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

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.


Introduction Back Ground
Diarrhea is defined as a child with loose or watery stool for three or more times during a 24-hours period and caused by a host of bacterial, viral, protozoa and parasitic organisms. Rotavirus and Escherichia coli are the two most common etiological agents of moderate-to-severe diarrhea in low-income countries. It is more common when there is a shortage of adequate sanitation and hygiene and safe water for drinking, cooking and cleaning, improper feeding practices, and poor housing conditions [1]. Though most episodes of childhood diarrhea are mild, acute cases can lead to significant fluid loss and dehydration, which may result in death or other severe consequences [2].
Despite global success in the reduction of all cause and diarrhea specific mortality in the past 30 years, diarrhea remains the second leading cause of death due to infections among children under five years of age worldwide and account for 1,400 children death every day, around 1 in 10 child deaths worldwide due to diarrhea in 2015. It is more than the death of children due to AIDS, malaria, and measles combined [3]. It is estimated that diarrhea accounted for 9.9% of the 6.9 million deaths among children under 5 in 2011 [4]. Young children are especially vulnerable bearing 68% of the total burden of diarrhea disease. Among children less than five years, diarrhea accounts for 17% of all deaths [2].
While it is both preventable and treatable, each year around 526 000 deaths of under-five children and nearly 1.7 billion cases of childhood diarrheal disease every year. This rate varies between regions, Most deaths from diarrhea occur among children less than 2 years of age living in South Asia and sub-Saharan Africa many of those who survive suffer from malnutrition and lasting impairments to mental and physical development [2,5]. Diarrheal deaths are exceedingly prevalent in just a handful of countries and half of deaths due to diarrhea.
A large proportion of diarrheal disease in developing world is due to multiple risk factors are indicated, namely unsafe water supply, lack of water linked to inadequate hygiene, poor personal and domestic hygiene and agricultural practices, contact with unsafe water, inadequate sanitation and quality and quantity of water, availability of toilet facilities, housing conditions, level of education, household economic status, place of residence, feeding practices, and the general sanitary conditions around the house cause various disease outcomes, mainly diarrheal About 88% of diarrhea-associated deaths are attributable to unsafe water, inadequate sanitation, and insufficient hygiene.
As simple as hand washing may seem, it is one of the most important factors in preventing the spread of germs and staying healthy. Unwashed hands can accelerate the spread of bacteria, parasites, and viruses that are transmitted from human and animal faeces or the environment [6]. Nowadays, globally diarrhea accounts for 9% of all deaths among children under the age of five [7].
The morbidity and mortality related to diarrheal diseases in under-5 children are still sizeable and persistent in low income countries, especially in sub-Saharan Africa, and pose a significant, long-standing public health concern. Diarrhea is one of the major contributors to deaths for under age 5 children in Ethiopia. Diarrhea contributes to more than one in every ten (13%) child deaths in Ethiopia. The percentage of children under age 5 who had diarrhea accounts 12% in 2016 [8].
Diarrheal diseases are among the leading causes of under-five deaths worldwide. Globally diarrhea accounts for 9% of all deaths among children under the age of five. Low income nations like India, Nigeria, the Democratic Republic of Congo, Pakistan, and Ethiopia are hit especially hard. In these countries, children are often exposed to pathogens because of poor environmental sanitation and water supplies [7]. Childhood mortality rate in general and infant mortality in particular, are often used as broad indicators of social development or as specific indicators of health status. infections [5].
As compared with other regions of the world, the African region shows the smallest reductions in mortality rates and the most marked slowing down trend. The under-five mortality rate in the African region is seven times higher than that in the European region.
Though Ethiopia has recorded significant reduction in childhood mortality, still many children die from diarrhea before their 5th birth day. Over two-thirds of child deaths in Ethiopia are due to infectious diseases such as pneumonia, diarrhea, malaria, and measles; and problems of the newborn. Moreover diarrhea is the second cause for clinical presentation among under five-year child population next to pneumonia in Ethiopia .Nationally, diarrhea prevalence is 12% in 2016 and it is more abundant in rural than urban areas [8]. Even though improvement was made in reducing childhood mortality from 123 under five deaths per 1,000 live births in 2005 to 59 under five deaths per 1,000 live births in 2016, children in the country still suffer from diarrhea, respiratory problems and malnutrition [8].
Variations across communities in factors like accessible, safe and adequate water supply, environmental sanitation and person hygiene, availability and quality of MNCH services and facilities, maternal education level, place of residence (urban/rural) could play significant roles on diarrhea morbidity and mortality in a specific community. Thus this study was aimed to assess the magnitude and determinants of diarrhea morbidly in under-5 children at Harena Buluk wereda. Studies conducted that aimed to assess diarrhea morbidly in conjunction with its determinant factors among under-5 children at community level in Ethiopia particularly in the context of Bale zone, Harena Buluk wereda are limited. This suggests that many more studies are remaining to be done.
Even though there are different diarrhea prevention strategies and policies including the health extension program in the ground, diarrhea is still the leading cause of morbidity among children visiting under five years clinic in the study area. In addition to this the 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 and associated factors of diarrhea among under-five children in Harena Buluk woreda by the year of 2018.

Definitions of Key Terms
Diarrhea is defined as having three or more loose or watery stools per twenty four hours in two weeks period preceding the data collection, as reported by the mother/care taker of the child(WHO, 2010).
Prevalence of Diarrhea the number of diarrhea cases at the time of the interview divided by the total number of households included in the study. Exclusive Breast Feeding A child who receives breast milk only and no other food, solid or liquid with the exception of vitamins, minerals and medicines [1]. Improved Water Source Water from protected springs and/or wells, from pipe and from distribution post unless considered as unimproved [1]. Improved Latrine pour flush to piped sewer system/ septic tank/pit latrine, VIP and pit latrine with slab otherwise considered as unimproved [1].
Care Giver Hygiene is personal hygiene of the caregivers like short finger nail cut or long fingernail which could be factors for the occurrence of diarrheal disease among children Appropriate Hand Washing Practice is the way of child caregiver hand washing practice which shows clean hand palm, fingertip and between-fingers observed by data collectors to determine its relationship with the occurrence of diarrheal.
Hand Washing Facility refers to households having hand washing facilities like plastic or metal with water seated nearest to latrine for children to wash their hands after latrine utilization as observed by data collectors.
Hand Washing during Critical Time refers to caregivers' hand washing practice after utilization of latrine, before food preparation and child-feeding as identified by caregivers' oral report of their practice to identify its relationship with diarrheal occurrence Index Child refers to a child that was included in the study from a household to have information on the demographic and health characteristics.

Description of Study Area
The study was conducted in Harena Buluk woreda and data was collected in February, 2018. Harena Buluk is one of the pastoral woredas found in Bale zone of Oromiya region, Southeast Ethiopia. The study site is approximately 582 kilometers away from Addis Ababa and 152 kilometers from Bale Robe, the capital city of Bale zone. It is bounded by Goba, Madda Walabu, Delo Mena and Adaba woredas to the north, south, east and west direction respectively. The district is divided in to thirteen rural and one urban kebeles (the smallest administrative unit in Ethiopia), having a total population of 106, 987 residents. The total households of the district were 22899 and 17,587were children under five years of age. It had 52 primary and 3 secondary schools. The population is predominantly Muslim by religion. The main weather condition of the woreda is kola (low land) with some part of it having weyna-dega (mid land) weather condition which is accounts about 9 and 5 kebeles respectively. Agriculture and pasturing is the main sources of the district's livelihood. Health services in the district were provided by 5 health centers and 18 health posts. At the kebele level, health care is delivered by health extension workers who are assigned to render health services at the local level.

Study Design and Period
A community based cross-sectional study was done to assess the magnitude and associated

Sample Size Determination
Using EPI INFO for window version 7, sample size was calculated for each specific objective and the highest sample size is taken. Using single population proportion formula by considering 23% of the under five-children had two-week prevalence of diarrhea from a study done in Kersa, Eastern Ethiopia by Bezatu Mengistie, Yemane Berhane, Alemayehu Worku, 2011 with 95% confidence level, 5% desired precision and taking design effect of 1.5, accounted for two stage sampling [10]. Adding 10% for none response rate, the total calculated sample size was 450 mothers with less than five years children.

Sampling Techniques
Multistage sampling was employed to select kebeles and households which have under-five children in the woreda. In the first stage all the kebeles stratified by place of residence as urban (only one small kebele) and rural. On the second stage the rural kebeles again stratified based on geographical and climate condition as low land/pastoral and mid land/agrarian kebeles because the residence area (urban and rural) and geographic/ climate condition by itself make a difference in socio economics among source population. From the total 13 rural kebeles 5 are mid land and 8 are low land. Then, from each stratum kebeles to be included in the study was allocated proportionally and selected randomly. Therefore, from rural strata 3 low land and 1 mid land kebeles as well as the only one kebele from urban strata taken as study population, from which the study unit was selected. As a result 5 kebeles were selected out of the total of 14 kebeles found in the district.
Similarly the number of households to be a study unit selected from each kebeles allocated proportionally. The systematic random sampling technique was used to take the mothers/caretaker-child pairs from each of the selected kebeles (small villages). Households with at least one under five years of age child was eligible for the study. One child-mother pair was selected at random to collect information on the child's demographic and health characteristics for households with two or more under 5 years of age children. The first household was selected randomly and the subsequent households were selected systematically until the proportionately allocated sample size fulfilled.
When the selected households had no under-five children, the next neighborhood household was selected.
A brief illustration of the sampling procedure is displayed in the figure below.

Data Collection Instrument and Data Quality Control
The questionnaire was prepared based on EDHS and WHO core questionnaires related to diarrhea. The questionnaire was written in English, translated into Afan Oromo (local language), and then translated back into English to assure its accuracy. In order to ensure data quality data collectors and supervisors were trained on the data collection procedure. Data collection process was supervised by the principal investigators and supervisors. The filled questionnaire was checked for completeness and consistency on daily bases.

Data Collection Methods
Data was collected by interview using adapted standard questionnaire and administered by an interviewer. The respondents were primarily mothers of eligible children-under five years of age, but in the absence of the mother, the next primary caregiver will be interviewed. Five data collectors who were clinical nurses and Afan Oromo speakers were trained in questionnaire administration and data collection procedures. Pretest was done in 5% of the total sample size in another Kebele of the same study area. The result of the pretest was used to correct some unclear ideas and statements. The data collection was supervised by two supervisors (Health Officers) and the principal investigator at the center. Their role was to daily check the consistency, clarity and completeness of the collected questionnaires. The data collectors along with their supervisors took two days training about the questionnaire and data collection procedures.

Study Variables
The dependent variable is prevalence of diarrhea in under-five year children in the last two weeks period. The independent variables are socio-demographic factors such as place of residence, household size, parental education, maternal occupation, maternal age, number of children under-five years of age, family size and child's age and sex. Environmental factors were type of water source, distance to the water source, availability of latrine facility, availability of hand washing facility, number of rooms, livestock in house and refuse disposal method. Behavioral factors were feeding practices, hand washing practice, home based water treatment, duration of breast-feeding, breast feeding status, and time of introducing supplementary feeding.

Data Analysis
The data was coded and entered in to a computer using Epi-data 3.1 software and exported to SPSS V.20statistical software for cleaning and further analysis of the data. Descriptive statistics was done to describe the study populations using measures of frequency, disease occurrence, central tendency and dispersion that were displayed using tables and graph. The necessary assumption of logistic regression was checked using Hosmer and Lemeshow goodness-of-fit-test statistics. Due to the binary nature of the outcome variable, binary logistic regression analysis was used to determine the OR and 95% CI of the effect of the different independent variables on the outcome variable. To reduce excessive number of variables and instability of the model, only variables with P. value < 0.2 in the bivariate analysis will be considered for inclusion in the multivariate analysis to control for the effect of confounders. Variables with P-value < 0.05 in the multivariate analysis (final model) will be considered as independently associated with the outcome variable.

Ethical Consideration
Ethical approval and clearance was obtained from the research review committee of Madda Walabu University Goba Referral Hospital, Department of Public Health. Permission was obtained from concerned bodies of Harena Buluk district. Full verbal consent was obtained from the mothers/caretakers of the child after clear explanation given about the aim of the study. Confidentiality and privacy was maintained during data collection, analysis and reporting in which the information obtained from the respondents was not shared with anyone other than the data collectors and principal investigator. For Children with diarrhea and not get appropriate treatment during the data collection time, the data collectors were provide ORS and advised their family to take them to the nearby health institution for better management.

Result
A total of 450 households were included in the study and a complete response (100%) was obtained from all respondents. The mean age of the respondents   (Table 3).

Demographic and Health Characteristics of the Indexed Children
Two hundred thirty one (51.3%) of the children were females with the majority of the children 161 (35.8%) were in the age group of 12-24 months. The mean age of the children was 24.55(±13.63 SD) months. 263(58.4%) and 285(73.5%) of the children receive Rota and measles virus vaccine respectively. In this study, 128(28.4%) of the children had experience diarrhea in the two weeks period preceding the study ( Table 4).

Factors of Childhood Diarrhea
In the bivariate analysis number of under five children in the household, household family size, occupation of mother, education of the fathers, occupation of fathers, place of Residence, religion, average family monthly income were found to be significantly associated with under-five diarrhea. The . Children of house hold whose income more than one thousand were less likely to develop diarrhea compared to children of household whose income were one thousand and less birr per month [COR: 0.387, 95% CI(0.245,0.611)].Children of mothers whose occupation house wife were four times more likely to experience diarrhea as compared Children of mothers whose occupation were government employee. Children of mothers whose occupation were farmer three times more likely to have diarrhea compared to government employee Likewise children of mothers whose occupation were merchant two times more likely to have diarrhea compared to government employee. In this study Educational status of the mother, Age of mothers category, Occupation of fathers, Marital status, Ethnicity, Relation of respondents to child and Monthly income of family were not showed significant association with under five diarrhea (    (Table 6).

Behavioral Determinants
In the bivariate analysis, current breast feeding status, type of food the child take (Powder milk and gruel), eating unwashed fruit, eating uncooked food, prepare child food separately, utensil washing methods, methods of child feeding, hand washing before food preparation, hand washing before food serving, hand washing after visiting latrine, and hand washing after cleaning of child bottom were the behavioral variables that showed significant association with under-five diarrheal morbidity.    (Table 7) Factors for Under-five Diarrhea: Multivariate Analysis In the bivariate analysis any possible confounders were not controlled and assessing the independent effects of the covariates was difficult. So, an enter method of binary logistic regression technique was used to assess the independent effects of Time take less than 30 minuet to fetch water from source was 16.7 times less likely to develop diarrhea compared to time take more than 30 minutes to fetch water from source to home [AOR: 0.046, 95% CI (0.01,0. 22)]. children in the households who treat water before drinking were 1.9 times less likely to had diarrhea compared to children in the households who do not treat water at home before using (AOR = 0.15, 95% CI: (0.04, 0.62). The odds of under five years of age children who live in house with one room had 6.01 times more risk of diarrhea as compared to the odds of children who live in house with more than two rooms [(AOR = 6.01, 95% CI(1.01,36.01)]. Children living with animals in the same house were more likely to develop diarrhea compared to children live in the house separately from animals [AOR: 8.31, 95% CI (2.46,28.06)]. Children who take gruel type of food were four times less likely to develop diarrhea as compared to children taking other type of food [AOR: 0.24, 95% CI (0.07,0.81)] (Table 8)

Discussion
In this study the magnitude of under-five diarrhea in this study was 28.4% which is relatively similar with study conducted in India 25.2% [11], Cameron 23.8% [12], Rwanda 26.7% [13], Jabithennan District 26.1% [14], Jigjiga district 27% [15], and eastern Ethiopia kersa, Demographic Surveillance and Health Research Center (KDS-HRC) field site 22.5% [10]. However, the current finding was higher than the finding of the Ethiopian demographic and  health survey 2016 [8], in which the magnitude of diarrheal disease among children younger than 5 years old was 12%, and also the current finding also relatively high compared to a study done in Adama rural district 14.7 % [14] and relatively low compared to a study done in Enderta woreda, Tigray 35.6% [15]. This difference could be attributed to the sample size, study period (rainy season), socio-economic and cultural difference, and basic environmental and behavioral characteristics of the respondents.
Of all the socio-economic variables considered, only the number of under five children in the household remained significant after controlling child demographic and health, environmental and other socio-economic variables. The finding on number of under five children in the household had impacts on the occurrence of diarrhea in children. It proposed that households with small number of under-five children experienced low chance of a child being spared of diarrhea compared to household with large number of under five children. This study is consistent with cross-sectional studies done in Benishangul Gumuz [24], west Gojam zone [16] and eastern Ethiopia [10]. This might be due to the incapability of the caregiver to care for a large number of children. It is possible to suggest that child birth spacing might have a positive influence on prevention of diarrhea. Children of household who had clean latrine or not faces seen around the pit or on the floor of latrine were three times less likely to develop diarrhea compared to children of household who had not clean latrine or faces seen around the pit of the latrine. This study is consistent with the study conducted in Idiofa, Democratic Republic of the Congo [17]. This explored that there is a strongly positive relationship of the presence of feces around the pit hole with the higher prevalence of diarrhea.
In this study walking time to fetch water from source was an important determinant of diarrhea.
Children in households who spend less than 30 min to get water access for domestic purpose were the least vulnerable to diarrhea compared with those with who spend 30 and more minutes to get drinking water. This finding was in agreement with studies conducted in different study areas on the relationship between household walk time to water source and child health outcomes identified walk time to water source as an important determinant of child health such as study done in Haremaya , kersa [18] and in Shebedino by Bezatu Mengistu, 2013 [10]. These may be due to the time burden of water fetching has been suggested to influence the volume of water collected by households as well as time spent on income generating activities and child care. In addition even if the water is obtained from an improved source, when the water needs to be fetched from a source that is not immediately accessible to the household, it may become contaminated during transport or storage.
This study also revealed that availability of home based drinking water treatment practice was an independent predictor of diarrheal morbidity. Children whose household's families used home based drinking water treatment were less likely to prone for diarrheal disease when compared to those who did not use any home based water treatment. Because collected water is prone for contamination during collection, transportation and storage which may in turn increase risk of diarrheal diseases. This finding is in agreement with study conducted in Senegal [19], but contradicts with other previous studies done in different parts of Ethiopia [16] This difference might be attributed to the various methods of home based water treatment, and difference in the overall sanitation of the environment, access to safe drinking water, consumes drinking water of poor quality due to lack of proper handling and hygiene during transport and storage steps, and lifestyle of the community.
Children of mothers, who washed their hands before preparing/cooking food, one of the critical times for hand washing, were significantly negatively associated with the occurrence of diarrheal morbidity. Children of mothers who washed their hands before preparing food were more than five times less likely to report diarrhea, compared to children of mothers who were not washed their hand before preparing/cooking food. The finding was in agreement with similar study conducted in Jigjiga District, Somali Region [15]. Eastern Ethiopia, in Sheko district, Southwest Ethiopia [20] where mothers' hand washing habits affected the occurrence of diarrheal disease among their children. This indicates that since the mothers were the main caregivers for their children they should wash their hands before preparing food infants and young children to tackle the occurrence of hygiene related disease. Studies have also indicated that the proper hand washing before feeding. This study also indicated that poor maternal hand washing practices were positively associated with the occurrence of diarrheal morbidity.
Children living in the house of less than two rooms were found to have significantly higher of developing diarrhea morbidity compared to children from household that had more than two rooms. This finding is in agreement with study conducted in Meskanena, Mareko Woreda, Southern Ethiopia [21] and Debre Birhan [22].
This study also shows that households living together with the cattle in the same house were positively associated with the occurrence of diarrhea morbidity. who live separately from cattle were more than seven times less likely compared to Children from the household who live together with cattle in the same house. This study is supported by study conducted in Debre Birhan [22]. Unlikely most of the studies this study revealed that gruel type of food that children took had four times less likely to develop diarrhea compared children who took other type of food (powder milk, cow milk and adult food). This may be due to most of gruel types of foods are eaten after cooked and cooked separately for children; this may contribute for the food DOI : 10 Sheko district rural community [23]. But it is in contrast with cross-sectional studies done in Benishangul-Gumuz Regional State [24] and west Gojam zone [16]. This may be explained by having of this facilities doesn't necessarily indicate their utilization and again may be due to the homogeneous effect of the populations.

Conclusion
From this study we conclude that the magnitude of diarrhea among under five children was 28.4% and this was relatively high despite health extension package and water and sanitation programs were conduct in the district. The independent variables that were found to be the major predictors of under-five diarrhea were number of under five children in the household, number of rooms in the house, sanitation status/cleanness of latrine, living with animal in the same house, hand washing before food preparation, time take to fetch water from the source, home based water treatment, and type of food children take. The sanitation facilities (availability of latrine, type of latrine, hand washing facility, and waste disposal method) and source of water supplies were not showed any significant relation with the occurrence of diarrhea. So, expanding family planning service and improve the utilization rate, constructing improved water source and giving HE to the community about home and environmental sanitation and hand washing methods at critical hand washing time were recommended.