Diarrheal Diseases in Under-Five Children and Associated Factors among Farta District Rural Community, Amhara Regional State, North Central Ethiopia: A Comparative Cross-Sectional Study

Background Diarrheal diseases are the major cause of morbidity and mortality among under-five children in low- and middle-income countries including Ethiopia. One of the national initiatives to reduce its burden is an implementation of an open-defecation-free program. However, information related to the comparison of diarrheal diseases among residents in open-defecation-free and non-open-defecation-free. Hence, this study assessed the magnitude of diarrheal diseases among residents in open-defecation-free and non-open-defecation-free areas of Farta District, North Central Ethiopia. Methods A community-based comparative cross-sectional study was conducted among 758 households (378 in open-defecation-free and 380 in non-open-defecation-free kebeles) who have under-five children using a structured questionnaire. A systematic sampling technique was used to select study participants. Binary logistic regression was used to analyze factors associated with diarrheal diseases in the district. Results Overall, 29.9% of children had diarrheal diseases in the last two weeks prior to the study. The magnitude of diarrheal diseases among under-five children living in open-defecation-free and non-open-defecation-free residents was 19.3% and 40.5%, respectively. Lack of functional handwashing facilities (AOR: 11, 95% CI (8.1–29.6)), improper excreta disposal (AOR: 3.84, 95% CI (2.15–5.65)), and residing in non-open-defecation-free areas (AOR: 2.4, 95% CI (1.72–3.23)) were factors associated with diarrheal diseases. Conclusions The prevalence of diarrhea among children residing in open-defecation-free areas was lower than that among children those who resided in non-open-defecation-free areas. Lack of functional handwashing facilities, residing in non-open-defecation-free areas, and improper excreta disposal were significantly associated with diarrheal diseases in the district. Strengthening health promotion on non-open defecation, maintaining functional handwashing facilities, and preparing additional handwashing facilities are necessary. Continuous engagement of the community health extension workers is recommended, sustaining the implementation of open-defecation-free programs in the district.


Background
Diarrhea refers to either an increased stool frequency or decreased stool consistency. It is defined as three or more loose or watery stools within 24 hours [1,2]. Diarrhea is aggravated by a lack of access to sanitary disposal of waste [3]. Diarrheal diseases are a public health problem in Ethiopia [4]. According to EDHS 2016, 12% of children had diarrhea [5]. Diarrheal diseases are associated with poor environmental conditions. Ethiopia is one of the countries in which open defecation (OD) is still practiced. Most of the populations in rural areas defecate in an open field [6][7][8].
Similarly, in Ethiopia, graduating model families for the health extension program (HEP) and implementing community-led total sanitation and hygiene (CLTSH) are the strategies to address diarrheal diseases and other environment-related health problems in Ethiopia. e prevalence of diarrhea among children whose families were nonmodel for health extension programs ranged from 14% in Hawassa to 25.5% in Sheko [9,10]. However, the magnitude was lower among model families and ranged from 6.4% to 9% [9,10]. e study done in Kersa District, Jimma Zone, Ethiopia, revealed that the prevalence of diarrheal diseases among children living in CLTSH-implemented and nonimplemented areas was 18.9% and 22.2%, respectively [11]. Diarrheal diseases in children ranged from 6.5% in Hulet Ejju Enessie in North Western Ethiopia to 33.2% in Assosa, Western Ethiopia [12][13][14][15][16].
Studies done in Ethiopia in various corners of the country had reported that lack of latrine, faces seen around the house, lower maternal education, lower socioeconomic status, poor handwashing practice, improper refuse disposal, improper children's faeces disposal, and being nonmodel households were associated with children to develop diarrheal diseases [9-11, 13, 16-18].
To avert diarrheal diseases, Ethiopia has adopted the CLTSH strategy. is strategy is part of the health extension program and is implemented by health extension workers. Community-led total sanitation targets on ending open defecation, hygienic use of toilets, and handwashing at critical times. Little is known about the effect of the ODF on diarrheal diseases in children in Ethiopia in general and in the study area in particular. erefore, this study tried to compare the magnitude of diarrheal diseases among children who resided in ODF and NODF kebeles in Farta District, in Northwestern Ethiopia.

Study Setting and Study Period.
e study was conducted in Farta District. Farta District is one of the districts of South Gondar Zone, North Central Ethiopia. It is located 105 kilometres from Bahir Dar (the administrative town of the Amhara Region) and 666 kilometres far away from Addis Ababa, the capital city of Ethiopia. e district has a total of 43 kebeles (Kebeles are the smallest administrative unit in Ethiopia) (41 rural and 2 towns). Among which 31 kebeles are ODF areas and the rest 12 kebeles are non-open-defecation-free areas. All mothers who had under-five children were the source population, whereas all mothers who had under-five children in selected ODF and NODF kebeles were the study population.
e study was conducted in Farta District from January 1 to 30, 2017.

Study Design.
is is a comparative cross-sectional study.

Sample Size and Sampling Techniques.
e sample size was determined using the STATCALC program of EPI INFO statistical software version 7 by considering 18.91% prevalence of diarrheal disease among households living in ODF and 22.22% in NODF areas [15], 95% confidence interval, 80% power, and open defecation free ODF and non-defecation free households ratio 1 : 1, to detect 2 odds ratio, design effect 2. e final total sample size of 772 (386 ODF and 386 NODF) HHs with under-five children was included in the study. e study subjects were selected by the stratified sampling procedure. HHs were stratified as ODF and NODF areas. en, 5 kebeles were selected from each stratum. ree hundred eighty-six households were selected from both ODF and NODF residents. Proportional allocation was employed for kebeles. Finally, a systematic sampling technique was used to select each eligible HH. Mothers in these households were finally recruited and interviewed.

Data Collection
Procedures. Data were collected through face-to-face interviews using a structured questionnaire depending on different literatures [9,10]. Ten trained female nurses who have diploma and ample experiences had collected the data.

Data Quality Assurance
Procedures. Data quality was ensured before, during, and after data collection. e tool was developed after thorough review of related literatures. Two-day training was given. e questionnaire was pretested to check sequence of questions, language, comprehension, and understanding of questions by respondents among the participants. It was conducted in 5% of the sample size around Addis Zemen Town which is out of the main study area. Findings of pretesting were discussed among data collectors and researchers so that the tool was modified accordingly.
Supervision and follow-up of data collectors was conducted including observation of how they are administering questions and approaching the respondents. e filled questionnaires were checked for completeness by data collectors and the researchers on a daily basis. Consequently, any problems encountered were discussed among the survey team and solved immediately. e questionnaire was pretested to check sequence of question, language, comprehension of the questions among the participants, and duration of an interview on five percent of the sample size among health workers of Addis Zemen health facilities which was excluded out of the main study. e final interview was conducted using the modified questionnaire. Every problem during data collection was solved through contact with supervisors. Data cleaning was done before analysis.

Data Analysis.
After checking for completeness of data, they were coded and entered into Epi-Info version 7 databases and then exported to SPSS for analysis. Crude and adjusted odds ratio with 95% CI was calculated. A P value less than 0.05 was considered as a level of significance. Bivariate and multiple logistic regressions were done.

Ethical Approval.
Ethical clearance was obtained from the Debre Tabor University Research Ethics Review Committee. A permission letter was obtained from the Farta District Health Office. e participants were informed that participation is made entirely voluntarily, and written consent was taken from the mothers/caretakers of the under-five children before the actual data collection. For the affected children at the time of data collection, the respondent was advised to get medical treatment to the nearest health institution.

Sociodemographic Characteristics of Study Participants.
A total of 758 mothers with under-five children (378 opendefecation-free and 380 non-open-defecation-free kebele residents) participated in the study making a response rate of 98.19%. Out of these, 736 (97.1%) of respondents were biological mothers of the under-five children. e mean age of the respondents was 31.66 ± 6.74 standard deviations (SD) years, and 180 (23.7%) of the respondents were between the age group of 25 and 29 years. Nearly all mothers 736 (97.1) were married, and the majority of them 692 (91.3%) were housewives.
Regarding the educational status of the study participants, 420 (55.4%) of them had no formal education. e mean family size of the respondent was 5.1 ± 1.53 SD. About six in ten, 474 (62.5%), of households had a family size of less than five of which 221 (29.2%) HHs were in ODF and 253 (33.4%) were in non-open-defecation-free (NODF) kebeles. Half, 378 (49.92%), of the HHs had family income between 1001 and 2000 Ethiopian Birr per month (Table 1).

Demographic Characteristics of Under-Five Children of Study Participants (Mothers or Caregivers).
e mean age of under-five children was 21.3 months ±13.9 months (SD). About half of them, 401 (52.9%), were male, whereas females were 357 (47.1%). e majority of the children (77.0%) were born in the health facility, and the rest were born at home. ird quartiles of the children (76.4%) were fully immunized, and the rest (5.4%) were not immunized.

Prevalence of Diarrheal Disease among Under-Five
Children.
e overall prevalence of diarrheal diseases among under-five children was 29.9% of which 73 (19.3%) were from children who dwell in ODF kebeles and 154 (40.5%) were from children who dwell in NODF kebeles. Diarrheal diseases were most prevalent among children of aged 24-59 months (100 (13.2%)). About 17.2% of children's mothers had the diarrheal diseases.

Discussion
In this study, the overall two weeks prevalence of diarrheal diseases was 29.9%.
Similarly, in this study, the prevalence of diarrheal diseases among children residing in NODF kebeles was 40.5%. It is about 20% higher than that of those under-five children who resided in ODF kebeles which was 19.3%. is finding was supported by the study done in Kersa that CLTSH implementation reduces diarrheal diseases among children living in HHs compared to nonimplemented kebeles (18.91% and 22.22%, respectively) [11]. is difference might be due to the fact that proper disposal of the excreta implementation strategy of the government; capacity building of families to be role model to waste management, strict follow-up by health extension workers to build the capacity of the community and, support to those HHs living in ODF kebeles. is support may bring knowledge and skill development and access for excreta disposal infrastructure and community involvement in waste management issues to those HHs living in open-defecation-free kebeles, and it made them practice proper excreta disposal compared to those HHs living in non-open-defecation-free kebeles.
Seven in ten (71.3%) of the respondents disposed faeces around the house either in the bush or outside the compound, while only 28.7% of them had disposed in the latrine. e use of safe disposal of children's faeces in the present study was lower when compared with the study in Hulet Ejju Enessie; the prevalence of disposing faeces in the latrine was 65.9% [15]. Barriers to the transmission of enteric pathogens are safe excreta disposal. Open-field disposal did not remove the pathogen, rather the pathogenic organism reserves in the soil and later through the feco-oral route; it was reingested, resulting in repeated episodes of diarrheal diseases.
is study found that 10% of HHs residing in ODF and 251 (56.1%) HHs living in NODF kebeles had no latrine. Faeces were seen in the compound of about one in three of them (67.3% HHs) living in ODF and non-open-defecationfree (NODF) kebeles, respectively. From children who had developed diarrheal diseases, faeces were seen in nine in ten of their compounds. e difference may be due to the expansion of the HEP and the implementation of the opendefecation-free (ODF) strategy at a community level. is shows the possible effect of the ODF implementation strategy towards reducing diarrheal diseases by half among children; hence, these programs are noted to play a great role in the prevention of diarrheal diseases. e availability of latrine reduces contamination of the environment by excreta, and this further prevents transmission of diseasecausing organisms [6]. is study found that 10% HHs living in ODF kebeles returned to NODF kebeles.
Not attending formal education, low monthly income, and family size >5 were significantly associated with diarrheal diseases. is finding is supported by studies [9,10,13,16]. Socioeconomic status and level of education might have a direct effect on environmental hygiene practices. Children who live in NODF kebeles were 2.4 times more likely to develop diarrheal diseases than those who live in ODF kebeles. e possible reason might be that when there is improper disposal of waste, flies might have access for faeces, and it can contaminate the soil, food, and water. ese, combined with other situations, further predispose children to diarrheal diseases. is difference might be indicated by the possible effect of the ODF strategy among HHs. During the implementation of the ODF strategy at community level follow-up of health professionals, local administrators might be attributed to the behaviour changes being observed. e diarrheal diseases were nearly two times more likely (AOR: 1.8, 95% CI (1.2, 3.1)) among children whose families owning latrines for ≥4 years than owning latrines for less than four years of service. e disposal method of child faeces was found to be statistically significant with diarrheal diseases. Children from those HHs in which child faeces were throwing out of houses had about 1.4 times more likely to have diarrhea compared to those children from houses in which child faeces had disposed in the latrine (AOR: 1.4, 95% CI (1.1, 3.7)).
is finding was supported by the studies conducted in Hawassa and Nekemte [10,14].
In this study, children from those HHs in which faeces were observed around the compound had 28 times more likely to have developed diarrhea compared to those children from houses in which faeces had not been observed around the compound (AOR: 27.6, 95% CI (18.9, 37)). is finding is consistent with studies done in Sheko, Nekemte, Hawassa, and Cameroon [9,10,14,18]. When children live in an unhygienic compound, they will be more likely to have poor personal hygiene that leads to diarrheal diseases. Handwashing after touching the infant's faeces was found statistically significant with diarrheal diseases. is finding is consistent with studies done in Kabul, Afghanistan, that washing and the presence of improved sanitation facilities were protective for diarrheal diseases [17]. However, this study does have some inherent limitations. e prevalence of diarrheal may not reflect the actual situation that may be observed in the various seasons of the year.

Conclusions and Recommendations
Despite encouraging gains made in the reduction of diarrheal diseases among children living in ODF kebeles, this study demonstrated that the overall prevalence of diarrheal diseases in under-five children remains high in the study area. Significant numbers of respondents in ODF and NODF kebeles had no latrine. Low household income, not attending formal education, improper excreta disposal, living in nonopen-defecation-free kebeles, and lack of handwashing facilities were significantly associated with occurrence of diarrheal diseases among under-five children. To sustain and further strengthen the achievements gained, communities should accelerate their concerted efforts to open-defecationfree implementation.