1.

INTRODUCTION
1.1 BACKGROUND
Although there is global decline in the death rates of children younger than 5 years old, the
risk of a child dying before becoming 5 years of age remains highest in the WHO African
Region (90 per 1000 live birth), which is approximately seven times higher than that in the WHO
European Region (12 per 1000 live births) [1]. Children in developing countries are
disproportionately affected by preventable and treatable diseases with simple and affordable
interventions. Every day more than 4000 children lose their life due to diarrhea [2]. The vast
majority of these deaths are among children who live in low and middle-income countries [3]. In
Ethiopia, the 2010 report of the Ministry of Finance and Economic Development (MOFED)
indicated that 20% of childhood deaths in the country were due to diarrhea. The 2011 Ethiopia
Demographic and Health Survey of Ethiopia (EDHS) finding also showed that 13% of the
children had diarrhea in the 2 weeks preceding the survey at the national level [4,5]. Diarrhea is
generally defined as three or more loose or watery stools within a 24 hours period [6-8], or a
decrease in the consistency of the stool from that which is normal for the patient [9]. In
developing countries, diarrhea is most often a symptom of gastrointestinal infection caused
by bacteria, viruses or parasites which are commonly transmitted via the feco-oral route,
where the pathogens are excreted from the intestinal tract of a person or animal car ring the
illness and are ingested by another [9].
People in the economically poorest regions of the world and the least developed countries
continue to bear the heaviest burden of child deaths. More than four-fifths of all deaths among
children younger than 5 years old in 2011 occurred in sub-Saharan Africa and South Asia [10].
Diarrheal disease is not purely medical, but huge part of this should be traced back to the social,
economic, environmental and behavioral aspects of the family. The problem in Ethiopia is
even worse than elsewhere in the world, with an Ethiopian child being 30 times more likely to
die by his/her fifth birthday than a child in Western Europe [11]. Studies conducted in
Ethiopia, in other regions documented many socioeconomic factors such as overcrowding and
low maternal education, poor sanitation, contaminated water, failure to continue breast feeding
until one year of age, using infant bottles which are difficult to clean, storing food at room

1
temperature, failure to wash hands, failure to dispose of faces hygienically and inadequate food
hygiene were associated with a high incidence of under-five diarrheal diseases [12-21].

1.2 STATEMENT OF THE PROBLEM

Diarrheal disease is the leading causes of death in children under five years. Globally, it accounts
for 1.8million death per year and 80% of childhood death. The overall diarrheal episode
incidence is 3.2 per children per year. (4). A number of deaths of children due to any cause are
46%. The dangers of diarrhea related to dehydration and malnutrition, while dysentery is another
important cause of death due to fatal complication associated with it. (5).

In developing countries, morbidity and mortality associated with childhood diarrhea remains
challenging problem (4). Most of diarrheal episodes occur in children in the first year of life. In
some areas young children spend 15-20% of their time with diarrheal illness (5, 6).

Diarrheal illness can have a significant impact on psychomotor and cognitive development in
young children. Early and repeated episode of childhood diarrhea during a period of critical
development, especially associated with malnutrition, co-infection and anemia can have long
term effects on linear growth as well as on physical and cognitive function (1).

Diarrhea can last several days and can leave the body without water and salt that are necessary
for survival. Most people who die from diarrhea actually died from severe dehydration and fluid
loss (7).

Globally, mortality is declining but the overall diarrheal incidence remains unchanged and it is
estimated to account for 13% of childhood disability adjusted life years (1,5).

1.3 SIGNIFICANCE OF THE STUDY

Diarrhea is a common health problem in developing countries like Ethiopia and in our study
area. The study also helps Town Heath office and for stakeholders to create awareness to the
community on how big the problem is and methods of prevention based on our research
Findings. So we are interested to do this research and find prevalence and associated factors of
diarrhea amongunder five years of children. Similarly this research will contribute to policy

makers, stake-holders and program initiators on possible and actionable services required
to improve the situation of these children which can help for decision making.

2
2. LITERATURE REVIEW

Diarrhea remains the leading cause of morbidity and mortality in children under 5 years old
worldwide. The burden is disproportionately high among children in low and middle income
countries. Young children are especially vulnerable to diarrheal disease and a high proportion of
the deaths occur in the first 2 years of life. Worldwide, the majority of deaths related to diarrhea
take place in Africa and South Asia. Nearly half of deaths from diarrhea among young children
occur in Africa where diarrhea is the largest cause of death among children under 5 years old and
a major cause of childhood illness [1-4].

Although some of the factors associated with diarrhea in children in Ethiopia such as Acute
Respiratory Infection (ARI), maternal history of recent diarrhea, maternal education, well source
of water, obtaining water from storage container by dipping, availability of latrine facilities,
living in a house with fewer number of rooms, not breast feeding, duration of breast feeding, and
age of the child, have been identified, diarrhea is still a major public health problem among
children under 5 years old [5-

8]. Epidemiologic studies show that factors determining the occurrence of diarrhea in children
are complex and the relative contribution of each factor varies as a function of interaction
between socio-economic, environmental and behavioral variables [5,9-11]. Recent research
indicated that studies in differing environment and prioritizing interventions based on context
would be useful to prevent deaths from diarrhea [12]. In Ethiopia, despite the high prevalence of
the disease, reports from population based studies are sparse. The study would be helpful in
planning and implementation of prevention strategies at the community level. Thus, the objective
of this study was to assess the prevalence of diarrhea and associated factors among children of
age under five. In developing countries mortality and morbidity associated with childhood
diarrhea is still a big problem. A ten-year review of the global problem of diarrheal disease has
shown that there are more than 1 billion episodes and 3 million deaths occurring each year
among under-five children. It is also estimated that each child in developing countries
experiences 3.2 episodes diarrhea per year (4).

According to research done in India, west Bengal, the overall incidence of diarrhea in under five
children was 1.7 episodes per year per child(8). Comprehensive analysis of 73 studies from 23

3
Sub-Saharan African countries showed that children under five years of age experience about
five episodes of diarrhea each year. The analysis also showed that prevalence of childhood
diarrhea ranged from 10.5 to 19 percent (9). In their study on the determinants of childhood
diarrhea in The Republic of Congo, Mock et al found a two week period prevalence of 18.6
percent in children under-three years of age (10). In rural Zaire, a longitudinal study done on
children aged 3-35 months showed annual incidence of 6.3 episodes per child (11). Another
study child health research project report on childhood diarrhea in sub Saharan Africa, diarrhea
is one of the top three cause of childhood mortality and morbidities in sub Saharan African
countries. Over all death rate ranges from 3.4-31 per 1000 children per year. Acute diarrhea
accounted for 1.9-37% of all death with greatest proportion occurring in the first year of life.
Persistent diarrhea (duration of more than 14 days) is also responsible for significant childhood
mortality in Sub-Saharan Africa, where rates of 6.6 to 43 death per 1000 children per year have
been observed. The median annual incidence of diarrhea peaks among 6-12 months old children
and decreases progressively there after according to the same study. A review of longitudinal
community based studies with frequent surveillance found that 6-11 month old children in Africa
had a median of 4.5 diarrheal episodes per year(9).

According to Morris, Black and Tomas Cobik review of literature on the causes of diseases
among children under five for sub Saharan Africa and Asia 21.9% of all deaths of children up to
five years of age in sub-Saharan Africa in the year 2000 were due to diarrhea, corresponding to a
total of 935,000 deaths (12). Another study conducted in the republic of Congo showed that
highly educated mothers reported less diarrhea (13). In the same area the other study showed
that children coming from households that obtain water from protected source were less likely to
have diarrhea as compared to those who get water supply from unprotected source. This study
also revealed that children of families with latrine had a lower prevalence of diarrheal disease
than those children whose families didn't have latrine (14).

Study that was conducted in Eritrea shows that availability of toilet facility in the household was
associated with a 27% reduction of diarrhea in under five children (15). The prevalence of
diarrhea amongunder five years children in Botswana is 10% and 40% each in Senegal and
Liberia. (16). each child in sub-Saharan Africa has five episodes of diarrhea per year and
8,000,000 die each year due to diarrhea and dehydration. (17).

4
In Ethiopia the two weeks prevalence of diarrhea in under five children is about 24%. (18). The
Ethiopian Demographic and Health Survey (EDHS) 2011 report shows that diarrhea is a
considerable child health problem; 13% of children under five were reported to have had
diarrhea and 3% had had diarrhea with blood in the two weeks before the survey and watery
diarrhea was the commonest form. This study also shows that diarrhea was most common among
children of age 6-23 months (23-25%) with the prevalence varies seasonally. The prevalence of
diarrhea in under five children residing in the BenshanguleGumuze and Gambela (both 23%),
whereas oromia it is 18%. (19).

Studies in different parts of Ethiopia have shown that diarrheal incidence and prevalence is very
high among under five children (20). One study done in Tigray region on the patterns of
childhood morbidity found that 3.05 diarrheal episodes per child per year (21). Another study
that attempted to determine household illness prevalence in Gondar showed that diarrhea was
one of the most frequently occurring symptoms that account 11.4% of the overall illness
prevalence (22).

The analysis that was done on under five children mortality in Giligel Gibe field was found that
mortality rate due to acute watery diarrhea is 30%(23).

According to the research conducted in Nekemte town, western Ethiopia diarrhea morbidity
prevalence was 28.9% in under five years children (24). Another survey in Mana district and
Jimma town, south west Ethiopia revealed that the two week period of prevalence of childhood
diarrhea morbidity was 33.7% and 36.5% respectively (25).

The analysis of 1961 admission to Pediatric clinic in Adds Ababa indicates that diarrheal disease
accounts for 21% prevalence and 2.3% of deaths (26). In the same place research in 20 health
centers shows that among 576 children taken, 229 of them are affected with diarrhea(27).

According to a follow-up study in Butajira, the incidence of diarrhea was about two-episodes per
person per year (28). A community based study conducted in KeffaSheka Zone, southern
Ethiopia found a two-week childhood diarrhea prevalence of 15 %(29).

Children who are malnourished or have an impaired immunity are most at risk of life
threatening diarrhea. (7). Diarrhea and malnutrition are known to have a bi-directional

5
relationship that is they are potentially causing each other. Diarrhea may lead to malnutrition due
to reduced dietary intake, mal absorption, and mal-digestion. on the other hand, mal-nutrition
may cause and worsen diarrhea and other infections due to weekend immunity system. (30)

Contaminated foods are responsible for 70% of diarrheal episodes. In developing countries,
weaning foods are often prepared in hygienic manner. Thus, weaning age is especially dangerous
time for infants since they are exposed to infective dose of food borne pathogens. Food
contamination source includes unclean hands, feces, polluted water, Flies, pests, domestic
animals, unclean utensils, pots and unsanitary environment. (31). Diarrhea prevalence is highest
among children residing in households that drink from unprotected wells (15). Those residing in
rural and urban area 14% and 11% respectively one study showed that house hold income was
directly related to having in house water connection or private excreta disposal facility in which
both reduce the risk of having child hood diarrhea (32).
A study conducted in Wolayitasodo town on the determinants of diarrhea in under five children
showed that the probability of having diarrhea was 33-38% lower for children from the medium
and high socio economic status than the children from low socio economic status (15). Another
study on family size revealed that mothers having five or more living children reported more
frequently that their child had had diarrhea (13). The analysis on breast feeding and risk of
diarrhea indicated that the risk of developing diarrheal disease in partially breast feed infants
was five times higher than that of infants exclusively on breast milk(18). One study on hygienic
behavior sever child hood diarrhea also showed that unhygienic practices were important risk
factors for severe diarrhea in under five children(33). The autoregressive effect of diarrheal
episodes with a child's age was revealed in the longitudinal study from more than 14 episodes to
2 episodes per year –child (34).
People in the economically poorest regions of the world and the least developed countries
continue to bear the heaviest burden of child deaths. More than four-fifths of all deaths among
children younger than 5 years old in 2011 occurred in sub-Saharan Africa and South Asia [10].
Diarrheal disease is not purely medical, but huge part of this should be traced back to the social,
economic, environmental andbehavioral aspects of the family. the problem in Ethiopia is
even worse than elsewhere in the world, with an Ethiopian child being 30 times more likely to
die by his/her birthday than a child in Western Europe [11]. Studies conducted in Ethiopia,
in other regions documented many socioeconomic factors such as overcrowding and low

6
maternal education, poor sanitation, contaminated water, failure to continue breast feeding until
one year of age, using infant bottles which are difficult to clean, storing food at room
temperature, failure to wash hands, failure to dispose of faeces hygienically and inadequate food
hygiene were associated with a high incidence of under-five diarrheal diseases [12,21].

2.1 Conceptual framework

Figure 1 factors that might lead to the occurrence of diarrhea episodes among children
under 5 years are represented. The figure shows interaction of diverse factors In Figure
some of the socioeconomic, behavioral and environmental risk that include level of
education, mother working status, residence, income and other risk factors with each other
leading to the occurrence of diarrhea which in severe cases leads to under 5 child
mortality. This shows that several factors are interlinked to cause illness and that one
factor alone might not lead to a diarrheal episode but a combination of factors can.

7
 Socio demographic Factors
 Age
 Sex
 Marital status of the mother
 Religion
 Ethnic
 Educational Level
 Occupation
 Income

Environmental Risk Factors

 Source of drinking water

 Types of water storage
material Outcome Variable Occurrence
 Amount of water of Diarrhea disease
 Cleanness of compound
 Latrine cleanness

Behavioral distribution of the study

children

 Materials used to feed

 toilet facility with the family
 feeding abilities of the child

Figure 1. Conceptual framework Interacting Interlinked Risk Factors Leading to the

Occurrence of Diarrhea among Children under 5(35)

8
3. OBJECTIVE
3.1 General objective

-To assess the prevalence and associated factors of diarrheal disease among under five children
in Adama town, From April- August, 2018 GC

3.2 Specific objectives

-To determine the prevalence of diarrhea among under five children in Adama town.
-To determine the associated factors with the diarrheal diseases.

9
4. RESEARCH METHODS

4.1 STUDY AREA AND PERIOD

This study wasl conduct in Oromia Regional State, East Showa Zone, Adama town. Adama was
establishment in 1917 and It has got the municipal status in 1936; and named ‘Nazareth’ by
Emperor H/Sillassie in 1937 and was known by this name for more than half a century until
officially regains its original name ”Adama” by the Oromia Regional State Council in the year
2000.GC. Adama city is located at some 100 km from Addis Abeba on southeast along the main
road to Harer and the word Adama was pointed to have originated from an Oromo word
“adaamii “ it is the name for tree types called “cactus” in English according to local people ,there
were plenty of adaamii trees in and around old Adama areas. Adama has been the original name
of the town. Adama is the city of business, National & International Conference Centre. Adama
is situated within the wonji fault belt, the main structural system of Ethiopian rift
valley .geological studies indicates that the present physiographic of the area is the result of
volcano –tectonic activities occurred in the past and thus deposition of segment largely of luvial
and lacustraine (34).

Adama townhas been reorganized /restructured in to 18 kebeles (14 urban & 4 rural areas) each
of which has got its own council. In 2009 EFY population is estimated to be 341,974 of which
167,567 are males whereas 174,404 are females. In addition, the town has about 7,120
households. Furthermore, under five children are estimated to be 77,730,36,660 are 2-5 years,
31,940 are under three and 9,130 are 12-23 months of children

Regarding to Ethnicity composition, majority of the population are Oromo and the rests are
Gurage, Amhara, Silte which are fewer in number. And this study was conduct from April- June
2018 GC.

4.2 STUDY DESIGN

A community based cross sectional study was conducted among children under-five years of age.

4.3 SOURCE POPULATION

All children under-five years of age in Adama town were the source population.

4.4 SAMPLE POPULATION

The study populations are all under five children in selected kebeles of Adama town.

10
4.5 STUDY POPULATION
The study population for this study children under-five years of age in Adama town that was
randomly selected.

4.6 INCLUSION AND EXCLUSION CRITERIA

Inclusion criteriaChildren under-five years of age whose mothers/caretakers are permanent
residents of Adama town and respondent are included.

Exclusion criteria Respondents or child parents whose do notwilling to participate.

4.7 SAMPLING TECHNIQUE

The multistage cluster sampling technique was used to select study participants from the total
population. Out of a total of 18 kebeles, 7 was be selected by the simple random sampling
technique. Selected kebeles’ was clustered into 39 Ketenas, and 17 Ketenas was selected by the
systematic random sampling technique. There are 1417 households are found in those ketene
from all we start to select the first house hold by counting every 6 households we used simple
random sampling technique to select the first household. Finally, all households (223) with
under-five children were included in the study. For households which had more than one child
each, the younger one was selected for the study.

4.8 SAMPLING SIZE DETERMINATION.

To determine the sample size for this particular quantitative study, a single population proportion
formula was used considering the following assumptions. Assumptions: A 95% confidence
level, margin of error(0.05). Since the prevalence of diarrheal disease at age 0 -5 years
among children in Oromia, Ethiopia, in Adama town was 22.5% (8). So this prevalence
was used to obtain the possible sample size of the study area. The above assumptions are
substituted in the following single population proportion formula.

Where n = required sample size for this cross sectional survey

z = Percentiles of the standard normal distribution corresponding to 95% confidence level

11
Which is equals to 1.96.

P = Prevalence of acute diarrhea disease in Oromia, Ethiopia, in Adama Town (22.5 %)

(35).

d = 0.05 (5% margin of error)

n =1.96 *1.96 *0.225(1-0.225) 0.05* 0.05

n =223

So the sample sizes was 223 and by considering 10% of non-response rate a total of 1417
mothers or caregivers of children was selected for the study. From all Kebeles seven
Kebeles was selected by simple random sampling .Based on the average household of each
Kebele study participants were selected using simple random sampling technique by
considering proportional to size allocation.

4.9 STUDY VARIABLES

4.9.1 Dependent variable

Diarrhea in under five years children

4.9.2 Independent variables

 Socio-demographic factors like age, sex
 feeding practice
 economic status of family
 educational status
 source of water and storage
 personal hygiene and environmental sanitation

4.10 Data collection tool and procedure

Structured and pretested questionnaire and observational checklist was used to collect
quantitative data.The questionnaire was developed after reviewing relevant literatures to the
subject to include all the possible variables that address the objective of the study. The
questionnaire was first prepared in English and then was translated to Afan-Oromo and Amharic
and back to English to maintain the consistency of the contents of the instrument.

12
4.11 Data quality control
Data collectors were 5 nurses working in the health institutions. Data collectors were given one
day training on the objective of the study, content of the questionnaire and how to collect the
data. Each data collector has done five pretests. Then the questionnaire was structured. Daily
supportive supervision will be undertaken by supervisor as well as principal investigator. Vague
terms, phrases and questions identified during the pretest was modified and changed.

4.12 Data analysis plan

After collection of data the responses were coded and entered using EPI info version 3.1
statistical programs. After data entry was finished, attentively checked for consistency of data
entry. Data was cleaned accordingly and then exported to SPSS version 16.0 for further analysis.
Then frequency distribution of dependent and independent variables was worked out. To
establish association between dependent independent variables, X2 test and p-values were used.
Statistical significance was considered at p-value less than 0.05.

.4.13 Operational definition

Diarrhea–passage of three or more loose stool per 24 hours resulting excessive loss of fluid and
electrolyte
Acute diarrhea– Diarrhea that begins acutely and terminates in less than two weeks.
Chronic diarrhea–diarrhea that stays beyond 2 weeks not necessarily occur acutely.
Persistent diarrhea–diarrhea occurs acutely and lasts more than 2 weeks.
Feeding practice
Exclusive breast feeding- the child is fed only breast milk.
Complementary feeding –when the child start additional food besides breast milk.
On family diet- the child starts to eat food prepared for the family.
Care taker-any person other than the mother who take care of the child.
Cleanliness of the compound
Good: -ground of the compound is neat, use appropriate damping method, no feces and/or
animal dung and other wastes seen in the compound, burn collected and decomposable wastes.
Fair: - if feces and other wastes are found in the compound, have pit to dispose waste, but do not
burn it.

13
Poor: -if the compound is dirty, dispose waste on the open field, feces were there and full of
wastes which is good provides best opportunity for breeding of insects and rodents breeding and
does not meet either of criteria in good.
Cleanliness of the water container
Good: - if the water container is placed in clean area, inside of the container is clean, no fluid is
leaking is seen and no other opening rather than normal opening, and has cover.
Fair: -inside of the container is clean, no fluid is leaking, and no opening is seen other than
normal opening, but placed in unclean area.
Poor: -does not fulfill either of the above criteria.
Cleanliness of the latrine
Good: -well constructed, no feces seen around the hole, area is dry, does not allow housefly
breeding and ventilated well.
Fair:-fairly constructed, ventilated, but there are feces around hole and allows housefly
breeding.
Poor: -Poorly constructed, unventilated, the area is allow housefly breeding and wet (9)

4.14 Ethical consideration

Approval to conduct this study was obtained from Adama General Hospital and Medical
College, Faculty of Health Sciences, Department of Nursing the procedure and purpose of the
study was clearly explained permission was asked from Adama town and selected kebele
administrators with formally written letter. Oral consent was taken from respondents before
interview. Participation is in responding the questions are free. We were tell the respondents that
the responses was kept as secrete and was not be used for other purpose except for this study. We
were give advice and refer the sick children to the near health institution. We were not take the
name of either the respondent or the child.

4.15 Dissemination and utilization of results

Study finding was submitted to Adama General Hospital and Medical College, Faculty of Health
Sciences, Department of nursing and to Adama town Administration and health office in the
form of written document and also publish on reputable journals.

14
5.RESULT
5.1 socio economic condition of the household
Study participants 100% participated on the study providing response rate of 100%. Then
describe certain variables add. Majority of study participants were married which account
205(91.9 %) and Christian in religion. Among study participants 28.6 % attended primary
school. Among the 223 respondents asked 212(95.1%) were mothers and the rest
11(4.9%) were care takers to the child.

15
Table 1- the socioeconomic characteristics of the households in Adama town, Oromia,
Ethiopia, August, 2018 GC

Variables Responses Frequency )%( Percentage

Marital status of Married 205 91.9
the mother
Divorced 11 4.9
Unmarried 1 0.4
Widowed 6 2.7
Religion of mother Christian 216 96.9
Muslim 7 3.1
Other 0 0
Ethnic group of Oromo 190 85.2
mother
Amhara 15 6.7
Gurage 5 2.2
Afar 7 3.1
Other 6 2.7
Educational level Illiterate 41 18.3
of father
Primary 64 28.6
Secondary 58 26
twelve> 60 26.9

Educational Level
of Mothers
Primary 91 40.8
Secondary 44 19.7
twelve> 19 8.5

Illiterates 69 30.9
Occupation of House wife 162 72.6

16
 mother
Government employ 24 10.8
Private gainful work 27 12.1
Other 10 4.5
Occupation of Government employ 61 27.4
father
Merchants 105 47.1
Private gainful work 25 11.2
No job 3 1.3
Other 29 13
Estimated 1000birr> 136 61
household income
500-1000birr 69 30.9
500birr< 18 8.1
Family that owned Yes 198 88.8
radio/TV
No 25 11.2

Family that have Yes 23 10.3

livestock
No 200 89.7

Out of 223 participants of the study 80 under five children are affected by Diarrhea which is the
prevalence of 35.8 %, among 80 under five children affected by diarrhea 45 (56.25%) were
males and the other 35 (43.75%) were females. Among those affected with diarrhea 95%
were experienced watery diarrhea and the other 5% had had diarrhea mixed with mucus
and blood. 51% of children affected with diarrhea experience 3 episodes of diarrhea and
42.5% experienced more than 3 episodes of diarrhea.

17
 Prevalance of Diarrhea In Adama Town

FIG1
Prevalenc
35.80%
e of
Children With Diarrhea
Chidren with No Diarrhea Diarrhea
in Adama
64.10% town,
Oromia,
Ethiopia,
August
2018

Of 23 households having live stocks in 2 households (8.6%)animals live in the same house
where family live and in the rest 21(91.3%)household’s animals have their own home. Of
the total 223 households asked 219(98.2%) have latrine and the other 4(1.8%)didn't have
latrine. Of those 219 households with latrine 187(83.9%) were private owned latrines and
.the other 32(14.9%) were shared with neighbors

Majority of Households had clean latrine in fair condition which accounts 132(59.1%) and
.146(65.5%) of cleanness of compound in fair conditions

Table2- cleanness of the latrine and compound in Adama town, Oromia, Ethiopia, August,
2018 GC

RESPONSES FREQUENCY PERCENTAGE

Latrine cleanness Good 59 26.4
Fair 132 59.1
Poor 32 14.3
Cleanness of Good 66 29.6
compound
Fair 146 65.5

18
 Poor 11 4.9

Of 223 households 80(35%) 0f them dispose the wastes by burning, 66(29.6%) dispose
wastes in waste disposal pit, 40(17.9%) dispose in open field, 32(14.3%) dispose in
.garbage can and the other 5(2.2%) dispose in other places

Of the 223 households asked 216(96.8%) got their drinking water from pipe 3(1.3%) got
from unprotected Awash River, and the other 4(1.7%) got from other sources. 183(82.1%)
store the drinking water using Jeri can, 39(17.5%) store in plastic bucket and 1 household
(0.4%) store using pot. All mothers transport the drinking water from the source using
.covered container and the water consumption per day per individual was 7.8 Littre

Table3- the number of households and the amount of water they use per day in Adama
town, Oromia, Ethiopia, August, 2018 GC

Amount of water(Littre) Number of household Percentage

20-40 162 72.6
41-60 47 21
61-80 14 6.27

Of 223 children 29(13%) were on exclusive breast feeding but the other 194(87%) were
taking additional food other than breast. Of those who took other food, 99(44.4%) mothers
prepared food in separate material and other 95(42.6%) mothers did not prepared food in
the separate material. Again of the 194 children who took other food, 97(43.5%) took
cow's milk, 15(6.7%) took powder milk, 6(2.7%) took gruel and 76(34.1%) took food
.prepared for adults

For those children who took food 22 mothers(9.9%) used their hand to feed their child,
67(30%) used cup and spoon, 24(10.8%) used cup, 77(34.5%) children feed by themselves
.and 4(2.06%) mothers used other materials

.All respondents store the drinking water in a covered container

19
Of all 223 respondents 187(83.9%) have separate can to take water from storage container
and 36(16.1%) didn’t have separate can for taking water from the storage container.
216(96.9%) took water from the container by pouring and the other 7(3.1%) took by
.dipping

Of all respondents 191(85.7%) knew that fly can transmit diseases and the other
32(14.3%) did not know that fly can transmit diseases. Of 191 mothers who know that fly
transmit diseases 141(73.8%) knew as it can transmit diarrhea, 19mothers (9.4%) knew as
it transmit typhoid 6(2.7%) knew as it transmit cholera, 3(1.3%) knew as it transmit
trachoma but the rest 22mothers (9.9%) did not know the name of the diseases. From all
the respondents 180(80.7%) knew that excreta of the children can cause diseases and the
.other 43mothers(19.3 %) did not know this

5.2Behavioral distribution of the study children

From all participants of our study under five years old children Majority of they age group was
in between 36-59 months (35.4%) and next by 24.2% in between 24-35 age group classification.

04
4.53
53

03

52 2.42

02
7.51 7.51
51

01 9.8

5
% ni nerdlihc fo rebmun

0
shtnom6-0 shtnom11-7 shtnom32-21 shtnom53-42 shtnom95-63
htnom ni ega

Fig2 Number of under five children in their age distribution in Adama town, Oromia,
Ethiopia, August, 2018 GC

20
Of 223 study units 114(51.1%) were males and the other 109(48.9) were females.
.140(62.8%) were born in the health institution and 83(37.2%) of them were born at home

Among 223 children studied 80(35.9%)had had diarrhea in the past two weeks before the
survey. Of those had had diarrhea 41 children(51.25%) had experienced 3 episodes
34(42.5%) had experienced more than 3 episodes and for the other 5 children(6.5%)
.mothers didn’t know how many episodes were they experienced

All affected children experienced diarrhea that stays less than 14 days. Of the affected
children 76(95%) had watery diarrhea and 4(5%) had had diarrhea mixed with blood and
mucus. 75(93.7%) children were taken to the health institution, 1(1.25%) was given ORS,
1children(1.25%) given serial based food and 3children(3.75%) were given home based
.treatment

As shown in table 3, there was significant association between amount of water utilized per
day and risk of having diarrhea(P,0.001). Children of the households who use 20-40littre of
water per day have 4.4 times (OR:4.4) risk of having diarrhea than those children of
households who use 61-80 litter of water per day. Children of households who use 41-
60litter of water have 1.62 times(AOR:1.62) risk of having diarrhea than those children of
.households that use 61-80litter of water

There was also significant association between educational level of mother and risk of
diarrhea for under five children. Children of illiterate mothers have 2times (AOR:2) risk of
having diarrhea than those children of mothers who completed greater than twelve, those
children of mothers who completed their secondary education have 1.37 times having
diarrhea than those children of mothers who completed greater than twelve but Children
of mothers who completed their primary education are less likely (AOR:0.78 ) affected with
diarrhea than those children of mothers completed greater than twelve. This contradicted
against the common belief may be due to the social bias during data collection and the
method of data collection. There was significant association between cleanness of latrine
and risk of having diarrhea. Children of households whose latrine was fair have 2.66
times(AOR:2.66) risk of having diarrhea than those who have good latrine and those

21
children of households who have poor latrine have 3times(AOR:3.18) risk of having
diarrhea than those children of households having good latrine

Table4 – independent factors in relation to diarrhea morbidity in under five children in

Adama town, Oromia, Ethiopia, August, 2018 GC

x2(df2)
Amount of Diarrhea Crude
water utilized OR *)0.007(9.81
per day(l)
Yes No
61-80 2 12 1
41-60 10 37 1.62
20-40 68 94 4.4
Total 80 143
Educational OR X2 (df3)
level of *)043.(8.15
mother
Twelve> 6 13 1
Secondary 17 27 1.37
Primary 24 67 0.78
Illiterate 33 36 2
Total 80 143
Cleanness of OR X2(df2)
latrine *)0.015(8.42
Good 12 47 1
Fair 53 78 2.66
Poor 13 16 3.18
Total 78 141

22
 As shown in table 5, there was association between diarrhea and type of material used to
feed a child. Children who were feed with hand have 6 times risk of having diarrhea than
those children on exclusively breast feed [AOR: 5.76 ]. Those children feed with cup and
spoon have 2 times (AOR:2.34) risk of having diarrhea than on exclusively breast feed,
those feed with cup have 12 (AOR:11.65) times risk of diarrhea than those on exclusively
.breast feed

There was also significant association between age of the child and the risk of having
diarrhea. Children of age 7-11 month, 12-23month, 24-35month and 36-59month have 5
times(AOR:4.88), 2.32times(AOR:2.32), 4.36times(AOR:4.36), 2times(AOR:1.64) times risk
.of having diarrhea than those children age of 0-6 months

Table 5- behavioral aspects as related to the risk of diarrhea in under five children in
Adama town, Oromia, Ethiopia, August, 2018 GC

Characters Diarrhea Crude OR X2(df5)

Yes No )0.0003(22.87
Materials
used to
feed a
child
Only 5 24 1
breast feed
Hand 12 10 5.76

23
Cup and 22 45 2.35
spoon
Cup 17 7 11.65
Child feed 22 55 1.92
him self
Other 2 2 4.80
Total 80 143
Age of X2(df4)
child *)0.008(13.92
(months)
0-6 7 28 1
7-11 11 9 4.88
12-23 15 26 2.32
24-35 23 21 4.36
36-59 24 59 1.64
Total 80 143
Household X2(df2)2
income
1000birr> 51 85 )0.703(0.705
500- 22 47
1000birr
500birr< 7 11
80 143

24
CHAPTER SIX

6. DISCUSSION

The findings of this study revealed that the prevalence of diarrhea in under five children 2 weeks
before the survey was 35.9%. Diarrhea in Oromia (36.4%), Nekemte town (28.9%), Mana
district (33.7%), kefasheka zone(15%) Benishangule Gumuze and Gambela (both 23%) The
analysis of 73 comprehensive studies in sub Saharan African countries showed that prevalence of
diarrhea ranges from 10.5%-19%(9). This study finding shows that the prevalence of diarrhea in
under five children two weeks before the survey was 35.9% which is higher than the other
findings the factor that differ this study is probably due to study area, sample size, study period,
environmental conditions and socio-economic and cultural differences, but it is comparable with
the finding from Jima town. (36.5%) and but lower than the finding in Senegal and Liberia (each
40%). (17,19,24 25,29).

The most commonly affected age group was 7-11 months. This is consistent with the research
finding to longitudinal community based in sub-Saharan Africa (9).
Finding from this study showed that illiterate mothers' children experienced 2 times diarrhea
than children of mothers' who completed greater than twelve [AOR:2 (0.043)]. This is

25
consistent with the study conducted in the republic of Congo which showed that highly educated
mothers reported less diarrhea (13).

In this study there was no association between presence of latrine and risk of diarrhea. This is
different from the study conducted in republic Congo which shows that children of family with
latrine had lower prevalence of diarrhea than those children whose families didn't have latrine
(14). This is may be due to the number of households that are included in this study with no
latrine are small in number or social bias or desirability of respondents' to give information.
Analysis done in the Swedish hospital in Addis Ababa showed that prevalence of diarrhea was
21%. Our study finding was higher than this.
In addition, Children of the households who use 20-40 litter of water per day have 4.4 times
(AOR:4.4) risk of having diarrhea than those children of households who use 61-80 litter of
water per day. Children of households who use 41-60 litter of water have 1.62 times (AOR:1.62)
risk of having diarrhea than those children of households that use 61-80litter of water. The
finding was supported by similar studies con -ducted in Bangladesh [17, 31 ] and was also
supported by similar studies performed Jigjiga District , Somali Region , Eastern Ethiopia , and
in Sheko district , South west Ethiopia.

26
CHAPTER SEVEN

7. CONCLUSIONS AND RECOMMENDATIONS

7. CONCLUSIONS
This study has shown that the prevalence of diarrhea in under-five children is quite high.
There is significant association of having diarrhea with age of child, cleanness of latrine,
educational level of mother, amount of water utilized per day, and materials used to feed a child.
More over children of age 7-11months were affected.

Unlike common beliefs and results of some studies, economic status and availability of latrine
are not associated with diarrhea.
The most commonly affected children age was 7-11 months. It could be this age is the weaning
period.

27
7.1 RECOMMENDATIONS
As seen in this study, amount of water utilized per day and educational level of the mother are
associated to the occurrence of diarrhea. Therefore, the AdamaTown administrator is
recommended to increase the water supply and to give awareness and easy understanding to the
mothers on how to care their children.
7.2 Limitations
1. Being cross-sectional study design
2. There may be difference among mothers/Care givers in perceiving their child's health
3. The other limitation is related to the definition of the term “diarrhea.” There is a difference
among mothers in perceiving their child's health. And, the definition of diarrhea given by
mothers shares this difference in perception. This was considered during the design and it was
tried to give the definition of diarrhea to the mother.

7.3 Strengths of the study

1. Randomization was applied to select the households and the study subjects
2. Quality control measures were undertaken to maximize the validity of the study.
3. Response rate was 100%
4. Participants were representative of households in the town

CHAPTER EIGHT

8. REFERENCES
1. World health organization (2017) Global Health Observatory (GHO) 8nder-ive mortality.
2. PATH (2009) Diarrheal disease: solutions to defeat a global killer.
3. UNICEF (2013) Water, sanitation and hygiene annual report.
4. Nyantekyi LA, Legesse M, Belay M, Tadesse K, Manaye K (2010) Intestinal parasitic
infections among under-ive children and maternal awareness about the infections in
SheshaKekele, Wondo Genet, Southern Ethiopia. Ethiop J Health Dev 24: 3.
5. Dessalegn M, Kumie A, Tefera W (2011) Predictors of under-ive childhood diarrhea:
Mecha District, West Gojam, Ethiopia. Ethiopia J Health Dev 25: 192–200.
6. Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, et al. (2006) In:
Disease Control Priorities in Developing Countries. Washington (DC).

28
7. Ahs JW, Tao W, Löfgren J, Forsberg BC (2010) Diarrheal Diseases in Low-and Middle-
Income Countries: Incidence, Prevention and Management. Open Infect Dis J 4: 113-124.
8. Keusch GT, Fontaine O, Bhargava A, Boschi-Pinto C, Bhutta ZA, et al. (2006) Diarrheal
Diseases In: Jamison DT, Breman JG, Measham AR, Disease Control Priorities in
Developing Countries. International Bank for Reconstruction and 'evelopment/Нe World
Bank Group, Washington (DC) 2: 371-388.
9. WHO (2005) Treatment of Diarrhoea: A Manual for Physicians and Other Senior Health
Workers.
10. Mediratta RP, Feleke A, Moulton LH, Yifru S, Sack RB (2010) Risk factors and case
management of acute diarrhoea in North Gondar zone, Ethiopia. J Health PopulNutr 28:
253–263.
11. WHO (2017) Children: reducing mortality.
12. UN ICEF (2014) Reduce child mortality; Millennium development Goals.
13. Mengistie B, Berhane Y, Worku A (2013) Prevalence of Diarrhea and Associated
Risk Factors among Children Under-Five Years of Age in Eastern Ethiopia: A Cross-
Sectional Study. Open J Prev Med 3: 446-453.
14. Teklemariam S, Getaneh T, Bekele F (2000) Environmental Determinants of Diarrheal
Morbidity in Under-Five Children, .e‫ٶ‬a-6heka Zone, South West Ethiopia. Ethiop Med J 38: 27-
34.
15. Tarekegn M, Enqueselassie F (2012) A Case Control Study on Determinants of
Diarrheal Morbidity among Under-Five Children in WolaitaSoddo Town, Southern Ethiopia.
Ethiop J Health Dev 26: 78-85.
16. Mengistie B, Berhane Y, Worku A (2013) Household Water Chlorination Reduces Incidence
of Diarrhea among Under-Five Children in Rural Ethiopia: A Cluster Randomized
Controlled Trial. PLoS ONE, 8: e77887.
17. Mekasha A, Tesfahun A (2003) Determinants of Diarrhoeal Diseases: A Community Based
Study in Urban South Western Ethiopia. East Afr Med J 80: 77-82.
18. Assefa N, Oljira L, Baraki N, Demena M, Zelalem D (2016) HDSS 3roile НeKersa Health
and Demographic Surveillance System. Int J Epidemiol 45: 94–101.

29
19. Godana W, Mengistie B (2013) Environmental Factors Associated with Acute Diarrhea
among Children under Five Years of Age in Derashe District, Southern Ethiopia. Sci 1:
119-124.
20. Gebru T, Taha M, Kassahun W (2013) Prevalence of Diarrheain Under-Five Children
among Health Extension Model and Non-Model Households in Sheko District Rural
Community, Southwest Ethiopia. Sci 1: 230-234.
21. Desalegn M, Kumie A, Tefera W (2011) Predectors of Under-Five Childhood
Diarrhea: Mecha District, West Gojjam, Ethiopia. Ethiop J Health Dev 25: 174-232.
22. Berhe F, Berhane Y (2014) 8nder-ive Diarrhea among Model Household and Non-Model
Households in Hawassa, South Ethiopia: A Comparative Cross-Sectional Community. BMC
Public Health 14: 187.
23. Anteneh A, Kumie A (2010) Assessment of the impact of latrine utilization on
diarrhoeal diseases in the rural community of HuletEjjuEnessieWoreda, East Gojjam Zone,
Amhara Region. Ethiop. J Health Dev
24. Mediratta RP, Feleke A, Moulton LH, Yifru S, Sack RB (2010) Risk Factors and Case
Management of Acute Diarrhoea in North Gondar Zone, Ethiopia. J Health PopulNutr 28:
253-263.
25. Central statistical Authority, ORC Marko (2011) Ethiopia Demographic and Health Survey.
Addis Ababa Calverton Ethiopia and Maryland, USA.
26. Yassin K (2000) Morbidity and risk factors of diarrheal disease among under-five children in
rural Upper Egypt. J Trop Pediatric 46: 282-287.
27. Kuitunen M, Boadi KO (2005) Childhood diarrheal morbidity in the Accra
Metropolitan Area, Ghana: socio-economic, environmental and behavioural risk determinants.
World Health & Population J Health PopulDevCtries.
28. Mihrete TS, Alemie GA, Teferra AS (2014) Determinants of childhood diarrhoea among
under ive children in BenishangulGumuz Regional State, North West Ethiopia. BMC
Pediatrics 14: 102.
29. Dessalegn M, Kumie A, Tefera W (2011) Predictors of under-ive childhood diarrhoea:
Mecha District, West Gojam, Ethiopia. Ethiop J Health Dev 1: 25.
30. Mengistie B, Berhane Y, Worku A (2013) Prevalence of diarrhoea and associated risk factors
among children under-ive years of age in Eastern Ethiopia. Open J Prev Med: 446-453.

30
31. Mohammed S, Tilahun M, Tamiru D (2013) Morbidity and Associated Factors of Diarrheal
Diseases Among Under Five Children in Arba-Minch District, Southern Ethiopia. Science J
Public Health 1: 102-106.
32. Dessalegn M, Kumie A, Tefera W (2011). Predictors of under-five childhood diarrhea:
Mecha District, West Gojam, Ethiopia. Ethiop J Health Dev 25: 194-196.
33. Mengistie B, Berhane Y, Worku A (2013) Prevalence of diarrhoea and associated risk factors
among children under-ive years of age in Eastern Ethiopia: A cross-sectional study. J Prev Med
3: 446-453.
34 Adama town city Administration leaflet 2016
35 Hanaa Hussein (2017) Prevalence of Diarrhea and Associated Risk Factors in Children
Under Five Years of Age in Northern Nigeria: A Secondary Data Analysis of Nigeria
Demographic and Health Survey 2013.(14-15)

ANNEXES 1
8.1QUESTIONNAIRE- ENGLISH VERSION
ADAMA GENERAL HOSPITAL AND MEDICAL COLLEGE, FACULTY OF HEALTH
SCIENCES, DEPARTMENT OF NURSING

QUESTIONNAIRE PREPARED TO ASSESS THE PREVALENCE AND ASSOCIATED

FACTORS OF DIARRHEAL DISEASE IN UNDER FIVE CHILDREN IN ADAMA TOWN,
2018 G.C.

CONSENT

31
Good morning/afternoon! How are you? My name is ___________________. I am a student
of Adama General Hospital and Medical College, Now Me and my colleagues are conducting
a study on prevalence and associated factors of under-five childhood diarrhea in Adama
town.
I assure you that the information that you are going to give
Will be kept in secrete. We will not take your or your child's name. Therefore, you are free to
respond or not to respond the questions. Your support and willingness in responding the
questions will be very important for the success of this study.
Do you agree to participate in this study? Yes________ No________
If no, go to the next house.

THANK YOU FOR YOUR COOPERATION.

IDENTIFICATION
01. House number we gave during sampling frame: _______________
02. Address
Kebele: ______ House number: ____________
03. Number of persons in the household___________
04. Number of under-five children in the household_________

PART ONE SOCIO ECONOMIC CONDITIONS

No QUESTIONS Responses Rem

1.1 Relation of the respondent to the child 1.mother
2.care taker

1.2 Age of the mother/care taker s ---

---- year
1.3 Marital status of the mother / care taker 1.married
2.divorced
3.single
4.widowed
1.4 Religion of the mother/care taker 1.christian

32
 2. Muslim
3.other
1.5 Ethnic group of the mother/ care taker 1.Oromro
2. Amhara
3. Gurage
4.Afar
4.other (specify)

1.6 Educational level of the mother/care taker 1.illitrate

2.primary
3. secondary
4.>12

1.7 Occupation of the mother/care taker 1. Housewife

2. Government employee
3. Private gainful work
4. Other (specify)
1.8 Age of the child's father ------ years
1.9 Educational level of the father 1 illiterate
2. primary
3. secondary
4. > 12
1.1 Occupation of the father 1. Government employee
0 2. Merchant
3. Farmer
4. No job
5. Other (specify)
1.1 Estimated average house hold income 1. >1000 2. 1000-500
1 3.<500
1.1 Does the family own radio 1. Yes
2 2. No
1.1 Does the family have live stock 1. Yes 3. No response
3 2. No
1.1 If yes to Q113, number and type …………………………………
4

33
PART TWO ENVIRONENTAL HYGEINIC CONDITION

2.1 Do animals live in the same house where the 1.yes

members of the family live?(observation) 2.no
2.2 Is latrine available? 1.yes
2.no
2.3 Ownership of the latrine 1. Privately owned
2. Shared with neighbors
2.4 Cleanness of latrine(OBSERVATION) 1 good
2 fair
3 poor
2.5 Cleanness the compound(OBSERVATION) 1 good
2 fair
3 poor
2.6 If the family has no latrine, where do you 1. Open field
dispose human wastes? 2. Other (specify)

2.7 How do you dispose refuse 1. Pit 2.

Open field
3. Burning 4.
Garbage can
5.Other
2.8 From where do you get water for drinking? 1. Pipe
2. Protected well/spring
3. Unprotected well/spring
4. River
5. Other (specify)
2.9 Distance from the house to the water source -----meter

2.10 Type of water storage container 1. Pot

2. Plastic bucket
3. Iron bucket
4.Jerican
5.other
2.11 How did you transport the collected drinking 1. In a covered container
water to the house yesterday 2. In uncovered container
3. Other (specify
2.12 How many litters of water you use per day? _______ Litters

34
PART THREE BEHAVIORAL ASPECTS

35
 3.1 Does the child take other food than 1. Yes
breast milk? 2. No
3.2 If yes to Q3.1, Do you separately 1. Yes
prepare food for the child, using a 2. No
separate material?
3.3 What food/fluid is the child mostly 1. Cow's milk 4. Adults'
receiving (if the child food
is not on exclusive breastfeeding 2. Powder milk 5. Other
3. Gruel
3.4 What do you use to feed the child 1. Hand 3. Bottle
2. Cup and spoon
4. Child feeds by
himself/herself using
hand
5. Other

3.5 Does the drinking-water storage 1.yes

container have a cover? 2. no
3.6 Is there a separate can for taking 1. yes
drinking water from the storage 2. no
container
3.7 How do you take water from the 1. Pouring
drinking water storage container? 2. Dipping
3.8 Do you know that flies can transmit 1.yes
diseases? 2. no
3.9 If “Yes”, can you tell me the name of 1. Diarrhea
the diseases? 2. Typhoid fever
3. Cholera
4. Trachoma
5. Do not know the names
6. Other (specify)
3.10 Do you know that excreta of children 1.yes
can transmit diseases? 2. no

3.11 If “Yes” to Q3.10, what do you do to 1. By cleaning the

avoid this problem? environment
2. By getting
treatment of
sick child
3. Other

36
PART FOUR INFORMATION ON THE STUDY CHILD

4.1 Age of the study child ……….months

4.2 Sex of the study child 1.male 2.female

4.3 Where was your child born? 1. Health institution

2. Home
4.4 Did the child had diarrhea in the past 1. Yes No

37
 2 weeks?

4.5 If yes for Q4.4, how many times a 1. Three times

day he/she passes stool? 2. More than three times
3. Don't know
4.6 If yes for Q4.4, for how long the 1. Less than 14 days
diarrhea lasts? 2. Greater than 14 days
4.7 Type of diarrhea that the child had 1. Watery
2. mixed with blood and mucus
4.8 What actions do you take to 1. Take him/her to health
treat/stop the diarrhea? institution
2. Take him/her to traditional
healer
3. Increase feeding
4. Give him/her ORS
5. Give him/her cereal based
fluids
6. Stop/decrease feeding
7. Homemade treatment
8. Other (specify)

Thank you very much for your unreserved cooperation!!

Date of interview----------------------------------------------------------------

Name of the interviewer--------------------------------------------------------

Signature………………………………………………………………….

DECLARATION

Here we would like to confirm that this thesis paper is our own original work submitted to joint
bachelor degree of Nursingprogram of Adama General Hospital Medical College, in partial
.fulfillment of Bsc

38
We also like to ensure this paper was not submitted to any other institution for any reason and
.all our information source were appropriately acknowledged

Name signature

1. BARIA MOHAMMED

2. FOZIA DURI

3. HAYMANOT ANBESE

4. LENCHO MOHAMMED

5. MERON GETACHEW

6. SHURA ANBASE

39
Contents

List of tables………………………………………………………………………………………….…………………………………………………i

List of figures………………………………………………………………………………………..…………………………………………………ii

ACRONYMS………………………………………………………………………………………………………………………………………….…iii

ACKNOWLEDGMENTS…………………………………………………………………….………………………………………………………iv

ABSTRACT……………………………………………………………………………………..…………………………………………………………v

1. INTRODUCTION.................................................................................................................................1
1.1 BACKGROUND...........................................................................................................................1
1.2 STATEMENT OF THE PROBLEM.............................................................................................2
1.3 SIGNIFICANCE OF THE STUDY...............................................................................................2
2. LITERATURE REVIEW.......................................................................................................................3
2.1 Conceptual framework ………………………………………………………………………………………………………………….7

3. OBJECTIVE..........................................................................................................................................9
3.1 General objective...........................................................................................................................9
3.2 Specific objectives.........................................................................................................................9
4. RESEARCH METHODS......................................................................................................................10
4.1 STUDY AREA AND PERIOD...................................................................................................10
4.2 STUDY DESIGN........................................................................................................................10
4.3 SOURCE POPULATION............................................................................................................10
4.4 SAMPLE POPULATION............................................................................................................10
4.5 STUDY POPULATION..............................................................................................................11
4.6 INCLUSION AND EXCLUSION CRITERIA............................................................................11
4.7 SAMPLING TECHNIQUE.........................................................................................................11
4.8 SAMPLING SIZE DETERMINATION......................................................................................11
4.9 STUDY VARIABLES.................................................................................................................12
4.9.1 Dependent variable...................................................................................................................12
4.9.2 Independent variables...............................................................................................................12

40
 4.10 Data collection tool and procedure............................................................................................12
4.11 Data quality control...................................................................................................................13
4.12 Data analysis plan......................................................................................................................13
4.13 Operational definition................................................................................................................13
4.14 Ethical consideration.................................................................................................................14
4.15 Dissemination and utilization of results.....................................................................................15
5. RESULT.............................................................................................................................................16
5.1 socio economic condition of the household.............................................................................16
5.2 Behavioral aspects of the study child.......................................................................................20
6. DISCUSSION......................................................................................................................................26
6.1 Limitations...................................................................................................................................28
7. CONCLUSIONS AND RECOMMENDATIONS.............................................................................28
7. CONCLUSIONS...........................................................................................................................28
7.1 RECOMMENDATIONS.............................................................................................................28
8. REFERENCES....................................................................................................................................29
ANNEXES 1...............................................................................................................................................32
8.1QUESTIONNAIRE- ENGLISH VERSION.....................................................................................32
PART ONE SOCIO ECONOMIC CONDITIONS..............................................................................33
PART TWO ENVIRONENTAL HYGEINIC CONDITION...........................................................34
PART FOUR INFORMATION ON THE STUDY CHILD.............................................................36

41