Prevalence and associated factors of diarrhea among under-five children in Debre Berhan town, Ethiopia 2018: a cross sectional study

Background Diarrhea is responsible for 525,000 children under-five deaths and 1.7 billion cases globally and is the second leading cause of death among children under-five every year. It is a major public health problem in low income countries like Ethiopia. The main aim of this study was to assess the prevalence of diarrhea and associated risk factors among children under-five in Debre Berhan Town, Ethiopia. Methods A community-based cross-sectional study was conducted in 420 parent or caretaker/children pairs in Debre Berhan town between 13 and 18 April 2018. A multi-stage sampling strategy was used to select the study participants. Data were collected using pre-tested and structured questionnaires. Data were entered in Epi-info computer software version 3.5.1 and exported to SPSS Window Version-16 for analysis. Adjusted odds ratio with 95% confidence intervals were used to assess the level of significance. Results The two week prevalence of diarrhea among children under-five was 16.4% (69/351). Children aged 7–11 months (adjusted odds ratio (AOR): 4.2, 95% confidence interval (CI): 1.2–15.3), being the second-born child (AOR: 3.9, 95%CI: 1.8–8.5), not vaccinated against rotavirus (AOR: 10.3, 95%CI: 3.2–91.3) and feeding children by hand (AOR: 2.5, 95%CI: 1.1–6.1) were significant predictors of diarrhea. Conclusions This study revealed that the two weeks period prevalence of diarrhea among children under-five years was 16.4%. Education programs on the importance of vaccination against rotavirus, increasing breast feeding frequency with complementary food after six months and the critical points of hand washing are recommended.


Background
Diarrheal disease is a major public health problem worldwide. Globally, 525,000 children under-5 years die due to diarrhea every year, roughly 2195 every day [1]. This represents 8% of all deaths and is the second leading cause of death among children under-5 years old [2]. Annually, 1.7 billion diarrhea episodes occurred among children under-5 years worldwide [3]. The majority of morbidity and mortality occurred in south Asia and sub-Saharan African countries, which 88% were attributable to unsafe water, inadequate sanitation, and insufficient hygiene [4].
Despite global diarrheal deaths among children of under 5 years decreasing by 60% between 2000 and 2017. Ethiopian morbidity reports and community-based studies indicate that diarrheal diseases accounted for 20% of childhood death and 22% of childhood diarrheal disease in 2000 [3,5,6].
Studies in Ethiopia also showed that low maternal education, poor sanitation, contaminated water source, duration of breast feeding, failure to wash hands, absence of rotavirus vaccination, failure to dispose of feces hygienically, age of child and adequate food hygiene were significant predictors of diarrheal disease occurrence in children under-5 years [7][8][9][10][11][12][13].
However, information related to diarrheal disease in children under-five in Debre Berhan is limited. Therefore, the aim of this research was to assess the prevalence of diarrheal disease and associated factors in children under-5 years old in Debre Berhan town, Ethiopia. The findings will contribute to improving the lives of children under-5 years. In addition, the information can be used to develop effective educational program to improve child health overall. Similarly, this research will inform policy makers and program initiators on acceptable services.

Study area and period
The study was conducted in Debre Berhan town from April 13-28, 2018. Debre Berhan town is found in North Showa Zone of Amhara regional state, around 130 km away from the capital of Ethiopia, Addis Ababa. It has one referral hospital, 3 health centers, 14 clinics and around 16 pharmacies. Based on the Debre Berhan town health administration office report, the current population of the town is 103,450 of whom 46, 553 are men, 56,897 are women. From the total population, 14,011 are children under-5 years.

Study design
A community-based cross-sectional study design was used to assess the prevalence of diarrhea and associated factors among children under-5 years in Debre Berhan town.

Study population
All children under-5 years old with their mothers or caretakers who live in selected kebeles of Debre Berhan town were our study population.

Sample size determination
Sample size was determined based on the formula used to estimate single population proportion, assuming 21.5% 2 week period prevalence of diarrhea among children under-5 years [14], and a 5% margin of error with 95% confidence level. The sample size calculated was 256. After adjusting for a non-response rate of 10% and design effect of 1.5 the final sample size required was 428 mother/caretaker-child pairs.

Sampling procedure
Multi-stage sampling was used to obtain a representative sample of the study participants. Firstly, four kebeles were selected from the total fourteen kebeles using a lottery method. Then, a census was conducted in each of the selected kebeles to identify eligible households.
Finally, households were selected using systematic random sampling with a mother/caretaker-child pair selected from each household until the required sample size was fulfilled.

Operational definitions Diarrhea
The passage of three or more loose or watery stool in a 24 h period, as reported by the mother/caretaker of the child [4].

Caretaker
Any person who provides care for the child other than the mother.

Data collection tool and methods
Data were collected by seven trained midwives and three supervisors. Structured questionnaires were developed in English after review of different literature and guidelines. English version questionnaires were translated into Amharic language and again translated back into English by experts fluent in both languages (Additional file 1). The training was given for data collectors and supervisors for 2 days on the study instrument and data collection procedures. Pre-testing was conducted on 5% of the total sample size. Data were collected by face to face interview.

Data processing and analysis
The data collected from the field were edited, checked for completeness and consistency, coded and entered into Epi-info computer software version 3.5.1. Once entered, the data were exported to SPSS Window Version-16 for cleaning and further analysis. Both descriptive and inferential statistics were employed in the analysis. Bivariate logistic regression analysis was performed for each independent variable with the outcome variable and those variables with a p-value of < 0.2 included in multivariable logistic regression analysis to identify predictors of diarrhea. Enter method was used to select the variables in multivariate logistic regression analysis. Multicollinearity test was performed to assess the existence of correlation among the predictor variables. Additionally, goodness off fit to the final model was checked by Hosmer and Lemeshow and was found fit. Adjusted odds ratios with 95% confidence intervals were calculated and P-values less than 0.05 were considered statistically significant.

Results
Socio-demographic characteristics of the mother/ caretaker and children A total of 420 mother/caretaker completed the questionnaires. The majority 50.2% (211/420) of the mothers/caretakers were 20-29 years of age with a mean age of 29.7 years and SD of + 4.6 years. From the total study participants, 86.7% (364/420) were married and 83.6% (351/420) were orthodox religion. The majority 70.0% (294/420) of the household family size were between 1 and 4 people. Among the total respondents, 31.9% (134/420) had a college education or additional qualification. More than half 55.5% (233/420) of the children were male and 21.2% (89/ 420) were 12-23 months of age (Table 1).

Environmental and hygiene characteristics
In the study area, all of households have latrines in their dwellings. The majority 45.0% (189/420) of the households have traditional pit latrines and 61.9% (260/420) dispose of the solid waste by private vendors. The majority 80.2% (337/420) dispose of children's feces in the toilet. A further 57.6% (242/420) dispose of household waste in the seepage pits and 80.2% (337/420) of households get their water from a pipe ( Table 2).

Health and dietary characteristics of children
From the study participants, 50.0% (210/420) of children under-five were the first-born of their family. About, 90.7% (381/420) of the children were born in health institutions. The majority 71.2% (299/420) of children under-five started complementary feeding at 6 months of age. About, 79.5% (334/420) of children were vaccinated against measles and 96.0% (403/420) against rotavirus ( Table 3).

Prevalence of diarrhea among children under-five years
The prevalence of diarrhea among children under-five was reported to be 16.4% [95%CI: 12.7-20.0] in the 2  week surveillance period, of whom 8.6% (36/420) were males. Among children who had diarrhea, 15.9% (67/ 420) experienced watery diarrhea with a few reporting bloody or mucoid stools. The prevalence of diarrhea was 2.6% (11/420) in children aged 7-11 months (Table 4).

Factors associated with diarrhea among children underfive years
In the bivariate analysis, age of child, birth order, age of starting complementary food, vaccination against rotavirus and feeding children by hand were significantly associated with diarrhea (  (Table 4).
Children aged between 7 and 11 months were at high risk of developing diarrhea compared with children aged was less than 7 months. This result was in line with the results of the study conducted in Farta Wereda, Northwest Ethiopia [7]. The increased risk might be due to the decline/loss in maternal antibodies and at this age child start complementary feeding that might increase their exposure to contaminated foods and water. In addition, crawling begins at this age further increasing potential exposure to fecally contaminated environments.
This study found that diarrhea was more common among second-born children compared with first-born children (AOR: 3.9, 95%CI: 1.7-8.5). Similarly, a crosssectional study conducted in Jig-Jiga district, Somali region, Ethiopia showed that fourth-born children and above were more affected by diarrhea compared with first borne [21]. This may be due to quality of care and attention from parents decreases as mothers become incapable of caring for children [25].
According rotavirus vaccination were 10.3 times more likely to have diarrhea compared with children who received rotavirus vaccination (AOR: 10.3, 95%CI: 1.2-91.2). The result suggests that a major contributor to the diarrheal burden in children less than 5 years in the town is in fact rotavirus. This result was in agreement with study done in Farta Woreda, Northwest Ethiopia [7].
In this study, the following limitations were noted. The major limitation of the study was the limited time period over which the study was conducted, that may create over or under reporting of diarrhea since diarrheal diseases have some seasonal variations.

Conclusions
The 2 week prevalence of diarrhea among children under-5 years in Debre Berhan town was 16.4%. Childhood diarrheal disease was significantly associated with the age of children, birth order and hand feeding practice of mother. So, education program on the importance of vaccination against rotavirus, increase breast feeding frequency with complementary food after 6 months and the critical points of hand washing are recommended.

Additional file 1. Questionnaire on Diarrheal study
Abbreviations AOR: Adjusted odd ratio; BSc: Bachelors of science; CI: Confidence interval; SD: Standard deviation