Prevalence of diarrhea and associated risk factors among children under-five years of age in Eastern Ethiopia: A cross-sectional study

doi:10.4236/ojpm.2013.37060

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Vol.3, No.7, 446-453 (2013) Open Journal of Preventiv e Me dic ine

http://dx.doi.org/10.4236/ojpm.2013.37060

Prevalence of diarrhea and associated risk factors

among children under-five years of age in Eastern

Ethiopia: A cross-sectional study

Bezatu Mengistie1*, Yemane Berhane2, Alemayehu Worku2,3

1College of Health Sciences, Haramaya University, Harar, Ethiopia; *Corresponding Author: [email protected]

2Addis Continental Institute of Public Health, Addis Ababa, Ethiopia; [email protected]

3School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia; [email protected]

Received 25 July 2013; revised 1 September 2013; accepted 21 September 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Diarrhea remains a major cause of mortality in

children under 5 years of age in Sub-Saharan

countries in Africa. Risk factors for di arrhea vary

by context and have important implications for

developing appropriate strategies to reduce the

burden of the disease. The objective of this

study was to assess the prevalence of diarrhea

and associated risk factors among children un-

der 5 years of age in Kersa district, located in

Eastern Ethiopia. A community-based cross-

sectional study was conducted among 1456

randomly selected households with at least one

child under 5 years of age. A questionnaire and

an observational check list were used for col-

lecting information on socio-economic charac-

teristics, environmental hygiene and behavioral

practices, and occurrence of diarrhea among

children under 5 years of age. Logistic regres-

sion was used to calculate the adjusted odds

ratio of 95% confidence interval. The two-week

prevalence of diarrhea among children under 5

years of age was 22.5% (95% CI: 20.3 - 24.6).

Improper refuse disposal practices (OR = 2.22,

95% CI: 1.20 - 4.03), lack of hand washing facili-

ties (OR = 1.92, 95%CI: 1.29 - 2.86), living i n rural

area (OR = 1.81, 95% CI: 1.12 - 3.31), the pres-

ence of two or more siblings in a household (OR

= 1.74, 95% CI: 1.33 - 2.28), and age of the child

(OR= 2.25, 95% CI; 1.5-3.36) were the major risk

factors for diarrhea. This study demonstrated

that diarrhea morbidity was relatively high among

children under 5 years of age residing in Eastern

Ethiopia. Efforts to reduce childhood diarrhea

should focus on improving household sanitation,

personal hy giene, and child birth spacing.

Keywords: Diarrhea; Risk Factor; Children und er 5

Years; Ethiopia; Cross-Sectional Study; Hygiene

1. INTRODUCTION

Diarrhea remains the leading cause of morbidity and

mortality in children under 5 years old worldwide. The

burden is disproportionately high among children in low-

and middle-income countries. Young children are espe-

cially vulnerable to diarrheal disease and a high propor-

tion of the deaths occur in the first 2 years of life.

Worldwide, the majority of deaths related to diarrhea

take place in Africa and South Asia. Nearly half of deaths

from diarrhea among young children occur in Africa where

diarrhea is the largest cause of death among children under

5 years old and a major cause of childhood illness [1-4].

Although some of the factors associated with diarrhea

in children in Ethiopia such as Acute Respiratory Infec-

tion (ARI), maternal history of recent diarrhea, maternal

education, well source of water, obtaining water from

storage container by dipping, availability of latrine facili-

ties, living in a house with fewer number of rooms, not

breast feeding, duration of breast feeding, and age of the

child, have been identified, diarrhea is still a major pub-

lic health problem among children under 5 years old [5-

8].

Epidemiologic studies show that factors determining

the occurrence of diarrhea in children are complex and

the relative contribution of each factor varies as a func-

tion of interaction between socio-economic, environ-

mental and behavioral variables [5,9-11]. Recent re-

search indicated that studies in differing environment and

*The authors declare that they have no competing interest.

B. Mengistie et al. / Open Journal of Preventive Medicine 3 (2013) 446-453 447

prioritizing interventions based on context would be

useful to prevent deaths from diarrhea [12]. In Ethiopia,

despite the high prevalence of the disease, reports from

population-based studies are sparse. The study would be

helpful in planning and implementation of prevention

strategies at the community level. Thus, the objective of

this study was to assess the prevalence of diarrhea and

associated factors among children of age under five.

2. METHODS

The study was conducted in Kersa Demographic Sur-

veillance and Health Research Center (KDS-HRC) field

site, located in Eastern Ethiopia in January 2011. The

study site is approximately 482 kilometers from Addis

Ababa, and it is divided into 2 urban and 10 rural kebeles

(the smallest administrative unit in Ethiopia), with total

population of 55,394 residents. Agriculture is the main

source of the district’s livelihood. Health services in the

district are provided by six health centers and28 health

posts. At the kebele level, health care is delivered by

extension workers who are assigned to render health ser-

vices at the local level [13].

The sample size was calculated using the formula for

estimation of single proportion [14], n = Z2*P(1 - P)/r2.

Where: Z value is 1.96: P is the prevalence of diarrhea

among children under-five years old that was assumed to

be 18% [15]; and r is the margin error of estimation that

was assumed to be 2% (0.02). This provided a sample

size of 1417 children. To account for predicted 5% non-

response rate, the final sample was 1488 children.

Households with at least one child under 5years of age

were eligible for the study. Study participants were se-

lected using a simple random sampling technique from a

sampling registry obtained from Kersa Demographic

Surveillance and Health Research Center (KDS-HRC)

registration book. For households with two or more chil-

dren under 5 year of age, the index child was selected by

a lottery method.

Data were collected using questionnaire tested previ-

ously and administered by an interviewer and the obser-

vational check list. The questionnaire was prepared

based on the Multiple Indicator Cluster Survey (MICS),

Demographic and Health Survey (DHS) and World

Health Organization (WHO) core questionnaires related

to diarrhea. The questionnaire was written in English,

translated into Affan Oromo (local language), and then

translated back into English to assure its accuracy. The

respondents were primarily mothers of eligible children

under 5 years of age, but in the absence of the mother,

the next primary caregiver was interviewed.

Thirteen individuals who were trained, and experi-

enced in the KDS-HRC questionnaire administration,

and were fluent speakers of Affan Oromo collected the

data. The data collection was supervised by 3 supervisors

at the center. Their role was to daily check the consis-

tency and completeness of the collected questionnaires

and re-interview randomly selected 5% of the households

to check the data quality. Trained data clerks double en-

tered the data using EpiData 3.1 software.

The primary outcome variable was the occurrence of

diarrhea in the 2-week period preceding data collection.

The independent variables included socio-economic

(residence, family size, caregiver’s age, occupation,

educational status, parental age, occupation, educational

status, number of children under 5 years of age in the

household and wealth), environmental (the availability of

hand washing facility, latrine, type of and distance from

water source, refuse and stool disposal) and behavioral

and child-related (child feeding practice, measles vacci-

nation, age and gender of the child) factors.

In this study, diarrhea was defined as the passage of

three or more loose stools over 24 hours period or more

frequently than normal for a child [16]. Water from pro-

tected springs and/or wells, from pipe and from distribu-

tion post was considered as improved source [17]. Dis-

posal of child’s stool was considered proper if the stool

was put into the latrine or buried. The economic status of

the households was categorized into poor, middle and

better off using wealth index, which was calculated from

the households’ assets using principal component analy-

sis [18].

Descriptive statistics were used to summarize the study

variables. Logistic regression analysis was performed

separately for three variable blocks estimated the effect

socio-economic, environmental, and behavioral and child

related factors. The final model estimated the overall

effect of the three blocks of variables. All models used

simultaneous entry procedure to select the significant

determinants and adjusted for confounding factors. All

data were analyzed using SPSS v.16 statistical software

(IBM SPSS, Almaden, NY, US).

To reduce excessive number of variables and resulting

instability of the model, only variables with significance

P < 0.1 in the bivariate analysis were considered for in-

clusion in the multivariable analysis. Variables with P <

0.05 in the multivariable analysis were considered sig-

nificant. Multi-colinearity of variables was assessed by

calculating Variance Inflation Factor (VIF).

The study was approved by the Ethic Committee at the

College of Health and Medical Sciences of Haramaya

University. Mothers or caregivers of children were in-

formed about the study and its objectives before enroll-

ment. A written informed consent was obtained from the

mother or caregiver of each participating child. All col-

lected records were kept confidential.

B. Mengistie et al. / Open Journal of Preventive Medicine 3 (2013) 446-453

448

3. RESULT

A total of 1456 households participated in the study

with a response rate of 97.8%. Almost all respondents

were biological mothers (98.4%), married (97.3%) and

housewives (96.7%), most had no formal education

(82.2%) and were from rural area (85.3%). Mean chil-

dren age was 26.6 ± 13.5 months. There was slightly

more male (51.9%) than female children (51.9% and

48.1%).

Out of 1456 children, 327 had diarrhea two weeks be-

fore the interview, provided a prevalence of 22.5% [95%

confidence interval (CI) 20.3% - 24.6%]. Children in the

age group 6 - 11 months had the highest prevalence of

diarrhea followed by the age groups 12 - 23 months. The

distribution of prevalence of diarrhea by socio-eco-

nomic, environmental and behavioral characteristics is

shown in Tables 1-3.

Factors Associated with Diarrhea

Multivariate analyses were carried out to identifythe

risk factors associated with diarrhea. In the first block

logistic regression model, diarrhea was significantly

higher among children living in the rural than urban area.

In the second model, childhood diarrhea was signifi-

cantly associated with lack of hand washing facility, do-

mestic water supply from unimproved sources and open

dumping of refuse around the house. In the third model,

diarrhea was significantly associated with age of the

child and number of under-five children in the house-

hold.

In the final logistic regression model, diarrhea was in-

dependently associated with open dumping of refuse,

Table 1. Socio-economic determinants of diarrhea among children under 5 years of age in Kersa District, Eastern Ethiopia, 2011.

Diarrhea (N = 1456) COR (95%) CI

Va ri ab le s

Yes No

Residence

Urban 27 188 1

Rural 300 941 2.22 (1.45 - 3.39)

Age of mother/caregiver

15 - 24 70 194 0.75(0.55 - 1.02)

25 - 34 211 778 0.81(0.53 - 1.24)

>34 46 157 1

Education of mother/caregiver

No formal education 284 950 1.30(0.88 - 1.81)

Primary and above 42 179 1

Occupation of mother/caregiver

Housewife 317 1091 1.10(0.54 - 2.24)

Other 10 38 1

Education of father

No formal education 197 719 1.15(0.89 - 1.49)

Primary and above 130 410 1

Family size (persons per household)

≤4 94 398 1

>4 233 731 1.35(1.03 - 1.76)

Wealth index

Low 112 373 1.09(0.8 - 1.50)

Middle 106 379 1.03(0.93 - 1.41)

Better off 101 385 1

B. Mengistie et al. / Open Journal of Preventive Medicine 3 (2013) 446-453 449

Tab le 2. Environmental exposure variables associated with diarrhea among children under 5 years of age in Kersa district, Eastern

Ethiopia, 2011.

Diarrhea COR (95%) CI

Va ri ab le s

Yes No

Availability of latrine

Yes 68 325 1

No 259 804 1.54(1.14 - 2.07)

Availability of hand washing facilities

Yes 40 254 1

No 287 875 2.08(1.45 - 2.98)

Main source of domestic water

Improved 194 761 1

Unimproved 133 368 1.41(1.10 - 1.82)

Separate room for cooking

Yes 163 589 1

No 164 540 1.09(0.85 - 1.40)

Refuse disposal

Waste Pit/burning 57 275 1

Open dumping 27 39 3.34(1.89 - 5.89)

Used for manure 241 813 1.43(1.03 - 1.96)

Child stool disposal

Proper 106 441 1

Improper 221 688 1.33(1.03 - 1.73)

Time to obtain drinking water (round trip)

< 15 minutes 118 472 1

15 - 30 minutes 117 392 1.19(0.89 - 1.59)

More than 30 minutes 92 265 1.38(1.01 - 1.89)

Number of sleeping rooms

One 299 965 1.81(1.19 - 2.76)

Two and more 28 164 1

lack of hand washing facility, rural residence, and num-

ber of siblings under 5 years in a household and age of

the child. More specifically, children in the households

who open dumped refuse around the house had 2.22

times higher odds of having diarrhea compared to chil-

dren in the households who used a waste disposal pit

(OR = 2.22, 95% CI 1.2 - 4.03). The odds of diarrhea was

1.74 times higher in children from the households with

two or more siblings compared to children in the house-

holds with only one sibling (OR = 1.74, 95% CI 1.33 -

2.28). Children in the households without hand washing

facilities had 1.92 times higher odds of having diarrhea

compared to children in the households with no hand

washing facility(OR = 1.92, 95% CI 1.29 - 2.86) (Table 4).

4. DISCUSSION

This study investigated the prevalence and socio-

economic, environmental and behavioral risk factors of

diarrhea morbidity in children <5 years old in Eastern

Ethiopia. The two-week prevalence of diarrhea among the

ch ldren was 22.5% (95% CI: 20.3 - 24.6). The occurrence i

B. Mengistie et al. / Open Journal of Preventive Medicine 3 (2013) 446-453

450

Tab le 3. Behavioral, child and care related risk factors for diarrhea among children under 5 years of age, Kersa District, Eastern

Ethiopia, 2011.

Diarrhea COR (95%) CI

Va ri ab le s

Yes No

Bottle feeding (n = 737)

Yes 36 104 1.05(0.68 - 1.59)

No 159 438 1

Currently breast feeding (n = 737)

Yes 140 417 1

No 55 125 1.31(0.90 - 1.89)

Duration of breast feeding (n = 737)

<1 year 121 345 1.07(0.76 - 1.5)

≥1 year 74 197 1

Feeding children soon after food preparation

Yes 204 668 1.14(0.88 - 1.47)

No 123 461 1

Serving uncooked food to children

Yes 50 203 0.82(0.58 - 1.15)

No 277 926 1

Measles vaccination (n = 1302)

Yes 163 610 1

No 130 399 1.21(0.93 - 1.58)

Child sex

Male 166 590 1

Female 161 539 1.06(0.83 - 1.35)

Number of under 5 sibling per household

One 144 698 1

Two and more 183 431 2.05(1.60 - 2.64)

Child age (in months)

0 - 5 4 47 0.40(0.14 - 1.15)

6 - 11 61 114 2.54(1.73 - 3.73)

12 - 23 86 223 1.83(1.31 - 2.56)

24 - 35 84 308 1.29(0.93 - 1.80)

>35 92 437 1

*Measles vaccination is calculated for children 9 months and above; *bottle feeding and breast feeding is calculated for children < 2 years of age.

of diarrhea was positively associated with rural residence,

aged 6 to 23 months, open dumping of refuse around the

house, lack of hand washing facility and presence two or

more children under <5 years old in the household.

The two-week period of diarrhea occurrence used as a

criterion in our study is comparable with studies con-

ducted in Western Ethiopia [5], Egypt [19] and India

[20]. Such high rate of childhood diarrhea, despite con-

siderable improvements in water sources and sanitation

facilities, indicates the need for more attention.

B. Mengistie et al. / Open Journal of Preventive Medicine 3 (2013) 446-453 451

Table 4. Multivariable analysis of risk factors of diarrhea among children under 5 years of age in Kersa district, Eastern Ethiopia,

2011.

Risk factors Model I

AOR (95% CI)

Model II

AOR (95% CI)

Model III

AOR (95% CI)

Final model

AOR (95% CI)

Area of residence

Urban 1 1

Rural 2.15(1.35 - 3.43)* 1.81(1.12 - 3.31)*

Education mother/caretaker

No formal education 1.14(0.76 - 1.69) 1.23(0.79 - 1.92)

Primary and above 1 1

Family size

≤4 1 1

>4 1.30(0.98 - 1.71) 1.13(0.84 - 1.51)

Availability of latrine facility

Yes 1 1

No 1.13(0.77 - 1.67) 1.14(0.75 - 1.73)

Availability of hand washing facility

Yes 1 1

No 1.80(1.22 - 2.66)* 1.92(1.29 - 2.86)*

Main source of domestic water 1 1

Improved

Unimproved 1.35(1.02 - 1.80)* 1.16(0.86 - 1.55)

Time to fetch water (round trip)

< 15 minutes 1 1

15 - 30 minutes 1.03(0.75 - 1.40) 1.02(0.72 - 1.44)

More than 30 minutes 1.06(0.74 - 1.51) 1.04(0.71 - 1.51)

Refuse disposal

Waste pit/burning 1 1

Open dumping 2.68(1.51 - 4.79)* 2.22(1.20 - 4.03)*

Used for manure 1.22(0.87 - 1.72) 1.12(0.77 - 1.60)

Child stool disposal

Proper 1 1

Improper 1.23(0.88 - 1.70) 1.29(0.92 - 1.81)

Number of sleeping rooms

One 1.43(0.88 - 1.70) 1.40(0.91 - 2.20)

Two or more 1 1

Number of children under 5 in the household

One 1 1

Two or more 1.93(1.5 - 2.49)* 1.74(1.33-2.28)*

Child age (months)

0 - 5 0.39(0.13 - 1.11) 0.36(0.12 - 1.04)

6 - 11 2.31(1.56 - 3.41)* 2.25(1.50 - 3.36)*

12 - 23 1.71(1.22 - 2.4)* 1.83(1.29 - 2.60)*

24 - 35 1.30(0.99 - 1.81) 1.34(0.95 - 1.88)

>35 1 1

*= P < 0.05.

B. Mengistie et al. / Open Journal of Preventive Medicine 3 (2013) 446-453

452

The importance of refuse in transmitting diarrhea

pathogens has been documented [21]. In our study, open

disposal of refuse around the house was an independent

risk factor for diarrhea. This is in agreement with other

studies conducted elsewhere [22,23]. The simple expla-

nation might be that inappropriate disposal of refuse pro-

vides breeding site for insects, which may carry diarrhea

pathogens from the refuse to water and food.

Studies showed the importance of hand washing in

reducing the occurrence of childhood diarrhea [24,25].

However, monitoring correct hand washing behavior at

critical times is challenging. Hygiene behavior related

observational studies showed wide discrepancy between

what people said and did and suggested that reported

hand washing behavior over estimate observed behavior

[26-28] and supported the availability of water and soap

in places of hand washing as indicator of hand washing

behavior [29]. In this study, there was a significant posi-

tive association between the availability of hand washing

facility with childhood diarrhea.

The study showed that diarrhea was significantly as-

sociated with children in the age groups 6 - 11 months

and 12 - 23 months compared to children aged above 35

months. This finding is in agreement with other studies

[5,9]. The peak prevalence of diarrhea at the age of 6 - 11

months can be explained by the introduction of contami-

nated weaning foods [30]. In addition, crawling starts at

this age and the risk of ingesting contaminated materials

may cause diarrhea. The risk of diarrhea decreases sub-

sequently after 6 - 11 months; this is probably because

the children begin to develop immunity to pathogens

after repeated exposure [31].

The odds of diarrhea were higher among rural children

than urban ones and this was consistent with the findings

in Uganda [11] and Egypt [19]. This could be attributed

to the fact that the lack of access to water and sanitation

facilities in the rural areas was more than in the urban

areas [32].

In this study, diarrhea was significantly associated

with the presence of two or more under five children in

the family. This is in agreement with a study done in

Pakistan [33]. Other study also indicated that number of

children born was a predictor of diarrhea among under

five children [34]. This might be due to the incapability

of the caregiver to care for a large number of children

[19]. It is possible to suggest that child birth spacing might

have a positive influence on prevention of diarrhea.

In conclusion, childhood diarrhea remains an impor-

tant health concern in the study community. Occurrence

of diarrhea could be decreased by interventions aimed to

improve sanitation, hygiene and child birth spacing.

5. ACKNOWLEDGEMENTS

The authors would like to thank Haramaya University for its finan-

cial support. We are also thankful for study participants, data collectors

and supervisors for their devotion and full participation.

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