Determinants of diarrheal diseases among under five children in Jimma Geneti District, Oromia region, Ethiopia, 2020: a case-control study

The World Health Organization (WHO) defines diarrhea as the passage of three or more loose or liquid stools per day due to an abnormally high fluid content of stool or an abnormal increase in daily stool fluidity, frequency, and volume from what is considered normal for an individual and is caused by bacterial, viral, protozoa, and parasitic organisms [1]. In low-income countries, the two most common etiological agents of moderate-to-severe diarrhea are rotavirus and Escherichia coli [2]. Diarrhea is more common when there is a lack of adequate sanitation and hygiene, safe water supply for drinking, cooking, and cleaning, improper feeding practices, and a poor housing situation [3].

Globally, in 2017, a large number of deaths and more than 1.7 billion cases of childhood diarrheal disease occur every year. Sub-Saharan African and South Asian countries account for roughly 80% of morbidity and mortality. According to 2018 WHO reports, in each year, diarrhea kills more than 525, 000 under-5 years’ children. Five countries accounted for 50 % of the deaths, one of which was Ethiopia [4, 5]. Despite the global achievement in the reduction of all-cause of diarrheal diseases, particularly mortality, in the past 30 years, worldwide diarrhea remains the second most important cause of death due to infections among children under 5 years of age [6]. Likewise, in developing countries, childhood mortality is almost 10 times higher than in developed nations. In Africa, it is estimated that children below 5 years old experience a minimum of five episodes of diarrhea a year and about 800,000 children succumb to diarrhea annually [7]. Similarly, diarrheal disease is the most important community health problem in Sub-Saharan African countries and is accountable for greater than 50% of childhood illnesses and 50–80% of childhood deaths in the countries [1, 8]. Ethiopia is one of the emerging sub-Saharan-African countries contributing to the tall burden of diarrheal illness and death [9]. In the year of 2016 alone, generally, 1 in every 15 children dies before reaching their fifth birthday. Among these deaths, diarrhea kills almost fifteen thousand under-five children in Ethiopia [10]. In Ethiopia in particular, diarrheal diseases alone accounted for 23% of the causes of child mortality, which is greater than the annual deaths due to malaria, HIV/AIDS and measles all together [11, 12]. These were due to living conditions, high incidence of illness, lack of safe drinking water supply, sanitation and, hygiene, as well as poorer overall health and nutritional status [1]. In spite of all advances in health technology, improved management, and increased use of oral rehydration therapy in the past decades, diarrheal diseases still continue to be a major cause of morbidity and mortality. Moreover, there is no dramatic change in evidence about whether the health extension program has had an effect on the risk factors of childhood diarrhea [13, 14].

According to the Ethiopia Demographic and Health Surveys (EDHS), under-five mortality declined from 166 deaths per 1000 live births in 2000 to 67 deaths per 1000 live births in 2016. This indicates a 60% decrease in under-five mortality over a period of 16 years. However, the under-five mortality rate in the Oromia regional state was 79 per 1000, which is higher than the national mortality rate. According to this survey, there was no significant change in the prevalence of diarrheal disease among under-five children, which has dropped only from 13% in 2011 to 12% in 2016 [10].

According to the 2019/2020 Jimma Geneti District Health Office performance report, the prevalence of diarrheal diseases among under-five children is 13.5%. Despite the emphasis given by the Ethiopian Federal Ministry of Health, respective regional health offices, Zonal department, and district health offices to improve child health, there is still higher morbidity and mortality among under-five children due to diarrheal disease, specifically in Jimma Geneti District [15]. Generally, the burden of diarrheal diseases in developing countries is associated with different factors. Evidences revealed that, there is a significant variation in the determinants of diarrhea in Ethiopia, i.e., the determinants of diarrhea identified so far by different scholars was not uniform across the districts. Most of the research conducted in Ethiopia was cross-sectional, institutional-based, and used EDHS data to determine its prevalence. While there are insufficient reports on determinants of under-five diarrheal disease in the studied region, and there is no similar study in Jimma Ganti District, where the prevalence of diarrhea is high and higher child mortality and morbidity due to diarrhea were registered. Thus, to achieve the Sustainable Development Goal (SDG) targeting childhood mortality reduction, operational research designed to identify determinants of diarrhea across different geographical settings is required. Therefore, in this study, we aimed to identify determinants of diarrheal disease among under-five children in the Jimma Geneti District, Oromia Region, Ethiopia, which has important public health implications for planning suitable interventions and appropriate strategies to decrease the impact of diarrheal disease [Fig. 1].

The result of this study showed that children’s age groups 6–11 and 12–23 months were 2.5 and 3 times more likely to develop diarrhoea disease as compared to children in the age group 24–59 months, respectively. This result was consistent with the results of other case-control studies conducted in Medebay Zane District, Gobi District, and Rural Ethiopia [20‐22].

Similarly, this result was consistent with the study reported from Indonesia and Guatemala [23, 24]. In general, children older than 24 months had a lower risk of having diarrheal diseases than children whose ages were between 6 and 23 months. The likely explanation for this risk might be that children between the ages of 6–23 months are undergoing complementary feeding, which may make them vulnerable to diarrheal disease-causing infectious agents due to their undeveloped immunity. Moreover, children at these ages are starting to crawl and walk, thus they may pick dirty or other contaminated objects and take them to their mouth. Likewise, the 2016 EDHS report revealed that diarrhoea prevalence remains high (18%) at the age of 12–23 months, for the reason that weaning and walking often occur during these ages, which contribute to the increased risk of contamination from the environment [10].

The unavailability of a hand-washing facility near the latrine was positively associated with childhood diarrheal disease. In this study, under five-year-old children from households that had no hand-washing facilities adjacent to the latrines were about five times more likely to have diarrheal diseases than under-five-year-old children from households that had hand-washing facilities adjacent to the latrines. The result of this study was consistent with the study conducted in Jimma District and Yama Gulale [25, 26]. This might be expressed as where the hand-washing facilities were unavailable near the toilet; the mothers/caregivers may not frequently practice hand-washing after using the toilet and unintentionally feed their children with contaminated hands, which could be contributing to the high prevalence of under-five diarrheal diseases in the district.

Additionally, the findings of this study showed that mothers’/caregivers’ history of diarrheal diseases was significantly associated with diarrhea diseases among under-five children. Children whose mothers/caregivers had diarrheal diseases in the last 2 weeks prior to this study were 7 times more likely to develop diarrheal diseases than children whose mothers/caregivers had no history of diarrheal diseases in the last 2 weeks. The result of this study was similar to the study findings conducted in Ethiopia Harar Town, Medebay Zana District, and Pawi Hospital, Northwest Ethiopia [14, 20, 27]. The fact is that mothers/caregivers are the main food handlers in the family and the main childcare providers; hence, the possibility of diarrheal diseases among children with mothers/caregivers who have had diarrheal diseases is a common event. It also indicates poor hygienic practice in the household results in the occurrence of diarrheal diseases among under-five children. This might be due to mothers/caregivers with diarrheal diseases being considered as a source of infection for diarrheal diseases among under-five children. Moreover, the mother/caregivers might not be providing appropriate and comprehensive care for the child, which could be a contributing factor to the overall burden of under-five diarrhea and its consequences in the study area. The result of this study also revealed that households who improperly utilized latrines were 2 times more likely to develop diarrheal diseases among under-five children compared to households that utilized latrines properly. The result of this study was comparable with the study findings reported from West Gojjam, Ethiopia [13] and the Kawangware Slum in Nairobi County, Kenya [28]. This showed that the presence of a latrine alone does not ensure the prevention of diarrheal diseases among under-five children unless properly utilized. Many microorganisms that cause diarrheal diseases may be controlled when latrines are used properly.

This study found that children whose mothers/caregivers did not practice hand-washing during the critical period were 10.6 times more likely to be affected by diarrheal disease than children whose mothers/caregivers did practice hand-washing during the critical times. This finding was in line with the studies conducted in Adama Rural and Harena Buluk woreda in Ethiopia [29, 30] and in Zambia [31]. This might indicate that diarrheal diseases are largely spread through contaminated hands, water and food supplies. This contamination occurs mainly from inadequate hygiene and sanitation. Contaminated hand is the main source of infection thus; mothers/caregivers should wash their hands at a critical time to prevent diarrheal diseases.

The findings of this study revealed that improper domestic solid waste disposal practices were 2.7 times more likely to be at risk of developing diarrhea diseases compared to their counterparts. The results of this study were consistent with the studies conducted in the Medebay Zana District and Jamma District in Ethiopia [20, 26] and in Kenya [28]. This might be due to improper disposal of domestic solid waste, which serves as a source of infectious agents and reproduction sites for insects. As well, improper domestic solid waste disposal practices create a favorable environment for flies that carry pathogens and could be sources of contamination for water, food, and food utensils. These might cause children to be exposed to contaminated environments and are a leading risk factor for diarrheal diseases among under-five children.

The result of our study finding indicated that children who were not received the rotavirus vaccine were 2.5 times more likely to develop diarrheal diseases as compared to those children who were received the rotavirus vaccine. This finding was in line with the studies conducted at Harena Buluk Woreda, Bahir Dar, and Debre Berhan in Ethiopia [29, 32, 33] and in sub-Saharan Africa countries, Cameroon, and Madagascar [34, 35]. These findings were reported that the rotavirus vaccine showed a significant association with the occurrence of diarrheal diseases among under-five children. This confirmed that the rotavirus vaccination is one of the best ways to prevent diarrheal morbidity and its consequences, together with improvements of sanitation and hygienic practices. Thus, two-dose rotavirus vaccines should be given for children as part of a comprehensive approach to control diarrhea. Evidence from experts review on vaccines suggests that rotavirus vaccines effectiveness provide sufficient prevention against rotavirus episodes among under-five children thus reducing the morbidity of diarrhea among this age group [36, 37].

The unavailability of a hand-washing facility nearby latrine, mother’s/caregiver’s history of the last 2 weeks’ diarrheal diseases, improper latrine utilization, lack of hand-washing practice at a critical time, improper solid waste disposal practices, and rotavirus vaccination status were the determinants of diarrheal diseases among under-five children identified in this study. Most of the identified determinants of diarrheal disease among under-five children in the study area are preventable. Thus, promoting the provision of continuous and modified health information programs for households on the importance of sanitation (proper domestic solid waste disposal and latrine utilization), personal hygiene (hand-washing facilities and proper hand-washing practices at critical times), and vaccination against rotavirus are fundamental to decreasing the burden of diarrheal disease among under-five children.