Socio-economic characteristics
A total of 10,377 under-five children were included in the study. Table 1 highlights the distribution of participants across different characteristics. The majority of the children, 9,187 (88.87%) were from rural areas. The mean age of their mothers was 29.56 (± 6.59), 53% of whom were between the age of 25–34 years. More than half of the mothers, 5744 (55.56%) had no work with 6809(65.87%) had no formal education. Only 55.42% of respondents were access to an improved source of water. Among respondents, only 10% of then access improved toilet facilities. Only 20% of respondents were exposed to media (Table 1). Results suggest that overall, 11.87% of children in Ethiopia experienced childhood diarrheal illness in the 2 weeks before the Survey.
Table 1
Socio-demographic characteristics of mothers, parents, and children under five years of age, DHS 2016, Ethiopia
Characteristics | Categories | Weighted Frequency (n = 10,377) | Weighted % |
Region | Tigray | 682 | 6.60 |
Afar | 104 | 1.00 |
Amhara | 1954 | 18.90 |
Oromia | 4537 | 43.89 |
Somali | 473 | 4.57 |
Benishangul | 113 | 1.10 |
SNNP | 2149 | 20.79 |
Gambela | 25 | 0.24 |
Harari | 24 | 0.23 |
Addis Adaba | 233 | 0.26 |
Dire Dawa | 43 | 0.42 |
Mothers education level | No education | 6809 | 65.87 |
Primary | 2777 | 26.87 |
Secondary/Higher | 751 | 7.27 |
Partner's education status | No education | 5280 | 51.08 |
Primary | 3849 | 37.24 |
Secondary/Higher | 1208 | 11.69 |
Mother's age in years | 15–24 | 2288 | 22.14 |
25–34 | 5501 | 53.22 |
35–49 | 2548 | 24.65 |
Residence | Urban | 1151 | 11.13 |
Rural | 9187 | 88.87 |
The current age of children (years) | < 6 | 1195 | 11.56 |
6–11 | 1069 | 10.34 |
12–23 | 2001 | 19.35 |
24–35 | 1927 | 18.64 |
36–47 | 1980 | 19.16 |
48–49 | 2166 | 20.95 |
Number of Children under five years | 1 | 3901 | 37.74 |
2 | 4640 | 44.74 |
≥ 3 | 1796 | 17.37 |
Mother's Occupation | Not working | 5744 | 55.56 |
Working | 4593 | 44.44 |
Wealth Index | Poor | 4848 | 46.89 |
Middle | 2139 | 20.69 |
Rich | 3350 | 32.41 |
Source of Drinking water | Improved water | 5728 | 55.42 |
Unimproved water | 4609 | 44.58 |
Toilet facilities type | Improved | 1036 | 10.02 |
Unimproved | 9301 | 89.97 |
Child stool disposal | Safe | 2797 | 27.06 |
Unsafe | 7540 | 72.94 |
Sex of child | Male | 5307 | 51.34 |
Female | 5030 | 48.66 |
Marital Status | Married | 9715 | 93.98 |
Not Married | 622 | 6.02 |
Duration of breastfeeding | Ever breastfed, not currently breastfeeding | 5159 | 49.90 |
Never breastfed | 376 | 3.64 |
Still breastfeeding | 4802 | 46.46 |
Media exposure | Exposed | 2101 | 20.33 |
Not exposed | 8236 | 79.67 |
Diarrhea status of under-five children | No | 9110 | 88.87 |
yes | 1227 | 11.87 |
Distribution of Childhood Diarrhea
Overall, childhood diarrhea shows the patterns in the country. Generally, a high proportion of childhood diarrheal cases (red dot) and a low proportion of childhood diarrhea (green dot) were observed among under-five year's children in Ethiopia (Fig. 1).
Spatial patterns of childhood diarrhea
The spatial patterns of childhood diarrhea were found in the study period. The Global Moran's I value (0.044591) indicated that there was significant clustering of childhood diarrhea in the country. There is a statistically significant spatial variability in childhood diarrhea among under-five children in Ethiopia (Fig. 2).
Hot Spot Analysis of Childhood Diarrhea
Figure 3 indicates the geographical distribution of childhood diarrhea. The hot spot regions were SNNP, Amhara, Addis Ababa, and Oromia regions. Whereas, the eastern Oromia Benshangul-Gumuz; Harari; Somali, Gambella, Afar and northern Tigray regions were indicated as cold spot regions.
Spatial Interpolation
The red prediction areas show predicted risk regions and the children living in those areas were vulnerable to childhood diarrhea. In the first panel, western Tigray, Amhara, eastern Oromia, and northern SNNP regions were predicted as more risky areas compared to other regions. In the middle panel, the Afar, southern Oromia, and SNNP, eastern Somali were identified as risk areas (Fig. 4).
Spatial SaTScan analysis
A total of 21 significant clusters were identified. Of which, 3 were most likely (primary) clusters and 18 were secondary clusters. The primary cluster's spatial window was located in the west SNNP, which was centered at (7.146476 N, 37.651928 E) / 24.44 km, RR = 2.57 and Log-Likelihood ratio (LLR) of 17.84 at p < 0.001. It showed that children within the spatial window had 2.57 times higher childhood diarrhea than outside the window. The secondary clusters' spatial window was located in Gambella, Oromia and Benishangul Gumuz regions which were centered (8.989285 N, 34.767792 E) / 243.09 km, RR = 1.50 and Log-Likelihood 14.39 with p-vale < 0.001 (Table 2, Fig. 5).
Table 2
SaTScan analysis result of childhood diarrhea among under-five children in Ethiopia, 2016
Cluster | EA (enumeration Area) | Coordinate or Radi | RR | LLR | P-value |
Primary (3) | 565,126 360 | (7.146476 N, 37.651928 E) / 24.44 km | 2.57 | 17.84 | < 0.001 |
Secondary (18) | 248, 462, 558, 304, 433, 349, 165, 407, 555, 88, 285, 177, 586, 294,62, 437, 489, 325 | (8.989285 N, 34.767792 E) / 243.09 km | 1.60 | 14.39 | < 0.001 |
Factors associated with childhood diarrhea
From the multilevel multivariable logistic regression analysis result age of the child, the number of under-five children in the household, mother's occupation, and region were statistically significant factors of childhood diarrhea.
Regarding regions, children live in Tigray region (AOR = 1.69 95% CI, 1.01, 2.83), Amhara AOR = 1.80, (95% CI, 1.06, 3.06), SNNPR AOR = 2.04, (95% CI 1.22, 3.42), and Gambela (AOR = 2.05, (95% CI 1.22, 3.42)), had highest odds of getting diarrhea as compared to children live in Addis Ababa.
The age group of children in a month was a significant factor affecting childhood diarrhea. The odds of developing diarrheal disease among children age 6 to 12 month, 12 to 23 month, and 24 to 35 month, were (AOR = 2.66, (95% CI 2.01, 3.52)), (AOR = 2.45, (95% CI 1.89, 3.17)), and (AOR = 1.53, (95% CI 1.17, 2.01)), times higher than children age less than 6 month respectively. The odds of getting diarrhea among children age 48 to 59 month was decreased by 51% as compared to children aged less than 6 months (AOR = 0.49 (95% CI: 0.35, 0.66)). The odds of getting diarrhea decrease by 24% among households having 3 and above under-five children as compared to households having only one under-five child (AOR = 0.76 (95% CI: 0.61, 0.94)). The odds of children getting diarrhea among working mothers increase by 19% as compared to not working mothers (AOR = 1.19 (95% CI 1.03, 1.38)) (Table 3).
Table 3
Multilevel Multivariable logistic regression analysis of childhood diarrhea among under-five children in Ethiopia, 2016.
Characteristics | Categories | Crude OR (95%CI) | Adjusted OR (95%CI) |
Region | Addis Adaba | 1 | 1 |
Tigray | 1.84(1.16, 2.91) | 1.69(1.01, 2.83) * |
Afar | 1.56(0.97, 2.49) | 1.66(0.97, 2.85) |
Amhara | 1.94(1.23, 3.08) | 1.80(1.06, 3.06) * |
Oromia | 1.57(1.01, 2.47) | 1.52(0.90, 2.55) |
Somali | 0.82(0.51, 1.32) | 0.91(0.53, 1.55) |
Benishangul | 1.24(0.76, 2.03) | 1.19(0.68, 2.08) |
SNNP | 2.08(1.33, 3.26) | 2.04(1.22, 3.42) * |
Gambela | 1.93(1.19, 3.14) | 2.05(1.22, 3.42) * |
Harari | 1.46(0.87, 2.44) | 1.46(0.84, 2.54) |
Dire Dawa | 1.63(0.97, 2.75) | 1.70(0.98, 2.94) |
Mothers education level | No education | 1 | 1 |
Primary | 1.21(1.04, 1.42) | 1.05(0.89, 1.25) |
Secondary/Higher | 0.99(0.78, 1.25) | 0.84(0.64, 1.11) |
Mother's age in years | 15–24 | 1 | 1 |
25–34 | 0.89(0.77, 1.05) | 1.05(0.88, 1.24) |
35–49 | 0.71(0.58, 0.87) | 0.86(0.70, 1.06) |
Residence | Urban | 1 | 1 |
Rural | 1.17(0.95, 1.13) | 1.11(0.83, 1.49) |
Current age of children (month) | < 6 | 1 | 1 |
6–11 | 2.66(2.02, 3.52) | 2.66(2.01, 3.52) * |
12–23 | 2.53(1.96, 3.26) | 2.45(1.89, 3.17) * |
24–35 | 1.61(1.24, 2.10) | 1.53(1.17, 2.01) * |
36–47 | 1.05(0.79, 1.38) | 1.01(0.76, 1.34) |
48–49 | 0.50(0.37, 0.67) | 0.49(0.35, 0.66) * |
Number of Children under five years | 1 | 1 | 1 |
2 | 0.84(0.72, 0.97) | 0.86(0.74, 1.01) |
≥ 3 | 0.68(0.55, 0.82) | 0.76(0.61, 0.94) * |
Mother's Occupation | Not working | 1 | 1 |
Working | 1.18(1.02, 1.35) | 1.19(1.03, 1.38) * |
Wealth Index | Poor | 1 | 1 |
Middle | 1.15(0.95, 1.41) | 1.07(0.87, 1.33) |
Rich | 1.05(0.89, 1.23) | 1.08(0.88, 1.33) |
Source of Drinking water | Improved water | 1 | 1 |
Unimproved water | 1.04(0.89, 1.21) | 1.06(0.90, 1.25) |
Toilet facilities type | Improved water | 1 | 1 |
Unimproved water | 1.15(0.95, 1.39) | 1.04(0.82, 1.32) |
Child stool disposal | Safe | 1 | 1 |
Unsafe | 0.83(0.71, 0.96) | 1.07(0.9, 1.26) |
Media exposure | Exposed | 1.04(0.88, 1.23) | 1.02(0.85, 1.23) |
Not exposed | 1 | 1 |