title: Childhood diarrhea in high and low hotspot districts of Amhara Region, northwest Ethiopia: a multilevel modeling.
abstract: BACKGROUND
  Childhood diarrhea is one of the major public health problems in Ethiopia. Multiple factors at different levels contribute to the occurrence of childhood diarrhea. The objective of the study was to identify the factors affecting childhood diarrhea at individual and community level.
  
  
  METHODS
  A cross-sectional study design was employed from February to March 2015 in high and low hotspot districts of Awi and West and East Gojjam zones in Amhara Region, northwest Ethiopia. Districts with high and low hotspots with childhood diarrhea were identified using SaTScan spatial statistical analysis. A total of 2495 households from ten (five high and five low hotspot) randomly selected districts were included in the study. A semi-structured questionnaire was used to collect data. Data were entered and cleaned in Epi Info 3.5.2 version and analyzed using Stata version 12. A multilevel logistic regression was used to identify factors associated with childhood diarrhea.
  
  
  RESULTS
  The prevalence of childhood diarrhea was 13.5 % and did not show significant variation between high [14.3 % (95 % CI 12.3-16.2 %)] and low [12.7 % (95 % CI 10.9-14.6 %)] hotspot districts. Individual- and community-level factors accounted for 35 % of childhood diarrhea variation across the communities in the full model. Age of children (6-35 months), complementary feeding initiation below 6 months, inadequate hand washing practices, limited knowledge of mothers on diarrhea, lowest wealth status of households, and longer time interval to visit households by health extension workers were factors for increasing the odds of childhood diarrhea at the individual level. At the community level, lack of improved water supply and sanitation and unvaccinated children with measles and rotavirus vaccine were the factors associated with childhood diarrhea.
  
  
  CONCLUSIONS
  In this study, childhood diarrhea occurrences remained high. Both individual- and community-level factors determined the occurrence of diarrhea. Interventions should consider both individual- and community-level factors to reduce the occurrence of childhood diarrhea.
authors.affiliation: Ethiopian Institute of Water Resources, Addis Ababa University, Addis Ababa, Ethiopia. mulukenag@yahoo.com.
authors.forename: Muluken
authors.initials: M
authors.lastname: Azage
authors.affiliation: School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Abera
authors.initials: A
authors.lastname: Kumie
authors.affiliation: School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
authors.forename: Alemayehu
authors.initials: A
authors.lastname: Worku
authors.affiliation: Department of Civil and Environmental Engineering, School of Engineering, University of Connecticut, Storrs, CT, 06269-3037, USA.
authors.forename: Amvrossios C
authors.initials: AC
authors.lastname: Bagtzoglou
mesh_terms: D002675:Child, Preschool; D003430:Cross-Sectional Studies; D003906:Developing Countries; D003967:Diarrhea / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control; D003968:Diarrhea, Infantile / Q000453:epidemiology* / Q000209:etiology / Q000517:prevention & control; D005002:Ethiopia / Q000453:epidemiology; D005191:Family Characteristics; D005260:Female; D006306:Health Surveys; D006801:Humans; D017589:Immunization Programs; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D008954:Models, Biological; D015995:Prevalence; D012306:Risk; D012499:Sanitation; D062206:Spatial Analysis; D060753:Water Quality
keywords: Childhood diarrhea; Children; Ethiopia; Multilevel analysis; Sanitation; Water