Contribution of domestic animal feces, meteorological variability, environmental and human-behavioral attributes to the occurrence of diarrhea among under-five children in Sidama region, Ethiopia

Background: Diarrhea is a dominant public health issue worldwide, particularly in developing countries. To reduce childhood morbidity and mortality, Ethiopia has implemented a health extension program since 2003, along with other WASH programs throughout the country, with the assistance of various nonprofit organizations. However, it remains the third leading cause of under-five morbidity in Ethiopia. Despite a decrease in death, diarrhea remains the second leading cause of under-five morbidity in the Sidama National Regional State of Ethiopia. Although a few studies have been conducted on the prevalence and determinants of diarrhea in the Sidama National Regional State, it is unclear whether insufficient improvement in diarrhea among children under-five might be due to attributes related to exposure to domestic animal feces, meteorological variability, environmental factors, and human behavior. Thus, the objective of this study was to assess the relationship between domestic animal feces, meteorological variability, environmental and human behavioral attributes, and the occurrence of diarrhea among children under-five years of age in the Sidama region, Ethiopia. Methods: This research project employed various study designs and adopted different approaches to achieve specific objectives. It encompasses observational study designs conducted between November 2022 and October 2023 in the Sidama region, Ethiopia. We conducted a matched-pair case-control study involving 612 children under the age of five years (306 cases and 306 controls) in selected districts of the Sidama region from September 2022 to January 2023. An equal number of cases and controls were used to increase the reliability of the study findings on cases compared to the control groups. Data were collected using the Kobo toolbox application and analyzed using conditional logistic regression. The random forest method was also used to compare its results with those of the multivariate conditional regression analysis. Statistical analyses were conducted using SPSS software version 29 and R software version 4.4.2 A laboratory-based matched case-control study was conducted on children aged 6–48 months from February to June 2023. Children in this age group were chosen because they are more likely to develop hand-to-mouth behavior during this time, which increases their likelihood of touching and mouthing contaminated soil or animal excrement. Moreover, in rural communities, children in this age group frequently come into contact with chickens, young cattle, and sheep xiv within a house and around it. As a result, they may be more likely to come into contact with excrement, which could lead to contamination with germs that cause diarrhea. This study enrolled 113 cases and 113 controls, who visited selected health facilities during the study period. Fecal specimens from the case and controlling children and domestic animals were collected using transport media. Data were collected at children-residing homes by securing consent and interviewing caretakers. The presence of diarrhea-causing pathogens, including Campylobacter, E. coli, non-typhoidal Salmonella, Shigella, and Cryptosporidium, was detected using culture media, biochemical tests, gram staining, and catalase and oxidase tests. Additionally, a conditional logistic regression model and random forest method were used. A prospective time-series study design (case series) was employed over a one-year period from November 2022 to October 2023. This study enrolled under-five children with diarrhea who visited selected healthcare facilities during the study period. Socio-demographic and environmental determinant data were collected at the children's residences. Temperature (°C) and cumulative rainfall (mm) data were collected from the Hawassa Meteorology Agency. The individual and interactive associations in the models were examined using negative binomial regression. This study was performed using R software version 4.4.2, and the findings were reported with the incidence rate ratio (IRR) at 95% confidence intervals (CI). The quality of data collection and analysis was ensured using different techniques. A well structured and standardized questionnaire was adapted from the joint monitoring program (WHO/UNICEF, 2018) and the EDHS. The questionnaire prepared in English and translated into the “Sidamu-Afoo” local language was uploaded to the Kobo toolbox and pretested on 5% of the caretakers. Additionally, data quality was ensured by observing relevant WASH and animal related factors at the homestead. The data collectors' visitation of each child's homestead was cross-checked by observing the pictures taken and GPS locations recorded. The confounding effects of other variables were controlled during the design and analysis stages. The quality of fecal specimens during collection, pathogen isolation, and identification was maintained according to Standard Operating Procedures (SOPs). xv Results A matched pair case-control study indicated that having a caretaker who is a housewife [matched adjusted odds ratio (mAOR) = 3.09, 5% CI (1.09, 8.70)], a mean number of chickens ≥ 5 [mAOR = 5.18, 95% CI (2.70, 9.95)], the absence of soap at handwashing facilities [mAOR = 2.61, 95% CI (1.34, 5.10)], those who travel more than 30 minutes to fetch water [mAOR = 3.14, 95% CI (1.13, 8.78)], children who are in contact with animal feces [mAOR = 2.44, 95% CI (1.24, 4.82)], and households living with animals [mAOR = 3.28, 95% CI (1.71, 6.30)] showed significant associations with under-five diarrhea. Random forest analysis also identified the first five variables as the main risk factors for diarrhea in children under-five. Of the fecal specimens diagnosed, 250 (64.1%) tested positive for one or more pathogens. Fecal specimens from chickens tested more positive for E. coli and Campylobacter. Of the pairs of fecal specimens taken from case children and animals living in the same house, 104 (92%) tested positive for one or more similar pathogens. A prospective time-series study that comprised 1852 children with diarrhea identified that among the factors considered for the analysis, monthly maximum temperature and cumulative rainfall, thatched-roofed houses, disposal of animal feces in an inappropriate place, inappropriate latrine location, absence of handwashing service, and water collected by children (< 15 years old) were positively associated with diarrhea. Except for temperature, the final model demonstrates that rainfall interaction with these factors has a stronger positive association with diarrhea. Conclusions and recommendations The study findings suggest that hygienic management of animal feces and separation of poultry from household areas, specifically from playgrounds, is crucial in line with conventional water, sanitation, and hygiene (WASH) services in the study settings in the Sidama region. Additionally, the findings showed that there were diarrhea-causing pathogens in the feces of domestic animals and children aged 6–48 months residing in the same houses in the Sidama region. Thus, in addition to efforts to mitigate the influence of meteorological factors, greater attention should be paid to the proper handling of domestic animal exposure, better housing conditions, and problems associated with latrines, particularly in low- and middle-income countries.