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Environmental factors of diarrhea prevalence among under five children in rural area of North Gondar zone, Ethiopia

  • 1,
  • 2Email author,
  • 1,
  • 1,
  • 1,
  • 3,
  • 1 and
  • 3
Italian Journal of Pediatrics201844:95

https://doi.org/10.1186/s13052-018-0540-7

  • Received: 26 January 2018
  • Accepted: 12 August 2018
  • Published:

Abstract

Background

In the sub-Saharan countries, many of the children including found in health facilities are not having sufficient care of diarrhea. Diarrheal disease in these countries is one of the main causes of deaths for under-five children.

Methods

A community-based cross-sectional study design was used to collect data from May–June, 2016 to determine environmental factors of diarrhea prevalence among under five children in North Gondar Zone. Structured interview questionnaire and observational checklist were used to collect data. Using probability proportion to size, number of households was determined in each district. The multivariable binary logistic regression analysis with a 95% confidence interval and p < 0.05.was used to identify environmental factors associated with childhood diarrheal disease.

Results

Of the total 736 individuals surveyed from 736 households, a total of 163 (22.1%) with [95% CI (19.1–25.1)] under –five children had 2 week period diarrhea prevalence. Roof material [AOR: 1.99, 95% CI (1.1–3.82)], hand washing facility [AOR: 0.52, 95%CI (0.33–0.82)], presence of Latrine facility [AOR: 1.65, 95% CI (1.01–2.72)], presence of feces around the pit hole [AOR: 1.65, 95% CI (1.01–2.72)], presence of feces around the house compound [AOR: 1.65, 95% CI (1.01–2.72)] and risk of contamination of household storage had significant associations with diarrheal morbidity.

Conclusion

The prevalence of childhood diarrheal disease among under – five children in rural settings of northwest Ethiopia was high. Type of roof material, hand washing facility, presence of Latrine facility, presence of feces around the pit hole, presence of feces around the house compound and risk of contamination of household storage had significant associations with diarrheal morbidity.

Keywords

  • Diarrhea
  • Environmental factors
  • Under-five children
  • North Gondar zone

Background

In the sub-Saharan countries, many of the children including found in health facilities are not having sufficient care of diarrhea. Diarrheal disease in these countries is one of the main causes of deaths for under-five children [1]. One child passed away from the world within each 15 s due to diarrheal disease [2]. Moreover, in the developing countries alone about two millions of people most of which are under five children die annually [3]. Therefore, there should be an increased work at health care facilities and among the community for the childhood diarrhea care quality [1].

Many factors are responsible for the diarrheal disease. They are socio-economic [4, 5], behavioural like breastfeeding [6, 7] and environmental factors such as water, sanitation and waste disposal mechanism [811]. Different studies have been conducted in different parts of Ethiopia on diarrhea prevalence and reported 12.2, 35.6, 22.5, 9.9, and 28.9% [610], respectively.

Environmental factors like the type of water source, presence of sanitation facilities, solid waste disposal system and floor type in the kitchen are found to be crucial contributors for the high prevalence of diarrheal diseases. Particularly, diarrhea occurrence is more associated with unsafe/unprotected water sources e.g. ponds, wells, rivers, lakes [12]. Other more environmental health risk factors of childhood diarrhea include improved sanitation, hand washing facilities, poor knowledge on diarrheal cases, and improved latrine [8, 11]. Therefore, the current study was designed to determine the prevalence of diarrheal disease in under five children and assess the associated environmental factors in the rural areas of North Gondar zone, Ethiopia.

Method

Study area

A community-based cross-sectional study was conducted in North Gondar Zone from April to June 2016. Gondar town is located 739 km far from Addis Ababa to the Northwest of Ethiopia and 180 km in the north direction of Bahir Dar (Capital of Amhara Region). North Gondar is one of the eleven zones in Amhara Regional State having 22 administrative districts. As the data gained from North Gondar Zonal Health Department, the total projected population of North Gondar Zone in 2015/16 is 3,704,740. The majority of which 2,920,007 (78.8%) populations reside in rural areas whereas the rest 784,733 (21.2%) are in urban areas.

Study design and period

A community based cross-sectional study design was used to collect data from May–June 2016.

Sample size determination and sampling procedures

Epi info version 3.5.3 was used to calculate the sample size based on an assumption that 18% of the under-five children had two-week prevalence of diarrhea in North Gondar (26) with marginal error of 4%, a standard score corresponding to 95% certainty, design effect of 2, accounted for two-stage sampling and none response rate 5%. The total sample size that was included in the study is 743 households that should have at least one under-five child. From randomly selected four districts (Dembia, Gondar Zuriya, Chilga, and Sanja) of the 22 total districts of North Gondar Zone, multi-staged sampling procedure was employed.

Using probability proportional (PPS) to size, the number of households was determined in each district. Then, 25% of total kebeles was selected from each district by simple random sampling technique and systematic sampling technique was applied to select study households. In case, where there are more than one under-five children in the same household, index child was selected by lottery method to collect information on child’s health characteristics. The first household interview was identified by a modified random walk method and if there is no mother/care taker or under five child in the selected household, the next nearest household was included in the survey.

Data collection methods and tools

The data were collected by using face to face interview with pretested structured questionnaires and observational checklists which were prepared in English and translated to the local language, Amharic. To improve the quality of data collection, two-day training was given to 16 data collectors and 8 supervisors about way of interview, the nature of questionnaires, rechecking of filled questionnaires and approaches to household heads.

Data analysis

All data collection forms were checked for completeness and reliability before entry into software. Data entry and cleaning were done using Epi info version 3.5.3 computer software. Data were analyzed by using SPSS ver.20. Descriptive analyses were deployed for both dependents and independent variables. The frequency distribution of both dependent and independent variables were worked out. Logistic regression analysis was used to see the relationship of selected variables to diarrheal disease. Eight variables with P- value less than 0.2 in bivariate analysis were included in the multivariate logistic regression. Finally, data were presented in the form of tables and figures.

Ethical considerations

Ethical clearance was obtained from the Institutional Ethical Committee of the University of Gondar. Moreover, the consent of participants was obtained from the respective district health offices. The confidentiality of information was maintained during and after an interview in which coding was used for all the data collected. Participants in the study had given verbal consent.

Results

Socio-demographic characteristics of the study participants

In this study, a total of 736 respondents of households participated whose mean (±SD) age was 30 ± 7 years nearly half, 362 (49.2%) respondents were aged between 25 and 34 year. The majority, 690 (93.8%) of participants religion were orthodox and more than half of the respondents 431 (58.5%) were unable to read. Most of the respondents 693 (94.2%) were married and housewives 632 (85.8%). Majority, 463(62.9%) of the respondents had a family size less than five individuals and 423 (57.3%) of the respondent had income less than 1000 ETB (Table 1).
Table 1

Socio-demographic characteristics of the study participants in North Gondar Zone, June, 2016 (N = 736)

Variables

Number

Percent (%)

Age

 < 15

3

0.4

 15–24

149

20.2

 25–34

362

49.2

 > 35

222

30.2

Religion of parents

 Orthodox

690

93.8

 Protestant

6

0.8

 Muslim

40

5.4

Educational level

 Unable to read and write

431

58.6

 Read and write

62

8.4

 1–8

135

18.3

 9–12

75

10.2

 > 12

33

4.5

Marital Status

 Married

693

94.2

 Single

2

0.3

 Divorced

35

4.8

 Widowed

8

0.8

Occupation of the mother

 Government employee

24

3.3

 Housewife

632

85.8

 Merchant

35

4.8

 Farmer

45

6.1

Family size

 ≤ 5

463

62.9

 > 5

273

37.1

Income

 < 1000 Birr

423

5.3

 1000–1999 Birr

284

25.8

 2000–2999Birr

21

47

 > 3000 Birr

8

7

Environmental characteristics

Out of the 736 respondents interviewed, majority of respondents 562(76.4%) had less than two rooms per household whose most of living room floor and roof type is mud 725(98.5%) and corrugated iron 667(90.6%) respectively. Only 173(23.5%) of the household have separate house for animals. Most of the households, 395 (82.0%) used the Pit latrine without slab and only half of the households, 396 (53.8%) used piped water source for drinking. From sanitary risk assessment survey, majority of the source water, 356 (48.4) and household storage, 314 (42.7) had medium risk of contamination. Moreover, the majority of households 556 (75.5%) used open field solid waste disposal (Table 2).
Table 2

Environmental characteristics of respondent household in North Gondar Zone, June, 2016 (N = 736)

Variables

Number

Percent (%)

Type of roof material

 Thatched

69

9.4

 Corrugated iron

667

90.6

Type of floor material

 Mud

725

98.5

 Cement

11

1.5

Number of rooms per household

 < =2 rooms

562

76.4

 > 2 rooms

174

23.6

Animals live with human

  Yes

173

23.5

  No

563

76.5

Presence of Latrine facility

 Yes

482

65.5

 No

254

34.5

Type of Latrine facility (N = 482)

 Flush/pour flush latrine

14

2.9

 Ventilated improved pit latrine

39

8.1

 Pit latrine with slab

34

7.1

 Pit latrine without slab

395

82

Ownership of latrine (N = 482)

 Private

369

76.6

 Shared

113

23.4

Presence of feces around the pit hole (N = 482)

 Yes

56

7.6

 No

426

57.9

Presence of feces around the house compound

 Yes

112

15.2

 No

624

84.8

Source of drinking water

 Piped water

396

53.8

 Orotected spring and well

190

25.8

 Unprotected spring and well

133

18.1

 River

17

2.3

Intermittent of Water Supply

 Yes

461

62.6

 No

275

37.4

Consumption in liter/capita/day

 < 20 L/Capita/day

675

91.7

 > =20 L/Capita/day

61

8.3

Household water treatment

 Boiling

13

1.8

 Filtering

19

2.6

 Use of chemicals

40

5.4

 Allowing water to settle

12

1.6

 No treatment

652

88.6

Risk of contamination of Household storage

 Low

206

28

 Medium

314

42.7

 High

198

26.9

 Very high

18

2.4

Risk of contamination of source water

 Low

306

41.6

 Medium

356

48.4

 High

74

10.1

Hand washing facility

 Yes

392

53.3

 No

344

46.7

Place of solid waste disposal

 Pit

168

22.8

 Open field

556

75.5

 Burning

12

1.6

Prevalence of diarrhea

From a total of 736 under five children, 163 under – five children had diarrhea in the 2 week period prior to data collection. Therefore, the 2 week period prevalence of diarrhea was found to be 22.1% [95% CI (19.1–25.1)].

Environmental factors associated with diarrheal disease

In the Univariable binary logistic regression analysis type of roof material, hand washing facility, presence of Latrine facility, ownership of latrine, intermittent water supply, household water treatment, presence of feces around the pit hole, presence of feces around the house compound, risk of contamination of household storage had a p - value less than 0.2 and further analyzed by multivariable binary logistic regression. Finally type of roof material, hand washing facility, presence of Latrine facility, presence of feces around the pit hole, presence of feces around the house compound and risk of contamination of household storage had significant associations with diarrheal morbidity.

Children whose household roof material thatched had two times higher odds of diarrhea than children whose household roof material is corrugated iron [AOR: 1.99, 95% CI (1.1–3.82)]. The risk of developing diarrhea in children who had hand washing facility was 48% lower chance [AOR: 0.52, 95%CI (0.33–0.82)] compared to their counterparts (Table 3).
Table 3

Environmental factors associated with diarrheal disease prevalence among under five children in North Gondar Zone, June, 2016

Variable

Diarrhea prevalence

COR (95% CI)

AOR (95% CI)

Yes, n (%)

No, n (%)

Type of roof material

 Thatched

20(29.0)

49(71.0)

1.49(0.86–2.59)

1.99(1.1–3.82)*

 Corrugated iron

143(21.4)

524(78.6)

1.00

1:00

Number of rooms in the house

 < =2 room

124(22.1)

438(77.9)

0.98(0.65–1.47)

 

 > 2 room

39(22.4)

135(77.6)

1:00

 

Hand washing facility

 Yes

63(18.3)

281(81.7)

0.66(0.46–0.93)*

0.52 (0.33–0.82)*

 No

100(25.5)

292(74.5)

1.00

1.00

Animals live with human

 Yes

38(22.0)

135(78.0)

0.99(0.65–1.49)

 

 No

125(22.2)

438(77.68

1.00

 

Presence of Latrine facility

 Yes

100(20.7)

382(79.3)

1.00

1:00

 No

63(24.8)

191(75.2)

1.26(0.88–1.81)

1.65(1.01–2.72)*

Type of latrine facility

 Unimproved

84(21.3)

311(78.7)

1.20(0.66–2.17)

 

 Improved

16(18.4)

71(81.6)

1:00

 

Ownership of latrine

 Private

83(22.5)

286(77.5)

1.00

1:00

 Shared

17(15.0)

96(85.0)

0.61(0.34–1.08)

1.09(0.58–2.07)

Source of drinking water

 Unimproved

33(22.0)

117(78.0)

0.98(0.64–1.53)

 

 Improved

130(22.2)

456(77.8)

1.00

 

Intermittent water supply

 Yes

114(24.7)

347(75.3)

1.52(1.04–2.20)*

1.23(0.79–1.91)

 No

49(17.8)

226(82.2)

1.00

1.00

Water consumption in liter/capita/day

 < 20 L/Capita/day

153(22.7)

522(77.3)

0.669(0.332–1.349)

 

 > =20 L/Capita/day

10(16.4)

51(83.6)

1.00

 

Household water treatment

 No

131(20.1)

521(79.9)

2.45(1.51–3.95)

0.67(0.37–1.21)

  Yes

32(38.1)

52(61.9)

1.00

1.00

Presence of feces around the pit hole

 Yes

22(39.3)

34(60.7)

1.96(1.07–3.6)*

2.46(1.20–5.04)*

 No

78(18.3)

348(81.7)

1.00

1.00

Presence of feces around the house compound

 Yes

48(42.9)

64(57.1)

3.32(2.17–5.08)**

2.09(1.24–3.54)*

 No

115(18.4)

509(81.6)

1.00

1.00

Methods of solid waste disposal

 Pit

56(33.3)

112(66.7)

80,766(0.00-)

 

 Open field

107(19.2)

449(80.8)

38,494(0.00-)

 

 Burning

0(0)

12(100)

1:00

 

Risk of contamination of Household storage

 Low

29(14.1)

177(85.9)

1:00

1:00

 Medium

38(12.1)

276(87.9)

0.84(0.50–1.41)

1.07(0.61–1.89)

 High

79(39.9)

119(60.1)

4.05(2.49–6.58)**

5.21(3.01–show [?A3B2 show $9#?]9.03)**

 Very high

17(94.4)

1(5.6)

103.7(13.3–809.7)**

126.6(15.5–1036)**

Risk of contamination of source water

 Low

77(25.2)

229(74.4)

1:00

 

 Medium

71(19.9)

285(80.1)

0.74(0.51–1.07)

 

 High

15(20.3)

59(79.7)

0.77(0.41–1.41)

 

* Statistically significant with p-value < 0.05, **statistically significant at p-value < 0.001

Children who had no latrine facility had two times higher odds of diarrhea than children who had latrine facility [AOR: 1.65, 95% CI (1.01–2.72)]. Presence of feces around the pit hole [AOR: 1.65, 95% CI (1.01–2.72)] and the house compound [AOR: 1.65, 95% CI (1.01–2.72)] had a significant association with diarrheal disease. The risk of developing diarrheal disease in children who had high sanitary risk of contamination of household storage had five times higher odds of diarrheal disease [AOR: 5.21, 95% CI (3.01–9.03)] compared to sanitary low risk of contamination of household storage. Moreover, children who had very high sanitary risk of contamination of household storage had strong statistically significant association [AOR: 126.6, 95% CI (15.5–1036)] with diarrheal disease (Table 3).

Discussion

The current study determined the prevalence of diarrhea and assessed the environmental factors of diarrhea prevalence among under-five children. The prevalence of diarrhea in the current study was 22.1%. This result is higher than 9.9% in Sebeta town, Oromiya Region of Ethiopia [8] and 19.6% in a rural area of Shebedino district, southern Ethiopia [13] and it is close with the result 22.5% of east Ethiopia [9]. However, it is lower than 26.1% in Hadaleala District, Afar Region of northeast Ethiopia [5], 27.3% in Jigjiga district, Somali region of Ethiopia [12], 35.6% in Enderta Woreda, Tigray Region of Ethiopia [6] and 32.6% in Burundi [14].

In this study, type of roof material, hand washing facility, presence of Latrine facility, presence of feces around the pit hole, presence of feces around the house compound and risk of contamination of household storage had significant associations with diarrheal morbidity.

Children whose household roof material thatched had two times higher odds of diarrhea than children whose household roof material is corrugated iron. This might be due to the poor sanitation of the house in thatched roof compared to the corrugated iron.

The risk of developing diarrhea in children who had hand washing facility was 48% lower chance compared to their counterparts. This finding is similar with studies done in Sebeta town of Ethiopia [15] and also in Adama District Rural Kebeles [16]. The hand washing facility is important to mothers to easily wash their hands at critical times during the day which is important to reduce fecal-oral transmission of disease.

Children who had no latrine facility had two times higher odds of diarrhea than children who had latrine facility. This finding is in agreement with studies done in West Gojam Ethiopia [17] and in Deresha district, Southern Ethiopia [18]. The presence of latrine increases the chance of its utilization which in turn facilitates the safe disposal of feces. This is one way of decreasing contact between causative organisms of diarrhoeal and the host.

Presence of feces around the pit hole had a significant association with diarrheal disease. This result is comparable with studies done in Nekemte town, western Ethiopia [10] and in Addis Ababa, Ethiopia [19]. Presence of feces around the house compound had a significant association with diarrheal disease. This is due to the fact pathogens in feces disposed in compounds near the house can contaminate the environment and the food eaten by children which leads to diarrheal disease [2023].

The risk of developing diarrheal disease in children who had high sanitary risk of contamination of household storage had five times higher odds of diarrheal disease compared to sanitary low risk of contamination of household storage. Moreover, children who had very high sanitary risk of contamination of household storage had strong statistically significant association with diarrheal disease. This finding is similar with studies done in Nigeria [24].

The rest variables like type of latrine facility, ownership of latrine, source of drinking water, intermittent water supply, and household water treatment were not significant variables in this study. But, they were significant in the previous studies conducted in different regions of Ethiopia [8, 11]. These discrepancy might be due to the strengthen of Ethiopia’s Health Extension Program (HEP) from time to time that has created greater awareness of how to prevent communicable diseases such as malaria, tuberculosis, HIV/AIDS and waterborne disease like diarrhea to the community [25]. Moreover, the discrepancy can be due to difference in seasonal variation.

Conclusion

In the current study, prevalence of diarrhea found to be high (22.1%). Type of roof material, hand washing facility, presence of latrine facility, presence of feces around the pit hole, presence of feces around the house compound and risk of contamination of household storage had significant associations with diarrheal morbidity.

Abbreviations

AOR: 

Adjusted odd ratio

Cl: 

Confidence interval

COR: 

Crude odd ratio

ETB: 

Ethiopian birr

PPS: 

Probability proportion to size

WHO: 

World health organization

Declarations

Acknowledgements

The authors would like to thank University of Gondar for its financial support. We are also thankful for study participants, data collectors and supervisors for their devotion and full participation.

Funding

The authors of this study did not receive funds from any funding organization. However, University of Gondar had covered questionnaire duplication and the per diem for data collector.

Availability of data and materials

Data will be made available upon requesting the primary author.

Authors’ contributions

AG: participated in the conception and design of the study, data collection and analysis, interpretation of the findings. AT: Participated in the design of the study, data collection, drafting the manuscript and write up, analysis and interpretations of the findings. MG: Participated in the design of the study, interpretations of the findings. TG: Participated in the design of the study, data collection. TG: Participated in the design of the study, data collection. DH: Participated in the design of the study. ZG: Participated in the design of the study. MA: Participated in analysis, interpretations of the findings. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Ethical clearance was obtained from University of Gondar. After thoroughly discussing the ultimate purpose and method of the study, a written consent was obtained from Institutional Ethical Committee of University of Gondar. Then, community consent was obtained from the respective community leaders. The privacy and confidentiality were maintained during interview. Therefore, only coding was included in the data collection tools. In addition, participants in the study that were not willing to take part in the study had full right to do so. Children that have diarrheal disease were referred to the near health facilities for treatment.

Consent for publication

This manuscript does not contain any individual person’s data.

Competing interests

The authors declare that they have no competing interests.

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Authors’ Affiliations

(1)
College of Medicine and Health Sciences, Institute of Public Health, Department of Environmental & Occupational Health & Safety, University of Gondar, P.O. Box 196, Gondar, Ethiopia
(2)
Department of Ecological and Systematic Zoology, College of Natural and Computational Science, University of Gondar, Gondar, Ethiopia
(3)
Department of Medical Microbiology, Institute of Biomedical Sciences, University of Gondar, Gondar, Ethiopia

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