A cross-sectional study on the prevalence and associated risk factors for intestinal parasitic infections among under-five aged children in Dabat primary hospital, north Gondar, Ethiopia

Abstract

Intestinal parasitic infections (IPIs) are the main public health problems in several developing countries, and under-five-aged children are the most vulnerable groups of the population. The current study aimed to determine the prevalence and associated risk factors of IPIs among under-five-aged children at Dabat primary hospital, northwest Ethiopia. A cross-sectional hospital-based study including 384 under-five-aged children was conducted from February to June 2022. A structured questionnaire was used to collect relevant information on risk factors, and stool samples were collected and examined using wet mount and sedimentation techniques to determine prevalence. Chi-square and logistic regression were used to evaluate the possible association and the strength of the association between dependent and independent variables. The overall prevalence of intestinal parasites was 32.81%. Ten species of intestinal parasites were identified. Entamoeba histolytica / dispar was the predominant intestinal parasite species, with a prevalence of 7.55%. Giardia lamblia and hookworm had prevalence of 6.77% and 5.47% respectively. Those children whose Mother/guardian do not wash their hand before feeding their child are more than five time infected than those who do wash (AOR = 5.26, CI = 2.28–12.2, p < 0.001). Children who do not wear shoe are more infected than who did (AOR = 14.5, CI = 5.77–36.5, p < 0.001). Several risk factors were identified in this study among these washing hands after toilet before touching child, washing hands before feeding their child, Child meal and habit of shoes wearing were the main predictors of IPI. Since the prevalence of IPI observed in this study is that of under-five-aged children; raising awareness of mothers/guardians about how to keep hygiene; transmission ways and health impacts of IPIs; and proper way of feeding their children to avoid risk is crucial.

Background

A parasite is an organism that lives inside or on the surface of another host organism and nutritionally dependent on this host (Sastry and Bhat 2018). The two main division of parasites are the protozoa and helminthes, which are the common causative agents of intestinal parasitic infections (IPIs) (Adullah et al. 2016). The IPIs are the main public health problem, especially in developing countries (Benhassine et al. 2020). The most common intestinal protozoan parasites of humans that cause IPI are Entamoeba histolytica / dispar, Giardia lamblia, and Cryptosporidium parvum, and those of helminthes are Ascaris lumbricoides, Trichiuris trichiura, hookworm (Ancylostoma duodenale and Necator americanus), and Strongyloides stercoralis (Tegen and Damtie 2021).

These infections are most prevalent in tropical and subtropical regions of the developing world, where adequate water and sanitation facilities are lacking (Tegen and Damtie 2021). According to estimates by the World Health Organization, more than 1.5 million peoples are affected by IPI globally, especially in Sub-Saharan African countries (SSAC) (WHO 2020). As the WHO assessment indicates, in SSACs, around 250 million people are affected by at least one IPI (WHO 2020). The global prevalence and health burden of IPI is high among economically poor people (Tegen and Damtie 2021) and is positively correlated with poverty, poor personal hygiene and living conditions, poor waste disposal system and environmental hygiene, lack of potable water, contamination of the soil by human and animal waste (Palmeirim et al. 2018).

Several studies have revealed that younger children are more vulnerable to heavy infections with intestinal parasites (Von Huth et al. 2019). Although IPI infects people at any age level, children are highly vulnerable to it due to their immature immune system, frequent contact with contaminated soil, fingers sucking, and the habit of defecation in an open field (Luz et al. 2017; Hamad et al. 2019). Most of cases of IPI are asymptomatic (Lewetegn et al. 2019), but severe infection can cause a wide spectrum of clinical symptoms such as chronic diarrhea, nausea, vomiting, dehydration, abdominal pain, fever, iron deficiency anemia, malnutrition, and vitamin deficiencies (Sitotaw et al. 2019). Furthermore, persistent infections can lead to chronic malnutrition, nutrient deficiency; and mental and physical growth retardation, especially in children (Luz et al. 2017).

In general, the most common means of IPI transmission is by the fecal–oral route through the ingestion of the parasite's infective life stage with contaminated food or water; and intact skin penetration by infective larvae during walking barefoot (Hamad et al. 2019). Majority of the IPI cases occur in areas around SSACs and the prevalence has exceeded 50% in the area, including Ethiopia (Von Huth et al. 2019). In Ethiopia IPI is the major reason of morbidity and mortality, causing series of public health problems (Sitotaw et al. 2019). The possible reason for the high prevalence of IPI in Ethiopia is mainly due to unsafe and inadequate water supply, poor personal hygiene and low living standards, poor waste disposal system, low level of knowledge of the prevention and control method of IPI, poor habit of proper use of latrines, and the habit of walking barefoot (Sitotaw et al. 2019; Yoseph and Beyene 2020). The national health survey showed that the prevalence of IPI among children under-five years of age was 39% and not decreasing in consecutive years (Central Statistical Agency of Ethiopia 2016). The magnitude, distribution and prevalence of IPIs differ in Ethiopia from region to region due to different factors. Additionally, due to the scarcity of published data, particularly in this study area, the present study was initiated to assess the prevalence and associated risk factors of IPIs among under 5 years of age at Dabat Primary Hospital, north Gondar Ethiopia.

Methods and materials

Description of the study area

This study was carried out at Dabat Primary Hospital in the north Gondar zone, Ethiopia. Dabat is located about 827 km from Addis Ababa, capital city of Ethiopia and located at a latitude and longitude of 12° 58′ 53.04'' N and 37° 45′ 44.28'' E, and an elevation of 2596 m above sea level. The main economic activity of the rural population is mixed farming. The district has one primary hospital, which is called Dabat Primary Hospital.

Study design and period

A cross-sectional study was conducted in health facilities from February to June 2022 to determine the prevalence and associated risk factors for IPIs among children under-five years at Dabat Primary Hospital, Northwest Ethiopia. All under-5-age children who visited the hospital during the study period for diagnosis and treatment of IPI were considered; and then one among the next three consecutives in the waiting room and those children their parent/guardian willing to give signed consent, were included in the study.

Sample size determination and sampling procedures

The sample size was determined using a single population proportion formula, as used in Mekonnen and Ekubagewargies (2019). Since the overall prevalence rate of IPI among under-five-aged children in the study area is not known, the prevalence was taken to be 50%. In the calculation, a 95% confidence level (Z); a 5% sampling error (d) and 5% of nonresponsive rate were taken into consideration. Therefore, approximately 404 under-five aged children were included in the study. The sampling frame of this study was prepared by collecting and calculating the average number of visitors’ under-5-age to the hospital in the last three years in the study period. Therefore, a simple random sampling was applied and 1 out of 7 consecutive visitors was taken as a participant.

Methods of data collecting

A questionnaire survey was conducted to assess the main sociodemographic and potential risk factors data. The questionnaire was first developed in English and translated into the two local languages (Amharic and Tigregna) and then translated back into English to verify its consistency. The prepared questionnaire was pretested by 10% of the sample, but the data was not included in the study. After all relevant information about the study was given and informed consent was obtained; the questionnaire was filled by mothers/guardian and stool sample was collected from the each study participants. After a training for one day on the general objective and measurement tools of the study, two laboratory technicians of the hospital collected the sociodemographic and risk factor data. The entire data collection process was strictly supervised by the supervisors and investigator. Every day, the completed questionnaires were reviewed and verified for completeness, and the necessary feedback was offered to the data collectors.

Stool sample collection and diagnosis

Stool samples were collected to diagnose the presence of intestinal parasites. The diagnostic task was carried out by laboratory technicians from Dabat Primary Hospital. After proper orientation was given to parents/guardian on how to collect sufficient amounts and contamination-free stool samples from their child, each of them received a labeled disposable plastic cup and an applicator stick; and was instructed to collect approximately 5gm of stool. Fresh stool samples (approximately 1gm each) were processed with direct wet mounting techniques (with drop of physiological saline (0.85%) and iodine separately) and then about three (3gm) of stool samples were examined with the formol-ether concentration technique as clearly described in Basic laboratory methods in medical parasitology (WHO 1991).

Data processing and analysis

The data recorded on the questionnaire and the laboratory results were verified for completeness and consistency, and then coded and entered into excel. The compiled data was analyzed using SPSS version 20. First, descriptive statistics were computed, and the result was reported using frequency and percentage. Chi-square (χ2) was used to test the possible association between dependent and independent variables. Logistic regression analysis was also used to measure the strength of the association. Univariate logistic regression was first performed and then variables with a p-value less than 0.25 were selected and processed in the multivariate analysis to identify the determinants of IPIs among under-five-aged children, as it was conducted by Sitotaw and Shiferaw (2020). Finally, variables with a p-value < 0.05 at a 95% confidence interval were considered as statistically significant.

Ethical consideration

Before starting the research, the study was first approved and an ethics clearance letter was obtained from the research ethics review committee of the Collage of Natural and Computational Sciences, University of Gondar, and then permission was obtained from Dabat Primary Hospital. Then informed consent was obtained from parents/guardians, after informing the entire purpose of the study. The information collected during the study was kept strictly confidential. A code number was given to each participant to manage all the data obtained.

Result

Sociodemographic characteristics of study participants

Of a total of 404 selected participants, only 384 under-five-aged children participated properly in the study by providing all the necessary information and stool samples with a 95.05% response rate. The mean age (± SD) of the study participants were 1.89 ± 1.33 years. Of the total study subjects, 56.2% (216/384) were female and the remaining 43.8% (168/384) were male. Regarding the age group, 18.2% (70/384) were less than one year, 24% (92/384) were of 1–2 years and of 2–3 years separately, 18.5% (71/384) were of 3–4 years, and the rest (15.3%) belonged to the age group of 4–5 years. Of the study participants, 47.4% (182/348) were rural residents and 52.6% (202/384) were urban residents. Regarding the occupation of the mothers, the majority 130 (33.9%) were farmers and some (15.1%) were government employees. Regarding the education level of the mother, 18.8% (72/384) were illiterate, 39.8% (153/384) could write and read, 27.9% (107/384) attended high school, and the rest (13.5%) attended college or university (Table 1).

Table 1.

Sociodemographic characteristics of study participants in the Dabat primary hospital, 2022 (n = 384)

Sociodemographic characteristics	Frequency	Percent (%)
Sex
Male	168	43.8
Female	216	56.2
Age category
< 1 year	70	18.2
1–2 year	92	24.0
2–3 year	92	24.0
3–4 year	71	18.5
4–5 year	59	15.3
Family Residence
Rural	182	47.4
Urban	202	52.6
Occupation of mother
Farmer	130	33.9
Merchant	98	25.5
Housewife	98	25.5
Government employee	58	15.1
Family monthly income
< 1000 birr (< 20 USD)	89	23.2
1000–3000 birr (20–60 USD)	172	44.8
> 3000 birr (≥ 60 USD)	123	32
Education level of Mother
Illiterate	72	18.8
Writing and reading	153	39.8
High school	107	27.9
College and university	52	13.5

Prevalence of IPI among under-five aged children

The result of the stool diagnosis revealed that the overall prevalence of IPI in under-five-aged children in the study area was 32.81% (126/384) and from this share of protozoans is 43.65% (55/126) and that of helminths is 56.35% (71/126) of the infection cases burden. The prevalence of intestinal protozoan parasites was 14.3% (55/384) and that of helminthes parasites was 18.5% (71/384). The prevalence of double infection in this study was 1.56% (6/384). In the current study, ten different species of intestinal parasites were identified, two protozoan’s and eight helminthes species. The predominant was E. histolytica/dispar with a prevalence rate of 7.6% (29/384), followed by G. lamblia 6.8% (26/384). In addition, among the helminthes identified in this study, hookworms were the dominant with a prevalence rate of 5.5% (21/384), followed by A. lumbricoides 4.7% (18/384) (Table 2).

Table 2.

Prevalence of intestinal parasitic species among under-five-aged children in Dabat primary hospital

Identified intestinal parasitic infection (n = 384)
Species of IPs	Frequency(Burden in %, n = 126)	Prevalence
Protozoa
E. histolytica	29 (23.02)	7.55
G. lamblia	26 (20.63)	6.77
Total Protozoa prevalence	55 (43.65)	14.32
Helminths
Hookworm	21 (16.67)	5.47
A. lumbricoides	18 (14.29)	4.69
T. trichiura	8 (6.35)	2.08
S. stercoralis	3 (2.38)	0.78
S. mansoni	5 (3.97)	1.30
Taenia spp.	8 (6.35)	2.08
H. nana	5 (3.97)	1.30
E. vermicularis	3 (2.38)	0.78
Total Helminths prevalence	71 (56.35)	18.49
Overall prevalence of IPIs	126	32.81
Double infection (n = 6)
T. trichiura and G. lamblia	2 (33.33)	0.52
A. lumbricoides and T. trichiura	1 (16.67)	0.26
A. lumbricoides and G. lamblia	1 (16.67)	0.26
H. nana and T. trichiura	1 (16.67)	0.26
E. histolytica and Hookworm	1 (16.67)	0.26
Total prevalence of double infection	6 (100)	1.56

Prevalence of IPIs across sociodemographic characteristics of study subjects

The presence of IPIs was assessed across sociodemographic characteristics of study subjects. Among this, age, family residence, family occupation, and family monthly income were significantly associated with IPIs (p < 0.05). Regarding sex, high prevalence was observed in males 35.7% (60/168), than females 27.8% (60/216). In terms of age group, high prevalence of IPI was observed in children whose age group was less than one year 50% (35/70) and a low prevalence was observed in the age group of 3–4 years 23.9% (17/71). Regarding family residence, a high prevalence was obtained in rural children, 40.7% (74/182) compared to urban, 22.8% (46/202) (Table 3).

Table 3.

The prevalence of IPIs by sociodemographic characteristics of study participants at Dabat primary hospital

Risk factors	IPIs (N = 384)			χ2	p-value
	No of examined (%)	Positive (%)	Negative (%)
Sex
Male	168 (43.8)	60 (35.7)	108 (64.3)	2.77	0.096
Female	216 (56.2)	60 (27.8)	156 (72.2)
Age category
< 1 year	70 (18.2)	35 (50.0)	35 (50.0)	15.1	0.005*
1–2 year	92 (24.0)	28 (30.4)	64 (69.6)
2–3 year	92 (24.0)	23 (25.0)	69 (75.0)
3–4 year	71 (18.5)	17 (23.9)	54 (76.1)
4–5 year	59 (15.4)	17 (28.8)	42 (71.2)
Family residence
Rural	182 (47.4)	74 (40.7)	108 (59.3)	14.3	0.0001*
Urban	202 (52.6)	46 (22.8)	156 (77.2)
Mothers occupation
Farmer	130 (33.9)	56 (43.1)	74 (56.9)	13.03	0.005*
Merchant	98 (25.5)	23 (23.5)	75 (76.5)
Housewife	98 (25.5)	26 (26.5)	72 (73.5)
Gover. employee	58 (15.1)	15 (25.9)	43 (74.1)
Family monthly income (in ETB)
< 1000 birr (< 20 USD)	89 (23.2)	43 (48.3)	46 (51.7)	19.96	0.0001*
1000–3000 (20–60 USD)	172 (44.8)	53 (30.8)	119 (69.2)
> 3000 birr (≥ 60 USD)	123 (32.0)	24 (19.5)	99 (80.5)
Education level of Mother
Illiterate	72 (18.8)	28 (38.9)	44 (61.1)	2.46	0.48
Writing and reading	153 (39.8)	45 (29.4)	108 (70.6)
High school	107 (27.9)	31 (29.0)	76 (71.0)
College and university	52 (13.5)	16 (30.8)	36 (69.2)

Prevalence of IPIs across potential risk factors of study participants

The prevalence of IPI was evaluated in terms of potential risk factors. Among these risk factors washing hands after the toilet before touching their child, washing hands before feeding their child, eating unwashed fruits and vegetables by the child, contact of the child with water bodies, child meal, feeding other food before the age of 6 months, source of drinking water, habit of wearing shoe, presence of latrine, eating soil, and mothers' knowledge of mode of transmission of IPIs were significantly associated with IPIs (P < 0.05). A relatively high prevalence of intestinal parasites was observed among children who rarely eat fresh meals (61.5%, 80/130), do not wear shoes (78.3%, 83/106), do not have a latrine (64.9%, 87/134), eat soil (63.5%, 73/115), and those whose mothers have no knowledge of the mode of transmission of intestinal parasitic infections (45.7%, 101/221) (Table 4).

Table 4.

The prevalence of IPIs in relation to risk factors among under-five-aged children (n = 384)

Risk factors		IPIs			χ2	p-value
		No examined (%)	Positive (%)	Negative (%)
Washing hands after toilet before touching their child	No	156(40.6)	69 (44.2)	87(55.8)	20.6	0.0001*
	Yes	228(59.4)	51(22.4)	177(77.6)
Washing hands before feeding their child	No	137(35.7)	72(52.6)	65(47.4)	44.9	0.0001*
	Yes	247(64.3)	48(19.4)	199(80.6)
Eating unwashed fruits and vegetables by the Child	Yes	109(28.4)	57(52.3)	52(47.7)	31.4	0.0001*
	No	275(71.6)	63(22.9)	212(77.1)
Child Contact with water bodies	Yes	150(39.1)	81(54)	69(46)	59.3	0.0001*
	No	234(60.9)	39(16.7)	195(83.3)
Child meal	Rarely fresh	130(33.9)	80(61.5)	50(38.5)	87.9	0.0001*
	Sometimes fresh	165(42.9)	33(20)	132(80)
	Always fresh	89(23.2)	7(7.8)	82(92.1)
Trimming child nails when grown	No	38(9.89)	9(23.7)	29(76.3)	1.12	0.29
	Yes	346(90.1)	111(32.1)	235(67.9)
Feeding other food before the age of 6 month	Yes	94(24.5)	13(13.8)	81(86.2)	17.6	0.0001*
	No	290(75.5)	107(36.9)	183(63.1)
Child playing ground	Not clean	45(11.7)	14(31.1)	31(68.9)	0.00	0.98
	Clean	339(88.3)	106(31.3)	233(68.7)
Source of drinking water	Stream water	162(42.2)	92(56.8)	70(43.2)	85.1	0.0001*
	Tap water	222(57.8)	28(12.6)	194(87.4)
Wearing shoes	No	106(27.6)	83(78.3)	23(21.7)	150.9	0.0001*
	Yes	278(72.4)	37(13.3)	241(86.7)
Presence of latrine	No	134(34.9)	87(64.9)	47(35.1)	108.6	0.0001*
	Yes	250(65.1)	33(13.2)	217(86.8)
Eating soil	Yes	115(29.9)	73(63.5)	42(36.5)	79.4	0.0001*
	No	269(70.1)	17(6.3)	222(82.5)
Mothers' knowledge of mode of transmission of IPIs	No	221(57.6)	101(45.7)	120(54.3)	50.6	0.0001*
	Yes	163(42.4)	19(11.7)	144(88.3)

Univariate analysis of sociodemographic and risk factors associated with IPIs

Logistic regression analysis was used to identify the significant risk factors and the strength of association with IPI among under-five-aged children at the Dabat primary hospital. A univariate analysis was performed first, then variables with P < 0.25 were selected, then included in the multivariate analysis. Univariate logistic regression analysis of sociodemographic and risk factors associated with intestinal parasitic infections (IPI) showed that age, family residence, washing hands after using the toilet, before touching their child, and before feeding their child were significantly associated with IPIs (p value < 0.05) (Table 5).

Table 5.

Univariate analysis on sociodemographic and risk factors associated with IPIs among under-five-aged children (n = 384)

Risk factors		IPIs		COR (95%CI)	P value
		Positive (%)	Negative (%)
Sex	Male	60 (35.7)	108 (64.3)	1.44 (0.94–2.23)	0.097
	Female	60 (27.8)	156 (72.2)	1
Age category	< 1 year	35 (50)	35(50)	2.47(1.19–5.14)	0.006*
	1–2 year	28(30.4)	64 (69.6)	1.08(0.53–2.22)
	2–3 year	23 (25)	69 (75)	0.82(0.39–1.72)
	3–4 year	17 (23.9)	54 (76.1)	0.78 (0.36–1.7)
	4–5 year	17 (28.8)	42(71.2)	1
Family Residence	Rural	74 (40.7)	108(59.3)	2.32 (1.49–3.62)	0.001*
	Urban	46(22.8)	156(77.2)	1
Mothers occupation	Farmer	56 (43.1)	74(56.9)	2.17(1.09–4.29)	0.005*
	Merchant	23 (23.5)	75 (76.5)	0.88(0.42–1.86)
	Housewife	26 (26.5)	72 (73.5)	1.04(0,49–2.17)
	Gover. employee	15 (25.9)	43 (74.1)	1
Family monthly income (in ETB)	< 1000 birr	43 (48.3)	46 (51.7)	3.86 (2.09–7.09)	0.001*
	1000–3000 birr	53 (30.8)	119 (69.2)	1.84(1.06–3.19)
	> 3000 birr	24(19.5)	99 (80.5)	1
Education level of Mother	Illiterate	28(38.9)	44 (61.1)	1.43(0.67–3.05)	0.490
	Writing & reading	45 (29.4)	108(70.6)	0.94(0.47–1.86)
	High school	31(29)	76 (71)	0.92(0.45–1.89)
	College/University	16 (30.8)	36 (69.2)	1
Washing hands after toilet before touching child	No	69 (44.2)	87(55.8)	2.75(1.77–4.29)	0.0001*
	Yes	51(22.4)	177(77.6)	1
Washing hands before feeding their child	No	72(52.6)	65(47.4)	4.59(2.89–7.28)	0.0001*
	Yes	48(19.4)	199(80.6)	1
Eating unwashed fruits & vegetables by the Child	Yes	57(52.3)	52(47.7)	3.69(2.3–5.89)	0.0001*
	No	63(22.9)	212(77.1)	1
Child Contact with water bodies	Yes	81(54)	69(46)	5.87(3.67–9.39)	0.0001*
	No	39(16.7)	195(83.3)	1
Child meal	Rarely fresh	80(61.5)	50(38.5)	18.7(8.0–43.79)	0.0001*
	Sometimes fresh	33(20)	132(80)	2.9(1.24––6.93)
	Always fresh	7(7.8)	82(92.1)	1
Trimming Childs nails	No	9(23.7)	29(76.3)	0.66(0.3–1.44)	0.290
	Yes	111(32.1)	235(67.9)	1
Feeding before the age of 6 month	Yes	13(13.8)	81(86.2)	0.27(0.15–0.52)	0.0001*
	No	107(36.9)	183(63.1)	1
Child playing ground	Not clean	14(31.1)	31(68.9)	0.99(0.51–1.94)	0.98
	Clean	106(31.3)	233(68.7)	1
Source of drinking water	Stream water	92(56.8)	70(43.2)	9.1(5.5–15.1)	0.000*
	Tap water	28(12.6)	194(87.4)	1
Wearing shoes	No	83(78.3)	23(21.7)	23.5(13.2–41.9)	0.000*
	Yes	37(13.3)	241(86.7)	1
Presence of latrine	No	87(64.9)	47(35.1)	12.2(7.3–20.27)	0.000*
	Yes	33(13.2)	217(86.8)	1
Eating soil	Yes	73(63.5)	42(36.5)	8.2(5.0–13.44)	0.0001*
	No	17(6.3)	222(82.5)	1
mothers' knowledge of mode of transmission of IPIs	No	101(45.7)	120(54.3)	6.38(3.69–11.0)	0.0001*
	Yes	19(11.7)	144(88.3)	1

*Reference category

Multivariate analysis of sociodemographic and risk factors association with IPIs

Multivariate analysis of sociodemographic characteristics and risk factors associated with IPIs was done in Table 6. Multivariate analysis showed that age, family residence, washing hands after toilet before touching their child and before feeding their child, child meal, Feeding other food before the age of 6 month, shoe wearing, and eating soil were significantly associated with IPIs among under-five-aged children (P < 0.05). Concerning the odds of infection, 2.34 times higher among the age group < 1 year (AOR = 2.34, 95% CI = 0.73–7.48), than those in age group 4–5 years old. The likelihood of infection by IPIs were 2.66 times higher in rural dweller children (AOR = 2.66, 95% CI = 1.19–5.97) compared with urban residents. The odds of infection was three and five times higher among under-five-aged children whose family didn’t wash hands after toilet before touching their child and before feeding their child (AOR = 3.04, 95% CI = 1.4–6.57), and (AOR = 5.26, 95% CI = 2.28–12.2) compared with under-five-aged children whose family wash their hands. The likelihood of infection by IPIs were four times higher in children who feed rarely fresh foods (AOR = 4, 95% CI = 1.26–12.75) compared with those who eat always fresh meal. The odds of infection were 14.5 times higher on children who didn’t wear shoe (AOR = 14.5, 95% CI = 5.77–36.5) than who wear shoe. The likelihood of infection was 2.59 times higher on children who eat soil (AOR = 2.89, 95% CI = 1.25–6.7) compared with who didn’t eat soil (Table 6).

Table 6.

Multivariable analysis on sociodemographic and risk factors associated with IPIs among under-five-aged children 2022 (n = 384)

Risk factors		IPIs		AOR (95%CI)	P value
		Positive (%)	Negative (%)
Sex	Male	60 (35.7)	108(64.3)	0.76(0.35–1.66)	0.494
	Female	60(27.8)	156(72.2)	1
Age	< 1 year	35 (50.0)	35(50.0)	2.34(0.73–7.48)	0.001*
	1–2 year	28(30.4)	64 (69.6)	0.35(0.09–1.23)
	2–3 year	23 (25.0)	69 (75.0)	0.46(0.13–1.68)
	3–4 year	17 (23.9)	54 (76.1)	0.21(0.05–0.85)
	4–5 year	17 (28.8)	42(71.2)	1
Family Residence	Rural	74 (40.7)	108(59.3)	2.66(1.19–5.97)	0.018*
	Urban	46(22.8)	156(77.2)	1
Mothers occupation	Farmer	56 (43.1)	74(56.9)	1.35(0.40–4.52)	0.671
	Merchant	23 (23.5)	75 (76.5)	0.89(0.25–3.29)
	Housewife	26 (26.5)	72 (73.5)	0.76(0.21–2.75)
	Gover. employee	15 (25.9)	43 (74.1)	1
Family monthly income (in ETB)	< 1000 birr	43 (48.3)	46 (51.7)	1.35(0.48–3.83)	0.617
	1000 – 3000 birr	53 (30.8)	119 (69.2)	1.57(0.64–3.89)
	> 3000 birr	24(19.5)	99 (80.5)	1
Washing hands after toilet before touching child	No	69 (44.2)	87(55.8)	3.04(1.4–6.57)	0.005*
	Yes	51(22.4)	177(77.6)	1
Washing hands before feeding their child	No	72(52.6)	65(47.4)	5.26(2.28–12.2)	0.000*
	Yes	48(19.4)	199(80.6)	1
Eating of unwashed fruits and vegetables by the Child	Yes	57(52.3)	52(47.7)	0.78(0.31–1.91)	0.580
	No	63(22.9)	212(77.1)	1
Child Contact with water bodies	Yes	81(54)	69(46)	0.75(0.3–1.84)	0.528
	No	39(16.7)	195(83.3)	1
Child meal	Rarely fresh	80(61.5)	50(38.5)	4(1.26–12.75)	0.018*
	Sometimes fresh	33(20)	132(80)	1.43(0.46–4.43)
	Always fresh	7(7.8)	82(92.1)	1
Feeding other food before the age of 6 month	Yes	13(13.8)	81(86.2)	0.27(0.1–0.69)	0.007*
	No	107(36.9)	183(63.1)	1
Source of drinking water	Stream water	92(56.8)	70(43.2)	1.94(0.84–4.53)	0.123
	Tap water	28(12.6)	194(87.4)	1
Wearing shoes	No	83(78.3)	23(21.7)	14.5(5.77–36.5)	0.000*
	Yes	37(13.3)	241(86.7)	1
Presence of latrine	No	87(64.9)	47(35.1)	1.8(0.74–4.42)	0.198
	Yes	33(13.2)	217(86.8)	1
Eating soil	Yes	73(63.5)	42(36.5)	2.59(1.05–6.39)	0.040*
	No	17(6.3)	222(82.5)	1
mothers' Knowledge of mode of transmission of IPIs	No	101(45.7)	120(54.3)	1.24(0.47–3.3)	0.666
	Yes	19(11.7)	144(88.3)	1

*Reference category

Univariate and multivariate analysis of factors associated with E. histolytica infection

Univariate and multivariate analysis of risk factors associated with the E. histolytica/dispar infection are presented in Table 7. Univariate analysis showed that, family monthly income, washing hands before feeding their child, presence of latrine, and habit of eating raw vegetable/meat by the child were significantly associated with E. histolytica/dispar infection. However, multivariate analysis showed that family monthly income and washing hands before feeding their child was the significant predictor of E. histolytica/dispar infection. The odds of infection was 2.71 times higher among whose family monthly income are less than 1000 ETB (AOR = 2.71, 95% CI = 0.64–5.34) compared with those having monthly income higher than 3000 ETB. Similarly the odds of infection was 2.63 times higher among whose family didn’t wash hands before feeding their child (AOR = 2.63, 95% CI = 0.74–9.28) compared with whose family wash their hands (Table 7).

Table 7.

Univariate and multivariable analysis of selected risk factors associated with E. histolytica/dispar infections among under-five aged children

Risk factor	E. histolytica		COR (95%CI)	P-value	AOR (95%CI)	P-value
	Positive (%)	Negative (%)
Family monthly income (in ETB)
Less than 100	16 (14)	98 (85.9)	4.26 (1.57–8.79)	0.001*	2.71 (0.64–5.34)	0.043*
1000–3000	12 (6.89)	162 (93.1)	2.2 (0.89–6.23)		1.86 (0.26–4.64)
Above 3000	1 (1.04)	95 (98.9)	1		1
Washing hands after toilet before touching child
No	13(27.1)	35(72.9)	3.25 (0.98–5.86)	0.067	1.26 (0.34–4.14)	0.153
Yes	16(4.76)	320(95.24)	1		1
Washing hands before feeding their child
No	11 (28.9)	27 (71)	5.23 (1.29–12.52)	0.004*	2.63 (0.74–9.28)	0.021*
Yes	18 (5.2)	328 (94.8)	1		1
Presence of latrine
No	10 (8.69)	105 (91.3)	3.49 (1.12–6.87)	0.026*	1.52 (0.23–3.41)	0.089
Yes	19 (7.06)	250 (92.9)	1		1
Eating unwashed fruit/vegetable by the child
Yes	21 (17.9)	96 (82.1)	4.25 (1.28–6.58)	0.001*	1.98 (1.05–4.65)	0.089
No	8 (2.99)	259 (97)	1		1

*Reference category

Univariate and multivariate analysis of factors associated with Giardia lamblia infection

Univariate and multivariate analysis of risk factors associated with the risk of G lamblia infection are presented in Table 8. Univariate analysis showed that, family Educational level, washing hands before feeding their child, and presence of latrine were significantly associated with G. lamblia infection. However, multivariate analysis showed that washing hands before feeding their child and source of drinking water were the significant predictor of G. lamblia infection. The odds of infection was 2.98 times higher among under-five-aged children whose family didn’t wash hands before feeding their child (AOR = 2.98, 95% CI = 0.92–6.73) compared with who wash their hands. Similarly the odds of infection was 4.56 times higher among under five aged children whose source of drinking water is stream water (AOR = 4.56, 95% CI = 1.13–9.87) compared with those who use tape water (Table 8).

Table 8.

Univariate and multivariable analysis of selected risk factors associated with G. lamblia infections among under-five aged children

Risk factor	Giardia lamblia		COR (95%CI)	P-value	AOR (95%CI)	P-value
	Positive	Negative
Family Educational level
Illiterate	9 (16.3)	46 (83.6)	4.23 (0.64–8.45)	0.0123*	2.18 (0.58–9.84)	0.089
Writing & reading	12 (7.3)	152 (92.68)	2.56 (0.53–6.56)		2.89 (0.36–6.89)
High school	4 (3.64)	106 (96.4)	1.45 (0.65–3.57)		1.08 (0.42–3.68)
College/University	1(1.8)	54 (98.2)	1		1
Washing hands before feeding their child
No	7 (9.3)	68 (90.7)	5.23 (1.56–8.76)	0.005*	2.98 (0.92–6.73)	0.016*
Yes	21 (6.75)	290 (93.24)	1		1
Source of drinking water
Stream water	12(56.8)	98(43.2)	6.6(1.25–12.62)	0.0001*	4.56(1.13–9.87)	0.002*
Tap water	14(12.6)	260(87.4)	1		1
Presence of latrine
No	9 (9.08)	118 (92.9)	3.23 (0.68–6.51)	0.161	3.23 (0.23–5.74)	0.135
Yes	17 (6.61)	240 (93.4)	1		1

*Reference category

Univariate and multivariate analysis of factors associated with hookworm Infection

Univariate and multivariate analysis of risk factors associated with the risk of hookworm infection are presented in Table 9. Univariate analysis showed that, monthly income and wearing shoes were significantly associated with hookworm infection. However, multivariate analysis showed that wearing shoes was the only significant predictor of hookworm infection. The odds of infection was 5.23 times higher among under-five-aged children who didn’t wear shoe (AOR = 5.23, 95% CI = 1.56–10.56) compared with under-five-aged children who wear shoe (Table 9).

Table 9.

Univariate and multivariable analysis of selected risk factors associated with hookworm infection among under-five aged children

Risk factor	Hookworm		COR (95%CI)	P-value	AOR (95%CI)	P-value
	Positive	Negative
Monthly income
Less than 1000	11 (11.5)	85 (88.5)	4.11 (1.68–9.78)	0.033*	2.57 (0.05–7.25)	0.075
1000–3000	8(4.85)	157 (95.2)	2.41 (0.25–7.46)		1.87 (0.35–6.73)
Above 3000	2 (1.6)	121 (98.4)	1		1
Child playing ground
No	4 (3.1)	125 (96.8)	2.8 (0.56–5.23)	0.061*	1.69 (0.23–6.58)	0.062
Yes	17 (6.67)	238 (93.3)	1		1
Wearing shoes
No	13 (11.9)	96 (88.1)	8.54 (2.12–12.98)	0.00*	5.23 (1.56–10.56)	0.002*
Yes	8 (2.9)	267 (97.1)	1		1
Habit of soil eating
Yes	5 (6.75)	69 (93.24)	3.25 (0.05–6.21)	0.051	1.25 (0.89–3.28)	0.094
No	16 (5.16)	294 (94.8)	1		1

*Reference category

Discussion

It is important to know the prevalence and the risk factors of intestinal parasitic infections to save the life of the people especially under-five aged children’s. In line with this idea, the present study attempted to assess the prevalence of IPIs and associated risk factors among under-five-aged children in Dabat primary hospital. The overall prevalence of IPIs among under-five-aged children in the present study was 32.81% (126/384). According to FMOH of Ethiopia classification, the prevalence of IPI (32.81%) in the study area is considered as medium (Federal ministry of Health, Ethiopia 2016). The present finding showed a higher prevalence rate than the prevalence done on under-five-aged children in Abakaliki local government area of Ebonyi state, Nigeria (13.7%) (Achi et al. 2017), Wonji Shoa Sugar Estate, Ethiopia (24.3%) (Gebrehiwot et al. 2014) and Woreta Health Center, Ethiopia (18.70%) (Mekonnen and Ekubagewargies 2019). However the present finding was lower compared to the study done on under-five children in Shesha Kekele, Wondo Genet, Ethiopia (85.1%) (Liza et al. 2010), preschool children in Senbete and Bete Towns, Ethiopia (52.3%) (Lewetegn et al. 2019), Pre-school Children in an Urban Squatter Settlement of Egypt (47.3%) (Mahfouz et al. 1997) and day Care Centre in Matanzas City, Cuba (45.2%) (Cañete et al. 2012). Under-two-age in rural area of Rutsiro district, Rwanda (44.8%) (Butera et al. 2019) and preschool children in rural community in Senegal (35%) (Sylla et al. 2018).

The reason for these variation and higher prevalence in others could be due to some research setting difference. For instance, this study has included the participants without checking presence of diarrhea and any other symptoms of IPI; and the investigator took only one sample. All these may decreased the probability of the detection of intestinal parasite. Additionally, the difference could be due to poor environmental sanitation including open field defecation, and poor personal hygiene, such as, don’t wash hand after using toilet, and before feeding their child, eating unwashed fruit and vegetable. The higher burden of infection in this study area was caused by helminthes (56.35%, 71/126) than protozoa (43.65, 55/126). Several researches confirmed that, children harbor higher levels of intestinal pathogens, especially eggs of helminths; because they play with their faeces and contaminated soil thereby exposed to the infection (Ferreira et al. 2020). Moreover, this study area is characterized mostly by warm and shaded soils which are suitable conditions for the egg of the helminthes. Most of the risking factors for the transmission of helminthes, including wearing shoes and eating of soil, are significantly associated.

The prevalence of protozoa parasitic infections in this study was 14.32% (55/384). The outcome of the study was comparative with the study done on Under-five-children at Woreta Health Center, Ethiopia (16.77%, 52/310) (Mekonnen and Ekubagewargies 2019) but lower than the result of children under five in the Central Hospital of Nampula, Mozambique (23.1%, 192/831) (Ferreira et al. 2020). On the other hand, the prevalence of helminths in the study area was 18.5% (71/384) which is higher than the result of children under five in the Central Hospital of Nampula, Mozambique (4.7%, 39/831) (Ferreira et al. 2020) and Woreta Health Center, Ethiopia (1.94%, 6/310) (Mekonnen and Ekubagewargies 2019). This study has implemented systematic sampling procedure and required 4 months (of woreta was 2 months) to achieve the necessary amount of participants and sample size of this study was 384 (of Woreta was 310). Therefore, the relative extended study period and having large number of participants increase the probability of getting infected person. The weather condition in the study area is relatively hot, making the environment conducive to IPI transmission.

The predominantly prevalent IPI in the study area was E. histolytica/dispar with the rate of 7.55% (29/384). This prevalence was lower than studies conducted in Under-five-children at Woreta Health Center, Ethiopia (6.77%, 21/310) (Mekonnen and Ekubagewargies 2019) and Dessie Referral Hospitals (6.5%, 15/232) (Gebretsadik et al. 2018). The second dominant parasite was G. lamblia in this study with the prevalence rate of 6.77% (26/384) which is lower than the studies done on under-five-aged children in Woreta Health Center, Ethiopia (10.0%, 31/310) (Mekonnen and Ekubagewargies 2019) but higher than studies from Dessie referral hospital, Ethiopia (1.29%, 3/232) (Gebretsadik et al. 2018) and Bachuma primary hospital, Ethiopia (4.0%, 13/323) (Duguma et al. 2023). Difference in the prevalence of both protozoans (E. histolytica/dispar and G. lamblia) among the different studies might be due to the differences in the levels of contamination of drinking water sources, consumption of raw vegetables, utilization of toilets, and hand washing habits of the study participants.

In this study the third dominant from the total and the first among helminths is Hookworm, with prevalence rate of 5.47% (21/384) which is lower than studies conducted on under-five children in Woreta Health Center, Ethiopia (0.65%, 2/310) (Mekonnen and Ekubagewargies 2019) and Bachuma primary hospital, Ethiopia (1.9%, 6/323) (Duguma et al. 2023). Variations in the prevalence of hookworm infection among studies could be attributed to differences in environmental sanitation, and shoes wearing habits of the children. In this study shoe wearing habits has shown statistically insignificant association with IPIs infection. Children who didn’t wear shoes were more affected by IPIs than those who did.

Male children were found to be more exposed to IPIs than females. This is might be due to male children have high availability to play in contaminated soil and water outside home than female this increased the chance of being infection with IPIs. In the current study age of under-five-aged children was significantly associated with IPIs. This finding is in agreement with a report in Hawassa, South Ethiopia (Mulatu et al. 2015) and in Riyadh, Saudi Arabia (Al-Megrin 2015) that showed significance association of age with prevalence of IPIs. This is because children have lower resistance to parasitic infections as compared to adults since many of the defense systems are not fully developed in children. There is a significant difference between infected and non-infected under-five-aged children regarding family residence where most of the infected under-five-aged children are rural residents (40.7%). Similar findings were observed in Sohag, Egypt (El-Nadi et al. 2017). Rural children mostly have risky behavior such as walking playing with soil, soil to mouth contact, walking bare footed, parents take cares are participating in agricultural activities and contact with domestic animal, poor fingernails and hand hygiene, and defecation in the open agricultural field which consequently leads to more soil contamination with parasites.

Regarding the risk factors, there were significant differences between infected and non-infected children regarding factors washing hands after toilet before touching their child and before feeding their child, child meal, Feeding other food before the age of 6 month, shoe wearing, and eating soil. These findings explain the high prevalence of parasitic infection among studied under-five-aged children which indicates improper implementation of prevention and control measures that are effective in reducing the IPIs such as improvement of personal hygiene and environmental sanitation especially washing hands before feeding their child and after toilet, providing fresh meals, proper sewage and refuse disposal, wearing shoe, increased public health awareness, and community involvement activities (Daryani et al. 2017). Hand washing are among the most effective ways to prevent intestinal parasitic infection (Curtis et al. 2009).

Conclusions

The result of this study indicated that, the overall prevalence of intestinal parasitic infections among under-five-aged children in Dabat primary Hospital was considerable. The proportion of helminth (18.5%) infection was higher than that of protozoan infection (14.8%). In the current study ten different intestinal parasitic species were identified including E. histolytica/dispar, G. lamblia, A. lumbricoides, hookworm, T. trichuria, Tania species; S. stercoralis, S. mansoni, H. nana, and E. vermicularis. This study also identified a number of risk factors associated with IPIs. age, family residence, washing hands after toilet before touching their child and before feeding their child, child meal, taking food before the age of 6 month, shoe wearing, and eating soil were strong predictors of intestinal parasitic infections in under-five-aged children. Therefore, based on the finding of the current study, immediate intervention strategies should be designed and implemented for overcoming the disease, including awareness creation and periodic deworming.

Authors contribution

Mrs. Yamlaksira Amare was a student and this study was conducted to fulfill the requirement to get M.Sc. in Biology. Mrs. Yamlaksira has collected, analyzed, interpreted the data and prepared the report in a thesis format. Mr. Tilahun Yohannes supervised of the entire work and prepared this manuscript. Solomon Tesfaye (PhD) has helped me in incorporating reviewers comment and finalizing the manuscript.

Funding

This study has no any funding bodies.

Data availability

The entire raw data of this study is in the hands of the authors and will be available for reasonable requests.

Declarations

Conflict of interest

We, the authors, declare that we don’t have any conflict of interest.

Ethical approval

Before the commencement of this study, ethical permission was obtained from research ethics review committee of college of natural and computational sciences, University of Gondar. Then further permission was obtained from Dabat Primary Hospital. Signed consent was obtained from the parents/guardians of all participants after briefing of the purpose of the research and what is required from the participants. Then the participants were instructed how to handle and submit their own fresh stool sample. The diagnosis of stool sample were done by trained parasitological laboratory technician of the health center. Those participants positive to any IPI were treated with appropriate drug by the physician of the health center. The cost of diagnosis and treatment was covered by the researchers.

Statement of the guidelines

In this study all tests and examination, questionnaire administration and stool sample diagnosis, were carried out in accordance with relevant WHO intestinal parasite diagnosis guidelines and regulations.