Socio-demographic, environmental and behavioural risk factors of diarrhoea among under-five children in rural Ethiopia: further analysis of the 2016 Ethiopian demographic and health survey

According to World Health Organisation (WHO), diarrhoea is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual) [1]. Diarrhoea is usually a symptom of an infection in the intestinal tract, which can be caused by a variety of bacterial, viral and parasitic organisms. It can last several days and can leave the body without the water and salts that are necessary for survival. It depletes the body fluids and can cause severe dehydration, which can lead to death if not treated properly. Furthermore, severe dehydration and fluid loss are the direct causes of diarrhoeal death for most people [1].

Diarrhoea is a leading cause of malnutrition [2] and the second leading cause of death in children under 5 years old being responsible for killing around 525,000 children every year. Globally, there are nearly 1.7 billion cases of childhood diarrhoeal disease every year [1]. According to United Nations International Children’s Emergency Fund (UNICEF), 88% of all diarrhoeal deaths in 2015 were concentrated in South Asia and sub-Saharan Africa [2]. Low and lower-middle-income countries are home to 62% of the world’s under-five population but account for more than 90% of global pneumonia and diarrhoeal death [2]. In low-income countries, children under 3 years old experience on average three episodes of diarrhoea every year [1].

Ethiopia is one of the top 10 countries with the highest number of diarrhoeal deaths. Based on UNICEF report, 15,500 diarrhoeal deaths occurred among under-five children in Ethiopia in 2015 [2]. The 2005, 2011 and 2016 Ethiopian Demographic and Health Survey (EDHS) reports showed that the percentage of under-five children who had diarrhoea in the 2 weeks before the survey period were 18, 13 and 12%, respectively [3]. Even though the magnitude of diarrhoea have reduced over the past periods, diarrhoeal disease is still the major cause of morbidity and mortality among children in Ethiopia.

Studies conducted in different countries showed that rural children are more severely affected by diarrhoea than urban children [4‐6]. The 2016 EDHS report showed that under-five children in rural Ethiopia had, relatively, more diarrhoea occurrence than urban ones [3]. Even though magnitude of diarrhoea disease in rural Ethiopia is high, there are limited pocket studies conducted at District/Zone/Town level to assess diarrhoeal disease and associated risk factors. Moreover, there is no study at the country/national level, which focused specifically on the rural part of the country, to show associated risk factors of diarrhoea occurrence among under-five children. So, evidence based information is needed for a child’s health improvement strategy by preventing and reducing the severity of diarrhoeal in under-five children in rural Ethiopia. Thus, this study was conducted to fill this gap by identifying the socio-demographic, environmental and behavioural associated risk factors of the occurrence of diarrhoea among children aged under 5 years in rural Ethiopia.

This study was intended to identify demographic, environmental and behavioural associated risk factors of the occurrence of diarrhoea among under-five children in rural Ethiopia based on 2016 EDHS data.

In this study, the variables current age of a child, sex of a child, region, birth order, toilet facilities shared with other households and the interaction effect of number of under-five children with age of mother were identified as associated risk factors for under-five diarrhoeal disease occurrence.

The result indicated that child’s age group 6–11, 12–23 and 24–35 months were 3.5, 3.1 and 1.7 times more affected by diarrhoea than child’s age greater than 35 months respectively after adjusting for the effect of other variables. In general, children age greater than 35 months had a lower risk of having diarrhoea than children whose age between 6 and 35 months. This may be due to the fact that children whose age between 6 and 23 months begin supplementary foods and also they start crawling and can touch contaminated materials in unclean environment and immediately return their hand to mouth, so this may cause them to be easily exposed to diarrhoeal disease. The 2016 EDHS also reported that diarrhoea prevalence remains high (18%) at age of 12–23 months, which is the time when children begin walking and are at increased risk of contamination from the environment [3]. Recent studies and scientific knowledge also show that a lot of diarrhoea in this age is due to rotavirus. For instance, a study conducted in Farta Woreda, North West Ethiopia showed that children age 6–11 months and not vaccinated for rotavirus are highly affected by diarrhoea [14, 15]. A study in Burkina Faso also showed that rotavirus is more prevalent in young children (< 12 months) and children less than 12 months of age were susceptible to diarrhoea [16]. Therefore, the role of rotavirus vaccines is also important. Moreover, increased risk of disease in younger children might be due to naive immune system in children of younger ages and waning of maternal antibodies [16‐21]. The finding of this study is also in line with studies done in Benishangul region, Eastern Ethiopia, Enderta Woreda, Wolitta Soddo and southern Ethiopia [4, 7, 22‐25].

Sex of a child had a significant association with diarrhoea occurrence. Male children were 1.3 times more affected by diarrhoea than female children after adjusting for the effect of other variables. A study conducted in Dhaka, Bangladesh in 2018 similarly concluded that more boys presented with acute diarrhoeal illness than girls [26]. This might be because of possibility of a sex-based difference in the pathophysiology of acute pediatric diarrhoea that we do not yet understand [26].

The study also revealed that the occurrence of diarrhoea was significantly associated with region of the mother. Children in rural Afar and rural Gambela regions were twice as likely to be affected by diarrhoea as compared to children in rural Tigray region. However, under-five children from the rural Somali region were 0.45 times less likely to be affected by diarrhoea than those from rural Tigray region.

Households those shared toilet facility with other households had a significant association with diarrhoeal disease. Children from households with shared toilet facility had around 39% more risk for having diarrhoea than those from households who did not share toilet facilities. Thus, children under the age of five face an increased risk of contracting diarrhoea when they share a toilet with just one or two other households. Epidemiological studies have identified an increased risk of diarrhoeal diseases associated with using shared sanitation facilities. A similar study conducted using data from 51 countries’ demographic and health surveys found that shared sanitation appears to be a risk factor for diarrhoea although differences in socioeconomic status are important [27]. An analytical review study conducted by Ramlal et al. in 2019 also found that the use of shared sanitation showed a significant increase in diarrhoeal disease, with an overall OR of 2.39 (85% CI 1.15–8.31) [28].

Children whose birth order 4th and 5th and above were around 1.8 times more likely to be affected by diarrhoea than 1st order children. This result was in line with the findings in the Benishangul Gumuz region [7] and in Jigjiga district, Somali region [29].

The effect of number of under-five children in the household on childhood diarrhoea varies by current age of mothers. Number of under-five children affects the occurrence of diarrhoea differently in older age mothers (35–49) versus younger age mothers (15–24). The odds of the occurrence of diarrhoea for three or more number of under-five children (relative to two or less number of under-five children) in older age mothers was 4.7 times as high as in younger age mothers. In other words, mother’s current age 35–49 years in a household with three or more under-five children had significantly greater prevalence of diarrhoea as compared to those maternal age of 15–24 years in a household less than or equal to 2 under-five children. Older mothers, on average, can have a higher number of children as compared to younger ones. As a result, it may be difficult to give care effectively when the number of under-five children becomes large in a household and then it may be a cause for the occurrence of diarrhoea. Therefore, to control the number of under-five children the role of family planning is important. Effective family planning can also reduce the number of high birth ordered children in the household. This finding is consistent with a study done in eastern Ethiopia [4], the Benishangul Gumuz region [7], northeast Ethiopia [30] and in northwest Tigray [31].

The age of a child, sex of a child, region, birth order, toilet facilities shared with other households and the interaction effect of number of under-five children with current age of mothers are identified as associated risk factors for diarrhoea occurrence among under-five children in rural Ethiopia. The findings show the need for planning and implementing appropriate prevention strategies considering the identified risk factors that target rural under-five children. For instance, strategies for reducing the number of under-five children and birth order in the household as well as supportive strategies about household sanitation facilities (toilet facility and its usage), and women education on appropriate child care practices tailored by their age might reduce prevalence of diarrhoea. Further research is recommended to investigate the determinants of diarrhoea using primary data including all modifiable associated risk factors like rotavirus vaccine, hand washing, malnutrition status, and others in rural Ethiopia.