Diarrhea causes more than half a million childhood mortality across low-income and middle-income countries (LMICs) . According to the Global Burden of Disease Study 2017, more than 910 million childhood diarrheal cases were reported each year . Globally, diarrhea remains a leading cause of under-five mortality-account for 1 in 9 child deaths . In addition to this staggering loss of under-five life, it can have a detrimental impact on childhood growth and cognitive development [4,5]. It is also estimated that the odds of stunting at 24 months increased by 5% with each diarrheal episode . Furthermore, the proportion of reported antibiotic use among sick children under 5 years of age with fever, diarrhea, or cough was less than fifty percent, 43.1% .
Diarrhea is preventable with the application of hand hygiene, basic sanitation, and the provision of safe drinking water . Almost 88% of diarrhea-associated deaths are attributable to unsafe water, inadequate sanitation, and insufficient hygiene . Several studies explore the effect of single and combined water, sanitation, and hygiene (WASH) intervention in the reduce risk of diarrheal morbidity [8,10–14]. For example, a systematic review for the effect of WASH interventions for acute childhood diarrhea found that various WASH interventions show diarrhea risk reductions between 27% and 53% in children under five years old, depending on intervention type . A recent updated meta-analysis showed that promoting handwashing with soap associated with reduced risk of diarrhea by 30% .
In Ethiopia, where there is a lack of safe excreta disposal facility, safe drinking water, and poor hygiene practice [8,15,16], diarrhea remains is an important public health problem. Over the past two decades, the prevalence of childhood diarrhea has shown a declining trend—from 24% in 2000 to 12% in 2016 [17,18]. Despite progress in the reduction of childhood diarrhea in Ethiopia, still it is the second leading cause of morbidity and mortality among under-five children next to pneumonia [15,18]. A recent systematic review finding revealed that the pooled prevalence of diarrhea among under-five children in Ethiopia was 22% .
Different studies showed that household-level risk factors such as lack of safe water and improved sanitation facility, poor maternal hygiene, household water treatment, methods of complementary feeding, types of water storage equipment, maternal education, and improper waste disposal practices were significant factors for the occurrence of diarrheal illness [8,10,12,13,15,19,20]. In previous works of literature, the effect of improved WASH on childhood diarrhea morbidity was well established. However, in some instances, WASH interventions fail to appear long-term impact , due to reinfection and contamination of the living home as a result of dirt floors. As dirt floors facilitate and increased defilement of finger, fluid, food, and materials that encounter these surfaces and possibly increase the risk of diarrhea among children [21–24]. A study from Zimbabwe showed that mothers of infants living in households with improved flooring were less likely to report diarrheal illness. Further, the association between flooring and diarrheal illness did not vary by the presence of improved/unimproved water or sanitation . It was also found that dirt and mud floors are a known predictor of diarrhea and parasitic infestations [23,24]. Eliminating a dirt floor from the home results in dramatic reductions in childhood diarrhea and Soil-Transmitted Helminth (STH) [23,25]. For instance, replacing a dirt floor with a concrete floor reduces diarrhea by 49% .
In many developing countries, including Ethiopia replacing a dirt floor with concrete or other improved material is unaffordable to the poor. And the challenges remain due to cleaning of sand or soil floors are so difficult, the proximity of latrine pits, and unsanitary environmental surrounding. This may be further exacerbated by contamination of the floor by fecal matter brought in on shoes, and especially when animals live in close proximity to humans [22,27,28]. According to the recent 2016 EDHS report, the two most commonly used materials for flooring in Ethiopia are earth or sand (48%) and dung (33%) . And children dwelling in households with mud floors are disproportionately affected by diarrheal diseases .
Numerous research articles from Ethiopia have identified the determinants of under-five diarrhea [15,19,29,30]. However, specific studies that focus on factors that influence childhood diarrhea in households with sub-optimal flooring (i.e. earth, mud or sand, and dung) are limited and not sufficient to show the underlying factors. As more than 80% of Ethiopians live and sleep on a dirt floor, the challenges remain enormous where diarrhea is spreads more easily in homes with dirt floors. Up to date, no study ever assessed the determinants of diarrhea solely among children residing in households with the sub-optimal floor in Ethiopia. Therefore, this present study aimed to investigate factors associated with childhood diarrhea among children residing in households with sub-optimal flooring in Ethiopia.