Diarrheal prevalence and associated risk factors among under-five children attending Robe Didea General Hospital, Arsi Robe Town, Oromia Regional State, Ethiopia: a cross-sectional study

ABSTRACT

Introduction

Globally, diarrheal disease continues to be the second leading cause of death among under-five children, especially in developing countries. This study aimed to determine the prevalence of diarrhea and associated risk factors among under-five attending Robe Didea General Hospital (RDGH) in Arsi Robe Town, Oromia Regional State, Ethiopia, from October 1 to December 30 2020.

Methods

A hospital-based cross-sectional study was conducted among under-five children who attended the pediatrics department of RDGH. Systematic random sampling was employed to select the study subjects. An interviewer-administered structured questionnaire was used for data collection and the analysis used SPSS version 21. Bivariate and multivariable logistic regression analyses were employed to determine the association between risky factors and diarrheal prevalence, and a p value <0.05 was taken as statistically significant.

Results

The prevalence of diarrhea during the 2 weeks preceding the interviews was 28.7%. Mothers/caregivers with formal education [AOR = 0.30; 95% CI (0.17–.053)], unimproved source of drinking water [AOR = 2.11; 95% CI (1.15–3.87)], absence of household-based water treatment [AOR = 4.42; 95% CI (2.20–8.86)], absence of a household latrine [AOR = 4.407; 95% CI (2.49–7.79)], no exclusive breast-feeding for 6 months [AOR = 1.89; 95% CI (1.06–3.38)] and hand wash using water only [AOR = 2.84; 95% CI (1.24–6.49)] were statistically significant risk factors associated with the prevalence of childhood diarrhea after adjusting for confounding variables.

Conclusions and Recommendations

A number of environmental and behavioral factors were found to exacerbate diarrheal prevalence among outpatients of RDGH. Promoting female education, washing the hands of mothers/caregivers with soap or detergents, exclusive breast-feeding for at least 6 months, provision of improved water sources and construction of family latrines and home-based water treatment are recommended for the prevention of diarrhea among under-five children.

KEYWORDS:

• Diarrhea
• prevalence
• under-five children
• associated risky factors
• Robe Didea General Hospital
• Ethiopia

1. Introduction

Diarrhea is an abnormal increase in daily stool fluidity, frequency of defecation and volume in under-five children [1]. It is the passage of three or more loose or watery stools per 24 h [2,3]. There are three types of diarrhea, namely acute watery diarrhea (diarrhea that lasts several hours or days, usually less than 2 weeks), acute bloody diarrhea also called dysentery (diarrhea containing blood with or without mucus) and persistent diarrhea (a diarrhea with or without blood that lasts 14 days or longer) [2].

According to UNICEF, diarrhea is the leading cause of morbidity worldwide and the second cause of death after pneumonia among children under five [4]. Diarrhea is caused by a variety of bacterial, viral, and parasitic organisms. Most deaths occur among young children who were vulnerable to diarrheal disease, and a high proportion of deaths occurs among children less than 2-years old in Asia, Africa, and Latin America [4,5]. In sub-Saharan African countries, childhood diarrhea accounts for more than 50% of all illnesses and 50–80% of childhood deaths [2,6]. In Ethiopia, in 2016 alone, diarrhea was responsible for the death of nearly 50000 under-five children [7].

Various global initiatives were designed to reduce mortality due to diarrhea in under-five children. The Integrated Global Action Plan for the prevention and control of pneumonia and diarrhea (GAPPD), released in 2013 by WHO and UNICEF and adopted by the Ethiopian Ministry of Health sought to reduce deaths and illnesses from these diseases by ensuring that 90% of all under-fives have access to appropriate pneumonia and diarrhea case management [4]. UNICEF reports [8] on sub-Saharan Africa, the region with the highest under-five mortality rate in the world reported an annual rate of reduction of under-five mortality which increased from 1.6% in 1990s to 4.1% in 2000–2015. Other UNICEF report [9] revealed that the Millennium Development Goal (MDG4) that planned to reduce under-five mortality by two-third by 2015 could not be met [9]. The MDG4 was replaced in 2015 by the Sustainable Development Goal (SDG), which aimed to reduce under-five mortality to 25 deaths per 1,000 live births by 2030 [9]. Despite the implementation of these initiatives, globally diarrheal diseases are still the leading cause of mortality in under-five children after pneumonia [10].

According to the Ethiopian 2016 Ethiopian Demographic and Health Survey (EDHS) report, the prevalence of acute diarrhea in under-five children during the 2 weeks preceding the survey was 12.0%, of which 23.0% were 6–11 months [7]. Studies from southeastern Ethiopia (28.4%) [11], Tigray Region in northern Ethiopia (35.6%) [12], Wollega Zone in western Ethiopia (24%) [13] and East Africa (27.0%) (Somalia, Kenya, and Ethiopia) [14] all reported high prevalence of diarrhea in under-fives. Variations in socio-economic and demographic, environmental, and behavioral characteristics of the study participants and their mothers/caregivers have contributed substantially for the high prevalence of diarrhea in under-five children [15,16].

In Ethiopia, control of diarrhea, promotion of breast-feeding, oral rehydration therapy, and specific health education, especially by the Health Extension Program (HEP), are part of national strategies aimed at reducing the burden of child diseases [3]. Ethiopia made remarkable progress in reducing under-five mortality in the last three decades, but studies done in different parts of Ethiopia showed that diarrhea is still a major public health problem [5,6]. No facility-based study has been conducted on prevalence of diarrhea and associated risk factors among under-five children attending Robe Didea General Hospital (RDGH). The objective of this study was to assess the prevalence of diarrhea among these patients and to identify the predictors of diarrhea. The result of this study may serve as a baseline for further studies and facilitate planning and implementation of appropriate diarrhea prevention strategies for under-five children.

2. Materials and methods

2.1. Study setting

The study was conducted in RDGH in Arsi Robe Town, Robe District, in Arsi Zone, Oromia Regional State, Ethiopia. The RDGH is a governmental hospital located in Arsi Robe Town, at latitude 09°36′N, longitude 39°08′E and at altitude of 2,435 m [17]. The RDGH is providing medical services to over 300,000 residents of Arsi Robe Town and of the adjacent districts. The hospital has been providing clinical services to both in- and out-patients, including under-five children since 2011.

2.2. Study design and period, and study population

A hospital-based cross-sectional study design was employed to assess the prevalence of diarrhea and associated risk factors (Figure 1) among under-five children attending RDGH in Arsi Robe Town from October 1 to December 30 2020. The study population was all under-five children attending the pediatrics unit at RDGH for any medical services during the study period.

Figure 1. Conceptual framework of associated factors for childhood diarrhea among under-five children in RDGH, Arsi Robe Town, Ethiopia, October to December, 2020.

2.3. Inclusion and exclusion criteria

The inclusion criteria included mothers/caregivers who had children less than 5-years old attending the pediatric unit of RDGH who were willing to participate in the study. Under-five children who had been given antibiotics, who were older than 5 years, and whose mothers/caregivers were not willing to participate in the study were excluded from the study.

2.4. Sampling procedure and sample size determination

The first under-five child attending the Pediatric Unit on the first day of the survey (October 1 2020) was selected using simple random sampling. Then every third of the under-five children attending the pediatrics unit was selected on each consecutive day until December 30 2023 using systematic sampling [16]. If a selected mother/caretaker did not consent, data was collected from the next mother-/caregiver. The sample size was calculated using a single population proportion formula [18] as n = (Z)²P(1-P)/d², where n is the required sample size, (Z) is the significant level with 95% confidence interval = 1.96, P is the estimated prevalence of diarrhea among under-five children = 50%, 1-P = 50% and d = precision (0.05). Based on the above assumption, an initial sample size of 384 was calculated. Considering non-response, the number of study subjects was increased by 10%, giving a final adjusted study population of 422 [19].

2.5. Study variables

The dependent variable was prevalence of diarrhea in under-five children. The independent variables were categorized into three parts, including 1: socio-economic and demographic factors, 2: environmental factors and 3: behavioral and health-related risk factors (Figure 1). Information was also collected on diarrheal types, and clinical manifestations (frequency and duration of diarrhea, presence or absence of watery, bloody, persistent diarrhea and dehydration status). The types of diarrhea were identified by attending health professionals (nurses) working in RDGH, but who were willing to participate in data collection for this study.

2.6. Operational definitions

Diarrhea: The passage of loose or watery stools at least three times per day or more frequently than normal for an individual during the previous 2 weeks [2–4,20].

Exclusive breast feeding: Children who do not receive any food and water other than breast milk except in medication campaigns [2,7].

Hand washing at critical times: Mothers/caregivers who reported hand washing with water and/or soap before food preparation, before child-feeding and after latrine use [21].

Improved drinking water source: Water sources that are well protected from fecal contamination and likely provide water suitable for drinking. This includes piped water, public taps, standpipes, tube wells, boreholes, protected dug wells and springs, rain water and bottled water [7].

Unimproved water sources: Water sources that are not protected from fecal contamination and do not provide water safe for drinking. This includes surface water (ponds, streams, rivers), and unprotected dug wells [7].

Improved latrine: Latrines not shared with others and not exposed to any type of contamination. This includes pit latrines with a slab, pour-flush latrines with a pit, and composite toilet [7].

Unimproved latrine: Pour flush latrines discharging to the outside, pit latrines without a slab (open pit) and absence of a latrine [7].

Prevalence of diarrhea: The total number of diarrhea cases reported for the period 14 days prior to the interviews divided by the total number of children under-five who visited the Pediatrics unit during the study period.

2.7. Data collection procedure and quality assurance

Structured interviewer-administered questionnaire that was adopted from WHO, EDHS, and related study [2,7,22] were used for data collection. The questionnaire was prepared in English and translated to the local Afan Oromo language by language experts and back to English to maintain consistency of content. Four data collectors (nurses) and two supervisors (health officers) were used for data collection and supervision of data collection, respectively. To assure the quality of data during data collection, two days training was provided for data collectors (nurse) and supervisors by a senior physician in the hospital on the purposes of the study, content of the questions, interviewing procedures and data quality, the confidentiality of information, informed consent, and ethical conduct issues. Pre-testing of the questionnaire was conducted before actual data collection on 10% (n = 42) of under-five children not included in study but who visited the pediatric unit of RDGH to check consistency and accuracy of data collection tools. At the start of each interview, the data collectors informed participants on the purpose of the study and the procedure of data collection and that they could discontinue the interview for any reason at any time. The questionnaire was filled by data collectors in the wards of pediatric unit using face-to-face interviews with mothers/caregivers of under-five children. The data collection process and completed datasets were supervised by both the investigators and the supervisors.

2.8. Data management and analysis

The collected data were checked manually for completeness and consistency, coded, entered into EpiData version 3.1 and then exported to the Statistical Package for Social Science (SPSS), version 21.0 (IBM. Corp., NY, USA). Descriptive statistics were employed to summarize the frequency, proportions and cross-tabulations. Reliability and validity of the data collection tools were confirmed using the Cronbach’s alpha (α) at cutoff point ≥0.7 [23]. Then, bivariate logistic regression analysis was done for each independent variable to compute crude odds ratios (COR); variables with p-value < 0.05 were fitted into the final model (multivariable logistic regression analysis) to calculate adjusted odds ratios (AOR). Multicollinearity between independent variables was checked using variance inflation factor with cutoff point greater than 2 [24], showing no values. In the final model, those variables with p < 0.05 were declared as statistically significant and associated with the dependent variable (prevalence of diarrhea).

2.9. Ethical statement

Ethical clearance letter was obtained from the ethics committee of the College of Natural and Computational Science, Madda Walabu University and permission to conduct the study was obtained from the RDGH’s administration. Both oral assent and signed informed consent were obtained from each study subject’s mothers/caregivers before the commencement of the survey. The confidentiality data was ensured by using codes for participants’ names.

3. Results

Out of 422 selected mothers/caregivers, 414 participated in the study (response rate 98.1%).

The prevalence of diarrhea in the 414 under-five children was 28.7%. The pretest data produced a Cronbach’s alpha (α) coefficient of 0.862 indicating the high strength of reliability and validity of the data collection tools.

3.1. Socio-economic and demographic characteristics

The age of the mothers/caregivers ranged from 18 to 43 years, with mean age (mean ± SD) of 28.15 ± 5.01 years. Most of them were housewives (69.1%), had formal education (72%), had more than one under-five child (60.9%) and lived in an urban area (56.3%). The age of the under-five children ranged from 4 to 59 months on the day of the survey, with mean age (mean ± SD) of 20.65 ± 12.75 months. Half (50.5%) were males and (49.5%) were females (Table 1).

Table 1. Socio-economic and demographic factors associated with diarrhea in under-five children attending RDGH, Arsi Robe Town, Ethiopia, October to December 2020 (n = 414).

Variables	Response category	Frequency	Percent
Age of mother/caregiver	18–24 years	104	25.1
	25–34 years	265	64.0
	>34 years	45	10.9
Residence	Urban	233	56.3
	Rural	181	43.7
Sex of child	Male	209	50.5
	Female	205	49.5
Child age	<6 months	22	5.3
	6–11 month	139	33.6
	12–23 months	114	27.5
	24–35 months	103	24.9
	>35 months	36	8.7
Number of under-five children in family	1	252	60.9
	≥2	162	39.1
Mother’s/caregiver’s education	No formal education	116	28.0
	Formal education	298	72.0
Mother’s/caregiver’s occupation	Housewife	286	69.1
	Farmer	58	14.0
	Salaried employee	47	11.4
	Merchant	11	2.7
	Laborer	12	2.9
Average monthly income in ETB*	≤1,000	132	31.9
	>1,000	282	68.1
Total		414	100

*ETB = Ethiopian Birr.

3.2. Environmental factors

More than half (57.2%) of the mothers/caregivers used drinking water from improved sources and 70.3% of them did not use household-based water treatment. Latrines were present in the homes of 61.8% of the mothers/caregivers; 39.9% of them lived with domestic animals in the same house, 72.2% disposed of child feces safely and 43.7% had no waste disposal places (Table 2).

Table 2. Environmental factors associated with diarrhea among under-five children attending RDGH, Arsi Robe Town, Ethiopia, October to December 2020 (n = 414).

Study Variables	Response category	Frequency	Percent
Source of household drinking water	Improved	237	57.2
	Unimproved	177	42.8
Household-based water treatment	Yes	123	29.7
	No	291	70.3
Sanitation frequency of kitchen/floor	Per day	206	49.8
	Seldom	208	50.2
Living with domestic animals in the same house	Yes	165	39.9
	No	249	60.1
Presence of household latrine	Yes	256	61.8
	No	158	38.2
Status of latrine (n = 256)	Improved	104	40.6
	Unimproved	152	59.4
Unsanitary disposal of child faeces	Yes	115	27.8
	No	299	72.2
Availability of waste disposal sites	Yes	233	56.3
	No	181	43.7

3.3. Behavioural and health-related factors

Nearly one-third of under-fives (31.4%) had not practiced exclusive breastfeeding for 6 months. Over 85% reported that they washed their hands at critical times. Regarding mother hand washing practise, 88.6% washed their hands by water and soap/ash/detergent. Nearly all (93.2%) of under-five children were vaccinated and only 25.0% of their mothers/caregivers had a diarrheal history (Table 3).

Table 3. Behavioral and health-related factors among associated with diarrhea under-five children attending RDGH, Arsi Robe Town, Ethiopia, October to December 2020 (n = 414).

Only exclusive breast feed for six months	Yes	284	68.6
	No	130	31.4
Age child started supplementary food	<6 Month	174	42.0
	≥6 Month	240	58.0
Status of milk served to child	Boiled	340	82.1
	Unboiled	74	17.9
Mother/caregiver wash hands before food preparation	Yes	392	94.7
	No	22	5.3
Mother/caregiver wash hands before feeding child	Yes	379	91.5
	No	35	8.5
Mother/caregiver wash hands after using latrine	Yes	360	87.0
	No	54	13.0
Hand washing material used by mother/caregiver	Soap, ash or detergent	367	88.6
	Water only	47	11.4
Vaccination (any type)	Yes	386	93.2
	No	28	6.8
Mother’s/caregivers diarrheal history	Yes	104	25.1
	No	310	74.9
Total		414	100

3.4. Types of diarrhea and clinical manifestation

The prevalence of diarrhea was higher in males (58.8%) than females (41.2%). Almost all 118 (99.2%) infected under-five children passed three or more loose stools per day and 105 (88.2%) had diarrhea for less than 14 days. The types of diarrhea were acute watery diarrhea, acute bloody diarrhea, and persistent diarrhea in 74.8%, 15.1%, and 10.1% of the study subjects, respectively. The dehydration status of the under-five children was some dehydration (75, 63.0%), no dehydration (36, 30.3%) and severe dehydration (8, 6.7%) (Table 4).

Table 4. Diarrheal types and clinical manifestations among under-five children with diarrhea attending RDGH, Arsi Robetown, Ethiopia, October to December 2020 (n = 119).

Study variables	Response category	Frequency (n)	Percent (%)
Number of children with diarrhea	Male	70	58.8
	Female	49	41.2
Frequency of loose stool per day	<3 times	1	0.8
	≥3 times	118	99.2
Type of diarrhea	Acute watery diarrhea	89	74.8
	Bloody diarrhea	18	15.1
	Persistent diarrhea	12	10.1
Dehydration status	No sign	36	30.3
	Some	75	63.0
	Severe	8	6.7
Duration of diarrhea	<14 days	105	88.2
	≥14 days	14	11.8

3.5. Factors associated with childhood diarrhea

In bivariate logistic regression analysis, 16 factors were found significantly associated with diarrhea prevalence in under-five children (p < 0.05) (Table 5), and these factors were entered into multivariable logistic regression analysis to identify the final predictors/or risk factors associated with diarrhea in under-five children. In multivariate logistic regression analysis, six variables such as mother’s/caregiver’s education, source of household drinking water, availability of household-based water treatment, presence of a family latrine, exclusive breast feeding for 6 months and mother’s/caregiver’s hand washing materials were significantly associated with the prevalence of diarrhea (p < 0.05) (Table 5). Under-five children from mothers/caregivers with formal education were 70% less likely to develop diarrhea than their counterparts [AOR = 0.30; 95% CI (0.17–0.53)]. Under-five children in households who used unimproved water sources had 2.11 times higher odds of developing diarrhea [AOR = 2.11; 95% CI (1.15–3.87)] than those who used improved drinking water sources. Likewise, under-five children whose mothers/care-givers did not treat their water were 4.42 times more likely to develop diarrhea [AOR = 4.42; 95% CI (2.20–8.86)] than those who did. Under-five children whose families did not have a latrine had a 4.4 times higher chance of having diarrhea [AOR = 4.41; 95% CI (2.49–7.79)] than those whose families had a latrine. Under-five children whose mothers/caregivers did not exclusively breast feed for 6 months were 1.89 times more susceptible to diarrhea than those who did [AOR = 1.89; 95% CI (1.06–3.38)]. Children whose mothers/caregivers did wash their hand only with water had about 2.8 times higher odds of having diarrhea [AOR = 2.84; 95% CI (1.24–6.49)] than those who washed their hand with water and soap, ashes or detergents (Table 5).

Table 5. Bivariate and multivariable logistic regression analyses of factors associated with diarrheal in under-five children attending RDGH, Southeast Ethiopia, 2020 (n = 414).

Variables	Response category	Prevalence	COR	P-value	AOR	P-value
	N (%)	N (%)	(95% CI)		(95% CI)
Sex of child
Male	209 (50.5)	70 (33.5)	1		1
Female	205 (49.5)	49 (23.9)	0.62 (0.40–0.96)*	0.032	0.67 (0.39–1.14)	0.137
Age of child
<6 months	22 (5.3)	9 (40.9)	1		1
6–11 months	139 (33.6)	50 (36.0)	0.811 (0.324–2.032)	0.656	1.23 (0.32–4.96)	0.733
12–23 months	114 (27.5)	34 (29.8)	0.614 (.240–1.571)	0.309	1.56 (0.39–6.29)	0.527
24–35 months	103 (24.9)	18 (17.5)	0.306 (0.114–0.824)*	0.019	0.57 (0.14–2.36)	0.441
>35 months	36 (8.3)	8 (22.2)	0.413 (0.130–1.313)	0.134	0.98 (0.19–5.14)	0.988
Number of under-five children
1	252 (60.9)	60 (23.8)	1		1
≥2	162 (39.1)	59 (36.4)	1.83 (1.19–2.83)*	0.006	1.7 (0.99–2.89)	0.052
Education of mother/caregiver
No formal education	116 (28.0)	58 (50.0)	1		1
Formal education	298 (72.0)	61 (20.5)	0.26 (0.16–0.41)**	0.0001	0.30 (0.17–0.53)**	0.0001
Source of household drinking water
Improved	237 (57.2)	57 (24.1)	1		1
Unimproved	177 (42.8)	62 (35.0)	1.70 (1.11–2.61)*	0.015	2.11 (1.15–3.87)*	0.016
Availability of household-based water treatment
Yes	123 29.7)	27 (22.0)	1		1
No	291 (70.3)	92 (31.6)	1.64 (1.00–2.69)*	0.048	4.42 (2.20–8.86)**	0.0001
Living with domestic animals
Yes	165 (39.9)	59 (35.8)	1		1
No	249 (60.1)	60 (24.1)	0.57 (0.37–0.87)*	0.011	0.84 (0.47–1.9)	0.554
Presence of household latrine
Yes	256 (61.8)	50 (19.5)	1		1
No	158 (38.2)	69 (43.7)	3.19 (2.05–4.96)**	0.0001	4.41(2.49–7.79)**	0.0001
Unsanitary disposal of child feces
Yes	115 (27.8)	44 (38.3)	1		1
No	299 (72.2)	75 (25.1)	0.54 (0.34–0.85)*	0.008	0.63 (0.34–1.15)	0.134
Availability of wastes disposal site
Yes	233 (56.3)	53 (22.7)	1		1
No	181 (43.7)	66 (36.5)	1.95 (1.27–2.99)*	0.002	1.10 (0.64–1.89)	0.737
Only exclusive breast feed for six months
Yes	284 (68.6)	68 (23.9)	1		1
No	130 (31.4)	51 (39.2)	2.05 (1.31–3.20)*	0.002	1.89 (1.06–3.38)*	0.031
Hand washing before food preparation
Yes	284 (68.6)	103 (27.6)	1		1
No	130 (31.4)	11 (50.0)	2.63 (1.11–6.24)*	0.028	3.10 (0.81–11.73)	0.098
Hand washing before feed child
Yes	379 (91.5)	103 (27.2)	1		1
No	35 (8.5)	16 (45.7)	2.26 (1.12–4.55)*	0.023	0.93 (0.31–2.75)	0.896
Hand washing after visiting latrine
Yes	360 (87)	93 (25.8)	1		1
No	54 (13)	26 (48.1)	2.66 (1.48–4.78)*	0.001	1.49 (0.70–3.14)	0.295
Hand washing material used
Water + Soap/ash/detergent	367 (88.6)	94 (25.6)	1		1
Water only	47 (11.4)	25 (53.2)	3.30(1.77–6.13)**	0.0001	2.84 (1.24–6.49)*	0.014
Child vaccination
Yes	386 (93.2)	106 (27.5)	1		1
No	28 (6.8)	13 (46.4)	2.29 (1.054–4.97)*	0.036	1.89 (0.59–6.01)	0.28

Values in bold were statistically significant at p < 0.05^* ; p < 0.001**; COR: Crude Odds Ratio; AOR: adjusted odds ratio; 1 = reference.

4. Discussion

The present hospital-based study, which was the first report in the study area, investigated prevalence of diarrhea and associated risk factors among under-five attending RDGH, Arsi Zone, Oromia Regional State, Southeast Ethiopia. The prevalence of childhood diarrhea in this study was 28.7%. The predictor factors significantly associated with prevalence of diarrhea were mothers/caregivers not attending formal education, unimproved drinking water sources, absence of household-based water treatment, absence of family latrine, non-exclusive breast feeding for 6 months and mother’s/caretaker’s hand wash using water only.

The prevalence of diarrhea among under-five children in our study (28.7%) was comparable with the results of other studies in south-eastern Ethiopia (28.4%) [11], Senegal (26.0%) [25] and a meta-analysis study from 2012 to 2017 in East African countries (27.0%) [14]. But it was lower than in Tigray, northern Ethiopia (35.6%) [12], Kenya (37.3%) [16] and rural Burundi (32.6%) [26]. The prevalence in our study was higher than reported from Ethiopian Demographic and Health Survey (12%) [7], Wollega, western Ethiopia (24%) [13], Sidama Zone (13.6%) [22], Somalia (22.4%) [27] and Cameroon 23.8% [28]. These variations might be due to the study dates and methods of data collection, study design and differences in socio-economic and demographic, environmental and behavioral characteristics of respondents. A facility-based study on household expenditures on pneumonia and diarrhea treatment in Ethiopia showed that one treatment of diarrhea cost on average US$ 6 in 35 health facilities, showing a substantial burden of payment on households at the point of service delivery [29], which might have a considerable effect on the prevalence of diarrhea through reducing the number of out-patients who visit the hospital due to high service charge.

Analysis of diarrheal types and clinical manifestations showed in under-five children who were males had higher proportion of diarrhea (58.8%) than females (41.2%) (Table 4). Similar results were reported from other countries [16,30]. This might be due to gender difference in the pathophysiology of acute pediatric diarrhea [31]. Among the 119 diarrheal cases, the most prevalent diarrheal types were acute watery diarrhea (75%) followed by dysentery (15%). These rates are similar to those reported from north-western Ethiopia [32] and Bangladesh [30]. Many diarrheal patients (63.0%) showed some signs of dehydration and 6.7% were severely dehydrated. The relatively small number of patients with severe dehydration indicates a high rate of health services utilization, although the magnitude of revisits could not be determined. Almost all diarrheic under five children (99.2%) had three or more episodes of diarrhea per day. This was higher than the result in Farta Wereda, North West Ethiopia where only 64.7% of diarrheic under-five children manifested three and more episodes of diarrhea per day [32]. Most of the diarrheal patients (88.2%) experienced diarrhea for ≤14 days. This was in agreement with study in North West, Ethiopia where 90.4% of under-five children confirmed loose stool for duration of less than 14 days [32].

In multivariable logistic regression analysis (Table 5), children whose mother’s/caregiver’s had formal education were 70% less likely to have diarrhea than those who had no formal education, in concordance with other studies [22,27,33,34]. Mothers with formal education are informed about the signs and symptoms of diarrhea transmission, prevention, and control [22,35,36] and are tended to adopt behavioral changes related to personal hygiene and sanitation, use health facilities to treat diarrhea, and know proper child feeding and general wellness requirements of their families [27,34]. Children whose mothers/caregivers drank water from unimproved sources were more likely to develop diarrhea than those using improved source of drinking water, in line with other studies conducted in Ethiopia [37–39] and African countries [34,40]. However, some studies [22,25,41] did not find unimproved sources of drinking water to be positively correlated with childhood diarrhea. Drinking water from unsafe sources could be the sources of water-borne pathogens.

The odds of diarrheal prevalence among under-five children whose families did not use home-based water treatment were four times than those in families which used home-based water treatment. This finding is consistent with other studies in Ethiopia [7,11], Senegal [25], Kenya [16] and Brazil [42]. Water from improved sources may not be safe for drinking because pathogens causing diarrheal diseases could contaminate water during collection, transportation, or storage, therefore, requiring home-based water treatment [4,11]. Under-five children of families lacking latrines were more likely to have diarrhea than their counterparts. This result is in agreement with studies in different parts of Ethiopia [43,44], but not in Senegal [25]. The absence of latrines promoted open defecation which increases environmental pollution fecal-oral transmission of pathogens [35,38], which latrines can prevent [45]. Studies from Ethiopia reported higher prevalence of diarrheal in households located near open defecation areas than areas where defecation was prohibited [36,41].

The finding that non-exclusive breastfeeding during the first 6 months increased the risk of diarrhea was corroborated other studies in Ethiopia [38,39], Nigeria [40] and Tanzania [46]. Infants that are not exclusively breastfed during the first 6 months become immune-compromised and are more susceptible to infections with enteropathogens [38,40]. Mothers/caregivers who used only water to wash their hands were more likely to develop diarrhea than children whose mothers/caregivers used water with soap, ashes or detergent. This finding is in line with five other studies in Ethiopia [22,32,39,44,47]. Hand washing with soap, particularly before eating, preparing food, feeding children and after using the toilet can considerably reduce the risk of diarrhea [32,44,47].

This study has several strengths and limitations. One strength is that it identified several independents that may be associated with diarrheal prevalence in under-five children. Systematic sampling of all children attending RDGH over a three-month period generated a representative sample of under-fives being treated in this hospital. Self-reporting of diarrhea events, severity and types in under-five children possibly resulted in over or underestimation of risk factors and disease prevalence. The study was conducted during the dry season (October to December) and did not take into account seasonal variations in diarrhea transmission and prevalence. Despite these limitations, this study may contribute to developing appropriate hospital-based health education and other diarrhea prevention and control programs for under- five children.

5. Conclusion

The study done in the RDGH revealed that the prevalence of diarrheal disease in under-five children was relatively high compared to the national rate. Multivariable logistic regression analysis revealed that mother/caregiver not attending formal education, unimproved drinking water source, lack of home-based water treatment, absence of family latrine, no exclusive breast feeding for 6 months and hand washing with water only were statistically significantly associated risk factors. Promoting maternal education, exclusive breast feeding of under-fives during the first 6 months and maternal/caregiver use of soap and detergents, as well as provision of safe drinking water and construction of household latrines by the village and district authorities are recommended to prevent diarrhea among under-fives among RDGH patients.

Authors’ contributions

Solomon Debebe and Addisu Assefa carried out all the conception and designing of the study, supervised data collection, and performed statistical analysis. Solomon Debebe and Addisu Assefa analyzed and interpreted data, and wrote the main manuscript of this study. Addisu Assefa and HK reviewed and edited the final draft of the manuscript. All authors read and approved the final manuscript.

Acknowledgments

We would like to acknowledge the Department of Biology and the School of Graduate Studies of Madda Walabu University for facilitating this research. We are grateful to RDGH administrators for giving permission to conduct this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

All data used to support the findings of this study are available from the corresponding author upon request.

Additional information

Funding

The authors received no specific funding from any sources.

Notes on contributors

Solomon Debebe

Solomon Debebe (M.Sc, Lecturer), I was born on 26th of July 1986 in Arsi Robe, central Ethiopia. I completed my first degree in Biology Education (B.Ed) at Jimma University on 20th of July 2006 and my second degree, M.Sc in Biology at Madda Walabu University on 31th of March 2022 Currently, I am working as a lecturer.

Helmut Kloos

Helmut Kloos (PhD, Professor) I was formerly an associate professor in medical geography at Addis Ababa University, a visiting professor in the Universidade Federal in Belo Horizonte, Brazil, a consultant for the ministries of health in Kenya and Egypt, and is currently a Research Associate in the Department of Epidemiology and Biostatistics at the University of California in San Francisco, USA. His research focused on the epidemiology of schistosomiasis and other water-related diseases, HIV/AIDS, and COVID-19, health services accessibility and utilization, traditional medicine, and the preparation of textbooks and bibliographies on public health in Ethiopia. He peer-reviewed articles such as Ethiopian Journal of Health Development, Ethiopian Medical Journal, Journal of the American Water Resources Association, PLoS Neglected Diseases.

Addisu Assefa

Addisu Assefa (PhD, Associate Professor), I was born on 14th of October, 1974 at Akasha Village in Ginnir district, Bale Zone, Southeastern Ethiopia. I completed my PhD study in Applied Microbiology at Addis Ababa University in July 2013. Currently, I am a teaching and research staff at Madda Walabu University (MWU), Bale Robe, Ethiopia. I published more than 25 articles in peer-reviewed and reputable journals with high impact factor. I have reviewed several manuscripts for various peer-reviewed and reputable journals. I am a member of professional organizations such as ASM, Ethiopian Society of Microbiology, and Biological Society of Ethiopia. Currently, I am an Associate Professor of Microbiology at Department Biology. I worked as Dean of School of Graduate Studies of MWU and was a former member of MWU Senate. I have been advising many masters and PhD students.