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Open Access Research article

Spoiled breast milk and bad water; local understandings of diarrhea causes and prevention in rural Sierra Leone

Shannon A McMahon1*, Asha S George12, Fatu Yumkella3 and Theresa Diaz2

Author Affiliations

1 Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, USA

2 Knowledge Management and Implementation Research Unit, Health Section, Programme Division, United Nations Children’s Fund (UNICEF), 3 U N Plaza, New York, NY, USA

3 Dalan Development Consultants, 12A King Street, off Marcus Jones Estate, Wilberforce, Freetown, Sierra Leone

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BMC Public Health 2013, 13:1172  doi:10.1186/1471-2458-13-1172

Published: 13 December 2013



Globally, diarrhea remains a leading killer of young children. In Sierra Leone, one in seven children die before their fifth birthday and diarrhea is a leading cause. Studies that emphasize the demand-side of health interventions -- how caregivers understand causation and prevention of diarrhea -- have been neglected in research and programming.


We undertook applied qualitative research including 68 in-depth interviews and 36 focus group discussions with mothers, fathers and older female caretakers to examine the causes and prevention of childhood diarrhea in villages near and far from health facilities across four rural districts. Verbal consent was obtained.


Respondents reported multiple, co-existing descriptions of causation including: contaminated water and difficulties accessing clean water; exposure to an unclean environment and poor food hygiene; contaminated breast milk due to sexual intercourse, overheated breast milk or bodily maternal conditions such as menstruation or pregnancy; and dietary imbalances and curses. Respondents rarely discussed the role of open defecation or the importance of handwashing with soap in preventing diarrhea.


Categorizing behaviors as beneficial, harmful, non-existent or benign enables tailored programmatic recommendations. For example, respondents recognized the value of clean water and we correspondingly recommend interventions that reinforce consumption of and access to clean water. Second, respondents report denying “contaminated” breast milk to breastfeeding children. This is a harmful practice that merits attention. Third, the role of open defecation and poor hygiene in causing diarrhea is less understood and warrants introduction or clarification. Finally, the role of exposed feet or curses in causing diarrhea is relatively benign and does not necessitate programmatic attention. Further research supportive of communication and social mobilization strategies building on these findings is required to ensure that improved understanding regarding diarrhea causation translates into improved diarrhea prevention.

Sierra Leone; Diarrhea; Cause; Prevention; Breast milk; Qualitative; Temne; Mende; Water