The effect of improved water and sanitation on diarrhea: Evidence from pooled Ethiopia Demographic and Health Surveys – A multilevel mixed-effects analysis

Abstract Background: In Ethiopia, diarrhoea is the leading cause of illness and hospital admissions among children, and the persistence of diarrheal epidemics in urban and rural areas warrants an exploration of the impact of WASH facilities over recent years. Objective: The study aimed to assess the effect of improved water sources and sanitation on the occurrence of diarrhea in Ethiopia, while controlling for household and child-related factors and accounting for higher-level variables. Methods: A total of 42,282 study subjects were pooled from the four rounds of the Ethiopian Demographic and Health Survey. A multilevel mixed-effects logistic regression model was run to identify the effect of water and sanitation on diarrhea, after adjusting for higher-level and confounding factors. SPSS version 24 was used for data management, while Stata version 15.1 was used for descriptive and multilevel analysis. Results: An improved water source was strongly associated with the occurrence of diarrhea in the final model, (AOR 95% CI: 1.02-1.2), while improved sanitation had a marginal association, (AOR 95% CI: 0.87-1.20). The interaction between improved water sources and improved sanitation has maintained the relevance of improved water sources, but not for improved sanitation, on diarrhea. Conclusions and recommendations: Improved water source was a strong predictor of diarrhea. Improved water sources and improved sanitation are both required to get the maximum benefit of reducing diarrhea among children. [Ethiop. J. Health Dev. 2020; 34(4):268-276] Key words: Diarrhea, improved water source, improved sanitation, interaction, effect, Demographic and Health Surve