Vol.3, No.7, 446-453 (2013) Open Journal of Preventiv e Me dic ine
http://dx.doi.org/10.4236/ojpm.2013.37060
Prevalence of diarrhea and associated risk factors
among children under-five years of age in Eastern
Ethiopia: A cross-sectional study
Bezatu Mengistie1*, Yemane Berhane2, Alemayehu Worku2,3
1College of Health Sciences, Haramaya University, Harar, Ethiopia; *Corresponding Author:
2Addis Continental Institute of Public Health, Addis Ababa, Ethiopia;
3School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia;
Received 25 July 2013; revised 1 September 2013; accepted 21 September 2013
Copyright © 2013 Bezatu Mengistie et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Diarrhea remains a major cause of mortality in
children under 5 years of age in Sub-Saharan
countries in Africa. Risk factors for di arrhea vary
by context and have important implications for
developing appropriate strategies to reduce the
burden of the disease. The objective of this
study was to assess the prevalence of diarrhea
and associated risk factors among children un-
der 5 years of age in Kersa district, located in
Eastern Ethiopia. A community-based cross-
sectional study was conducted among 1456
randomly selected households with at least one
child under 5 years of age. A questionnaire and
an observational check list were used for col-
lecting information on socio-economic charac-
teristics, environmental hygiene and behavioral
practices, and occurrence of diarrhea among
children under 5 years of age. Logistic regres-
sion was used to calculate the adjusted odds
ratio of 95% confidence interval. The two-week
prevalence of diarrhea among children under 5
years of age was 22.5% (95% CI: 20.3 - 24.6).
Improper refuse disposal practices (OR = 2.22,
95% CI: 1.20 - 4.03), lack of hand washing facili-
ties (OR = 1.92, 95%CI: 1.29 - 2.86), living i n rural
area (OR = 1.81, 95% CI: 1.12 - 3.31), the pres-
ence of two or more siblings in a household (OR
= 1.74, 95% CI: 1.33 - 2.28), and age of the child
(OR= 2.25, 95% CI; 1.5-3.36) were the major risk
factors for diarrhea. This study demonstrated
that diarrhea morbidity was relatively high among
children under 5 years of age residing in Eastern
Ethiopia. Efforts to reduce childhood diarrhea
should focus on improving household sanitation,
personal hy giene, and child birth spacing.
Keywords: Diarrhea; Risk Factor; Children und er 5
Years; Ethiopia; Cross-Sectional Study; Hygiene
1. INTRODUCTION
Diarrhea remains the leading cause of morbidity and
mortality in children under 5 years old worldwide. The
burden is disproportionately high among children in low-
and middle-income countries. Young children are espe-
cially vulnerable to diarrheal disease and a high propor-
tion of the deaths occur in the first 2 years of life.
Worldwide, the majority of deaths related to diarrhea
take place in Africa and South Asia. Nearly half of deaths
from diarrhea among young children occur in Africa where
diarrhea is the largest cause of death among children under
5 years old and a major cause of childhood illness [1-4].
Although some of the factors associated with diarrhea
in children in Ethiopia such as Acute Respiratory Infec-
tion (ARI), maternal history of recent diarrhea, maternal
education, well source of water, obtaining water from
storage container by dipping, availability of latrine facili-
ties, living in a house with fewer number of rooms, not
breast feeding, duration of breast feeding, and age of the
child, have been identified, diarrhea is still a major pub-
lic health problem among children under 5 years old [5-
8].
Epidemiologic studies show that factors determining
the occurrence of diarrhea in children are complex and
the relative contribution of each factor varies as a func-
tion of interaction between socio-economic, environ-
mental and behavioral variables [5,9-11]. Recent re-
search indicated that studies in differing environment and
*The authors declare that they have no competing interest.

B. Mengistie et al. / Open Journal of Preventive Medicine 3 (2013) 446-453 447
prioritizing interventions based on context would be
useful to prevent deaths from diarrhea [12]. In Ethiopia,
despite the high prevalence of the disease, reports from
population-based studies are sparse. The study would be
helpful in planning and implementation of prevention
strategies at the community level. Thus, the objective of
this study was to assess the prevalence of diarrhea and
associated factors among children of age under five.
2. METHODS
The study was conducted in Kersa Demographic Sur-
veillance and Health Research Center (KDS-HRC) field
site, located in Eastern Ethiopia in January 2011. The
study site is approximately 482 kilometers from Addis
Ababa, and it is divided into 2 urban and 10 rural kebeles
(the smallest administrative unit in Ethiopia), with total
population of 55,394 residents. Agriculture is the main
source of the district’s livelihood. Health services in the
district are provided by six health centers and28 health
posts. At the kebele level, health care is delivered by
extension workers who are assigned to render health ser-
vices at the local level [13].
The sample size was calculated using the formula for
estimation of single proportion [14], n = Z2*P(1 - P)/r2.
Where: Z value is 1.96: P is the prevalence of diarrhea
among children under-five years old that was assumed to
be 18% [15]; and r is the margin error of estimation that
was assumed to be 2% (0.02). This provided a sample
size of 1417 children. To account for predicted 5% non-
response rate, the final sample was 1488 children.
Households with at least one child under 5years of age
were eligible for the study. Study participants were se-
lected using a simple random sampling technique from a
sampling registry obtained from Kersa Demographic
Surveillance and Health Research Center (KDS-HRC)
registration book. For households with two or more chil-
dren under 5 year of age, the index child was selected by
a lottery method.
Data were collected using questionnaire tested previ-
ously and administered by an interviewer and the obser-
vational check list. The questionnaire was prepared
based on the Multiple Indicator Cluster Survey (MICS),
Demographic and Health Survey (DHS) and World
Health Organization (WHO) core questionnaires related
to diarrhea. The questionnaire was written in English,
translated into Affan Oromo (local language), and then
translated back into English to assure its accuracy. The
respondents were primarily mothers of eligible children
under 5 years of age, but in the absence of the mother,
the next primary caregiver was interviewed.
Thirteen individuals who were trained, and experi-
enced in the KDS-HRC questionnaire administration,
and were fluent speakers of Affan Oromo collected the
data. The data collection was supervised by 3 supervisors
at the center. Their role was to daily check the consis-
tency and completeness of the collected questionnaires
and re-interview randomly selected 5% of the households
to check the data quality. Trained data clerks double en-
tered the data using EpiData 3.1 software.
The primary outcome variable was the occurrence of
diarrhea in the 2-week period preceding data collection.
The independent variables included socio-economic
(residence, family size, caregiver’s age, occupation,
educational status, parental age, occupation, educational
status, number of children under 5 years of age in the
household and wealth), environmental (the availability of
hand washing facility, latrine, type of and distance from
water source, refuse and stool disposal) and behavioral
and child-related (child feeding practice, measles vacci-
nation, age and gender of the child) factors.
In this study, diarrhea was defined as the passage of
three or more loose stools over 24 hours period or more
frequently than normal for a child [16]. Water from pro-
tected springs and/or wells, from pipe and from distribu-
tion post was considered as improved source [17]. Dis-
posal of child’s stool was considered proper if the stool
was put into the latrine or buried. The economic status of
the households was categorized into poor, middle and
better off using wealth index, which was calculated from
the households’ assets using principal component analy-
sis [18].
Descriptive statistics were used to summarize the study
variables. Logistic regression analysis was performed
separately for three variable blocks estimated the effect
socio-economic, environmental, and behavioral and child
related factors. The final model estimated the overall
effect of the three blocks of variables. All models used
simultaneous entry procedure to select the significant
determinants and adjusted for confounding factors. All
data were analyzed using SPSS v.16 statistical software
(IBM SPSS, Almaden, NY, US).
To reduce excessive number of variables and resulting
instability of the model, only variables with significance
P < 0.1 in the bivariate analysis were considered for in-
clusion in the multivariable analysis. Variables with P <
0.05 in the multivariable analysis were considered sig-
nificant. Multi-colinearity of variables was assessed by
calculating Variance Inflation Factor (VIF).
The study was approved by the Ethic Committee at the
College of Health and Medical Sciences of Haramaya
University. Mothers or caregivers of children were in-
formed about the study and its objectives before enroll-
ment. A written informed consent was obtained from the
mother or caregiver of each participating child. All col-
lected records were kept confidential.

B. Mengistie et al. / Open Journal of Preventive Medicine 3 (2013) 446-453
448
3. RESULT
A total of 1456 households participated in the study
with a response rate of 97.8%. Almost all respondents
were biological mothers (98.4%), married (97.3%) and
housewives (96.7%), most had no formal education
(82.2%) and were from rural area (85.3%). Mean chil-
dren age was 26.6 ± 13.5 months. There was slightly
more male (51.9%) than female children (51.9% and
48.1%).
Out of 1456 children, 327 had diarrhea two weeks be-
fore the interview, provided a prevalence of 22.5% [95%
confidence interval (CI) 20.3% - 24.6%]. Children in the
age group 6 - 11 months had the highest prevalence of
diarrhea followed by the age groups 12 - 23 months. The
distribution of prevalence of diarrhea by socio-eco-
nomic, environmental and behavioral characteristics is
shown in Tables 1-3.
Factors Associated with Diarrhea
Multivariate analyses were carried out to identifythe
risk factors associated with diarrhea. In the first block
logistic regression model, diarrhea was significantly
higher among children living in the rural than urban area.
In the second model, childhood diarrhea was signifi-
cantly associated with lack of hand washing facility, do-
mestic water supply from unimproved sources and open
dumping of refuse around the house. In the third model,
diarrhea was significantly associated with age of the
child and number of under-five children in the house-
hold.
In the final logistic regression model, diarrhea was in-
dependently associated with open dumping of refuse,
Table 1. Socio-economic determinants of diarrhea among children under 5 years of age in Kersa District, Eastern Ethiopia, 2011.
Diarrhea (N = 1456) COR (95%) CI
Va ri ab le s
Yes No
Residence
Urban 27 188 1
Rural 300 941 2.22 (1.45 - 3.39)
Age of mother/caregiver
15 - 24 70 194 0.75(0.55 - 1.02)
25 - 34 211 778 0.81(0.53 - 1.24)
>34 46 157 1
Education of mother/caregiver
No formal education 284 950 1.30(0.88 - 1.81)
Primary and above 42 179 1
Occupation of mother/caregiver
Housewife 317 1091 1.10(0.54 - 2.24)
Other 10 38 1
Education of father
No formal education 197 719 1.15(0.89 - 1.49)
Primary and above 130 410 1
Family size (persons per household)
≤4 94 398 1
>4 233 731 1.35(1.03 - 1.76)
Wealth index
Low 112 373 1.09(0.8 - 1.50)
Middle 106 379 1.03(0.93 - 1.41)
Better off 101 385 1

B. Mengistie et al. / Open Journal of Preventive Medicine 3 (2013) 446-453 449
Tab le 2. Environmental exposure variables associated with diarrhea among children under 5 years of age in Kersa district, Eastern
Ethiopia, 2011.
Diarrhea COR (95%) CI
Va ri ab le s
Yes No
Availability of latrine
Yes 68 325 1
No 259 804 1.54(1.14 - 2.07)
Availability of hand washing facilities
Yes 40 254 1
No 287 875 2.08(1.45 - 2.98)
Main source of domestic water
Improved 194 761 1
Unimproved 133 368 1.41(1.10 - 1.82)
Separate room for cooking
Yes 163 589 1
No 164 540 1.09(0.85 - 1.40)
Refuse disposal
Waste Pit/burning 57 275 1
Open dumping 27 39 3.34(1.89 - 5.89)
Used for manure 241 813 1.43(1.03 - 1.96)
Child stool disposal
Proper 106 441 1
Improper 221 688 1.33(1.03 - 1.73)
Time to obtain drinking water (round trip)
< 15 minutes 118 472 1
15 - 30 minutes 117 392 1.19(0.89 - 1.59)
More than 30 minutes 92 265 1.38(1.01 - 1.89)
Number of sleeping rooms
One 299 965 1.81(1.19 - 2.76)
Two and more 28 164 1
lack of hand washing facility, rural residence, and num-
ber of siblings under 5 years in a household and age of
the child. More specifically, children in the households
who open dumped refuse around the house had 2.22
times higher odds of having diarrhea compared to chil-
dren in the households who used a waste disposal pit
(OR = 2.22, 95% CI 1.2 - 4.03). The odds of diarrhea was
1.74 times higher in children from the households with
two or more siblings compared to children in the house-
holds with only one sibling (OR = 1.74, 95% CI 1.33 -
2.28). Children in the households without hand washing
facilities had 1.92 times higher odds of having diarrhea
compared to children in the households with no hand
washing facility(OR = 1.92, 95% CI 1.29 - 2.86) (Table 4).
4. DISCUSSION
This study investigated the prevalence and socio-
economic, environmental and behavioral risk factors of
diarrhea morbidity in children <5 years old in Eastern
Ethiopia. The two-week prevalence of diarrhea among the
ch ldren was 22.5% (95% CI: 20.3 - 24.6). The occurrence i

B. Mengistie et al. / Open Journal of Preventive Medicine 3 (2013) 446-453
450
Tab le 3. Behavioral, child and care related risk factors for diarrhea among children under 5 years of age, Kersa District, Eastern
Ethiopia, 2011.
Diarrhea COR (95%) CI
Va ri ab le s
Yes No
Bottle feeding (n = 737)
Yes 36 104 1.05(0.68 - 1.59)
No 159 438 1
Currently breast feeding (n = 737)
Yes 140 417 1
No 55 125 1.31(0.90 - 1.89)
Duration of breast feeding (n = 737)
<1 year 121 345 1.07(0.76 - 1.5)
≥1 year 74 197 1
Feeding children soon after food preparation
Yes 204 668 1.14(0.88 - 1.47)
No 123 461 1
Serving uncooked food to children
Yes 50 203 0.82(0.58 - 1.15)
No 277 926 1
Measles vaccination (n = 1302)
Yes 163 610 1
No 130 399 1.21(0.93 - 1.58)
Child sex
Male 166 590 1
Female 161 539 1.06(0.83 - 1.35)
Number of under 5 sibling per household
One 144 698 1
Two and more 183 431 2.05(1.60 - 2.64)
Child age (in months)
0 - 5 4 47 0.40(0.14 - 1.15)
6 - 11 61 114 2.54(1.73 - 3.73)
12 - 23 86 223 1.83(1.31 - 2.56)
24 - 35 84 308 1.29(0.93 - 1.80)
>35 92 437 1
*Measles vaccination is calculated for children 9 months and above; *bottle feeding and breast feeding is calculated for children < 2 years of age.
of diarrhea was positively associated with rural residence,
aged 6 to 23 months, open dumping of refuse around the
house, lack of hand washing facility and presence two or
more children under <5 years old in the household.
The two-week period of diarrhea occurrence used as a
criterion in our study is comparable with studies con-
ducted in Western Ethiopia [5], Egypt [19] and India
[20]. Such high rate of childhood diarrhea, despite con-
siderable improvements in water sources and sanitation
facilities, indicates the need for more attention.

B. Mengistie et al. / Open Journal of Preventive Medicine 3 (2013) 446-453 451
Table 4. Multivariable analysis of risk factors of diarrhea among children under 5 years of age in Kersa district, Eastern Ethiopia,
2011.
Risk factors Model I
AOR (95% CI)
Model II
AOR (95% CI)
Model III
AOR (95% CI)
Final model
AOR (95% CI)
Area of residence
Urban 1 1
Rural 2.15(1.35 - 3.43)* 1.81(1.12 - 3.31)*
Education mother/caretaker
No formal education 1.14(0.76 - 1.69) 1.23(0.79 - 1.92)
Primary and above 1 1
Family size
≤4 1 1
>4 1.30(0.98 - 1.71) 1.13(0.84 - 1.51)
Availability of latrine facility
Yes 1 1
No 1.13(0.77 - 1.67) 1.14(0.75 - 1.73)
Availability of hand washing facility
Yes 1 1
No 1.80(1.22 - 2.66)* 1.92(1.29 - 2.86)*
Main source of domestic water 1 1
Improved
Unimproved 1.35(1.02 - 1.80)* 1.16(0.86 - 1.55)
Time to fetch water (round trip)
< 15 minutes 1 1
15 - 30 minutes 1.03(0.75 - 1.40) 1.02(0.72 - 1.44)
More than 30 minutes 1.06(0.74 - 1.51) 1.04(0.71 - 1.51)
Refuse disposal
Waste pit/burning 1 1
Open dumping 2.68(1.51 - 4.79)* 2.22(1.20 - 4.03)*
Used for manure 1.22(0.87 - 1.72) 1.12(0.77 - 1.60)
Child stool disposal
Proper 1 1
Improper 1.23(0.88 - 1.70) 1.29(0.92 - 1.81)
Number of sleeping rooms
One 1.43(0.88 - 1.70) 1.40(0.91 - 2.20)
Two or more 1 1
Number of children under 5 in the household
One 1 1
Two or more 1.93(1.5 - 2.49)* 1.74(1.33-2.28)*
Child age (months)
0 - 5 0.39(0.13 - 1.11) 0.36(0.12 - 1.04)
6 - 11 2.31(1.56 - 3.41)* 2.25(1.50 - 3.36)*
12 - 23 1.71(1.22 - 2.4)* 1.83(1.29 - 2.60)*
24 - 35 1.30(0.99 - 1.81) 1.34(0.95 - 1.88)
>35 1 1
*= P < 0.05.

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452
The importance of refuse in transmitting diarrhea
pathogens has been documented [21]. In our study, open
disposal of refuse around the house was an independent
risk factor for diarrhea. This is in agreement with other
studies conducted elsewhere [22,23]. The simple expla-
nation might be that inappropriate disposal of refuse pro-
vides breeding site for insects, which may carry diarrhea
pathogens from the refuse to water and food.
Studies showed the importance of hand washing in
reducing the occurrence of childhood diarrhea [24,25].
However, monitoring correct hand washing behavior at
critical times is challenging. Hygiene behavior related
observational studies showed wide discrepancy between
what people said and did and suggested that reported
hand washing behavior over estimate observed behavior
[26-28] and supported the availability of water and soap
in places of hand washing as indicator of hand washing
behavior [29]. In this study, there was a significant posi-
tive association between the availability of hand washing
facility with childhood diarrhea.
The study showed that diarrhea was significantly as-
sociated with children in the age groups 6 - 11 months
and 12 - 23 months compared to children aged above 35
months. This finding is in agreement with other studies
[5,9]. The peak prevalence of diarrhea at the age of 6 - 11
months can be explained by the introduction of contami-
nated weaning foods [30]. In addition, crawling starts at
this age and the risk of ingesting contaminated materials
may cause diarrhea. The risk of diarrhea decreases sub-
sequently after 6 - 11 months; this is probably because
the children begin to develop immunity to pathogens
after repeated exposure [31].
The odds of diarrhea were higher among rural children
than urban ones and this was consistent with the findings
in Uganda [11] and Egypt [19]. This could be attributed
to the fact that the lack of access to water and sanitation
facilities in the rural areas was more than in the urban
areas [32].
In this study, diarrhea was significantly associated
with the presence of two or more under five children in
the family. This is in agreement with a study done in
Pakistan [33]. Other study also indicated that number of
children born was a predictor of diarrhea among under
five children [34]. This might be due to the incapability
of the caregiver to care for a large number of children
[19]. It is possible to suggest that child birth spacing might
have a positive influence on prevention of diarrhea.
In conclusion, childhood diarrhea remains an impor-
tant health concern in the study community. Occurrence
of diarrhea could be decreased by interventions aimed to
improve sanitation, hygiene and child birth spacing.
5. ACKNOWLEDGEMENTS
The authors would like to thank Haramaya University for its finan-
cial support. We are also thankful for study participants, data collectors
and supervisors for their devotion and full participation.
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