Diarrhea Prevalence and Associated Factors among Under-Five Children in the Periphery Area of Azezo Sub-city, Gondar, Northwest Ethiopia: A community based cross-sectional study

DOI: https://doi.org/10.21203/rs.3.rs-1129227/v2

Abstract

Background: Although there has been a global decrease in childhood diarrheal disease in parallel with improvements in the standard of living, it remains a significant public health problem that occurs due to poor WASH status and other related factors that cause massive childhood morbidity and mortality particularly in sub-Saharan Africa countries including Ethiopia. 

Objective: To assess diarrheal disease prevalence and associated factors among under-five children in the periphery area of Azezo sub-city, Gondar, northwest Ethiopia. 

Methods: A community-based cross-sectional study was conducted in April 2019. A simple random sampling technique was applied to recruit the eligible clusters/villages. Structured interview questionnaires were used to collect data. The completed data were entered into Epi Info version 7 and exported to SPSS version 20 for further analysis. A binary logistic regression model was used to process bivariate and multivariable analysis of the data to establish the association between dependent and independent variables. The adjusted odds ratio (AOR) with 95% CI was used for the interpretation of data after controlling the confounders.  

Results: The two-week prevalence of U5C diarrheal disease was 24.9 % with 95% CI: (20.4 – 29.7). Age group of 1-12months [AOR: 9.22,  95%CI: (2.93-29.04)], age group of 13-24months [AOR: 4.44, 95%CI: (1.87-10.56)], low monthly income (AOR: 3.68, 95% CI: (1.81-7.51)], small family size [AOR: 0.32,  95% CI: (0.16-0.65)],   poor hand washing practice [AOR:   8.37,  95 % CI: (3.12-22.52), and  immediate feed for cooked foods [AOR: 0.39, 95%CI: (0.19-0.81)] were significantly associated factors with childhood diarrhea.

Conclusion: Diarrhea was a common health problem among under-five children in the periphery area of Azezo sub-city. Age of children, family size, monthly income, hand-washing practice, and feeding time for cooked food were identified statistically significant risk factors. Therefore, an appropriate intervention program through health education would be recommended with a focus on identified risk factors to reduce the burden of diarrheal diseases. 

Background

Diarrhea illness remains the significant cause of morbidity and mortality of under-five children globally. However most incidents of childhood diarrhea have occurred in mild and acute cases can lead to severe dehydration, which may consequences in mortality and other health risks as a result of malnutrition (1). The most recurrent clinical form of diarrhea comprises acute watery diarrhea which is characterized by abrupt onset of frequent, watery loose, stools without visible blood, lasting less than two weeks (2, 3). Bloody diarrhea; often referred to as dysentery, is marked by visible blood and mucus in the stools (4). Whereas persistent diarrhea is an episode of diarrhea, with or without blood lasts at 14 days and causes substantial weight loss in most patients (2, 4).

Diarrheal illness is a main public health problem around the globe. Internationally, 525, 000 under-5-year-old children die from diarrhea annually, approximately 2195 every single day(5). It accounts for 9% of child deaths worldwide and making childhood diarrhea the second leading cause of mortality next to pneumonia(6). Although there is a global reduction in the death rates of under-five children, the risk of a child for death earlier the age of under five years remains the highest in sub-Saharan African countries (90 per 1000 live births), which is approximately 7 times higher than that in European Regions (12 per 1000 live births)(7). That implies the burden of diarrheal diseases in developing countries is higher than in more developed countries (812).

In Ethiopia, the toll of diarrhea is another killer of under-five children following pneumonia(11). A previous study showed that in Ethiopia the incidence of diarrhea declined from 2000 to 2016, the problem is extremely high for children under five years old by causing loss of fluids with substantial mortality in infancy stages (13). Various studies revealed that diarrheal illness in unindustrialized countries like Ethiopia is due to many reasons such as unsafe water supply, lack of water linked to inadequate hygiene, poor personal and domestic hygiene, poor sanitation, failure to wash hands at the critical time, accessibility of toilet facilities, housing environments, educational status of mothers, and poor feeding practices (812, 14, 15). Still, there is limited evidence in the study area towards diarrheal disease and predictors among under-five children. Therefore, this investigation aimed to evaluate the prevalence of diarrheal disease and associated factors of under-five children in the periphery area of Azezo sub-city, Gondar, northwest Ethiopia.

Methods And Materials

Study design and period  

A community-based cross-sectional study design was employed to collect data from households having U5C in April 2019.

Study area and population

The study was conducted at the periphery area located at Azezo sub-city, Gondar, about 727 km far from Addis Ababa, northwest Ethiopia. According to the 2019 Ethiopian budget year, the total residents of this study area were estimated to be about 68,538 populations. Total population of 68,538 of which urban residents account for about 40,430 while the remaining 28,108 are rural inhabitants. In Azezo periphery area there are more than 513 U5C exists from a total population of 4198 and a total of 901 households with 14 villages.

Sample size determination and sampling technique

The optimal sample size was determined using a single population proportion formula, [n=Z2α/2 * P(1-P)*D/d2] based on the following assumptions as 95% confidence interval (Z=1.96), the proportion of childhood diarrhea 22.1% a study finding from central Gondar zone(16), and 5% margin of error (d), and design effect (D =1.5). Then after adding the non -response rate (5%), the total sample size was 417 households paired with at least one U5C. Cluster sampling technique was implemented to select ten legible villages with a simple random sampling technique from the total number of fourteen villages present in the study area and then all households with U5C were recruited in randomly selected villages.

Data collection tools

Quantitative data were collected through face-to-face interviews with mothers or guardians using a pretested structured questionnaire after being developed by reviewing different related articles (13, 17, 2125).

The questionnaires were divided into three sub-sections to address a different part of the questions. Section-I: Socio-demographic and economic factors: age, sex, number of family members, level of education, occupation, religion, housing condition, and household income. Section-II: Water-related factors: distance of water source to the household and waste disposal sites, type of water storage containers, type of water source, eating food prepared, and utensils washed with contaminated water, bathing, and washing in unhygienic water. Section-III: Sanitation factors: availability of human and animal waste and household garbage disposal sites, latrine availability, type of latrine, utilization of latrine, cleanliness of latrine, availability of sewage system, presence of domestic animals and flies inside the house. Section-IV: Behavioral factors: hand-washing practice at critical time, raw and prepared food and drink storage places and handling habits, unclean feeding bottles, washing utensils, cleanliness of domestic places, water drawing practice, cleaning practice of the floor, waste disposal practice, vaccination status and breastfeeding.

Data quality control

The questionnaire was first prepared in English and then translated to the local language Amharic and back to English for data entry purposes to evaluate the consistency of the questionnaire. Three B.Sc. in Environmental Health professionals were involved in data collection with close supervision after delivering two-day training. Pretest was done from five percent of samples outside of the study area to check the response, language clarity, and appropriateness of the questionnaires before starting the actual data collection. Then the identified ambiguous questions had been corrected before the interview. Every day after data collection each questionnaire was reviewed and checked for its completeness by the supervisors and principal investigators. Double-entry of data and frequency checks were also done during the data entry, processing, and analysis. The test result of Cronbach-alpha was 0.8, which indicates the acceptable internal consistency of the measurement reliabilities.

Data processing and analysis

Data were checked for completeness and relevance, coded and entered into Epi Info version 7 computer software, and analyzed using SPSS for Windows version 26. The descriptive statistical (frequency, percentages, mean and standard division ) analysis was used to compute the findings of this study. The results were then presented using tables, graphs, and texts. The strength of association of predictors with the outcome variable had been computed using the odds ratio with a 95% confidence interval. Bivariate analysis was performed to assess the binary relation between the outcome and independent variables. All variables with P-value less than 0.2 were included in the multivariable analysis model and then a P-value of less than 0.05 was considered as statistically significant predictors.

Results

Socio-demographic and economic characteristics of respondents

Four hundred and seven participants were enrolled in this study with a 100% response rate. All the respondents were women with a mean (±SD) age of 32.5 (±5.5) years. Most (96.4%) of participants were biological mothers. Ninety-two percent (384/417) of the mothers were married and had a median family size was six persons per household. The average family income of participants was 4458 ETB. The majority (62.6%) of participants could not read and write (Table 1).

Diarrheal prevalence among under-five Children

The two-week prevalence of U5C diarrheal disease was 24.9% with 95% CI: (20.4, 29.7) in which watery diarrhea takes a higher proportion, which was 78.8% of the overall prevalence. The prevalence of under-five diarrhea is higher in children in the age group 13-14 months of age 42(40.4%) followed by age group 1-12months 40(38.5%). The rest 22 (21.1%) was aged 25 and higher.

Table 1

Sociodemographic characteristics of the respondents in the periphery area of Azezo sub-city, Gondar, northwest Ethiopia, April 2019 (n=417).

Characteristics

Category

Number

Percent (%)

Relation of the respondent to child

Mother

402

96.4

Caretaker

15

3.6

Age of mother/caretaker

15-24

21

5

25-34

221

53

>35

175

42

Marital status of mother/caretaker

Married

384

92.1

Unmarried

33

7.9

Education of mother/caretaker

Educated

156

37.4

uneducated

261

62.6

Occupation of mother/caretaker

Housewife

327

78.4

Employed

90

21.6

Family size

≤6

266

63.8

>6

151

36.2

Family having livestock

Yes

326

78.2

No

91

21.8

The family produce a cash crop

Yes

78

18.7

No

339

81.3

Monthly family income (ETB)

≤ 4000

236

56.6

>4000

181

43.4

Characteristics of children

Out of 417 study participants, 260(62.4%) were males. The median age of children was 20 months with IQR: 11-31. The highest number 163 (39.1%) of children were above twenty months of age. More than half 230 (55.1%) of the children were born in hospitals. About 260 (62.4%) children were partial breastfeeders preceding the survey. The majority 340 (87.6%) of children started their supplementary food at the age of 6 months. The highest numbers 284 (79.4%) of children were received measles vaccination. Almost half 54(51.9%) of the diarrheic children were admitted to health institutions (Table 2).

Table 2

Characteristics of under-five children (U5C) in the periphery area of Azezo sub-city, Gondar, northwest Ethiopia, April 2019 (n=417).

Characteristics

Category

Number

Percent (%)

Age of children (month)

≤12

122

29.3

13-24

132

31.7

>24

163

39.1

Sex

Male

260

62.4

Female

157

37.6

Childbirth

Hospital birth

230

55.1

Home

187

44.9

Birth order

First

53

12.7

Second

83

19.9

Third

103

24.7

Fourth and above

178

42.7

Current breastfeeding status

Exclusive

28

6.7

Partial breastfeeding

260

62.4

Not breastfeeding

129

30.9

Duration of breastfeeding (month)

≤20

218

52.3

>20

199

47.7

Started supplementary food (month) (n=388)

≤ 6

340

87.6

>6

48

12.4

Measles vaccination

(n = 356)

Vaccinated

284

79.7

Unvaccinated

72

20.3

Two weeks diarrheal disease

Yes

104

24.9

No

313

75.1

Type of diarrhea (n= 104)

Watery diarrhea

82

78.8

Blood and mucus

22

21.2

Actions are taken at the household level (n=104)

Diet change

9

8.7

Health center

54

51.9

No treatment

41

39.4

Environmental characteristics

Water-related factors

Half 221(50.6%) of the study households with children paired were used drinking water from the unimproved water source. Most of 223 (53.5%) households were collected water for round within 30 minutes time span. The highest number of households 165 (55.2%) did not experience household water treatment methods as they are using unprotected drinking water sources. All study households used Jerry can for water storage at home. The majority of households 330(79.1%) stored water at home for consistent usage. The higher number 178 (42.7%) of households consumed about 60 L of water per day. However, the larger population segment of the study area experiences a median of 8 days of water shortage per month (Table 3).

Table 3

Characteristics of drinking water in the periphery area of Azezo sub-city, Gondar, northwest Ethiopia, April 2019 (n=417).

Characteristics

Category

Number

Percent (%)

Water source

Improved

206

49.4

Unimproved

221

50.6

Method of household water treatment n= 299

Boiling

5

1.7

Filtering

4

1.3

Chlorine/ wuha agar

29

9.7

Sedimentation

96

32.1

No treatment

165

55.2

Distance of water source in round trip

(in minutes)

≤30

223

53.5

>30

194

46.5

Drinking water storage and collection material (repeated response)

Pot

6

1.4

bucket

30

7.2

Jerry can

417

100.0

Daily water consumption per Household( litter)

≤60

178

42.7

60-80

93

22.3

>80

146

35.0

The common purpose of Water container

Yes

120

28.8

No

297

71.2

Water shortage

Yes

330

79.1

No

87

20.9

Frequency of water shortage/month

≤8days

176

42.2

>8days

241

57.8

Cleaning storage containers before use

Yes

389

93.3

No

28

6.7

Water drawing method

By dipping

17

4.1

By pouring

364

87.3

Both

36

8.6

Housing status and Sanitation conditions

Of the total 417 households, about 355 (85.1%) had mud floors. All households were constructed with corrugated iron sheet roofs. Two-thirds 275(65.9%) of participants lived in a house having two or more rooms. Nearly three-fourths 281 (74.5%) of households did not have separate keeping rooms of livestock. Most of the households 277 (66.4%) did not have latrines. The majority of households 332(79.6%) disposed of their refuse into the open field (Table 4).

Table 4

Housing and sanitation condition of the participants in the periphery area of Azezo sub-city, Gondar, northwest Ethiopia, April 2019 (n=417).

Characteristics

Category

Number

Percent (%)

Type of floor material

Mud

355

85.1

Cement

62

14.9

livestock living condition (n=377)

Separated

96

25.5

Not separated

281

74.5

Number of rooms

≤2

142

34.1

>2

275

65.9

Latrine availability

Yes

140

33.6

No

277

66.4

Frequency of latrine cleaning/week(n=140)

≤1

74

52.9

>1

66

47.1

Feces seen around the compounds

Yes

246

59.0

No

171

41.0

Ways of waste disposal@

Garbage can

50

12.0

burning

131

31.4

Open field

332

79.6

@One household disposed of the waste by using more than one method.

Behavioral/hygienic practices of the participants

The majority of 293(70.3%) household members were poorly practiced hand-washing at the critical time. However, only water is the most accessible hand-wash material for the majority of households accounting for 329 (78.9%) of the total participants. The larger proportion of the study participants did not have separate food preparing materials for their children. More than three-quarters (76.7%) of the study participants fed cooked foods immediately after cooking to their children. Of the one-third (33.6%) of the participants were had leftover food storing habits. From which about 87 (62.1%) of participants reheat leftover foods before consumption (Table 5).

Table 5

Behavioral/hygienic practices of the participants in the periphery area of Azezo sub-city, Gondar, northwest Ethiopia, April 2019 (n=417).

Characteristics

Category

Number

Percent (%)

Hand-washing practice

Good

124

29.7

Poor

293

70.3

Hand washing agents

Plain Water

329

78.9

Water with soap

88

21.1

Proper washing of raw food for children (n=388)

Yes

313

80.7

No

75

19.3

Food purchase from street vendors (n=388)

Yes

165

42.5

No

223

57.5

Separate materials for child food preparation (n=388)

Yes

233

60.0

No

155

40.0

Child feeding time after food preparation (n=356)

Feed immediately

273

76.7

Feed late

83

23.3

Hand-wash practice of children support with guardians ( n=388)

Yes

356

91.7

No

32

8.3

Left-over food storing habit

Yes

140

33.6

No

277

66.4

Reheat left over foods before consumption (n=140)

Yes

87

62.1

No

53

37.9

Kitchen cleaning habit

Yes

343

82.3

No

30

7.1

Child bathing farcicality

At home with bidet

391

93.8

River

26

6.2

Factors associated with the diarrheal disease among under-five children

In the bivariate analysis, level of education, family size, latrine availability, the sanitary condition of the compound, hand hygiene practice at the critical time, shelf time of prepared foods, children’s age, duration of breastfeeding, measles vaccination, and household monthly income were had p-value < 0.2 and then they were entered into the multivariate analysis. In the final steps of the multivariable analysis: age of children, family size, hand hygiene practice at critical times, shelf time of prepared foods, and household monthly income were significantly associated with under-five children diarrheal disease. Children between the age group of 13 to 24 months (AOR: 4.44; 95% CI: (1.87-10.56]) were 4 times more likely to develop diarrhea relative to more than 24 months age groups. Children aged from 1 to 12 months [AOR: 9.22; 95% CI: (2.93-29.04)] were also had higher odds of developing diarrhea when compared with above 24 months age group children. The occurrences of diarrheal disease were significantly associated with a household monthly income in which children of poor families were 3.68 times more likely to develop diarrhea [AOR:3.68; 95% CI: (1.81-7.51)] compared to higher-income households. The family size of household members was also associated with childhood diarrheal disease development. Small family size (≤6) can reduce childhood diarrhea by 68% relative to households of higher family size (>6) [AOR: 0.32; 95% CI: 0.16 -0.65)]. The risk of developing diarrhea was 8 times among children with mothers having poor hand washing practice at critical times [AOR: 8.37; 95% CI: (3.12-22.52)] in relative to children whose mothers had good hand washing practice at critical times. Moreover, shelf time of prepared food was also one of the significantly associated factors and children who feed cooked foods immediately can reduce the diarrheal disease by 61% [AOR: 0.39; 95%CI: (0.19-0.81)] when compared with children that are feeding cooked foods late (Table 6).

Table 6

Factor analysis related to diarrhea among under-five children in the periphery area of Azezo sub-city, Gondar, northwest Ethiopia, April 2019 (n=417).

Variable

Category

Diarrhea

COR (95% CI)

AOR (95%CI)

Yes

No

Age of child (month)

1-12

40

82

3.12(1.74-5.62)***

9.22(2.93-29.04) ***

13-24

42

90

2.99(1.68-5.34)***

4.44(1.87-10.56)**

>24

22

141

1.0

1.0

Mother/caretaker level of education

Educated

48

108

0.61(0.39-0.96)*

0.73(0.37-1.46)

uneducated

56

205

1.0

1.0

Family size

≤6

53

213

0.49(0.31-0.77)*

0.33(0.16,0.65) **

>6

51

100

1.0

1.0

Duration of breast feeding(month)

≤20

65

153

1.74(1.11-2.75)*

0.97(0.42-2.27)

>20

39

160

1.0

1.0

Measles vaccination

Unvaccinated

29

43

1.0

1.0

Vaccinated

63

221

0.42(0.24-0.73)**

0.73(0.35-1.54)

Latrine availability

Yes

26

114

1.0

1.0

No

78

199

1.72(1.04-2.83)*

0.59(0.26-1.34)

Feces seen around the compound

Yes

75

171

2.15(1.32-3.48)**

1.78(0.82-3.89)

No

29

142

1.0

1.0

Hand washing practice

Poor

97

196

8.27(3.72-18.42) **

8.37(3.12-22.52) ***

Good

7

117

1.0

1.0

Child Food consumption time

Feed immediately

62

211

0.44(0.26-0.75) **

0.39(0.19-0.81) *

Feed late

33

50

1.0

1.0

Household monthly income

≤4000

81

155

3.59(2.15-6.00)***

3.68(1.81-7.51) ***

>4000

23

158

1.0

1.0

*=P-value < 0.05,**=p-value <0.01, ***=p-value <0.001

Hosmer and Lemeshow model fitness test was 0.814 i.e., P>0.05

Discussion

The findings of this study revealed that the two-week prevalence of diarrhea in under-five children was 24.9% with 95% CI: (20.4, 29.7%). In the factor analysis of this study, the children’s age group, family size, hand wash practice, cooked food retention time, and household income were found statistically significant predictors of childhood diarrheal disease.

In this study, almost a quarter of under-five-children experienced the toll of diarrheal disease (24.9%). This finding is lower than the findings in rural Burundi (32.6%)(17), Hodan district Mogadishu-Somalia (47.9%) (3) and in Arba Minch, Ethiopia (30.5%)(18). This finding is in line with findings from Eastern Ethiopia (22.5%)(15), Bahir Dar Zuria district (20%)(19), rural areas of North Gondar Zone(22.1%)(16), Senegal (26%)(20) and Afar region, (26.1%)(21). However, This find is higher than the findings in Serobo town Jimma (12%)(22), Wolaita Sodo (11%)(23) and the 2016 EDHS national report (12%)(16), Tanzania (6.1%)(24), Northern Nigeria, (12.7%) (9). These differences might be due to the variation in the socio-demographic characteristics, study setting, environmental factors, study period, behavioral characteristics of the study households. This showed that the occurrence of diarrheal disease was varied among children in different study areas.

In factor analysis outcome, the present study revealed that young children were more exposed to the burden of diarrheal disease. The odds of childhood diarrhea were higher than in children whose age is less than two years when compared with two years and above age groups. This could be due to multiple reasons such as the young children started crawling and walking which increases environmental exposure for infectious agents, children’s transition period from exclusive breastfeeding to complementary food supplementation that may be contaminated, and less development of immune systems that may easily be affected by diarrheal diseases. This finding is supported by the findings from the study was done in different parts of Ethiopia such as Kersa district, Afar, Benishangul Gumuz, and Sidama zone (15, 21, 2527).

As shown in this study, the burden of diarrheal disease was about 3.5 times higher among children with lower family incomes than their high-income counterparts. This might be related to the inability to access water, sanitation, and hygiene technologies and to cover direct medical costs as well as it might be a bottleneck to fulfill the necessary dietary components to their children as a result they might become malnourished and increase the risk of acquiring the diarrheal disease. Our study finding is consistent with the findings in India, Bangladesh, Senegal, Nigeria, Rwanda, and Eretria (21, 2832).

The finding of the current study revealed that lower family size was a protective factor for the burden of childhood diarrhea. This is the fact that high family size might be positively associated with under-five diarrheal disease in which as the number of siblings increases mothers/caretakers are exposed to high burden responsibility in different household activities. As a result, this might be diverted the mother’s attention of care to their children and this may create an abandoned opportunity for children to expose unhygienic environments. This study finding is consistent with findings of other similar studies in Kersa district, Sengale, Wolitta Soddo Town, and Eritrea (15, 20, 23, 28).

The current finding was also obtained a statistically significant association of diarrheal disease with poor hand hygiene practices of child guardians at a critical time. The occurrence of childhood diarrhea was increased by eightfold due to poor hand-washing practices after latrine visits, during child meal preparation, and after refuse handling. The possible explanation might be the high microbial load may be exposed to various health threats as contamination of hands by various types of pathogens. This finding was in line with studies in India, Somalia, Ethiopia in which children’s whose mothers/caretakers are failed to practice good hand-washing at critical times were at higher risk of diarrhea as compared with children’s whose mothers/caretakers who are practicing good hand washing abilities (3, 18, 33).

The outcome of this study was also indicated that odds of diarrheal disease were strongly associated with the time elapsed for the prepared food given to children. The odds of diarrhea among children who feed cooked foods immediately were lower when compared with children who feed cooked foods that are waiting for an undefined period. This might be due to some strains of pathogenic agents having the capacity to survive and reproduce in prepared foods through time which leads to diarrheal diseases. In addition, the prepared child food may be exposed to recontamination when stored for a long time. Studies were done in Afar and Dessie Ethiopia showed that long storage of cooked food-related problems was strongly associated with under-five diarrheal disease (34, 35).

Limitations

It is very difficult to establish a causal relationship due to the inherent nature of the cross-sectional study design. Recall and/or social desirability biases may be introduced in interview-based data collection. The self-report of mothers/caretakers may cause under or over-estimation of diarrheal disease outcomes.

Conclusions

This study demonstrated that childhood diarrheal disease was a common health problem among under-five children in the periphery area of the Azezo sub-city like another part of Ethiopia. Compared with the national and other similar study findings, a higher prevalence of diarrhea was reported in this study area. This study was also identified that children in the young age group, a high family size, low household income, poor hand-wash practice, and longtime storage for cooked food were statistically significant potential risk factors of childhood diarrheal diseases. Therefore, an appropriate intervention program through health education would be recommended with a focus on identified risk factors to reduce the burden of diarrheal diseases.

Abbreviations

AOR: Adjusted odds ratio, COR: Crude odds ratio, EDHS: Ethiopian Demographic and Health Survey, LMICs: low and middle-income countries, MOFD: Ministry of Finance and Education, SDGs: Sustainable Development Goals, UNICEF: United Nations Children’s Fund, U5C: Under-Five Children, WASH: Water Sanitation and Hygiene, and WHO: World Health Organization

Declarations

Ethics approval and consent to participate

Ethical clearance and approval were obtained from the research and ethical review committee of the University of Gondar, Institute of public health, department of Environmental and Occupational Health and Safety. Supportive letters were obtained from Azezo sub-city health office to get permission and acceptance. The written informed consent was obtained from all subjects and/or their legal guardian(s). The participants that are mothers/caretakers with child paired had been informed about the aim of the study and the right to withdraw at any time if they were felt discomfort. The participant’s privacy and confidentiality were strongly maintained using codes rather than personal identifiers. A statement to confirm that all methods were carried out following relevant guidelines and regulations of the cross-sectional study.

Consent for publication

Not applicable in consent for publication due to participants’ images or identity revealing data is not used.

Availability of data  

 All data generated or analyzed during this study are included in this to be published article [and its supplementary information files]. 

Conflicts of Interest

The authors declared that they have no conflicts of interest in financial and non-financial perspectives.

Funding

This study had no special fund. However, the University of Gondar had covered questionnaire duplication and data collection fees.

Authors’ Contributions

All stated authors BDB, AG, and JA were actively involved in the study from the inception to design, acquisition of data, analysis, and interpretation, and drafting of the manuscript. All authors have read and agreed to its content and that the manuscript conforms to the journal’s policies.

Acknowledgments

We would like to express our sincere acknowledgments to the University of Gondar, Department of Environmental and Occupational Health and Safety, data collectors, supervisors, and study participants

Author Details

1Department of Environmental and Occupational Health and Safety, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar Ethiopia. 2Department of Environmental Health, Debre Markos University, Debre Markos, Ethiopia

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