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JOURNAL OF PUBLIC HEALTH INTERNATIONAL

ISSN NO: 2641-4538

Research Article DOI : 10.14302/issn.2641-4538.jphi-18-2470

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

Solomon Getahun Beyene1, Abulie Takele Melku2,*

1
Comitato Collaborazione Medica (CCM), Ethiopia Bale Project.
2
Madda Walabu University Goba Referral Hospital School of Health Science Department of Nursing, Assistant
Professor (PhD).

Abstract
Background: Acute diarrheal diseases are the leading cause of preventable childhood death, especially in
developing countries. It is the second leading cause of death in under-five year children nest to pneumonia.
Objectives: The aim of this study was to determine the magnitude and associated factors of
diarrhea in under-five in Harena Buluk district.
Methods: A community based Cross sectional study was conducted in February, 2018. A two stage stratified
sampling method was done to select the eligible households. Data was collected by trained data collectors using
pretested questionnaire list which was prepared based on EDHS and WHO core questionnaires related to diarrhea.
Data was entered in to a computer using Epi data 3.1 and exported to SPSS V.20 for further analysis. Logistic
regression was used to determine level of association with 95% CI. A p-value <0.05 in the final model were
considered as significant.
Result: The two weeks period magnitude of diarrhea among under-five children was 28.4% with 95% CI
(14.5-20.8) which was associated with households with one under five children [AOR: 0.268, 95% CI(.08,0.90)],
living in the home with single room [(AOR = 6.01, 95% CI(1.01,36.01)], clean latrine/faces not seen around the pit
or on the floor of latrine[AOR: 0.298, 95% CI(0.097,0.92)], long time take to fetch water from source [AOR:
0.046,95%CI(0.01,0.22)], home based water treatment [(AOR = 0.15, 95% CI: (0.04, 0.62)], living with animal in
the same house[AOR: 8.31, 95% CI(2.46,28.06)], children who took gruel type of food[AOR: 0.24, 95% CI
(0.07,0.81)], hand washing practice before cooking food [AOR: 0.195(0.066, 0.574)].
Conclusion: The two weeks period magnitude of acute under-five diarrhea was relatively high and number of
under five children in the household, cleanness latrine, time taking from the source of water, home based water
treatment, number of rooms in the home, live with animal in the same house, type of food child take, hand washing
before food preparation had significant association with the occurrence of under-five diarrhea. Improve community
about home and environmental sanitation and hand practices were recommended.

Corresponding author: Abulie Takele Melku, Madda Walabu University, Goba Referral Hospital School of
Health Science, Department of Nursing, Assistant Professor (PhD) Mobile: +251911060837,
Email: [email protected]
Keywords: Acute diarrhea, Children, Diarrheal Disease, under five
Received: Nov 07, 2018 Accepted: Nov 22, 2018 Published: Dec 05, 2018
Editor: Masoud Mohammadnezhad, Associate Professor, Public Health (Health Promotion) School of Public
Health & Primary Health Care Fiji National University

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Introduction unsafe water, inadequate sanitation and quality and

quantity of water, availability of toilet facilities, housing
Back Ground
conditions, level of education, household economic
Diarrhea is defined as a child with loose or status, place of residence, feeding practices, and the
watery stool for three or more times during a 24–hours general sanitary conditions around the house cause
period and caused by a host of bacterial, viral, protozoa various disease outcomes, mainly diarrheal About 88%
and parasitic organisms. Rotavirus and Escherichia coli of diarrhea-associated deaths are attributable to unsafe
are the two most common etiological agents of water, inadequate sanitation, and insufficient hygiene.
moderate-to-severe diarrhea in low-income countries. It As simple as hand washing may seem, it is one of the
is more common when there is a shortage of adequate most important factors in preventing the spread of
sanitation and hygiene and safe water for drinking, germs and staying healthy. Unwashed hands can
cooking and cleaning, improper feeding practices, and accelerate the spread of bacteria, parasites, and viruses
poor housing conditions [1]. Though most episodes of that are transmitted from human and animal faeces or
childhood diarrhea are mild, acute cases can lead to the environment [6]. Nowadays, globally diarrhea
significant fluid loss and dehydration, which may result accounts for 9% of all deaths among children under the
in death or other severe consequences [2]. age of five [7].
Despite global success in the reduction of all The morbidity and mortality related to diarrheal
cause and diarrhea specific mortality in the past 30 diseases in under-5 children are still sizeable and
years, diarrhea remains the second leading cause of persistent in low income countries, especially in sub-
death due to infections among children under five years Saharan Africa, and pose a significant, long-standing
of age worldwide and account for 1,400 children death public health concern. Diarrhea is one of the major
every day, around 1 in 10 child deaths worldwide due to contributors to deaths for under age 5 children in
diarrhea in 2015. It is more than the death of children Ethiopia. Diarrhea contributes to more than one in every
due to AIDS, malaria, and measles combined [3]. It is ten (13%) child deaths in Ethiopia. The percentage of
estimated that diarrhea accounted for 9.9% of the 6.9 children under age 5 who had diarrhea accounts 12% in
million deaths among children under 5 in 2011 [4]. 2016 [8].
Young children are especially vulnerable bearing 68% of
Diarrheal diseases are among the leading causes
the total burden of diarrhea disease. Among children less
of under-five deaths worldwide. Globally diarrhea
than five years, diarrhea accounts for 17% of all
accounts for 9% of all deaths among children under the
deaths [2].
age of five. Low income nations like India, Nigeria, the
While it is both preventable and treatable, each Democratic Republic of Congo, Pakistan, and Ethiopia
year around 526 000 deaths of under-five children and are hit especially hard. In these countries, children are
nearly 1.7 billion cases of childhood diarrheal disease often exposed to pathogens because of poor
every year. This rate varies between regions, Most environmental sanitation and water supplies [7].
deaths from diarrhea occur among children less than 2 Childhood mortality rate in general and infant mortality
years of age living in South Asia and sub-Saharan Africa in particular, are often used as broad indicators of social
many of those who survive suffer from malnutrition and development or as specific indicators of health status.
lasting impairments to mental and physical Child mortality reduction by two-third is one target of
development [2,5]. Diarrheal deaths are exceedingly Millennium Development Goal [9]. The majority of
prevalent in just a handful of countries and half of morbidity and mortality related to under-five diarrhea
deaths due to diarrhea. were in Africa and South Asia. Diarrhea can last several
A large proportion of diarrheal disease in days, and can leave the body without the water and
developing world is due to multiple risk factors are salts that are necessary for survival. Most people who
indicated, namely unsafe water supply, lack of water die from diarrhea actually die from severe dehydration
linked to inadequate hygiene, poor personal and and fluid loss. It also predisposes children to malnutrition
domestic hygiene and agricultural practices, contact with which makes children more susceptible to other

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infections [5]. and associated factors of diarrhea among under-five

As compared with other regions of the world, children in Harena Buluk woreda by the year of 2018.
the African region shows the smallest reductions in Definitions of Key Terms
mortality rates and the most marked slowing down Diarrhea is defined as having three or more loose or
trend. The under-five mortality rate in the African region watery stools per twenty four hours in two weeks period
is seven times higher than that in the European region. preceding the data collection, as reported by the
Though Ethiopia has recorded significant mother/care taker of the child(WHO, 2010).
reduction in childhood mortality, still many children die Prevalence of Diarrhea the number of diarrhea cases at
from diarrhea before their 5th birth day. Over two-thirds the time of the interview divided by the total number of
of child deaths in Ethiopia are due to infectious diseases households included in the study.
such as pneumonia, diarrhea, malaria, and measles; and
Exclusive Breast Feeding A child who receives breast
problems of the newborn. Moreover diarrhea is the
milk only and no other food, solid or liquid with the
second cause for clinical presentation among under
exception of vitamins, minerals and medicines [1].
five-year child population next to pneumonia in
Ethiopia .Nationally, diarrhea prevalence is 12% in 2016 Improved Water Source Water from protected springs
and it is more abundant in rural than urban areas [8]. and/or wells, from pipe and from distribution post unless
Even though improvement was made in reducing considered as unimproved [1].
childhood mortality from 123 under five deaths per Improved Latrine pour flush to piped sewer system/
1,000 live births in 2005 to 59 under five deaths per septic tank/pit latrine, VIP and pit latrine with slab
1,000 live births in 2016, children in the country still otherwise considered as unimproved [1].
suffer from diarrhea, respiratory problems and Care Giver Hygiene is personal hygiene of the caregivers
malnutrition [8].
like short finger nail cut or long fingernail which could be
Variations across communities in factors like factors for the occurrence of diarrheal disease among
accessible, safe and adequate water supply, children
environmental sanitation and person hygiene, availability Appropriate Hand Washing Practice is the way of child
and quality of MNCH services and facilities, maternal caregiver hand washing practice which shows clean
education level, place of residence (urban/rural) could hand palm, fingertip and between-fingers observed by
play significant roles on diarrhea morbidity and mortality data collectors to determine its relationship with the
in a specific community. Thus this study was aimed to occurrence of diarrheal.
assess the magnitude and determinants of diarrhea
Hand Washing Facility refers to households having hand
morbidly in under-5 children at Harena Buluk wereda.
washing facilities like plastic or metal with water seated
Studies conducted that aimed to assess diarrhea
nearest to latrine for children to wash their hands after
morbidly in conjunction with its determinant factors
latrine utilization as observed by data collectors.
among under-5 children at community level in Ethiopia
particularly in the context of Bale zone, Harena Buluk Hand Washing during Critical Time refers to caregivers’
wereda are limited. This suggests that many more hand washing practice after utilization of latrine, before
studies are remaining to be done. food preparation and child-feeding as identified by
caregivers’ oral report of their practice to identify its
Even though there are different diarrhea
relationship with diarrheal occurrence
prevention strategies and policies including the health
extension program in the ground, diarrhea is still the Index Child refers to a child that was included in the
leading cause of morbidity among children visiting under study from a household to have information on the
five years clinic in the study area. In addition to this the demographic and health characteristics.
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

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Methodology cannot respond to the interview, children who are

Description of Study Area critically ill and with persistent diarrhea were excluded
from the study.
The study was conducted in Harena Buluk
woreda and data was collected in February, 2018. Sample Size Determination
Harena Buluk is one of the pastoral woredas found in Using EPI INFO for window version 7, sample
Bale zone of Oromiya region, Southeast Ethiopia. The size was calculated for each specific objective and the
study site is approximately 582 kilometers away from highest sample size is taken. Using single population
Addis Ababa and 152 kilometers from Bale Robe, the proportion formula by considering 23% of the under
capital city of Bale zone. It is bounded by Goba, Madda five-children had two-week prevalence of diarrhea from
Walabu, Delo Mena and Adaba woredas to the north, a study done in Kersa, Eastern Ethiopia by Bezatu
south, east and west direction respectively. The district Mengistie, Yemane Berhane, Alemayehu Worku, 2011
is divided in to thirteen rural and one urban kebeles (the with 95% confidence level, 5% desired precision and
smallest administrative unit in Ethiopia), having a total taking design effect of 1.5, accounted for two stage
population of 106, 987 residents. The total households sampling [10]. Adding 10% for none response rate, the
of the district were 22899 and 17,587were children total calculated sample size was 450 mothers with less
under five years of age. It had 52 primary and 3 than five years children.
secondary schools. The population is predominantly Sampling Techniques
Muslim by religion. The main weather condition of the
Multistage sampling was employed to select
woreda is kola (low land) with some part of it having
kebeles and households which have under-five children
weyna-dega (mid land) weather condition which is
in the woreda. In the first stage all the kebeles stratified
accounts about 9 and 5 kebeles respectively. Agriculture
by place of residence as urban (only one small kebele)
and pasturing is the main sources of the district’s
and rural. On the second stage the rural kebeles again
livelihood. Health services in the district were provided
stratified based on geographical and climate condition as
by 5 health centers and 18 health posts. At the kebele
low land/pastoral and mid land/agrarian kebeles because
level, health care is delivered by health extension
the residence area (urban and rural) and geographic/
workers who are assigned to render health services at
climate condition by itself make a difference in socio
the local level.
economics among source population. From the total 13
Study Design and Period rural kebeles 5 are mid land and 8 are low land. Then,
A community based cross-sectional study was from each stratum kebeles to be included in the study
done to assess the magnitude and associated was allocated proportionally and selected randomly.
factors of acute diarrheal disease among children under- Therefore, from rural strata 3 low land and 1 mid land
five years of age in Harena Buluk woreda from February kebeles as well as the only one kebele from urban strata
1 to February 20, 2018. taken as study population, from which the study unit
Population was selected. As a result 5 kebeles were selected out of
the total of 14 kebeles found in the district.
The source populations are all households with
mothers/care takers who have under-five children in the Similarly the number of households to be a
district, Harena Buluk woreda. The study populations are study unit selected from each kebeles allocated
all households with mothers/care takers who have proportionally. The systematic random sampling
under-five children in the in the selected kebeles, technique was used to take the mothers/caretaker-child
Harena Buluk woreda. And the study units are randomly pairs from each of the selected kebeles (small villages).
selected household with at least one under five-child in Households with at least one under five years of age
selected kebeles. Those households under five years child was eligible for the study. One child- mother pair
children and lived in the area for more than six months was selected at random to collect information on the
are included in the study; while mothers who are ill and child’s demographic and health characteristics for

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households with two or more under 5 years of age age, family size and child’s age and sex. Environmental
children. The first household was selected randomly and factors were type of water source, distance to the water
the subsequent households were selected systematically source, availability of latrine facility, availability of hand
until the proportionately allocated sample size fulfilled. washing facility, number of rooms, livestock in house
When the selected households had no under-five and refuse disposal method. Behavioral factors were
children, the next neighborhood household was selected. feeding practices, hand washing practice, home based
A brief illustration of the sampling procedure is displayed water treatment, duration of breast-feeding, breast
in the figure below. feeding status, and time of introducing supplementary
Data Collection Instrument and Data Quality Control feeding.

The questionnaire was prepared based on EDHS Data Analysis

and WHO core questionnaires related to diarrhea. The The data was coded and entered in to a
questionnaire was written in English, translated into computer using Epi-data 3.1 software and exported
Afan Oromo (local language), and then translated back to SPSS V.20statistical software for cleaning and further
into English to assure its accuracy. In order to ensure analysis of the data. Descriptive statistics was done to
data quality data collectors and supervisors were trained describe the study populations using measures of
on the data collection procedure. Data collection process frequency, disease occurrence, central tendency and
was supervised by the principal investigators and dispersion that were displayed using tables and graph.
supervisors. The filled questionnaire was checked for The necessary assumption of logistic regression
completeness and consistency on daily bases. was checked using Hosmer and Lemeshow
Data Collection Methods goodness-of-fit-test statistics. Due to the binary nature
of the outcome variable, binary logistic regression
Data was collected by interview using adapted
analysis was used to determine the OR and 95% CI of
standard questionnaire and administered by an
the effect of the different independent variables on the
interviewer. The respondents were primarily mothers of
outcome variable. To reduce excessive number of
eligible children-under five years of age, but in the
variables and instability of the model, only variables with
absence of the mother, the next primary caregiver will
P. value < 0.2 in the bivariate analysis will be considered
be interviewed. Five data collectors who were clinical
for inclusion in the multivariate analysis to control for
nurses and Afan Oromo speakers were trained in
the effect of confounders. Variables with P-value < 0.05
questionnaire administration and data collection
in the multivariate analysis (final model) will be
procedures. Pretest was done in 5% of the total sample
considered as independently associated with the
size in another Kebele of the same study area. The
outcome variable.
result of the pretest was used to correct some unclear
ideas and statements. The data collection was Ethical Consideration
supervised by two supervisors (Health Officers) and the Ethical approval and clearance was obtained
principal investigator at the center. Their role was to from the research review committee of Madda Walabu
daily check the consistency, clarity and completeness of University Goba Referral Hospital, Department of Public
the collected questionnaires. The data collectors along Health. Permission was obtained from concerned bodies
with their supervisors took two days training about the of Harena Buluk district. Full verbal consent was
questionnaire and data collection procedures. obtained from the mothers/caretakers of the child after
Study Variables clear explanation given about the aim of the study.
Confidentiality and privacy was maintained during data
The dependent variable is prevalence of
collection, analysis and reporting in which the
diarrhea in under-five year children in the last two
information obtained from the respondents was not
weeks period. The independent variables are
shared with anyone other than the data collectors and
socio-demographic factors such as place of residence,
principal investigator. For Children with diarrhea and not
household size, parental education, maternal occupation,
get appropriate treatment during the data collection
maternal age, number of children under-five years of

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time, the data collectors were provide ORS and advised diarrhea in the two weeks period preceding the study
their family to take them to the nearby health institution (Table 4).
for better management. Factors of Childhood Diarrhea
Result In the bivariate analysis number of under five
A total of 450 households were included in the children in the household, household family size,
study and a complete response (100%) was obtained occupation of mother, education of the fathers,
from all respondents. The mean age of the respondents occupation of fathers, place of Residence, religion,
was 27.93+6.52SD years with the majority of them 247 average family monthly income were found to be
(54.9%) were 25-35 years of age. The majority of the significantly associated with under-five diarrhea. The
respondents 270(60%) were illiterate and 386(85.8%) odds of having diarrhea in household with tow and less
were house wife by occupation. The majority of the number of under five children were 4.18 times less likely
Households 334(74.2%) had one or two under five than the odds in household with more than two under
children in their family and the mean family size of the five children [COR: 0.239, 95% CI (0.152-0.375)]
Households was 6.55 persons. Almost all 403(89.6%) of children who live in the household of five or less family
the respondents were Muslim in religion. (Table 1). size were 1.83 times less likely prone to diarrhea when
Environmental Characteristics of the Households compared to those children live in the household greater
than five family member [COR: 0.545, 95% CI (0.347-
Three hundred thirty four (74.2%) and 75
0.857)]. Children of fathers who completed primary
(22.5%) of the households had latrine and hand
education were less probable to have diarrhea compared
washing facility respectively. Majority of the latrine
to children of mothers who were illiterate [COR: 0.69,
facility of the households were 304(91%) private and
95% CI(0.45-1.06)]. Likewise children of fathers who
330(98.8) of them were not improved type and 72
were secondary and above educational status were
(21.3%) of the households had unclean latrine or feces
more than three times less likely to experience diarrhea
seen around the hole of pit latrine. Most of the
compared to children of mothers who were illiterate
households 232(51.6%) disposes their waste material
[COR: 0.28, 95% CI(0.11-.71)]. Children from
properly. 230(51.1%) of the households use improved
households of urban community were about 1.5 times
type of water source and 118(26.2%) of the households
less likely to have diarrhea compared to children of rural
take 30 minute or more to fetch water. 170(37.8%) of
community households [COR: 0.67, 95% CI (0.37,
the households treat their drinking water at home
1.234)]. Children of house hold whose income more
(Table 2)
than one thousand were less likely to develop diarrhea
Behavioral Characteristics of the Respondents compared to children of household whose income were
Majority of the respondents give their child 410 one thousand and less birr per month [COR: 0.387, 95%
(91%) other food in addition to BF. Most of the CI(0.245,0.611)].Children of mothers whose occupation
respondents 243(59.3%) were prepare gruel and 239 house wife were four times more likely to experience
(58.3%) of the respondents feed their diarrhea as compared Children of mothers whose
children using their hand. Most of the respondents 209 occupation were government employee. Children of
(46.4) wash their hand using water only (Table 3). mothers whose occupation were farmer three times
more likely to have diarrhea compared to government
Demographic and Health Characteristics of the Indexed
employee Likewise children of mothers whose
Children
occupation were merchant two times more likely to have
Two hundred thirty one (51.3%) of the children
diarrhea compared to government employee. In this
were females with the majority of the children 161
study Educational status of the mother, Age of mothers
(35.8%) were in the age group of 12-24 months. The
category, Occupation of fathers, Marital status, Ethnicity,
mean age of the children was 24.55(±13.63 SD)
Relation of respondents to child and Monthly income of
months. 263(58.4%) and 285(73.5%) of the children
family were not showed significant association with
receive Rota and measles virus vaccine respectively. In
under five diarrhea (Table 5)
this study, 128(28.4%) of the children had experience

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Table 1. Distribution of study subjects by demographic and socio-economic characteristics of the households
in Harena Buluk, Oromia region, Ethiopia, 2018
Frequency Percentage
Variables Responses
(n=450) (%)
Number of under five children in the Two and Less 334 74.2
household More than two 116 25.8
Five and Less 162 36.0
Household family size
More than five 287 63.8
Illiterate 270 60.0
Primary school 149 33.1
Educational status of the mother
secondary and preparatory 26 5.8
12+ 5 1.1
Government employee 11 2.4
Housewife 386 85.8
Occupation of the mothers Merchant 25 5.6
Farmer 26 5.8
Others 2 .4
15-24 142 31.6
Age of mothers category 25-35 247 54.9
35 and more 61 13.6
Illiterate 183 40.7
Primary school 221 49.1
Education of the fathers
Secondary and preparatory 29 6.4
12+ 17 3.8
Government employee 23 5.1
Merchant 29 6.4
Occupation of fathers Farmer 385 85.6
Daily labor 9 2.0
Others 4 .9
Married 428 95.1
Divorced 10 2.2
Marital status
Single 6 1.3
Widowed 6 1.3
Urban 72 16.0
Residence
Rural 378 84.0
Muslim 403 89.6
Religion
Christian 47 10.4
Oromo 442 98.2
Ethnicity Sidama 6 1.3
Amara 2 .4
Mother 418 92.9
Relation of respondents to child
Caretaker 32 7.1
<1000 269 59.8
Monthly income of family
>1000 181 40.2

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Table 2. Distribution of study subjects by environmental characteristics of the households in Harena Buluk
district, Oromia region, Ethiopia, 2018

Frequency Percentage
Variables Response
(n=450) (%)
One room 52 11.6

Number of rooms Two rooms 289 64.2

Three or more rooms 109 24.2

yes 135 30.0

Animals live in same house
No 315 70.0
Yes 334 74.2
Latrine availability
No 116 25.8
Improved 4 1.2
Type of latrine n=334
Not improved 330 98.8

Private 304 91
Latrine ownership n=334
Shared 30 9
Yes 85 25.4
Feces seen around the pit hole n=334
No 250 74.6
yes 75 22.5
Hand wash facility n=334
no 259 77.5
Open field 116 100
If no latrine where they use n=116
Other 0 0
proper 232 51.6
Refuse disposal method
improper 218 48.4
Improved 230 51.1
Water source
Not improved 220 48.9
Thirty minute and less 332 73.8
Time to water source
More than thirty minute and less 118 26.2
yes 170 37.8
Home based water treatment
no 280 62.2

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Table 3. Distribution of study subjects by behavioral characteristics of the respondents in

Harena Buluk district, Oromia region, Ethiopia, 2018
Frequency Percentage
Variables Response
(n=450) (%)
The child take other food than Yes 410 91.1
breast feed No 40 8.9
Cow’s milk 109 26.6
Powder milk 4 1
Type of food the child take mostly
Gruel 243 59.3
Adult food 54 13.1
Hand 239 58.3
Child feed method Cup and spoon 142 34.6
Bottle 29 7.1
Soap and water 167 37.1
Hand washing method Ash and water 74 16.4
Only water 209 46.4

Table 4. Distribution of demographic and health characteristics of the indexed children in Harena
Buluk district, Oromia region, Ethiopia, 2018
Frequency Percentage
Variables Response
(n=450) (%)
Male 231 51.3
Sex
Female 219 48.7
Less than twelve month 116 25.8
12-24 month 161 35.8
Age category
25-35 month 45 10.0
Greater than35 month 128 28.4
Exclusive breast feeding 40 8.9
Current breast feeding status Partial breast feeding 186 41.3
Not breast feeding 224 49.8
Less than six month 10 2.4
Age at supplementary feeding
At six month 341 83.2
n=410
Greater than six month 59 14.4
Less than one year 102 22.7
Duration of breast feeding
One year and more 348 77.3
Yes 285 73.5
Measles virus vaccine n=388
No 103 26.5
Yes 263 58.4
Rota virus vaccine
No 187 41.6
Have diarrhea in the last two Yes 128 28.4
weeks No 322 71.6

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Table 5. Bivariate analysis of Demographic and socio-economic determinants (P. value<0.2) of under-five
diarrhea in Harena Buluk district, Oromia region, Ethiopia, 2018.

No diarrhea n
Variables Responses Diarrhea n(%) COR(95% C.I)
(%)

No of under five children in Two and Less 266(79.6) 68(20.4) 0.239(0.152-0.375)

the HH
More than two 56(48.3) 60(51.7) 1

Five and Less 128(79) 34(21) 0.545(0.347-0.857)

Household family size
More than five 193(67.2) 94(32.8) 1

Government
11(91.7) 1(8.3) 1
employee

Occupation of mother House wife 267(69.7 116(30.3) 4.78(0.61-37.45)

Merchant 26(81.2) 6(18.8) 2.54(0.27-23.64)

Farmer 18(78.3) 5(21.7) 3.06(0.31-29.70)

Illiterate 120(65.6) 63(34.4) 1

Primary school 162(73.3) 59(26.7) 0.69(0.45-1.06)

Education of the fathers
Secondary and
40(87) 6(13) 0.28(0.11-0.71)
above

Government
21(91.3) 2(8.7) 1
employee

Occupation of fathers Merchant 24(82.8) 5(17.2) 2.18(0.38-12.47)

Farmer 266(69.1) 119(30.9) 4.69(0.08-20.35)

Daily labor 11(84.6) 2(15.4) 1.9(0.23-15.45)

Urban 56(77.8) 16(22.2) 0.67(0.37,1.234)

Place of Residence
Rural 266(70.4) 112(29.6) 1

Muslim 284(70.5) 119(29.5) 1

Religion
Christian 38(80.9) 91(9.1) 0.51(0.27,1.20)

<1000 Birr 173(64.3) 96(35.7) 1

Average family monthly
income >1000 Birr 149(82.3) 32(17.7) 0.387(0.245,0.611)

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Environmental Determinants house hold who had house of more than two rooms
Households’ environmental variables and their [COR: 1.69, 95% CI(0.98,2.897)], and child of house
relationship with under-five diarrhea were hold live with animal in the same house were four times
assessed on the bivariate analysis. But latrine more likely to develop diarrhea compared to those
availability, feces seen in the pit hole, hand washing children of house hold live in separated room from
facility, refuse disposal method, time to fetch water from animal[COR: 3.9, 95% CI(2.52,6.04)] (Table 6).
source, home water treatment, number of rooms and Behavioral Determinants
animals live in same house were found to be In the bivariate analysis, current breast feeding
significantly associated with under-five diarrheal status, type of food the child take (Powder milk and
morbidity. gruel), eating unwashed fruit, eating uncooked food,
Children from household who had no latrine prepare child food separately, utensil washing methods,
were 3 times more likely to experience diarrhea methods of child feeding, hand washing before food
compared to children from household who had latrine preparation, hand washing before food serving, hand
[COR: 2.91, 95% CI(1.86,4.54)]. Children from washing after visiting latrine, and hand washing after
household who had clean latrine/ faces not seen around cleaning of child bottom were the behavioral variables
the pit or on the floor of latrine were 1.5 times less likely that showed significant association with under-five
to experience diarrhea compared to children from diarrheal morbidity.
household who had not clean latrine/ feces seen around Children who partially breast feeding were 4.5
the pit or on the floor of latrine [COR: 0.65, 95% CI times more likely to develop diarrhea when compared to
(0.37,1.14)]. Children from households had no hand children exclusively breast feed[COR: 4.5, 95% CI
washing facilities were five times more likely prone for (1.53,13.21)]. Similarly children who didn’t breast
diarrhea compared to those children of households who feeding were three times more likely to develop diarrhea
had hand washing facilities[COR: 5.18, 95% CI when compared to children exclusively breast feed
(0.19,0.53)]. Children from households experience [COR: 3.44, 95% CI(1.18,10.08)]. Children usually
improper waste disposal were 2.2 times more likely to taking gruel type of food were 1.5 times less likely
develop diarrhea compared to those children of compared to children eating other type of food [COR:
household who dispose waste properly[COR: 2.22, 95% 0.64, 95% CI(0.416,0.98)]. But child cow milk and adult
CI(1.46,3.38)]. Children from households who take type of food were not showed any significant association
below 30 minute to get water from source were four with under-five diarrheal morbidity. Children who didn’t
times less likely to develop diarrhea compared to those ate unwashed food were two times less likely to develop
children of household get water after walking more than compared to those children who ate unwashed fruit
30 minute [COR: 0.262, 95% CI(0.17,0.41)]. Children [COR: 0.49, 95% CI(0.32,0.76)]. Children used to eat
from households who treat water before using were less uncooked food were two times more likely to develop
likely to develop diarrhea compared to those children diarrhea compared to those children not used to eat
from households who didn’t treat water before using uncooked food [COR: 2.02, 95% CI(1.2,3.39)]. Children
[COR: 0.52, 95% CI(0.33,0.82)]. Children of households of mothers who prepare their children food in separately
use improved water source were three times less likely were two times less likely to develop diarrhea compared
to experience diarrhea compared to children from to children of mothers prepare children food together
households who use unimproved water source [COR: with the family [COR: 0.42, 95% CI(0.27,0.65)].
0.32, 95% CI(0.19,0.53)]. Children of households had Children of mother who used only water to wash utensil
one room house were 3.5 times more likely to were 1.5 times more likely to develop diarrhea
experience diarrhea compared to those children of compared to children of mothers who used soap and
house hold who had house of more than two rooms water[COR: 1.58, 95% CI(1.01,2.48)]. Children of
[COR: 3.6, 95% CI(1.74,7.41)]. likewise children of mother who wash their hand before food preparing were
household had house of two rooms were 1.7 times more six times less likely to develop diarrhea compared to
likely to develop diarrhea compared to those children of children of mothers who were not wash their hand

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Table 6. Bivariate analysis of Environmental determinants (P. value<0.2) of under-five diarrhea in Harena
Buluk district, Oromia, Ethiopia, 2018.

Variables Responses No diarrhea n Diarrhea n(%) COR(95% C.I)

(%)

Yes 259(77.5) 75(22.5) 1

Latrine availability
No 63(54.3) 53(45.7) 2.91(1.86,4.54)

Yes 61(71.8) 24(28.2) 1

Feces seen around the pit
hole
No 199(79.6) 51(20.4) 0.65(0.37,1.14)

Yes 70(93.3) 5(6.7) 1

Hand washing facility
No 189(73) 70(27) 5.18(2.01,13.37)

Proper 184(79.3) 48(20.7) 1

Refuse disposal method
Improper 138(63.3) 80(36.7) 2.22(1.46,3.38)

30 minute and
263(79.2) 69(20.8) 0.262(0.17,0.41)
less
Time to water source
More than 30 59 (50) 59 (50) 1
minute

Yes 135(79.4 35(20.6) 0.52(0.33,0.82)

Home water treatment
No 187(66.8 93(33.2) 1

One 28(53.8 ) 24(46.2) 3.6(1.74,7.41)

Number of rooms Two 206(71.3 83(28.7) 1.69(0.98,2.897)

More than two 71.60% 28.40% 1

Yes 69(51.1) 66(48.9) 3.90(2.52,6.04)

Animals live in same
house
No 253(80.3) 62(19.7) 1

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before food preparing[COR: 0.158, 95% CI the family, utilization of latrine, time from the source of
(0.098,0.254)]. Children of mother who wash their hand water, home based water treatment, number of rooms
before food serving were two times less likely to develop in the home, animal live in the same house with the
diarrhea compared to children of mothers who were not family, type of food child take, hand washing before
wash their hand before food serving [COR: 0.49, 95% CI food preparation, and mothers/care takers hand
(0.32,0.76)]. Children of mother who wash their hand washing method had significant association with the
after visiting latrine were three times less likely to occurrence of under-five diarrhea. The odds of having
develop diarrhea compared to children of mothers who diarrhea in household with tow and less number of
were not wash their hand after visiting latrine [COR: under five children were 3.7 times less likely than the
0.29, 95% CI(0.19, 0.44)]. Children of mother who wash odds in household with more than two under five
their hand after cleaning bottom of children were four children [AOR: 0.268, 95% CI(.08,0.90)].According to
times less likely to develop diarrhea compared to this study, children of household who had clean latrine/
children of mothers who were not their hand after faces not seen around the pit or on the floor of latrine
cleaning bottom of children [COR: 0.24, 95% CI was 3.4 times less likely to develop diarrhea compared
(0.14,0.40)]. But hand washing before eating was not to those clean latrine/faces seen around the pit or on
show significant association with under five children the floor of latrine[AOR: 0.298, 95% CI(0.097,0.92)].
diarrhea. Children of mothers/care takers who wash Time take less than 30 minuet to fetch water from
their hand using water and soap/ash were 1.5 times less source was 16.7 times less likely to develop diarrhea
likely to develop diarrhea compared to those children of compared to time take more than 30 minutes to fetch
mothers/care takers who wash their hand with water water from source to home [AOR: 0.046, 95% CI
only [COR: 0.69, 95% CI(0.46,1.04)]. Children who (0.01,0.22)]. children in the households who treat water
received Rota vaccine were two times less likely prone before drinking were 1.9 times less likely to had diarrhea
to diarrheal diseases compared to children not received compared to children in the households who do not treat
rata vaccine[COR: 0.43, 95% CI(0.28,0.65)]. Similarly water at home before using (AOR = 0.15, 95% CI:
those children received measles vaccine were four times (0.04, 0.62). The odds of under five years of age
less likely prone to diarrheal diseases compared to children who live in house with one room had 6.01 times
children not received Rota vaccine[COR: 0.26, 95% CI more risk of diarrhea as compared to the odds of
(0.16,0.42)]. Length of breast feeding, age at children who live in house with more than two rooms
supplementary food and method of children feeding [(AOR = 6.01, 95% CI(1.01,36.01)]. Children living with
were not show significant association with under five animals in the same house were more likely to develop
children diarrhea. (Table 7) diarrhea compared to children live in the house
Factors for Under-five Diarrhea: Multivariate Analysis separately from animals [AOR: 8.31, 95% CI
(2.46,28.06)]. Children who take gruel type of food were
In the bivariate analysis any possible
four times less likely to develop diarrhea as compared to
confounders were not controlled and assessing the
children taking other type of food [AOR: 0.24, 95% CI
independent effects of the covariates was difficult. So,
(0.07,0.81)](Table 8)
an enter method of binary logistic regression technique
was used to assess the independent effects of Discussion
explanatory variables on under five diarrhea. To avoid In this study the magnitude of under-five
excessive number of variables and unstable estimate in diarrhea in this study was 28.4% which is relatively
the final model, only variables with P-value less than 0.2 similar with study conducted in India 25.2% [11],
in the bivariate analysis were taken in the multivariate Cameron 23.8% [12], Rwanda 26.7% [13], Jabithennan
analysis. Model fit was checked by Hosmer-Lemeshow District 26.1% [14], Jigjiga district 27% [15], and
goodness-of-fit test statistics. eastern Ethiopia kersa, Demographic Surveillance and
The multivariate binary logistic regression Health Research Center (KDS-HRC) field site
analysis identified that number of under five children in 22.5% [10]. However, the current finding was higher
than the finding of the Ethiopian demographic and

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Table 7. Analysis of behavioral characteristics of the respondents and health characteristics of index child
(P. value<0.2) in Harena Buluk district, Oromia region, Ethiopia, 2018.

No diarrhea n Diarrhea n
Variables COR(95% C.I)
(%) (%)

Exclusive breast
feeding 36(90) 4(10) 1

Current breast feeding status Partial breast 124(66.7) 62(33.3) 4.5(1.53,13.21)

feeding
Not on breast
162(72.3) 62(27.7) 3.44(1.18,10.08)
feeding

Taking Grule of food the Yes 179(73.7) 64(26.3) 0.64(0.416,0.98)

child take
No 107(64.1) 60(35.9) 1

Yes 123(62.1) 75(37.9) 1

Eating unwashed fruit
No 163(76.9) 49(23.1) 0.493(0.32,0.76)

Yes 42(56.8) 32(43.2) 2.02(1.2,3.39)

Eating uncooked food
No 244(72.6) 92(27.4) 1
Yes 169(78.2) 47(21.8) 0.42(0.27,0.65)
Prepare child food separately
No 117(60.3) 77(39.7) 1
Water only 171(66.3) 87(33.7) 1.58(1.01,2.48)
Utensil washing Methods
Water and soap 115(75.7) 37(24.3) 1
Hand 160(66.9) 79(33.1) 0.70(0.32,1.54)

Methods of child feeding Cup and spoon 109(76.8) 33(23.2) 0.43(0.19,0.99)

Bottle 17(58.6) 12(41.4) 1

Hand washing Before Food Yes 206(88) 28(12) 0.16(0.098,0.254)

preparation No 116(53.7) 100(46.3) 1

Hand washing Before Food Yes 239(76.1) 75(23.9) 0.49(0.32,0.76)

serving No 83(61) 53(39) 1

Hand washing After visiting Yes 215(82.1) 47(17.9) 0.29(0.19, 0.44)

latrine No 107(56.9) 81(43.1) 1

Hand washing After cleaning Yes 142(87.7) 20(12.3) 0.24(0.14,0.40)

child bottom No 180(62.5) 108(37.5) 1
Soap or Ash 181(75.1) 60(24.9) 0.69(0.46,1.04)
Means of hand wash
Water only 141(67.5) 68(32.5) 1
Vaccinated 221(77.5) 64(22.5) 0.26(0.16,0.42)
Child measles vaccination
status
Not vaccinated 49(47.6) 54(52.4) 1

Vaccinated 208(78.8) 56(21.2) 0.43(0.28,0.65)

Child Rota vaccination status
Not vaccinated 114(61.3) 72(38.7) 1

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Table 8. Multivariate analysis of determinants (Value<0.05) of under-five diarrhea in Harena Buluk district,
Oromia region, Ethiopia, 2018.

Variable name COR(95%C.I) AOR(95%C.I)

0.239(0.152- 0.268
Number of under five children Two and Less
0.375) (0.08,0.902)
in the household
More than two 1 1
0.298
No faces seen in the pit 0.65(0.37,1.14)
(0.097,0.918)
Cleanness of latrine
Faces seen pit of the latrine 1 1
0.046
30 minute and less 0.262(0.17,0.41)
(0.009,0.219)
Time to fetch water from source
More than 30 minute 1 1
0.153
Yes 0.52(0.33,0.82)
Home water treatment (0.038,0.619)
No 1 1
6.025(1.008,
One 3.6(1.74,7.41)
36.007)
Number of rooms Two 1.69(0.98,2.897 0.871(0.231,3.274)
More than two 1 1
0.313
Yes 3.90(2.52,6.04)
Animals live in same house (2.463,28.058)
No 1 1
0.243
Gruel 0.64(0.416,0.98)
Type of food the child take (0.073,0.806)
Other type of food 1 1
0.158 0.195
Hand washing before food Yes
(0.098,0.254) (0.066,0.574)
preparation
No 1 1

health survey 2016 [8], in which the magnitude of and health, environmental and other socio-economic
diarrheal disease among children younger than 5 years variables. The finding on number of under five children
old was 12%, and also the current finding also relatively in the household had impacts on the occurrence of
high compared to a study done in Adama rural district diarrhea in children. It proposed that households with
14.7 % [14] and relatively low compared to a study small number of under-five children experienced low
done in Enderta woreda, Tigray 35.6% [15]. This chance of a child being spared of diarrhea compared to
difference could be attributed to the sample size, study household with large number of under five children. This
period (rainy season), socio-economic and cultural study is consistent with cross-sectional studies done in
difference, and basic environmental and behavioral Benishangul Gumuz [24], west Gojam zone [16] and
characteristics of the respondents. eastern Ethiopia [10]. This might be due to the
Of all the socio-economic variables considered, incapability of the caregiver to care for a large number
only the number of under five children in the household of children. It is possible to suggest that child birth
remained significant after controlling child demographic spacing might have a positive influence on prevention of
diarrhea.

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Freely Available Online

Children of household who had clean latrine or safe drinking water, consumes drinking water of poor
not faces seen around the pit or on the floor of latrine quality due to lack of proper handling and hygiene
were three times less likely to develop diarrhea during transport and storage steps, and lifestyle of the
compared to children of household who had not clean community.
latrine or faces seen around the pit of the latrine. This Children of mothers, who washed their hands
study is consistent with the study conducted in Idiofa, before preparing/cooking food, one of the critical times
Democratic Republic of the Congo [17]. This explored for hand washing, were significantly negatively
that there is a strongly positive relationship of the associated with the occurrence of diarrheal morbidity.
presence of feces around the pit hole with the higher Children of mothers who washed their hands before
prevalence of diarrhea. preparing food were more than five times less likely to
In this study walking time to fetch water from report diarrhea, compared to children of mothers who
source was an important determinant of diarrhea. were not washed their hand before preparing/cooking
Children in households who spend less than 30 min to food. The finding was in agreement with similar study
get water access for domestic purpose were the least conducted in Jigjiga District, Somali Region [15]. Eastern
vulnerable to diarrhea compared with those with who Ethiopia, in Sheko district, Southwest Ethiopia [20]
spend 30 and more minutes to get drinking water. This where mothers’ hand washing habits affected the
finding was in agreement with studies conducted in occurrence of diarrheal disease among their children.
different study areas on the relationship between This indicates that since the mothers were the main
household walk time to water source and child health caregivers for their children they should wash their
outcomes identified walk time to water source as an hands before preparing food infants and young children
important determinant of child health such as study to tackle the occurrence of hygiene related disease.
done in Haremaya , kersa [18] and in Shebedino by Studies have also indicated that the proper hand
Bezatu Mengistu, 2013 [10]. These may be due to the washing before feeding. This study also indicated that
time burden of water fetching has been suggested to poor maternal hand washing practices were positively
influence the volume of water collected by households associated with the occurrence of diarrheal morbidity.
as well as time spent on income generating activities Children living in the house of less than two
and child care. In addition even if the water is obtained rooms were found to have significantly higher of
from an improved source, when the water needs to be developing diarrhea morbidity compared to children from
fetched from a source that is not immediately accessible household that had more than
to the household, it may become contaminated during two rooms. This finding is in agreement with study
transport or storage. conducted in Meskanena, Mareko Woreda, Southern
This study also revealed that availability of home Ethiopia [21] and Debre Birhan [22].
based drinking water treatment practice was an This study also shows that households living
independent predictor of diarrheal morbidity. Children together with the cattle in the same house were
whose household’s families used home based drinking positively associated with the occurrence of diarrhea
water treatment were less likely to prone for diarrheal morbidity. who live separately from cattle were more
disease when compared to those who did not use any than seven times less likely compared to Children from
home based water treatment. Because collected water is the household who live together with cattle in the same
prone for contamination during collection, transportation house. This study is supported by study conducted in
and storage which may in turn increase risk of diarrheal Debre Birhan [22]. Unlikely most of the studies this
diseases. This finding is in agreement with study study revealed that gruel type of food that children took
conducted in Senegal [19], but contradicts with other had four times less likely to develop diarrhea compared
previous studies done in different parts of Ethiopia [16] children who took other type of food (powder milk, cow
This difference might be attributed to the various milk and adult food). This may be due to most of gruel
methods of home based water treatment, and difference types of foods are eaten after cooked and cooked
in the overall sanitation of the environment, access to separately for children; this may contribute for the food

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Freely Available Online

hygiene and to make it free of pathogen organisms and prepared the manuscript.
when compared to cow milk or powder milk. Acknowledgement
In this study, the sanitary facility (availability of We would like to thank Madda Walabu
hand washing facility, availability of latrine, University Goba Referral Hospital, Department of public
type of latrine, and waste disposal method) were not health for their support in the study. We would also like
showed any significant association with to thank data collectors and study participants for their
under-five diarrhea after controlling the other factors. time and support during the study
This is in line with the findings from
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