Prevalence of diarrhea and its associated factors among children under five years in Awi Zone, Northwest Ethiopia

Abstract

Background

Globally, diarrhea continues to be the leading cause of morbidity and mortality for children under five, with an annual rate of 149 million cases of illness and 760,000 deaths. This study aimed to assess prevalence and contributing factors of diarrhea among children under-five years in Awi Zone, Northwest Ethiopia.

Methods

A community based cross-sectional study was conducted on 1387 participants from February to June 2023. A multistage sampling method was conducted. Structured and pretested questionnaires were used to collect the data. Data were entered in to Epi data and exported to STATA for analysis. A multivariable logistic regression was performed to determine factors associated with diarrhea with p-value < 0.05.

Results

The prevalence of diarrheal disease among children under five was 17.16%. Child’s age 12 to 23 months [AOR = 16.642; 95% CI: (3.119, 88.805)], protected drinking water [AOR: 0.629; 95% CI: (0.840, 0.928)], health insurance [AOR = 0.571;95% CI: (0.386, 0.844)], institutional delivery [AOR = 0.426, 95% CI: (0.256, 0.707)], water shortage [AOR = 1.570, 95% CI: (1.083, 2.277)], and vaccinated for measles [AOR = 0.124, 95% CI: (0.065, 0.236)] were associated with diarrhea.

Conclusion

Age of children, source of drinking water, health insurance, place of delivery, family size, water shortage, liquid waste disposal, and measles vaccination were significantly associated with diarrhea among under five children. Interventions targeting improvements in drinking water sources, health insurance coverage, sanitation practices, and vaccination rates are crucial for mitigating the impact of diarrheal disease among children under five years in Awi Zone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-024-05191-2.

Introduction

Diarrhea is defined as the passage of 3 or more loose or liquid stools within a day [1, 2]. It is usually a symptom of gastrointestinal infection, which can be caused by a variety of bacterial, viral, and parasitic organisms which is spread through contaminated food or drinking-water, or from person to person as a result of poor hygiene [3].

Globally, diarrhea continues to be the leading cause of morbidity and mortality in children which accounting for around 149 million deaths among children under five in 2019 [4]. Worldwide, World Health Organization (WHO) revealed that diarrhea is the second leading cause of death among under-five children, which accounting for about 1.7 billion cases and 760, 000 mortality every year [5, 6].

In Africa, diarrhea disease is the leading cause of mortality responsible for an estimated 30 million cases and 333,000 children death [5, 7, 8]. Diarrhea disease associated with mortality is more concentrated in Sub-Saharan African countries (88 per 1000 live births) [9]. It is the cause of reduced food appetite, energy intake, nutrient loss and mal-absorption [10]. The burden of diarrhea diseases in developing countries is higher than developed countries, where hygiene and sanitation are poor, and low vaccination coverage [4, 11]. In Sub-Saharan and South Asia countries, diarrhea accounted about 90% of deaths [12].

In Ethiopia, three-fourths of the health problems of under five children are communicable diseases which are caused due to poor environmental health conditions arising from unsafe and inadequate water supply and poor hygienic and sanitation practices [13].

According to data from the 2016 Ethiopian Demographic and Health Survey indicates that 11.79% of children in Ethiopia had diarrhea in the 2 weeks before the survey [14]. Furthermore, other studies in different parts of Ethiopia indicated that the prevalence of childhood diarrhea was in the range of 13.5 to 30.5% [15–19]. Different studies showed that, diarrhea among children under the age of 5 years were significantly influenced by the family size [20], wealth index [21, 22], sex [23], place of residence, mothers’ educational status, mothers’ age, child’s age [21–24], vaccination status [21, 22], place of birth [15], birth order [21, 25], types of drinking water sources [20], liquid waste disposal [22], toilet facilities [20], hand washing at critical time, solid waste disposal [10], and member of health insurance [21]. The illness burden and risk of diarrhea in children varied greatly even among these small studies. There is little knowledge regarding the factors that contribute to childhood diarrhea, despite the higher child mortality rate and high prevalence of diarrhea. Thus, determining the risk factors for diarrhea is critical to the successful implementation of child health intervention programs, to the overall evaluation of resource needs and intervention priorities, and to the reduction of diarrhea among children under five in the Awi Zone through the strengthening of healthcare systems. Therefore, the purpose of this study was to assess the prevalence and associated risk factor of diarrhea among under-five children in Awi Zone, Northwest Ethiopia.

Methods and materials

Study design, setting and period

A community-based cross-sectional study design was employed to investigate the problem in Awi zone from February to June 2023. Awi zone is one of ten zones in Amhara region of Ethiopia, with an estimated total population of 982,942 of whom 491,865 are men and 491,077 women according to Central Statistical Agency, 2007 [26]. The zone has 15 districts, six urban and nine rural, which bordered on the west by Benishangul-Gumuz Region, on the north by west Gondar Zone and on the east by West Gojjam Zone. It is located 114 km from Bahir Dar, the capital of Amhara region, and 449 km from Addis Ababa, the capital city of Ethiopia. Awi zone elevations vary from 1,800 to 3,100 m above sea level, with an average altitude of about 2,300 m. It has five governmental hospitals, 46 health centers, 125 private clinics and one hospital in the zone that provide preventive and curative services to the community [27]. Women/caregivers were interviewed to get information about the history of under five children in the five years preceding the surveys.

Study and source population

The source of population was all under-five children living in the Awi zone, while all under-five children lived in randomly selected kebeles in the Awi Zone were the study population.

Inclusion and exclusion criteria

Mothers/caregivers-child pairs lived in Awi Zone at least for 6 months prior to data collection was incorporated under this study. However, Mothers/caregivers-child pairs had resided in the research area for less than 6 months prior to data collection (those visiting), as well as those who were not volunteer to participate, caregiver with mental illness, and severely ill were excluded from this study.

Sample size determination and sampling technique

Sample size was computed based on single population proportion formula by using: confidence level = 95% [28], margin of error (d) = 3%, design effect = two (Awi zone-districts-kebeles-households), and the prevalence of diarrhea among under five children in Mecha district, North West Ethiopia (p = 0.18), which is that gave a relatively larger sample size was taken into consideration and 10% non- response rate [29].

The final sample size was estimated as 630.02 × 2 = 1260.04 by adding 10% non-response rate becomes 1387.

Household numbers having under-five children were taken from health extension workers registration books. The youngest child was selected for a household having two or more under 5 years of children. Multistage sampling technique was employed to select study subject among the fifteen districts which were stratified into urban and rural. Eight districts (three urban and five rural districts) were selected by lottery method from a cluster created sample frame as primary sampling unit. Similarly, six urban and twenty nine rural kebeles from each urban and rural district were chosen using simple random sampling technique in second stage. The first household was selected randomly at the center of the kebeles and the subsequent households were selected systematically and sampling interval used for selected kebeles was calculated by dividing the total number of households in each kebeles to the allocated sample size. Mothers/ caregivers who have under-five year children were the respondents in a household. Finally, a total of 1387 households were selected with probability proportional to population size using systematic random sampling technique.

Data collection technique and quality control

The data was collected by using a face-to-face interviewer-administered questionnaire which was adapted from different literature, including socio-economic and demographic, environmental and community related, health and child caring related factors and an observation checklist was also applied and submitted as supplement file (Additional file 1).

The data was conducted by eight data collectors and two supervisors with a degree holder in public health officers or nurses. Further, measurement and observational checklist was also used. The training was given for three days for data collectors and supervisors prior to the start of the data collection process about interview technique, how to maintain quality of data, and ethical issue. Daily supervision and follow-up were done by the supervisors and principal investigators. Original questionnaire was prepared in English and then translated into Amharic and Agewegna (local languages) and translated back to English to check consistency, and the pretest was done on the data collection instrument before conducting the study. The vaccination history of the children was validated by checking against immunization cards. The questionnaire was pre-tested on 5% of study participants in kebeles not included in the main survey before the actual survey and necessary modifications were done. The collected data quality consistency and completeness were checked; the data were entered into Epi data 4.0.2 software by two data clerks, and then exported to STATA 14 for analysis.

Variables of the study

Outcome variable

The outcome variable for this study was occurrence of diarrhea, reported by the mother/caregivers of the child and coded as “Yes = 1” and “No = 0”. In this study, socio-economic and demographic variables (place of residence, education status of the mother, occupational status of mother, household wealth index, age of the child, sex of the child, marital status of mother, number of children less than 59 months in HH, family size, current age of mother, birth order, media exposure and religion of mother), environmental and community related variables (toilet facility for HH, shortage of water for HH, source of drinking water for HH, distance to fetch water, solid waste disposal system, liquid waste disposal system, type of floor of house made), and behavioral and health caring related variables (measles vaccination, duration of breast feeding status, Knowledge of mothers/caregivers on diarrhea prevention and transmission, age at complementary feeding, place of delivery, health insurance, mother’s hand washing at critical times) were included.

Data management and analysis

The data was entered and cleaned in Epi info version 4.0.2 and analyzed using STATA 14. The frequency and percentages of the variables were presented using descriptive statistics. Bivariable and multivariable logistic regression analyses were done. Binary logistic regression model was used to assess the associations between dependent and independent variables. The binary logistic regression model was used to analyze the diarrheal disease. Hence, diarrheal disease was classified as either yes (coded as 1) or not (coded as 0). The ratio of the success (Y_i=1) probability, P (x_i) to that of 1-P(x_i) (failure (Y = 0) probability) is given by: is known as the odds of success.

In terms of the odds, the logistic model can be written as:

and the odds in favor of success for multivariable logistic regression will be.

The odds of some event happening is defined as the ratio of the probability of occurrence to the probability of non-occurrence. The binary logistic regression analysis requires the assumptions of observations are independent and no perfect correlation between the independent variables. Additionally, the relationship between continuous predictors and the outcome should be linear. Bivariable logistic regression analysis was applied to identify factors associated with diarrhea. Bivariable logistic regression analysis, with the crude odds ratio (COR) was carried out to identify associations between the diarrhea and each independent variable. All variables with p-value < 0.2 in the bivariable logistic regression analysis were chosen for the multivariable logistic regression analysis to compensate confounders [30]. In the multivariable logistic regression analysis, the adjusted odds ratio was used to determine factors associated with diarrhea among under-five children which were expressed at a 95% confidence interval. Significant predictors were defined as factors with a p-value of less than 0.05.

Results

Socio-demographic characteristics of the study participants

In this study, a total of 1387 households with under-five children were included and a complete response was obtained from all (100%) respondents. Out of total respondents, the prevalence of diarrhea varies based on place of residence; children living rural areas were 908 (65.47%). About more than half of the children 783 (56.45%) were males. About 746 (53.79%) mothers/caregivers were in the age group of 25–34 years. The majority of mothers 1319 (95.10%) were married at the time of the study, and 736(53.06%) were unable to read and write [Table 1].

Table 1.

Socio demographic characteristics of household for predictors of diarrhea among under-five children in Awi Zone, Northwest Ethiopia, 2023

characteristics	categories	frequency	percentage
residence	urban	479	34.53
	rural	908	65.47
sex of child	male	783	56.45
	female	604	43.55
religion	orthodox	1310	94.38
	other	78	5.62
educational status of mother/caregiver	no education	736	53.06
	primary	347	25.02
	secondary and above	304	21.92
marital status	married	1319	95.10
	other*a	68	4.90
Main occupation of mothers/caretakers	farmer	778	56.09
	Employed	78	5.62
	housewife	455	32.80
	other*b	76	5.48
age of mother	below 24	125	9.01
	25–34	748	53.93
	35 and above	514	37.06
child birth order	first	337	24.30
	2–3	514	37.06
	4–5	327	23.58
	6 and above	209	15.07
family size of house hold	5 and less than	620	44.70
	above 5	767	55.30
Number of children in the family	one	1050	75.70
	two and above	337	24.30
Age of the child in months	less than 6	124	8.94
	6–11	208	15.00
	12–23	388	27.97
	24–59	667	48.09
wealth index of house hold	poor	562	40.52
	middle	287	20.69
	Rich	538	38.79
media exposure	No	671	48.38
	Yes	716	51.62

∗a Widowed, divorced, or separated *b daily laborer, merchant

Environmental and community characteristics of households

Of the total participants, 1287 (92.79%) had latrines and 211 (15.21%) respondents use unprotected drinking water source [Table 2].

Table 2.

Environmental and community characteristics for predictors of diarrhea among under five children in Awi Zone, Northwest Ethiopia, 2023

characteristics	categories	frequency	percentage
Main source of drinking water	unprotected	211	15.21
	protected	1176	84.79
Round trip distance to fetch water	=<30 min	746	53.79
	> 30 min	641	46.21
water shortage	no	387	27.90
	yes	1000	72.10
Solid waste disposal system	improper	621	44.77
	proper	766	55.23
liquid waste disposal system	improper	983	70.87
	proper	404	29.13
Type of floor of house made from	mud	1086	78.30
	cement	301	21.70
toilet facility for household	no	100	7.21
	yes	1287	92.79

Behavioral and health caring practice of the children

From the total study participants, 1295 (93.37%) of respondents were delivery from health facility and 92(6.63%) were from home. About 997(71.88%) had knowledge about the mode of transmission and prevention mechanisms of diarrheal diseases; 721 (51.98%) gave supplementary food to their children at 6 months [Table 3].

Table 3.

Behavioral and health caring practice characteristics for predictors of diarrhea among under five children in Awi Zone, Northwest Ethiopia, 2023

characteristics	categories	frequency	percentage
place of delivery	home	92	6.63
	health facility	1295	93.37
The child initiated complementary feeding at 6 month	no	547	39.44
	yes	721	51.98
	not starting	119	8.58
child vaccination	no	284	20.48
	yes	1103	79.52
duration of breast feeding	less than 24 months	789	56.89
	24 and above months	598	43.11
Soap use for hand washing at critical time	No	346	24.95
	Yes	1041	75.05
Knowledge of mothers/caretakers on diarrhea prevention and transmission	poor	390	28.12
	good	997	71.88
health insurance	No	314	22.64
	Yes	1073	77.36

Prevalence of diarrhea and its associated factors among under-five children

The finding of this study revealed that the prevalence of diarrhea among under five children in Awi zone was 17.16% with 95% confidence interval of 15.26–19.24 in last two weeks preceding of the data collection date (Fig. 1).

Fig. 1.

Prevalence of diarrhea among under five years of children in Awi zone

In bivariable logistic regression analysis, age of child in months, child birth order, number of under five children in the household, educational status of mother, marital status of mother, family size of household, media exposure, main source of drinking water, round trip distance of fetch water, water shortage, liquid waste disposal system, solid waste disposal system, type of floor of house made, place of delivery, child initiated complementary feeding at 6 month, child vaccination for measles, Soap use for hand washing at critical time, knowledge of mothers/caretakers on diarrhea prevention, and health insurance were identified as candidate variables for the multivariable logistic regression analysis. In this study, age of children, type of drinking water source, health insurance, place of delivery, family size, water shortage, liquid waste disposal system, and child vaccination against measles showed that statistically significant association among under-five children diarrhea [Table 4].

Table 4.

Bivariable and multivariable logistic regression analysis of diarrhea and associated risk factors in Awi Zone, Northwest Ethiopia (n = 1387)

Characteristics	Categories	COR (95% CI)	AOR (95% CI)	p-value
Age of the child in months	less than 6	1	1
	6–11	1.573(0.773,3.199)	2.067(0.429,9.950)	0.365
	12–23	2.860(1.508,5.423)	16.642(3.119,88.805)*	0.001
	24–59	1.744(0.928,3.277)	10.901(2.062,57.631)*	0.005
child birth order	first	1	1
	2–3	1.383(0.948,2.017)	1.094(0.691,1.732)	0.701
	4–5	1.437(0.953,2.167)	0.759(0.415,1.387)	0.370
	6 and above	1.049(0.643,1.709)	0.591(0.294,1.184)	0.138
Number of children in the family	one	1	1
	two and above	1.447(1.063,1.970)	1.271(0.877,1.840)	0.205
educational status of mother/caregiver/	no education	1	1
	primary	0.968(0.694,1.350)	1.083(0.723,1.622)	0.700
	secondary+	0.694(0.475,1.013)	0.723(0.436,1.198)	0.207
marital status	married	1	1
	other*a	1.656(0.939,2.921)	1.503(0.806,2.801)	0.200
family size of household	5 and less than	1	1
	above 5	1.470(1.102,1.959)	1.669(1.096,2.542)*	0.017
media exposure	No	1	1
	Yes	0.724(0.547,0.959)	0.800(0.572,1.118)	0.191
Main source of drinking water	unprotected	1	1
	protected	0.574(0.405,0.815)	0.629(0.426,0.928)*	0.020
Round trip distance to fetch water	=<30 min	1	1
	> 30 min	1.357(1.026,1.795)	1.141(0.840,1.549)	0.399
Water shortage	No	1	1
	Yes	1.560(1.114,2.185)	1.570(1.083,2.277)*	0.017
Solid waste disposal system	improper	1	1
	proper	0.730(0.552,0.965)	1.032(0.740,1.440)	0.853
liquid waste disposal system	improper	1	1
	proper	0.529(0.375,0.748)	0.587(0.394,0.874)*	0.009
Type of floor of house made from	mud	1	1
	cement	0.640(0.441,0.930)	0.864(0.551,1.356)	0.526
place of delivery	home	1
	health facility	0.395(0.250,0.627)	0.426(0.256,0.707)*	0.001
The child initiated complementary feeding at 6 month	No	1	1
	yes	0.804(0.602,1.072)	0.981(0.715,1.345)	0.905
	No starting	0.414(0.215,0.797)	0.741(0.149,3.689)	0.715
child vaccination (measles)	no	1	1
	yes	0.680(0.491,0.940)	0.124(0.065,0.236)*	< 0.001
Soap use for hand washing at critical time	No	1	1
	Yes	0.624(0.461,0.845)	0.818(0.558,1.200)	0.304
Knowledge of mothers/caretakers on diarrhea prevention	poor	1	1
	good	0.636(0.473,0.854)	0.752(0.517,1.093)	0.135
health insurance	No	1	1
	yes	0.529(0.375,0.748)	0.571(0.386,0.844)*	0.005

*Significance at p-value ≤ 0.05; COR: crude odds ratio; AOR: adjusted odds ratio

This study revealed that the children’s exposure to diarrhea was increased when they completed their first 11 months of life and the risk was highest at the age of 12–23 months. Children whose group of age 12 to 23 months were 16.642 times (AOR = 16.642; 95% CI: 3.119, 88.805) and 24 to 59 months were 10.901 times (AOR = 10.901; 95% CI: 2.062, 57.631) higher risk of developing diarrhea compared to those whose age were less than 6 months. This study also showed that children who deliver in health institution were 0.426 times less likely to develop diarrhea compared to their counterparts [AOR = 0.426; 95% CI: 0.256, 0.707]. Children living in households with shortage of water were 1.570 times more likely to develop diarrhea as compared to their counterparts [AOR = 1.570; 95% CI: 1.083, 2.277].

Additionally, the odds of having diarrheal diseases in children whose family have appropriate liquid waste disposal were 0.587 times less likely compared with a family that practiced inappropriate liquid waste disposal [AOR = 0.587; 95% CI: 0.394, 0.874]. Children living in households who had above five family member were 1.667 times more likely to develop diarrheal disease compared to children living in households with five or less family member [AOR = 1.667; 95% CI: 1.096, 2.542].

This study also showed that children who get measles vaccination were 0.124 times less likely to develop diarrhea compared to their counterpart [AOR = 0.124, 95% CI: 0.065, 0.236].

Regarding to drinking water source, households that used improved water sources decreases the likelihood of childhood diarrhea by 0.629 times compared to households that used unimproved water source [AOR = 0.629; 95% CI: 0.840,0.928]. Pertaining member of health insurance, the odds of developing diarrhea in children living in households who were a member of health insurance were 0.571 times (AOR = 0.571; 95% CI: 0.386, 0.844) less likely as compared to children living in households who were not a member of health insurance [Table 4].

Discussion

This study was conducted to assess the prevalence of diarrhea and its associated factors among children under-five years in Awi Zone, Northwest Ethiopia. The finding of this study revealed that the two weeks prevalence of childhood diarrhea among under-five years was 17.16% (95% CI: 15.26–19.24%). This finding was comparable with the study conducted in the West Gojjam zone (18%) [31]. The result this finding was higher as compared with studies done in East Gojjam zone (6.5%) [32], Malaysia (4.4%) [33], Kamashi district (14.5%) [34], EDHS 2016 report (12%) [35], and Dale District, Sidama zone, Southern Ethiopia (13.6%) [36]. However, the finding was lower as compared with study conducted in Burundi (32.6%) [37], and Arba-Minch rural community (31%) [38]. The difference might be attributed to the variation in the socio demographic, behavioral, and environmental factors of study households compared to other studies like, people’s way of life, educational levels of the community, maternity care of child’s immunization, and nutritional differences.

Age of children has showed a statistically significant association with diarrhea occurrence in which the odds of developing diarrhea among children in the age groups 12– 23 months and 24–59 months were 16.642 and 10.901 times higher as compared with children aged below 6 months respectively. This finding was supported by previous studies conducted in Ethiopia [39], Uganda [40], Eritrea [41], Oromia Region [22], Arba Minch District [16], and Dale District, Sidama zone, Southern Ethiopia [36]. The study from the Benishangul Gumuz Regional State, Northwest Ethiopia also supports this finding in which the odds of developing diarrhea was 1.94 times higher among children aged from 12 to 24 months when compared to children aged below 6 months [42]. This could be due to children in this age groups are the time of crawling and mouthing whatever they get even their feces that causing diarrhea pathogens, making this aged children at a more risk of developing diarrheal diseases. In addition to this, this age is the transition from an exclusive breastfeeding, and starting of solid complementary foods which is poor in hygiene to children whose immunity was not well developed [43].

Additionally, children from household with more than five family members had 1.669 times higher risk of diarrhea than children from households with less than or equal to five family members. This result is consistent with previous studies conducted in rural settings of Dangila district, Ethiopia [5], and rural areas of North Gondar zone, Ethiopia [44]. Similarly, study in Ethiopia [45] showed that children who were from households who had greater than six family members were 1.41 times more likely to develop diarrhea as compared to children who were from households who had less than five family members. This could be due to more family members living in the household, it is expected that children will be more susceptible to diarrhea due to parents’ decreased level of care and attention, as well as the increased risk of disease transmission through contaminated food and water, poor personal hygiene, and unsanitary surroundings [46].

Findings on measles vaccination revealed that children who were vaccinated for measles were less risk to experience diarrhea as compared to those children who were not vaccinated. This finding was in agreement with the previous study conducted in Ethiopia [45], low-income and middle-income countries [47], rural settings of Danglia district, Ethiopia [5], and Amhara region [30], which found that the diarrhea disease was high during outbreak of measles. A child who is vaccinated against measles has advantage to minimize a developing of measles infection. Measles is extremely contagious disease measles damages epithelial cells and weakens the immune system, which can result in infections of various organ systems and protein-losing enteropathy. As a result, children may develop measles, which indirectly causes diarrhea as a complication to measles [48].

Furthermore, children living in household having water shortage had 1.570 times higher chance of getting diarrhea occurrence as compared to household having no water shortage. The findings from rural settings of Danglia district, Ethiopia [5] also showed that households with water shortage increases the chance of diarrhea occurrence by 18 times as compared to households having no water shortage. This could be explained by the fact that households having water shortage could not keep their personal hygiene as necessary [49].

This finding reveled that liquid waste disposal system was significantly associated with diarrhea among under five children. The odds of diarrhea among children lived in household with appropriate liquid waste disposal system were 0.587 times less likely as compared to children lived in household with improper liquid waste disposal system. This study was consistent with a studies conducted in Senegal [50], Somali region [18], and Oromia region [22]. This could be the reason that liquid waste contains different diarrheal pathogen, which can be easily distributed by flies, that pathogens may contaminate foods and water that child eat and drink.

In this study, place of delivery was significantly associated with diarrhea among under five children. Children born at health facilities were 0.426 times less likely to develop diarrheal disease compared to delivery at home. The finding is consistent with other studies conducted in Ethiopia [51], and Jawi district, Ethiopia [15]. In addition to this, a study conducted in Wama Hagelo District, West Ethiopia is consistent with our finding which showed that under-five children born at health facilities had 79% less risk of developing diarrhea compared to home delivery [20].This can be explained by the fact that mothers who give birth at health institution know more about how to prevent diarrheal illness and how to care for their children. Moreover, mothers who gave birth in health institution are given information on exclusive breast feeding, which might decrease the chance of getting an infection that may lead to diarrheal disease.

In present study, the incidence of diarrhea was significantly associated with a source of drinking water supply. Children from household who used protected sources of drinking water were 0.629 times less likely to develop diarrhea compared to their counterparts. This result is consistent with several study findings done in Medebay Zana district, Ethiopia [52], Ethiopia [21], Gamo Gofa Zone, Southern Ethiopia [53], and Cameroon [54]. This is because contaminated water supplies, which usually considers as a main source of water borne diseases may carry diarrhea-causing pathogens that may lead to diarrhea. Additionally, a study conducted in Pakistan demonstrates that the involvement of the water and sanitation expansion program reduced the likelihood of diarrhea in children [55].

According to this study the odds of developing diarrhea among children living in households who were a member of health insurance were 0.571 times lower as compared to children living in households who were not a member of health insurance. This finding was supported by a study conducted in Ethiopia [45]. This might be due to the fact that households who have not community based health insurance may not access health care services easily.

Strength and limitation of the study

The strength of this study was the study employed a variety of data gathering techniques, such as on-site observation, to evaluate latrine utilization practices. Additionally, a pretest was conducted before to the real data collection in order to ensure the quality of the data, and a consistent data gathering method. As limitation, the study was a cross-sectional survey, which may not help establish a temporal relationship between the possible risk factors of children under five year old diarrhea and difficult to entertain the seasonal effect on diarrhea disease. The data was self-reported; there might also be a possibility of recall and social desirability biases that will result in underreporting and misreporting of events. Although the recall period of illnesses, in this case, was limited to only 2 weeks preceding the survey. Mothers/Caregivers of the child were questioned about their children’s health status in the two weeks prior to the survey, which might measure their perceptions rather than actual morbidity that might have an impact on the outcome [56].

Conclusion

The prevalence of childhood diarrhea disease was high in Awi zone. The household family size, age of child in months, liquid waste disposal system, place of delivery, drinking water source, member of health insurance, measles vaccination, and water shortage of family were significantly associated with diarrhea among under five children in Awi zone, northwest Ethiopia. These finding implies a need for public health interventions, such as increased vaccination coverage, increase the coverage of health insurance, strengthening and scaling up of behavioral change packages of the community regarding to keeping hygiene and sanitation of the community and their environment, access to a clean source of drinking water to prevent the high incidence of diarrhea disease among children. Furthermore, integrated efforts are needed from the government organization with inline concerned stakeholders and non-governmental organization to improve water shortage in households, and institutional deliveries to reduce the burden of diarrheal disease among children under five years in Awi Zone. In addition, the findings of this study will serve as baseline evidence and gave the way for other researchers to conduct more rigorous studies on diarrhea by including seasonal effect.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

CI

Confidence interval

COR

Crude odds ratio

AOR

Adjusted Odds Ratio

HH

Household

Author contributions

All authors contributed to design, data analysis, drafting or revising the article, have agreed on the journal to which the article will be submitted, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.

Funding

The financial support was provided by Injibara University. The funding organization had no role in data collection, analysis, and write-up of the report.

Data availability

The data used to support the study findings are available from the corresponding author upon request.

Declarations

Ethics approval and consent to participate

The study was carried out after receiving an ethical clearance endorsement from Injibara University College of Natural and Computational Science Research and Community service vice dean with a reference number of CNCS/PG/R/CS/V/Dean/255/23 and all methods were carried out in accordance with relevant guidelines and regulations. Consent of the respondent formal letter of permission was obtained from administrative bodies of the district and then from the respective Kebeles (lower administrative). After explaining the objective and procedure of the study, written informed consent was taken from the parents / legal guardians of the under-five children to confirm willingness to participate in the study. For this purpose, a one-page consent form was attached to the cover page of each questionnaire stating the general purpose of the study and issues of confidentiality, which were discussed by data collectors before proceeding to the survey. The consent form was read and their thumb print impression was taken to replace signature for illiterate respondents. Unique identification household number was used to ensure confidentiality of individual participants’ information. The study participants were informed that all the collected data can only be used for the objective of the study. For those not willing to take part in the study, their right was respected to withdraw from the study. All responses were kept confidential and children with diarrhea during the visit were advised to seek treatment.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.