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  • Open Access

Exclusive breastfeeding and rotavirus vaccination are associated with decreased diarrheal morbidity among under-five children in Bahir Dar, northwest Ethiopia

  • 1,
  • 2,
  • 3 and
  • 4Email author
Public Health Reviews201839:28

https://doi.org/10.1186/s40985-018-0107-6

  • Received: 29 December 2017
  • Accepted: 2 August 2018
  • Published:

Abstract

Background

More than one in every ten (14%) of under-five child deaths is associated with diarrheal morbidity in Ethiopia. Although Ethiopia has implemented different health interventions like its immunization program, childhood diarrhea morbidity, on which literature is limited, continues as a public health problem. Hence, the aim of this study was to assess the prevalence of diarrheal morbidity and associated factors among under-five children in Bahir Dar, northwest Ethiopia.

Method

A community based cross-sectional study was carried out from March 05 to April 03/2015 in Bahir Dar in which 553 mother-child pairs participated. A structured questionnaire was adapted from the World Health Organization (WHO) and the Ethiopian Demography and Health Survey (EDHS) to collect the data. Bivariate and multivariate logistic regression analyses were carried out to identify the independent predictors of diarrheal morbidity.

Result

The overall prevalence of diarrheal morbidity was 9.4% [95% Confidence Interval (CI): 4.8, 14.0%]. No receipt of Rotavirus vaccine dose 2 [AOR = 3.96, 95%CI; 2.13, 7.33], non-exclusive breastfeeding [AOR = 2.69, 95%CI; 1.39, 5.19], unavailability of solid waste disposal system [AOR = 2.62, 95%CI; 1.19, 5.77], employed and private business occupational status of mothers [AOR = 2.10, 95%CI; 1.02, 4.31)], and less than Ethiopia Birr (ETB) 600 household monthly income [AOR = 2.10, 95% CI; 1.2, 7.2] were independently associated with diarrheal morbidity.

Conclusion

In Bahir Dar, one in every ten of the under-five children surveyed suffered from diarrheal morbidity. Thus, implementing effective rotavirus vaccination programs, encouraging exclusive breastfeeding and emphasizing appropriate solid waste management would reduce childhood diarrheal morbidity in the region. In addition, the finding suggests that improved child care mechanisms, especially for mothers working outside the home, and efforts to increase household income should be intensified to reduce incidence of diarrhea.

Keywords

  • Diarrheal morbidity
  • Rotavirus vaccination
  • Under five
  • Ethiopia

Background

Diarrhea is associated with many common childhood infectious diseases and one of the immediate causes of undernutrition, which in turn interferes with physical growth, mental development, and increases the risk of death [1, 2]. It remains the second leading cause of death in children under 5 years of age, and 90% of the burden is in resource limited settings [1, 3]. About 50% of childhood morbidity and 50–80% of childhood mortality is associated with diarrhea in Sub-Saharan Africa [4, 5]. Each year, an estimated 2.5 billion cases of diarrhea occur among under-five children, but the incidence has been relatively stable over the past two decades [6]. In resource limited countries, poor declining trend of diarrheal disease is associated with multiple reasons such as, poor environmental sanitation, low educational status of mothers, and other behavioral issues [7, 8].

A variety of bacterial, viral, and parasitic organisms are able to spread through contaminated food or drinking water or from person to person as a result of poor hygiene [2]. Rotavirus in particular is the most common etiological agent of diarrhea both in high and low income countries, and 6% of all child death globally is associated with it [9, 10], and child diarrheal morbidity mostly depends on the interaction of behavioral, socio-economic, and environmental factors [11, 12]. Various studies in different settings have explored that unavailability of water, lack of hand washing facilities, hand washing with water only, private business, children aged between 6 and 24 months, illiteracy of mothers, delay to initiate breastfeeding, no breastfeeding, and lack of exclusive breastfeeding were positively associated with diarrheal morbidity [1316]. On the other hand, rotavirus vaccination has a protective effect on diarrheal morbidity [16].

Ethiopia is implementing health strategies [17, 18] and immunization programs, including more recently rotavirus vaccination, to prevent the burden of diarrheal morbidity [19]. However, about 21% of under-five children are still suffering from diarrhea due to rotavirus [20]. Also, more than one in every ten (14%) of under-five child deaths is associated with diarrhea morbidity in the country [21]. According to the Ethiopian Demographic and Health Survey, the prevalence of diarrheal disease in under-five children in the 2 weeks before the survey has dropped from 18% in 2005 to 13% in 2011 [22, 23]. Conducting a study in an evidence dearth setting is critical to explore information on diarrheal morbidity and its determinants. The study is expected to provide a prominent input to policymakers and program managers about the implementation of current strategies, including rotavirus vaccination. Therefore, the aim of this study was to assess the prevalence and associated factors of diarrheal morbidity among under-five children in Bahir Dar, northwest Ethiopia.

Methods

Study setting and design

A community based cross-sectional study was carried out from March 05 to April 03, 2015 in Bahir Dar, the capital of Amhara national regional state, which has an estimated population of 297,749 [24]. Bahir Dar is located 565 km from Addis Ababa in Amhara national regional state in northwest Ethiopia. The major economic sectors of the city are horticulture, commerce, agro-industrial processing, urban agriculture, manufacturing, and diverse service industries. Bahir Dar is also one of the leading tourist destinations in Ethiopia; attractions include the nearby Lake Tana and Blue Nile river. Currently, Bahir Dar is divided into 19, 9 urban and 10 rural kebeles (smallest administrative unit). According to the zonal health department, the city administration has 1 referral hospital, 1 zonal governmental hospital, 10 government health centers, 10 health posts, one private hospital, 10 advanced and 17 medium clinics, and 12 small private clinics which provide comprehensive health services including vaccination. Four, 2 urban and 2 rural kebeles (Zenzelima, Sefen Selam, Shimbete and Meshenti) were selected out of 19 kebeles by lottery method (Fig. 1).
Fig. 1
Fig. 1

Presentation of the study area. NB: Bahir Dar Zuria is one district in west Gojjam which surround Bahir Dar town

Study population and sampling procedure

All mothers/caregivers with under-five children who lived in Bahir Dar for at least 6 months were included in this study. Sample size was calculated using the single population proportion formula on the following assumptions: 95% confidence interval, 5% margin of error, prevalence of diarrhea 21.5% in Jabithennan district, northwest Ethiopia [25], 10% non-response rate, and a design effect of 2%. The final calculated sample size was 572. A multistage sampling technique was employed to select participants; initially, the list of the dwellers of the 19 kebeles was taken from the city administration. Four kebeles were selected using the lottery method. Then, the computed sample size was proportionally allocated according to the number of under-five children in each kebele. Finally, a systematic sampling technique was employed to obtain the required study participants. In cases of more than one study child in a household, the simple random sampling method was used to select a single participant. The outcome variable, diarrhea morbidity, is the presence of three and more loose or liquid stools per day within the 2-week period prior to survey.

Data collection tools and procedures

A structured questionnaire was adapted from the World Health Organization (WHO) and the Ethiopian Demography and Health Survey (EDHS) to collect the data [23, 26]. The questionnaire was composed of socio-demographic, maternal and child characteristics, child feeding practices, environmental health conditions, and the outcome interest (diarrhea morbidity). Eight diploma graduate and four BSc nurses were recruited for data collection and supervision, respectively. One-day training was given to data collectors and supervisors. A pretest was administered out of the actual study area. After a few modifications like clarifying the ambiguity of word expressions, the questionnaire was administered in the local language, Amharic.

Data analysis

Data were entered into the EPI-info version7 statistical software and exported to SPSS version 20 statistical package for analysis. Frequencies and proportions were used to summarize variables in tables. The association between diarrhea morbidity and each independent variable was assessed using the binary logistic regression model. Variables significant at P value < 0.2 in the bivariate analysis were further entered into the multivariate analysis. The significance of association was determined at a P value of< 0.05 in the multivariate analysis, while the strength of association was measured by adjusted odds ratio with 95% confidence interval.

Results

Socio-demographic and behavioral characteristics of study participants

In this study, 553 eligible under five years children were included with a response rate of 96.7%. More than three-fourths of the participating mothers (80.5%) were married, and 83.2% had primary school and above educational status. The majority of the mothers (61.7%) were employed or in private business with 41.6% of their children ranging in age from 7 to 24 months.

Nine in every ten (91.7%) of the households had latrine facilities. However, 71.1% had no hand washing facilities near toilets. Three fourths (76.9%) of the participants had a habit of hand washing after visiting toilets. However, more than half (57.9%) of the participants were practiced hand washing without using detergents. Two-thirds of children were vaccinated with rotavirus vaccine dose 1 (66.5%) and dose 2 (64.0%). 71.6% of under-five children were exclusively breastfed for 6 months (Table 1).
Table 1

Socio-demographic and behavioral characteristics of study participants in Bahir Dar city administration, northwest Ethiopia, 2015

Characteristics

Frequency

Percentage (%)

Age of mothers in years

15–24

186

33.6

25–35

292

52.8

> 35

75

13.6

Current marital status

Married

445

80.5

Unmarried

108

19.5

Religion

Orthodox

403

72.9

Muslim

100

18.1

Protestant and Catholic

50

9.0

Age of child

0–6 months

105

19.0

7–24 months

230

41.6

> 24 months

218

39.4

Sex of child

Male

283

51.2

Female

270

48.8

Monthly income of household

≤ 600

221

40.0

601–2000

156

28.2

≥ 2001

176

31.8

Mothers educational status

Uneducated

93

16.8

Educated

460

83.2

Mothers occupation

Housewife

212

38.3

Employed and private business

341

61.7

Latrine availability

No

46

8.3

Yes

507

91.7

Sanitation facilities

Improved sanitation facilities*

231

41.77

Unimproved sanitation facilities**

322

58.23

Availability of solid waste facility

No

110

19.9

Yes

443

80.1

Hand washing facility near toilet

No

393

71.1

Yes

160

28.9

Availability of liquid waste facility

No

371

67.1

Yes

182

32.9

Source of water

Improved drinking water sources1

455

82.2

Unimproved drinking water sources2

98

17.8

Protected spring water

1

.2

Unprotected well, spring and surface water

32

5.8

Trend of using toilet

Always

465

84.1

Rarely

46

8.3

Not at all

42

7.6

Hand wash practice

No

128

23.1

Yes

425

76.9

Rotavirus vaccine dose 1

No

185

33.5

Yes

368

66.5

Rotavirus vaccine dose 2

No

199

36.0

Yes

354

64.0

Antenatal care

No

99

17.9

Yes

454

82.1

Exclusive breastfeeding

No

157

28.4

Yes

396

71.6

Current breastfeeding status

Breast milk only

92

16.6

Partially

327

59.1

No breast feed currently

134

24.2

*Pour-flush latrine, ventilated improved pit latrine, **Open pit latrine, communal and open filed

1Pipe, protected well and protected spring water a, 2Unprotected well, spring and surface water

Prevalence of diarrhea

Approximately, one in every ten (9.4%) (95% CI: 4.8, 14.0) of the under-five children had diarrheal morbidity in the 2 weeks preceding the survey.

Factors associated with diarrheal morbidity

The odds of diarrheal morbidity was higher among children who were not exclusively breastfed for 6 months [AOR = 2.69, 95% CI; 1.39, 5.19], and who had no receipt of rotavirus vaccine dose 2 [AOR = 3.96, 95% CI; 2.13, 7.33] compared to children who were exclusively breastfed for 6 months and with receipt of rotavirus vaccine dose 2, respectively. Children from households that had no solid waste disposal systems [AOR = 2.62, 95% CI; 1.19, 5.77] were more likely to develop diarrheal morbidity compared to children from households with availability of solid waste disposal systems. Employed and private business occupational status of mothers [AOR = 2.10, 95%CI; 1.02, 4.31] and ≤ ETB 600 monthly income of households [AOR = 2.10, 95% CI; 1.2, 7.2] were significantly associated with diarrheal morbidity as compared to their counterparts (Table 2).
Table 2

Predictors of diarrheal morbidity in Bahir Dar town administration, northwest Ethiopia, May, 2015

Explanatory variable

Diarrheal morbidity

Yes No

Crude odds ratio(95% CI)

Adjusted odds ratio(95% CI)

Sex of the child

Male

33

250

1.74 (0.97, 3.15)

1.65 (0.89, 3.05)

Female

19

251

1.00

1.00

Solid waste disposal system

No

15

95

1.73 (0.91, 3.23)

2.62 (1.19, 5.77)

Yes

37

406

1.00

1.00

Occupation of the mothers

House wife

18

194

1.00

1.00

Employed and private business

34

307

1.19 (0.66,2.17)

2.10 (1.02, 4.31)

Monthly income of the family

≤ 600

26

195

2.47 (1.13, 5.43)

2.99 (1.23, 7.24)

601–2000

9

139

2.27 (0.96, 5.25)

2.65 (0.99, 6.67)

≥ 2001

52

167

1.00

1.00

Rotavirus vaccine dose 2

No

32

167

3.20 (1.78,5.77)

3.96 (2.13, 7.33)

Yes

20

334

1.00

1.00

Exclusive breastfeeding

No

22

135

1.20 (1.11, 3.57)

2.69 (1.39, 5.19)

Yes

30

266

1.00

1.00

Hosmer and Lemeshow goodness of fit test was checked; the result was 0.76

Discussion

In the current study, approximately one in every ten (9.4%) (95% CI: 4.8, 14.0) of under-five children suffered from diarrheal morbidity; children with no receipt of rotavirus vaccine dose 2, no exclusive breastfeeding, unavailability of a solid waste disposal system, employed and private business occupational status of mothers, and household monthly income less than ETB 2000 were independent predictors of diarrheal morbidity.

The prevalence of diarrheal morbidity was similar to the national report of 13% [23] and other local studies in hot spot districts of the Amhara region (13.5%) [27], Hawassa (11.7%) [28], and Jigjiga town (14.6%) [13]. However, the current finding was lower than reported from Hadaleala district, Afar region, Ethiopia (31.3%) [16]. The high prevalence in Afar region compared to the current study might be due to the nomadic nature of the population. Nomads may not have access to basic health care, water, and sanitation services due to their migration from place to place in search of pasture and water. Nomads have no permanent residence and practice open defecation. The main sources of water are rivers, streams, and wells; hence, they are prone to contamination and diarrheal diseases, especially children who routinely play in the unhygienic environment [29].

This study found that children who did not receive rotavirus vaccine dose 2 suffered 3.96 times more from diarrheal morbidity compared to those in receipt of rotavirus vaccine dose 2. A similar local study on children who did not receive rotavirus vaccine dose 2 showed that children suffered from diarrheal morbidity [16]. This might be due to the fact that rotavirus vaccinated children are immunized from the highest impact of acute gastroenteritis (AGE) morbidity in Africa, where the burden of disease is the greatest [30]. This implies that rotavirus vaccination is one of the best ways to prevent diarrheal morbidity and its consequences. Thus, two-dose rotavirus vaccines (dose 1 and 2) should be given for children as part of a comprehensive approach to control diarrhea.

The odds of diarrheal morbidity were 2.69 times higher among under-five children who were not exclusively breastfed for 6 months. A similar finding was observed in nomadic populations of Ethiopia; children who were not exclusively breastfed suffered from diarrheal morbidity [16]. Breast milk contains all the nutrients that an infant needs in the first 6 months of life. Additionally, breast milk contains bioactive factors that augment infants’ immature immune system, providing protection against infection. Also, breast milk is available all the time and is practically free from pathogenic microorganisms. On the other hand, non-exclusive breastfeeding is an important risk factor of infant diseases like diarrheal morbidity. This finding suggest that exclusive breastfeeding during the first 6 months of life is one of the most effective interventions to improve child health [31].

Like the local study from Debrebirehan town [15], the current study found that employed and private business occupational status of mothers was significantly associated with diarrheal morbidity in under-five children compared to housewife mothers occupational status. The possible explanation might be that mothers working outside the home may have less time to better care and feed their children compared to housewives. Another possible reason might be that mothers working outside the home may not have as much contact time to breastfeed their children as compared with housewives.

According to this study, children from households that had no solid waste disposal systems were more likely to develop diarrheal diseases. This study is consistent with another local study in northwest Ethiopia [32]. This might be due to children putting contaminated fingers, pica, or fomites into their mouths while crawling or playing around contaminated environments associated with poor waste disposal practices [29, 33].

The last significant variable, the odds of diarrheal disease, is nearly three times higher among children whose household income is ≤ ETB 600 compared to children whose household income is ≥ ETB 2000. It may be the case that mothers/caregivers who have higher incomes may have the opportunity to buy and use detergents for hand washing and the resources to construct and use standard toilets.

Limitation

This study showed the prevalence of diarrheal morbidity and its associated factors; like rotavirus vaccination among the most vulnerable population groups, under-five children, in Bahir Dar, Ethiopia where there is scarcity of literature. However, the study has some limitations. For example, the cross-sectional design of the study may limit its capacity to measure the cause-effect relationship between the outcome and the potential correlates. As well, there may be recall bias of diarrhea episodes/rotavirus vaccination and difficulty distinguishing the time order of exposures. Finally, wealth index is not addressed in this study.

Conclusion

In the study area, approximately one in every ten of the under-five children had diarrheal morbidity. Thus, implementing effective rotavirus vaccination programs, encouraging exclusive breastfeeding, and emphasize appropriate solid waste management would reduce childhood diarrheal morbidity in the region. In addition, the finding suggests that improved child care mechanisms, especially for mothers working outside the home, and efforts to increase household income should be intensified to reduce incidence of diarrhea.

Abbreviations

AOR: 

Adjusted odds ratio

CI: 

Confidence interval

COR: 

Crude odds ratio

DDS: 

Dietary diversity score

EDHS: 

Ethiopian Demographic Health Survey

GDP: 

Gross Domestic Production

SPSS: 

Statistical Package for Social Science

VIPL: 

Ventilated and improved pit latrine

WHO: 

World Health Organization

Declarations

Acknowledgements

We would like to thank the mothers for their willingness to participate in the study. Our appreciation will also go to the Bahir Dar city administration for material support.

Availability of data and materials

We confirm that all data underlying the findings would be fully available without restriction if the manuscript is published.

Authors’ contributions

GS and MG conceived the study, developed the tool, coordinated data collection, carried out the statistical analysis, and drafted the manuscript. AK and TD conceived the study, participated in the statistical analysis, and drafted the manuscript. TD conceived the study and reviewed the drafted manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Bahir Dar University approved the study protocol, and then ethical clearance was obtained from the research and publication committee of Bahir Dar University. After explanation of the study objective, further permission was obtained from the Amhara National Regional State Health Bureau. Verbal consent was also obtained from parents or legal guardians. The confidentiality of information was guaranteed by using code numbers rather than personal identifiers and by keeping the data locked. Participants were told to decline at any time if they felt uncomfortable, even after the interview was started.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interest.

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Authors’ Affiliations

(1)
ORDA/PSI MULU HIV Prevention Project, Bahir Dar, Amhara region, Ethiopia
(2)
College of Medicine and Health Science, Bahir Dar University, Bahir Dar, Ethiopia
(3)
Department of Health Service Management and Heath Economics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
(4)
Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia

References

  1. Glass RI, Parashar U, Patel M, Gentsch J, Jiang B. Rotavirus vaccines: successes and challenges. J Infect. 2014;68:S9–18.View ArticlePubMedGoogle Scholar
  2. CDC. Epidemiology and prevention of vaccine-preventable diseases. 2012;12(2):1–4.Google Scholar
  3. Boschi-Pinto C, Velebit L, Shibuya K. Estimating child mortality due to diarrhoea in developing countries. Bull World Health Organ. 2008;86(9):710–7.View ArticlePubMedPubMed CentralGoogle Scholar
  4. WHO U. Diarrhoea: why children are still dying and what can be done. Geneva: UNICEF/WHO; 2009.Google Scholar
  5. Walker CL, Rudan I, Liu L, Nair H, Theodoratou E, Bhutta ZA, O'Brien KL, Campbell H, Black RE. Global burden of childhood pneumonia and diarrhoea. Lancet. 2013;381(9875):1405–16.View ArticlePubMedGoogle Scholar
  6. WHO. Reducing mortality from major childhood killer diseases. Mort Country Fact Sheet. 2006:1-4.Google Scholar
  7. Kumar SG, Subita L. Diarrhoeal diseases in developing countries: a situational analysis. Kathmandu Univ Med J. 2013;10(2):83–8.View ArticleGoogle Scholar
  8. UNICEF. Pneumonia and diarrhea: tackling the deadliest diseases in the world. New York: UNICEF; 2012.Google Scholar
  9. Ndze VN, Akum AE, Kamga GH, Enjema LE, Esona MD, Banyai K, Therese OA. Epidemiology of rotavirus diarrhea in children under 5 years in northern Cameroon. Pan Afr Med J. 2012;11(1):1937-8688.Google Scholar
  10. Tate JE, Burton AH, Boschi-Pinto C, Steele AD, Duque J, Parashar UD. 2008 estimate of worldwide rotavirus-associated mortality in children younger than 5 years before the introduction of universal rotavirus vaccination programmes: a systematic review and meta-analysis. Lancet Infect Dis. 2012;12(2):136–41.View ArticlePubMedGoogle Scholar
  11. Freij L, Kidane Y, Sterky G, Wall S. Exploring child health and its ecology. The Kirkos study in Addis Ababa. Research frame, project description and data evaluation. 1976.Google Scholar
  12. Mosley WH, Chen LC. An analytical framework for the study of child survival in developing countries. Popul Dev Rev. 1984;10(0):25–45.View ArticleGoogle Scholar
  13. Bizuneh H, Getnet F, Meressa B, Tegene Y, Worku G. Factors associated with diarrheal morbidity among under-five children in Jigjiga town, Somali regional state, eastern Ethiopia: a cross-sectional study. BMC Pediatr. 2017;17(1):182.View ArticlePubMedPubMed CentralGoogle Scholar
  14. Rohmawati N, Panza A, Lertmaharit S. Factors associated with diarrhea among children under five years of age in Banten province. Indonesia J Health Res. 2012;26(1):31–4.Google Scholar
  15. Mamo A, Hailu A. Assessment of prevalence and related factors of diarrheal diseases among under-five year’s children in Debrebirehan Referral Hospital, Debrebirehan Town, north Shoa zone, Amhara region, Ethiopia. jourlib org J. 2014;1(1):1-14.Google Scholar
  16. Gizaw Z, Woldu W, Bitew BD. Child feeding practices and diarrheal disease among children less than two years of age of the nomadic people in Hadaleala district, afar region, northeast Ethiopia. Int Breastfeed J. 2017;12(1):24.View ArticlePubMedPubMed CentralGoogle Scholar
  17. Federal Ministry of Health, Family Health Department Ethiopia. National strategy for infant and young child feeding. Addis Ababa: Federal Ministry of Health, Family Health Department Ethiopia; 2004.Google Scholar
  18. Government of the Federal Democratic and Republic of Ethiopia: National Nutrition Program June 2013–June 2015.Google Scholar
  19. Ethiopia National Expanded Programme on Immunization. Comprehensive multi-comprehensive multi-year plan 2016 year plan 2016 year plan 2016–2020. Addis Ababa: Federal ministry of health; 2015.Google Scholar
  20. Abebe A, Teka T, Kassa T, Seheri M, Beyene B, Teshome B, Kebede F, Habtamu A, Maake L, Kassahun A, Getahun M. Hospital-based surveillance for rotavirus gastroenteritis in children younger than 5 years of age in Ethiopia: 2007–2012. Pediatr Infect Dis J. 2014;33:S28–33.View ArticlePubMedGoogle Scholar
  21. World Health Organization. CHERG-WHO methods and data sources for child causes of death 2000-2012. , 2014.Google Scholar
  22. Central Statistical Authority [Ethiopia] and ORC Macro. Ethiopia Demographic and Health Survey 2005. Addis Ababa: Ethiopia and Calverton; 2005.Google Scholar
  23. Central Statistical Authority [Ethiopia] and ORC Macro. Ethiopia Demographic and Health Survey 2011. Addis Ababa: Ethiopia and Calverton; 2011.Google Scholar
  24. Bahirdar city administration zonal health department, 2015.Google Scholar
  25. Anteneh ZA, Andargie K, Tarekegn M. Prevalence and determinants of acute diarrhea among children younger than five years old in Jabithennan district, northwest Ethiopia, 2014. BMC Public Health. 2017;17(1):99.View ArticlePubMedPubMed CentralGoogle Scholar
  26. WHO/UNICE. Core questions on drinking-water and sanitation for household surveys; 2008. p. 6–19.Google Scholar
  27. Azage M, Kumie A, Worku A, Bagtzoglou AC. Childhood diarrhea in high and low hotspot districts of Amhara region, northwest Ethiopia: a multilevel modeling. J Health Popul Nutr. 2016;35(1):13.View ArticlePubMedPubMed CentralGoogle Scholar
  28. Berhe F, Berhane Y. Under five diarrhea among model household and non model households in Hawassa, south Ethiopia: a comparative cross-sectional community based survey. BMC Public Health. 2014;14(1):187.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Sonko A, Worku A. Prevalence and predictors of exclusive breastfeeding for the first six months of life among women in Halaba special woreda, southern nations, nationalities and peoples’ region/SNNPR/, Ethiopia: a community based cross-sectional study. Archives Publ Health. 2015;73(1):53.View ArticleGoogle Scholar
  30. O’Ryan M, Giaquinto C, Benninghoff B. Human rotavirus vaccine (Rotarix): focus on effectiveness and impact 6 years after first introduction in Africa. Expert Rev Vaccines. 2015;14(8):1099–112.View ArticlePubMedGoogle Scholar
  31. Gupta A, Sarker G, Rout AJ, Mondal T, Pal R. Risk correlates of diarrhea in children under 5 years of age in slums of Bankura, west Bengal. J Global Infect Dis. 2015;7(1):23.View ArticleGoogle Scholar
  32. Ayele A, Awoke W, Tarekegn M. Crossectional survey; assessment of diarrheal disease prevalence and the associated factors among children under five in Enemay district, northwest Ethiopia. Global J Med Res. 2014;13:0975-5888.Google Scholar
  33. Moya J, Bearer CF, Etzel RA. Children’s behavior and physiology and how it affects exposure to environmental contaminants. Pediatrics. 2004;113(Supplement 3):996–1006.PubMedGoogle Scholar

Copyright

© The Author(s). 2018

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