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Biology Thesis and Dissertations

2021-07-26

PREVALENCE OF DIARRHEA AND

ITS ASSOCIATED FACTORS AMONG
UNDER-FIVE CHILDREN VISITING
BAHIR DAR HEALTH CENTER, BAHIR
DAR CITY, NORTH WEST, ETHIOPI

BEKELE, LIDIYA

http://ir.bdu.edu.et/handle/123456789/12255
Downloaded from DSpace Repository, DSpace Institution's institutional repository
 BAHIR DAR UNIVERSITY

GRADUATE STUDIES OFFICE

COLLEGE OF SCIENCE

DEPARTMENT OF BIOLOGY

PREVALENCE OF DIARRHEA AND ITS ASSOCIATED

FACTORS AMONG UNDER-FIVE CHILDREN VISITING
BAHIR DAR HEALTH CENTER, BAHIR DAR CITY,
NORTH WEST, ETHIOPIA
BY
LIDIYA BEKELE

JUNE, 2021
BAHIR DAR, ETHIOPIA
 BAHIR DAR UNIVERSITY
GRADUATE STUDIES OFFICE
COLLEGE OF SCIENCE
DEPARTMENT OF BIOLOGY

PREVALENCE OF DIARRHEA AND ITS ASSOCIATED

FACTORS AMONG UNDER-FIVE CHILDREN VISITING
BAHIR DAR HEALTH CENTER, BAHIR DAR, CITY
NORTH WEST, ETHIOPIA

A THESIS SUBMITTED TO THE DEPARTMENT OF BIOLOGY IN PARTIAL

FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTERS OF
SCIENCE DEGREE IN BIOLOGY (BIOMEDICAL SCIENCES)

BY
LIDIYA BEKELE

ADIVSOR: SISSAY MENKIR (Ph.D.)

JUNE, 2021
BAHIR DAR, ETHIOPIA

© 2021 Lidiya Bekele

 BAHIR DAR UNIVERSITY

GRADUATE STUDIES OFFICE

COLLEGE OF SCIENCE

DEPARTMENT OF BIOLOGY

Approval sheet of thesis for defense in Advisor’s

As the thesis advisor, I hereby certify that I have supervised, read, and evaluated this thesis
entitled “prevalence of diarrhea and its association with nutritional status among under-five
children visiting Bahir Dar Health Center, Bahir Dar town, North West, Ethiopia” prepared by
Lidiya Bekele prepared under my guidance. I recommend that it can be submitted as fulfilling
the thesis requirement.

Sissay Menkir (Ph.D.) ----------------- ------/----/----

Advisor‟s name Signature Date

Lidiya Bekele Atara ----------------- ----/------/----

Student‟s name Signature Date

i
 BAHIR DAR UNIVERSITY

GRADUATE STUDIES OFFICE

COLLEGE OF SCIENCE

DEPARTMENT OF BIOLOGY

Approval sheet of thesis for defense result in Examiners

As members of the Board of Examiners of the MSc. Thesis opens Defense Examination, we
certify that we have read, evaluated the thesis entitled “prevalence of diarrhea and its association
with nutritional status among under-five children visiting Bahir Dar Health Center, Bahir Dar
town, North West, Ethiopia” prepared by Lidiya Bekele , and examined the candidate. We
recommended that the thesis be accepted as fulfilling the thesis requirement for the degree of
Master of Science in Bio-Medical Science.

Board of Examiners

___________________________ __________________ ___/____/____

Internal Examiner I Signature Date

____________________________ ____________________ ___/_____/____

Internal Examiner II Signature Date

___________________________ _____________________ ___/____/____

External Examiner Signature Date

ii
 DEDICATION
I dedicate this thesis to my family for their love, affection, and unrestricted encouragement
during this research work and my success in life. A special feeling of gratitude to my loving
parents, Bekele Atara and Dinknesh Diki whose words of encouragement and push for tenacity
ring in my ears. My sisters Fasika Bekele and Mintwab Bekele have never left my side and are
very special.

iii
 DECLARATION

For this thesis first, I declare that this thesis is the result of my work and that all sources or
material used have been duly acknowledged (cited). This thesis is submitted for partial
fulfillment of the requirements of an MSc. in Biology (Biomedical sciences) degree at Bahir Dar
University and to be made available at the university‟s Library under the rules of the Library. I
confidently declare that this thesis has not been submitted to any other institution anywhere for
the award of any academic degree or certificate.

Brief quotations from this thesis are allowable without special permission provided that accurate
acknowledgment of the source is made. Requests for permission for extended quotation from or
reproduction of this thesis in whole or in part may be granted by Dean of the School of Graduate
Studies when in his or her judgment the proposed use of the material is in the interests of
scholarship. In all other instances, however, permission must be obtained from the author.

Lidiya Bekele Atara __________________

Name of the student Signature

Bahir Dar University, Bahir Dar Ethiopia

Place

_____/________/_______

Date of submission

iv
 ACKNOWLEDGMENTS
I am profoundly grateful and thankful to Sissay Menkir (Ph.D.) my advisor, who helped me
starting from title selection up to a completion of my research work. Successful accomplishment
of this research would have been very difficult without his giving time care from the early design
of the topic, questionnaire development, up to final write-up of the thesis by providing valuable,
practical, and useful comments. The advice and encouragement of my advisors was so helpful on
accomplishing this research.

Next, I would like to thank Bahir Dar University, College of Sciences, Department of Biology
for ethical approval. I would like to express my thanks to Bahir Dar Health Center for providing
me the necessary information allowing the laboratory facilities, sample collection, sample
diagnosis, and technical support, especially I am grateful to sister Hagere and the study
participants for their devoted cooperation during data collection and for spending their precious
time to accomplish my survey successfully. I am very grateful to all those who directly or
indirectly involved to my thesis work.
The last but not the least I extend my deepest gratitude to all my family and friends who had
contributions to achieve this work.

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 TABLE OF CONTENTS
Approval sheet of thesis for defense in Advisor‟s ........................................................................................ i
Approval sheet of thesis for defense result in Examiners ............................................................................ ii
DEDICATION ........................................................................................................................................... iii
DECLARATION ....................................................................................................................................... iv
ACKNOWLEDGMENTS .......................................................................................................................... v
LIST OF TABLES ..................................................................................................................................... ix
LIST OF ABBREVIATIONS/ACRONYMS.............................................................................................. x
ABSTRACT .............................................................................................................................................. xi
1. INTRODUCTION .................................................................................................................................. 1
1.1. Background of the study .................................................................................................................. 1
1.2. Statement of the problem ................................................................................................................. 3
1.3. Objectives ........................................................................................................................................ 4
1.3.1 General Objective ...................................................................................................................... 4
1.3.2. Specific Objectives ................................................................................................................... 4
1.4. Significance of the study .................................................................................................................. 5
1.5. Limitation of the study ..................................................................................................................... 5
2. LITERATURE REVIEW ....................................................................................................................... 6
2.1. Definition of diarrhea ....................................................................................................................... 6
2.2. Epidemiology ................................................................................................................................... 7
2.2.1. Global burden of diarrheal diseases........................................................................................... 7
2.2.2. Epidemiology of diarrheal diseases in under five children ........................................................ 7
2.2.3 Prevalence of diarrhea in under five children in Ethiopia ........................................................... 8
2.3. Etiology- The main causative agents of diarrhea............................................................................ 10
2.4. Clinical presentation, symptoms and clinical signs of diarrheal illness .......................................... 11
2.5. Transmission routes of diarrheal disease ........................................................................................ 11
2.6. Risk factors of diarrheal disease among under five years children ................................................. 11
2.6.1. Demographic factors ............................................................................................................... 12
2.6.2. Socio-economic factors ........................................................................................................... 12
2.6.3. Lack of safe drinking water, sanitation and hygiene ............................................................... 12
2.6.4. Malnutrition ............................................................................................................................ 13
2.6.5. Breastfeeding .......................................................................................................................... 14
2.7. Prevention and Control of Diarrhea ............................................................................................... 14

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3. MATERIAL AND METHODS ............................................................................................................ 15
3.1. Description of the study area .......................................................................................................... 15
3.2 Study design .................................................................................................................................... 17
3.3 Study Population ............................................................................................................................. 17
3.4 Source Population ........................................................................................................................... 17
3.5. Sample Size Determination ............................................................................................................ 17
3.6. Eligibility criteria ........................................................................................................................... 18
3.6.1. Inclusion criteria ..................................................................................................................... 18
3.6.2. Exclusion criteria .................................................................................................................... 18
3.7. Sampling technique ........................................................................................................................ 18
3.8. Methods of Data Collections .......................................................................................................... 18
3.8.1. Questionnaire survey ............................................................................................................... 18
3.8.2. Anthropometric measurements ................................................................................................ 18
3.8.3. Stool sample collection and examination ................................................................................ 19
3.9. Variables of the study .................................................................................................................... 19
3.10. Data analysis ................................................................................................................................ 19
3.11. Ethical consideration .................................................................................................................... 20
3.12. Operational definition ................................................................... Error! Bookmark not defined.
4. RESULT ............................................................................................................................................... 21
4.1. Socio demographic characteristics of participants .......................................................................... 21
4.2. Behavioral and child health and caring practices of study participants .......................................... 23
4.3. Environmental characteristics of study participants ....................................................................... 24
4.4. Malnutrition among under five children visiting Bahir Dar Health Center .................................... 25
4.5. Prevalence of diarrhea .................................................................................................................... 25
4.6. Prevalence of intestinal protozoan parasites and helminthes parasites ........................................... 26
4.7. Potential risk factors associated with diarrhea among under five children visiting Bahir Dar Health
Center. .................................................................................................................................................. 27
4.7.1. Chi-square association of the different risk factors with diarrhea............................................ 27
4.7.2. Logistic regression analysis of the most important risk factors for diarrhea ............................ 30
5. DISCUSSION ....................................................................................................................................... 34
6. CONCLUSION ..................................................................................................................................... 37
7. RECOMMENDATIONS ...................................................................................................................... 38
8. REFERENCES ..................................................................................................................................... 39

vii
APPENDICES .......................................................................................................................................... 48
APPENDIX A: Informed Consent Declaration (English Version) ............................................................ 48
Informed Consent Declaration (Amharic Version) ................................................................................... 49
APPENDIX B: Questionnaire (English version)....................................................................................... 50
Questionnaire (Amharic version) .............................................................................................................. 54
APPENDIX C: Ethical clearance .............................................................................................................. 57

viii
 LIST OF TABLES
Table 1: Socio-demographic characteristics of under five children visiting Bahir Dar Health Center. ..... 22
Table 2: Behavioral and Child health and caring practices of under five children visiting Bahir Dar Health
Center ....................................................................................................................................................... 23
Table 3: Environmental characteristics of under five children visiting Bahir Dar Health Center. ............. 24
Table 4: Stunting, wasting and underweight among under five children visiting Bahir Dar Health Center.T
.................................................................................................................................................................. 25
Table 5: Prevalence of diarrhea among under five children visiting Bahir Dar Health Center. ................ 26
Table 6. Major intestinal parasites. ........................................................................................................... 27
Table 7: Chi-square association of different risk factors with diarrhea among under five children visiting
Bahir Dar health center. ............................................................................................................................ 28
Table 8. Univariate and multivariate logistic regression analysis of potential risk factors associated with
diarrhea among under five children in Bahir Dar Health Center Northwest, Ethiopia. ............................. 31

ix
LIST OF ABBREVIATIONS/ACRONYMS
AOR Adjusted odd ratio

CDC Center for Disease Control and prevention

CI Confidence interval

COR Crude odd ratio

CSA Central Statistical Agency

EDHS Ethiopia Demographic and Health Survey

ETEC Enter toxigenic Escherichia Coli

GBD Global Burden of Diseases

HEP Health Extension program

HIV Human Immune Virus

JMP Joint monitoring program

MDG Millennium Development Goal

MMT Morbidity-Mortality and Treatment

MOFED Ministry of Finance and Economic Development

NGOs Non-governmental organization

OD Open defecation

SD Standard deviation

SPSS Statistical Package for Social Science

UNICEF United Nations International Children‟s Emergency Fund

WHO World Health Organization

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 ABSTRACT
Diarrhea is a major health problem in Ethiopia. Most importantly, burden of diarrhea is
disproportionately high among under-five children. Therefore, the objective of this study was to
assess the prevalence of diarrhea and its associated factors among under five children visiting
Bahir Dar Health Center, Bahir Dar city, Northwest, Ethiopia, 2021. A hospital-based cross-
sectional study was conducted among under-five children from February to march 2021. Simple
random sampling method was used to select the 200 participants. The socio-demographic data
were collected by using structured and pretested questionnaire survey. Both univariate and
multivariate logistic regression analyses were employed to identify predictor variables. Factors
with a p-value of < 0.05 were considered as independently associated with diarrhea.
Anthropometric measurements were used to collect height and weight following the standard
measurement tools and procedures. Data was entered into SPSS version 23 and anthropometric
measurements were converted into Z-score by WHO Anthro version 3.2.2 Software. The
prevalence of diarrhea among under five children was 38% and intestinal protozoan parasite
found to be 4% and intestinal helminthes 1%. In univariate analysis age group of child 7-12 were
found to be (COR=2.429, CI: 0.849, 6.945), Maternal age group 18-24 (COR = 2.641 CI: 0.768,
9.074), wasting (COR= 2.769 CI: 0.748, 10.257) and hand washing only with water (COR =
4.667 CI: 0.374, 58.248) were predictors of the occurrence of diarrhea. In multivariate analysis
ten of the risk factors found were not significantly associated with diarrhea infection (P<0.05).
Complementary feeding at 6 month and putting complementary feeding in covered shelf were found to be
protective against diarrhea.

Keyword: Bahir Dar Ethiopia, Children, Diarrhea, Nutritional status Prevalence, Under-five.

xi
 1. INTRODUCTION
1.1. Background of the study
Diarrhea is the passage of liquid stools three or more times per day, or many times than normal
for the individual. It is usually a symptom of gastrointestinal infection, which can be caused by
different types of bacterial, viral and parasitic organisms (WHO, 2013). Around 2.5 billion of
diarrhea cases each year, occurring among under five children, and estimates suggest that overall
incidence has remained relatively stable over the past two decades (UNICEF, 2009). Diarrheal
diseases account for 9% of child deaths worldwide, making diarrhea the second leading cause of
death among under five children (CDC, 2013). The acute diarrhea causes high loss of water and
salts from a body which results in both severe dehydration and death within a short period of
time or predisposes malnutrition to the children and makes them more susceptible to related
infections. Infectious diarrhea is acquired by fecal-oral transmission route, by person to person
contact, through water and food or directly to the mouth. The lack of a proper water supply, with
rubbish and dirty surroundings and an abundance of flies, are the typical situation in which
diarrheal diseases are transmitted. Diarrheal diseases have been a major public health concern of
low-income countries leading to high morbidity and mortality among under-five children (WHO,
2015).

Globally, there are nearly 1.7 billion cases of childhood diarrheal infection every year (WHO,
2017). Diarrheal diseases are one of the leading causes of morbidity and mortality and accounts
for more deaths in early childhood after the neonatal period. 525,000 children of under-5 years
old die due to diarrhea every year, roughly 2195 every day (UNICEF, 2016). Diarrheal
infections are associated with an estimated 1.3 million deaths yearly with most occurring in
resource – limited countries (Mokomane et al., 2018). In Africa diarrhea account for the largest
cause of disease and death among young children and nearly 50% of deaths due to diarrhea
among young children occurs in Africa (Walker et al., 2012).

Sub-Saharan Africa is still with the highest rates of under-five child mortality where 1 in 9
children dies before age five that is more than 16 times the average for developed regions (1 in
152) and Southern Asia (1 in 16). Under-five mortality are highly concentrated in Sub-Saharan
Africa and Southern Asia regions, while in the rest of the world dropped from 31 percent in 1990

1
to 17 percent in 2011. About 11% of under-five mortality was attributed to diarrhea in Sub-
Saharan Africa regions (Liu et al., 2017).

In Ethiopia, diarrheal disease is a major public health problem. The 2010 report of the Ministry
of Finance and Economic Development (MOFED) showed that 20% of childhood deaths in the
country were due to diarrhea. The 2011 Demographic and Health Survey of Ethiopia (EDHS)
findings also indicated that 13% of the children had diarrhea in the 2 weeks preceding the survey
at the national level. The incidence of illnesses contributing to avoidable death's diarrhea is
higher in Ethiopia compared to other Sub Saharan African countries partly due to living
conditions, high incidence level of illness, lack of safe drinking water, sanitation and hygiene; as
well as poorer overall health and nutritional status (Wondwoson Woldu et al., , 2016; Genet
Gedamu et al., 2017). In Ethiopia, morbidity reports and community-based studies have shown
that diarrhea is a major public health problem that causes morbidity and mortality in the
population. A recent report of the World Health Organization showed that about 80% of diseases
in Ethiopia are attributed to infectious diseases related to personal and environmental hygiene
and malnutrition. Most of the disease infections are caused by water-borne and food borne
pathogens and parasites. According to the same report, Ethiopia was the 35th country from 172
countries in the world, in having 49.54 death rates per 100,000 people in diarrheal diseases
(WHO, 2014).

Malnutrition and diarrheal mortality have a bidirectional association (Azandjian et al., 2009),
Malnutrition causes immune-deficiency and increased susceptibility to infections such as
diarrhea. Diarrhea in turn causes malnutrition through reduced food appetite, energy intake,
nutrient loss and mal-absorption (Neumann et al., 2004).

In Ethiopia, several studies were conducted to estimate the prevalence as well as to identify
modifiable factors of under-five diarrheal diseases. However, the prevalence reflected in these
small and fragmented studies varied widely and remained inconclusive. Besides prevalence,
identifying modifiable risk factors is a critical step in identifying potential interventions. The
lack of a nationwide study that determines the prevalence and determinants of diarrhea among
under-five children is a significant gap. Therefore the current study was conduct to assess the
diarrheal cases and its association with nutritional status in under five children visiting Bahir Dar
Health Center.

2
1.2. Statement of the problem
Diarrheal diseases are still the major cause of morbidity and mortality among children worldwide
and mainly in sub-Saharan Africa. Different studies in Ethiopia indicate that, socioeconomic
status, monthly income, number of under-five children, methods of complementary feeding,
types of water storage equipment, mother‟s poor hand washing practices, lack of hand washing
facilities, duration of breastfeeding and improper waste disposal practices were significant
factors for diarrhea occurrences (Wakigari Regassa and Seblewengel Lemma, 2015).

Children with poor nutritional status and overall health, as well as those exposed to unsafe
drinking water are more susceptible to severe diarrhea and dehydration than healthy children.
Children are at greater risk than adults of life-threatening dehydration since water constitutes a
greater proportion of children‟s bodyweight. In Ethiopia, still the national open defecation (OD)
rate in 2014 was 34.1% (37.9% in rural and 8.7% in urban) (CSA, 2014). This practice facilitates
the transmission of diarrheal diseases, and one of the leading causes of mortality in under-five
children in sub-Saharan Africa (Abireham misganaw et al., 2018). Households in rural part of the
city monthly income, failure to use separate container for storing drinking water, presence of human
excreta in the compound were found to be predictors of childhood diarrhea (Molla Gedefaw et al.,
2015).

A research conducted in Bahir Dar town indicate that lack of hand washing facility, lack of
separately feeding materials for children, no breastfeed exclusively and hand washing practice
were predictors of occurrence of diarrhea (Amare Belachew et al.,2019). Therefore, it is
important to assess diarrhea cases and its association with nutritional status among under five
children visiting Bahir Dar Health Center.

3
1.3. Objectives
1.3.1 General Objective
 To assess the level of diarrhea and its association with nutritional status of under-five
children visiting Bahir Dar Health Center, Northwest Ethiopia.

1.3.2. Specific Objectives

 To determine the prevalence of diarrhea among under-five year old children visiting
Bahir Dar Health Center
 To determine the major intestinal parasite species that causes diarrhea among under-five
children visiting Bahir Dar Health Center
 To identify the determinants of diarrhea in under-five children visiting Bahir Dar Health
Center

4
1.4. Significance of the study
The results of this study is important to inform decision makers on factors associated with
diarrhea among children and they may set adequate and suitable strategies to address diarrhea
diseases among under five children. Furthermore, the health professionals such as nurses may
use results of this study to design and implement responsive health program targeting to tackle
morbidity and mortality related to diarrhea disease among children and the communities aware
of diarrhea especially mothers and caregivers. In addition the study contributes to the field of
knowledge in diarrheal diseases and serves as a basis for further investigations. Finally, the study
provides and establishes much information about the prevalence of diarrhea infection and
association with nutritional status for other researcher interested to conduct on the same issue in
the study area.

1.5. Limitation of the study

The study was limited to only wet mount method. Despite this, a bigger picture of the prevalence
of major intestinal parasites leads to diarrhea in the study area was not being found. Including
other techniques like formol ether concentration and other techniques could help to get a bigger
picture of the prevalence of major intestinal parasite species in the study area. As being cross-
sectional in the design, this study shared the drawbacks of similar cross sectional studies. In
cross-sectional studies, it was difficult to entertain the seasonal differences in the occurrence of
diarrheal diseases.

5
 2. LITERATURE REVIEW
2.1. Definition of diarrhea
Diarrhea is the passage of three or more loose or liquid stools per day, or many times than
normal for the individual (WHO, 2013). It is usually a symptom of gastrointestinal infection,
which can be caused by different types of bacterial, viral and parasitic organisms. Infection is
spread via contaminated food or drinking water, or from one person to another as a result of poor
hygiene. Severe diarrhea leads to fluid loss, and may be life threatening, particularly in young
children and people who are malnourished or have impaired immunity (WHO, 2013). In fact the
diseases are characterized by intestinal disorder with abnormal fluidity and frequency of fecal
evacuations (Afroza et al., 2013).The infectious agents associated with diarrheal diseases are
transmitted chiefly through the fecal- oral route (Shivali and Dinesh, 2015).
Diarrheal diseases can be classified according to their clinical pattern as: persistent diarrhea (i.e.
diarrhea lasting 14 days or more) and acute watery diarrhea (i.e. diarrhea without blood lasting
less than 14 days) (UNICEF, 2009).
Acute diarrhea characterized by abrupt onset of frequent, watery, loose stools without visible
blood, lasting less than two weeks. Acute bloody diarrhea (i.e. diarrhea with blood lasting less
than 14 days).Usually, acute watery diarrhea episodes subside within 72 hours of onset. Acute
diarrhea, dehydration is the main contributor to mortality. It may be accompanied by flatulence,
malaise and abdominal pain. Nausea, vomiting may occur and also fever may be present. The
common causes of acute watery diarrhea are viral, bacterial, and parasitic infections. Bacteria
also can cause acute food poisoning. The enteric pathogens causing this diarrhea in developing
countries are largely the same that are encountered in developed countries, but their proportions
are different (Jay, 2013). However, persistent diarrhea is defined as diarrheal episodes of
presumed infectious etiology that have an unusually long duration and last at least 14 days (Jay,
2013). persistent diarrhea is associated with malnutrition, delayed growth and development,
vitamin A deficiency and systemic infections such as respiratory infections and urinary tract
infection which makes treatment more complex (Das et al., 2012).

6
2.2. Epidemiology
2.2.1. Global burden of diarrheal diseases
Diarrhea is a leading cause of children, accounting for approximately 8 percent of all deaths
among children under age 5 worldwide in 2017. This translates to over 1,300 young children
dying each day, or about 480,000 children a year, despite the availability of a simple treatment
solution (UNICFE, 2017)

Pneumonia, diarrhea and malaria remain leading causes of death among children under age five,
accounting for about 1.3 million about 40 percent of under-five deaths in Sub-Saharan Africa
and roughly half a million about 25 percent in Southern Asia. Diarrhea killed roughly 2 million
children in 2013 and accounted for almost a third of global under-five deaths (UNICEF/WHO,
2014). The youngest children are most vulnerable with the incidence of severe gastroenteritis
being highest in the first 2 years of life (Oloruntoba et al., 2014). Morbidity due to diarrhea is
further concentrated in marginalized communities within resource-limited countries (Bulled et
al., 2014). Despite improvements in standard of living, advances in sanitation, water treatment
and food safety awareness, diarrheal disease still accounts for significant economic and societal
losses (Reddington et al., 2014).

2.2.2. Epidemiology of diarrheal diseases in under five children

As indicated in World Health Organization there are about two billion cases of diarrheal disease
worldwide every year, and 1.9 million children younger than 5 years of age die from diarrhea
each year, mostly in developing countries. This accounts 18% of all the deaths of children under
the age of five and means that more than 5000 children are dying every day because of diarrheal
diseases. Of all child deaths from diarrhea, 78% occur in the African and South-East Asian
regions (Farthing, 2012). Diarrheal diseases account for 1 in 9 child deaths worldwide, making
diarrhea the second leading cause of death among children under five children. Sub-Saharan
Africa is still with the highest rates of under-five child mortality where 1 in 9 children dies
before age five that is more than 16 times the average for developed regions (1 in 152) and
Southern Asia (1 in 16). Under-five mortality are highly concentrated in Sub-Saharan Africa and
Southern Asia regions, while in the rest of the world dropped from 31 percent in 1990 to 17
percent in 2011. About 11% of under-five mortality was attributed to diarrhea in Sub-Saharan
Africa regions (Liu et al., 2017).

7
A study from Pakistan shows child‟s own characteristics (age and sex), total number of children
born, mothers characteristics (age and education) and economic characteristics (ownership of
agricultural land and housing) were significant predictors of under-five‟s diarrheal morbidity.
Similar study from Iran revealed that diarrhea was associated with age of child, area of
residence, maternal education (Asma and Rukshana , 2012), in Cameron 23.8% (Tambe et
al.,2015), Tanzania 32.7% (Jean et al.,2017), Senegal 26% (Kakulu,2012), Rwanda 26.7%
(Sokhna et al.,2014), Egypt 19.5% (Yassin,2000) Ghana 19.2% (Boadi and kuitunen,2005), Iraq
21.3% (Siziya et al.,2000), India 25.2% (Siraj et al.,2010), Burundi, 32.6% (Diouf et al.,2014).

In Ethiopia, morbidity reports and community based studies have shown that diarrheal disease is
a major public health problem that causes morbidity and mortality in children. Morbidity-
Mortality-and Treatment (MMT) surveys conducted in Ethiopia in 2000 at different times
revealed five diarrheal episodes per child/year; and the two-week incidence rate to be 16%.The
diarrhea associated mortality rate is about 10/1000 under-five population. For children with HIV,
diarrhea is even more deadly; the death rate for these children is 11 times higher than the rate for
children without HIV. Despite these sobering statistics, strides made over the last 20 years have
indicate that, in addition to rotavirus vaccination and breastfeeding, diarrhea prevention focused
on safe water and improved hygiene and sanitation is not only possible, but cost effective (CDC,
2012).

2.2.3 Prevalence of diarrhea in under five children in Ethiopia

The 2016 Demographic Health Survey of Ethiopia finding showed that 12% of the children had
diarrhea in the 2 weeks preceding the survey at the national level (CSA, 2016). In 2017 Ethiopia
also showed that two weeks period prevalence of diarrhea among under-five children was 20%.
In Ethiopia studies have indicate that the prevalence of diarrhea both in urban and in rural areas
was 13%. The prevalence of diarrhea was relatively high among children aged from 6 to 23
months. In southern Ethiopia, 25.5% of children experience diarrhea, but three-fourths occurred
among rural children (CSA and ORC Macro, 2011).

Similarly, a community-based cross-sectional study conducted in Jabitehnan district, West

Gojjam Zone, Amhara Region, Ethiopia, reported a 21.5% two-week period prevalence of
diarrhea (Desalegn Tesfa et al., 2017). But in most remote and pastoralist areas, the prevalence is

8
expected to be higher because of shortage of drinking water, poor sanitation, and low educational
and awareness levels. For example, a study in Somali Region, Eastern Ethiopia (a predominantly
pastoralist area), has shown the two-week period prevalence of diarrhea among under-five
children to be more than two times that of the national level prevalence (Hashi Abdiwahab et
al.,2017). Benna Tsemaye District is one of a pastoralist districts in the South Omo Zone of
Southern Ethiopia. According to the District Health Office 2016/17 report, 28.5% of all under
five outpatient department visits in the district were due to diarrheal diseases and diarrheal
disease was the first leading cause of morbidity in the district. Laelay Michew District of Tigray
Region, North Ethiopia (17.7%) (Angesom, 2015). In another study conducted in Debre Berhan
Town, the prevalence of diarrheal illness among under five children was found to be 12.2%
indicating storage of water in a pot, observation of feces on the latrine hole, lack of maternal
education and age of mothers/guardians as a risk factors for the disease. The overall prevalence
of diarrhea among under-five children in the study conducted in predictors of under-five
childhood diarrhea in Mecha District, West Gojam, was 18 %, i.e.12.5% in urban and 20.6% in
the rural of the study area( Muluken Dessalegn et al.,2011).
The prevalence of diarrhea among under five children was 14.5% among under-five children in
Kamashi district, western Ethiopia (Adugna Fenta et al., 2020), in Dire Dawa city 20% (Ephrem
Tefera et al., 2020), In Hadaleala district, Afar region 26% (Bikes Destaw et al., 2017), in tigray
region Mekelle zone (Serawat, Harena, Maynebri & Tsuwanet) 27.7% (Araya Gebreyesus et al.,
2018), in Addis Ababa Gullele & Lideta Sub-City‟s District 11.9% (Metadel Adane et al.,2017).
In somali region Jigjiga District 27.3% (Hashi et al., 2016) and in Jigjig Town 14.6% (Bizuneh
et al., 2017).

The prevalence of diarrhea in SNNPR among under five children 30.9% in Worabe Town (Aseb Arba et
al., 2020), in Wonago district 30.9% (Tinsae Shemelise et al., 2020), in Benna Tsemay District
23.5 % (Mulusew Alemayehu et al., 2020), in Sidama zone, Dale District 13.6% (Behailu
Melese et al., 2019), in Wolitta Soddo Town 11% (Alambo Kedir, 2015),in Arba-Minch district
30.5% (Shikur Mohammed & Dessalegn Tamiru, 2014).

The prevalence of diarrhea in amhara region among under five children 14.5% conducted in Bahir
Dar city (Amare Belachew et al., (2019), in Bahir Dar City 21.6% (Molla Gedefaw et al., 2015),
In farta wereda 16.7% (Genet Gedamu et al., (2017), in Bahir Dar Zuria district 20% (Desalegn

9
Tesfa et al., 2017), North Gondar Zone 22.1% (Atalay Getachew et al.,2018), Debrebirehan
Town 31.7% (Ayele Mamo & Awraris Hailu ,2014), Dejen District 23.8% (Demeke Getu et
al.,2013), Jamma district, South Wello zone 23.1% (Getachew Yismaw,2019), Debre Berhan
town 16.4% (Sisay Shine et al., 2020), Jabithennan District 21.5% (Zelalem Alamrew et
al.,2017), Central Gondar Zone 30.09% (Zewudu Andualem et al.,2019).

Prevalence of diarrhea in oromia region among under five children 28.4% the study conducted in
Harena Buluk Woreda (Solomon Getahun and Abulie Takele, 2018), in Serbo Town 14.9%
(Legefa Futa et al.,2018), and (14.5%), in Kersa 22.5% (Bezatu Mengistie et al.,2013), in
nekemte town 28.9% (Girma Regassa, 2008), in Adama district rural kebeles 14.5% (Wakigari
Regassa and Seblewengel Lemma,2016),in Sebeta 9.9% (Mohammed Abdulwahid and Li
Zungu), district of diarrhea prevalence conducted in different parts of Ethiopia

2.3. Etiology- The main causative agents of diarrhea

Diarrhea is a symptom of infections caused by a host of bacterial, viral and parasitic organisms,
most of which are spread via faeces-contaminated water. Infection is more common when there
is a lack of adequate sanitation and hygiene and safe water for drinking, cooking and cleaning.
Rotavirus and Escherichia coli are the two most common etiological agents of moderate-to-
severe diarrhea in low-income countries. Other pathogens including cryptosporidium and
shigella species may also be important. Location-specific etiologic patterns also need to be
considered (WHO, 2017).

Diarrhea caused by infections usually results from eating or drinking contaminated food or
water. Signs and symptoms of infection usually begin 12 hours to four days after exposure and
resolve within three to seven days (WHO, 2012). The major bacterial pathogens that are
associated with diarrheal diseases are; Shigella, Salmonella, Campylobacter, Vibrio cholera, and
Enterotoxigenic Escherichia coli (ETEC) (Afroza et al., 2013).

10
2.4. Clinical presentation, symptoms and clinical signs of diarrheal illness
A person with diarrhea may be mildly to severely ill. A person who has mild illness may have a
few loose bowel movements but otherwise feels well. By contrast, a person with severe diarrhea
may have 20 or more bowel movements per day, happening up to every 20 or 30 minutes. In this
situation, a significant amount of water and salts can be lost, seriously increasing the risk of
dehydration (WHO, 2012).

Due to rapid loss of fluids (up to 20 liters daily), severe dehydration and shock can occur in
these individuals. Signs of dehydration include loss of skin plasticity, sunken eyes, fast heartbeat,
low blood pressure, and rapid weight loss. Diarrhea may be accompanied by fever (temperature
greater than 100.4ºF or 38ºC), abdominal pain, or cramping (WHO, 2012).

2.5. Transmission routes of diarrheal disease

Diarrhea infection is acquired via fecal-oral transmission that includes consumption of
contaminated water or food, direct contact with person-to-person or direct contact with faecal
matter. Considering water-borne-diarrhea, transmission can occur when in-household there is
storage of contaminated water (WHO, 2010). There are four routes of transmission of diarrheal
illnesses through which infectious agents reach human hosts. Among them are person to person
via the environment; person to person multiplying in the environment; human to animal to
human via the environment; and animal to human via the environment. In situations where faecal
matter contamination of the domestic environment is high, the majority of cases of endemic
disease probably occur either by person to-person transmission, or from the person-to-person
transmission of pathogenic agents that have multiplied in the environment (Bain et al., 2015).

2.6. Risk factors of diarrheal disease among under five years children
Childhood mortality rates in general and infant mortality in particular, are often used as broad
indicators of social development or as specific indicators of health status. Child mortality
reduction by two-third is one target of Millennium Development Goal (MDG) (International
ICF: 2011). Worldwide diarrheal disease is the second leading cause of death in under-five year
children. It is responsible for 1.7 million morbidity and 760, 000 mortality of children every year
(WHO, 2013). In Ethiopia diarrhea kills half million under-five children annually secondary to
pneumonia. Poor sanitation, lack of access to clean water supply and inadequate personal
hygiene are responsible for 90% of diarrheal disease occurrence, these can be easily improved by

11
health promotion and education (UNICEF, 2004). In effect, Ethiopia introduced a new initiative
Health Extension program (HEP) in 2002/03 as a means of providing a comprehensive,
universal, equitable and affordable health service for the rural population on the base of
promotive, preventive and basic curative services. The program was provided as a 16 packages
focusing on health promotion and education supported by demonstration targeting households,
particularly mothers and women through house to house visits (Argaw, 2007).
2.6.1. Demographic factors
The potential factors identified were in several studies have recognized that the diarrhea prevalence
is increased in younger children especially in children ranged between 6-11months. Child age
(36–47 months) (Araya Gebreyesus et al., (2018), age of the child (Aseb Arba et al., (2020). Same
of findings showed that the diarrhea rate was greater in boys than girls. Other demographic
factors, like low level of mother's education, mothers‟ younger age, birth order, and high number
of siblings were notably associated with diarrhea in children below five years (Agustina et al.,
2013), Educational level (Behailu Melese et al., (2019), living in rural area (Bezatu Mengistie et
al.,2013).

2.6.2. Socio-economic factors

Economic factors associated with diarrhea in under five children were, crowded conditions, poor
housing, low income; and elevated rate of diarrhea was statistically significant. For example, the
socio-economic determinants of health, such as low socioeconomic status, lack of education
among mothers or care givers, insufficient safe drinking-water, and inadequate sanitation, are
likely to be leading factors of diarrheal disease, which continues to affect millions of children
below 5 years, in low- and middle-income countries (Agustina et al., 2013).

2.6.3. Lack of safe drinking water, sanitation and hygiene

Sanitation factors: evidence showed that sanitation plays a major role in reducing diarrhea
morbidity. Some sanitation factors, like improper disposal of children's stool and no existence of
latrine or unhygienic toilet, sharing latrine and house without sewage system. These elements
were reported as the risk factors for diarrhea in children under five years (Teklemichael Gebru et
al., 2014).

Water-related factors: According to the 2014 update study report of JMP (joint monitoring
programme) to estimate global exposure to fecal contamination in drinking water. The study

12
estimates that 1.8 billion people globally use a source of drinking water that is fecal
contaminated (UNICEF, 2014). The water-storage containers used in developing countries
households which are often not cleaned and opened are exposed to contamination due to children
who put their hands into the water, unhygienic handling of the storage containers, use of dirty
utensils to withdraw water, dust, animals, birds and various types of insects. Most of the time
children are the first line of victims for the problem associated to it (WHO, 2009).

Hygiene practices: various studies noticed that children who did not wash hands before eating or
after defecation, mothers who don‟t wash hands before feeding children or mothers who don‟t
clean foods before cooking, children who eat with their hands rather than with a spoon, eating of
cold leftovers, dirty feeding bottles and utensils, unhygienic domestic places (kitchen, living
room, yard), improper food storage, living with animals inside the house, lack of strategies to
limit flies inside the house, were associated with greater risk of diarrhea occurrence in children
(Teklemichael Gebru et al., 2014). Poor latrine hygiene, had no hand washing facilities near latrines,
poor hand washing practice at a critical time, who stored water at home ( Adugna Fenta et al., 2020)

2.6.4. Malnutrition
Diarrhea and malnutrition are associated with water, sanitation, and hygiene through different
mechanisms. For example, faecal exposure through contaminated water, unimproved sanitation
and poor hygiene, leads to diarrhea which affects physical and mental growth of a child (Ngure
et al., 2014).

Malnutrition: the relationship between diarrhea and malnutrition is so common in low-income

societies that the concept of a vicious circle is appalling, with diarrhea leading to malnutrition
and malnutrition predisposing to diarrhea. Children whose immune systems have been weakened
by malnutrition are the most vulnerable to diarrhea. Diarrhea, especially persistent and chronic
diarrhea weakens nutritional status, leading to mal-absorption of nutrients or the inability to use
nutrients properly to maintain health. A number of studies have reported a higher incidence of
diarrhea in malnourished children. A tendency of increased incidence of diarrhea was also found
in children with low weight-for-age, or, in particular, in stunted children (Teklemichael Gebru et
al., 2014).

13
Globally, more than 3 million children under the age of 5 years die per year due to malnutrition
(Black et al., 2013). Malnourished children are negatively and irreversibly affected in their
school performance, physical growth and cognitive development (Guerrant et al., 2008)

2.6.5. Breastfeeding
Exclusive breastfeeding of babies is described by WHO (2017) as feeding a baby on breast milk
only without giving any other liquids or solids including water, with the exception of oral
rehydration solution or drops of medicine from birth up to six months of age. Studies have
shown that it reduces the risk of childhood illnesses such as respiratory and gastrointestinal
infections (Demewoz Haile and Sibhatu Biadgilign, 2015). The morbidity of diarrhea is lower in
exclusive breast-fed children; it is higher in partially breast-fed children, and highest in fully-
weaned-children (Teklemichael Gebru et al., 2014).

2.7. Prevention and Control of Diarrhea

The prevention of diarrheal disease is first and foremost based on access to safe drinking-water
sources; use of improved sanitation; hand-washing with soap; exclusive breastfeeding for the
first six months of life; personal and food hygiene. Health professionals like nurses could make
more effort in health education talks on how diarrheal infections spread, and sensitize all mothers
of children under five years to immunize them with rotavirus vaccine (Tate et al., 2016). All
major cases of diarrheal diseases in children under five years old can be prevented by proper
household practices of water, sanitation and hygiene (Diouf et al., 2014).

14
 3. MATERIAL AND METHODS
3.1. Description of the study area
The study was conducted in Bahir Dar City, which is the capital city of Amhara Regional State,
which is located in west Gojjam Amhara region, Northwest of Ethiopia. It is 565km far away
from capital city of Addis Ababa (Figure1). Bahir Dar is located at 11°36' North and 37°23' East
and has an average elevation of 1801m above sea level (CSA, 2017).The city has nine sub cities
and with a total of 17 kebeles. Bahir Dar's climate is classified as warm and temperate. The
summers here have a good deal of rainfall, while the winters have very little. In Bahir Dar, the
average annual temperature is 19.6 °C | 67.2 °F. The rainfall here is around 1419 mm | 55.9 inch
per year. The total population of Bahir Dar City 168,899. Under five children are approximately
41,834, of which 26,238 are aged 24-59 months (from Amhara regional health bureau). The city
has government and private health institutions. It has two government and private hospitals, and
nine health centers. Bahir Dar Health Center is situated in Fasilo sub city in Bahir Dar town.

15
Figure 1: map of study area

16
3.2 Study design
A hospital-based cross sectional survey was conducted from February to March 2021 to
determine the prevalence of diarrhea and its association with nutritional status among under five
children visiting Bahir Dar Health Center, Northwest Ethiopia

3.3 Study Population

All the under-five children who came Bahir Dar Health Center in the specified period of time
from February to March 2021and full fill the inclusion criteria of the study are considered as
study population.

3.4 Source Population

All the children who visited Bahir Dar Health Center from February to March 2021.

3.5. Sample Size Determination

The sample size to this study was determined based on 14.5% prevalence report of other study
(Amare Belachew et al., 2019).

The sample size is estimated using the following statistical formula (Naing et al., 2006).

( ) ( ) ( )
Or )
(

Where: n = sample size required

Z = 95% confidence interval (1.96)

d = Marginal error between the sample and populations (0.05)

P = prevalence rate (14.5%)

Since the overall prevalence of rate (p) of diarrheal cases and its association with nutritional
status in the study area was known the sample size of the proposed study was calculated as a
function of the 14.5%. For calculation, a 95% confidence interval (Z) and a 5% margin of error
(d) was used. Therefore, in this study one hundred ninety one (191) under five age children was
chosen to participate in the study. To compensate for non-response rate, 5% of the sample size
was added and finally 200 individuals are included for the assessment of diarrheal cases and its
association with nutritional status of under five children visiting Bahir Dar Health Center during
the study period.

17
3.6. Eligibility criteria
3.6.1. Inclusion criteria
All the children aged under five who visited Bahir Dar Health Center in the specified period of
time from February to March 2021. Mothers/care-givers who visited the Health Center with their
under-five children and signed consent form were included.

3.6.2. Exclusion criteria

Mothers/care-givers who have visited the Health Center with their children above five year and
not suspected for diarrhea are excluded. All children who are suspected for diarrhea prior to the
study and take ant-diarrhea drug and vaccinated also excluded.

3.7. Sampling technique

The study was conducted by using simple random sampling technique. The data was obtained
from daily admission of under five children and information was collected by using
questionnaire which contained questions related to socioeconomic factors, demographic factors,
child health and caring practice, behavioral habits, and environmental conditions.

3.8. Methods of Data Collections

3.8.1. Questionnaire survey
Face to face structured questionnaire was conducted on mothers or caretakers of the children
who were recruiting into the study. The questionnaire was first prepared in English based on
known associated risk factors, and then it was translated in to local language, Amharic, then after
the response was translated back into English. The questionnaire survey was conducted on the
day of admission. The respondents were informed about the purpose of the questionnaire survey
and participation in the study was voluntary. The respondents were also asked for their
permission to be involved in the survey and the information they provided would be handled as
confidential.

3.8.2. Anthropometric measurements

Height/length and weight measurement of the child were taken by the health extension workers
who are already trained by the government and work the health posts. Weight scale was used to
measure weight of children. Weight was recorded to the nearest0.1 kg with the child barefoot
and wearing light clothing. Children who were unable to stand on the scale, and 6–24 months
were weighed with the mother or legal guardian, then the mother/ guardian was weighed alone,

18
and the differences were used to obtain the net weight of the children. The height of the children
was measured using a calibrated height measuring board. A child who could not stand erect was
measured in supine position. A child who could stand erect and above 24 month was measured
standing against a calibrated height measuring board. The height measurement was taken to the
nearest 0.1 cm. WHO Anthro version 3.2.2 software used to convert the anthropometric
measures; age, weight, height/length values into Z-scores of the indices; Weight-for-Height
(WHZ), Weight for-Age (WAZ), and Height-for-Age (HAZ) taking gender of the child into
consideration using WHO 2006 standards. An anthropometric measurement was carried out by
the above standard method.

3.8.3. Stool sample collection and examination

During stool collection, disposable plastic cups and spoon are used to each study subject.
Mothers or caregivers were advised to fill up the disposable plastic cup about the size of the tip
of the thumb (approximately 5gof stool) of fresh stool using disposable spoon that was given
with the container.

Each stool sample was first examined macroscopically to determine whether it was diarrheic or
not. The direct wet mount was processed by conventional iodine to identify the presence of
motile intestinal parasites, cysts, eggs, and trophozoite under a light microscope at 10X and 40 X
magnifications. About 2g of each stool sample was emulsified with 3-4 ml normal saline (0.85%
NaCl solution). Then a drop of the emulsified sample was placed on a clean microscopic glass
slide. A few drops of iodine solution were added to samples on glass slides and were covered
with a coverslip. The processed stool sample was checked for the presence of intestinal parasite
ova or cysts under light microscopy using objectives 10X and 40 X.

3.9. Variables of the study

The independent variables of the present study were socio-demographic factors, environmental
factors, child health and caring practices, nutritional status, parasitic infections, behavioural and
hygienic practices of the respondents. The dependent variable was the prevalence of diarrhea
among under five children in Bahir Dar Heath Centre.

3.10. Data analysis

Statistical package for social science (SPSS) version 23.0 was used to analyze the collected data.
Chi-square (χ2) test was performed to verify the possible association between the prevalence of

19
diarrhea and socio-demographic characteristics, behavioral factors, child health and caring
practice, and environmental sanitation factors. Logistic regression was used to measure the
strengths or degrees of association between the prevalence of diarrhea and the associated risk
factors. In the modeling process, univariate analyses were first done and the variables having a
significant value which is less than 0.25 were selected for multivariate analysis. The variables,
significant at the univariate analysis, were then being included in the multivariate analysis. The
results of the association were considered significant when the p-value was below 0.05. The 95%
CI was used to show the accuracy of data analysis.

3.11. Ethical consideration

Before conducting the investigation, the investigator obtained ethical clearance from the ethical
committee of Science College, Bahir Dar University. A letter describing the aim of the research
was written to Bahir Dar Health center before the collection of required data to keep the
confidentiality of the information regarding the study population. Consent forms were obtained
from the parents/guardians of children after explaining the purpose and the procedures of the
study. The laboratory test was conducted with strict privacy and confidentiality.

20
 4. RESULT
4.1. Socio demographic characteristics of participants
Table 1 depicts the socio-demographic and socio-economic characteristics of the study
participants. Of the 200 randomly identified participants, One-hundred seventy one (85.5%) of
them resided in urban and the rest of twenty nine (14.5%) reside in rural. One hundred seven
(53.5%) were males and the rest ninety-three (46.5%) females. The age of the child‟s ranged
from 6 to 59 month. The participants were grouped into six age categories (0–6, 7–12, 13–24,
25-36, 37-48 and 49-59). Twenty-three (11.5%) individuals fall in the age group 0-6 month,
thirty-seven (18.5%) in 7-12 month, sixty-five (32.5%) in 13-24 month, thirty-six (18.0%) in 25-
36 month, thirty-one (15.5%) in 37-48 month and eight (4%) in 49-59 month. The age of mother
or caretaker also grouped in to three age categories (18-25, 26-35 and 36-45). Fifty-eight
(29.0%) of them in the age group 18-25 year, one hundred twenty five (62.5%) in the age group
26-35 year and seventeen (8.5%) of mother or caretaker in the age group 36-45.

From a total of 200 participants one hundred eighteen (59.0%) of mother or care givers attend
formal education, forty-six (23.0%) of them able to read and write, thirty-three (16.5%) of them
did not attended formal education and three (1.5%) of them illiterate.

Thirty three (16.5%), 29 (14.5%), 134 (67.0%) and four (2.0%) of the mothers or care takers
were employed, merchant, farmer and house wife, respectively. Likewise, 81 (40.5%), 69
(34.5%), 38 (19.0%), and 12 (6%) of the fathers of the children were employed, merchants, daily
labors and farmers respectively. The average monthly income ranged from <2000- 35000. Forty
six (23.0%), 143 (71.5%) and 11 (5.5%) were getting monthly income <2000, 2000-10000 and
11000-35000, respectively.

21
Table 1: Socio-demographic characteristics of under five children visiting Bahir Dar Health
Center.

Socio-demographic
Categories Frequency Percent
Urban 171 85.5
Residence Rural 29 14.5

Total 200 100

Sex Male 107 53.5
Female 93 46.5
Total 200 100
Age of child (month) 0-6 23 11.5
7-12 37 18.5
13-24 65 32.5
25-36 36 18.0
37-48 31 15.5
49-59 8 4
Total 200 100
18-25 58 29.0
Mother age 26-35 125 62.5
36-45 17 8.5
>45 0 0
Total 200 100
Illiterate 3 1.5
Educational status of mother read and write 46 23.0
informal education 33 16.5
formal education 118 59.0
Total 200 100
house wife 4 2.0
Employed 33 16.5
Mothers‟ occupation Merchant 29 14.5
Farmer 134 67.0
Total 200 100
Employed 81 40.5
Merchant 69 34.5
Father occupation Farmer 12 6.0
Daily labour 38 19.0
Total 200 100
Monthly income <2000 46 23.0
2000-10000 143 71.5
11000-35000 11 5.5
Total 200 100

22
4.2. Behavioral and child health and caring practices of study participants
Behavioral and Child health and caring practices of the study participants stated in table 2. Of
the total children 200, 193 (96.5%) were exclusively breast feed for the first six month while two
(1.0%) of them didn‟t and the remaining five children are less than six month. One hundred
thirty six (68.0%) were currently breast feed children and the rest of 63 (31.5%) of them not
currently breast feed.

Eighty five (42.5%) mothers breast feed >8times, forty one (20.5%) of them breast feed 4-7
times, eleven (5.5%) of the <3times in 24 hour and two (18.0%) of them not know the frequency
of the breast feed. From a total respondents one hundred thirty two (66.0%) of the children
started complementary feeding in <6month in addition to breastfeed, forty (20%) in 6month,
eight (4.0%) of them in >6month and twenty (10.0%) of them not started complementary
feeding. With regards to cleansing material used to wash their hand 167 (83.5%) of them use
water and soap, 30 (15.0%) of them use only water to wash their hands and three (1.5%) of them
use water and ash. Out of a total, one hundred thirty two (66.0%) of the participants usually put
child food in refrigerator, 40 (20%) of them put child food in open shelf, 20 (10.0%) of them put
child food anywhere and eight (4.0%) of them usually put child food in covered shelf.

Table 2: Behavioral and Child health and caring practices of under five children visiting Bahir
Dar Health Center.

Behavioral and Child health

and caring practices Categories Frequency Percent
Yes 193 96.5
Exclusive breastfeeding for No 7 3.5
first six month

Total 200 100

Currently breastfeed Yes 137 68.5
No 63 31.5
Total 200 100
Breastfeeding >8times 85 42.5
frequency(24hr) 4-7times 41 20.5
<3times 12 6.0
Not breastfeed 62 31.0
Total 200 100
<6month 132 66.0
Complementary feeding 6month 40 20

23
 >6month 8 4
Not yet start 20 10.0
Total 200 100
Water 30 15.0
Cleansing material used to Water and soap 167 83.5
wash hand Water and ash 3 1.5
Total 200 100
Refrigerator 28 14.0
Place of Complementary open shelf 33 16.5
feeding(usually put child covered shelf 129 64.5
food) Anywhere 10 5.0
Total 200 100

4.3. Environmental characteristics of study participants

Of total respondents, 79 (39.5%) got child caring and health information from TV, radio and
other sources and 121 (60.5%) didn‟t. Almost all respondents (99.5%) wash their hand. One
hundred fifty six (78.0%) of the respondents had a pit latrine with slab, 25 (12.4%) of them had
Ventilated improved pit latrine and 19 (9.5%) of them with pit latrine without slab. With regards
to their drinking water source 187 (93.5%) respondents reported that they get from the public
tap.

Table 3: Environmental characteristics of under five children visiting Bahir Dar Health Center.

Environmental
characteristics Categories Frequency Percent
Yes 79 39.5
Getting health information No 121 60.5

Total 200 100

Hand wash Yes 199 99.5
No 1 0.5
Total 200 100
Toilet type Ventilated improved pit 25 12.5
latrine
Pit latrine with slab 156 78.0
pit latrine without 19 9.5
slab/open
Total 200 100
public tap 187 93.5
Drinking water source protected spring 11 5.5
dug well 2 1
unprotected spring 0 0.0
Total 200 100

24
4.4. Malnutrition among under five children visiting Bahir Dar Health Center
From the total 200 respondents 28(14.0%) of them were stunted and 21 (10.5%) were severely
stunted. Whereas, 36 (18.0%) children were underweight and 8(4%) were severely underweight.
the prevalence of wasting were 42 (21.0%) and 10 (5%) were severely wasted. And the
prevalence of wasting is higher compared with stunting and underweight.
Table 4: Stunting, wasting and underweight among under five children visiting Bahir Dar Health Center.
Malnutrition Category Frequency Percent
Stunting Stunted 28 14.0
Severely stunted 21 10.5
Not stunted 151 75.5

Wasting Wasted 42 21.0

Severely wasted 10 5.0
Not wasted 148 74.0
Underweight Underweight 36 18.0
Severely underweight 8 4.0
Not underweight 156 78.0

4.5. Prevalence of diarrhea

From the 200 examined stool samples, 76 (38%) of them positive for diarrhea. Of the total 200 children
examined, 11 (39.7%) of them rural residents followed by 65 (38.0%) from urban residents.

Females were more infected than males 38 (40.9%). The most infected age group was 7 to 12 (48.6%,
18), followed by the age group 13 to 24 (46.2%, 30), 25 to 36 (36.1%, 13), 0 to 6 (26.1%, 6) and the age
group 49 to 59 (25.0%, 2) in descending order. Children whose mother or care taker in the age group 18
to 24 were more infected (44.8%, 26) followed by children whose mother were in the age group 25 to 35
(36.8%, 46) and children whose mother were in the age group 36 to 45 were (23.5%, 4).

Children whose mothers (45.5%, 15) attend informal education were more infected than those who were;
attend formal education (38.1%, 45). Children whose mothers merchant were more infected (44.8%, 13)
followed by children whose mothers farmer (38.8%, 52), children whose mothers were employed (30.3%,
10), and children whose mothers were house wife (25.0%, 1) in descending order.

25
Table 5: Prevalence of diarrhea among under five children visiting Bahir Dar Health Center.
Variable Categories Infection status
Positive cases Negative (%) Total (%)
(%)
Residence Urban 65(38.0) 106(62.0) 171 (85.5)
Rural 11(39.7) 18(62.1) 29 (14.5)
Sex Male 38(35.5) 69 (64.5) 107 (53.5)
Female 38 (40.9) 55 (59.1) 93 (46.5)
Age in month 0-6 6 (26.1) 17 (73.9) 23(11.5)
7-12 18 (48.6) 19 (51.4) 37 (18.5)
13-24 30 (46.2) 35 (53.8) 65 (32.5)
25-36 13 (36.1) 23 (63.9) 36 (18.0)
37-48 7 (22.6) 24 (77.4) 31 (15.5)
49-59 2 (25.0) 6 (75.0) 8 (4.0)
Maternal age 18-24 26 (44.8) 32 (55.2) 58 (29.0)
25-35 46 (36.8) 79 (63.2) 125 (62.5)
36-45 4 (23.5) 13 (76.5) 17 (8.5)
Maternal Illiterate 1 (33.3) 2 (66.7) 3 (1.5)
education
Read and write 15 (32.6) 31 (67.4) 48(23.0)
Informal education 15 (45.5) 18 (54.5) 33 (16.5)
Formal education 45 (38.1) 73 (61.9) 118 (59.0)
Maternal House wife 1 (25.0) 3 (75.0) 4 (2.0)
Occupation
Employed 10 (30.3) 23 (69.7) 33 (16.5)
Merchant 13 (44.8) 16 (55.2) 29 (14.5)
Farmer 52 (38.8) 82 (61.2) 134 (67.0)

4.6. Prevalence of intestinal protozoan parasites and helminthes parasites

The prevalence of protozoan parasitic infections in the study area was 4 (2%). Protozoan
infections accounted 3(100%) males and 1(33.3%) females. The prevalence of helminthes
infection on the other hand was 2(1.0%), of which 2 (66.7%) were females and (0.0%) males.
The prevalence of protozoa was 2(100%) in females and (0.0%) males. The prevalence of
26
 protozoan and helminthes parasitic infections among age groups was 3 (75.0%) and 1(25.0%) in
the age group 25-36 months respectively, 1(100%) helminthes in the age group 7-12, 1(100%) in
49-59 and 0(0%) in other age groups.
Table 6. Major intestinal parasites.

Frequency Gender Age group

Parasite (%) N=200 Female Male 7-12 25-36 49-59
(N=93) (N=107) (N=37) (N=36) (N=8)

Protozoa 4(2%) 1(25.0%) 3(75.0%) 0(0.0%) 3(75.0%) 1(25.0%)

E. histolytica 2(33.3%) 1(33.3%) 1(33.3%) 0(0.0%) 1(25.0%) 1(100%)

G. lamblia 2(33.3%) 0(0.0%) 2(66.7%) 0(0.0%) 2(50%) 0(0.0%)

Helminthes 2(1%) 2(100%) 0(0.0%) 1(50.0%) 1(50%) 0(0.0%)

A. lumbricoid 2(33.3%) 2(66.7%) 0(0.0%) 1(100%) 1(100%) 0(0.0%)

Total 6(100%) 3(100%) 3(100%) 2(100%) 4(100%) 2(100%)

4.7. Potential risk factors associated with diarrhea among under five children
visiting Bahir Dar Health Center.
4.7.1. Chi-square association of the different risk factors with diarrhea
The prevalence of diarrhea among under five children and chi-square association of the different
risk factors with diarrhea is presented in Table 5. Residence, sex, age, maternal educational
status, paternal occupation, maternal occupation, toilet type, source of drinking water, income
hand washing habit and cleansing material for hand washing, getting health information,
exclusive breastfeeding and complementary feeding in addition to breastfeeding were not
associated with diarrhea (P > 0.05).This study showed that there was significant association
between place of complementary feeding of the children and risk of having diarrhea 9.628 (P,
0.022), breastfeeding frequency and risk of having diarrhea 13.689 (P, 0.003), and there was
significant association between current status of breastfeeding of the child and the of having
diarrhea 8.077 (P, 0.013)

27
Table 7: Chi-square association of different risk factors with diarrhea among under five children
visiting Bahir Dar health center.

Variable Categories Infection status Chi- P-value

square
Positive Negative Total (%) (χ2)
cases (%)
(%)
Residence Urban 65(38.0) 106(62.0) 171 (85.5) 0.000 0.993
Rural 11(39.7) 18(62.1) 29 (14.5)
Sex Male 38(35.5) 69 (64.5) 107 (53.5) 0.604 0.437
Female 38 (40.9) 55 (59.1) 93 (46.5)
Age in month 0-6 6 (26.1) 17 (73.9) 23(11.5) 8.757 0.119
7-12 18 (48.6) 19 (51.4) 37 (18.5)
13-24 30 (46.2) 35 (53.8) 65 (32.5)
25-36 13 (36.1) 23 (63.9) 36 (18.0)
37-48 7 (22.6) 24 (77.4) 31 (15.5)
49-59 2 (25.0) 6 (75.0) 8 (4.0)
Maternal age 18-24 26 32 (55.2) 58 (29.0) 2.735 0.255
(44.8)
25-35 46 79 (63.2) 125 (62.5)
(36.8)
36-45 4 (23.5) 13 (76.5) 17 (8.5)
Maternal Illiterate 1 (33.3) 2 (66.7) 3 (1.5) 1.375 0.712
education
Read and 15 (32.6) 31 (67.4) 48(23.0)
write
Informal 15 (45.5) 18 (54.5) 33 (16.5)
education
Formal 45 (38.1) 73 (61.9) 118 (59.0)
education
Paternal Employed 30 (37.0) 51 (63.0) 81 (40.5) 0.359 0.949
Occupation
Merchant 28 (40.6) 41 (59.4) 69 (34.5)
Farmer 4 (33.3) 8 (66.7) 12 (6.0)
Daily labour 14 (36.8) 24 (63.2) 38 (19.0)
Maternal House wife 1 (25.0) 3 (75.0) 4 (2.0) 1.727 0.631
Occupation
Employed 10 (30.3) 23 (69.7) 33 (16.5)

28
 Merchant 13 (44.8) 16 (55.2) 29 (14.5)
Farmer 52 (38.8) 82 (61.2) 134 (67.0)
Getting health Yes 31(39.2) 48(60.8) 79(39.5) 0.085 0.770
information
No 45(37.2) 76(62.8) 121(60.5)
Hand wash Yes 76(38.2) 123(61.8) 199(99.5) 0.616 0.433
No 0(0) 1(100.0) 1(0.5)
Toilet type Ventilated 9(36.0) 16(64.0) 25(12.5) 2.735 0.255
improved pit
latrine
Pit latrine 63(40.4) 93(59.6) 156(78.0)
with slab
pit latrine 4(21.1) 15(78.9) 19(9.5)
without
slab/open
Drinking water public tap 71(38.0) 116(62.0) 187(93.5) 1.485 0.476
source
protected 5(45.5) 6(54.5) 11(5.5)
spring
dug well 0(0.0) 2(100) 2(1.0)
Exclusive Yes 73(37.8) 120(62.2) 193(99.0) 2.233 0.072
breastfeeding for
first six month No 2(100.0) 0(0.0) 2(1.0)

Currently Yes 61(44.9) 75(55.1) 136(68.3) 8.077 0.013*

breastfeed No 15(23.8) 48(76.2) 63(31.7)
Breastfeeding >8times 33(38.8) 52(61.2) 85(61.6) 13.689 0.003*
frequency(24hr)
4-7times 24(58.5) 17(41.5) 41(29.7)
<3times 5(41.7) 7(58.3) 12(8.7)
Complementary <6month 44(33.6) 87(66.4) 131(65.8) 6.573 0.160
feeding
6month 18(45.0) 22(55.0) 40(20.1)
>6month 11(55.0) 9(45.0) 20(10.1)
Not yet start 2(25.0) 6(75.0) 8(4.0)
Place of Refrigerator 39(30.2) 90(69.8) 129(66.2) 9.628 0.022*
Complementary open shelf 17(53.1) 15(46.9) 32(16.4)
feeding(usually covered 14(53.8) 12(46.2) 26(13.3)
put child food) shelf
Anywhere 4(50.0) 4(50.0) 8(4.1)
Cleansing Water 9(30.0) 21(70.0) 30(15.0) 1.922 0.383

29
material used to Water and 65(38.9) 102(61.1) 167(83.5)
wash hand soap
Water and 2(66.7) 1(33.3) 3(1.5)
ash
Monthly income <2000 18(39.1) 28(60.9) 46(23.0) 1.941 0.379
2000-10000 56(39.2) 87(60.8) 143(71.5)
11000- 2(18.2) 9(81.8) 11(5.5)
35000
Note: * Statistically significant at p < 0.05

4.7.2. Logistic regression analysis of the most important risk factors for diarrhea

The most important risk factors for diarrhea among under five children visiting Bahir Dar Health Center
were identified using Univariate and Multivariate Logistic Regression Analyses (Table 6).

4.7.2.1. Univariable analysis

The univaraible analysis is described below on Table 6. Age(month), maternal age, maternal occupation,
income, current breastfeeding status, breastfeeding frequency, complementary feeding, place of
complementary feeding, toilet type, cleansing material for hand washing and wasting were the variables
which have passed the cut off value (P<0.25) (Lemeshow et al., 1990) for further analysis.

4.7.2.2. Multivariable analysis

The multivarable analysis is described on Table 6. In the multivariate regression, giving complementary
feeding at 6 month were protective against diarrhea and putting child food in covered shelf were
protective against diarrhea (P<0.05).Complementary feeding at 6 month and putting complementary
feeding in covered shelf were found to be protective against diarrhea. However, Age(month), maternal
age, maternal occupation, income, current breastfeeding status, breastfeeding frequency, toilet type,
cleansing material for hand washing and wasting were not significantly associated with diarrhea (P >
0.05).

30
Table 8. Univariate and multivariate logistic regression analysis of potential risk factors
associated with diarrhea among under five children in Bahir Dar Health Center Northwest,
Ethiopia.

Infection status
Positive Total
Variables Categorie Cases Examined COR, 95% CI P- AOR, 95% P-
s (%) (%) value CI value
Residence Urban 65(38.0) 171(85) 1 0.993
Rural 11(39.7) 29(14.5) 0.997
(0.443,2.243)
sex male 38(35.5) 107(53.5) 0.797(0.450,1 0.437
.413)
female 38 (40.9) 93(46.5) 1
Age of the 0-6 6 (26.1) 23(11.5) 1
child(month) 7-12 18 (48.6) 37(18.5) 2.429,(0.849, 0.098 0.247(0.058, 0.05
6.945) * 1.043) 7
13-24 30 (46.2) 65(32.5) 1.601(0.506,5 0.423 0.945(0.359, 0.91
.071) 2.491) 0
25-36 13 (36.1) 36(18.0) 0.826(0.236,2 0.766 0.736(0.179 0.67
.889) ,3.028) 1
37-48 7 (22.6) 31(15.5) 0.944(0.148,6 0.952 0.255(0.046, 0.11
.014) 1.398) 6
49-59 2 (25.0) 8(4.0) 2.684(0.865,8 0.087 0.338(0.032, 0.36
.327) 3.568) 7
Maternal age 18-24 26 58(29.0) 2.641(0.768,9 0.123 1.747(0.373, 0.47
(44.8) .074) * 8.169) 9
25-35 46 125(62.5) 1.892(0.583,1 0.289 1.753(0.404, 0.45
(36.8) .147) 7.613) 4
36-45 4 (23.5) 17(8.5) 1
Maternal Formal 45 (38.1) 118(59.0 1
education
Illiterate 1 (33.3) 3(1.5) 0.811(0.71,9. 0.866
204)
Informal 15 (45.5) 33(16.5) 1.352(0.620,2 0.488
.947)
Read and 15 (32.6) 46(23.0) 0.785(0.087,1 0.510
write 2.319)
Maternal Employed 10 (30.3) 33(16.5) 1
occupation Farmer 52 (38.8) 134(67.0) 0.767(0.071,8 0.827 0.453(0.109, 0.27
.299) 1.876) 5
House 1 (25.0) 4(2.0) 1.459(0.643,3 0.367 0.143(0.009, 0.16
wife .311 2.256) 7
Merchant 13 (44.8) 29(14.5) 1.869(0.659,5 0.240 0.620(0.199, 0.41
.300) * 1.933) 0
Paternal Employed 30 (37.0) 81(40.5) 1

31
Occupation Daily 14 (36.8) 38(19.0) 0.850(0.236,3 0.804
labour .064)
Merchant 28 (40.6) 69(34.5) 0.857(0.218,3 0.825
.371
Farmer 4 (33.3) 12(6.0) 0.732(0.201,2 0.636
.667)
Income <2000 18(39.1) 46(23.0) 0.346(0.067,1 0.205 0.735(0.308, 0.48
.787) * 1.754) 8
2000- 56(39.2) 143(71.5) 0.345(0.072,1 0.184 0.324(0.40,2 0.29
10000 .657) * .663) 5
11000- 2(18.2) 11(5.5) 1
35000
Exposure to yes 31(39.2) 79(39.5) 1
information No 45(37.2) 121(60.5) 1.091(0.609,1 0.770 3.673(0.207, 0.37
.954) 65.220) 5
Exclusive Yes 73(37.8) 193(99.0) 0.000 0.999
breast No 2(100.0) 2(1.0) 1
feeding
Currently Yes 61(44.9) 136(68.3) 0.384(0.196,0 0.005
breastfeed .752) *
No 15(23.8) 63(31.7) 1
Breastfeedin >8times 33(38.8) 85(61.6) 1
g Frequency 4-7times 24(58.5) 41(29.7) 0.506(0.137,1 0.306 0.447(0.087, 0.33
.866 0.970) 5
<3times 5(41.7) 12(8.7) 0.450(0.210,0 0.039 0.400(0.159, 0.05
.960) * 1.007) 2
Not 14 (22.6) 62 (31.0) 0.207 (0.087, 0.000 0.062(0.004 0.05
breastfeed 0.488) * ,1.067) 5
Complement >6month 44(33.6) 131(65.8) 1
ary feeding 6month 18(45.0) 40(20.1) 0.659(0.787,3 0.619 0.290(0.087, 0.04
.3261) 0.970) 4*
<6month 11(55.0) 20(10.1) 1.618(0.044,1 0.191 0.117(0.011, 0.07
.695) * 1.272) 8
Not yet 2(25.0) 8(4.0) 2.417(0.932,6 0.069 48620.2(0.0
start .265) * 0)
Place of Refrigerat 39(30.2) 129(66.2) 1
complement or
ary(usually Anywher 17(53.1) 32(16.4) 1.062(0.388,2 0.906 0.323(0.039, 0.29
put child e .901) 2.694) 6
food) Covered 14(53.8) 26(13.3) 0.433(0.189,0 0.048 0.248(0.032, 0.18
shelf .994) * 1.937) 4
Open 2 (16.7) 12 (2.9) 0.806 (0.17, 0.786 0.082(0.012, 0.01
shelf 3.817) 0.566) 1*
Drinking Public tap 71(38.0) 187(93.5) 0.000(0.000) 0.999
water source Protected 5(45.5) 11(5.5) 0.000(0.000) 0.999
spring

32
 Dug well 0(0.0) 2(1.0) 1
Toilet type Ventilate 9(36.0) 25(12.5) 0.474(0.120,1 0.286 0.605(0.098, 0.58
d pit .870) 3.717) 7
latrine
Pit latrine 63(40.4) 156(78.0) 0.394(0.125,1 0.112 1.247(0.385, 0.71
without .241) * 4.038) 2
slab/open
pit
Pit latrine 4(21.1) 19(9.5) 1
with slab
Hand wash Yes 76(38.2) 199(99.5) 0.0000 1.000
No 0(0) 1(0.5) 1
Cleansing Only 9(30.0) 30(15.0) 4.667(0.374,5 0.232 0.408(0.140, 0.10
material to water 8.248) * 1.191) 1
wash hand Water and 65(38.9) 167(83.5) 3.138(0.279,3 0.354 1.037(0.385, 0.61
soap 5.313) 4.038) 2
Water and 2(66.7) 3(1.5) 1
ash
stunting stunted 13(46.4) 28(14.0) 0.848(0.323,2 0.738
.228)
Severely 7(33.3) 21(10.5) 1.47(0.652,3. 0.353
stunted 314)
Not 56(37.1) 151(75.5) 1
stunted
wasting wasted 18(42.9) 42(21.0) 2.769(0.748,1 0.127 0.534(0.216, 0.17
0.257) * 1.323) 6
Severely 6(60.0) 10(5.0) 1.385(0.689,2 0.361 2.248(0.391, 0.36
wasted .783) 12.935) 4
Not 52(35.1) 148(74.0) 1
wasted
underweight Underwei 15(19.7) 36(18.0) 0.548(0.107,2 0.470
ght .805)
Severely 2(25.0) 8(4.0) 1.174(0.562,2 0.669
underwei .455)
ght
Not 59(37.8) 156(78.0) 1
underwei
ght
Note: * values which passed the cut off value (p < 0.25); * statistically significant at p < 0.05; 1 =
Reference value; AOR = adjusted odds ratio; COR = Crude odds ratio.

33
 5. DISCUSSION
The primary aim of this study was to determine the prevalence of diarrhea and its association
with nutritional status of under five children visiting Bahir Dar Health Center Northwest
Ethiopia. The overall prevalence of diarrhea in the present study was 38%. It was comparable
with the studies done in Dire Dawa (37%) (Keneni et al., (2016). This result found to be higher
from other studies conducted in Bahir Dar city (14.5%) Amare Belachew et al., (2019), in Bahir
Dar City (21.6%) Molla Gedefaw et al., (2015). The possible explanation for the difference might be
socio demographic factors of the participants, the year of the study conducted and the specific study area.
And also the distribution is quite different in community and health center.

In farta wereda (16.7%) Genet Gedamu et al., (2017), in Bahir Dar Zuria district 20% Desalegn
Tesfa et al., (2017), North Gondar Zone 22.1%, Atalay Getachew et al., (2018), Debrebirehan
Town (31.7%) Ayele Mamo & Awraris Hailu (2014), Dejen District 23.8% Demeke Getu et al.,
(2013), Jamma district, South Wello zone (23.1%) Getachew Yismaw, (2019), Debre Berhan
town (16.4%) Sisay Shine et al., (2020), Jabithennan District (21.5%) Zelalem Alamrew et al.,
(2017), Central Gondar Zone (30.09%) Zewudu Andualem et al., (2019), Dire Dawa city (20%)
Ephrem Tefera et al., (2020), (26%) Bikes Destaw et al., (2017), Wonago district (30.9%) Tinsae
Shemelise et al., (2020), (28.4%) Solomon Getahun and Abulie Takele, (2018), (23.5%)
Mulusew Alemayehu et al., (2020), (14.9%) Legefa Futa et al., (2018), (13.6%) Behailu Melese
et al., (2019), (30.9%) Aseb Arba et al., (2020), (27.7%) Araya Gebreyesus et al., (2018) and
(14.5%) Adugna Fenta et al., (2020) of diarrhea prevalence conducted in different parts of
Ethiopia and the current study higher than all studies stated above. The finding also was higher
than those of previous studies conducted in Cameron 23.8% (Tambe et al.,2015), Tanzania
32.7% (Jean et al.,2017), Senegal 26% (Kakulu,2012), Rwanda 26.7% (Sokhna et al.,2014),
Egypt 19.5% (Yassin,2000) Ghana 19.2% (Boadi and kuitunen,2005), Iraq 21.3% (Siziya et
al.,2000), India 25.2% (Siraj et al.,2010), Burundi, 32.6% (Diouf et al.,2014). These differences
could be attributed to the differences in the socio-economic status of the people, socio-
demographic distinctions, knowledge, hygiene, and sanitary facilities, weather, climate, and
environmental factors.

The current study lower than the study conducted in Tigray region by (Hailemariam Berhe et al.,
2016) reported 54% of diarrhea prevalence. That might be because of water storage practices at home

34
and latrine cleanness and the availability of hand washing facilities around latrines. Starting
complementary foods at six month and due to place of complementary feeding in addition to breast milk.

The odds of having diarrhea in children mother or care taker age group 18-24 were (COR= 2.641
CI: 0.768, 9.074) 2.641times infected than mothers with age group 36-45. This result lower than
the study conducted in Dire Dawa city administration 1.14 times infected (Ephrem Tefera et al.,
2020). The odds of having diarrhea were 0.346 times (0.067, 1.78) higher in children family
who have monthly income less than 2000 than children family having monthly income 11000-
35000 and children family who have monthly income 2000-10000 were 0.345(0.072, 1.657)
times higher than children family having monthly income 11000-35000. Children who were
currently breast feed 0.384 (0.196, 0.752) times infected than children do not.

The children food usually put in open shelf were 0.433 times (0.189, 0.994) infected than
children food usually put in covered shelf. The odds of having diarrhea in children who have pit
latrine without slab were 0.394 times higher than ventilated pit latrine. The odds of getting
diarrhea in children whose family were wash their hands with water only 4.667times (0.324,
58.248) higher than who wash their hand with water and ash. The odds of getting diarrhea in
children whose mother were merchant were 1.869 times (0.659, 5.300) higher than children
whose mother employed. Children breast feed 3 times in 24hr (COR=0.450 CI: 0.210, 0.960)
higher chance of getting diarrhea than those who breastfeed more than 8 times in 24hr. The odds
of getting diarrhea in children starting complementary feeding less than 6 month 1.61 times
(0.044,1,695) infected than those who started complementary feeding greater than 6 month. In
the final multivariable regression, twelve factors were tested to identify the predisposing factors
for childhood diarrhea. Ten of the risk factors found were not significantly associated with
diarrhea infection (P<0.05).

Complementary feeding at 6 month and putting complementary feeding in covered shelf were found to
be protective against diarrhea. Complementary feeding at 6 month (AOR=0.290 CI: 0.087, 0.970) and
putting complementary feeding in covered shelf (AOR=0.082 CI: 0.012, 0.566). The differences might be
due to variations in hygiene and sanitation practices and the initiation of children into supplementary
feeding. Children who started supplementary food before 6 months had more chance of getting acute
diarrhea than those who started supplementary feeding after 6 months.

35
Nutritional status in this study showed that prevalence of child stunting (14%), and underweight
(18%) were lower in the study area in comparison with the study conducted in Tigray region
stunting 36% and underweight 37% (Araya Gebreyesus et al.,2018), regional prevalence
reported by Ethiopian DHS 2016 of 39.3% stunting and underweight 23% (CSA,2016).
Prevalence of stunting in the current study found to be 14% was lower than the study conducted
among a pastoralist community of Ethiopia 34.4% (Solomon Demissie and Amare Worku,
2013), Bule Hora district, south Ethiopia 47.6% (Mandefro Asfaw et al.,2015). The difference
might be attributed due to difference in balance of nutrient consumption, dietary diversity, feeding
habit of child and other factors.

On the contrary, prevalence of wasting and (21%) and severely wasting (5%) in the study area
was very high compared to the study conducted in Tigray region 7.9% wasting and 3.6%
severely wasting (Araya Gebreyesus et al.,2018). Prevalence of severely stunting of the current
study (10%) lower than the study conducted in Tigray region (21%) (Araya Gebreyesus et al.,
2018). Variations in nutritional status of children could be the result of socio-demographic,
feeding habit of child, environmental hygiene, and cultural difference among societies. This
indicates other factors may lead to malnutrition such as shortage of food, limited access to balanced diet
both for the mother and the child, and child feeding practices.

The prevalence of intestinal protozoa parasitic infections in the current study was 4 (2%) and the
prevalence of helminthes in the study area was 2 (1%). In the remaining 194(97.0%) participants
the intestinal parasites not observed.

36
 6. CONCLUSION
The prevalence of diarrhea among under-five children visiting Bahir Dar Health Center found to
be 38.0% out of 200 participants. The findings in the present study showed that intestinal
parasites that lead to diarrhea are protozoa (E.histolytica and tropozoite and cyst of giardia
lamblia) and helminthes (A. lumbercoid), and none of other intestinal parasites observed. Start
Complementary feeding, breastfeeding frequency in 24hr and current status of breastfeeding
were significantly associated with diarrhea at p, 0.05 in chi-square analysis. In bivariate analysis
age of the child, maternal age, maternal occupation, monthly income, current breastfeeding
status, breastfeeding frequency, complementary feeding, toilet type, cleansing material for hand
washing, place of complementary and wasting were significant at p, 0.25. In the final
multivariable regression, twelve factors were tested to identify the predisposing factors for
childhood diarrhea. Ten of the risk factors found were not significantly associated with diarrhea
infection (P<0.05). Putting complementary feeding in covered shelf and complementary feeding
at 6 month were protective against diarrhea at p, 0.05. The current study findings of diarrheal
disease prevalence among under-five children were significantly higher compared to some other
similar studies.

37
 7. RECOMMENDATIONS

In the country diarrhea were the major public health problem and risk factor of under-five
children mortality, identifying and understanding factors that determine diarrhea Thus, based on
the finding of the study, the following recommendations are forwarded:
 In order to reduce the prevalence of diarrhea and improve child health, attention should
be given to improving breast feeding frequency, create awareness especially in rural area
and hand hygiene knowledge to diarrhea .
 Knowledge should be addressed to mother or care giver giving complementary feeding at
6 month and greater than six month for their children.
 Knowledge, attitude and awareness should be enhanced in the community, level by the
region health office and women and youth affaires office, education office as well as
NGO‟s working in the area through providing continuous training and information
provision regarding the health care, attention should be provide to the children.

38
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APPENDICES

APPENDIX A: Informed Consent Declaration (English Version)

I am conducting a study to assess diarrheal cases and its association with nutritional status to
understand the prevalence and associated risk factor of the diarrheal infection among under five
children. Your child is being to participate in this study. If you agree, I would like to obtain a
stool specimen from your child, which would be used only to detect the presence of diarrhea. He/
She will not get any risk in participating. The record‟s information is strictly confidential.
Your child participation in this study is completely voluntary and you/ He/ She can refuse to
participate or free to withdraw from the study at any time.
Do you understand what has been said to you? If you have questions, you have the right to get a
proper explanation.
I am informed of my satisfaction with the purpose of this study nature of laboratory
investigation. I am also aware of my right to out of the study at any time during the study without
having to give reasons for doing so. This consent form has been read out to me in my language
(Amharic language) and I understand the content and I voluntarily consent to participate in the
study.
Study code no. ________

Name __________________________Signature ________ Date _____/______/___

Investigator Name Lidiya Bekele Atara Signature ____________Date___/___/_

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Informed Consent Declaration (Amharic Version)
ይህ ጥናት የሚጠናው ከአምስት አመት በታች ሕፃናት ሊይ የተቅማጥ ኢንፋክሽኑን ስርጭት እና ተዛማጅ ተጋሊጭነት ሁኔታ
ሇመረዳት የተቅማጥ በሽታዎችን እና ከአመጋገብ ሁኔታ ጋር ያሇውን ቁርኝት ሲሆን ጥናቱ በሚካሄድበት ቦታ በምን ዯረጃ ሊይ
እንዳሇ ሇማወቅና ከጥናቱም በኋሊ የመፌትሄ አቅጣጫዎችን ሇማስቀመጥም ነው፡፡
በጥናቱ ሊይ ሇመሳተፌ ሌጅዎትም ሆነ/ነች እርሶዎ ፇቃዯኛ ከሆኑ ሇሚቀርብሌዎት ጥያቄ መሌስ እንዲሰጡና ከሌጅዎ
የአይነምድር ናሙና በመውሰድ የተቅማጥ ኢንፋክሽን ምርመራ ብቻ እንዲካሄድ ይዯረጋሌ፡፡ በዚህም ጥናት ሊይ ሌጅዎት
በመሳተፈ/ፏ ምንም አይነት ችግር የማያጋጥመዉ/ማት መሆኑን እገሌፃሇሁ፡ሁለም ነገር በሚስጥር እንዲያዝ ይዯረጋሌ፡፡
በጥናቱ ሊይ ሌጅዎት እንዲሳተፌ/ እንድትሳተፌ ፇቃዯኛ ካሌሆኑ በማንኛውም ሰዓት ማቋረጥ ይችሊለ፡፡ ይህም በመሆኑ
ምንም አይነት የሚያጋጥምዎት/ የሚያጋጥመዉ/ የሚያጋጥማት ችግር አይኖርም፡፡ እንዯዚሁም ግሌፅ ያሌሆኑ ጥያቄዎች
ቢኖርዎት የመጠየቅና መሌስ የማግኘት መብትዎት የተጠበቀ ሲሆን የተሟሊ ማብራሪያ እንዲያገኙ ይዯረጋሌ፡፡
ስሇጥናቱ በሚገባኝ መንገድ ገሇፃ ከተዯረገሌኝና በጉዳዩ ሊይ በአግባቡ እንዳስብበት ጊዜ ከተሰጠኝ በኃሊ እንዯዚሁም ግሌፅ
ያሌሆኑ ነገሮችን የመጠየቅና ከፇሇኩም በማንኛውም ጊዜ ያሇማሳተፌና የማቋረጥ መብቴ የተጠበቀ መሆኑን ጥናቱ ሇሌጀም
ሆነ ሇማህበረሰቡ የሚሰጠውን ጠቀሜታ በመረዳቴ የሚቀርቡሌኝን ጥያቄዎች ሇመመሇስና ሌጄ የአይነምድር ናሙና እንዲሰጥ
ፇቃዯኝነቴን እግሌፃሇሁ፡፡
ፉርማ፡----------------------------------------
ቀን፡----------/-----------------/----------------

49
APPENDIX B: Questionnaire (English version)
My name is Lidiya Bekele I am Student of Bahir Dar University college of Sciences and. I‟m
conducting a research for the partial fulfillment of masters‟ degree on “Assessment of
Diarrheal cases and its Association with Nutritional status of under-five Children visiting in
Bahir Dar Health Center”, I am going to ask you several questions about those factors and
related issues about the research.

I assure that the interview process will not bring any harm to you and your family. Whatever
information you provide will be kept strictly confidential, and will not be shared with
anyone other than the investigator.

THANK YOU!!!!

Interviewer Name: _________________________________

Date: ____________________________________________

SECTION ONE: Identification Information

1. Patient ID number ___________________________

2. Place of Residence 1: Urban 2: Rural

SECTION TWO: Demographic Factors

3. Sex? 1: Female 2: Male

4. Age? (write in months) ______________________

5. Age of mother/caregiver _______________________

SECTION THREE: Socioeconomic Factors

6. Educational status of the mother/ caregiver?

1: Illiterate

2: Read and write

3: Non formal education

50
4: Formal education __________________

7. Occupation of the mother/caregiver

1: Housewife

2: Employee

3: Merchant

4: Farmer

8. Occupation of the father

1: Employed

2: Merchant

3: Farmer

4: Daily labour

9. Average monthly income _______________

1: <2000 2: 2000-10000 3 :> 11000

10. In the past six months do you get any information related to child health care, how to take
care of your child or care from radio, TV, or any other sources?

1: Yes 2: No

SECTION FOUR: Child Health and Caring Practices

11. Is the child exclusively breastfeed for first six months?

1: Yes 2: No

12. When did your child start complimentary feeding in addition to breast milk?

1: < 6 months

51
2: At 6 months

3: > 6 months

4: Not yet start

5: Don‟t know

13. Where do you usually put your baby food/drink?

1: Refrigerator

2: Open shelf

3: Covered shelf

4: Anywhere

SECTION FIVE: Environmental Factors

14. What is your main source water for drinking?

1: Public tap

2: dug well

3: Protected spring

15. What kinds of toilet facility do have?

1: Ventilated improved pit latrine (VIP)

2: Pit latrine with slab

3: Pit latrine without slab/open pit latrine

SECTION SIX: Behavioral Factors

16. Do you wash your hands?

1: Yes 2: No

52
 17. What do you usually use to wash your hands?

1: Water only

2: Water and soap

3: water and ash

53
Questionnaire (Amharic version)
ስሜ ሉዲያ በቀሇ እኔ የባህሪ ዳር ዩኒቨርሲቲ የሳይንስ ኮላጅ ተማሪ ነኝ፡፡ በ Assessment of Diarrheal cases and its
Association with Nutritional status of under-five Children visiting in Bahir dar health
center”,” በማስተርስ ዲግሪ በከፉሌ ሇመፇፀም ምርምር እያካሄድኩ ነው ፡፡ ስሇ ጥናቱ ምክንያቶች እና ተዛማጅ
ጉዳዮች የቃሇ መጠይቁ ሂዯት በእርስዎ እና በቤተሰብዎ ሊይ ምንም ዓይነት ጉዳት እንዯማያመጣ እርግጠኛ ነኝ ፡፡.
የሚሰጡት ማንኛውም መረጃ በጥብቅ ሚስጥራዊ ሆኖ ይቀመጣሌ ፣ እና ከመርማሪው ውጭ ሇማንም አይጋራም ፡፡

አመሰግናሇሁ!!!!

የቃሇመጠይቅ አቅራብ ስም:

የተቆጣጣሪው ስም:

ቀን:

ክፌሌ አንድ: መታወቂያ መረጃ።

1. የታካሚ መታወቂያ ቁጥር _____________

2. የመኖሪያ ቦታ 1 ከተማ 2 ገጠር ፡፡

ክፌሌ 2 የስነ ሕዝብ አወቃቀር ምክንያቶች ፡፡

3. ፆታ፡ 1: ሴት 2 ወንድ

4. የሌጁ ዕድሜ? (በወራት ውስጥ ይፃፈ) __________________________

5. የእናት ዕድሜ / ተንከባካቢ ______________________________

ክፌሌ 3 -ማህበራዊ ኢኮኖሚያዊ ምክንያቶች ፡፡

6. የእናት / ተንከባካቢ የትምህርት ሁኔታ።?

1: ያሌተማረች ፡፡

2: ማንበብና መጻፌ፡፡

3: መዯበኛ ያሌሆነ ትምህርት ፡፡

4: መዯበኛ ትምህርት

7. የእናት / ተንከባካቢ ሥራ ፡፡

1: የቤት እመቤት

2: ሠራተኛ።

3: ነጋዴ

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4: ገበሬ።

8. የአባት / ተንከባካቢ ሥራ ፡፡

1: የቤት እመቤት

2: ሠራተኛ።

3: ነጋዴ

4: ገበሬ።

9. አማካይ ወርሃዊ ገቢ ___________________።

10. ሌጅዎን እንዴት እንዯሚንከባከቡ ሊሇፈት ስድስት ወራት ከሌጆች ጤና ጥበቃ ወይም እንክብካቤ ጋር በተያያዘ
ማንኛውንም መረጃ ያገኛለ ፣ ከሬዲዮ ፣ ከቴላቪዥን ወይም ከላሊ ከማንኛውም ምንጮች?

1: አዎ 2: አይ

ክፌሌ 4. የሕፃናት ጤና እና እንክብካቤ ሌምዶች።

11. ሌጁ ሇመጀመሪያዎቹ ስድስት ወራት ጡት ጠብቷሌ ፡፡?

1: አዎ 2: አይ

12.ሌጅዎ ከጡት ወተት በተጨማሪ ማሟያ የጀመረው መቼ ነበር??

1: <6 ወር።

2: በ 6 ወር ፡፡

3:> 6 ወር።
4: ገና አሌተጀመረም።

5: አታውቅም ፡፡

13.አብዛኛውን ጊዜ የሕፃን ምግብዎን / መጠጥዎን የት ያዯርጉታሌ??

1: ማቀዝቀዣ።

2: ክፌት መዯርዯሪያ።

3: ሽፊን ያሇው መዯርዯሪያ።

4: በየትኛውም ቦታ።

ክፌሌ 5. የአካባቢ ሁኔታዎች ፡፡

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14.ሇመጠጥ ውሃ ዋነኛው ምንጭዎ ምንድነው??

1: የህዝብ ቧንቧ

2: የተጠበቀ ምንጭ ።

3: የጉድጋድ ውሃ

15. ምን ዓይነት የመጸዳጃ አሊቸው ?

1: የተስተካከሇ የተሻሻሇ የመተንፇሻ ቱቦ (ቪአይፒ) ።

2: የመፀዳጃ ቤቱ በመከሇያ ፡፡

3: -የመፀዳጃ ቤቱ ያሇመከሇያ

ክፌሌ 6-የባህሪ ምክንያቶች ፡፡

16.እጆችዎን ይታጠባለ??

1: አዎ 2: የሇም

17.ብዙውን ጊዜ እጆችዎን ሇመታጠብ ምን ይጠቀማለ??

1: ውሃ ብቻ።

2: ውሃ እና ሳሙና።

3: ውሃ እና አመድ።

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APPENDIX C: Ethical clearance

57