Introduction

Globally, diarrheal disease accounts for 15% of all under five mortality, making it the second biggest cause of death among society’s youngest members1,2. Countries that are developing or economically disadvantaged regions bear the greatest burden of under five mortality, with Sub-Saharan Africa and South Asia accounting for roughly four-fifths of all under five mortality3,4. Among the world’s poorest countries, just five nations contribute to over half of all deaths caused by pneumonia and diarrhea: India, Nigeria, the Democratic Republic of the Congo, Pakistan, and Ethiopia5.

Slums are defined by dangerous, informal settlements that pass for unofficial, frequently illegal homes. They are also characterized by a dearth of access to basic amenities like electricity, water, and sanitation facilities. They also offer fairly precarious housing. During storms and earthquakes, weak constructions are frequently blown away or destroyed6. Ongoing neglect of the world’s ever-expanding urban slum populations may undoubtedly result in increased expenditure and allocation of healthcare resources to the treatment of preventable end-stage complications7. In the year 2000, the United Nations Millennium Declaration vowed to confront the challenge of setting precise goals of “significant improvement in the lives of at least 100 million slum dwellers by the year 2020”8.

Encouraging and enhancing health-seeking behaviour among communities residing in slums can be achieved by increasing the proximity of health facilities within these areas. Additionally, implementing health education programs and socioeconomic development initiatives targeted at illiterate mothers/caregivers and impoverished households can further promote accessibility to healthcare services9. The slum environment poses a high risk for under five diarrhea due to the proximity of sanitation facilities to homes, the sharing of sanitation facilities, and the poor hygiene of both the sanitation facilities and housing compounds10.

According to the 2016 Ethiopia Demographic and Health Survey, 12% of under five children experienced diarrhea in the two weeks preceding the survey11. In addition, studies conducted in various locations in Ethiopia stated that the prevalence of childhood diarrhea ranges from 15 to 29%12,13,14,15,16,17. Low maternal education, poor sanitation, contaminated water sources, duration of breastfeeding, failure to wash hands, lack of rotavirus vaccination, improper disposal of faeces, child’s age, and inadequate food hygiene were identified as significant predictors of diarrheal disease occurrence in under five children’s in Ethiopia18,19,20,21,22. Studies conducted in various locations of Ethiopia have revealed that diarrhea among under five population remains a serious public health problem23,24,25.

Slum areas in Ethiopia have a high poverty status. In addition, they possess poor water, sanitation and hygiene accesses such as unsafe drinking water, a lower number of sanitation facilities and poor hygienic conditions. These scenarios are important in the occurrence of diarrhea among under five children’s. However, there are many studies conducted on diarrhea among under five children’s in Ethiopia, unfortunately, the majority usually didn’t give enough coverage for the burden of diarrhea among under five children in slum areas. Slum areas in Gondar City have frequently contaminated food, housing and drinking water as a result diarrhea is common, especially among under five children’s26. Therefore, this study aimed to determine the prevalence and associated factors of diarrhea among under five children’s in slum areas of Gondar City, Northwest Ethiopia.

Methods

Study design and setting

A community-based cross-sectional study was conducted in slum areas of Gondar City among under five children between March 28 and April 28/2023. Gondar City is approximately 734.3 km, from Addis Ababa and approximately 180 km from Bahir Dar City the capital of the Amhara region27,28. According to the most recent administration report, Gondar has an estimated population of more than 454,446, with 218,378 men and 236,068 women. In the city, there are a total of 41,623 under five children 20,191 males and 21,432 females. It has six sub-city administration areas comprising 36 Kebeles. All sub-cities within Gondar City contain slum areas which are identified by the recent administration of Gondar City. Out of 36 Kebeles, 13 Kebeles were identified as slum areas by the Gondar City administration. The city has nine health centers, one referral hospital, and one general hospital that serves the people of Gondar City and the surrounding area (Fig. 1).

Figure 1
figure 1

Map of Gondar City, Northwest Ethiopia. The study area map was created by running on ArcGIS software version 10.7.1. (https://www.arcgis.com/index.html).

Full size image

Sample size calculation and sampling procedures

The sample size was calculated using a single population proportion formula while keeping the following assumptions in mind: P = 50% of under five children with diarrhea and 95% confidence interval, 5% margin of error (d), 10% of the nonresponse rate and we used a design effect of 2 for multistage sampling since we have 2 stages.

$$ n = \frac{{\left( {\frac{Z\alpha }{2}} \right)^{2} P\left( {1 - P} \right)}}{{d^{2} }} = \frac{{\left( {1.96} \right)^{2*} 0.5^{*} 0.5}}{{0.05^{2} }} = 384 $$

The total sample size was 845.

The target populations were included in the study using a multistage sampling technique with a total of two stages (Fig. 2).

Figure 2
figure 2

Flow chart of the sampling procedures for the selection of study participants in Gondar City, Northwest Ethiopia, 2023.

Full size image

We utilized a multistage sampling technique with two stages to include the target populations. Four sub-cities were chosen out of a total of six sub-cities using the lottery method in the first stage. Subsequently, proportional allocation was computed for each of the selected four sub-cities. Within the selected four sub-cities, eight slum Kebeles were found out of a total of thirteen slum Kebeles. In the second stage, house numbers were used for each household found within the selected four sub-cities (eight slum kebeles) to select a final sample size of 845 using the lottery method. (Fig. 2).

Data collection tools and procedures

Structured and pretested questionnaires were used to collect the data. The questionnaire and observation checklists were prepared based on a review of the relevant literature23,29,30. The questionnaire was first prepared in the English language, translated to the local Amharic language, and back-translated into English to check consistency. We performed the pretest on 5% of the total sample size in a nearby town called “Koladiba”. The data were collected from mothers/primary caretakers using an interviewer-administered structured questionnaire. The questionnaire included a total of four parts, which included questions about socio-demographic characteristics, the child’s diarrhea status, environmental, household and behavioural factors. The data collectors were given two days of training on the tool and exercised it. The questionnaire was discussed thoroughly question by question. The study participants were asked to complete the questionnaire in their respective areas through a face-to-face interview at the participants’ homes. The data collection process and completeness of the data were closely supervised.

Measurement of study variables

Diarrhea was defined as a mother/caretaker self-reported that the child had three or more loose or watery stools within 24 h, in the past 2 weeks before data collection31.

A clean playing ground is a surface with no visible dust, dirt, mud or contaminating particles on which children climb, slide, crawl, push, pull, swing and contact for playing purposes32.

Data processing and analysis

All the questionnaires were checked manually for completeness, coded, and entered into EPI info version 7.1.5.2 and exported to Stata version 14.1 software for further analyses. Descriptive analyses were performed to describe independent variables and diarrheal status using summary measures, frequencies, figures and tables. Explanatory variables for diarrhea among under five children were identified by running binary logistic regression analysis. Explanatory variables with a P-value < 0.20 in the bivariable logistic regression were analyzed via multivariable logistic regression. The degree of association between outcome & explanatory variables was assessed using odds ratios (ORs) and 95% confidence interval (CIs). Independent variables with a p-value < 0.05 in the multivariable logistic regression were considered statistically significant. Finally, the multicollinearity of variables was assessed by calculating the variance inflation factor (VIF). Additionally, the goodness of fit of the model was checked by Hosmer and Lemeshow.

Ethics approval and consent to participate

Ethical clearance was obtained from the Research and Institutional Review Board of the Institute of Public Health, College of Medicine and Health Science, University of Gondar (reference number: IPH/2501/2023). All methods were carried out following the Helsinki Declarations and guidelines and regulations of the University of Gondar research and ethics review committee Gondar City officials and administrators were contacted and permission was obtained. Informed consent was obtained from the mother or caretakers of each participating child. The importance of the study was explained to the study participants. We informed the right to withdraw at any time during the study period. All the collected records were kept confidential. No personal identification such as name was collected to maintain the privacy and confidentiality of the participants. Children who were found to be sick during the visits were informed to mothers and caretakers to visit the nearby health institution immediately.

Results

Socio-demographic characteristics of mothers/caretakers of under five children

A total of 836 participants were enrolled in this study with a response rate of (98.93%). Seven hundred seventy-nine (93.18%) were female mothers/caretakers and fifty-seven were male mothers/caretakers (6. 82%). The majority (87.44%) of mothers/caretakers were Orthodox Christians followed by Muslims (9.69%). Five hundred eighteen (61.96%) mothers/caretakers were housewives.86% of mothers/caretakers were married 14.71% of mothers/caretakers had no formal education. 29.07% of households had an income level between 5644 and 8000 Ethiopian Birr (Table 1).

Table 1 Socio-demographic characteristics of mothers/caretakers of under five children in slum areas of Gondar City between March–April 2023(n = 836).
Full size table

Under five children socio-demographic characteristics

Among the 836 under five children, the majority two hundred fifty-five (30.50%) were age between 48 and 59 months old, whereas two hundred forty-three (29.07%) were age between 24 and 35 months. The median age of the under five children was 43 ± 18.43(SD). Four hundred thirty (51.44%) were males and four hundred six (48.56%) were females (Table 2). The majority of the under five children (39.47%) had first birth orders. Out of 836 households with under five children (68.30%) only one under five children.

Table 2 Under five children socio-demographic characteristics in slum areas of Gondar City between March–April 2023(n = 836).
Full size table

Housing characteristics and latrine facility status

The majority of the households six hundred seventy-one (80.26%) constructed their house with mud and less than one-fifth (19.14%) constructed their house with the concert. More than three-fourths (88.28%) of the households had latrine facilities; the majority of the facilities were pit latrines with slabs (79.89%), (85.77%) households had shared latrine facilities and less than one-fifth (18.78%) had handwashing facilities (Table 3).

Table 3 Housing characteristics and latrine facility status in slum areas of Gondar City between March–April 2023(n = 836).
Full size table

Waste disposal and water-related characteristics of the respondents

More than half (58.37%) of the households used a garbage can for waste disposal and eight hundred (95.69%) had improved water sources (Table 4).

Table 4 Waste disposal and water-related characteristics in slum areas of Gondar City between March–April 2023(n = 836).
Full size table

Under five children diarrheal disease morbidity in slum areas of Gondar City, Northwest, Ethiopia

The prevalence of diarrhea among under five children at 95% confidence interval was 24.64% (CI 21.71–27.56) (Fig. 3).

Figure 3
figure 3

The prevalence of diarrhea among under five children in slum areas of Gondar City, Northwest Ethiopia, 2023.

Full size image

Determinants of diarrheal diseases morbidity among under five children

Age of mother/caretaker, educational status of mother/caretaker, average monthly income (Ethiopian Birr), family size, flies observed around the house, child playground, child breastfeeding period in the year, mothers/caretakers washing their hands before food preparation and eating, and mothers/caretakers washing their hands after visiting the latrine were factors significantly associated on multivariable analysis with under five children diarrhea in slum areas of Gondar City.

Under five children whose mothers/caretakers age < 25 years were 1.88 times more likely to experience diarrhea than those mothers/caretakers age between 25 and 27 and ≥ 32 years (AOR = 1.88, 95% CI 1.16–3.06). Under five children whose mothers/caretakers age between 28 and 31 years were1.82 times more likely to experience diarrhea than those under five children whose mothers/caretakers age between 25 and 27 and ≥ 32 years (AOR = 1.82, 95% CI 1.08–3.05). Under five children whose mothers/caretakers had no formal education were 3.18 times more likely to experience diarrhea than those who enrolled in secondary and above formal education (AOR = 3.18, 95% CI 1.86–5.41). Under five children whose mothers/caretakers had a primary education were 1.67 times more likely to encounter diarrhea than were those whose mothers/caretakers had enrolled in secondary and above formal education (AOR = 1.67, 95% CI 1.09–2.57).

Households who had an income level between 4877 and 5643 Ethiopian Birr and their under five children were 1.81 times more likely to experience diarrhea than households who had an income level between 1000 and 4876, 5644 and 8000 and ≥ 8001 Ethiopian Birr (AOR = 1.81, 95% CI 1.04–3.15). Households who had a family size greater than five and their under five children were 1.54 times more likely to develop diarrhea than those households who had a family size lower than five (AOR = 1.54, 95% CI 1.00–2.36). Households who had flies around the house their under five children were 2.27 times more likely to develop diarrhea than their counterparts (AOR = 2.27, 95% CI 1.38–3.73). Under five children whose playground is not clean were 2.70 times more likely to develop diarrhea than their counterparts (AOR = 2.70, 95% CI 1.62–4.50). Under five children who had been breastfed for ≥ 1 year were 37% less likely to encounter diarrhea than those below 1 year (AOR = 0.63, 95% CI 0.41–0.97). Under five children whose mothers/caretakers did not wash their hands before food preparation and eating on a regular basis, their children were 2.31 times more likely to develop diarrhea than their counterparts (AOR = 2.31, 95% CI 1.39–3.58). Under five children whose mothers/caretakers did not wash their hands after visiting the latrine on a regular basis, their under five children were 1.60 times more likely to develop diarrhea than their counterparts (AOR = 1.60, 95% CI 1.07–2.38). (Table 5).

Table 5 Factors associated with under five children diarrhea in slum areas of Gondar City Northwest Ethiopia, 2023.
Full size table

Bivariable and multivariable binary logistic regression analysis of associated factors with diarrhea among under five children in slum areas of Gondar City

See Table 5.

Discussion

A community-based cross-sectional study was conducted to determine the prevalence and factors associated with diarrhea among children under five years of age in slum areas of Gondar City. The prevalence of diarrhea among under five children was 24.64%. In the covariate analysis of this study, the mother’s/caretaker’s education, number of under five children, hygiene of latrine facilities, child playground, breastfeeding and hand hygiene were found statistically significant predictors of childhood diarrheal disease.

In this study, diarrheal illness affected nearly 25% of children under five (24.64%). Our finding is in line with the findings in the Eastern part of Ethiopia (22.5%)33, in rural areas of North Gondar Zone (22.1)34, in Jabithennan District Northwest Ethiopia (21.5%)35 and Senegal (26%)36. This comparability could be due to similar population characteristics since all studies may have sampled the same under five populations with similar demographic characteristics. Additionally, consistency in measurement methods because all have employed similar methods for defining, identifying, and measuring cases of under five diarrhea37. Furthermore, it could be due to methodological limitations since all studies were conducted through crossectional study design they may suffer from similar methodological limitations or biases37. This result is less than what was found conducted in the Southern part of Ethiopia (30.5%)11, the Northern part of Ethiopia almost half (54%)38 and Hodan district Mogadishu-Somalia (47.9%)18. However, our result is greater than what was found in Debre Berhan town (16.4%)39, Woldia Town (17.6%)40, Serobo town Jimma (12%)18 and the 2016 EDHS National Report (12%)41. These discrepancies may result from variations in the sociodemographic features, study setting, behavioural traits of the study dwellings, study environment and study duration. This demonstrated that children in various research areas had varying rates of diarrheal illness. Furthermore, because the study was conducted in slum areas overcrowding, poor hygiene, malnutrition, poor sanitation and higher poverty status may contribute to the higher prevalence of diarrhea.

The covariate analysis of this study reveals that under five children whose mothers/caretakers were age < 25 years and age between 28 and 31 years were more likely to experience diarrhea than those mothers/caretakers age between 25 and 27 and ≥ 32. The finding is in line with the study conducted in Iran and a systematic review of 34 Sub-Saharan African countries42,43. This is due to older mothers/caretakers having more experience in preventing and managing childhood diseases and taking responsibility than the younger ones for their children42. In addition, young women are believed to be fresh to childcare methods and hence lack such experience43. The educational level of mothers/caretakers especially those mothers/caretakers who have no formal education and those who engage in primary education is significantly associated with under five children diarrhea. This could be because mothers/caretakers who have lower education levels are less likely to know safe infant feeding practices, proper hygiene for newborns, and early recognition of diarrheal symptoms. In addition, they have lower socioeconomic status and may not have better access to and utilization of healthcare services. This finding is supported by the findings from the study in Mecha District West Gojam Ethiopia, multilevel analysis from 2011 to 2016 EDHS data and a study in Nigeria12,44,45.

Households who had an income level between 4877 and 5643 Ethiopian Birr their under five children were more likely to experience diarrhea than households who had an income level between 1000 and 4876, 5644–8000 and ≥ 8001 Ethiopian Birr. The reason for this could be households with lower income levels may lack access to clean water or adequate sanitation, increasing the likelihood of diarrheal infections among children. Lower-income households may face food insecurity and have limited access to nutritious foods, increasing the vulnerability of children to infections such as diarrhea. Furthermore, lower-income households may face barriers to accessing healthcare services. Lower-income households may struggle to maintain adequate hygiene standards due to limited resources or lack of awareness. The finding was also supported by other findings in Enderta Woreda, Tigray, Northern Ethiopia and systematic review from 34 Sub Saharan African countries38,43.

In households where were flies observed around the house odds of having diarrhea among under five children were higher compared to households free from flies. This is because flies can carry diarrhea-causing microorganisms to people’s residential areas. This result is comparable with those studies performed in the slums of Addis Ababa, Ethiopia and India10,46.

The likelihood of diarrhea was significantly higher in children with dirty playgrounds than in those with clean playgrounds. This is due to the fact that dirty surfaces harbour infectious germs that can cause diarrhea. Other findings in Ethiopia also supported this idea, it was also supported by findings from Bangladesh and Côte d’Ivoire30,47,48.

Under five children who had been breastfed for ≥ 1 year had lower odds of diarrhea than under five children who had been breastfed for less than one year. This could be because breast milk contains antibodies to protect against infectious diseases and breast milk is rich in prebiotics and probiotics to eliminate pathogens that cause diarrhea, additional breast milk provides nutritional benefits. This finding is comparable with other finding from Bahir Dar city, Northwest Ethiopia, Egypt29,49.

Mothers/caretakers who did not wash their hands before food preparation, or eating and those who did not wash their hands after visiting latrine regularly. Their children were associated with higher odds of experiencing diarrhea. This can be explained by the fact that regularly washing your hands with soap and water can help stop the spread of pathogens. This will break the chain of infection and decrease the causes of diarrheal diseases. This was consistent with studies from rural Eastern, Ethiopia, slums of Addis Ababa and Jigjiga District, Eastern Ethiopia50,51,52.

Limitations of the study

Recall bias and the inability to establish causality, which is common in cross-sectional studies, along with the lack of medical records for under five children with diarrhea, were the limitations of this study.

Conclusion

In this study, the prevalence of diarrhea is higher in slum areas of Gondar City. The independent predictors for diarrhea occurrences among under five children in slum areas of Gondar City were mothers/caretakers age < 25 years, and mothers/caretakers age between 28 and 31 years. Mothers/caretakers who had no formal education, mothers/caretakers who had primary education, income level between 4877 and 5643 Ethiopian Birr, flies around the house, children’s playgrounds not clean, breastfeeding for ≥ 1 year, mothers/caretakers did not wash their hands before food preparation and eating. Finally, mothers/caretakers did not wash their hands after visiting the latrine regularly. The findings from this study indicated that diarrhea is a major public health concern for under five population slum areas of Gondar City. The Gondar City Administration Education Bureau should work towards improving mother’s and caretaker’s education in the slum areas of Gondar City. In addition, the Gondar City Administration Health Bureau, USAID, and WHO, should collaborate to provide education on sanitation and hygiene practices and promote the importance of breastfeeding for mothers and caretakers of under five children.