Prevalence of diarrheal diseases among schools with and without water, sanitation and hygiene programs in rural communities of north-eastern Ethiopia: a comparative cross-sectional study AUTHORS

Introduction:  Diarrheal diseases are a significant cause of morbidity among school-aged children due to inadequate sanitation, lack of access to potable water and poor hygiene practices. Although the incidence of these illnesses can be reduced through improved water quality and the introduction of sanitation and hygiene programs in schools, there is limited evidence to demonstrate the impact of interventions in schools in Ethiopia. The purpose of this study was to compare the prevalence and associated factors of diarrheal diseases in school-aged children between schools in Habru District, northeastern Ethiopia that adopted water, sanitation and hygiene (WASH) interventions and those that did not. Methods:  A comparative cross-sectional study was conducted among 640 randomly selected school children (160 from schools that adopted WASH interventions and 480 from schools that did not). Trained data collectors used a pre-tested r Rural and Remote Health rrh.org.au James Cook University ISSN 1445-6354


Introduction
Diarrheal disease, a major cause of death across the world, is associated with inadequate sanitation, lack of access to potable water for consumption and absence of hygienic behavior such as hand-washing to reduce the transmission of disease . WHO has estimated that, globally, approximately 1.7 billion cases of childhood diarrhea occur annually . Also, close to 600 000 children die each year from diarrheal disease, the majority in low-and middle-income countries . This is remarkable because the problem can be easily prevented with clean water, availability of latrines and good hygiene practices . Even though access to sanitation, the practice of good hygiene, and safe water supply could save many children every year, 768 million people around the world must rely on unimproved water sources . Therefore, the purpose of this study was to compare the prevalence and associated factors of diarrheal diseases in school-aged children between those schools in the study area that adopted WASH interventions and those that did not. The findings from this study may help school directors, rural health policymakers and health managers in the development and implementation of WASH programs in schools and other communities in Ethiopia.

Study area and period
The study was conducted in the rural Habru District of Wollo

Study population and sample detail
All students aged 8-15 years from 35 primary schools of the Habru District (10 WASH-implementing and 25 non-WASHimplementing schools) were the source population of the study.
Randomly selected students in selected primary schools were the study population.
Eleven primary schools were randomly selected for the study from 35 Habru District primary schools -three of these schools were implementing WASH interventions. Students aged 8-15 years were randomly selected from these 11 primary schools. Students attending night school or who had not been attending a WASH-implementing or non-WASH-implementing school for at least 2 years were then excluded from the study The required sample size to provide a robust measure of the prevalence of diarrhea was calculated using Epi-Info v7 (Centers these 11 schools were identified, and 575 students in WASH schools and 2178 students in non-WASH schools were listed as a sampling frame. Then, a sampling interval (K) of N/n was computed and the first student was selected using the lottery method and every third student in WASH schools and fourth student in non-WASH schools was selected until the required sample size was achieved.

Study variables
The outcome variable was the occurrence of a diarrhea episode during the 2 weeks preceding the survey (yes/no). Independent variables included the following: (i) demographic factors (age, sex, grade, educational status of the mother, educational status of the father); (ii) WASH-related awareness factors (awareness of the causes and the means of transmission and prevention of diarrhea); (iii) WASH-related practice factors (self-reported latrine utilization at school and home, self-reported handwashing practice at school at critical times); and (iv) enabling factors (such as hygiene education in the school, availability of water throughout the year in the school, cleanliness of the school latrine, availability of a latrine at home, regular hygiene inspection in the school).

Operational definitions
Acute diarrhea: Diarrhea was defined as the passage of three or more abnormally loose, watery, or liquid stools over 24 hours .
Improved water source: A water source was considered to be improved if it was collected from protected springs and/or wells, a pipe or a distribution point.
Latrine utilization: Latrine utilization was defined as regular and consistence use of a latrine at home/school.
Hand-washing at critical times: Critical times for handwashing included after visiting the latrine and before eating food. Hand-washing was defined as using clean water and soap or ash.

Data collection and analysis
Four trained diploma nurses used a pre-tested structured questionnaire to collect data by face-to-face interview. A checklist was used to observe and assess the WASH condition of the studied schools. Finally, multivariate binary logistic regression analysis was performed to control for the possible confounding effect. The Hosmer-Lemeshow statistic was used to test the goodness-offit of the final model. Adjusted odds ratio (AOR) with corresponding 95%CI was used to estimate the association between dependent and independent variables, and a p-value ≤0.05 was used to declare statistical significance.

Ethics approval
The study was approved by the health research ethical review committee of Mekelle University College of Health Science (ERC 06133/2016). A formal letter was obtained from the district education office, and the assent of school directors and school committee assigned by families of the students was obtained.
Both oral and written consents were obtained from the study participants before the interview and, at all levels, confidentiality was assured. After data collection, health education on WASH issues was provided to all students. During data collection, children who had diarrhea were immediately referred to a nearby health institution for management.

Sociodemographic characteristics of study participants
In total, 640 school children (160 from schools with WASH    Factors associated with diarrhea prevalence Table 4 shows factors associated with diarrheal diseases among children attending schools with WASH programs and schools without WASH programs. In WASH-implementing schools, factors associated with decreased odds of diarrheal diseases among students included availability of a latrine in the home  variables. Being a cross-sectional study rather than using a longitudinal design, the study is limited in assessing the longterm impact of school-based WASH interventions. Second, the study does not allow for seasonal changes in diarrhea prevalence. Third, common issues related to self-reported practices and recall bias should not be ignored. Fourth, the study didn't use multilevel analysis, which is the ideal alternative to address nested data since there might be a dependency between school-related factors and the presence of diarrhea at an individual level. Despite this limitation, the study detected a significant difference in diarrhea prevalence among students from schools with WASH programs and without WASH programs. Last, the lack of standardized questionnaires with acceptable reliability and validity for assessing WASH interventions in Ethiopia limits the findings of this study. In future studies, researchers are recommended to use a strong design such as observational study designs to assess the impact of school WASH programs.

Conclusion
The prevalence of diarrheal disease among students in schools without WASH programs was higher than in students attending schools with a WASH program. Environmental factors (cleanliness of the school latrine), hygiene practices (latrine utilization by students at their homes) and students' awareness about the causes of diarrheal diseases were factors associated with reduced prevalence of diarrheal diseases among schoolgoing children. Hence, scaling up WASH programs across all rural primary schools along with awareness creation activities on latrine utilization and hygienic behavior at school and in the broader community are strongly recommended.