Prevalence and associated factors of acute diarrhea among under-five children in Kamashi district, western Ethiopia: community-based study

Diarrheal diseases are the second largest cause of death among children under 5 years of age globally. The World Health Organization (WHO) estimated 1.5 million children in this age group died from diarrheal diseases every year with almost half of them in Africa. The most vulnerable children are the youngest ones, particularly before their second birthday [1, 2]. Even though there is a global decline in the death rates of under-five children, the risk of a child for dying before the age of 5 years remains the highest in the WHO African Region (90 per 1000 live births), which is approximately 7 times higher than that in the WHO European Region (12 per 1000 live births) [3].

Many studies revealed that acute diarrheal disease prevalence varied from country to country. For example, in Gaza Strip, Iraq (17.7–46.1%) [4], Cameron (23.8%) [2], Tanzania (32.7%), Rwanda (26.7%) [5, 6] and in Ethiopia, ranged from 8.5 to 54% [7, 8]. In Ethiopia, the acute diarrheal diseases varied across the country: Debre Berhan referral hospital, (31.7%) [9], Arba Minch, South Ethiopia (30.5%) [10], Bahir Dar town, northwest Ethiopia (21.6%) [11], Farta district, northwest Ethiopia (16.7%) [12], Jigjiga, East Ethiopia 14.6% [13], and Adama town, Central Ethiopia, 14.7% [14] the 2016 Ethiopian Demographic Health Survey report, 12% [14], Wolaita Sodo, South Ethiopia (11%) [15] and Yeka sub-city, Addis Ababa, Central Ethiopia (8.5%) [16]. About 23% of the under 5 years child mortality in the country was caused by diarrheal diseases alone, which is greater than the annual deaths due to malaria, HIV/AIDS and measles all together [1].

Exclusive breastfeeding, maternal educational status, family monthly income, source of drinking water, hand washing practice of mothers/caregivers and washing of water storage tanks had a significant association with under-five child mortality [4], quality of water used for drinking, cooking, cleaning kitchen utensils and laundry, quality of the environment in which children lived, caregivers’ knowledge of safe sources of water, type of containers used for the storage of water, age of children and child toilet facility were significantly associated with diarrhea in Sub-Saharan countries [2, 5, 6, 17]. In Ethiopia, inadequate water supply, lack of handwashing facilities and lack of formal maternal education [6, 18], monthly income less than birr 500 and 12–23 months of age, personal hygiene practice, food handling and storage, breastfeeding practice, and improper refuse disposal practices [3, 4, 7, 11, 12, 16, 19‐23] reported as predictors of acute diarrhea among under-five children.

Although interventions, like rotavirus vaccinations, improving breastfeeding, diarrhea prevention focused on safe water and improved hygiene and sanitation were carried out, the problem remains one of the leading causes of preventable morbidity and mortality among under-five children in Ethiopia, especially in Benishangul Gumuz region.

There were few research done in a different part of Ethiopia to determine prevalence and risk factors associated with acute diarrheal diseases among under-5 year’s children at different time. But, there was a great difference in diseases burden (from 8.5 to 54%) and risk factors related to diarrhea among studies. Therefore, this study was used to determine the prevalence and associated factors with acute diarrheal diseases in Kamashi district, west Ethiopia, to develop effective prevention strategies and baseline for further research.

All the 717 mothers/caregivers were included in the study (100% response rate). Of the participants, 362(50%) had primary school education; 698 (97.4%) were married; 333 (46.4%) were in the age range of 24 to 29 years (mean ± SD==25.74 ± 3.92) and 346 (48.3%) of the children were 7 to 24 months of age (mean ± SD = 24.57 ± 15.17), 526 (73.4%) had one under-five child each, and 104 (14.5%) (95% CI: 12.3–17.3) reported their children had acute diarrhea 14 days before data collection (Table 1).

Of the total participants, 697(94.7%) had latrines, and 536 (74.8%) traditional pit latrines. Of these, 497(73.2%) had handwashing facilities, 647(90.2%) had no liquid waste disposal pits and 699(97.5%) used safe (public or standpipe source of water) for daily consumption (Table 2).

Of the 717 mothers/caregiver, 715 (99.7%) had children whose nutritional status was normal; 530(74%) had knowledge about the mode of transmission and prevention mechanisms of diarrheal diseases; 692 (96.5%) gave supplementary food to their children after 6 months, while 633(88.3%) had no knowledge about homemade treatment and its practice (Table 3).

The primary aim of this study was to determine the prevalence and associated factors of acute diarrheal diseases in Kamashi district, western Ethiopia. In the current study, 104 (14.5%) of mothers/caregivers reported that their children had acute diarrhea in the previous 2 weeks. The finding was lower than those of previous studies conducted in Cameron (23.8%), Tanzania (32.7%), Senegal (26%) and Rwanda (26.7%) [2, 5, 17, 24]. That might be because of socio-cultural differences and the knowledge gap about handwashing at critical times. Mothers/caregivers who had handwashing practices at a critical time had a higher chance of interrupting feco-oral disease transmissions than those who did not wash at critical times [2, 3, 9]. In the current study, we found that knowledge about homemade treatment for diarrhea was 11.7%. This result was lower than those of studies conducted in Ethiopia like in Enderta district (54%), Debre Berhan town (31.7%), Arba Minch (30.5%), and Bahir-Dar (21.6%) [7, 9‐11]. That might be because of water storage practices at home and latrine cleanness and the availability of handwashing facilities around latrines. On top of that, mothers/caregivers who stored water in narrow materials had a low probability of water contamination by hand and fetching objects. And, mothers whose latrines were clean and had handwashing facilities reduced the contamination of food and water by flies and hands [12, 16, 18].

The prevalence in this study was in line with those of studies conducted in Jig Jiga (14.6%), Serbo town (14.9%), and 2016 EDHS (12%) [3, 4, 20]. However, our result was higher than those of studies conducted in Wolaita Sodo (11%), and Yeka sub-city (8.5%) [3, 21]. The differences might be due to variations in hygiene and sanitation practices and the initiation of children into supplementary feeding. Children who started supplementary food before 6 months had more chance of getting acute diarrhea than those who started supplementary feeding after 6 months.

For children whose mothers/caregivers did not wash their hands at critical times, the odds of acquiring acute diarrhea were 5.9 times higher than for those whose mothers/caregivers practiced hand washing at such times. Studies in Gaza strip [4], Tanzania [17], Debre Berhan referral hospital [9], district 03, Yeka sub-city [16], and Enderta district reported similar findings [7]. This might be because mothers who did practice handwashing critical times had less chance of being infected by diarrheal disease-causing agents than mothers who did not keep their hygiene and sanitation [5, 12].

The odds of acquiring acute diarrhea for a child whose mother/caregiver did not store water in “jerricans” were 7.6 times more than those of a child whose mother/caregiver did not store water in that manner. This finding is consistent with those of studies conducted in Gaza strip [4], Tanzania [17], Debre Berhan Referral Hospital [9], Yeka sub-city [16], and Enderta district [7]. This positive association might be due to the fact that mothers/caregivers who stored water at home in wide materials had a higher probability of contaminating water by hands and objects than those who stored in narrow materials.

A child who started supplementary feeding before 6 months of age was 5.49 more likely to get acute diarrhea than a child who started supplementary feeding after 6 months. Different studies conducted in Gaza strip [4], Tanzania [17], Debrebirehan referral hospital [9], Yeka sub-city [16] Enderta district [7], Afar region [25] and systematize review in developing countries [26] reported results consistent with ours. The reason might be that a child who starts supplementary food before 6 months can be exposed to organisms that cause diarrhea and food intolerance than a child who starts after 6 months [5, 6].

For children whose mothers/caregiver’s latrines were not clean, the odds of getting acute diarrhea were 11.48 times more likely than for their counterparts. This finding is supported by those of studies conducted in Rwanda [5], Farta district [12], Geze Gofa district [6], and Kotebe sub-city [21]. The possible reason might be that there is a possibility of contacting pathogens (which causes diarrhea) in unclean environments. Therefore, mothers/caregivers whose latrine are not clean increase the probability of food and water contamination by flies and hands than those whose latrines are clean at sources and consumption.

Children whose mothers/caregivers had no handwashing facilities around latrines were 7.07 times more likely to acquire acute diarrhea compared to their counterparts. This finding is supported by those of studies conducted in Rwanda [5], Farta district [12], Geze Gofa district [6], and Kotebe sub-city [21]. Mothers/caregivers who had no hand-washing facilities around latrines had low chances of removing microorganisms that contaminant hands after latrine utilization than those who had such washing facilities [6, 22].

The limitation of the study might be the study was not engaged with seasonal differences. The prevalence of acute diarrhea reported might not reflect the actual situation that could be observed in various seasons of the year, as the information on diarrhea was collected in August, which is a wet season. It does not identify the etiological agents of diarrheal diseases because of the study design behavior.

The prevalence of acute diarrhea in Kamashi district was high. Latrine cleanness, availability of handwashing facilities around latrine, hand washing practice at a critical time, storage of water by “jerrican” and time of initiation of supplementary food had a determinant factor of diarrheal disease occurrence. Therefore, health education on personal and environmental hygiene should be delivered. Additionally youth and child feeding practice should be provided to the community through a different mechanism.