Hindawi

Journal of Environmental and Public Health

Volume 2018, Article ID 4271915, 8 pages
https://doi.org/10.1155/2018/4271915

Research Article
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

Abireham Misganaw Ayalew ,1 Worku Tefera Mekonnen,2 Samson Wakuma Abaya,2

and Zeleke Abebaw Mekonnen1
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; [email protected]

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

Academic Editor: Csaba Siffel

Copyright © 2018 Abireham Misganaw Ayalew et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Background. Open defecation (OD) is a widespread problem in the developing world. This practice facilitates the transmission of
diarrheal diseases. In Ethiopia, still the national open defecation rate in 2014 was 34.1% (37.9% in rural and 8.7% in urban). Objective.
To assess diarrheal morbidity in under-five children and its associated factors in Dangla district, Northwest Ethiopia, 2016. Methods.
A community-based comparative cross-sectional study design with a multistage random sampling technique was applied. The total
sample size was 550 (275 ODF and 275 OD). Descriptive and inferential statistics were done. Results. A total of 525 participants were
interviewed making the response rate 95.45%. The prevalence of diarrhea was 9.9% in ODF and 36.1% in OD kebeles. In ODF kebeles,
child immunization (AOR � 0.037; 95% CI: 0.006–0.243), latrine presence (AOR � 0.036; 0.006–0.233), water shortage (AOR � 8.756;
95% CI: 1.130–67.831), and solid waste disposal (AOR � 0.143; 95% CI: 0.020–0.998) have statistically significant association with
diarrhea occurrence. While in OD kebeles child immunization (AOR � 0.032; 95 CI: 0.008–0.123), water access of 7.5–15 liters/day
(AOR � 0.029; 95% CI: 0.006–0.152), water shortage (AOR � 18.478; 95% CI: 4.692–72.760), and proper solid waste disposal
(AOR � 0.023; 95% CI: 0.005–0.117) have significant association with diarrhea occurrence. Conclusions. The overall prevalence of
under-five diarrhea was low in ODF kebeles as compared with OD kebeles. The study showed that child immunization, latrine
presence, water shortage in household, and solid waste disposal practices had statistically significant association with diarrhea
occurrence in ODF kebeles, while water access at the individual level, water shortage in household, child immunization, and solid
waste disposal have statistically significant association with diarrhea occurrence in OD kebeles. Integrated efforts are needed from the
Ministry of Health together with line ministries and developmental partners in improving latrine utilization at household level, water
shortage in households, and solid waste disposal practices.

1. Introduction According to 2014 Joint Monitoring Program (JMP), OD

was reducing by half in developing regions from 1990 to
The majority of OD practices, referred to in national surveys 2012. About 825 million people practicing OD reside in just
as defecating in fields, forests, bushes, bodies of water, or 10 countries of which five are in Africa (Nigeria, 39 million;
other open spaces, take place in rural areas of low-income Ethiopia, 34 million; Sudan, 17 million; Niger, 13 million;
countries [1]. Worldwide diarrheal disease is the second and Mozambique, 10 million) [4]. In the rest of the world,
leading cause of death in under-five children responsible for the number of people practicing OD is estimated to be 182
1.7 million morbidity and 760, 000 mortality every year [2]. million [1, 4].
In Ethiopia, diarrhea kills half million of under-five children In sub-Saharan Africa, it is estimated that 215 million
annually next to pneumonia [3]. people that is 8% of the urban population and 35% of the
2 Journal of Environmental and Public Health

rural population continue to engage in OD [1]. In Ethiopia, in turn plays a major role in the proper planning and
still the national OD rate in 2014 was 34.1% (37.9% in rural monitoring of sanitation and hygiene activities and pro-
and 8.7% in urban) [5]. This practice facilitates the trans- grams that contribute for diarrhea prevention.
mission of diarrheal diseases, one of the leading causes of
mortality in under-five children in sub-Saharan Africa [6]. 2. Materials and Methods
Total sanitation approaches, the most promising ap-
Study Area. The study was conducted in Dangla woreda, Awi
proaches aimed at empowering communities as a whole to
zone, a city located 480 kilometers away from the capital city
become “OD FREE,R aimed at raising awareness of the risks
Addis Ababa. In this woreda, there are 27 rural kebeles (kebeles
associated with OD and generating a collective sense of
are smaller administrative units); 15 of the kebele were ODF,
intolerance towards OD [7].Nevertheless, it has been sug-
and 19309 under-five children are living in the woreda. The
gested that total sanitation approaches can result in rapid
map shows the kebele under the Dangla district (Figure 1).
significant improvements and hold promise for decreasing
OD in sub-Saharan Africa [8]. In Ethiopia, the Southern
Study Design and Period. The study was a community-based
Nations, Nationalities, and Peoples’ Region (SNNPR)
comparative cross-sectional study conducted from July 2015
adapted CLTS to local Ethiopian conditions in the 2003
to June 2016.
Gregorian calendar and achieved a remarkably rapid re-
duction in OD. The approach was scaled up and main-
Source Population. All children under five years of age in the
streamed in the National Sanitation Strategy and integrated
Dangla district.
into the Health Extension Worker program. Poor sanitation,
lack of access to clean water supply, and inadequate personal
Study Population. Caregivers and children under five years
hygiene are responsible for 90% of diarrheal disease oc-
of age living in ODF and OD settings of Dangla woreda.
currence; these can be easily improved by health promotion
and education [3].
Inclusion Criteria. Those households that have at least one
It is estimated that 1.7 billion cases of diarrhea occur every
child under five years of age in the house residing in the ODF
year, causing 800,000 deaths among children under 5 years of
or OD kebeles.
age worldwide [9], and 15% of the global population still
engage in OD [1]. It also underlines that OD leads to deadly
Exclusion Criteria. Those households located in the urban
diarrhea and other intestinal diseases which kill hundreds of
settings.
thousands of children every year. Evidences also showed that
about 80% of the rural and 20% of urban sub-Saharan
2.1. Sample Size Calculation. The sample size was calculated
population have no access to safe water and sanitation [10].
by Epi Info version 7 software (source: CDC) using double-
In Ethiopia, three-fourths of the health problems of under-
proportion formula with the following assumptions:
five children are communicable diseases which come from the
environment, specially water and sanitation [11]. Diarrhea is (i) From a study done in Sidama Zone [12], diarrhea
the leading cause of under-5 mortality causing 23% of deaths prevalence in ODF kebele (P1) � 24.7% and in OD
and around 44% stunted [4]. In Ethiopia, over 75–80% of the kebele (P2) � 26.5%
communicable diseases are caused due to poor environmental (ii) 95% confidence interval
health conditions arising from unsafe and inadequate water
(iii) 80% power of test
supply and poor hygienic and sanitation practices [11].
An estimated 64,540 children could be saved every year (iv) Ratio between ODF and OD kebeles �1
by improving water, sanitation, and hygiene in the country (v) To detect odds ratio of �2
[4]. It is critical to understand what factors influence the
Having the assumptions above, the sample size was 332.
pace to reduce OD in order to develop effective strategies to
Since multistage sampling was used for this particular study,
improving sanitation and reducing diarrhea morbidity and
the design effect of 1.5 was considered and then the sample
mortality caused by the lack of sanitation. Furthermore,
size became 498. With 10% contingency, the total sample
there is a need for more realistic targets for global campaigns
size was determined to be 550 (275 for non-ODF and 275 for
that will put forth following the MDGs that ended in 2015.
OD free).
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 2.2. Sampling and Data Collection Techniques. A multistage
living in the ODF kebeles will have reduced diarrheal-related sampling technique was applied, the kebele from each group
morbidity and mortality compared with people living in OD was selected randomly by the lottery method, and the
kebeles. However, all exposure routes to the increased samples were distributed proportionally by their number of
burden of disease must be considered. under-five children. Children under five years of age residing
The knowledge of existing gaps in the differences be- in ODF and OD households were identified through
tween ODF and OD kebeles can be linked to a proper a house-to-house enumeration prior to the actual data
problem inventory. This research also helps to explore the collection using the family folder by health extension
basics of the ODF status in the prevention of diarrhea and workers. For a household having two or more children, we
also what changes can come after the ODF verification which have taken the youngest child. The actual data collection was
Journal of Environmental and Public Health 3

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.

Latitude: 11°24′59.99″N
Longitude: 36°39′59.99″E 2.7. Data Analysis. Data were coded and entered into Epi
Figure 1: Map of the study area. Info version 7 and cleaned and checked for completeness.
Initially, descriptive statistics were done to determine the
carried out in February 2016 by trained nursing students diarrhea prevalence and to characterize the variables’ fre-
using a structured questionnaire. An observation checklist quency and percentages. Bivariate and multivariate analyses
was also applied to assess latrine utilization. were done using SPSS version 20 software. In the multi-
variate analyses, an Enter method was used and a statistical
significance of 0.05 was considered. Results were presented
2.3. Data Collection Instruments. A structured questionnaire using tables, graphs, and charts.
which was adopted from different literatures was used, and
an observation checklist was also applied to assess latrine
utilization. 3. Results
3.1. Descriptive Results. A total of 525 (263 households from
2.4. Variables. Dependent variable is the occurrence of ODF and 262 households from OD) participants were
diarrheal diseases in children under five years of age. In- interviewed making the response rate 95.45%. Among the
dependent variables are as follows: respondents, 162 (61.8%) from ODF kebeles and 112 (42.6%)
from OD kebeles were females. The total respondents’ age
(i) Household income
ranged from 17–75 years with a mean (SD) age of 39.14
(ii) Sociocultural factor (±11.97) (Table 1).
(iii) Hygiene and sanitation variables As shown in Table 2, the prevalence of diarrhea among
(iv) Household water access, treatment, and storage ODF kebeles was 9.9%, whereas in OD kebeles, it was 36.1%.
From the total diarrhea cases, the majority 121 (77.9%) of
(v) Hygiene and sanitation perception and practices under-five diarrhea cases were from those OD kebeles, but
(vi) Maternal and child health factors the magnitude of under-five diarrhea in ODF kebeles was 26
(22.1%).
2.5. Operational Definitions The study also revealed that majority of respondents in
both ODF (235 (89.7%)) and OD (244 (92.8%)) kebeles have
2.5.1. ODF. A status given by the woreda by their latrine, a private latrine. From those households that have latrines,
hand washing, household water access, and safe storage majority (87.4%) of respondents from ODF kebeles and
coverage and practices as per the ministry of health ODF 87.8% of respondents from OD kebeles have traditional pit
verification and certification criteria. latrines, respectively (Table 3).
Regarding waste disposal, 90 (34.4%) of households from
ODF and 156 (59.3%) of households from OD kebeles
2.5.2. Diarrhea. A disease characterized by frequent (>3)
dispose openly their solid waste, while 20 (7.6%) from ODF
loose or watery stools in 24 hours, or a single stool with
and 117 (44.5%) from OD kebeles dispose their liquid waste
blood/mucus with a 14-day prior to study.
openly (Table 4).
From the observations made in latrines, a majority of
2.5.3. Unimproved Water Sources. Unprotected dug well, 88% in OD and 82% in ODF kebeles had fresh foot path and
unprotected spring, cart with small tank or drum, surface splash of urine. Similarly, 86% of latrines in OD kebeles and
water (e.g., river, dam, lake, pond, stream, canal, or irrigation 81% in ODF kebeles had fresh stool during observations
channel), and bottled water. (Figure 2).
4 Journal of Environmental and Public Health

Table 1: Participants characteristics in selected both ODF and OD kebeles in Dangla woreda, Northwest Ethiopia, 2016.
ODF OD
Variables
Number % Number %
15–24 31 11.8 17 6.5
Age (years) 25–34 75 28.6 64 24.3
35+ 156 59.5 182 69.2
Female 162 61.8 112 42.6
Sex
Male 100 38.2 151 57.4
≤5 133 50.8 95 36.1
Family size (mean � 5.53)
>5 129 49.2 168 63.9
Unmarried 8 3.1 5 1.9
Married 228 87.0 235 89.4
Marital status
Divorced 10 3.8 13 4.9
Widowed 16 6.1 10 3.8
Literate 87 33.2 90 34.2
Educational status of mother
Illiterate 175 66.8 173 65.8
Literate 148 56.5 120 45.6
Educational status of father
Illiterate 114 43.5 143 54.4
Farmer 198 75.6 207 78.7
Occupation of mother
Housewife 64 24.4 56 21.3
Farmer 249 95.0 251 95.4
Occupation of father
Private 13 5.0 12 4.6
No 78 29.8 58 22.1
Educated child in household
Yes 184 70.2 205 77.9
Higher education 19 10.3 35 17.1
Educational level of child Primary/secondary education 144 78.3 153 74.6
Read/write 21 11.4 17 8.3
No 52 19.8 110 41.8
Child immunization (any type)
Yes 210 80.2 153 58.2
<1000 177 67.6 202 76.8
Average monthly net income (in ETB) 1000 to 2000 77 29.4 31 11.8
2001 and above 8 3.1 30 11.4

Table 2: Diarrhea occurrences among ODF and OD kebeles in Dangla woreda, Northwest Ethiopia, 2016.
ODF OD
Variables Chi-square (P value)
Number % Number %
No 236 90.1 168 63.9
Diarrhea occurrence 50.791 (0.001)
Yes 26 9.9 95 36.1
≤5 days 19 73.1 69 72.6
Diarrhea persists 0.002 (0.964)
>5 days 7 26.9 26 26.3
Food 21 43.8 51 41.1
Perception on sources of diarrhea Water 26 54.2 71 57.3 51.535 (0.001)
Utensils 1 2.1 2 1.6
Nothing done 5 1.9 18 6.9
Special food for the child 113 43.1 161 61.2
Diarrhea prevention mechanisms
Clean food for the child 207 79.0 190 72.2 29.714 (0.001)
done for the child
Care for hygiene of the child 160 61.1 209 79.5
Care for hygiene of the family 182 69.5 192 73.0

3.2. Multivariate Analysis Result in ODF Kebeles. The mul- Keeping other factors constant, immunized children
tivariate analysis result showed that child immunization, were 96% less likely (AOR � 0.037; 95% CI: 0.006–0.243) to
latrine presence, water shortage in the household, and solid have diarrhea as compared to nonimmunized children,
waste disposal had a statistically significant association with and the association was statistically significant. Similarly,
diarrhea occurrence in ODF kebeles. those households having a latrine were 96.4% less likely
Journal of Environmental and Public Health 5

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
Variables ODF Non-ODF Chi-square (P value)
Number % Number %
No 27 10.3 19 7.2
Latrine presence 1.56 (0.212)
Yes 235 89.7 244 92.8
Shared 6 2.3 13 4.9
Latrine type 3.97 (0.137)
Traditional pit 229 87.4 231 87.8
<1 year 9 3.8 13 5.3
1–2 years 72 30.6 76 31.1
Years for latrine construction 0.79 (0.852)
2–3 years 113 48.1 111 45.5
3+ years 41 17.4 44 18.0
No 205 87.2 165 62.7
Defecate openly after the latrine construction 27.74 (0.001)
Yes 30 12.8 79 30.0

Table 4: Households solid and liquid waste management in Dangla woreda, Northwest Ethiopia, 2016.
Kebele status
Variables ODF OD Chi-square (P value)
Number % Number %
Improper 90 34.4 156 59.3
Liquid waste disposal 32.85 (0.001)
Proper 172 65.6 107 40.7
Proper 242 92.4 146 55.5
Solid waste disposal 92.43 (0.001)
Improper 20 7.6 117 44.5

(AOR � 0.036; 95% CI: 0.006–0.233) to have diarrhea as 4.692–72.760) of diarrhea occurrence as compared to
compared to those who did not have a latrine, and the households having no water shortage. Keeping other factors
association was statistically significant. constant, safe waste disposal reduces the chance of diarrhea
Regarding water shortage, holding other factors con- occurrence by 97% (AOR � 0.023; 95% CI: 0.005–0.117) as
stant, households with water shortage had 8.7 times higher compared to open disposal, and the association was sta-
chance (AOR � 8.756; 95% CI: 1.130–67.831) of diarrhea tistically significant (Table 5).
occurrence as compared to the reference category. Per-
taining solid waste disposal, those who dispose safely were 4. Discussion
86% less likely (AOR � 0.143; 95% CI: 0.020–0.998) to have
diarrhea as compared to those who dispose openly, and the To date, scientific evidence on the impact of the ODF kebele on
association was statistically significant (Table 5). 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
3.3. Multivariate Analysis Result in OD Kebeles. The multi- the prevention of diarrhea that contributes for designing ef-
variate analysis result showed that child immunization, fective interventions at different segments of the health system.
water access at the individual level, water shortage in the Accordingly, the prevalence of diarrhea among ODF
household, and solid waste disposal had statistically sig- kebeles was found to be 9.9%, while in OD kebeles, it was
nificant association with diarrhea occurrence in OD kebeles. 36.1% showing significant differences. The prevalence in
Keeping other factors constant, immunized children were ODF kebeles was still much lower as compared with the
97% less likely (AOR � 0.032; 95 CI: 0.008–0.123) to have study done in ODF kebeles of Sidama zone, and in SNNPR,
diarrhea as compared to nonimmunized children, and the the prevalence was 24.7% [12]. The reason behind the
association was statistically significant. Regarding water decrement of diarrhea prevalence in the ODF study area may
access at the individual level, water access of 7.5–15 liters/day be due to the quality of ODF declaration, certification, and
reduces the chance of diarrhea occurrence by 97% follow-up. After ODF declaration, this follow-up may also be
(AOR � 0.029; 95% CI: 0.006–0.152) and water access of related with the commitment of the region, zone, woreda,
greater than 15 liters/day reduces the chance of diarrhea and kebele’s ODF verification and certification teams.
occurrence by 93% (AOR � 0.068; 95% CI: 0.010–0.474) as The prevalence of under-five diarrhea in OD kebele
compared to the reference category, and the association was (36.1%) was higher as compared with the study done in
statistically significant. Sidama zone which was 26.5% [12], and in a study in India,
Pertaining to water shortage, households with water the prevalence was 15.9% in OD kebeles [2], but it is almost
shortage had 18 times higher chance (AOR � 18.478; 95% CI: similar with national under-five diarrhea prevalence that
6 Journal of Environmental and Public Health

88.2% 87.1% 85.9% 84.8% 84.8%

74.1%
54.0%
81.7% 81.7% 80.9% 77.9% 71.4% 79.4%
45.4%
22.1%
20.2%

Fresh foot Splash of Fresh stool Feces Latrine wall Cleanable Latrine roof Danger to
path urine 50cm below floor the user
the slab

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

Table 5: Bivariate and multivariate analysis of variables with under-five diarrhea among ODF and OD kebeles in Dangla woreda, Northwest
Ethiopia, 2016.
ODF OD
Variables COR AOR COR AOR
(95% CI) (95% CI) (95% CI) (95% CI)
<1000 Ref Ref
Monthly
1000 to 2000 1.3 (0.111, 15.088) 0.374 (0.147, 1.002)
income (in birr)
2001 to 3000 18.6 (0.065, 5173) 0.778 (0.346, 1.750)
≤5 Ref Ref Ref Ref
Family size
>5 3.109 (1.260, 7.674) 0.715 (0.115, 4.443) 2.774 (1.565, 4.917) 0.840 (0.233, 3.035)
Literate Ref Ref Ref
Education of mother
Illiterate 0.775 (0.336, 1.787) 0.542 (0.321, 0.917) 0.512 (0.129, 2.035)
Farmer Ref Ref Ref
Occupation of mother
Housewife 1.429 (0.589, 3.462) 0.461 (0.233, 0.910) 2.431 (0.422, 13.995)
No Ref Ref Ref Ref
Child vaccination
Yes 0.018 (0.005, 0.065) 0.037 (0.006, 0.243)∗ 0.051 (0.027, 0.098) 0.032 (0.008, 0.123)∗
No Ref Ref Ref Ref
Latrine presence
Yes 0.013 (0.004, 0.040) 0.036 (0.006, 0.233)∗ 0.177 (0.062, 0.510) 0.382 (0.050, 2.913)
Improved Ref Ref Ref
Main source of water
Unimproved 1.059 (0.461, 2.434) 4.150 (2.100, 8.201) 1.640 (0.360, 7.472)
<�1000 Ref Ref Ref Ref
Distance of water source
>1000 6.320 (2.253, 17.726) 3.845 (0.291, 50.895) 9.506 (2.656, 34.019) 1.988 (0.239, 16.556)
Per capita water <7.4 Ref Ref Ref Ref
consumption 7.5–15 0.091 (0.032, 0.264) 0.332 (0.046, 2.405) 0.088 (0.044, 0.177) 0.029 (0.006, 0.152)∗
(liters/day) >15.1 0.292 (0.099, 0.866) 0.527 (0.060, 4.600) 0.126 (0.056, 0.285) 0.068 (0.010, 0.474)∗
No Ref Ref Ref Ref
Water shortage
Yes 13.768 (5.232, 36.229) 8.756 (1.13, 67.831)∗ 10.828 (5.824, 20.13) 18.478 (4.692, 72.76)∗
No Ref Ref Ref Ref
Water treatment
Yes 2.833 (1.138, 7.056) 1.884 (0.268, 13.271 2.907 (1.605, 5.267) 0.858 (0.166, 4.438)
No Ref Ref
Soap/Ash use yesterday Ref
Yes 0.873 (0.333, 2.293) 0.655 (0.374, 1.149)
Dispose openly Ref Ref Ref
Liquid waste disposal
Dispose safely 0.484 (0.214, 1.095) 0.171 (0.092, 0.318) 0.435 (0.108, 1.751)
Dispose openly Ref Ref Ref Ref
Solid waste disposal
Dispose safely 0.016 (0.005, 0.052) 0.143 (0.020, 0.998)∗ 0.066 (0.035, 0.124) 0.023 (0.005, 0.117)∗
∗
Indicates statistically significantly associated variables.

ranges from 11% to 38% [11]. Differences might be because The prevalence of under-five diarrhea among ODF and
of the people’s way of life, educational levels of the com- OD kebeles had a statistically significant difference with
munity, maternity care of child’s immunization, and nu- X2 � 50.791 and P � 0.001, but the study done in Sidama
tritional differences that are not related with the status of zone showed that there is no significant difference between
being ODF or OD. the two communities with X2 � 0.721 and P � 0.396. The
Journal of Environmental and Public Health 7

difference with a study in Sidama might come because of the person per day which have no statistically significant as-
differences in the quality of the ODF status. sociation with under-five diarrhea. The result also showed
Latrine presence has showed a statistically significant that, in ODF kebeles, people who dispose solid wastes
association with diarrhea occurrence both in ODF and OD properly were 86% less likely to have diarrhea as compared
kebeles in which the odds of developing diarrhea for families to those who dispose improperly which is comparable with
having a latrine was 96.4% times lower in ODF kebeles and the result from OD kebeles in which safe disposal reduces
61.8% times lower in OD kebeles. The percentage of the the chance of diarrhea occurrence by 97%. This finding is in
latrine in ODF kebeles that is less than OD kebeles indicates line with a study done in the Mecha district of West Gojjam
that individuals living here are still practicing OD, and in the [18]. This finding is explained by the fact that proper waste
true sense, these are not ODF kebeles. The result is consistent management reduces the risk of contamination and in turn
with a study in Mali [13]. This is also in line with ODF risk of having diarrheal disease.
verification and certification guideline and CLTSH imple-
mentation guideline [14, 15]. The study from the Derashe 5. Strength and Limitation of the Study
district of SNNPR also supports this finding in which the
odds of developing diarrhea was 2.43 times higher among The study explored factors that have an association with
children of families who had no latrine when compared to diarrhea in both ODF and OD kebeles comparatively against
children of families who had latrine [16]. the standard guidelines. The study also used multiple
In ODF kebeles, immunized children were 96% less methods of data collection like on-site observation to assess
likely to have diarrhea as compared to nonimmunized practice of latrine utilization. In addition, to assure the
children which is much comparable with the result from OD quality of the data, the standardized data collection tool was
kebeles that showed the odds of immunized children were used and pretest was done before the actual data collection.
96.8% less likely to have diarrhea as compared to non- As limitation, the study was cross-sectional which cannot
immunized children. The similarities between these two measure the cause-and-effect relationship. There might also
settings come because of the socioeconomic, agroecological, be a possibility of recall bias that will result in under-
MCH services, and way of life similarities since they are reporting and misreporting of events. For more information,
administered in one district. This finding is inconsistent with refer the thesis report [19].
a result from Eastern Ethiopia where immunization had no
significant association with diarrhea occurrence in under- 6. Conclusion and Recommendations
five children [17].
Regarding water shortage in OD kebeles, households The overall prevalence of under-five diarrhea among the
with water shortage had 18 times higher chance of diarrhea individuals living in the ODF kebeles was lower as compared
occurrence as compared to households having no water with the OD kebeles. Child immunization, latrine presence,
shortage which is much higher as compared with the result water shortage in household, and solid waste disposal in
in ODF kebeles where water shortage increases the chance of ODF kebeles and per capita water consumption/water access
diarrhea occurrence by eight times. This could be explained at the individual level, water shortage in households, child
by the fact that households having water shortage could not immunization, and solid waste disposal in OD kebeles had
keep their personal hygiene as necessary. Results from both statistically significant association with diarrhea occurrence
settings are not comparable with a result from the Derashe in the Dangla district.
district of SNNPR in which diarrhea among children have Ministry of health needs to reconsider the ODF status
no statistically significant association with water shortage certification process of the kebeles which can be based on
[16]. sustainability. Together with line ministries, regions, zones,
The analysis result from OD kebeles also showed that woreda health structures, and stakeholders, the ministry has
those households who got minimum standard (7.5– to improve child immunization, latrine presence and uti-
15 liters/day) water access at the individual level reduce the lization, water shortage in household, and solid waste dis-
chance of diarrhea occurrence by 97%. This result is linked posal practices that are directly linked with under-five
with the recommendation from the sphere handbook of diarrhea. Health workers and local authorities must give
water, sanitation, and hygiene for humanitarian charter and health education and sensitization for the community to
minimum standard that average water use for drinking, improve OD practices. In addition, the findings of this study
cooking, and personal hygiene in any household is at least will serve as baseline evidence and pave the way for other
7.5–15 liters per person per day which means that those researchers and policymakers to conduct more rigorous
household who got the water and care for their drinking, studies on this arena.
cooking, and personal hygiene can prevent their children
from diarrhea that can be transmitted by drinking water, Abbreviations
cooking materials contamination, and by not keeping their
personal hygiene safely. Water access of greater than CLTSH: Community-led total sanitation and hygiene
15 liters/day also reduces the chance of diarrhea occurrence EDHS: Ethiopian Demographic and Health Survey
by 93% which is incomparable with the result from ODF FMOH: Federal Ministry of Health
kebeles that indicate those households having 7.5–15 liters HEP: Health Extension Program
per person per day and households who access 15 liters per HEW: Health Extension Workers
8 Journal of Environmental and Public Health

[6] I. G. Deise, K. Seung-Sup, and P. G. Jay, “Exploring changes in

HMIS: Health Management Information System OD prevalence in sub-Saharan Africa based on national level
MEDHS: Mini Ethiopian Demographic and Health Survey indices,” BMC Public Health, vol. 13, no. 527, 2013.
MDG: Millennium Development Goals [7] M. Jenkins and V. Curtis, “Achieving the ‘good life’: why some
OD: Open defecation people want latrines in rural Benin,” Social Science & Medi-
ODF: Open defection free cine, vol. 61, no. 11, pp. 2446–2459, 2005.
WASH: Water, Sanitation, and Hygiene [8] P. Harvey, “Zero subsidy strategies for accelerating access to
WHO: World Health Organization. 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
Ethical Approval Diseases for the World’s Poorest Children, UNICEF, New York,
NY, USA, 2012.
The study was approved by the Ethical Review Committee of [10] C. Robert, “Sanitation and stunting in India: undernutrition’s
Addis Ababa University School of Public Health and Dangla blind spot,” in Proceedings of Learning Workshop on Partic-
Woreda Administration. ipatory Community Approach on ODFREE-Rural Spaces,
pp. 15–17, India, 2013.
[11] A. Andualem and K. Abera, “Assessment of the impact of
Consent latrine utilization on diarrhoeal diseases in the rural com-
munity of Hulet Ejju Enessie Woreda, East Gojjam Zone,
Verbal consent and written consent were taken from the
Amhara Region,” Ethiopian Journal of Health Development,
guardians of the under-five children before the actual data vol. 24, no. 2, 2010.
collection. [12] B. Hunachew, D. Wakgari, K. Abera, and G. Delia, “Effect of
Community Led Total Sanitation interventions on Diarrheal
Conflicts of Interest Diseases and Other Hygienic Behaviors and Sanitation In-
frastructure Sustainability Challenges,” in Proceedings of the
The authors declare that they have no conflicts of interests. University of North Carolina Water Institute, Southern
Ethiopia, 2015.
[13] A. J. Pickering, H. Djebbari, C. Lopez, M. Coulibaly, and
Authors’ Contributions M. L. Alzua, “Effect of a community-led sanitation in-
tervention on child diarrhoea and child growth in rural Mali:
AM initiated the research, wrote the research proposal, a cluster-randomised controlled trial,” The Lancet Glob
carried out the data analysis, interpreted the results, and Health, vol. 3, no. 11, pp. e701–e711, 2015.
drafted the manuscript. WT, SW, and ZA were involved in [14] Ministry of Health, Health Sector Transformation Plan
designing the study, revising the proposal, guiding the (2015–2020), Ministry of Health, Addis Ababa, Ethiopia, 2015.
statistical analysis, and writing the manuscript. All authors [15] Ministry of Health, National Monitoring and Reporting System
read and approved the final manuscript. for the Implementation of Community-Led Total Sanitation
and Hygiene, HPDP, Ministry of Health, Addis Ababa,
Ethiopia, 2012.
Acknowledgments [16] W. Godana and B. Mengiste, “Environmental factors asso-
ciated with acute diarrhea among children under five years of
The authors acknowledge Addis Ababa University School of age in Derashe district, Southern Ethiopia,” Science Journal of
Public Health, Federal Ministry of Health, and Dangla Public Health, vol. 1, no. 3, pp. 119–124, 2013.
District Health Office for their financial support and kind [17] B. Mengistie, Y. Berhane, and A. Worku, “Prevalence of di-
assistance during the entire process of the study. arrhea 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.
References [18] M. Dessalegn, A. Kumie, and W. Tefera, “Predictors of under-
five childhood diarrhea: Mecha District, West Gojam,
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[2] C. Terry, C. Christian, A. W. Rita, and P. Pragati, World Toilet diarrhea in under-five children: a comparative cross-sectional
Day, Beyond Infrastructure: Building New Attitudes Also study in open defecation and open defecation free rural
Needed to End OD, Un Press Release, New York, NY, USA, settings in Dangla District, North-West Ethiopia,” Addis
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[3] G. Teklemichael, T. Mohammed, and K. Wondwosen, “Risk
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