Hygiene practice and diarrhea prevalence among underfive children in Myanmar: a cross-sectional study

Abstract

Background

Over 1.7 billion instances of diarrheal illness in children are reported worldwide yearly. Diarrhea was a major cause of death in children, accounting for 9% of all global under-five child deaths in 2021. The objective of this study was to identify the association between hygiene practices and childhood diarrhea among under-five children in Myanmar.

Method

This cross-sectional study was conducted in 16 townships from 8 states and regions of Myanmar. 1207 children between the ages of 6 and 59 months were recruited by multistage random sampling. Data were collected with a preformed questionnaire after participants provided consent. Multiple logistic regressions were administered to determine the factors associated with childhood diarrhea.

Result

This study found that 86 (7.13%) under-five children experienced diarrhea disease. This study identified that children receiving limited hygiene services were 2.85 times (AOR = 2.85, 95% CI: 1.31 to 6.21; p value 0.01) and children without hygiene services were 2.63 times (AOR = 2.63, 95% CI: 1.42 to 4.89; p value 0.01) more likely to have diarrhea disease than those with basic hygiene services. Other factors associated with diarrhea included: fathers who washed their hands less than four steps (AOR = 2.20, 95% CI: 1.29 to 3.74; p value 0.01), families taking more than 15 min to collect water (AOR = 1.77, 95% CI: 1.06 to 2.97; p value 0.03), families sharing toilet usage (AOR = 2.00, 95% CI: 1.15 to 3.48; p value 0.01), mother’s inadequate and problematic hygiene promotion health literacy (AOR = 2.20, 95% CI: 1.24 to 3.90; p value 0.01), houses made of bamboo or lacking floors (AOR = 2.31, 95% CI: 1.38 to 3.89; p value 0.01), families with three or more children (AOR = 1.68, 95% CI: 1.01 to 2.79; p value 0.05) and breastmilk being the primary food after 6 months of age (AOR = 2.07, 95% CI: 1.09 to 3.93; p value 0.03).

Conclusions

Ensuring access to basic hygiene services, getting water at home 24 h per day, seven days per week, using private toilets, promoting hygiene health literacy, improving house flooring, family planning and introducing a variety of foods after age 6 months could significantly prevent diarrhea among under-five children in Myanmar. This study underscores the critical role of handwashing facilities in reducing the diarrhea incidence in children.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-024-05158-3.

Background

Every year, 1.7 billion instances of diarrheal illness in children are reported worldwide [1]. Every year, around 443,832 children die from diarrhea worldwide [1]. Diarrhea is the third leading cause of death in children, accounting for 9% of all deaths in children under the age of five worldwide in 2021 [2]. According to the Myanmar Demographic Health Survey (MDHS) study on causes of under-five children mortality, diarrhea is a prevalent child ailment. According to the MDHS findings, one of ten under-five children had diarrhea in the two weeks preceding the survey [3].

Diarrhea is defined as three or more defecations with liquid or semiliquid feces in a 24-hour period [1]. Diarrhea can last for several days, causing a loss of body fluids and salt constitution, both of which are essential for existence. The most prevalent cause of mortality from diarrhea is the abrupt loss of a large amount of bodily fluid. Undernourished children are at a higher risk of developing severe deadly diarrhea [1].

A number of studies have underlined the role of water, sanitation, and hygiene (WASH) status in reducing childhood diarrhea [4]. Diarrhea occurs more frequently in situations where there is a lack of proper sanitation, hygiene, and access to safe water for drinking, cooking, and cleaning [3]. Many studies have established an association between clean water usage and childhood diarrhea [5–11]. A study in Tanzania found that the usage of unprotected wells and public taps by households was a risk factor for childhood diarrhea [12].

Furthermore, the accessibility of improved sanitation facilities is critical for reducing the risk of diarrhea in children [8, 10, 11, 13]. Children under the age of five who live in families with inadequate sanitation are roughly four times more likely to suffer from acute diarrhea than children who live in households with adequate sanitation [3]. Childhood diarrhea is also linked to child excrement disposal practices [14]. Cronin and others discovered that children who do not properly dispose of their feces are 48% more likely to suffer diarrhea than others [15]. A study in India highlighted improper child feces disposal as a critical problem for childhood diarrhea [16].

Using the toilet with other households, inadequate toilet facilities, and a long journey from home to the toilet are all concerns for children suffering from diarrhea. Households that shared sanitation facilities with other families exhibited higher risk of diarrhea [17, 18]. Children in unimproved toilet households are 18% more likely to suffer childhood diarrhea than children in improved toilet households [19]. The chance of developing acute diarrhea was also higher for family members whose toilet was more than two minutes’ walk from their home [20].

The risk of childhood diarrhea is influenced by the caregiver’s handwashing habits. The chances of contracting diarrhea were three times higher in children whose mothers did not grasp the health benefits of handwashing practices than in children whose mothers understood diarrhea prevention through handwashing activities [6]. Handwashing before and after eating [21], as well as understanding the important periods for effective handwashing with soap and water, were major determinants in having a child without diarrhea [22]. Handwashing, food hygiene, and menstrual hygiene management are examples of hygiene conditions and behaviors that help maintain health and prevent disease spread [23]. The presence of handwashing facilities with soap and water at home has been identified as a critical indicator for global hygiene monitoring [23].

In summarize, numerous studies have emphasized the importance of WASH in reducing childhood diarrhea. Diarrhea is more common in areas lacking proper sanitation, hygiene, and access to safe water. Clean water usage and improved sanitation facilities are critical, as inadequate sanitation can quadruple the likelihood of acute diarrhea in children. Proper disposal of child excrement and good handwashing practices are also essential, with children in households with unimproved toilets or shared facilities at higher risk. Handwashing before and after meals significantly reduces diarrhea risk, highlighting the need for accessible handwashing facilities with soap and water at home.

Despite the recognized impact of diarrhea on child health, comprehensive data on its prevalence and associated determinants among under-five children in Myanmar remain limited. This study aims to address this knowledge gap by providing new data on the prevalence of childhood diarrhea and examining the association between handwashing practices and diarrhea among under-five children. The objective of this study is to assess the prevalence of diarrhea among under-five children in Myanmar and to identify the association between handwashing practices and childhood diarrhea within this age group.

Methods

Study area and design

This research was carried out in 16 townships from three regions and five states of Myanmar. Five states and three regions with varying geographical contexts were chosen. For the five states, Kachin, Kayin, Mon, Rakhine, and Shan were evaluated. For three regions, Magway, Mandalay, and Ayeyarwady were included. A cross-sectional analytical study was conducted to examine the association between hygiene practices and childhood diarrhea among under-five children in Myanmar. At the time of data collection, the children were between 6 months and 60 months old. The eligible sample participant met the inclusion and exclusion criteria. The inclusion criteria were (i) a child aged 6 months to equal and less than 60 months old at the time of data collection, (ii) a child whose parents provided informed consent to participate in this study, and (iii) a child whose family had lived in the same location for at least one year. Exclusion criteria included (i) a child with serious and chronic health problems such as cancer or HIV, (ii) a child with congenital health problems, and (iii) a child with any type of disability. The multiple logistic regression formula was used to calculate the sample size [24].

Multistage random sampling was used in this study. A total of 1207 people were recruited from both rural and urban areas. In the first stage, 16 townships were selected from eight states and regions across Myanmar. After that, one ward and two villages of each 16 townships were selected by using simple random sampling. The sample population was selected from the family list of under-five children in the township health department by using a systematic random selection technique with Microsoft Excel application. Finally, the mothers of the children were interviewed with a preformed questionnaire form. The researcher developed the preformed questionnaire based on existing findings of associated factors. Following the interview, the toilet containment type and handwashing actions of the children, mother, and father were observed. Handwashing took place at the participants’ customary handwashing area. If children were unable to wash their hands independently, parents were requested to assist with handwashing as usual. Subsequently, the number of handwashing steps performed was recorded in the preformed questionnaire form. A limitation of this study is that participants exhibited more positive handwashing behaviors when they were aware of being observed by the researcher. Therefore, information bias cannot be excluded from this study.

Research indicators

In this study, the World Health Organization (WHO) operational definition of diarrhea was applied. Diarrhea is defined as three or more defecations with liquid or semiliquid feces in a 24-hour period within two weeks prior to survey time, as reported by the mother/caregiver [1].

According to the WHO/United Nations Children’s Fund (UNICEF) Joint Monitoring Program (JMP) criteria, basic drinking water was categorized as drinking water from an improved source if the water collection time was less than 30 min, including queuing [25]. Safely managed sanitation was characterized as accessing an improved sanitation facility that is not shared with other households and where excreta are safely disposed of in situ or treated off site. The existence of a soap and water handwashing facility on premises was regarded as the basic hygiene level [25]. Handwashing procedures were observed for the child, mother, and father. Handwashing occurred in the designated handwashing areas of the participants. In cases where children were unable to wash their hands independently, parents were asked to assist with handwashing according to their usual routine. During each handwashing session, the researcher recorded the number of handwashing steps performed using the preformed questionnaire. Myanmar’s Ministry of Health (MoH) encouraged seven handwashing steps to include palm to palm, back of hand, finger interlaced, back of fingers, base of thumbs, fingernails and wrist [26].

Rinsing child feces into toilets, burying methods and using toilets by children are considered adequate child feces disposal, but throwing the child feces into drain or rubbish or open space and direct usage as fertilizer are considered unsuitable child feces disposal [25]. Garbage disposal through public service providers, private waste collectors, disposal in designated areas, burying, and burning were categorized as proper garbage disposal, whereas disposal inside one’s own plot and elsewhere was defined as improper garbage disposal [25]. The drainage of waste water to the sewer line, designated pit, and soak pit was considered proper domestic wastewater disposal, whereas drainage to septic tanks, open ground, water bodies, and elsewhere was considered improper domestic wastewater disposal [25].

Health literacy was measured for sanitation promotion, hygiene promotion and diarrhea prevention. The health literacy score intervals were classified into four levels for each %age: less than 60 as “inadequate,” 60–69 as “problematic,” 70–79 as “adequate,” and more than 80 as “excellent”. Health literacy section includes eight questions with four points Likert scale “very difficult”, “difficult”, “easy” and “very easy”. Some examples of health literacy questions were “To find information about diarrhea such as cause, symptoms, prevention, etc,”, “To understand the diarrhea information that was given by health personals and other communication channels such as radio, TV, Facebook, etc.,” and “To dispose feces properly according the diarrhea prevention messages”. The authors developed a set of customized health literacy questions.

The data collection utilized a paper-based preformed structured questionnaire. Participants were informed about the study’s objectives, benefits, and confidentiality measures prior to data collection. Written consent was obtained from eligible participants before proceeding. Data collection involved face-to-face interviews and observations conducted by the researcher. Researchers recorded the responses on paper and subsequently entered the data into an Excel spreadsheet. All collected information was securely stored and converted into an Excel format. Access to this data was restricted to the researcher via a securely locked file cabinet. Data retention was set for 5 years, and subsequent analysis was performed comprehensively. Personal identifying information was anonymized and destroyed one-year post-publication. Ethical approval was granted by the Khon Kaen University Ethics Committee, and written informed consent was obtained from the mothers of the children before the interview sessions.

The preformed structured questionnaires included six sections: (1) sociodemographic, (2) child, (3) parent, (4) WASH, (5) food safety and dietary pattern and (6) health literacy. Sociodemographic data encompassed residence, house flooring and family size. Child related questions covered age, gender, gestational age, vitamin A supplementation, deworming and breast-feeding. Parental section included education, income and occupation details. The WASH segment addressed water supply, sanitation, hygiene, garbage, child feces disposal and waste water management. The food safety and dietary pattern section focused on food safety score, main food types and dietary habits. Health literacy section included questions regarding sanitation and hygiene promotion and diarrhea prevention.

Statistical analysis

The collected data of 1207 respondents were primarily entered into Microsoft Excel. The data were exported to Stata version 13.0. Bivariate logistic regression was used to determine the factors associated with under-five childhood diarrhea. A multivariate logistic regression analysis included covariates that were significant in a bivariate analysis with a p value of 0.25. Adjusted odds ratios with 95% confidence intervals and p values less than 0.05 were used to identify the factors associated with childhood diarrhea.

Results

Baseline characteristics

Tables 1 and 2 show the baseline characteristics of the respondents. The majority of children (78.62%) came from rural areas. This study comprised children from hilly regions, coastal locations, and plain zones. Most of the children (84.76%) were living in cement or wooden floor houses. A total of 37.37% of the total families had fewer than four family members. In this study, 46.98% were girls, and 53.02% were boys. A total of 79.29% of families with under-five children had fewer than three children. A total of 3.35% of total children were born before 37 weeks of labor. One-third of children had not taken the oral vitamin A supplement. Deworming medications were used by 59.15% of all children. Exclusive breast milk was used by 76.22% of the total children. A total of 43.58% of women were under the age of 30, 46.31% were between the ages of 30 and 40, and 10.11% were over the age of 40. The majority (35.29%) of under-five children’s mothers completed middle school. The major occupation of mothers (34.13%) was manual labor, and the average family income was 77.55 USD.

Table 1.

Baseline characteristics of respondents (part 1) (N = 1207)

Characteristics	Total (n = 1207)
	Number	Percentage (%)
Residencial location
Ward (Municipal area)	258	21.38
Village (Rural area)	949	78.62
Geolocation
Hilly	418	34.63
Coastal	423	35.05
Plain	366	30.32
House floor type
Cement or wooden	1023	84.76
Bamboo or Not have floor	184	15.24
Family size
< 4 members	451	37.37
≥ 4 members	756	62.63
Child’s sex
Female	567	46.98
Male	640	53.02
Children parity
Have less than 3 children	957	79.29
Have 3 or more children	250	20.71
Labor type
Labor before 37 weeks of gestation	44	3.65
Labor on 37 weeks and after 37 weeks of gestation	1163	96.35
Have ever taken oral vitamin A supplement
Have not taken	435	36.04
Have taken	772	63.96
Have ever taken deworming medicine
Have not taken	493	40.85
Have taken	714	59.15
Breast feeding
Not exclusive breast feeding	287	23.78
Exclusive breast feeding	920	76.22
Age of mother at data collection time
Less than 30 years	526	43.58
Between 30 to under 40 years	559	46.31
Equal or more than 40 years	122	10.11
Education level of mother
University graduate	122	10.11
High school	272	22.54
Middle school	426	35.29
Primary school	313	25.93
Can read and write	46	3.81
Illiterate	28	2.32
Education level of father
University graduate	96	7.95
High school	288	23.86
Middle school	428	35.46
Primary school	315	26.10
Can read and write	75	6.21
Illiterate	5	0.42
Occupation of mother
Government staff	54	4.47
Private employee	27	2.24
Dependent	278	23.03
Manual labor	412	34.13
Own business	328	27.18
Farmer	7	0.58
Other	101	8.37
Average family (monthly) income in USD
Less than 100	670	55.51
Equal or more than 100	537	44.49

Table 2.

Baseline characteristics of respondents (part 2) (N = 1207)

Characteristics	Total (n = 1207)
	Number	%age (%)
Water services level
At least basic	826	68.43
Limited	14	1.16
Unimproved	134	11.11
Surface water	233	19.30
Sanitation services level
Safely managed	719	59.57
Basic	80	6.63
Limited	221	18.31
Unimproved	100	8.28
Open defecation	87	7.21
Hygiene services level
Basic	1058	87.65
Limited	49	4.06
No handwashing facility	100	8.29
Water collection time
No need to go for water collection	677	56.09
From 1 to 15 min	302	25.02
More than 15 min	228	18.89
Share use of toilet with others
No	986	81.69
Yes	221	18.31
Toilet location
In house/compound	1108	91.80
Elsewhere	99	8.20
Safe containment of toilet
Not safely contained	80	6.63
Safely contained	719	59.57
Limited/unimproved/open defecation	408	33.80
Child excreta disposal
Proper excreta disposal	1025	84.92
Unproper excreta disposal	182	15.08
Garbage disposal
Proper garbage disposal	836	69.26
Unproper garbage disposal	371	30.74
Domestic wastewater disposal
Proper domestic wastewater disposal	532	44.08
Unproper domestic wastewater disposal	675	55.92
Handwashing facility type
Fixed facility	854	70.75
Mobile facility	253	20.96
No handwashing place	100	8.29
Availability of water at handwashing facility
Yes	1092	90.47
Not have water and facility	115	9.53
Availability of soap at handwashing facility
Yes	1061	87.90
Not have soap and facility	146	12.10
Handwashing with 7 steps by mother
Yes	177	14.66
No	1030	85.34
Mother’s handwashing steps
4–7 steps	783	64.87
Less than 4 steps	424	35.13
Father’s handwashing steps
4–7 steps	672	55.68
Less than 4 steps	535	44.32
Child’s handwashing steps
4–7 steps	357	29.58
Less than 4 steps	850	70.42
Food safety score
< 17 scores	99	8.20
17 to 24 scores	1108	91.80
Mean (SD)	19.67	(± 2.18)
Median (Min: Max)	20	(12 : 24)
Main type of food
Rice or others	1,110	91.96
Breastmilk	97	8.04
Avoiding some kinds of food
Not avoiding	974	80.70
Yes, is avoiding some kinds of food	233	19.30
Mother’s health literacy level on sanitation promotion
Inadequate level	217	17.98
Problematic level	263	21.79
Adequate level	641	53.11
Excellent level	86	7.12
Mother’s health literacy level on Hygiene promotion
Inadequate level	326	27.01
Problematic level	283	23.45
Adequate level	526	43.58
Excellent level	72	5.96
Mother’s health literacy level on Diarrhea prevention
Inadequate level	233	17.48
Problematic level	278	24.69
Adequate level	634	51.78
Excellent level	72	6.05

Regarding WASH status, 11.11% and 19.30% of households used unimproved and surface water without any treatment, respectively. A total of 8.28% and 7.21% of respondents were at the unimproved and open defecation sanitation service levels, respectively. A total of 87.65% were at the basic hygiene level, and 4.06% were at the limited hygiene level. A total of 8.29% did not have a dedicated handwashing facility at their home. A total of 18.89% of all households needed more than 15 min to collect water.

A total of 18.31% of households with under-five children shared toilet facilities with other families. The vast majority (91.80%) had a toilet in their home or compound. A total of 59.57% of those polled had a toilet with a secure containment structure. A total of 15.08% of households disposed of child excreta improperly. A total of 30.74% and 55.92% of households with under-five children disposed of the garbage and domestic wastewater improperly.

In terms of handwashing practices, a fixed-position handwashing facility was used by 70.75% of families, while a movable kind was used by 20.96%. Water was available in 90.47% of households, while soap was available in 87.90% of households. One of seven under-five-year-old children’s mothers washed their hands according to the seven steps recommended by the Myanmar MoH. One-third of all mothers cleansed their hands in fewer than four steps. A total of 44.32% of fathers cleansed their hands in fewer than four steps. Almost 30% of the children cleansed their hands in 4–7 steps.

The food safety section comprised eight questions, each rated on a 3-point Likert scale, resulting in a total possible score ranging from 0 to 24 points. The majority of the respondents (91.80%) had 17 to 24 food safety scores, which is satisfactory score range. A total of 8.04% of children still eat breastmilk as their main food after 6 months of age. A total of 19.30% of children avoided some kinds of food since birth. Regarding mothers’ health literacy level, 17.98% had inadequate sanitation health literacy, 27.01% had inadequate hygiene health literacy, and 17.48% had inadequate diarrhea health literacy.

Diarrhea prevalence

Table 3 shows the prevalence of diarrhea among under-five children in Myanmar, categorized by age and gender. Out of a total of 1207 under-five children, 86 (7.13%) experienced diarrhea within two weeks of data collection, which represents the overall diarrhea prevalence among under-five children of Myanmar. According to age group, the highest prevalence of diarrhea was found in 36- to 47-month-old (8.63%) children, followed by children aged 6 to 11 months (7.66%), 24 to 35 months (6.69%), 12 to 23 months (6.23%), and 48 to 59 months (6.15%). In terms of diarrhea prevalence by gender, 7.58% of girls and 6.72% of boys had diarrhea.

Table 3.

Diarrhea prevalence among under-five children in Myanmar (N = 1207)

Diarrhea status	Total	Yes		95% CI
		Number	%
Child’s Gender
Female	567	43	7.58	5.67 to 10.08
Male	640	43	6.72	5.02 to 8.94
Age of children
6 months to 11 months	222	17	7.66	4.81 to 11.99
12 to 23 months	257	16	6.23	3.84 to 9.93
24 to 35 months	229	16	6.69	4.32 to 11.12
36 to 47 months	255	22	8.63	5.74 to 12.77
48 to 59 months	244	15	6.15	3.73 to 9.96
Total	1207	86	7.13	5.80 to 8.72

Associated factors

Table 4 shows factors associated with diarrhea among under-five children in Myanmar. After running the final analysis model, household hygiene service level was found to be a significant associated factor for childhood diarrhea among 6- to 59-month-old children. Fathers’ handwashing steps, water collection times, shared use of toilet facilities, hygiene health literacy, house floor type, parity and main food type were found to be factors associated with childhood diarrhea among under-five children in Myanmar.

Table 4.

Factors associated with diarrhea among under-five children in Myanmar (N = 1207)

Variable	Total (No.)	Diarrhea (%)	COR	AOR	95% CI	p value
Hygiene services level						< 0.01
Basic	1058	4.91	1	1
Limited	49	22.45	5.60	2.85	1.31 to 6.21
No facility	100	23.00	5.78	2.63	1.42 to 4.89
Father’s handwashing steps						< 0.01
4–7 steps	672	3.72	1	1
Less than 4 steps	535	11.40	3.33	2.20	1.29 to 3.74
Water collection time						0.03
Less than 15 min	979	25.41	1	1
More than minutes	228	14.47	2.96	1.77	1.06 to 2.97
Share use of toilet with others						0.01
No	986	6.19	1	1
Yes	221	11.31	1.93	2.00	1.15 to 3.48
Mother’s health literacy level on Hygiene promotion						0.01
Adequate and excellent	598	3.01	1	1
Inadequate and problematic	609	11.17	4.05	2.20	1.24 to 3.90
House floor type						< 0.01
Cement or wooden	1023	5.28	1	1
Bamboo or not have floor	184	17.39	3.78	2.31	1.38 to 3.89
Parity						0.05
1–2 children	597	5.75	1	1
3 and more children	250	12.40	2.32	1.68	1.01 to 2.79
Main food						0.03
Rice and others	1110	6.13	1	1
Breastmilk	97	18.56	3.49	2.07	1.09 to 3.93

* A multivariate logistic regression analysis included covariates that were significant in a bivariate analysis with a p value of 0.25

After bivariate analysis, urban/rural residency, geolocation, house floor type, parity, birthweight, vitamin A supplement, deworming, exclusive breast feeding, mother’s education, father’s education, mother’s occupation, family income, water collection time, water shortage, water supply services level, sharing use of toilet facility, toilet facility location, child feces disposal, toilet containment, sanitation services level, handwashing facility type, availability of water at handwashing facility, availability of soap at handwashing facility, solid waste disposal, waste water disposal, handwashing systematically by mother, handwashing systematically of father, handwashing systematically of child, food security score, main food, food avoidance, sanitation health literacy, hygiene health literacy and diarrhea health literacy were added to final analysis model as p values less than 0.25.

In terms of hygiene practices, children who received limited hygiene services were 2.85 times more likely to suffer from diarrhea disease than children who received basic hygiene services (AOR = 2.85, 95% CI: 1.31 to 6.21; p value 0.01). Similarly, children who do not have access to handwashing facilities are approximately 2.63 times more likely to have diarrhea than children who do have access to basic hygiene services (AOR = 2.63, 95% CI: 1.42 to 4.89; p value 0.01).

Other associated variables were father’s handwashing procedures, water collection time, shared toilet usage with others, hygiene promotion health literacy, house floor type, parity, and major meal among Myanmar’s under-five children. Children whose father cleaned his hands less than four steps were approximately twice as likely as other children whose father washed his hands more than four steps (AOR = 2.20, 95% CI: 1.29 to 3.74; p value 0.01). Children whose families needed 15 to 60 min to gather water (AOR = 1.77, 95% CI: 1.06 to 2.97; p value 0.03) were 77% more likely to have diarrhea disease than children whose families needed less than 15 min to get water.

Furthermore, children who lived in a household sharing the toilet were twice as likely as other children to have diarrhea (AOR = 2.00, 95% CI: 1.15 to 3.48; p value 0.01). Children with inadequate and problematic hygiene promotion health literacy levels were twice as likely as children with adequate and excellent hygiene promotion health literacy levels (AOR = 2.20, 95% CI: 1.24 to 3.90; p value 0.01).

The type of house floor also has an impact on childhood diarrhea. Children from houses with earth or bamboo floors were more likely to have diarrhea than children from houses with concrete or wood floors (AOR = 2.31, 95% CI: 1.38 to 3.89; p value 0.01). Children under the age of five in families with three or more children were 86% more likely to have diarrhea than children with one to two siblings (AOR = 1.68, 95% CI: 1.01 to 2.79; p value 0.05). Furthermore, 6- to 5-year-old children who ate breastmilk as their primary food were substantially more likely to have diarrhea than children who ate rice or other foods as their main food (AOR = 2.07, 95% CI: 1.09 to 3.93; p value 0.03).

Discussion

Diarrhea is a leading cause of disease in many countries, including Myanmar. This study found that (7.13%) of 1207 children were suffering diarrhea disease within two weeks of data collection, meaning that nearly one out of 15 under-five children defecated three or more times with liquid or semi liquid feces over a 24 h period. The MDHS 2016 found that 10% of under-five children had diarrhea disease [3]. In contrast, the childhood diarrhea prevalence of the current study was less than approximately 3.0% of the MDHS 2016 findings.

This study introduces several innovative aspects and advancements within the realm of child health in Myanmar. One significant contribution is the detailed examination of father’s handwashing habits. Previous research has demonstrated the significance of handwashing at critical times for diarrhea prevention and its association [6]. Findings from our study strengthen the body of evidence that supports using adequate handwashing procedures to prevent diarrhea. By identifying that children whose fathers performed proper handwashing (four to seven steps) were twice as likely to avoid diarrhea, this research underscores the importance of involving all family members in hygiene practices, not just mothers and caregivers.

This finding is particularly interesting given that mothers are typically the primary caregivers. However, our analysis did not find a significant association between mothers’ handwashing practices and childhood diarrhea, which warrants further investigation. Future research should explore why fathers’ handwashing practices had a significant effect and examine the stepwise handwashing habits in greater detail.

Another novel aspect is the comprehensive analysis of hygiene health literacy among mothers. This study extends previous research by quantifying the impact of inadequate and problematic hygiene health literacy on childhood diarrhea, revealing that children whose mothers had lower hygiene literacy were twice as likely to suffer from diarrhea. In relation to hygiene health literacy, a study by Getahun and others [6] discovered that a child from a mother who did not receive information on the importance of handwashing and soap in diarrhea prevention was three times more likely than others to have childhood diarrhea. A study of Bennion and others [22] also looked at the link between hygiene knowledge and childhood diarrhea. This finding emphasizes the need for targeted educational programs to improve hygiene practices and health literacy among mothers.

Children from households with basic hygiene levels were approximately three times less likely to experience childhood diarrhea than those from households with limited or no handwashing facilities. This finding underscores the critical role of hand hygiene in preventing diarrhea among children. Previous studies have highlighted various handwashing practices associated with reduced diarrhea risk, such as handwashing before and after eating, after assisting a child with defecation, before preparing food, before feeding a child, and after using the toilet [18, 21, 22, 27]. Additionally, the absence of handwashing practices by children, handwashing with soap and water before water collection, and handwashing at critical times were all identified as significant behavioral factors influencing diarrhea incidence [5, 18]. This study aligns with these findings, emphasizing that basic hygiene practices serve as a protective factor against childhood diarrhea. This is consistent with previous research, which has consistently shown that hand hygiene is a crucial intervention in reducing diarrhea morbidity.

In terms of the impact of water on childhood diarrhea, this study discovered that children from families that need more than 15 min to collect water were 3 times more likely to suffer diarrhea than others. Previous research has linked public tap water [12], water consumption per day [6], source of drinking water [8], water storage pattern [28], and water quantity [5] to childhood diarrhea. The study supported previous findings about the link between water accessibility and diarrhea. Water can be contaminated at any point along the water collection route, including the water source, fetching, carrying, and carrier material. Polluted water could have increased children’s risk of diarrhea.

Sanitation facilities are crucial in the prevention of diarrhea. A number of studies have demonstrated the significance of toilet sharing practices in the occurrence of childhood diarrhea. According to a study from Nigeria, children from families who shared a toilet with two or more households were five times more likely to acquire diarrhea than other children [18]. Furthermore, a study from Ethiopia found that sharing a toilet increased the likelihood of toddlers developing diarrhea [17]. This study among children under the age of five bolstered previous findings on the association between shared toilet use and diarrhea.

This study also discovered a link between the type of floor in the home and childhood diarrhea. Floors made of concrete or wood are easier to clean and are therefore associated with a decreased risk of diarrhea. Children with earth or bamboo floors were twice as likely to have diarrhea as children with concrete or wood floors. A study from Myanmar [29] discovered a link between house floor and diarrhea. A similar outcome was discovered in a study from Nepal [30]. The current study’s findings confirmed prior studies by providing significant evidence for a link between the house floor and childhood diarrhea.

Previous Ethiopian study of Soboksa [31] found that children with two or more siblings were 21% more likely to have diarrhea sickness than children with fewer than two siblings. Furthermore, Ferede [17] revealed that fourth youngest child or younger children were substantially associated with an increased risk of diarrhea. The current study also found that children from families with three or more children were 68% more likely to suffer from diarrhea compared to those from families with one or two children. This association could be due to several factors: larger families may face challenges in maintaining optimal hygiene practices, and the caregiving attention each child receives may be reduced, potentially leading to increased exposure to pathogens. Additionally, the higher likelihood of resource constraints in larger families could contribute to less effective sanitation and overall child health management, thereby increasing the risk of childhood diarrhea.

When addressing food as a risk factor, this study specifically examined the role of breastfeeding in the incidence of diarrhea. The finding that children who continued to rely on breastmilk as their main food after the age of six months were 3.5 times more likely to develop diarrhea is significant. This could be attributed to several factors. Children over six months need a diversified diet that includes solid foods rich in essential nutrients. Exclusive reliance on breast milk beyond this age may result in nutritional deficiencies, weakening the child’s immune system and making them more prone to infections like diarrhea. Moreover, in many rural and low-resource settings, breast milk storage practices may not always adhere to recommended hygiene standards. Contamination of breast milk during storage and handling can introduce pathogens that cause diarrhea. Furthermore, improper breastfeeding techniques can lead to insufficient feeding and increased susceptibility to infections. Additionally, inadequate cleaning of breastfeeding equipment, such as bottles and nipples, can be a source of bacterial contamination.

Limitation of study

A number of limitations could be found in this study because of its cross-sectional design and assessment of childhood diarrhea at a single time point. In fact, it was impossible to evaluate the diarrhea status of under-five children over time, and the extent of generalizability was limited only to those similar children. As it was the cross-sectional study, it could not say the cause and effect relationships as strong evidence between main interest factors and children’s diarrhea. This study was totally dependent on the participants’ self-reports and memory recalls while assessing diarrhea, social determinants, feeding patterns and health literacy-related factors; therefore, recall bias could not be excluded. When the researcher observed the participants’ handwashing practices, the participants tended to exhibit more positive behavior due to their awareness of being observed. Therefore, information bias could not be excluded from this study. Researchers recorded responses on paper and later converted them into an Excel spreadsheet, a process that have a risk of errors and inaccuracies due to manual data entry. Despite this limitation, this finding is useful for public health policy makers as a baseline to develop appropriate strategies for diarrhea prevention among under-five children in Myanmar.

Conclusions

Father’s handwashing procedures, water collection time, sharing toilet usage with others, hygiene promotion health literacy, house floor type, parity numbers, and main meal types were significant predictors in determining childhood diarrhea. Hygiene promotion to be more accessible for basic hygiene practice, arranging for water at home twenty-four seven, improving own toilet usage without sharing with others, raising hygiene health literacy, improving house floor status, family planning, and encouraging to eat a variety of foods after 6 months old could all help to reduce childhood diarrhea among under-five children in Myanmar.

Study findings suggest that the following interventions could reduce the risk of childhood diarrhea in Myanmar: (i) implementing hygiene promotion programs that focus on practicing basic hygiene, systematic handwashing steps, and enhancing health literacy within the community; (ii) improving household water supply systems; (iii) promoting proper household toilet usage without sharing facilities; (iv) providing community health messages on the importance of house floor types, family planning, and food consumption patterns in preventing diarrhea; and (v) conducting operational research to better understand the association between hygiene behaviors and childhood diarrhea.

As a result, this research study can be a reference for future Myanmar and other country studies on childhood diarrhea. This study’s evidence-based recommendations might be beneficial to policymakers in developing hygiene promotion and diarrhea prevention programs.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

AOR

Adjusted Odds Ratio

CI

Confidence Interval

COR

Crude Odds Ratio

COVID-19

Coronavirus Disease 2019

JMP

Joint Monitoring Program

MDHS

Myanmar Demographic Health Survey

MOH

Ministry of Health

SD

Standard Deviation

UNICEF

United Nations Children’s Fund

USD

United States Dollar

WASH

Water, Sanitation and Hygiene

WHO

World Health Organization

Author contributions

TKS generated the idea, designed the experiment, and assessed the results. KS supervised the data analysis and helped write and revise the first draft of the paper. WL and RMK assisted with data analysis and provided feedback on the initial draft. The final manuscript was read and approved by all writers.

Funding

No funding was received from any agencies.

Data availability

Data will be available upon request to the corresponding author.

Declarations

Ethics approval and consent to participate

The Khon Kaen University Ethics Committee approved this study. The ethical reference number for this study was HE652157. Written informed consent was gathered from the mothers of the children.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.