Prevalence of Diarrhea and Associated Factors among Under Five Years Children in Harena Buluk Woreda Oromia Region, South East Ethiopia, 2018

Diarrhea is defined as a child with loose or watery stool for three or more times during a 24–hours period and caused by a host of bacterial, viral, protozoa and parasitic organisms. Rotavirus and Escherichia coli are the two most common etiological agents of moderate-to-severe diarrhea in low-income countries. It is more common when there is a shortage of adequate sanitation and hygiene and safe water for drinking, cooking and cleaning, improper feeding practices, and poor housing conditions ¹. Though most episodes of childhood diarrhea are mild, acute cases can lead to significant fluid loss and dehydration, which may result in death or other severe consequences ².

Despite global success in the reduction of all cause and diarrhea specific mortality in the past 30 years, diarrhea remains the second leading cause of death due to infections among children under five years of age worldwide and account for 1,400 children death every day, around 1 in 10 child deaths worldwide due to diarrhea in 2015. It is more than the death of children due to AIDS, malaria, and measles combined ³.It is estimated that diarrhea accounted for 9.9% of the 6.9 million deaths among children under 5 in 2011 ⁴. Young children are especially vulnerable bearing 68% of the total burden of diarrhea disease. Among children less than five years, diarrhea accounts for 17% of all deaths ².

While it is both preventable and treatable, each year around 526 000 deaths of under-five children and nearly 1.7 billion cases of childhood diarrheal disease every year. This rate varies between regions, Most deaths from diarrhea occur among children less than 2 years of age living in South Asia and sub-Saharan Africa many of those who survive suffer from malnutrition and lasting impairments to mental and physical development ^{2, 5}. Diarrheal deaths are exceedingly prevalent in just a handful of countries and half of deaths due to diarrhea.

A large proportion of diarrheal disease in developing world is due to multiple risk factors are indicated, namely unsafe water supply, lack of water linked to inadequate hygiene, poor personal and domestic hygiene and agricultural practices, contact with unsafe water, inadequate sanitation and quality and quantity of water, availability of toilet facilities, housing conditions, level of education, household economic status, place of residence, feeding practices, and the general sanitary conditions around the house cause various disease outcomes, mainly diarrheal About 88% of diarrhea-associated deaths are attributable to unsafe water, inadequate sanitation, and insufficient hygiene. As simple as hand washing may seem, it is one of the most important factors in preventing the spread of germs and staying healthy. Unwashed hands can accelerate the spread of bacteria, parasites, and viruses that are transmitted from human and animal faeces or the environment ⁶. Nowadays, globally diarrhea accounts for 9% of all deaths among children under the age of five ⁷.

The morbidity and mortality related to diarrheal diseases in under-5 children are still sizeable and persistent in low income countries, especially in sub-Saharan Africa, and pose a significant, long-standing public health concern. Diarrhea is one of the major contributors to deaths for under age 5 children in Ethiopia. Diarrhea contributes to more than one in every ten (13%) child deaths in Ethiopia. The percentage of children under age 5 who had diarrhea accounts 12% in 2016 ⁸.

Diarrheal diseases are among the leading causes of under-five deaths worldwide. Globally diarrhea accounts for 9% of all deaths among children under the age of five. Low income nations like India, Nigeria, the Democratic Republic of Congo, Pakistan, and Ethiopia are hit especially hard. In these countries, children are often exposed to pathogens because of poor environmental sanitation and water supplies ⁷. Childhood mortality rate in general and infant mortality in particular, are often used as broad indicators of social development or as specific indicators of health status. Child mortality reduction by two-third is one target of Millennium Development Goal ⁹. The majority of morbidity and mortality related to under-five diarrhea were in Africa and South Asia. Diarrhea can last several days, and can leave the body without the water and salts that are necessary for survival. Most people who die from diarrhea actually die from severe dehydration and fluid loss. It also predisposes children to malnutrition which makes children more susceptible to other infections ⁵.

As compared with other regions of the world, the African region shows the smallest reductions in mortality rates and the most marked slowing down trend. The under-five mortality rate in the African region is seven times higher than that in the European region.

Though Ethiopia has recorded significant reduction in childhood mortality, still many children die from diarrhea before their 5th birth day. Over two-thirds of child deaths in Ethiopia are due to infectious diseases such as pneumonia, diarrhea, malaria, and measles; and problems of the newborn. Moreover diarrhea is the second cause for clinical presentation among under five-year child population next to pneumonia in Ethiopia .Nationally, diarrhea prevalence is 12% in 2016 and it is more abundant in rural than urban areas ⁸. Even though improvement was made in reducing childhood mortality from 123 under five deaths per 1,000 live births in 2005 to 59 under five deaths per 1,000 live births in 2016, children in the country still suffer from diarrhea, respiratory problems and malnutrition ⁸.

Variations across communities in factors like accessible, safe and adequate water supply, environmental sanitation and person hygiene, availability and quality of MNCH services and facilities, maternal education level, place of residence (urban/rural) could play significant roles on diarrhea morbidity and mortality in a specific community. Thus this study was aimed to assess the magnitude and determinants of diarrhea morbidly in under-5 children at Harena Buluk wereda. Studies conducted that aimed to assess diarrhea morbidly in conjunction with its determinant factors among under-5 children at community level in Ethiopia particularly in the context of Bale zone, Harena Buluk wereda are limited. This suggests that many more studies are remaining to be done.

Even though there are different diarrhea prevention strategies and policies including the health extension program in the ground, diarrhea is still the leading cause of morbidity among children visiting under five years clinic in the study area. In addition to this the woreda has been affected by acute watery diarrhea (AWD) epidemic and a lot of children died in 2016/2017. Therefore this study was done to assess the magnitude and associated factors of diarrhea among under-five children in Harena Buluk woreda by the year of 2018.

Diarrhea is defined as having three or more loose or watery stools per twenty four hours in two weeks period preceding the data collection, as reported by the mother/care taker of the child(WHO, 2010).

Prevalence of Diarrhea the number of diarrhea cases at the time of the interview divided by the total number of households included in the study.

Exclusive Breast FeedingA child who receives breast milk only and no other food, solid or liquid with the exception of vitamins, minerals and medicines ¹.

Improved Water Source Water from protected springs and/or wells, from pipe and from distribution post unless considered as unimproved ¹.

Improved Latrine pour flush to piped sewer system/septic tank/pit latrine, VIP and pit latrine with slab otherwise considered as unimproved ¹.

Care Giver Hygiene is personal hygiene of the caregivers like short finger nail cut or long fingernail which could be factors for the occurrence of diarrheal disease among children

Appropriate Hand Washing Practice is the way of child caregiver hand washing practice which shows clean hand palm, fingertip and between-fingers observed by data collectors to determine its relationship with the occurrence of diarrheal.

Hand Washing Facility refers to households having hand washing facilities like plastic or metal with water seated nearest to latrine for children to wash their hands after latrine utilization as observed by data collectors.

Hand Washing during Critical Time refers to caregivers’ hand washing practice after utilization of latrine, before food preparation and child-feeding as identified by caregivers’ oral report of their practice to identify its relationship with diarrheal occurrence

Index Child refers to a child that was included in the study from a household to have information on the demographic and health characteristics.

The study was conducted in Harena Buluk woreda and data was collected in February, 2018. Harena Buluk is one of the pastoral woredas found in Bale zone of Oromiya region, Southeast Ethiopia. The study site is approximately 582 kilometers away from Addis Ababa and 152 kilometers from Bale Robe, the capital city of Bale zone. It is bounded by Goba, Madda Walabu, Delo Mena and Adaba woredas to the north, south, east and west direction respectively. The district is divided in to thirteen rural and one urban kebeles (the smallest administrative unit in Ethiopia), having a total population of 106, 987 residents. The total households of the district were 22899 and 17,587were children under five years of age. It had 52 primary and 3 secondary schools. The population is predominantly Muslim by religion. The main weather condition of the woreda is kola (low land) with some part of it having weyna-dega (mid land) weather condition which is accounts about 9 and 5 kebeles respectively. Agriculture and pasturing is the main sources of the district’s livelihood. Health services in the district were provided by 5 health centers and 18 health posts. At the kebele level, health care is delivered by health extension workers who are assigned to render health services at the local level.

A community based cross-sectional study was done to assess the magnitude and associated factors of acute diarrheal disease among children under-five years of age in Harena Buluk woreda from February 1 to February 20, 2018.

The source populations are all households with mothers/care takers who have under-five children in the district, Harena Buluk woreda.The study populations are all households with mothers/care takers who have under-five children in the in the selected kebeles, Harena Buluk woreda. And the study units are randomly selected household with at least one under five-child in selected kebeles. Those households under five years children and lived in the area for more than six months are included in the study; while mothers who are ill and cannot respond to the interview, children who are critically ill and with persistent diarrhea were excluded from the study.

Using EPI INFO for window version 7, sample size was calculated for each specific objective and the highest sample size is taken. Using single population proportion formula by considering 23% of the under five-children had two-week prevalence of diarrhea from a study done in Kersa, Eastern Ethiopia by Bezatu Mengistie, Yemane Berhane, Alemayehu Worku, 2011 with 95% confidence level, 5% desired precision and taking design effect of 1.5, accounted for two stage sampling ¹⁰. Adding 10% for none response rate, the total calculated sample size was 450 mothers with less than five years children.

Multistage sampling was employed to select kebeles and households which have under-five children in the woreda. In the first stage all the kebeles stratified by place of residence as urban (only one small kebele) and rural. On the second stage the rural kebeles again stratified based on geographical and climate condition as low land/pastoral and mid land/agrarian kebeles because the residence area (urban and rural) and geographic/ climate condition by itself make a difference in socio economics among source population. From the total 13 rural kebeles 5 are mid land and 8 are low land. Then, from each stratum kebeles to be included in the study was allocated proportionally and selected randomly. Therefore, from rural strata 3 low land and 1 mid land kebeles as well as the only one kebele from urban strata taken as study population, from which the study unit was selected. As a result 5 kebeles were selected out of the total of 14 kebeles found in the district.

Similarly the number of households to be a study unit selected from each kebeles allocated proportionally. The systematic random sampling technique was used to take the mothers/caretaker-child pairs from each of the selected kebeles (small villages). Households with at least one under five years of age child was eligible for the study. One child- mother pair was selected at random to collect information on the child’s demographic and health characteristics for households with two or more under 5 years of age children. The first household was selected randomly and the subsequent households were selected systematically until the proportionately allocated sample size fulfilled. When the selected households had no under-five children, the next neighborhood household was selected. A brief illustration of the sampling procedure is displayed in the figure below.

The questionnaire was prepared based on EDHS and WHO core questionnaires related to diarrhea. The questionnaire was written in English, translated into Afan Oromo (local language), and then translated back into English to assure its accuracy. In order to ensure data quality data collectors and supervisors were trained on the data collection procedure. Data collection process was supervised by the principal investigators and supervisors. The filled questionnaire was checked for completeness and consistency on daily bases.

Data was collected by interview using adapted standard questionnaire and administered by an interviewer. The respondents were primarily mothers of eligible children-under five years of age, but in the absence of the mother, the next primary caregiver will be interviewed. Five data collectors who were clinical nurses and Afan Oromo speakers were trained in questionnaire administration and data collection procedures. Pretest was done in 5% of the total sample size in another Kebele of the same study area. The result of the pretest was used to correct some unclear ideas and statements. The data collection was supervised by two supervisors (Health Officers) and the principal investigator at the center. Their role was to daily check the consistency, clarity and completeness of the collected questionnaires. The data collectors along with their supervisors took two days training about the questionnaire and data collection procedures.

The dependent variable is prevalence of diarrhea in under-five year children in the last two weeks period. The independent variables are socio-demographic factors such as place of residence, household size, parental education, maternal occupation, maternal age, number of children under-five years of age, family size and child’s age and sex. Environmental factors were type of water source, distance to the water source, availability of latrine facility, availability of hand washing facility, number of rooms, livestock in house and refuse disposal method. Behavioral factors were feeding practices, hand washing practice, home based water treatment, duration of breast-feeding, breast feeding status, and time of introducing supplementary feeding.

The data was coded and entered in to a computer using Epi-data 3.1 software and exported to SPSS V.20statistical software for cleaning and further analysis of the data. Descriptive statistics was done to describe the study populations using measures of frequency, disease occurrence, central tendency and dispersion that were displayed using tables and graph. The necessary assumption of logistic regression was checked using Hosmer and Lemeshow goodness-of-fit-test statistics. Due to the binary nature of the outcome variable, binary logistic regression analysis was used to determine the OR and 95% CI of the effect of the different independent variables on the outcome variable. To reduce excessive number of variables and instability of the model, only variables with P. value < 0.2 in the bivariate analysis will be considered for inclusion in the multivariate analysis to control for the effect of confounders. Variables with P-value < 0.05 in the multivariate analysis (final model) will be considered as independently associated with the outcome variable.

Three hundred thirty four (74.2%) and 75(22.5%) of the households had latrine and hand washing facility respectively. Majority of the latrine facility of the households were 304(91%) private and 330(98.8) of them were not improved type and 72(21.3%) of the households had unclean latrine or feces seen around the hole of pit latrine. Most of the households 232(51.6%) disposes their waste material properly. 230(51.1%) of the households use improved type of water source and 118(26.2%) of the households take 30 minute or more to fetch water. 170(37.8%) of the households treat their drinking water at home (Table 2)

Majority of the respondents give their child 410(91%) other food in addition to BF. Most of the respondents 243(59.3%) were prepare gruel and 239(58.3%) of the respondents feed their children using their hand. Most of the respondents 209(46.4) wash their hand using water only (Table 3).

Two hundred thirty one (51.3%) of the children were females with the majority of the children 161(35.8%) were in the age group of 12-24 months. The mean age of the children was 24.55(±13.63 SD) months. 263(58.4%) and 285(73.5%) of the children receive Rota and measles virus vaccine respectively. In this study, 128(28.4%) of the children had experience diarrhea in the two weeks period preceding the study (Table 4).

In the bivariate analysis number of under five children in the household, household family size, occupation of mother, education of the fathers, occupation of fathers, place of Residence, religion, average family monthly income were found to be significantly associated with under-five diarrhea. The odds of having diarrhea in household with tow and less number of under five children were 4.18 times less likely than the odds in household with more than two under five children (COR: 0.239, 95% CI (0.152-0.375)) children who live in the household of five or less family size were 1.83 times less likely prone to diarrhea when compared to those children live in the household greater than five family member (COR: 0.545, 95% CI (0.347-0.857)). Children of fathers who completed primary education were less probable to have diarrhea compared to children of mothers who were illiterate (COR: 0.69, 95% CI(0.45-1.06)). Likewise children of fathers who were secondary and above educational status were more than three times less likely to experience diarrhea compared to children of mothers who were illiterate (COR: 0.28, 95% CI(0.11-.71)). Children from households of urban community were about 1.5 times less likely to have diarrhea compared to children of rural community households (COR: 0.67, 95% CI (0.37, 1.234)). Children of house hold whose income more than one thousand were less likely to develop diarrhea compared to children of household whose income were one thousand and less birr per month (COR: 0.387, 95% CI(0.245,0.611)).Children of mothers whose occupation house wife were four times more likely to experience diarrhea as compared Children of mothers whose occupation were government employee. Children of mothers whose occupation were farmer three times more likely to have diarrhea compared to government employee Likewise children of mothers whose occupation were merchant two times more likely to have diarrhea compared to government employee. In this study Educational status of the mother, Age of mothers category, Occupation of fathers, Marital status, Ethnicity, Relation of respondents to child and Monthly income of family were not showed significant association with under five diarrhea (Table 5)

Households’ environmental variables and their relationship with under-five diarrhea were assessed on the bivariate analysis. But latrine availability, feces seen in the pit hole, hand washing facility, refuse disposal method, time to fetch water from source, home water treatment, number of rooms and animals live in same house were found to be significantly associated with under-five diarrheal morbidity.

Children from household who had no latrine were 3 times more likely to experience diarrhea compared to children from household who had latrine(COR: 2.91, 95% CI(1.86,4.54)). Children from household who had clean latrine/ faces not seen around the pit or on the floor of latrine were 1.5 times less likely to experience diarrhea compared to children from household who had not clean latrine/ feces seen around the pit or on the floor of latrine (COR: 0.65, 95% CI(0.37,1.14)). Children from households had no hand washing facilities were five times more likely prone for diarrhea compared to those children of households who had hand washing facilities(COR: 5.18, 95% CI(0.19,0.53)). Children from households experience improper waste disposal were 2.2 times more likely to develop diarrhea compared to those children of household who dispose waste properly(COR: 2.22, 95% CI(1.46,3.38)). Children from households who take below 30 minute to get water from source were four times less likely to develop diarrhea compared to those children of household get water after walking more than 30 minute (COR: 0.262, 95% CI(0.17,0.41)). Children from households who treat water before using were less likely to develop diarrhea compared to those children from households who didn’t treat water before using(COR: 0.52, 95% CI(0.33,0.82)). Children of households use improved water source were three times less likely to experience diarrhea compared to children from households who use unimproved water source (COR: 0.32, 95% CI(0.19,0.53)). Children of households had one room house were 3.5 times more likely to experience diarrhea compared to those children of house hold who had house of more than two rooms(COR: 3.6, 95% CI(1.74,7.41)). likewise children of household had house of two rooms were 1.7 times more likely to develop diarrhea compared to those children of house hold who had house of more than two rooms [COR: 1.69, 95% CI(0.98,2.897)), and child of house hold live with animal in the same house were four times more likely to develop diarrhea compared to those children of house hold live in separated room from animal(COR: 3.9, 95% CI(2.52,6.04)) (Table 6).

In the bivariate analysis, current breast feeding status, type of food the child take (Powder milk and gruel), eating unwashed fruit, eating uncooked food, prepare child food separately, utensil washing methods, methods of child feeding, hand washing before food preparation, hand washing before food serving, hand washing after visiting latrine, and hand washing after cleaning of child bottom were the behavioral variables that showed significant association with under-five diarrheal morbidity.

Children who partially breast feeding were 4.5 times more likely to develop diarrhea when compared to children exclusively breast feed(COR: 4.5, 95% CI(1.53,13.21)). Similarly children who didn’t breast feeding were three times more likely to develop diarrhea when compared to children exclusively breast feed (COR: 3.44, 95% CI(1.18,10.08)). Children usually taking gruel type of food were 1.5 times less likely compared to children eating other type of food (COR: 0.64, 95% CI(0.416,0.98)). But child cow milk and adult type of food were not showed any significant association with under-five diarrheal morbidity. Children who didn’t ate unwashed food were two times less likely to develop compared to those children who ate unwashed fruit (COR: 0.49, 95% CI(0.32,0.76)). Children used to eat uncooked food were two times more likely to develop diarrhea compared to those children not used to eat uncooked food (COR: 2.02, 95% CI(1.2,3.39)). Children of mothers who prepare their children food in separately were two times less likely to develop diarrhea compared to children of mothers prepare children food together with the family (COR: 0.42, 95% CI(0.27,0.65)). Children of mother who used only water to wash utensil were 1.5 times more likely to develop diarrhea compared to children of mothers who used soap and water(COR: 1.58, 95% CI(1.01,2.48)). Children of mother who wash their hand before food preparing were six times less likely to develop diarrhea compared to children of mothers who were not wash their hand before food preparing(COR: 0.158, 95% CI(0.098,0.254)). Children of mother who wash their hand before food serving were two times less likely to develop diarrhea compared to children of mothers who were not wash their hand before food serving (COR: 0.49, 95% CI(0.32,0.76)). Children of mother who wash their hand after visiting latrine were three times less likely to develop diarrhea compared to children of mothers who were not wash their hand after visiting latrine (COR: 0.29, 95% CI(0.19, 0.44)). Children of mother who wash their hand after cleaning bottom of children were four times less likely to develop diarrhea compared to children of mothers who were not their hand after cleaning bottom of children (COR: 0.24, 95% CI(0.14,0.40)). But hand washing before eating was not show significant association with under five children diarrhea. Children of mothers/care takers who wash their hand using water and soap/ash were 1.5 times less likely to develop diarrhea compared to those children of mothers/care takers who wash their hand with water only (COR: 0.69, 95% CI(0.46,1.04)). Children who received Rota vaccine were two times less likely prone to diarrheal diseases compared to children not received rata vaccine(COR: 0.43, 95% CI(0.28,0.65)). Similarly those children received measles vaccine were four times less likely prone to diarrheal diseases compared to children not received Rota vaccine(COR: 0.26, 95% CI(0.16,0.42)). Length of breast feeding, age at supplementary food and method of children feeding were not show significant association with under five children diarrhea. (Table 7)

In the bivariate analysis any possible confounders were not controlled and assessing the independent effects of the covariates was difficult. So, an enter method of binary logistic regression technique was used to assess the independent effects of explanatory variables on under five diarrhea. To avoid excessive number of variables and unstable estimate in the final model, only variables with P-value less than 0.2 in the bivariate analysis were taken in the multivariate analysis. Model fit was checked by Hosmer-Lemeshow goodness-of-fit test statistics.

The multivariate binary logistic regression analysis identified that number of under five children in the family, utilization of latrine, time from the source of water, home based water treatment, number of rooms in the home, animal live in the same house with the family, type of food child take, hand washing before food preparation, and mothers/care takers hand washing method had significant association with the occurrence of under-five diarrhea. The odds of having diarrhea in household with tow and less number of under five children were 3.7 times less likely than the odds in household with more than two under five children (AOR: 0.268, 95% CI(.08,0.90)).According to this study, children of household who had clean latrine/faces not seen around the pit or on the floor of latrine was 3.4 times less likely to develop diarrhea compared to those clean latrine/faces seen around the pit or on the floor of latrine(AOR: 0.298, 95% CI(0.097,0.92)). Time take less than 30 minuet to fetch water from source was 16.7 times less likely to develop diarrhea compared to time take more than 30 minutes to fetch water from source to home (AOR: 0.046, 95% CI(0.01,0.22)). children in the households who treat water before drinking were 1.9 times less likely to had diarrhea compared to children in the households who do not treat water at home before using (AOR = 0.15, 95% CI: (0.04, 0.62). The odds of under five years of age children who live in house with one room had 6.01 times more risk of diarrhea as compared to the odds of children who live in house with more than two rooms ((AOR = 6.01, 95% CI(1.01,36.01)). Children living with animals in the same house were more likely to develop diarrhea compared to children live in the house separately from animals (AOR: 8.31, 95% CI(2.46,28.06)). Children who take gruel type of food were four times less likely to develop diarrhea as compared to children taking other type of food (AOR: 0.24, 95% CI(0.07,0.81))(Table 8)