Sitasi

RESEARCH ARTICLE
Prevalence and determinants of diarrhea

among under-five children in Ethiopia: A
systematic review and meta-analysis
Animut Alebel1*, Cheru Tesema1, Belisty Temesgen2, Alemu Gebrie1,
Pammla Petrucka3,4, Getiye Dejenu Kibret1
1 College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia, 2 Debre Markos Referral
Hospital, Debre Markos, Ethiopia, 3 College of Nursing, University of Saskatchewan, Saskatoon, Canada,
4 School of Life Sciences and Bioengineering, Nelson Mandela African Institute of Science and Technology,
a1111111111 Arusha, Tanzania
a1111111111
a1111111111 * animut.a23@gmail.com
a1111111111
a1111111111
Abstract
OPEN ACCESS Background

Citation: Alebel A, Tesema C, Temesgen B, Gebrie Despite remarkable progress in the reduction of under-five mortality, childhood diarrhea is
A, Petrucka P, Kibret GD (2018) Prevalence and still the leading cause of mortality and morbidity in this highly susceptible and vulnerable
determinants of diarrhea among under-five population. In Ethiopia, study findings regarding prevalence and determinants of diarrhea
children in Ethiopia: A systematic review and meta-
analysis. PLoS ONE 13(6): e0199684. https://doi.
amongst under-five children have been inconsistent. Therefore, this systematic review and
org/10.1371/journal.pone.0199684 meta-analysis estimates the pooled prevalence of diarrhea and its determinants among
Editor: Mark Pietroni, South Gloucestershire,
under-five children in Ethiopia.
UNITED KINGDOM
Received: January 5, 2018

Methods
Accepted: June 12, 2018
International databases, including PubMed, Web of Science, EMBASE, CINAHL, Google
Scholar, Science Direct, and the Cochrane Library, were systematically searched. All identi-
Published: June 28, 2018
fied observational studies reporting the prevalence and determinants of diarrhea among
Copyright: © 2018 Alebel et al. This is an open under-five children in Ethiopia were included. Two authors independently extracted all
access article distributed under the terms of the
Creative Commons Attribution License, which
necessary data using a standardized data extraction format. STATA Version 13 statistical
permits unrestricted use, distribution, and software was used. The Cochrane Q test statistics and I2 test were used to assess the het-
reproduction in any medium, provided the original erogeneity of the studies. A random effects model was computed to estimate the pooled
author and source are credited.
prevalence of diarrhea. Moreover, the associations between determinant factors and child-
Data Availability Statement: All relevant data are hood diarrhea were examined using the random effect model.
within the paper and its Supporting Information
files.
Results
Funding: The authors received no specific funding
for this work. After reviewing of 535 studies, 31studies fulfilled the inclusion criteria and were included in
the meta-analysis. The findings from the 31 studies revealed that the pooled prevalence of
Competing interests: The authors have declared
that no competing interests exist. diarrhea among under-five children in Ethiopia was 22% (95%CI: 19, 25%). Subgroup anal-
ysis of this study revealed that the highest prevalence was observed in Afar region (27%),
Abbreviations: CI, Confidence Interval; DHS,
Demographic and Health Survey; EDHS, Ethiopia followed by Somali and Dire Dawa regions (26%), then Addis Abeba (24%). Lack of mater-
Demographic and Health Survey; OR, Odds ratio; nal education (OR: 2.5, 95% CI: 1.3, 2.1), lack of availability of latrine (OR: 2.0, 95%CI: 1.3,
PLOS ONE | https://doi.org/10.1371/journal.pone.0199684 June 28, 2018 1 / 20

Prevalence of diarrhea among under-five children in Ethiopia: A systematic review and meta-analysis
SDG, Sustainable Development Goals; SNNPR, 3.2), urban residence (OR: 1.9, 95%CI: 1.2, 3.0), and maternal hand washing (OR: 2.2, 95%
Southern Nations, Nationalities, and Peoples CI: 2.0, 2.6) were significantly associated with childhood diarrhea.
Region; WHO, World Health Organization.
Conclusion
In this study, diarrhea among under-five children in Ethiopia was significantly high. Lack of
maternal education, lack of availability of latrine, urban residence, and lack of maternal hand
washing were significantly associated with childhood diarrhea.
Introduction
Childhood diarrhea is defined as the passage of three or more loose or watery stools per 24
hours or an increase in stool frequency or liquidity that is considered abnormal by the mother
[1, 2]. Despite remarkable progress in the reduction of under-five mortality, childhood diar-
rheal disease is still a leading cause of mortality and morbidity [3, 4]. Globally, diarrheal disease
contributed to 15% of all under-five deaths (approximately 2.5 million deaths each year), mak-
ing diarrheal disease the second leading cause of death in the youngest members of society [5,
6]. Developing countries or economically disadvantaged regions carried the highest burden of
under-five mortality, with nearly four fifths of all under-five mortality occurring in Sub-Saha-
ran Africa and south Asia [7, 8]. According to World Health Organization (WHO) (2016), the
under-five mortality rate in low-income countries was 73.1 deaths per 1000 live births, nearly
14 times the average rate in high-income countries (i.e., 5.3 deaths per 1000 live births) [9].
In Ethiopia, diarrheal diseases are major contributors to under-five mortality. According to
the 2016 Ethiopia Demographic and Health Survey report,12% of under-five children had a
diarrheal episode in the 2 weeks before the survey [10]. More than half of under-five child
deaths are attributable to diseases that are easily preventable and treatable through simple, cost
effective, and affordable interventions. Strengthening health systems to provide such interven-
tions to all children will potentially save many young lives [7]. In 2015, the United Nation
adopted the Sustainable Development Goals (SDGs) to reduce child mortality and to promote
well-being for all children. The SDG goal #3 Target 3.2 aims to end preventable deaths of new-
borns and under-five children by 2030 [7]. Likewise, the Ethiopian government also imple-
mented various strategies, such as the Health Extension Program, to prevent and control
infectious diseases like diarrhea [11].
Despite interventions and innovations by a range of stakeholders, under-five mortality
related to diarrhea remains a major concern, especially in developing countries like Ethiopia.
In Ethiopia, several studies were conducted to estimate the prevalence as well as to identify
modifiable factors of under-five diarrheal diseases [11–32]. However, the prevalence reflected
in these small and fragmented studies varied widely and remained inconclusive. Besides preva-
lence, identifying modifiable risk factors is a critical step in identifying potential interventions.
The lack of a nationwide study that determines the prevalence and determinants of diarrhea
among under-five children is a significant gap. Therefore, this systematic review and meta-
analysis aimed to determine the pooled prevalence and determinants of diarrhea among
under-five years of children using available studies in Ethiopia. The findings from this system-
atic review will highlight the prevalence and determinants of childhood diarrhea with implica-
tions to improve health workers’ interventions, to ensure cost-effectiveness, and to accelerate
the reduction of childhood diarrhea in Ethiopia.

Methods
Study design and setting
A systematic review and meta-analysis was conducted to estimate the prevalence and determi-
nants of diarrhea among under-five children in Ethiopia. Ethiopia is located in the horn of
Africa. It is bounded by Eritrea to the north, Djibouti and Somalia to the east, Sudan and
South Sudan to the west, and Kenya to the south. Currently, the Ethiopian population is esti-
mated to be 106,059,710 with 20.2% living in urban areas [33, 34].
Search strategies
We prepared and presented this meta-analysis according to the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis (PRISMA) [35] (S1 Table). To find potentially relevant
articles, a comprehensive search with no date limits was performed in the following databases:
PubMed/MEDLINE, Web of Science, EMBASE, CINAHL, Google Scholar, Science Direct and
Cochrane Library (Table 1). All searches were limited to articles written in English given that
such language restriction does not alter the outcome of the systematic reviews and meta-analy-
ses[36]. Gray literature of observational studies was searched through the review of reference
lists and input of content experts. In addition, to find unpublished papers relevant to this sys-
tematic review and meta-analysis, some research centers, including the Addis Ababa Digital
Library were searched. Studies identified by our search strategy were retrieved and managed
using Endnote X7 (Thomson Reuters, Philadelphia, PA, USA) software. The search of the
literature was conducted between the 1st of October to the 1st of November,2017. All papers
published until the 1st of November, 2017 were considered. The search used the following key-
words “prevalence”, “diarrhea”, “diarrheoa”, “under-five”, “children”, “determinants”, “associ-
ated factors” and “Ethiopia”. The search terms were used separately and in combination using
Boolean operators like “OR” or “AND”.
Eligibility criteria
Inclusion criteria. Study area: Only studies conducted in Ethiopia
Population: Only studies involving under-five year children
Publication condition: Both published and unpublished articles were included
Study design: All observational study designs (i.e., cross-sectional, case-control and cohort)
reporting the prevalence of diarrhea in under-five children were eligible for this review.
Language: Only articles reported in English language were considered
Table 1. Example of searches for the MEDLINE/ PubMed and Google Scholar databases to assess the prevalence and determinants of diarrhea among under-five
children in Ethiopia.
Databases Searching terms Number of
studies
Google scholar "prevalence" and "determinants" or "associated factors " and "children" or "under-five" and "diarrhea" or "diarrhoea" 124
and "Ethiopia"-Adults
MEDLINE/ PubMed ("epidemiology"[Subheading] OR "epidemiology"[All Fields] OR "prevalence"[All Fields] OR "prevalence"[MeSH 43
Terms]) AND ("diarrhoea"[All Fields] OR "diarrhea"[MeSH Terms] OR "diarrhea"[All Fields]) AND under-five[All
Fields] AND ("child"[MeSH Terms] OR "child"[All Fields] OR "children"[All Fields]) AND ("ethiopia"[MeSH Terms]
OR "ethiopia"[All Fields])
From other databases 368
Total retrieved articles 535
Final full text relevant to 31
our review
https://doi.org/10.1371/journal.pone.0199684.t001

Exclusion criteria. Articles, which were not fully accessible, after at least two-email con-
tact with the primary authors, were excluded. Exclusion of these articles is because of the
inability to assess the quality of articles in the absence of full text.
Measurement of outcome variables

This study has two main outcomes. Childhood diarrheal disease, as the primary outcome vari-
able of this study, is defined as having three or more loose or watery stools in a 24 hour period
[37, 38]. The prevalence of childhood diarrhea was estimated as the total number of diarrhea
cases divided by the total number of under-five children participating in the study multiplied
by 100. The second outcome of this study was to identify the determinants of diarrhea among
under-five children. For the second outcome, we determined the association between under-
five diarrhea and determinants in the form of the log odds ratio. For major determinants, the
odds ratio was calculated based on binary outcomes from the primary studies. The determi-
nants included in this review were: residence (urban versus rural), educational status of care-
giver (unable to read and write versus able to read and write), hand washing practices of
caregiver (yes versus no), and availability of any type of latrine (yes versus no).
Data extraction
Data from included articles were extracted using a standardized data extraction format,
adapted from the Joanna Briggs Institute (JBI), by two authors (AA and CT) independently
extracting all necessary data. Any disagreements during the data extraction were resolved
through discussion and consensus (i.e., a Delphi process). The primary author of the original
research was contacted for additional information or to clarify method details as needed. For
the first outcome (prevalence), the data extraction format included primary author, publica-
tion year, region(s) of the country where the study was conducted, study area, sample size,
response rate and prevalence with 95%CI. For the second outcome (determinants), data were
extracted in a format of two by two tables, and then the log odds ratio for each factor was cal-
culated based on the findings of the original studies.
Risk of bias
Two authors (AA and CT) independently assessed the risk of bias for each original study using
the tool. To assess the risk of bias, we used the Hoy 2012 addressing internal and external
validity tool using 10 criteria [39]. The tool mainly included (1) representation of the popula-
tion, (2) sampling frame, (3) methods of participants’ selection, (4) non-response bias, (5) data
collection directly from subjects, (6) acceptability of case definition, (7) reliability and validity
of study tools, (8) mode of data collection, (9) length of prevalence period, and (10) appropri-
ateness of numerator and denominator. Each item was classified as either low or high risk of
bias. Not clear was classified as high risk of bias. Finally, the overall score of risk of bias was
then categorized according to the number of high risk of bias per study: low ( 2), moderate
(3–4), and high ( 5) (S2 Table).
Data processing and analysis

Data were extracted in Microsoft Excel format, followed by analysis using STATA Version
13 statistical software. The standard error for each original study was calculated using the
binomial distribution formula. Heterogeneity among reported prevalence was assessed by
computing p-values of Cochrane Q-test and I2statics [40]. As the test statistic showed there is
significant heterogeneity among the studies (I2 = 96.31%, p <0.001) as a result a random

effects meta-analysis model was used to estimate the DerSimonian and Laird’s pooled effect.
In the current meta-analysis, arcsine-transformed proportions were used. The pooled propor-
tion was estimated by using the back-transform of the weighted mean of the transformed pro-
portions, using arcsine variance weights for the fixed-effects model and DerSimonian-Laird
weights for the random-effects model [41]. To minimize the random variations between the
point estimates of the primary study subgroup, analysis was done based on study settings (i.e.,
region(s) where the study occurred). In addition, to identify the possible source of heterogene-
ity, univariate meta-regression was undertaken by considering year of publication, quality
score, region of the country where the study was conducted and sample size, however, none of
these were found to be statistically significant. Egger’s and Begg’s tests at 5% significant level
were not significant for publication bias [42]. Point prevalence, as well as 95% confidence
intervals, was presented in the forest plot format. In this plot, the size of each box indicated the
weight of the study, while each crossed line refers to 95% confidence interval. For the second
outcome, a log odds ratio was used to determine the association between determinant factors
and diarrhea among under-five children in the included evidence set.
Results
Initially, 535 articles were retrieved reporting prevalence and determinants of diarrhea among
under-five children using the range of databases previously described. Of these initial articles,
180 articles were excluded due to duplication. From the remaining 355 articles, 294 articles
were excluded after review of their titles and abstracts confirmed non-relevance to this review.
Therefore, 61 full text articles were accessed, and assessed for eligibility based on the pre-set
criteria, which resulted in further exclusion of 30 articles primarily due to the study locations
[30, 43–70] (S3 Table). Ultimately, 31 studies met the eligibility criteria and were included in
the final meta-analysis (see Fig 1).
Description of included studies

As described in Table 1, the 31included studies were cross-sectional study design, and pub-
lished between 2003 to 2017. In the current meta-analysis, 22,744 study participants were
involved to determine the pooled prevalence of diarrhea among under-five children. Regard-
ing sample size, the sample size of the studies ranged from 278 to1, 807. The lowest prevalence
(8%) of under-five diarrhea was reported in studies conducted in Wolitta Soddo Town, South-
ern Nations, Nationalities, and Peoples Region (SNNPR) [32] and Mecha District, Amhara
region [28]whereas the highest prevalence (37%) was reported in a study conducted in a rural
Dire Dawa [18]. In the present meta-analysis, six Ethiopian regions and two administrative
towns were represented. Ten of the studies were from Amhara [19, 24, 25, 28, 31, 71–75], five
from SNNPR [20, 26, 32, 76, 77], five from Oromia [17, 18, 21, 22, 78], three from Afar [13, 79,
80], three from Addis Ababa [12, 15, 29], two from Tigray [14, 81], two from Somali [23, 82]
and one from Dire Dawa [18]. No studies were reported from Benishangul Gumiz, Harari,
and Gagmbela regions. Regarding to response rate, almost all studies had a good response rate
(>85%), which may, in part be attributable to the use of interviewer-administered question-
naires to collect the data (Table 2).
Risk of bias
The risk of bias for each original study was conducted using a risk of bias tool which encom-
passed ten different items [39]. Among the 31 included studies, our summary assessment
revealed that more than three fourth (77.4%) of the included studies had low risk of bias [12–
14, 17–19, 22–26, 28, 29, 32, 71, 73–80, 82] whereas, about 16.1% of the included studies had

Fig 1. Flow chart of study selection for systematic review and meta-analysis of the prevalence and determinants of diarrhea among under-five
children in Ethiopia.
https://doi.org/10.1371/journal.pone.0199684.g001
moderate risk of bias [15, 16, 21, 31, 72] the remaining, 6.5% of the studies had high risk of
bias [20, 81].
Prevalence of diarrhea among under-five children in Ethiopia

The 31 included studies revealed that a pooled prevalence of under-five diarrhea in Ethiopia
was 22% (95%CI: 19, 25) (Fig 2). High heterogeneity was observed across the included studies
(I2 = 96.31, p<0.001). Therefore, a random effect meta-analysis model was computed to esti-
mate the pooled prevalence of under-five diarrhea in Ethiopia. From this meta-analysis, the
highest prevalence was 37% (95%CI: 32, 43) reported in a study by Keneni et al [18]whereas
the lowest prevalence of 8% was reported elsewhere [28, 32]. To identify possible sources of
heterogeneity, different factors associated with heterogeneity, such as year of publication, qual-
ity score, region of the country where the study conducted and sample size, were investigated
by using univariate meta-regression models, although none of these variables were found to be
statistically significant (Table 3). Funnel plot asymmetry was used to check the presence of
publication bias (Fig 3). The result of funnel plot showed that there was a slight asymmetrical
distribution of articles. To confirm this asymmetry, we conducted an objective (Begg’s and
Egger’s tests) based tests. The results of Begg’s and Egger’s tests showed that there was no

Table 2. Descriptive summary of 31 studies included in the meta-analysis of the prevalence and determinants of diarrhea among under-five children in Ethiopia
2017.
No Author Publication Year Region Study Area Sample Size Response Rate Prevalence with 95%
1. Hailemariam Berhe[81] 2016 Tigra Enderta 278 94.2 36 (30, 41)
2. Mohammed et al [20] 2013 SNNPR Arba Minch 590 100 31 (27, 34)
3. Mohammed and Zungu[21] 2016 Oromia Sebeta 477 100 10 (7, 13)
4. Mengistie et al [22] 2013 Oromia Kersa District 1456 97.8 16 (14, 18)
5. Woldu et al [13] 2016 Afar Hadaleala District 704 100 26 (23, 30)
6. Regassa and Lemma [16] 2016 Oromia Adama Rural District 442 100 15 (12, 18)
7. Teklit Angesom[14] 2015 Tigray Laelay-Maychew District 543 100 18 (15, 21)
8. Dessalegn et al [28] 2011 Amhara Mecha District 768 100 8 (6, 10)
9. Gedamu et al [25] 2017 Amhara FartaWereda 988 99 17 (15, 19)
10. Zeleke and Alemu [12] 2014 Addis Ababa Yeka Sub City 350 100 33 (29, 39)
11. Anteneh et al [31] 2017 Amhara Jabithennan District 775 99.2 25 (22, 28)
12. Gedefaw et al [24] 2015 Amhara Bahir Dar 667 99.1 22 (19, 25)
13. Tadesse Yared[15] 2016 Addis Ababa Yeka Sub City Woreda 3 399 99.7 9 (6, 11)
14. Hashi et al [23] 2016 Somalia Jigjiga District 1807 100 27 (25, 29)
15. Alambo Kedir Addisu[32] 2015 SNNPR Wolitta Soddo Town 954 98.4 8 (6, 10)
16. Regassa et al [17] 2008 Oromia Nekemte Town 461 96.6 29 (25, 33)
17. Demelash Ayele[29] 2014 Addis Ababa Addis Ababa 348 83.3 30 (25, 35)
18. Jamboree et al [26] 2016 SNNPR Gummer Woreda, Guragie 611 96.4 15 (12, 18)
19. Mulugeta Teklu[19] 2003 Amhara Meskanena Mareko Woreda 987 100 22 (20, 25.0)
20. Keneni et al [18] 2016 Dire Dawa Dire Dawa Rural District 291 98.6 37 (32, 43)
21. Gebru et al [77] 2014 SNNPR Sheko Rural District 792 96 19 (17, 22)
22. Awoke [72] 2013 Amhara Bahir Dar Town 415 98.34 27 (22, 31)
23. Tamiso et al [76] 2014 SNNPR rural area of Shebedino 769 98.8 20 (17, 23)
24. Mamo and Hailu [71] 2014 Amhara Debre Birehan Town 483 100 32 (28, 36)
25. Bitew et al [80] 2017 Afar Hadaleala District 704 NR 26 (23, 30)
26. Gizaw et al [79] 2017 Afar Hadaleala District 367 100 31 (27, 36)
27. Ayele et al [74] 2014 Amhara Enemay District 634 100 19 (16, 22)
28. Mekasha and Tesfahun[78] 2003 Oromia Jimma Town 605 NR 23 (20, 27)
29. Alelign et al [75] 2016 Amhara Debre Birehan Town 312 NR 12 (9, 16)
30. Getu et al [73] 2014 Amhara Dejen District 710 96.5 24 (21, 27)
31. Bizuneh et al [82] 2017 Somali Jigjig Town 492 92.8 15 (12, 18)
NR: not reported, SNNPR: Southern Nations, Nationalities, and Peoples Region.
statistical significant publication bias in estimating the prevalence of diarrhea among under-
five children [(p = 0.2) and (p = 0.4) respectively].
Subgroup analysis
In this meta-analysis, we performed subgroup analysis based on the region of the country
where studies were conducted as well as sample size. Accordingly, the highest prevalence was
observed in Afar region with a prevalence of 27% (95% CI: 25, 30) followed by Somali and
Dire Dawa regions at 26% (95% CI: 15, 37) and then Addis Abeba at 24% (95% CI: 7, 41).
With regard to sample size, the prevalence of diarrhea was higher in studies having a sample of
size<670, 23% (95% CI: 19, 27) compared to those having a sample size> = 670, 20% (95%CI:
16, 24) (Table 4).

Fig 2. Forest plot of the pooled prevalence of diarrhea among under-five children in Ethiopia.
Determinants of under-five diarrhea in Ethiopia

The association between maternal education and childhood diarrhea. In this meta-
analysis, we examined association between maternal educational status and childhood diarrhea
by using seven studies [12–14, 20, 22, 23, 25]. The findings from these seven studies revealed
Table 3. Related factors with heterogeneity of diarrheal prevalence among under-five children in the current
meta-analysis (based on univariate meta-regression).
Variables Coefficient P-value
Publication year -0.17 0.70
Sample size -0.004 0.30
Quality score 0.006 0.98
Regions
Addis Ababa -2.44 0.72
Afar 1.73 0.80
Amhara -5.51 0.33
Oromia -7.53 0.23
SNNPR -7.76 0.22
Tigray 0.22 0.97
Somali and Dire Dawa (Constant) 26.01 <0.001

Fig 3. Funnel plot with 95% confidence limits of the pooled prevalence of diarrhea among under-five children in Ethiopia.
that the occurrence of childhood diarrhea was significantly associated with mothers’ educa-
tional status. Accordingly, the likelihood of diarrhea occurrence was 1.7 times higher among
children whose mothers’ were unable to read and write as compared to their literate counter-
parts (OR: 2.5, 95% CI: 1.3, 2.1). The result of the test statistics indicated that moderate
Table 4. Subgroup prevalence of diarrhea among under-five children in Ethiopia, 2017 (n = 31).
Variables Characteristics Included studies Sample size Prevalence with (95% CI)
By region Amhara 10 6,714 21 (16, 25)
Oromia 5 3,441 18 (13, 24)
Afar 3 1,775 27 (25, 30)
Addis Ababa 3 1,079 24 (7, 41)
SNNPR 5 3,716 18 (11, 25)
Tigray 2 821 22 (19, 25)
Somali and Dire Dawa 3 2,590 26 (15, 37)
By sample size > = 670 12 10,704 20 (16,24)
<670 19 6,722 23 (19, 27)
Overall 31 22,744 22(19, 25)

Fig 4. The pooled odds ratio of the association between maternal education and childhood diarrhea in Ethiopia.
heterogeneity (I2 = 57.3% and p = 0.03) was presented across the included studies. Therefore, a
random effect meta-analysis model was employed to determine the association(Fig 4).
Association between latrine availability and childhood diarrhea. Similarly, the associa-
tion between the availability of any type of latrine and childhood diarrhea was examined by
using eight studies [14, 16, 17, 20, 22, 23, 25, 28]. Four of the included studies reported that the
availability of any type of latrine were not significantly associated with childhood diarrhea [14,
16, 20, 25] whereas, four indicated that absence of any type of latrine was positively associated
with childhood diarrhea [17, 22, 23, 28]. The result of this meta-analysis revealed that the
absence of any type of latrine was positively associated with childhood diarrhea. From this
result, children living in households without latrine facilities were found to be 2.0 times more
likely to develop diarrhea than children living in households with such facilities (OR: 2.0, 95%;
CI: 1.3, 3.2) (Fig 5). The included studies exhibited high heterogeneity (I2 = 90.9% and p<
0.001), hence random effect meta-analysis was computed.
Association between residence and childhood diarrhea. To examine the association
between residence and childhood diarrhea, studies that examined the association between
respondents’ residences and under-five diarrhea were included [14, 21, 22, 24, 25, 28, 31].
According to Mohammed and Zungu [21], children from households of rural households
were less likely to have diarrhea than their urban counterparts. Conversely, five studies dis-
closed that children from rural households were more likely to have diarrhea as compared to

Fig 5. The pooled odds ratio of the association between latrine availability and childhood diarrhea in Ethiopia.
children from urban households [14, 22, 24, 25, 28]. One study [31]found residence was not
significantly associated with childhood diarrhea. The pooled result of this meta-analysis indi-
cated that children from rural households were 1.9 times more likely to have diarrhea as com-
pared to their urban counterparts (OR: 1.9, 95%CI: 1.2, 3.0) (Fig 6). In this meta-analysis,
included studies were characterized by high heterogeneity (I2 = 74.1%; p = 00.1), we computed
a random effect meta-analysis.
Association between maternal hand washing practices and childhood diarrhea. Finally,
in this review, we examined the association between mothers’ hand washing practices and
childhood diarrhea. Eight studies that examined the association between childhood diarrhea
and mothers hand washing practice were included. Seven studies indicated that mothers’ hand
washing practice after toilet visiting was significantly associated childhood diarrhea [12, 15, 16,
23, 26, 80]. These studies reported that mothers who did not practice hand washing after visit-
ing a toilet were positively associated with childhood diarrhea. One study reported that moth-
ers’ hand washing practices were not significantly associated with diarrhea [76]. The overall
result of this study revealed that children whose mothers did not practice hand washing after
visiting a toilet were 2.3 more likely to develop diarrhea as compared to their counterparts

Fig 6. The pooled odds ratio of the association between residence and childhood diarrhea in Ethiopia.
(OR: 2.2, 95%CI: 2.0, 2.6) (Fig 7). Moderate heterogeneity (I2 = 38.4%; p-value = 0.12) was
observed among the included studies; hence, a random effect meta-analysis model was
employed to estimate the final analysis.
Discussion
Diarrhea is one of the major causes of morbidity and mortality among under-five children in
Ethiopia. Based on the WHO estimates, diarrhea contributes to more than one in every ten
(13%) child deaths in Ethiopia [83]. Estimating the pooled prevalence of under-five diarrhea
and its contributing factors in Ethiopia may contribute to informing policy makers. To the
best our knowledge, this meta-analysis is the first of its kind to estimate the pooled prevalence
of diarrhea and its determinants among under-five children in Ethiopia.
The overall prevalence of under-five diarrhea obtained from this study indicated that
almost one in five (22%; 95% CI: 19, 25) children under the age of five in Ethiopia experienced
diarrhea. The result of this meta-analysis is in line with the 2000 Ethiopian DHS [84, 85]
report, which shows the prevalence of diarrhea as 24%. However, this finding is almost two
times higher than the 2011 Ethiopian DHS, which suggests 13% of under-five children had
diarrhea [86]. In addition, this finding is much higher than 2016 Ethiopian DHS [10]and 2005

Fig 7. The pooled odds ratio of the association between maternal hand washing practices and childhood diarrhea in Ethiopia.
[87] reports with reported prevalence of childhood diarrhea of 12% and 18% respectively. Sim-
ilarly, our finding is two times higher than Ghana’s 2014 DHS (12%) [88], higher than Kenya’s
2014 DHS finding of 15% [89]. The possible explanation for the above variation could be
attributed to methodological variation in the assessment of prevalence. The difference in the
prevalence of diarrhea between our study and other sub-Saharan countries could be explained
by the difference in socio-demographics and sociocultural practices, which has a great impact
on child feeding.
The subgroup analysis of this study indicated that the highest prevalence of diarrhea was
observed in Afar region, 27% (95% CI: 25, 30) followed by Somali and Dire Dawa regions, 26%
(95% CI: 15, 37) whereas the lowest prevalence was observed in Oromia and SNNPR with
prevalences of 18% (95%CI: 13, 24) and 18% (95%CI: 11, 25) respectively. This finding of this
study is in agreement with the 2011 Ethiopian DHS, which shows Somali region (19.5%) has
higher prevalence of diarrhea next to Benishangul-Gumuz (22.7%) and Gambela (22.6%)
regions [86]. The possible explanations for this variation might be due to the difference in
basic environmental and behavioral characteristics of caregivers. Another possible explanation
for this variation could be due to the difference in the socio-demographic, environmental, and
behavioral characteristics of households. As the communities living in Somali and Afar regions

were nomadic, they go from place to place in search of pasture and water. They have no per-
manent residential places, hence, lacking access to basic healthcare facilities and sanitation ser-
vices. The main sources of water for these populations were rivers, streams, and wells that are
high risk for contamination. In addition, those populations more commonly practicing open
defecation, which leads to the living environment, is polluted with human excreta that are the
main source of diarrheal disease, especially for the children who routinely play in the unhy-
gienic environment. Moreover, people suffering from illiteracy and poverty, which, in turn,
deteriorates their quality of life. All these phenomena are the direct risk factors for the occur-
rence of childhood diarrheal disease [90]
The present study was also aimed to identify the determinants of diarrhea among under-
five children in Ethiopia. In this study, lack of maternal education, lack of availability of latrine,
urban residence, and lack of maternal hand washing were significantly associated with child-
hood diarrhea. The likelihood of diarrhea occurrence was 1.7 times higher among children
whose mothers were unable to read and write as compared to their counterparts. The finding
of this study is consistent with studies done in Ghana and Nigeria, which showed that the prev-
alence of diarrhea was significantly, varieties in related to the caregiver’s educational status.
These studies reported that diarrhea was higher among children whose mothers have no for-
mal education [91–93]. This finding may relate to these educated mothers have better knowl-
edge about the rules of hygiene, appropriate child feeding practices, and early signs and
symptoms of diarrhea which are the major determinant factors for the occurrence of child-
hood diarrhea. In addition, education has a great impact in changing behaviors at the house-
hold level. Moreover, education may increase the mother’s awareness about methods of
transmission and prevention of diarrhea.
Latrine availability was another determinant of under-five diarrhea. Accordingly, children
living in households without latrine facilities were 2.0 times more likely to develop diarrhea
than children living in households with such facilities. This finding is congruent with a study
conducted in Tanzania [94]. Different studies also reported that the absence of latrine facility
was strongly associated with the occurrence of diarrheal disease [69, 70, 95]. The accessibility
to a latrine in the family unit is an indication of sanitation conditions, which will have an
implications to prevent the possibility of transmission of pathogens through fecal contamina-
tion [96].
Furthermore, it is indicated that children living in rural areas were more vulnerable to diar-
rhea than their urban counterparts. Children from rural households were 1.9 times more likely
to have diarrhea as compared to their counterparts. This finding is contradictory to a study
reported from Iraq [97]; however, similar to a study conducted in Pakistan [98]. This variance
could be due to the population living in urban areas having better access to an improved water
source, sanitation facility, health care facility and better knowledge about the prevention and
control of diarrheal disease in comparison to rural populations. Another possible reason could
be that people living in rural areas tend to be poorer than their urban counterparts are, a factor
known to have an impact on the level of hygienic practice.
Lastly, lack of maternal hand washing was significantly associated with childhood diarrhea.
Children whose mothers did not practice hand washing after visiting a latrine were 2.3 more
likely to develop diarrhea as compared to their counterparts. This finding to those of a study
conducted in Nigeria [91]. The rationale for hand washing after going to latrine to reduce the
load of microorganisms has been well documented as fecal-oral microorganism transmissions
due to post-defecation contamination of hands and fingers is well known [20, 22, 77, 99]. As
mothers are the most frequent primary caregivers for their children, it is important to assess
the contribution of maternal hand washing practices.

Limitations of the study

This meta-analysis has several limitations. The first limitation of this study was only English
articles or reports were considered to conduct this nationally based review. In addition, all of
the studies included in this review were cross-sectional in nature; as a result, the outcome
variable might be affected by other confounding variables. The majority of the studies
included in this review had a relatively small sample size, which could affect the estimated
prevalence reported. Almost all research included in this meta-analysis used the WHO tool
for diarrheal assessment, its occurrence was determined based on the reports of mothers
without the confirmation of physicians. Therefore, this result might be affected social desir-
ability bias. Furthermore, this meta-analysis represented only studies reported from six
regions and two administrative town of the country, which may reflect under-representation
due to the limited number of studies included.
Conclusion
In this study, diarrheal disease among under-five children in Ethiopia was significantly high.
In addition, childhood diarrhea is significantly higher in nomadic population. Lack of mater-
nal education, lack of availability of latrine, urban residence, and lack of maternal hand wash-
ing found significantly associated with childhood diarrhea. Therefore, based our findings, we
recommend particular emphasis shall be given to the rural communities. Moreover, health
educations about personal hygiene as well as, proper disposal of wastes including excreta in
integration with the existing national health extension program are recommended.
Supporting information
S1 Table. PRISMA checklist.
(DOC)
S2 Table. Risk of bias assessment of included studies.
(XLSX)
S3 Table. List of excluded full texts and reasons of exclusion.
(DOCX)
Author Contributions
Conceptualization: Animut Alebel.
Data curation: Animut Alebel, Cheru Tesema.
Formal analysis: Animut Alebel.
Methodology: Animut Alebel, Alemu Gebrie.
Software: Animut Alebel.
Validation: Pammla Petrucka, Getiye Dejenu Kibret.
Writing – original draft: Animut Alebel, Cheru Tesema, Belisty Temesgen, Alemu Gebrie,
Pammla Petrucka, Getiye Dejenu Kibret.
Writing – review & editing: Animut Alebel, Cheru Tesema, Belisty Temesgen, Alemu Gebrie,
Pammla Petrucka, Getiye Dejenu Kibret.

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RESEARCH ARTICLE

Prevalence and determinants of diarrhea

OPEN ACCESS Background

Received: January 5, 2018

PLOS ONE | https://doi.org/10.1371/journal.pone.0199684 June 28, 2018 1 / 20

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Measurement of outcome variables

Data processing and analysis

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Description of included studies

PLOS ONE | https://doi.org/10.1371/journal.pone.0199684 June 28, 2018 5 / 20

Prevalence of diarrhea among under-five children in Ethiopia

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Determinants of under-five diarrhea in Ethiopia

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Limitations of the study

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