Children in Kenema City, Sierra Leone.

Abstract:

Introduction: Water-related diseases remain a leading cause of morbidity among underfive children in low-income urban settings, driven by inadequate access to safe water, sanitation, and hygiene. In Sierra Leone, rapid urbanisation has intensified these risks, particularly in secondary cities such as Kenema, where WASH infrastructure remains limited. Aim: This study assessed the prevalence, determinants, and impacts of water-related diseases among underfive children in selected communities in Kenema city, with an emphasis on water access, sanitation, hygiene practices, and prevention strategies. Methods: A mixed-methods cross-sectional study was conducted among 400 households with underfive children. Quantitative data were collected via structured household questionnaires that captured sociodemographic characteristics, water sources, sanitation facilities, hygiene practices, and childhood illness episodes. The data were analysed via SPSS version 28 via descriptive statistics, chi-square tests, and multivariate logistic regression at the 5% significance level. Qualitative data were obtained through five focus group discussions with caregivers and 15 key informant interviews with community leaders, health workers, and local officials. Thematic analysis was conducted via NVivo to contextualise the quantitative findings. Results: Overall, 83.0% of households reported at least one episode of water-related disease among underfive children in the preceding 12 months, with diarrhea (31%), cholera (29%), and typhoid fever (26%) most frequently reported. The use of unimproved water sources (χ², p < 0.001), shared sanitation facilities (p = 0.002), the absence of handwashing with soap (p < 0.001), and walking ≥ 1 km to water sources (p = 0.01) were significantly associated with disease occurrence. In the multivariate analysis, a lack of household water treatment (AOR = 2.4; 95% CI: 1.5–3.9) and poor hand hygiene (AOR = 3.1; 95% CI: 1.9–5.0) were independently associated with elevated health risk. Recurrent illness episodes were linked to reported weight loss, reduced appetite, and delayed care seeking. Conclusion: Water-related diseases, driven by structural WASH deficits and constrained hygiene practices, remain highly prevalent among children under five years of age in Kenema city. Integrated investments in safely managed water, sanitation, and community-centred hygiene interventions are essential to reduce recurrent childhood illness and associated nutritional and economic impacts.