Research Article
iMedPub Journals
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Journal of Health & Medical Economics
ISSN 2471-9927
2016
Vol. 2 No. 2: 12
DOI: 10.21767/2471-9927.100018
A Cross Sectional Study on the Incidence
and Risk Factors of Diarrheal Illness among
Children Under-five Years of Age in Debre
Berhan Town, Ethiopia
Abstract
Alelign T1, Asegidew W2
and Abera A2
1 Department of Biology, Debre Birhan
University, Debre Birhan, Ethiopia
2 Department of Health Sciences, Debre
Birhan University, Debre Birhan, Ethiopia
Corresponding author: Alelign T
Diarrheal diseases are important causes of mortality and morbidity globally among
children under 5 years of age. In Ethiopia, only few studies have been carried out
to investigate the incidence and risk factors of diarrheal illness among children
under- five years of age. Therefore, the objective of this study was to determine
the prevalence and risk factors of diarrheal illness among children under-five years
of age in Debre Berhan town, Ethiopia. A community based cross sectional study
was conducted to assess the incidence and risk factors associated with diarrheal
illness. Pre-tested structural questionnaire and observational check lists were used
to collect data on the incidence and risk factors of diarrhea. Data was analyzed
using SPSS software version 18. Adjusted odds ratio (AOR) test was employed to
assess the associations between variables. Mothers/guardians of children with
diarrhea were asked to provide detailed information about the incidence and
factors associated with diarrheal illness. A total of 312 children were participated
in the study, of which 38 were suffering from diarrhea, thus giving a two-week
prevalence of 12.2%. The main risk factors for diarrheal illness were found to be
lack of hand washing habits after latrine usage (OR = 0.51, 95% CI: 0.29 - 0.87),
household storage of water in a pot (OR = 0.32, 95% CI: 0.16 - 3.08), observation
of feces on the slab/latrine hole (OR = 3.13, 95% CI: 1.51 - 6.48), lack of maternal
education (OR = 2.61, 95% CI: 1.28 - 5.08), age of mothers younger than 35 years
(OR = 0.39, 95% CI: 0.19 - 0.78) and age of children being 3 to 5(OR = 2.53, 95%
CI: 1.07 - 5.93). The findings showed that there is a high prevalence of diarrheal
illness associated with various factors. Therefore, creating community awareness
about diarrheal illness through addressing these risk factors should be prioritized.
tilalewa@gmail.com
Department of Biology, Debre Birhan
University, Debre Birhan, Ethiopia.
Tel: 251116815440
Citation: Alelign T, Asegidew W, Abera A.
A Cross Sectional Study on the Incidence
and Risk Factors of Diarrheal Illness among
Children Under-five Years of Age in Debre
Berhan Town, Ethiopia. J Health Med
Econ. 2016, 2:2.
Keywords: Diarrhea; Risk factors; Under five children
Received: January 25, 2016; Accepted: Febraury 09, 2016; Published: February 19,
2016
Introduction
Diarrheal illness remains one of the major causes of child
morbidity and mortality in the world [1]. It kills an estimated
2.5 million people each year, with about 60-70% of them being
children under five years of age. Most of these deaths occur
in developing countries where an estimated 25% of under-five
mortality is directly attributed to diarrheal disease [2-4].
Diarrheal disease has a detrimental effect on growth and
predisposes children to malnutrition and other infections
[5-8]. It has been reported that about 10% and 0.5% of children
with diarrheal illness severely dehydrated and die, respectively
[5]. Moreover, about 25% of the growth differential between
children in developed and developing countries can be attributed
to diarrhea [9,10].
A wide variety of bacterial, viral and protozoan pathogens excreted
in the faces of humans and animals are known to cause diarrhea
[5]. Over 90% of deaths from diarrheal diseases due to unsafe
water and sanitation occur in children under 5 years old in the
developing world [11]. Risk factors for diarrhea are multi-factorial
(vary by context) and it is widely recognized that the occurrence
of diarrhea is affected by several socio-economic, environmental
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and behavioral factors [12]. For instance, maternal education,
source of water, habit of washing hands after the use of toilet,
availability of latrine facilities, living in a house with a number
of children, and age of the child are suggested to be the main
determinants of diarrhea in children living in Ethiopia [9,13,14].
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Vol. 2 No. 2: 12
The two-week period prevalence of diarrhea (28.9%) (P = 0.289)
among U5C reported in Nekemte town, Ethiopia was taken to
calculate the sample size [17]. The sample size (n) was determined
using the following single population proportion formula based
on the assumptions of design effect 2, desired precision 5%,
confidence level 95% and an anticipated non-response rate 5%. A
total of 312 sample size was determined.
In Ethiopia, few studies were conducted to determine the
incidence and risk factors of diarrheal illness. It has been
estimated that the prevalence of diarrheal illness in Ethiopia
Z 2 P(1 − P) (1.96) 2 × (0.289)(1 − 0.289)
n
=
=
= 312
varied from 11.4% to 37% [15]. Moreover, yearly childhood deaths
(0.05) 2
d2
due to diarrheal illness in Ethiopia is estimated to be 95,000
based on an overall under-five mortality rate of 170 deaths/1000 Considering none response rates, the required sample size was
and the assumption that 20% of those are caused by diarrhea calculated to be 328, but only 312 of them were considered for
[11-15]. Knowledge of risk factors have important implications data analysis.
for developing appropriate strategies to reduce the burden
In case, where there were more than one U5C in the same
of the disease [16]. The objective of this study was, therefore,
to determine the incidence and risk factors of diarrheal illness household, only the youngest child was considered. Mothers/
among children under- five years of age in Debre Berhan town, Care givers of U5C who had critical health problem, and those
who did not live at least six months in the town prior to the
Ethiopia.
survey were excluded.
Materials and Methods
Methods of Data Collection
Study area
Debre Berhan town is found in North Shoa Zone, Amhara Regional
state, 130 km away from Addis Ababa. The town is divided into
9 Kebeles (small administrative units) and it has a total area of
18,081.95 hectares. According to the central statistics agency
(CSA), Debre Berhan town has a population of 95,908. Of which
7792 were under five children and 10,000 were households. The
population is multiethnic, Amhara constituting the majority.
Study design and population
A community-based cross sectional study was conducted from
February to March, 2011. Children under-five years of age were
enrolled in the study after being selected at random among those
who lived in Debre Berhan town, Ethiopia. Mothers / guardians of
the children were asked about the occurrence of diarrheal illness
on the day of the visitation or within two weeks prior to the day
of the visitation.
Sampling techniques and sample size
determination
Three of the nine Kebeles (smallest administrative unit), Kebele
(2,6,9) were selected using a lottery method. That is, the names
of 9 kebeles were written in number on a piece of paper. Then,
putting them in a container, mixed and picked up three kebeles
blindly one by one and taken up for sampling.
In Kebele [2,6,9], there were a total of 3517 households. After
clustering each kebele into a small group called ‘Ketena’, 997
households having under five children (U5C) were registered
through house-to-house survey by trained enumerators. Then,
households with U5C were allocated to each Kebele proportional
to size via stratified random sampling techniques. Hence, a total
households of 123, 155 and 34 were taken from kebele 02, kebele
06, and kebele 09, respectively. The first household from each
kebele registery was selected randomly and the rest subjects
were included through systematic sampling techniques.
2
Pre-test structured questionnaires and observation checklists
were used to collect data on the incidence and risk factors of
diarrhea. Eight data collectors who had Technical and Vocational
Education and Training (TVET) were recruited and basic training
was given for one day prior to data collection by investigators.
The study participants were visited by members of the research
team who inquired their mothers or guardians about the
occurrence of diarrheal illness on the day of the visitation or
two weeks prior to the day of the visitation. Data about the
demographic characteristics of children and their family was
collected at the beginning of the study. Occurrence of diarrhea
is defined as having loose or watery stools at least three times
in 24 hours period as reported by the mother/caretaker of the
children under-five years of age in the house within two weeks
period prior to the survey. Only two weeks situation was taken
to avoid loss of memory of events as well as misinterpretation for
respondents. The presence of feces on latrine/slab hole, cover
of latrine opening, hand washing facilities near toilet and the
location of latrine were registered.
Data analyses
Data was sorted and checked for cleanness, quality and validity.
Then the data was analyzed using SPSS software version 18.
Adjusted odds ratio (AOR) multiple logistic regressions test
was employed to assess the association between the variables
with 95% confidence interval (CI). Values were considered to be
statistically significant when P-values are less than 0.05.
Ethical considerations
The study was reviewed and approved by Debre Berhan University,
Department of Biology Ethical review committee. Written consent
was obtained from mother/guardians of children. Confidentiality
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2016
Vol. 2 No. 2: 12
and privacy of information was ensured. Advising about homemade therapy or appointment to bring children to health posts
was made when children with diarrheal illness were found during
data collection.
hand washing facilities near toilet, availability of latrine, location
of latrines and the presence of cover for latrine opening were
not significantly associated with incidence of diarrhea (P>0.05)
(Table 2).
Results
Discussions
A total of 312 children under-five years of age were participated
in the study, of which 38 children had diarrheal illness, thus
giving a prevalence of 12.2%. Most of the mother’s/guardians of
the children were greater than 35 years of age (64.4%), illiterate
(79.5%), had more than or equal to five children (65.1%) and
married (70.2%). Thirty eight children had diarrhea illness, thus
giving a prevalence of 12.2% (Table 1).
In this study, the two-week prevalence of diarrheal illness among
under five children was found to be 12.2%. The prevalence of
diarrheal illness among children under-five years of age differ
from that obtained in other parts of the country: 28.9% in
Nekemte [15], 22.5% in Kersa district/Eastern Ethiopia [17]; 18%
in Mecha/West Gojjam [16] and 17.9% in North Gondar [17]. It
also differs much from that obtained in other countries: 22.5% in
Nepal [20], 23.6% in Dakahlia / Egypt [21] and 18% in Ghana [18].
These variations may be due to difference in awareness about
diarrheal illness and its risk factors among mothers/guardians of
children of this study and previous studies. Moreover, this could
be attributed to the fact that there is lack of access to clean water
and sanitation facilities in the rural areas than in the urban areas.
The incidence of diarrhea was 0.4 times higher among children
whose mother/guardian aged 18-35 years than those with
mother/guardian aged greater than 35 years (AOR = 0.39, 95% CI:
0.19 - 0.78, P = 0.007). Children with illiterate mother/guardian
had diarrhea 2.6 times more often than those with literate
mother/guardian (AOR = 2.61, 95% CI: 1.28 -5.08, P = 0.006).
Moreover, the incidence of diarrhea was 2.5 times higher in
children aged 3-5 years than one year old (AOR = 2.53, 95% CI:
1.07 - 5.93, P = 0.03) (Table 1).
Incidence of diarrhea was significantly associated with household
storage of water (AOR = 0.32, 95% CI: 0.16 - 3.08, P<0.01), hand
washing habits after latrine usage (AOR = 0.51, 95% CI: 0.29 - 0.87,
P = 0.013) and observation of feces on the slab/latrine hole (AOR
= 3.13, 95% CI: 1.51 - 6.48, P = 0.001). However, the presence of
The observation that the incidence of diarrhea was higher in
children whose mothers/guardians had no formal education is in
agreement with the reports of Ekanem et al. [19] from Nigeria. The
findings of this study substantiate earlier reports that education
is important to change healthcare seeking behavior and practice
of mothers/guardians [20-23]. The finding of a strong association
between the risk of having diarrhea and mother’s education also
supports the hypothesis that mothers/guardians education will
reduce the incidence of diarrhea in children [24].
Table 1 Demographic and Socio-economic characteristics of mothers/caretakers in relation to childhood diarrhea among under-five children, Debre
Berhan town, February to March, 2011, (N = 312).
Variables
Age of Mothers (year)
18 – 35
>35
Maternal education
Literate
illiterate
Marital status
Single
Married
Family size(number)
<5
5-10
>10
Age of children (year)
<1
1-3
3-5
Monthly income ( Eth. Birr)
<500
500 - 1000
>1000
Frequency n (%)
Diarrhea
AOR (95%) CI, P value
Yes(n)
No(n)
111(35.6)
201(64.4)
21
17
90
184
0.39 (0.19-0.78) 0.007*
R
64(20.5)
248(79.5)
14
24
50
224
R
2.61 (1.28 -5.08) 0.006*
93 (29.8)
219 (70.2)
9
29
84
190
1.42 (0.65 - 3.14) 0.37
R
109(34.9)
199(63.8)
4(1.3)
14
23
1
95
176
3
R
0.89 (0.44- 1.80) 0.74
2.26 (0.22 - 23.29) 0.48
57(18.3)
119(38.1)
136(43.6)
12
13
13
45
106
123
R
0.46 (0.19- 1.09) 0.07
2.53 (1.07- 5.93) 0.03*
198(63.5)
76(24.4)
38(12.1)
24
8
6
174
68
32
1.36 (0.52 -3.59)0.53
0.85 (0.36 - 1.99) 0.71
R
* Statistical significance, R = reference; Illiterate = cannot read and write.
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Table 2 Environmental characteristics of mothers/caretakers in relation to childhood diarrhea among under-five children, Debre Berhan town,
February to March, 2011.
Variables
Hand washing facilities near toilet
Absent
Present
Availability of latrine
Absent
Present
House hold water storage
Jar/’Jerican’
Pot
Location of latrine (N = 293)
Near to kitchen
Near to main house
Far from both
Faeces on the slab/latrine hole (N = 293)
Present
Absent
Cover for latrine opening (N = 293)
Present
Absent
Mothers previous knowledge about diarrheal diseases
Yes
No
Hand washing habits after latrine usage
Yes
No
Frequency n (%)
AOR (95%) CI, P value
Yes(n)
No(n)
254(81.4)
58(18.6)
31
7
223
51
0.54(0.23 -1.32)0.17
R
19(6.1)
293(93.9)
4
34
15
259
0.49(0.15 - 1.57)0.22
R
229(73.6)
83(26.4)
14
24
215
59
R
0.32 (0.16 - 3.08)<0.01*
69(23.3)
42(14.4)
182(62.3)
11
7
20
58
35
162
0.64(0.28 - 1.46).06
0.96(0.32 - 2.89)1
R
87(29.5)
206(70.5)
18
20
69
186
3.13(1.51 -6.48)0.001*
R
41(14)
252(86)
6
32
35
220
R
1.06(0.37 -2.93)1
240(76.9)
72(23.1)
26
12
214
60
R
1.65 (0.78 - 3.45)0.18
172(55.1)
140 (44.9)
9
29
163
111
R
0.51 (0.29 – 0.87) 0.013*
In the present study, there was a high case of diarrheal diseases
in children from households where there were feces around the
pit-hole. This was in agreement with the study in Egypt [19],
where there was a strong association between the presence of
feces in the yard and non-flush toilets with under-five childhood
diarrheal morbidity. But, acute childhood diarrhea presence was
associated with latrine availability [25]. This has an important
implication that the mere presence of latrine facility does not
have a great contribution for prevention excreta-related disease,
but it is the proper utilization that had a vital importance.
Mothers’ age was found to be a risk factor for diarrheal disease
in children. In contrast, a study conducted in Nepal [18] had
shown no significant associations between the caregiver’s ages
and diarrheal disease occurrence among under-five children.
Reduced risk of diarrhea in children from elderly caretakers
could be related to increased caretakers experience in child care.
However, this may be limited to within reproductive aged group.
In addition, ages of children between 3 to 5 are significantly
associated with diarrhea than lower age groups. This could be
related to their more environmental exposure and unsafe child
feces disposal methods (poor hygienic practices) associated with
increased risk of diarrhea.
Moreover, children with hand washing habits after latrine usage
had a lower chance of diarrhea than those without hand washing
habits. This is in agreement with a study conducted among
4
Diarrhea (N=312)
children under- five years of age in eastern Ethiopia [26-28]. It is
clear that hand washing reduces the transmission of pathogens
causing diarrhea. However, monitoring correct hand washing
behavior at critical times is challenging. With this regard, hygiene
behavior related observational studies showed wide discrepancy
between what people said and did and suggested that the
availability of water and soap in places of hand washing may reveal
as indicators of hand washing behavior [16,29]. The strength of
this study is being community based, but the limitation may be
its cross sectional study design focusing only on two-week period
of diarrheal occurrence among under five children. Moreover,
this study was conducted during the dry season which might
underestimate the degree of diarrhea prevalence [30-32].
Conclusion
The present study identified high two-week’s prevalence of
diarrhea in children under the age of 5 years. Findings of the study
revealed that household storage of water in a pot, observation
of feces on the latrine hole, lack of maternal education and age
of mothers/guardians as risk factors of diarrhea. Therefore, this
highlights the need for promoting environmental sanitation and
hygienic child care practices. Moreover, interventions through
effective health education of the community, paying special
attention to maternal education is recommended to reduce the
incidence of diarrhea in the study area.
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Acknowledgements
The authors thank Debre Berhan University for funding the study.
Our thanks also extended to Debre Berhan town Kebele (02, 06
and 09) administrative bodies and Health Extension workers, data
collectors, and mothers/caretakers of children for their cooperation
© Under License of Creative Commons Attribution 3.0 License
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Vol. 2 No. 2: 12
in the study. Moreover, we thank very much Mr. Zinaye Tekeste,
for his involvement in the manuscript preparation, Aklilu Lemma
Institute of Pathobiology, Addis Ababa University, Ethiopia.
Conflicts of Interest
No potential conflicts of interest to disclose.
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