International Journal of Advanced Research and Publications

ISSN: 2456-9992

Maternal Hygiene Practice And Its Association

With Acute Diarrheal Disease Among Under Five
Children: A Case Control Study In Babile District,
East Hararghe Zone, Oromia Region, East Ethiopia
Sisay Yami Gudeta

Development Partners Consulting firm, Addis Ababa, Ethiopia.

Abstract: Background: Diarrhea is one of the leading causes of mortality in developing countries, especially among
children under the age of five years. Despite efforts to curb acute diarrheal disease, there exists knowledge gap in identifying
maternal hygiene practice associated with diarrheal disease among under five years old children in Babile district.
Objectives: The objective of the study was to assess maternal hygiene practice & its association with acute diarrheal disease
among under five children in Babile district, East Hararghe Zone, Oromia Region, East Ethiopia. Methods: The study design
was community based unmatched case control and data collection was conducted from May 10-30, 2016. Multi-stage
sampling , then simple random sampling was employed to select four kebeles. Data entry, cleaning and analysis was done
using SPSS software. Result: A total of 219 sample (73 cases and 146 controls) were interviewed in this study making
100% response rate. Occurrence of under five children diarrhea was significantly associated with unsanitary disposal of
children feces (AOR=4.342,95% CI:1.021-18.459), mothers fail to wash hands with soap always in critical times
(AOR=6.721, 95% CI:1.053-42.875) and recent episode of diarrhea in mothers (AOR=16.754,95% CI: 5.526-
50.791)..Conclusion: Child feces management, proper hand washing in critical time and recent episode of maternal diarrhea
were found to be predictors of under five diarrheal disease.

Key words: Acute diarrhea, under five children, sanitary disposal, hand washing, hygiene, Babile district.

1. INTRODUCTION is limited, ash can be used as substitute for

Diarrhea is defined as passing of three or more episodes of
loose or watery stools during a 24-hour’s
period(1).Diarrhea causes death by depleting body fluids
resulting in profound dehydration(2). It’s effects, varies
from severe dehydration to malnutrition, resulting in
weakening of immune system and make the children
vulnerable for infection. Moreover; research showed that
diarrhea can cause long term physical impairment like
stunted growth and reduced intellectual development(3).
Under five diarrheal disease is known to kill 2195 children
daily exceeding deaths from AIDS, malaria and measles
together(3). The WHO region office for Africa estimated
that 300,000 deaths happen due to diarrhea in Africa every
year(4). According to EDHS report, under five mortality in
Ethiopia was 88 death/1000 live birth in 2011 while under
five mortality for Oromia National Regional State was
112/1000 live birth in the same period(5). The fact that
mothers are the primary care giver, responsible for food
handling, preparation, serving and hygiene practice are the
main reason for the occurrence of the acute diarrheal
disease in their child whilst failing to apply hygienic
procedures(6).It is indicated in 2011 EDHS report that
36% of household with under five children dispose feces of
children in sanitary way while 40.3% of household left
children feces in the open(5). A review of case control
studies done in developing countries on child feces
management were considered risky (open defecation, stool
disposal in open fields, stools not removed from soil, stools
seen in household soil and children seen contaminated with
feces) were found to increase the risk of diarrhea (7).
Appropriate hand washing with soap could decreases
diarrhea by 45% fold. In rural areas with soap accessibility
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cleaning(4).Here, it is advisable to aware mother/care
givers about proper hand washing and its contribution to
prevention of diarrheal disease (4). The study in Eastern
Ethiopia indicated that presence of hand washing facility
with soap usage were known to have positive significance
association with decreased occurrence of diarrheal disease
among under five children(8). Mother's education level has
a substantial effect on the health of their children and also
plays an important role in enhancing awareness of health
and cleanliness practice(9). Evidence from 2011 EDHS
study suggest that education of mother was closely related
to child mortality trend in Ethiopia. Mother’s education is
inversely related to a child’s risk of dying from diarrhea(5).
Even though efforts have been underway to tackle the
incidence and burden due to diarrheal disease in under five
children, still there exists knowledge gap in identifying the
maternal hygiene practice and its association with under
five children acute diarrheal disease in Babile district. The
objective of this study is to identify the behavioral
determinant of acute diarrheal disease among under five
children in Babile district.
2. METHODS
2.1 Study Period and Area
The data collection period was from May 10-30, 2016. The
study area was Babile district, which is found in East
Hararghe Zone, Oromia National Regional Sate, East
Ethiopia. It is located at a distance of 544 km from Addis
Ababa. There are 22 kebeles with health posts and four
health centers. According to CSA Woreda population
Projection(10), the total population of Babile district was
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estimated to be 118,537 in 2015. The urban population was
26,058 people whereas 92,479 people have been residing in
rural areas. According to CSA population projection 17934
(15.13%) of the population were under five children(10).
2.2 Study Design
A community based unmatched case control study was
employed to assess behavioral determinant of acute
diarrheal disease among under five children in Babile
district.
2.3 Source Population
The source population for cases were all under five
children with acute diarrhea in selected kebeles of Babile
district in two weeks preceding the census as reported by
mother/ care giver. The source population for controls were
all under five children without acute diarrhea in selected
kebeles of Babile district in two weeks preceding the
census as reported by mother/care giver.
2.4 Study Population
A selected cases of under five years old children with acute
diarrhea in two weeks preceding the census in selected
kebeles as reported by mother/care giver. A selected
controls of under five children without acute diarrhea in
two weeks preceding the census in selected kebeles as
reported by mother/care giver.
2.5 Inclusion and Exclusion Criteria
2.5.1 Inclusion criteria
Inclusion criteria for cases were all under five children with
acute diarrhea in selected kebeles of Babile district.
Inclusion criteria for controls were all under five children
without acute diarrhea in selected kebeles of Babile district.
2.5.2 Exclusion criteria
Exclusion criteria for cases: Mother/care givers who could
not respond because of serious illness and mother/care
givers who did not lived in the area for at least six months
was excluded from the cases. Moreover; children who were
healthy and chronically ill were excluded from the study as
cases. Exclusion criteria for controls: Mother/care givers
who could not respond because of serious illness and
mother/care givers who did not lived in the area for at least
six months was excluded from the study. Moreover;
children who were ill with diarrhea for two weeks
preceding the census were excluded from the study as a
control.
2.6 Sample Size Determination
The sample size was calculated using Epi Info v3.5.3
software (http://wwwn.cdc.gov/epiinfo/). First sample size
was calculated for the key variables and decision was
made to take predictor which provide larger sample size.
Thus, insanitary child feces management was taken as
predictors of acute diarrheal disease(11). Calculation of
sample size was done taking p1= 0.61, p2=0.39, Z1-α/2=1.96
(95% C.I) Z1−β =0.84 (power of 80%),ratio of cases to
controls 1:2, the sample size was 198(Cases=66 and
Controls=132).Finally; adding 10% non response rate
made the final sample size to be 219 (Cases=73 and
Controls=146).
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2.7 Sampling Procedures
Multi-stage sampling procedure was used to select four
kebele out of 22 kebeles. Then, all under five children who
have diarrhea and who did not have diarrhea within 14 days
preceding census date were registered with qualified Bsc
Nurses in accordance of case definition. Finally, cases as
well as controls were selected using simple random
sampling method from the list of cases and controls
respectively. Proportionate sample size allocation was used
for each chosen kebeles to get the final sample size.
2.8 Data Collection Procedures
The tool used for data collection was structured and
pretested standardized core questionnaire of WHO/Unicef
which was designed to assess the factors related to acute
diarrheal diseases(12).Data collection were conducted by
four trained B.sc Nurses. There were also three health
professional supervisors including the principal investigator
in follow up of data collection and supervision. Pre-test
was done on 5% of the sample before the beginning of
actual data collection for checking the validity and make
some modification on ambiguous questions. A pretest was
carried out in other kebele and non study groups.
2.9 Variables of the Study
The study variables were selected after review of related
literatures on the study subject.
Dependent variable
Acute diarrheal disease status among under five children
two weeks preceding the census in Babile District, East
Hararghe Zone, Oromia Region, East Ethiopia,2016.
Independent variables
Demography and Socio-economic variables:- Age of child,
sex of child, educational status of mother/caregiver and
income of the household
Maternal hygiene practice:- Child feces management, hand
washing with soap/ash, proper hand washing with soap
always at critical time and recent episode of diarrhea in
mother .
2.10 Operational Definitions
Sanitary disposal of children’s feces:- Are child use latrine,
put feces in latrine and buried feces(12). Proper hand
washing with soap at critical time:- Are hand washing with
soap after visiting toilet, before feeding a child, after
handling of child feces, before preparation & eating
foods(13).
2.11 Data Processing and Analysis
Statistical package for social sciences (SPSS) 20th version
was used for data entry, cleaning and analysis. Descriptive
statistics was calculated and crude odds ratio with 95%
confidence intervals were used to determine the strength of
association between binary dependent variables &
independent categorical variables in bivariate analysis.
Finally, a multivariate analysis using Binary logistic
regression was done to control confounding effect and
determine predictors of out come variable for those that
appeared to be statistically significant (P≤0.05) in the
bivariate analysis.
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2.12 Data Quality Management
Standardized, structured and pre-tested questionnaire was
used for data collection. The questionnaire was translated
into local language (Affan Oromo) from its English version
then back to English. Training was provided for the data
collectors for two days on how the data should be obtained
and recorded. Adequate supervisors including the principal
investigator was deployed. Checking of consistency and
completeness was performed on daily basis up to the final
data collection day.
2.13 Ethical Considerations
Ethical clearance was obtained from the research and
ethical review committee of Wollega University. Babile
district health office and health centers was communicated
legally for their permission and each of the interviewee was
asked for their consent before the interview. Confidentiality
was assured by not recording interviewee name on the
questionnaire.
3 RESULTS
3.1 Descriptive Statistics
A total of 219 (Cases=73 and Controls=146) were
interviewed in the study making the response rate of
100%.The Mean±SD age of the child was 23.90±12.33
months for cases and 27.98±12.54 months for controls.
The median income of the household in cases was 1946.04
birr while it was 3159.60 birr in controls. Regarding sex of
the child, males were 34(46.6%) and 64(43.8%) in cases
and controls while females were 39(53.4%) and 82(56.2%)
in cases and controls respectively.
3.2 Demography & Socio-economic Factors Related to
Acute Diarrheal Disease in under Five Children
The bivariate analysis showed that child age group above
23 months(p=0.004) was significantly associated with acute
diarrhea compared to the age group less than 12 months.
Children living with mother with no education has more
odds(p=0.004) to develop diarrhea than children living
with mother who have primary and above education. Yet,
children living with mother who were able to read and
write were more likely(p=0.014) to be caught by acute
diarrhea than children living with mother who have
primary and above education. Children living in household
who got monthly income less or equal to 1200 birr have
more likely to develop (p=0.000) acute diarrhea than their
counterparts(Table:1).

Table:1 Bivariate analysis of demography & socioeconomic factors associated with acute diarrheal disease among under
five children in Babile district, East Hararghe zone, Oromia Region, East Ethiopia,2016.

Variables Category Cases(%) Controls(%) COR (95% CI) P-value

<12months 6(8.2) 11(7.5) 1
Age of index child 12-24 28(38.4) 30(20.5) 0.681(0.236-1.966) 0.478
Above 23 months 39(53.4) 105(71.9) 0.398(0.211-0.749) 0.004
Male 34(46.6) 64(43.8) 1
Sex of child
Female 39(53.4) 82(56.2) 0.895(0.509-1.574) 0.701
Education of No education 50(68.5) 66(45.2) 2.755(1.286-5.901) 0.009
mother/Care Read & write 11(15.1) 40(27.4) 2.525(1.202-5.306) 0.014
giver Primary education & above 12(16.4) 40(27.4) 1
≤1200birr 25(36.2) 14(10.0) 5.114(2.443-10.705) 0.000
Monthly income
>1200 44(63.8) 126(90.0) 1

3.3 Maternal Hygiene Practice Related to Acute Diarrheal
Disease in Under Five Children
All indicated maternal hygiene practices had statistically
significant association with acute diarrheal disease among
under five children in this study. Child feces management
(p=0.000), hand washing with soap/ash (p=0.000), hand
washing practice in critical time(p=0.000 and episode of
diarrhea in mother/Care giver (p=0.000) showed statistical
significance association with acute diarrheal disease among
under five children(Table:2).

Table 2: Bivariate analysis of maternal hygiene practice associated with acute diarrheal disease among under five children
in Babile district, East Hararghe zone, Oromia Region, East Ethiopia,2016.

Variables Category Cases(%) Controls(%) COR (95% CI) P-value

Child feces Sanitary disposal 6(8.2) 108(74.0) 1
management Unsanitary disposal 67(91.8) 38(26.0) 31.737(12.732-79.110) 0.000
Hand washing with Yes 6(8.2) 111(76.0) 1
soap/ ash No 67(91.8) 35(24.0) 35.414(14.148-88.649) 0.000
Proper hand washing Fully 6(8.2) 112(76.7) 1
practice with
soap in critical Partially 67(91.8) 34(23.3) 36.784(14.672-92.225) 0.000
time
Recent episode of Yes 50(68.5) 12(8.2) 24.275(11.242-52.420) 0.000
diarrhea in
mother/ Care No 23(31.5) 134(91.8) 1
giver

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ISSN: 2456-9992

3.4 Factors Independently Associated with Acute
Diarrheal Disease in Under Five Children
All variables which showed statistical significance
association with acute diarrhea disease among under five
children (p≤0.05) in the crude analyses were entered in to
final logistic regression. In multivariate analysis; only three
maternal hygiene practices were independently associated
with acute diarrheal disease among under five children in
this study (Table:3). Children whose feces were disposed
in unsanitary way were 4.342 more likely to develop
diarrhea than children whose feces were disposed in
sanitary way(AOR=4.342,95% CI:1.021-18.459). Children
living with mother who didn’t washed their hands with
soap always in critical times were 6.721 times more likely
to develop acute diarrhea than their counterparts
(AOR=6.721, 95% CI:1.053-42.875). Children whose
mother/care givers had recent episode of acute diarrhea
were 16.754 times more likely to develop diarrheal disease
compared to children whose mother/care giver did not have
recent episode of diarrhea (AOR=16.754,95% CI: 5.526-
50.791) (Table:3).

Table 3:Multivariate analysis of factors associated with acute diarrheal disease among under five years old children in
Babile district, East Hararghe zone, Oromia Region, East Ethiopia,2016.

Variables Category COR (95% CI) AOR (95% CI) P-value

<12months 0.681(0.236-1.966) 1.106(0.180-6.788) 0.914
Age of child 12-24 0.398(0.211-0.749) 1.905(0.362-10.020) 0.447
Above 23 months 1 1
No education 2.755(1.286-5.901) 0.978(0.294-3.219) 0.972
Read & write 2.525(1.202-5.306) 0.887(0.173-4.550) 0.885
Education of
mother/Care giver
Primary education & above 1 1

Monthly income of the ≤1200birr 5.114(2.443-10.705) 1.096(0.373-3.219) 0.867

HH >1200 1 1
Child feces Sanitary disposal 1 1
management Unsanitary disposal 31.737(12.732-79.110) 4.342(1.021-18.459) 0.049
Hand washing with Yes 1 1
soap/ash No 35.414(14.148-88.649) 2.451(0.396-15.169) 0.335
Hand washing practice Fully 1 1
with soap always
Partially 36.784(14.672-92.225) 6.721(1.053-42.875) 0.044
in critical time
Recent episode of Yes 24.275(11.242-52.420) 16.754(5.526-50.791) 0.000
diarrhea in
No 1 1
mother/Care giver

4. DISCUSSION
The finding of this study showed that children whose feces
disposed in unsanitary ways were 4.342 times more likely
to develop diarrhea that children whose feces were
disposed in sanitary way. The result of this study was also
supported from review of case control studies in
developing countries which showed increased risk of
diarrhea for children whose feces disposed in unsanitary
way(7). The study also revealed that children living with
mother who didn’t washed their hands with soap always in
critical time were 6.721 more likely to develop acute
diarrhea than children living with mother who didn’t
washed their hands always in critically time. According to
WHO, appropriate hand washing with soap would have
beneficial effect in decreasing diarrhea incident by 45%
fold(4) Children whose mother/care givers had recent
episode of diarrhea were 16.754 times more likely to
develop diarrheal disease compare to children whose
mother/care givers didn’t had recent episode of diarrhea.
This finding was in line with the result of West Gojam
Mecha and Shebedino district of Ethiopia which showed
higher odds of developing diarrhea in children whose
mother had recent episode of diarrhea than children whose
mother had no recent episode of diarrhea respectively
(14,15).
5. STRENGTH AND LIMITATIONS OF
THE STUDY
The study employed standardized, structured and pre-
tested core questionnaire of WHO/Unicef. The limitation
of this study arise from the retrospective nature of the study
and there might be recall bias of respondents.
6. CONCLUSIONS
It was concluded that maternal hygiene practice such as
child feces management, proper hand washing always in
critical time with soap and recent episode of maternal
diarrhea were predictors of under five children diarrheal
disease in Babile district.
7. RECOMMENDATIONS
Based on the findings of this study, the following
recommendations were forwarded:-
 Health education should focus on maternal hygiene
and sanitation practice
 Health extension workers should enhance awareness
on proper hand washing in critical time
 The health sector should focus on behavioral change
and communication on hygiene and prevention of
diarrhea transmission
 Further research on causative agents & associated
factors of diarrheal disease among under five years old
children
8. CONFLICT OF INTEREST
I declare that there is no conflict of interest on this
research.

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ISSN: 2456-9992

9. ACKNOWLEDGMENTS [10] CSA, 2013.Population projection for Ethiopia 2007-

I owe my deepest gratitude to Babile district health office
for the support provided to me in data collection. My
appreciation also delivered to the study subject for their
patience in providing valid information. Finally, I thanks
my wife W/o Hiwot Samuel and our beloved Son Christian
for unconditional love, support, encouragement throughout
this study.
2037.Addis Ababa, Ethiopia.
[11] Wanzahun Godana, Bezatu Mengiste Environmental
factors associated with acute diarrhea among children
under-five years of age in Derashe district, Southern
Ethiopia. Science Journal of Public Health,
2013;1(3):119–24.

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