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Bizuneh et al.

BMC Pediatrics (2017) 17:182
DOI 10.1186/s12887-017-0934-5

RESEARCH ARTICLE Open Access

Factors associated with diarrheal morbidity
among under-five children in Jigjiga town,
Somali Regional State, eastern Ethiopia: a
cross-sectional study
Hailemichael Bizuneh1* , Fentabil Getnet2, Beyene Meressa2, Yonatan Tegene3,1 and Getnet Worku1

Abstract
Background: The prevalence of underfive diarrhea in Somali Regional State, Ethiopia is one of the highest in the
country. This study attempted to examine the multiple factors associated with underfive diarrhea and how they
might influence its prevalence in Jigjiga, Somali regional state, Ethiopia.
Methods: A community based cross-sectional study was conducted from February 15 to 28, 2015. Multistage
sampling technique was used to collect data from 492 mothers via household survey. A pre-tested, structured
questionnaire was used to collect data through face-to-face interview. Ethical clearance was obtained before data
collection. Stepwise multivariable logistic regression was used to calculate adjusted odds ratios.
Results: The two weeks prevalence of under five diarrhea in Jigjiga town was 14.6%. Up on multivariable analysis,
maternal educational level of primary school and above was found to be protective against childhood diarrhea
[AOR: 0.227(0.100–0.517)] whereas, unavailability of water [AOR: 2.124(1.231–3.664)] and lack of hand washing facility
[AOR: 1.846(1.013–3.362)] were associated with diarrhea.
Conclusion: Poor water supply, lack of hand washing facilities and lack of formal maternal education were
associated with underfive diarrhea in the study area. Improved access to water supply along with environmental
health intervention programs designed to promote good hygiene behavior could be of paramount importance to
alleviate burden of childhood diarrhea.
Keywords: Underfive, Diarrhea, Factors, Hygiene, Jigjiga, Ethiopia

Background mortality in Ethiopia is still a long way ahead if the
Diarrhea is one of the leading infectious causes of mor- country is to achieve the Millennium Development Goal
bidity and mortality in underfive children [1, 2]. In 2015, 4 target of reducing the underfive mortality rate by
it was estimated that 1.3 million deaths were caused by two-thirds between 1990 and 2015. In 2010, in Ethiopia,
diarrheal diseases, of which 499,000 were underfive diarrhea was responsible for 8% of all under-5 mortality
children [3]. Eventhough decline in diarrheal diseases and 13% of morbidity amongst under five children. The
is reported [4] Sub-sahran Africa, including Ethiopia, proportion of children with diarrhea for whom advice or
remains one of the highly affected regions [5–8]. treatment was sought from a health care provider was
The underfive mortality rate in Ethiopia, 88 per 1000, only 32% [9, 10].
indicates that the effort towards reduction of underfive According to Ethiopian Demographic and Health
Survey data for under-5 mortality, Somali regional state
reported 93 deaths per 1000 live births and two weeks
* Correspondence: hailemichaelbiz@gmail.com
1
Epidemiology and Biostatistics Unit, Department of Public Health, College of
prevalence of diarrhea was 19.5%, which is the third
Medicine and Health Sciences, Jigjiga University, Jigjiga, Somali Regional highest in the country next to Gambella and Benishangul
State, Ethiopia regional states. In Somali region, 54.4% of underfive
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

8. Operational definitions unsafe human waste disposal. The population of the town is estimated container and disposing in designed site to be 159. the third highest underfive diarrheal morbidity and ceramic tiles or cement mortality rate in the country. choose one. A questionnaire adapted from World sions of kebeles) as second-stage units. palm/ specifically Jigjiga town is lacking. Diarrhea – the presence three and more loose or liquid So far. In households with major strategy. underfive diarrhea in Jigjiga. and host respondents unavailable at the time of data collection. rheal morbidity [10]. disposal ferral and one zonal hospital. Ethiopia. tanker-truck. and households Health Organization (Core questions on drinking water as third-stage units. Kebeles (administrative sub divisions of town) as first. 13]. conducted from February 15–28. household. lottery method was used to Africa [11. public tap or stand pipe. after latrine use. The In Ethiopia. a design effect of before and after cooking foods. As Somali region has bamboo. a census was conducted in all the selected ketenas that guides the development of sub national plans and to have a sampling frame. ketenas were chosen from each of the 5 kebeles. children residing in the selected ketenas was not avail- which is a policy implementation strategic document able. feeding practices. of the total 10 kebeles in the and sanitation for household surveys) [14] composed of . poor diet and housing conditions [2. with poor socioeconomic conditions such as: lacking ac- cess to safe water and sanitation. education. and two health centers in Improved liquid waste disposal – flush toilet.5% (two weeks elsewhere. Unimproved liquid waste disposal – flush to 5% margin of error. There is one re. pit latrine without slab. BMC Pediatrics (2017) 17:182 Page 2 of 7 children did not receive any form of treatment for diar. various strategies have been implemented number of ketenas included was proportionally allocated to reduce child mortality from diarrhea. few studies have been conducted to identify stools per day within two weeks period prior to survey factors associated with underfive diarrhea in Ethiopia.Bizuneh et al. piped water to yard/plot. System- births to 68/1000. The population is mainly of Somali ex. has been implemented as a select households for interview. Improved water source: piped water. and 2 (since multistage cluster sampling was used) and a before feeding child non-response rate of 10% which gave a final sample size of 530. parquet/polished. underfive child mortality more than one under five index children or more than in the country remains one of the highest in sub-sahran one mother or caregiver. vinyl or asphalt strips. environmental. Since the number of underfive Sector Development Program IV (2010/11–2014/15). Two revisits to a household were made for Sociodemographic.300. the final sample size of 530 to decrease under-five mortality rate from 101/1000 live was proportionally allocated among the ketenas. poor hygiene practices. Despite the effort. protected dug well Methods and bottled water This study was a community based cross-sectional study Unimproved water sources: unprotected dug well. ventilated improved pit latrine and Sample size was computed based on single population pit latrine with slab proportion formula assuming 95% confidence interval. 12]. flush/ town. hygiene behavior and child stage units. Many of the risk an index underfive child. limited access to health care. a study which addresses Hand washing: the physical removal of microorganisms the topic is much needed. Dirt floor: floor made of earth. The Health to the size of the kebeles. Ethiopia) [10]. Based on this sampling frame sets the rule of engagement in the health sector. 5 kebeles were selected by lottery method. household and environmental. prevalence (P) of 19. bucket and no facility prevalence of diarrhea among children under age five in Hand washing at critical times – washing hands Somali Regional State. First. surface water (river. pour to pit latrine. town. 2015. Then. aimed obtained from the census. the Integrated Management atic random sampling was used within each ketenas to of Childhood Illness approach. pond and stream) ital town of Somali Regional State located in the eastern Proper solid waste disposal – burying or storing in a part of Ethiopia. and Ketenas (non-administrative sub divi. Jigjiga is the cap. The outcome variable was diarrhea and independent A multistage sampling technique was used including variables were composed of socio demographic variables. In doing so. Improper solid waste disposal – burning. sand or dung but a study conducted in Somali Regional State and Non-dirt floor – floor made of wood planks. This study attempted to from the hands using soap (plain or antimicrobial) and examine the prevalence and factors associated with running water. characteristics play an important role in determining risk Inclusion criteria for the study participants were being and recovery from diarrheal episodes. open field traction and most residents are Muslim. and a mother or care giver factors for contracting diarrheal illnesses are associated who is permanent resident of the town.

787)].06).57) years. In houses where water was not confidence interval were also calculated in univariate and available all the time.095–0.6%) of households used protected water sources such of the country.1%) and hand washing at critical times in trines were shared with one or more neighbors.846(1. The studies conducted in Ethiopia.263–3. ate of Research. Majority (94.227(0. After backward stepwise multivar- proficient in the local Somali language were trained by the iable regression.05.6%) of the households had a family size differences in socio demographic and environmental fewer than five with a mean of 5 (±2. This might be due to the fact that mothers who Main variables which were significantly associated with had formal education are prone to have more awareness underfive diarrhea upon univariate analysis were: lack of on good hygiene behaviours.284–3.53 education was found to be an independent predictor of (±1.5%). lack of hand washing stand consistency. Presence pendent factors associated with the outcome. i. BMC Pediatrics (2017) 17:182 Page 3 of 7 closed-ended questions was used in preparation of the in.195(1. For instance.1%).357)] and 12–23 months [COR: face-to-face interviews Additional file 1. safe handling of water.987)].664)].5%) of households la. poor Institutional Review Board of Jigjiga University. Director. Most (65. Uganda and Afghanistan two weeks prevalence of diarrhea was 14.1%) of mothers. Children of mothers with primary educa- Package for Social Sciences. In order to identify inde. Gilgel Gibe research centre (30%) and 146 (29.3%) were shared with more than five than that of Jigjiga’s (67.231–3. unavailability of water. Crude and adjusted odds ratio with 95% 0.48) months. 141 (44. cleaned and analyzed using Statistical ing facility. Close to West Gojam (18%) [15–19]. Diarrhea was significantly as- tion in the study. maternal education [COR: 0. Out of Sheko was reported to be 61.6% [Table 1].8%) of the households water was drawn from storage coverage in Nekemte town (91. Children of educated mothers were protected breast feeding. and district (25%).752)]. variables sig.362)] [Table 2].517)]. 492 mothers were interviewed.100–0. and lack of hand wash- Data was entered.100–0.e. identify final adjusted odds ratios of independent factors associated with diarrhea at a cut-off point p-value 0.6 (±6. Data collectors 0.013–3. Descriptive statistics was used tion and above were less likely to have diarrhea [AOR: to present results. especially at post-secondary level. where mothers’ education.227(0. On-field supervision of data collectors was the outcome variable were: lack of formal education of carried out. the latrine (23. . reduced the probability of occurrence of diarrhea Factors associated with underfive diarrhea [17–22].3%) of the toilet facilities were Among socio-demographic variables studied. This might be attributed to one-half (52. Publication and Technology Transfer. Hand washing stand was not hygienic services which might strongly affect underfive present in most (77.124(1.548(0. of Jigjiga’s (97.6%. Ethical clearance was obtained from the sociated with lack of formal maternal education. Almost all factors. mothers.408(0. two weeks prevalence of diarrhea among underfive children was 14.517)]. and 443 (90.212–0. Finally a 2. In most (64. The mean age of index children was 22. This finding is consistent with time was self-reported by 330 (67.Bizuneh et al. dren was doubled [AOR: 2. The questionnaire was pretested on 5% of the [COR: 2. This prevalence is relatively Results lower as compared to findings of studies done in other Out of the total of 530 mothers and underfive children parts of Ethiopia which reported higher prevalences such targeted for the study. latrine sharing [COR: total sample size.3 were put in to multivariable model for further were 1. The final questionnaire was translated to Somali family size [COR: 1. important factors such as provision basic as public standpipes. children in the study area. as: Nekemte (28. structured questionnaire was used to conduct [COR: 0.049–4.7%) mothers had no formal education. drawing water by dipping [COR: who resided in a Kebele outside the study area. Discussion This study identified socio-demographic and environ- Ethical consideration mental factors associated with diarrhea among underfive All caregivers underwent informed consent for participa.9%).3%) of children were currently diarrhea.585)].8%) [15] is lower than that containers by dipping. Backward stepwise regression was implemented to 1. In this study. variables significantly associated with researchers. 27 mothers of underfive children 0.305–0. maternal improved. bigger strument. water supply and lack of hand washing facilities.119(1. the odds of diarrhea among chil- multivariable logistic regressions. of hand washing stand was a significant predictor as nificantly associated on univariate analysis at a cut off point children in households with no hand washing stand p value 0.846 times more likely to have diarrhea [AOR: analysis.281)]. households.025–2. lack of water language and back to English language to check for [COR: 2.2%) of the households.719(1.128 (1.5% [17] which is also lower which.184(0. Eastern Ethiopia (22. Hand washing at critical with no formal education. Sheko The mean age of mothers was 28. child age groups 6–11 month pretested. As the studies were conducted in various parts (97.4%) started complementary against diarrhea as compared to children of mothers food after the age of six month. In 117 diarrhea differ across settings.885)].

5 15–24 146 29. Method of water drawing Quantity of water and convenience of the source are Dipping 117 23.7 Household size Hand washing at critical times <5 259 52.1 Diarrhea in past two weeks Sex Yes 72 14.2 Environmental characteristics point-of-use treatment. in Jigjiga town. The water is delivered to households by plastic bar- rels pulled by donkey carts.8 >5 141 44.7 Improved 479 97.8 pipes.6 High 330 67.2 the town are often intermittent leaving the community Latrine availability without water and forced to use alternative unprotected Yes 478 97.8 more important than quality of water for reducing Pouring 375 76.4 > 23 237 48. improper child Source of water stool disposal. Jigjiga town.6 found to be at higher risk of having diarrhea.6 Male 250 50.4 Low 162 32.9 ities [17. Similarly. Floor type and good child feeding practices.4 Female 242 49. 22–24].Bizuneh et al.3 Non-improved 13 2. Jigjiga town.7 Age of index child Age complementary food started <6 49 10 < 6 (Not yet started) 41 8. In this study area. children Water available all the time living in households where water was not available were Yes 244 49.3 Child characteristics No 171 34.2 diarrheal illnesses [7]. safe disposal of domestic waste.5 Before 6 month 8 1. . BMC Pediatrics (2017) 17:182 Page 4 of 7 Table 1 Characteristics of children under age five.6 Shared with how many households (n = 318) 25–34 234 47.9 Number of underfive children Feeding characteristics One 358 72.3 6–11 81 16. improper refuse disposal.6 12–23 125 25.3 Primary and above 346 70.1 Studies have shown that household and environmental factors contribute to childhood diarrhea in Ethiopia.9 Main factors include: lack of latrine. Dirt 104 21.7 35–49 112 22.9 ply could serve as a disabling factor for mothers’ safe hy- giene practices which could explain the higher prevalence of diarrhea in households without water.1 5 and above 233 47.8 No 420 85. water sources in No 380 77.1 of water in households and lack of hand washing facil- Unprotected 334 67. 18. This is also in line with a studies conducted in low and middle in- No 248 50.5 Age Shared 318 64.4 come countries [7].8 Currently breast feeding Two and above 134 27. Not dirt 388 78.3 Educational status Toilet facility No education 146 29. most of the Hand washing facility present community primarily uses water from communal stand Yes 112 22.1 sources. Moreover. This lack of accessible and consistent water sup- No 14 2.4 After 6 month 443 90. Table 1 Characteristics of children under age five.6 <5 177 55. poor handling Protected 158 32. 2015 2015 (Continued) Variable Frequency Percent Ownership of latrine Primary care giver’s characteristics Private 174 35.2 Yes 321 65.

February.987)* >5 20 121 1.00 1. It is also impossible to know if lack of consistent source of water supply could have some risk factors preceded the outcome or changed be- served as a factor that exacerbated lack of hand wash. 2015 Variables Diarrhea Crude OR Adjusted OR P value Yes No Maternal age 15–24 22 124 0.787)* > 23 19 218 1.664)* Method of drawing water Dipping 10 107 2. mated true magnitude.263–3.676(0.212–0.00 Maternal education No education 13 133 1.897)* 0.00 Hand washing facility Yes 26 86 1.197) 35–49 12 100 1.227(0.045 Toilet facility Improved 70 409 1.846(1.00 0. of diarrhea over a two week period could have underesti- cility and childhood diarrhea [16].475(0.125) Latrine shared <5 41 136 0.025–2. lack of hand washing stand was a sig. . Hygiene behaviour was assessed Eastern Ethiopia which reported a significant positive based on self report rather than observation.625(0. This finding is similar to a study conducted in with underfive diarrhea.195(1.305–0. In addition.Bizuneh et al.00 >5 26 207 1.013–3.585)* 2.124(1.100–0. due to lack of data on the distri- ing facilities which in turn predicted diarrhea.236–1.00 1.600(0. Possible limitations of the study include that it did not nificant factor to predict diarrhea among under five comprehensively address the possible factors associated children. In the current study.007 No 25 223 2.457–1.049–4.408(0.153–2.319–1.570(0.719(1.281)* Pouring 62 313 1.184(0. bution of pathogens among the children with diarrhea.548(0.433) 25–34 39 195 0.00 Non-improved 3 10 0.344) Family size <5 46 213 1.00 0.885)* Water availability Yes 47 197 1.517)* Child age <6 6 43 0. Self-report association between the availability of hand washing fa.00 *P value <0.00 1. cause of it.655) 6–11 26 55 0.119(1.128(1.000 Primary and above 59 287 0.301–1. BMC Pediatrics (2017) 17:182 Page 5 of 7 Table 2 Multivariable analysis results of factors associated with diarrhea among underfive children in Jigjiga town.362)* 0.095–0.00 No 46 334 2.284–3.752)* 1.05 In this study.00 Two and above 23 111 0.231–3.357)* 12–23 22 103 0.00 Number of underfive children One 50 308 1.252–0.783(0.

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