Study setting and period
Goba district is found in Oromia region Bale administrative zone, at the Southeast of the country and 445 km far from the center of the country, Addis Ababa. In year 2017, from 15 Sub-districts almost half of Sub-districts (7) were verified as open defecation free Sub-districts by the Woreda Health office. The study was conducted from March to April 2017.
Study design and population
A community-based comparative cross-sectional study design was implemented. All households that had at least one under-five children in ODF and non-ODF sub- districts of Goba Districts were the source population. The study population were all randomly selected households that had at least one under-five in selected ODF and non ODF Sub-districts of Goba District.
Inclusion and exclusion criteria
Only those sub- districts that declare ODF status before one year was included in ODF setting. In addition, a sub-district that declared ODF at village ('gare’ local name) level but not declared as ODF status at Sub-districts level were excluded. Those households with critically ill mother or care givers during the survey were excluded from the study.
Sample size determination and sampling techniques
The sample size was determined using Epi-info version 7 statistics software by considering prevalence of diarrhea in ODF sub- districts 24.7% from study done in Northwest Ethiopia [18], 95% confidence interval (CI), 80% power, ratio of ODF to non-ODF Sub-districts 1:1, to detect 2 odd ratio (OR), design effect of 2 and 10% non-response rate. Accordingly, the sample size was 732 (366 from ODF and 366 from non ODF) households that had at least one under five-children were included in the study.
A multistage sampling technique was employed to select study participants. In the first stage, all Sub-districts were classified by their OD status into ODF and non-ODF Sub-districts (7 ODF and8 non-ODF). Accordingly, three ODF and three non-ODF Sub-districts were randomly selected using lottery method. Then the calculated sample size was allocatedproportional to size of households for each selected sub-district. In the second stage using health post family folder as sampling frame households with under-five children were selected by systematic random sampling. After determining the Kth interval, the first household was selected randomly, and the next household was identified systematically onwards by adding cumulatively Kth intervals to the first selected household.
Data collection instruments and technique
The questionnaire was adapted from WHO and UNICEF [5], ICF International [19], EDHS [6.20], and from other related literatures and modified contextually. Data were collected by trained female healthcare workers using pre-tested structured questionnaire and observational checklist. The reason for selecting female data collector was for ease of communication since the study participants were female who may easily communicate with female health workers.
To check consistency of the data collection tool, it was translated to local language (Afan Oromo) and re-translating back to English was done by another individual who is expertise in both languages. Throughout the data collection process close supervision was carried out to assure data completeness and consistency. During data collection Sub-districts were coded and all data collectors were blinded regarding household ODF status.
Study variables
Dependent variable: Diarrheal prevalence among under five children
Independent variables: -
Socio-economic and demographic factor: -family monthly income, age of the mother/caregiver, age of the index child and educational status of the mother/caregiver.
Environmental factors: ODF status, availability of latrine, ownership of latrine, latrine type, the presence of feces around latrine, latrine cleanliness status, and hand washing facility.
Behavioral factors: breast feeding practice, and child feces disposal method.
Operational definition
Open Defecation (OD): is a practice whereby human feces are disposed of in fields, forest, bushes, open bodies of water, beaches/other open spaces or disposed of with solid waste [5].
Open defecation free status: - is a status given by an independent, third-party group of relevant stakeholders for a given community whether village, sub districts, district, or an entire region has 100 percent latrine coverage and totally free of open defecation practices as per the ministry of health ODF verification and certification criteria [15].
Hand washing at critical time: if a mother/caregiver reported to practiced hand washings with soap before eating, before food preparation, before child feeding, after child cleaning and after latrine visiting was considered as “all practiced” unless considered as “partially practiced” [21].
Hygienic latrine: if there were no human or animal fecal matter present inside the facility—on seat, floor, door, or walls [22].
Index child: a child that is included in the study from a household to have information on the demographic and health characteristics and used to calculate the prevalence of diarrhea.
Unsanitary disposal of children’s feces: - includes put/rinsed feces into drain or ditch, feces were thrown into the garbage or feces left, or the child was not seen during defecation [19].
Method of Data analysis
Raw data were coded, entered, cleaned, and analyzed using statistical package for social science (SPSS) statistical software version 20. Descriptive statistics such mean, percentage and frequency table were computed to summarize data. Bivariate and multivariable analysis was done to identify independent factors associated with diarrheal disease in under-five. Variables in the bivariate analysis which were found at p-value ≤ 0.25 were further considered in the multivariable binary logistic analysis to identify the independent predictor of diarrheal diseases.
Hosmer-Lemeshow statistic was used to test the goodness-of-fit of the model. Crude and adjusted odds ratios (AOR) with 95% confidence interval (CI) were used to measure the strength of association. The p values of less than 0.05 were considered as a statistical significance.