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Assessment of Diarrhea and Its Associated Factors in Under-Five Children among Open Defecation and Open Defecation-Free Rural Settings of Dangla District, Northwest Ethiopia.

1. Introduction

The majority of OD practices, referred to in national surveys as defecating in fields, forests, bushes, bodies of water, or other open spaces, take place in rural areas of low-income countries [1]. Worldwide diarrheal disease is the second leading cause of death in under-five children responsible for 1.7 million morbidity and 760, 000 mortality every year [2]. In Ethiopia, diarrhea kills half million of under-five children annually next to pneumonia [3].

According to 2014 Joint Monitoring Program (JMP), OD was reducing by half in developing regions from 1990 to 2012. About 825 million people practicing OD reside in just 10 countries of which five are in Africa (Nigeria, 39 million; Ethiopia, 34 million; Sudan, 17 million; Niger, 13 million; and Mozambique, 10 million) [4]. In the rest of the world, the number of people practicing OD is estimated to be 182 million [1, 4].

In sub-Saharan Africa, it is estimated that 215 million people that is 8% of the urban population and 35% of the rural population continue to engage in OD [1]. In Ethiopia, still the national OD rate in 2014 was 34.1% (37.9% in rural and 8.7% in urban) [5]. This practice facilitates the transmission of diarrheal diseases, one of the leading causes of mortality in under-five children in sub-Saharan Africa [6].

Total sanitation approaches, the most promising approaches aimed at empowering communities as a whole to become "OD FREE,R aimed at raising awareness of the risks associated with OD and generating a collective sense of intolerance towards OD [7].Nevertheless, it has been suggested that total sanitation approaches can result in rapid significant improvements and hold promise for decreasing OD in sub-Saharan Africa [8]. In Ethiopia, the Southern Nations, Nationalities, and Peoples' Region (SNNPR) adapted CLTS to local Ethiopian conditions in the 2003 Gregorian calendar and achieved a remarkably rapid reduction in OD. The approach was scaled up and mainstreamed in the National Sanitation Strategy and integrated into the Health Extension Worker program. 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 health promotion and education [3].

It is estimated that 1.7 billion cases of diarrhea occur every year, causing 800,000 deaths among children under 5 years of age worldwide [9], and 15% of the global population still engage in OD [1]. It also underlines that OD leads to deadly diarrhea and other intestinal diseases which kill hundreds of thousands of children every year. Evidences also showed that about 80% of the rural and 20% of urban sub-Saharan population have no access to safe water and sanitation [10].

In Ethiopia, three-fourths of the health problems of underfive children are communicable diseases which come from the environment, specially water and sanitation [11]. Diarrhea is the leading cause of under-5 mortality causing 23% of deaths and around 44% stunted [4]. In Ethiopia, over 75-80% of the communicable diseases are caused due to poor environmental health conditions arising from unsafe and inadequate water supply and poor hygienic and sanitation practices [11].

An estimated 64,540 children could be saved every year by improving water, sanitation, and hygiene in the country [4]. It is critical to understand what factors influence the pace to reduce OD in order to develop effective strategies to improving sanitation and reducing diarrhea morbidity and mortality caused by the lack of sanitation. Furthermore, there is a need for more realistic targets for global campaigns that will put forth following the MDGs that ended in 2015.

To date, information on the impact of being the ODF kebele on under-five diarrhea is limited or meager as a comprehensive package. It is hypothesized that people living in the ODF kebeles will have reduced diarrheal-related morbidity and mortality compared with people living in OD kebeles. However, all exposure routes to the increased burden of disease must be considered.

The knowledge of existing gaps in the differences between ODF and OD kebeles can be linked to a proper problem inventory. This research also helps to explore the basics of the ODF status in the prevention of diarrhea and also what changes can come after the ODF verification which in turn plays a major role in the proper planning and monitoring of sanitation and hygiene activities and programs that contribute for diarrhea prevention.

2. Materials and Methods

Study Area. The study was conducted in Dangla woreda, Awi zone, a city located 480 kilometers away from the capital city Addis Ababa. In this woreda, there are 27 rural kebeles (kebeles are smaller administrative units); 15 of the kebele were ODF, and 19309 under-five children are living in the woreda. The map shows the kebele under the Dangla district (Figure 1).

Study Design and Period. The study was a community-based comparative cross-sectional study conducted from July 2015 to June 2016.

Source Population. All children under five years of age in the Dangla district.

Study Population. Caregivers and children under five years of age living in ODF and OD settings of Dangla woreda.

Inclusion Criteria. Those households that have at least one child under five years of age in the house residing in the ODF or OD kebeles.

Exclusion Criteria. Those households located in the urban settings.

2.1. Sample Size Calculation. The sample size was calculated by Epi Info version 7 software (source: CDC) using double-proportion formula with the following assumptions:

(i) From a study done in Sidama Zone [12], diarrhea prevalence in ODF kebele (P1) = 24.7% and in OD kebele (P2) = 26.5%

(ii) 95% confidence interval

(iii) 80% power of test

(iv) Ratio between ODF and OD kebeles =1

(v) To detect odds ratio of =2

Having the assumptions above, the sample size was 332. Since multistage sampling was used for this particular study, the design effect of 1.5 was considered and then the sample size became 498. With 10% contingency, the total sample size was determined to be 550 (275 for non-ODF and 275 for OD free).

2.2. Sampling and Data Collection Techniques. A multistage sampling technique was applied, the kebele from each group was selected randomly by the lottery method, and the samples were distributed proportionally by their number of under-five children. Children under five years of age residing in ODF and OD households were identified through a house-to-house enumeration prior to the actual data collection using the family folder by health extension workers. For a household having two or more children, we have taken the youngest child. The actual data collection was carried out in February 2016 by trained nursing students using a structured questionnaire. An observation checklist was also applied to assess latrine utilization.

2.3. Data Collection Instruments. A structured questionnaire which was adopted from different literatures was used, and an observation checklist was also applied to assess latrine utilization.

2.4. Variables. Dependent variable is the occurrence of diarrheal diseases in children under five years of age. Independent variables are as follows:

(i) Household income

(ii) Sociocultural factor

(iii) Hygiene and sanitation variables

(iv) Household water access, treatment, and storage

(v) Hygiene and sanitation perception and practices

(vi) Maternal and child health factors

2.5. Operational Definitions

2.5.1. ODF. A status given by the woreda by their latrine, hand washing, household water access, and safe storage coverage and practices as per the ministry of health ODF verification and certification criteria.

2.5.2. Diarrhea. A disease characterized by frequent (>3) loose or watery stools in 24 hours, or a single stool with blood/mucus with a 14-day prior to study.

2.5.3. Unimproved Water Sources. Unprotected dug well, unprotected spring, cart with small tank or drum, surface water (e.g., river, dam, lake, pond, stream, canal, or irrigation channel), and bottled water.

2.5.4. Proper Disposal. A way of disposal refuses that which included burning, burying in a pit or storing in a container, and disposing in the designed site.

2.6. Data Quality Control Measures. During data collection, kebeles were coded, all field workers were trained prior to data collection, and regular supervision was done during the field work. Each data collector checked the questionnaires for completeness before leaving each study participant. All filled questionnaires were reviewed at the end of the day by the supervisor. Original questionnaire was prepared in English and then translated into Amharic and translated back to English to check consistency, and the pretest was done on the data collection instrument before conducting the study.

2.7. Data Analysis. Data were coded and entered into Epi Info version 7 and cleaned and checked for completeness. Initially, descriptive statistics were done to determine the diarrhea prevalence and to characterize the variables' frequency and percentages. Bivariate and multivariate analyses were done using SPSS version 20 software. In the multivariate analyses, an Enter method was used and a statistical significance of 0.05 was considered. Results were presented using tables, graphs, and charts.

3. Results

3.1. Descriptive Results. A total of 525 (263 households from ODF and 262 households from OD) participants were interviewed making the response rate 95.45%. Among the respondents, 162 (61.8%) from ODF kebeles and 112 (42.6%) from OD kebeles were females. The total respondents' age ranged from 17-75 years with a mean (SD) age of 39.14 ([+ or -]11.97) (Table 1).

As shown in Table 2, the prevalence of diarrhea among ODF kebeles was 9.9%, whereas in OD kebeles, it was 36.1%. From the total diarrhea cases, the majority 121 (77.9%) of under-five diarrhea cases were from those OD kebeles, but the magnitude of under-five diarrhea in ODF kebeles was 26 (22.1%).

The study also revealed that majority of respondents in both ODF (235 (89.7%)) and OD (244 (92.8%)) kebeles have a private latrine. From those households that have latrines, majority (87.4%) of respondents from ODF kebeles and 87.8% of respondents from OD kebeles have traditional pit latrines, respectively (Table 3).

Regarding waste disposal, 90 (34.4%) of households from ODF and 156 (59.3%) of households from OD kebeles dispose openly their solid waste, while 20 (7.6%) from ODF and 117 (44.5%) from OD kebeles dispose their liquid waste openly (Table 4).

From the observations made in latrines, a majority of 88% in OD and 82% in ODF kebeles had fresh foot path and splash of urine. Similarly, 86% of latrines in OD kebeles and 81% in ODF kebeles had fresh stool during observations (Figure 2).

3.2. Multivariate Analysis Result in ODF Kebeles. The multivariate analysis result showed that child immunization, latrine presence, water shortage in the household, and solid waste disposal had a statistically significant association with diarrhea occurrence in ODF kebeles.

Keeping other factors constant, immunized children were 96% less likely (AOR = 0.037; 95% CI: 0.006-0.243) to have diarrhea as compared to nonimmunized children, and the association was statistically significant. Similarly, those households having a latrine were 96.4% less likely (AOR = 0.036; 95% CI: 0.006-0.233) to have diarrhea as compared to those who did not have a latrine, and the association was statistically significant.

Regarding water shortage, holding other factors constant, households with water shortage had 8.7 times higher chance (AOR = 8.756; 95% CI: 1.130-67.831) of diarrhea occurrence as compared to the reference category. Pertaining solid waste disposal, those who dispose safely were 86% less likely (AOR = 0.143; 95% CI: 0.020-0.998) to have diarrhea as compared to those who dispose openly, and the association was statistically significant (Table 5).

3.3. Multivariate Analysis Result in OD Kebeles. The multivariate analysis result showed that child immunization, water access at the individual level, water shortage in the household, and solid waste disposal had statistically significant association with diarrhea occurrence in OD kebeles. Keeping other factors constant, immunized children were 97% less likely (AOR = 0.032; 95 CI: 0.008-0.123) to have diarrhea as compared to nonimmunized children, and the association was statistically significant. Regarding water access at the individual level, water access of 7.5-15 liters/day reduces the chance of diarrhea occurrence by 97% (AOR = 0.029; 95% CI: 0.006-0.152) and water access of greater than 15 liters/day reduces the chance of diarrhea occurrence by 93% (AOR = 0.068; 95% CI: 0.010-0.474) as compared to the reference category, and the association was statistically significant.

Pertaining to water shortage, households with water shortage had 18 times higher chance (AOR = 18.478; 95% CI: 4.692-72.760) of diarrhea occurrence as compared to households having no water shortage. Keeping other factors constant, safe waste disposal reduces the chance of diarrhea occurrence by 97% (AOR = 0.023; 95% CI: 0.005-0.117) as compared to open disposal, and the association was statistically significant (Table 5).

4. Discussion

To date, scientific evidence on the impact of the ODF kebele on under-five diarrhea and the factors that play a role in its implementation are meager as a comprehensive package. Hence, this research explored the basics of the ODF status in the prevention of diarrhea that contributes for designing effective interventions at different segments of the health system.

Accordingly, the prevalence of diarrhea among ODF kebeles was found to be 9.9%, while in OD kebeles, it was 36.1% showing significant differences. The prevalence in ODF kebeles was still much lower as compared with the study done in ODF kebeles of Sidama zone, and in SNNPR, the prevalence was 24.7% [12]. The reason behind the decrement of diarrhea prevalence in the ODF study area may be due to the quality of ODF declaration, certification, and follow-up. After ODF declaration, this follow-up may also be related with the commitment of the region, zone, woreda, and kebele's ODF verification and certification teams.

The prevalence of under-five diarrhea in OD kebele (36.1%) was higher as compared with the study done in Sidama zone which was 26.5% [12], and in a study in India, the prevalence was 15.9% in OD kebeles [2], but it is almost similar with national under-five diarrhea prevalence that ranges from 11% to 38% [11]. Differences might be because of the people's way of life, educational levels of the community, maternity care of child's immunization, and nutritional differences that are not related with the status of being ODF or OD.

The prevalence of under-five diarrhea among ODF and OD kebeles had a statistically significant difference with [X.sup.2] = 50.791 and P = 0.001, but the study done in Sidama zone showed that there is no significant difference between the two communities with [X.sup.2] = 0.721 and P = 0.396. The difference with a study in Sidama might come because of the differences in the quality of the ODF status.

Latrine presence has showed a statistically significant association with diarrhea occurrence both in ODF and OD kebeles in which the odds of developing diarrhea for families having a latrine was 96.4% times lower in ODF kebeles and 61.8% times lower in OD kebeles. The percentage of the latrine in ODF kebeles that is less than OD kebeles indicates that individuals living here are still practicing OD, and in the true sense, these are not ODF kebeles. The result is consistent with a study in Mali [13]. This is also in line with ODF verification and certification guideline and CLTSH implementation guideline [14, 15]. The study from the Derashe district of SNNPR also supports this finding in which the odds of developing diarrhea was 2.43 times higher among children of families who had no latrine when compared to children of families who had latrine [16].

In ODF kebeles, immunized children were 96% less likely to have diarrhea as compared to nonimmunized children which is much comparable with the result from OD kebeles that showed the odds of immunized children were 96.8% less likely to have diarrhea as compared to nonimmunized children. The similarities between these two settings come because of the socioeconomic, agroecological, MCH services, and way of life similarities since they are administered in one district. This finding is inconsistent with a result from Eastern Ethiopia where immunization had no significant association with diarrhea occurrence in underfive children [17].

Regarding water shortage in OD kebeles, households with water shortage had 18 times higher chance of diarrhea occurrence as compared to households having no water shortage which is much higher as compared with the result in ODF kebeles where water shortage increases the chance of diarrhea occurrence by eight times. This could be explained by the fact that households having water shortage could not keep their personal hygiene as necessary. Results from both settings are not comparable with a result from the Derashe district of SNNPR in which diarrhea among children have no statistically significant association with water shortage [16].

The analysis result from OD kebeles also showed that those households who got minimum standard (7.515 liters/day) water access at the individual level reduce the chance of diarrhea occurrence by 97%. This result is linked with the recommendation from the sphere handbook of water, sanitation, and hygiene for humanitarian charter and minimum standard that average water use for drinking, cooking, and personal hygiene in any household is at least 7.5-15 liters per person per day which means that those household who got the water and care for their drinking, cooking, and personal hygiene can prevent their children from diarrhea that can be transmitted by drinking water, cooking materials contamination, and by not keeping their personal hygiene safely. Water access of greater than 15 liters/day also reduces the chance of diarrhea occurrence by 93% which is incomparable with the result from ODF kebeles that indicate those households having 7.5-15 liters per person per day and households who access 15 liters per person per day which have no statistically significant association with under-five diarrhea. The result also showed that, in ODF kebeles, people who dispose solid wastes properly were 86% less likely to have diarrhea as compared to those who dispose improperly which is comparable with the result from OD kebeles in which safe disposal reduces the chance of diarrhea occurrence by 97%. This finding is in line with a study done in the Mecha district of West Gojjam [18]. This finding is explained by the fact that proper waste management reduces the risk of contamination and in turn risk of having diarrheal disease.

5. Strength and Limitation of the Study

The study explored factors that have an association with diarrhea in both ODF and OD kebeles comparatively against the standard guidelines. The study also used multiple methods of data collection like on-site observation to assess practice of latrine utilization. In addition, to assure the quality of the data, the standardized data collection tool was used and pretest was done before the actual data collection. As limitation, the study was cross-sectional which cannot measure the cause-and-effect relationship. There might also be a possibility of recall bias that will result in underreporting and misreporting of events. For more information, refer the thesis report [19].

6. Conclusion and Recommendations

The overall prevalence of under-five diarrhea among the individuals living in the ODF kebeles was lower as compared with the OD kebeles. Child immunization, latrine presence, water shortage in household, and solid waste disposal in ODF kebeles and per capita water consumption/water access at the individual level, water shortage in households, child immunization, and solid waste disposal in OD kebeles had statistically significant association with diarrhea occurrence in the Dangla district.

Ministry of health needs to reconsider the ODF status certification process of the kebeles which can be based on sustainability. Together with line ministries, regions, zones, woreda health structures, and stakeholders, the ministry has to improve child immunization, latrine presence and utilization, water shortage in household, and solid waste disposal practices that are directly linked with under-five diarrhea. Health workers and local authorities must give health education and sensitization for the community to improve OD practices. In addition, the findings of this study will serve as baseline evidence and pave the way for other researchers and policymakers to conduct more rigorous studies on this arena.

Abbreviations
CLTSH: Community-led total sanitation and hygiene
EDHS:  Ethiopian Demographic and Health Survey
FMOH:  Federal Ministry of Health
HEP:   Health Extension Program
HEW:   Health Extension Workers
HMIS:  Health Management Information System
MEDHS: Mini Ethiopian Demographic and Health Survey
MDG:   Millennium Development Goals
OD:    Open defecation
ODF:   Open defection free
WASH:  Water, Sanitation, and Hygiene
WHO:   World Health Organization.


Ethical Approval

The study was approved by the Ethical Review Committee of Addis Ababa University School of Public Health and Dangla Woreda Administration.

Consent

Verbal consent and written consent were taken from the guardians of the under-five children before the actual data collection.

Conflicts of Interest

The authors declare that they have no conflicts of interests.

Authors' Contributions

AM initiated the research, wrote the research proposal, carried out the data analysis, interpreted the results, and drafted the manuscript. WT, SW, and ZA were involved in designing the study, revising the proposal, guiding the statistical analysis, and writing the manuscript. All authors read and approved the final manuscript.

https://doi.org/10.1155/2018/4271915

Acknowledgments

The authors acknowledge Addis Ababa University School of Public Health, Federal Ministry of Health, and Dangla District Health Office for their financial support and kind assistance during the entire process of the study.

References

[1] WHO/UNICEF, WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP), WHO/ UNICEF, New York, NY, USA, 2012.

[2] C. Terry, C. Christian, A. W. Rita, and P. Pragati, World Toilet Day, Beyond Infrastructure: Building New Attitudes Also Needed to End OD, Un Press Release, New York, NY, USA, 2014.

[3] G. Teklemichael, T. Mohammed, and K. Wondwosen, "Risk factors of diarrhoeal disease in under-five children among health extension model and non-model families in Sheko district rural community, Southwest Ethiopia: comparative cross-sectional study," BMC Public Health, vol. 14, no. 395, 2014.

[4] UNICEF, UNICEF Sanitation Priority Country Factsheet 2014, UNICEF, New York, NY, USA, 2014.

[5] Central Statistical Agency AA, Mini EDHS 2014, Central Statistical Agency, Addis Ababa, Ethiopia, 2014.

[6] I. G. Deise, K. Seung-Sup, and P. G. Jay, "Exploring changes in OD prevalence in sub-Saharan Africa based on national level indices," BMC Public Health, vol. 13, no. 527, 2013.

[7] M. Jenkins and V. Curtis, "Achievingthe 'good life': why some people want latrines in rural Benin," Social Science & Medicine, vol. 61, no. 11, pp. 2446-2459, 2005.

[8] P. Harvey, "Zero subsidy strategies for accelerating access to rural water and sanitation services," Water Science and Technology, vol. 63, no. 5, pp. 1037-1043, 2011.

[9] UNICEF, Pneumonia and Diarrhoea-Tackling the Deadliest Diseases for the World's Poorest Children, UNICEF, New York, NY, USA, 2012.

[10] C. Robert, "Sanitation and stunting in India: undernutrition's blind spot," in Proceedings of Learning Workshop on Participatory Community Approach on ODFREE-Rural Spaces, pp. 15-17, India, 2013.

[11] A. Andualem and K. Abera, "Assessment of the impact of latrine utilization on diarrhoeal diseases in the rural community of Hulet Ejju Enessie Woreda, East Gojjam Zone, Amhara Region," Ethiopian Journal of Health Development, vol. 24, no. 2, 2010.

[12] B. Hunachew, D. Wakgari, K. Abera, and G. Delia, "Effect of Community Led Total Sanitation interventions on Diarrheal Diseases and Other Hygienic Behaviors and Sanitation Infrastructure Sustainability Challenges," in Proceedings of the University of North Carolina Water Institute, Southern Ethiopia, 2015.

[13] A. J. Pickering, H. Djebbari, C. Lopez, M. Coulibaly, and M. L. Alzua, "Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial," The Lancet Glob Health, vol. 3, no. 11, pp. e701-e711, 2015.

[14] Ministry of Health, Health Sector Transformation Plan (2015-2020), Ministry of Health, Addis Ababa, Ethiopia, 2015.

[15] Ministry of Health, National Monitoring and Reporting System for the Implementation of Community-Led Total Sanitation and Hygiene, HPDP, Ministry of Health, Addis Ababa, Ethiopia, 2012.

[16] W. Godana and B. Mengiste, "Environmental factors associated with acute diarrhea among children under five years of age in Derashe district, Southern Ethiopia," Science Journal of Public Health, vol. 1, no. 3, pp. 119-124, 2013.

[17] B. Mengistie, Y. Berhane, and A. Worku, "Prevalence of diarrhea and associated risk factors among children under-five years of age in Eastern Ethiopia: a cross-sectional study," Open Journal of Preventive Medicine, vol. 3, no. 7, pp. 446-453, 2013.

[18] M. Dessalegn, A. Kumie, and W. Tefera, "Predictors of underfive childhood diarrhea: Mecha District, West Gojam, Ethiopia," Ethiopian Journal of Health Development, vol. 25, no. 3, 2011.

[19] M. Abireham, T. Worku, and W. Samson, "Assessment of diarrhea in under-five children: a comparative cross-sectional study in open defecation and open defecation free rural settings in Dangla District, North-West Ethiopia," Addis Ababa University, Ethiopia, 2016.

Abireham Misganaw Ayalew, (1) Worku Tefera Mekonnen, (2) Samson Wakuma Abaya, (2) and Zeleke Abebaw Mekonnen (1)

(1) Federal Ministry of Health, Addis Ababa, Ethiopia

(2) Addis Ababa University, College of Health Sciences, Addis Ababa, Ethiopia

Correspondence should be addressed to Abireham Misganaw Ayalew; ehealth70@gmail.com

Received 12 December 2017; Revised 13 July 2018; Accepted 31 July 2018; Published 12 September 2018

Academic Editor: Csaba Siffel

Caption: Figure 1: Map of the study area.
Table 1: Participants characteristics in selected both ODF and OD
kebeles in Dangla woreda, Northwest Ethiopia, 2016.

                                                          ODF

Variables                                           Number    %

Age (years)                      15-24                31     11.8
                                 25-34                75     28.6
                                  35+                156     59.5

Sex                             Female               162     61.8
                                 Male                100     38.2

Family size            [less than or equal to]5      133     50.8
(mean = 5.53)                     >5                 129     49.2

Marital status                 Unmarried              8      3.1
                                Married              228     87.0
                               Divorced               10     3.8
                                Widowed               16     6.1

Educational status             Literate               87     33.2
of mother                     Illiterate             175     66.8

Educational status             Literate              148     56.5
of father                     Illiterate             114     43.5

Occupation of                   Farmer               198     75.6
mother                         Housewife              64     24.4

Occupation of                   Farmer               249     95.0
father                          Private               13     5.0

Educated child                    No                  78     29.8
in household                      Yes                184     70.2

Educational level          Higher education           19     10.3
of child              Primary/secondary education    144     78.3
                              Read/write              21     11.4
Child immunization                No                  52     19.8
(any type)                        Yes                210     80.2

Average monthly net              <1000               177     67.6
income (in ETB)              1000 to 2000             77     29.4
                            2001 and above            8      3.1

                                                          OD

Variables                                           Number    %

Age (years)                      15-24                17     6.5
                                 25-34                64     24.3
                                  35+                182     69.2

Sex                             Female               112     42.6
                                 Male                151     57.4

Family size            [less than or equal to]5       95     36.1
(mean = 5.53)                     >5                 168     63.9

Marital status                 Unmarried              5      1.9
                                Married              235     89.4
                               Divorced               13     4.9
                                Widowed               10     3.8

Educational status             Literate               90     34.2
of mother                     Illiterate             173     65.8

Educational status             Literate              120     45.6
of father                     Illiterate             143     54.4

Occupation of                   Farmer               207     78.7
mother                         Housewife              56     21.3

Occupation of                   Farmer               251     95.4
father                          Private               12     4.6

Educated child                    No                  58     22.1
in household                      Yes                205     77.9

Educational level          Higher education           35     17.1
of child              Primary/secondary education    153     74.6
                              Read/write              17     8.3
Child immunization                No                 110     41.8
(any type)                        Yes                153     58.2

Average monthly net              <1000               202     76.8
income (in ETB)              1000 to 2000             31     11.8
                            2001 and above            30     11.4

Table 2: Diarrhea occurrences among ODF and OD kebeles in Dangla
woreda, Northwest Ethiopia, 2016.

                                                               ODF

Variables                                                Number    %

Diarrhea                             No                   236     90.1
occurrence                           Yes                   26     9.9

Diarrhea                [less than or equal to]5 days      19     73.1
persists                          > 5 days                 7      26.9

Perception on                       Food                   21     43.8
sources of diarrhea                 Water                  26     54.2
                                  Utensils                 1      2.1
Diarrhea prevention             Nothing done               5      1.9
mechanisms done for      Special food for the child       113     43.1
the child                 Clean food for the child        207     79.0
                        Care for hygiene of the child     160     61.1
                       Care for hygiene of the family     182     69.5

                                                               OD

Variables                                                Number    %

Diarrhea                             No                   168     63.9
occurrence                           Yes                   95     36.1

Diarrhea                [less than or equal to]5 days      69     72.6
persists                          > 5 days                 26     26.3

Perception on                       Food                   51     41.1
sources of diarrhea                 Water                  71     57.3
                                  Utensils                 2      1.6
Diarrhea prevention             Nothing done               18     6.9
mechanisms done for      Special food for the child       161     61.2
the child                 Clean food for the child        190     72.2
                        Care for hygiene of the child     209     79.5
                       Care for hygiene of the family     192     73.0

                                                           Chi-square
                                                           (P value)
Variables

Diarrhea                             No                  50.791 (0.001)
occurrence                           Yes

Diarrhea                [less than or equal to]5 days    0.002 (0.964)
persists                          > 5 days

Perception on                       Food                 51.535 (0.001)
sources of diarrhea                 Water
                                  Utensils
Diarrhea prevention             Nothing done             29.714 (0.001)
mechanisms done for      Special food for the child
the child                 Clean food for the child
                        Care for hygiene of the child
                       Care for hygiene of the family

Table 3: Households latrine ownership, the type of latrine, years for
latrines construction, and household latrine utilization practice in
Dangla woreda, Northwest Ethiopia, 2016.

                                                Kebele status

                                             ODF           Non-ODF

Variables                              Number    %     Number    %

Latrine presence           No            27     10.3     19     7.2
                           Yes          235     89.7    244     92.8

Latrine type             Shared          6      2.3      13     4.9
                     Traditional pit    229     87.4    231     87.8

Years for latrine        <1 year         9      3.8      13     5.3
construction            1-2 years        72     30.6     76     31.1
                        2-3 years       113     48.1    111     45.5
                        3+ years         41     17.4     44     18.0

Defecate openly            No           205     87.2    165     62.7
after the latrine          Yes           30     12.8     79     30.0
construction

Variables                              Chi-square (P value)

Latrine presence           No              1.56 (0.212)
                           Yes

Latrine type             Shared            3.97 (0.137)
                     Traditional pit

Years for latrine        <1 year           0.79 (0.852)
construction            1-2 years
                        2-3 years
                        3+ years

Defecate openly            No              27.74 (0.001)
after the latrine          Yes
construction

Table 4: Households solid and liquid waste management in Dangla
woreda, Northwest Ethiopia, 2016.

                                   Kebele status

                                ODF             OD

Variables                 Number    %     Number    %

Liquid waste   Improper     90     34.4    156     59.3
disposal        Proper     172     65.6    107     40.7

Solid waste     Proper     242     92.4    146     55.5
disposal       Improper     20     7.6     117     44.5

Variables                 Chi-square (P value)

Liquid waste   Improper       32.85 (0.001)
disposal        Proper

Solid waste     Proper        92.43 (0.001)
disposal       Improper

Table 5: Bivariate and multivariate analysis of variables with under-
five diarrhea among ODF and OD kebeles in Dangla woreda, Northwest
Ethiopia, 2016.

                                              ODF

Variables                                     COR
                                            (95% CI)

Monthly                 <1000                 Ref
income               1000 to 2000     1.3 (0.111, 15.088)
(in birr)            2001 to 3000      18.6 (0.065, 5173)

Family size         [less than or             Ref
                      equal to]5
                          >5          3.109 (1.260, 7.674)

Education              Literate               Ref
of mother             Illiterate      0.775 (0.336, 1.787)

Occupation              Farmer                Ref
of mother             Housewife       1.429 (0.589, 3.462)

Child                     No                  Ref
vaccination              Yes          0.018 (0.005, 0.065)

Latrine                   No                  Ref
presence                 Yes          0.013 (0.004, 0.040)

Main source            Improved               Ref
of water              Unimproved      1.059 (0.461, 2.434)

Distance of             <=1000                Ref
water source            >1000        6.320 (2.253, 17.726)

Per capita               <7.4                 Ref
water consumption       7.5-15        0.091 (0.032, 0.264)
(liters/day)            >15.1         0.292 (0.099, 0.866)

Water shortage            No                  Ref
                         Yes         13.768 (5.232, 36.229)

Water treatment           No                  Ref
                         Yes          2.833 (1.138, 7.056)

Soap/Ash use              No                  Ref
yesterday                Yes          0.873 (0.333, 2.293)

Liquid waste        Dispose openly            Ref
disposal            Dispose safely    0.484 (0.214, 1.095)

Solid waste         Dispose openly            Ref
disposal            Dispose safely    0.016 (0.005, 0.052)

                                              ODF

Variables                                     AOR
                                            (95% CI)

Monthly                 <1000
income               1000 to 2000
(in birr)            2001 to 3000

Family size         [less than or             Ref
                      equal to]5
                          >5          0.715 (0.115, 4.443)

Education              Literate
of mother             Illiterate

Occupation              Farmer
of mother             Housewife

Child                     No                  Ref
vaccination              Yes         0.037 (0.006, 0.243) *

Latrine                   No                  Ref
presence                 Yes         0.036 (0.006, 0.233) *

Main source            Improved
of water              Unimproved

Distance of             <=1000                Ref
water source            >1000        3.845 (0.291, 50.895)

Per capita               <7.4                 Ref
water consumption       7.5-15        0.332 (0.046, 2.405)
(liters/day)            >15.1         0.527 (0.060, 4.600)

Water shortage            No                  Ref
                         Yes         8.756 (1.13, 67.831) *

Water treatment           No                  Ref
                         Yes          1.884 (0.268, 13.271

Soap/Ash use              No
yesterday                Yes

Liquid waste        Dispose openly
disposal            Dispose safely

Solid waste         Dispose openly            Ref
disposal            Dispose safely   0.143 (0.020, 0.998) *

                                               OD

Variables                                     COR
                                            (95% CI)

Monthly                 <1000                 Ref
income               1000 to 2000     0.374 (0.147, 1.002)
(in birr)            2001 to 3000     0.778 (0.346, 1.750)

Family size         [less than or             Ref
                      equal to]5
                          >5          2.774 (1.565, 4.917)

Education              Literate               Ref
of mother             Illiterate      0.542 (0.321, 0.917)

Occupation              Farmer                Ref
of mother             Housewife       0.461 (0.233, 0.910)

Child                     No                  Ref
vaccination              Yes          0.051 (0.027, 0.098)

Latrine                   No                  Ref
presence                 Yes          0.177 (0.062, 0.510)

Main source            Improved               Ref
of water              Unimproved      4.150 (2.100, 8.201)

Distance of             <=1000                Ref
water source            >1000        9.506 (2.656, 34.019)

Per capita               <7.4                 Ref
water consumption       7.5-15        0.088 (0.044, 0.177)
(liters/day)            >15.1         0.126 (0.056, 0.285)

Water shortage            No                  Ref
                         Yes         10.828 (5.824, 20.13)

Water treatment           No                  Ref
                         Yes          2.907 (1.605, 5.267)

Soap/Ash use              No                  Ref
yesterday                Yes          0.655 (0.374, 1.149)

Liquid waste        Dispose openly            Ref
disposal            Dispose safely    0.171 (0.092, 0.318)

Solid waste         Dispose openly            Ref
disposal            Dispose safely    0.066 (0.035, 0.124)

                                               OD

Variables                                     AOR
                                            (95% CI)

Monthly                 <1000
income               1000 to 2000
(in birr)            2001 to 3000

Family size         [less than or             Ref
                      equal to]5
                          >5          0.840 (0.233, 3.035)

Education              Literate               Ref
of mother             Illiterate      0.512 (0.129, 2.035)

Occupation              Farmer                Ref
of mother             Housewife      2.431 (0.422, 13.995)

Child                     No                  Ref
vaccination              Yes         0.032 (0.008, 0.123) *

Latrine                   No                  Ref
presence                 Yes          0.382 (0.050, 2.913)

Main source            Improved               Ref
of water              Unimproved      1.640 (0.360, 7.472)

Distance of             <=1000                Ref
water source            >1000        1.988 (0.239, 16.556)

Per capita               <7.4                 Ref
water consumption       7.5-15       0.029 (0.006, 0.152) *
(liters/day)            >15.1        0.068 (0.010, 0.474) *

Water shortage            No                  Ref
                         Yes         18.478 (4.692, 72.76) *

Water treatment           No                  Ref
                         Yes          0.858 (0.166, 4.438)

Soap/Ash use              No                  Ref
yesterday                Yes

Liquid waste        Dispose openly            Ref
disposal            Dispose safely    0.435 (0.108, 1.751)

Solid waste         Dispose openly            Ref
disposal            Dispose safely   0.023 (0.005, 0.117) *

* Indicates statistically significantly associated variables.

Figure 2: Observation result of households that have a latrine in
Dangla woreda, Northwest Ethiopia, 2016.

                              ODF     OD

Fresh foot path              81.7%   88.2%
Splash of urine              87.1%   81.7%
Fresh stool                  80.9%   85.9%
Feces 50 cm below the slab   45.4%   54.0%
Latrine wall                 77.9%   84.8%
Cleanable floor              71.4%   74.1%
Latrine roof                 84.8%   79.4%
Danger to the user           20.2%   22.1%

Note: Table made from line graph.
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Article Details
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Title Annotation:Research Article
Author:Ayalew, Abireham Misganaw; Mekonnen, Worku Tefera; Abaya, Samson Wakuma; Mekonnen, Zeleke Abebaw
Publication:Journal of Environmental and Public Health
Geographic Code:0DEVE
Date:Jan 1, 2018
Words:5962
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