Factors affecting under-five diarrhea in households with dirt floors: a multilevel mixed-effects analysis from a national survey of Ethiopia

Abstract Introduction: Diarrhea remains the second leading cause of mortality among under-five children in Ethiopia, spreads more easily in homes with dirt floors. Even though the determinants of diarrheal illness is widely recognized at the global level, there is a limited number of studies that identified the individual and community-level factors solely among children residing in households with sub-optimal flooring (i.e. earth, mud or sand, and dung). Therefore, this study aims to identify individual and community-level factors associated with childhood diarrhea in households with sub-optimal flooring in Ethiopia.Methods: Data from the fourth round of the Ethiopian Demographic and Health Survey (EDHS) conducted in 2016 is used to carry out the analysis. The EDHS was large, cross-sectional by design, and nationally representative. A total of 9,097 under-five children living in households with sub-optimal floors and 645 community clusters were included in the current analysis. A multi-level logistic regression analysis was used to examine both individual and community level factors while accounting for the hierarchal structure of the data.Results: The overall prevalence of childhood diarrhea in households with suboptimal flooring in Ethiopia was 11.9% (95% CI:11.2-12.6). Children aged 6-11 months (adjusted OR [AOR]=2.68, 95%CI: 1.89-3.82), and ≥ 12 months (AOR=1.65, 95%CI: 1.22-2.24) were more likely to have diarrhea compared with children aged 0-5 months. Having cough (AOR=6.09, 95% CI=4.93-7.52) and fever (AOR=1.62, 95%CI: 1.30-2.01) were found to increase the risk for the development of diarrhea in children. Maternal age (25-34 years) and paternal lack of educated were found to be associated with lower odds of childhood diarrheal prevalence rates. Further, children from households with higher family size (≥ 5 family size), low birth order (firstborn), and the number of under-five children (2-3 children) were reported decreased odds of diarrhea. At the community level, children living in pastoralist regions (such as Afar and Somali region) significantly less likely to have diarrhea vulnerability (AOR: 0.61, 95%CI: 0.40-0.91) compared to those who reside in cities. Conclusion: Both individual-level (age of the child, birth order, presence of cough and fever, maternal age, paternal education, household size, improper child stool disposal, number of under-five children) and community-level factor (place of residence) were revealed to be important factors for childhood diarrhea in households with suboptimal flooring.