Introduction

The World Health Organization defines diarrhea as the passage of three or more loose or liquid stools per day [1]. It is caused by bacterial, viral, and parasitic organisms and is usually causes gastrointestinal infection. It can be transmitted through the fecal-oral route and is spread through contaminated food and drinking water or from person to person as a result of poor hygiene and sanitation practice [2]. Whereas acute diarrhea, a major public health problem, is characterized by abrupt onset of frequent, watery, loose of stools with blood or without blood, and mucus in feces lasting less than two weeks. Usually, acute watery diarrhea episodes subside within 72 hours of onset. It may be accompanied by flatulence, malaise, and abdominal pain. Nausea, vomiting may occur and also fever may be present [3].

Next to pneumonia, it is the leading cause of death in children under-five years old. Globally, there are nearly 1.7 billion cases of childhood diarrheal disease every year [2]. In developing countries, acute gastroenteritis is one of the most common causes of consultation in the emergency room and admission among the pediatric age group [4]. Morbidity in young children is a serious problem because early childhood is a critical period in terms of development. Physical growth and cognitive pathways during this period are faster than during any other time. Disruption of these processes by acute diarrhea in the short term can lead to mortality and have long term consequences [5].

Annually, an estimated 1.3 million under-five deaths are attributed to diarrheal diseases, and most affecting children in resource-limited countries [5]. Young children in Africa and South-east Asia are most vulnerable with the incidence of severe gastroenteritis being highest in the first 2 years of life. Morbidity due to diarrhea is further concentrated in marginalized communities within resource-limited countries. Despite improvements in the standard of living, advances in sanitation, water treatment, and food safety awareness, diarrheal disease still accounts for significant economic and societal losses [5]. In Ethiopia, diarrheal diseases are the major contributors to under-five mortality. According to the 2016 Ethiopia Demographic and Health Survey report,12% of under-five children had a diarrheal episode and among sick under 5 children, about 56 percent for whom advice or treatment was not sought in the 2 weeks before the survey [6]. Studies conducted in different parts revealed that, diarrhea is one of the common causes of under-five mortality; the prevalence’s ranges from 8% to 32% that is in Mecha district a community based, cross sectional study (8%) [7], Farta district 17%, Dejen district, a community based, cross-sectional study (24%) [8], Jabithennan District, a community based, cross-sectional study (25%) [9], a systematic review and meta-analysis conducted based on 31 studies revealed that 27% in Afar region, 26% in Dire-Dawa, and 24% in Addis Ababa [10].

Socioeconomic status (SES) affects health care quality and education. Moreover, SES affects the diet, housing conditions, and increases the likeliness of acquiring infectious diseases. Children in households with lower socioeconomic status receive oral rehydration therapy less often than children in households with higher socioeconomic status [1, 7, 11]. The same is true in Siyadebirena Wayu district, North Shoa, Amhara Regional States Ethiopia in which acute diarrhea is the common problem of children aged 6–59 months. As of the 2017 or 2018 annual performance report of the health office, it was the top leading causes of under-five morbidity in the district. However, there was no scientific evidence of causative factors [12]. Thus, this study was aimed to assess behavioral and environmental determinants of acute diarrhea among under-five children from public health facilities at Siyadebirena Wayu district, North Shoa Zone, Amhara, Ethiopia.

Methodology

Sampling techniques

Siyadebirena Wayu district has 3 health centers and 1 primary hospital. Deneba Health Center was selected randomly and Deneba primary hospital was included in this study due to accessibility and feasibility reasons. A systematic random sampling technique was used to select 315 study participants. Cases were proportionally allocated to the health centers and primary hospital-based on the previous 2 months’ experience. By considering the last two months’ performances of under-five children who visited health institutions cases and controls were selected by a systematic random sampling technique. Hence, K (sampling interval) was 2 for cases and 3 for controls. The first case and control to be included in the sample were chosen randomly, then every 2^nd for cases and every 3^rd for controls were taken until the sample size was reached (Fig 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Fig 1. Sampling procedures for cases and controls in Siyadebirena Wayu district, North Shoa Zone, Amhara region, Ethiopia, 2019.

https://doi.org/10.1371/journal.pone.0259828.g001

Data processing and analysis

The data were entered into EPI-data version 3.1 for windows and exported to SPSS 20 for windows for analysis. The first step before analysis was data exploration to visualize the general feature of the data to be analyzed. After exploration, bi-variate analysis and multi-variable analysis were performed step by step.

The bi-variate analysis using cross-tabulation and bi variable logistic regression was done. Bi-variate analysis using cross-tabulation was done to determine the distribution of study subjects by independent variables of interest. Bivariate logistic regression technique was done to see the crude association between the independent variables and the dependent variable.

The final step of the analysis was multivariable analysis using a hierarchical logistic regression technique to assess the relative effect of the explanatory variables on the outcome variable. Independent variables which result in a p-value less than 0.20 [15] in an unadjusted model are candidates to be considered for the final multivariable model. Multivariable logistic regression was fitted to obtain adjusted odds ratios (AOR) after controlling the confounding effects of different variables and to determine factors associated with the outcome variable. Significance level at p-value less than 0.05 with a 95% confidence interval (CI) was taken to decide that there is a significant association between outcome and explanatory variables. Hosmer-Lemeshow goodness of fit test was performed to check the adequacy of the final model (Table 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Model describing the hierarchical logistic regression analysis on the determinants of acute diarrheal disease among children aged 6–59 months in public health facility in Siyadebirena Wayu district, Ethiopia, 2019.

https://doi.org/10.1371/journal.pone.0259828.t001

Results

Determinants of acute diarrhea among under-five children

After controlling the confounding effects of independent variables, the following variables were statistically significant in a multivariable analysis at a 5% significance level. These predictors were family monthly income (AOR = 6.22; 95% CI: 1.30, 29.64), hand washing without soap (AOR = 3.75, 95% CI: 1.16–12.13), families who did not treat their drinking water at home (AOR = 9.36; 95% CI: 2.73, 32.08), families who dispose infant feces outside the latrine (AOR = 11.01; 95% CI: 3.37, 35.96), mothers/caregivers who had poor knowledge about the major risk factors of acute diarrhea (AOR = 15.3; 95% CI: 4.18, 55.88), and families who consume leftover food at room temperature (AOR = 5.52; 95% CI: 1.60, 19.03) (Table 2).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Factors associated with acute diarrhea among children aged 6–59 months who visited selected public health facilities in Siyadebirena Wayu District, North Shoa Zone, Amhara region, Ethiopia, 2019.

https://doi.org/10.1371/journal.pone.0259828.t002

Discussion

Childhood diarrhea diseases have been hypothesized by different studies to be associated with socio-demographic, environmental, and behavioral factors. This study tried to assess potential amenable factors of acute diarrhea among children aged 6–59 months at the health facility level.

The average monthly income of the family was one of the predictors of childhood acute diarrhea. Children whose family average monthly income between 12–23 USD was about 6 times more likely to contract acute diarrhea than children whose income was more than 24 USD. This finding was similar to studies conducted at Gaza strip where the richer children’s family the lesser to develop diarrhea [16]. These studies state that children living in poor households have higher rates of infection with acute diarrhea than their wealthier counterparts. The reasons probably could be because of inadequate access to sanitary facilities, unsanitary environments in the home, and poor hygienic practice of children’s’ parents. Moreover, children from these household could not afford clean and safe food. At the same time, rich families may have greater opportunity to use soap for handwashing and aqua-guard at their houses to protect microbial contamination in water, and they may construct toilets. However, the monthly income of the family was not significant in other studies [11, 17]. The possible explanation for this difference might be explained by socio-demographic variations between study participants.

The current study showed that children from mothers who washed their hands without soap were nearly 4 times more likely to develop acute diarrhea than those children whose mothers washed their hands with water, and soap. In a parallel way, a study done on under-five diarrhea in Jabithennan district reported that being from mothers of poor handwashing practice was significantly associated with childhood diarrhea disease (AOR = 5.53; 95% CI: 2.19, 13.99) [9]. Similarly, studies conducted at Dejen, Northwest Ethiopia (AOR = 1.61; 95% CI: 1.04, 2.84) [8], Hadaleala, Afar Region, Northeast Ethiopia (AOR = 24.94; 95% CI: 6.68, 93.12) [18], and Farta district, North West Ethiopia (AOR = 1.59; 95% CI: 1.11, 2.27) [19] found that mothers handwashing practices without soap were associated with increased risk of acute diarrhea in their children. A study was done in the Philippines strengthen the idea; handwashing with soap is most effective in reducing acute gastroenteritis by 42–47% [4]. A study conducted at Keresa district [20] supported this evidence too.

The quality of the drinking water supply is another predictor of childhood diarrhea. It was found that children whose families did not treat drinking water at their homes were 9 times more likely to develop acute diarrhea compared with those families who treated water for drinking purpose. This finding is in agreement with study from Pawi Hospital (AOR = 2.46; 95% CI: 1.32, 4.57) [17], Derashe district, southern Ethiopia (AOR = 2.25; 95% CI: 1.43, 3.56) [21], Wolaita Soddo town (AOR = 2.34; 95% CI: 1.33, 4.14) [22]. However, it contradicts with previous studies in Northern Gondar and Yaya Gulele in which household water treatment was not significant for acute diarrhea [23, 24]. This can be justified by the fact that collected water is liable for contamination during collection, transportation, and storage which may, in turn, increase the risk of diarrheal diseases. In addition, the discrepancy might be explained by design difference since other studies, unlike the present study, used cross-sectional study design.

The proper disposal of children’s feces is extremely important in preventing the spread of diarrhea disease. Contact with human feces directly, or indirectly by animal, can lead to diarrhea diseases. In this study, families who dispose infant feces outside the latrine were 11 times more likely to develop acute diarrhea compared with children whose families disposed infant feces inside the latrine. Similarly, study conducted in Dejen district (AOR = 1.53; 95% CI: 1.05, 2.24) [8], Chire district (AOR = 3.69; 95% CI: 1.13, 5.93) [14], Pawi Hospital (AOR = 2.72; 95% CI: 1.54, 4.81) [17], West Gojjam (AOR = 1.90; 95% CI: 1.12, 3.22) [25], and Benishangul Gumuz Regional State (AOR = 0.49; 95% CI: 0.34, 0.78) [26] showed the association of diarrhea diseases and improper disposal of human feces. In a similar fashion, studies done in Nigeria and Indonesia also supported that safe and proper disposal of children’s feces is highly important in preventing the spread of disease, as direct contact with human feces can cause diarrhea and/or other related infectious diseases [27, 28]. This implies that the safe disposal of feces can inhibit the direct contamination of farmed crops, indirect contamination of water supplies, a breeding place for flies, and a source of the fecal pathogens that flies can spread. However, some studies reported that proper disposal of child feces is not significantly associated with diarrhea diseases[29, 30]. The difference might be attributed to methodological variation and socio-demographic variations of study participants.

Since diarrhea disease transmits from person-to-person, leftover food can act as a mechanism for indirect transmission of diseases. Our study showed that children who consumed left-over food stored at room temperature were 5.52 times more likely to have diarrhea compared with children who did not consume left-over food. This pattern was consistent with studies conducted in Derashe district in which children who consumed left-over food stored at room temperature were more likely to have diarrhea compared with children who did not consume (AOR = 1.65; 95% CI: 1.01, 2.71) [21]. This idea was also supported by a similar study conducted in Hadaleala district, Afar Region, Northeast Ethiopia, which strengthens that diarrheal disease was highly prevalent among children who didn’t eat foods immediately after cooking (AOR = 3.74; 95% CI: 1.48, 9.45) [18].

Moreover, as knowledge is the foundation for committing healthy behavior, children’s’ mothers/ care givers with poor knowledge on the major risks of acute diarrhea were 15 times more likely to develop acute diarrhea than children whose families had good knowledge. Similarly, a study conducted in Chire district, Ethiopia reported that the maternal or caretakers’ knowledge has a significant preventive and control effect on diarrhea disease (AOR = 4.00; 95% CI: 2.52, 6.35) [14]. This could be explained as the more the respondents are knowledgeable about the mechanism of disease transmission, the more they practice the different preventive measures [31]. This study also showed that mothers/ caretakers’ knowledge on appropriate actions taken to their children when they had acute diarrhea was independently associated. Thus, the lesser appropriate action taken corresponds to 14 times higher risk of diarrhea among children with poor knowledge about the actions taken to the child. This result implies that it is possible to reduce acute diarrhea by increasing awareness of mothers about actions taken to acute diarrhea. On the contrary, a study done in Surakarta reported that poor knowledge of mothers about healthy life is a risk factor that causes diarrhea in infants (AOR = 2.30; 95% CI: 3.46, 1.14) [31]. Similarly, developing diarrhea was higher among children whose mothers/caretakers had better knowledge about the causes of diarrhea and had handwashing practice (AOR = 2.46, 95% CI: 1.07, 5.63) [22]. However, a study done in Arba Minch Zuria district stated that knowledge is not a significant predictor [32]. This disagreement might be attributed to methodological differences as the study done in Arba Minch district used a cross-sectional study design.

In summary, the findings of this study have a paramount implication for the control of diarrhea morbidity among under-five children. It would provide helpful insights for stakeholders and program implementer working on the potential risk factors of acute diarrhea to take priority interventions in order to prevent and control the disease. One of the strengths of this study was its design being a case-control, and cases and controls confirmation was done by a physician provides strong evidence for the association. However, this study did not identify the causative agents and the pathogens involved in different factors. For example what type of microbes were involved during improper handwashing, untreated drinking water, and consumption of leftover food were not explained. Other limitations can be, the results might have been biased because of potential recall bias; however, this was minimized by using reported-incident cases within two weeks. Some behavioral practices including handwashing practices used in the analysis were self-reported by the respondents; self- reported data have been found to introduce inaccuracy and bias into estimates of behavior. Moreover, the wider confidence interval as a result of smaller frequency in some categories of predictor variables may reduce the precision of the measure of association. Therefore, the use of this study findings should be considered as having these inherent limitations.

Conclusion and recommendations

In conclusion, the potential determinant factors for childhood diarrhea morbidity were improper hand washing, not treating drinking water at home, unsafe disposal of child feces, consumption of leftover food at room temperature, mothers’ poor knowledge about the major risk factors for diarrhea, mothers’ poor knowledge on action to be taken after children develop acute diarrhea, and low monthly income of the family. Therefore, health workers are highly recommended to take actions on the contextual behavioral factors of acute diarrhea and should provide regular health education on the prevention and control of childhood acute diarrhea. District health office should plan strategies for the distribution of disinfectant to treat drinking water at home level and to reach the rural community where the risk of water-borne diseases is high. Furthermore, effective educational programs that emphasize hand washing practice with soap at critical period, safe disposal of human excreta, community lead total sanitation, and promote eating foods immediately after cooking, avoid eating leftover foods should be strengthened in collaboration with health extension workers’ who integrate water hygiene and environmental sanitation while conducting a home visit. Lastly, other researchers are advised to further identify the causative agents and the pathogens involved in different risk factors of acute diarrhea.

Supporting information

Acknowledgments

We would like to thank the Department of Public Health, College of Health Sciences, Debre Berhan University for their facilitation and guidance to undertake this work. Besides, we are very glad to forward our special thanks for the unlimited assistance of Siyadebirena Wayu district Health Office for their cooperation and provision of the necessary information for this project. Last but not least, our acknowledgment goes to study participants, data collectors, and supervisors for their willingness to exert their efforts and time sacrificed for this study.