In this study, we compared diarrhea prevalence (recall period: 2 weeks) and risk factors among infants of Dessie Referral Hospital. We found that the 2-week, caregiver-reported prevalence of diarrhea among infants was 29.1%, which is slightly above the rate reported for the same age group in the 2016 Ethiopian DHS (23%) [7]. Similarly, it was also slightly above the research that was done at 2006 Mekelle Ethiopia 26.4 % [41] and with the diarrhea prevalence in Butajirra 23% [22]. But higher than the prevalence in Wolayta 14.1% and keffa-sheka zone (15%) [23, 28]. Our finding was lower than the prevalence in Jimma 39.3% [20]. Similarly, it was also lower than the prevalence in Eritrea 30.1 % [27]. This is also lower than the prevalence in Gondar (59.3%), Illubabor (41.9%) and Welega (45.7%) [41]. Moreover, the prevalence was much lower than the prevalence in Manna district of Jimma 33.7% [21]. However, our rate is below that reported in the National Survey on Food Security and Nutrition 2013 survey report (32%) in Senegal [22]. It is also lower than the 35% prevalence among children previously reported in Kaédi, Mauritania by Touray and colleagues (2012) [23]. Other studies in secondary cities of sub-Saharan Africa reported lower rates: 23.6% in a 2008 survey in Nouakchott, Mauritania; 14% in 2006 in Yopougon, Côte d’Ivoire; and 13.5% in 2010 in other districts of Nouakchott, Mauritania [23-27].

Our study showed that the risk of diarrhea was significantly associated with the mother’s occupation (i.e. housewife was associated with higher diarrhea risk compared to those working in the private or public sector). This finding is consistent with other reports, which found that parental occupation was associated with diarrheal occurrence [31, 32]. Although socioeconomic status (middle and poorest) showed a significant association with the occurrence of diarrhea in the bivariate analysis, it was not significant when other variables were included. In the multivariate analyses, we found that children living in better off households were less likely to have diarrhea compared to their lower wealth counterparts. A likely explanation of this observation is that wealth is associated with better access to household amenities and facilities, including those related to better hygiene and environmental health, which might reduce the risk of diarrhea. In addition, wealth allows parents to use health services more frequently [33, 34]. However, Root suggested that wealthy parents may be unable to reduce the risk of diarrhea due to factors beyond their control, such as contaminated community environment or lack of water [35]. However, many other studies indicate that socioeconomic factors are strongly associated with the occurrence of diarrhea; this appears to confirm the social determinants of health [36, 37].

Our study also showed that using private tap water less affected by diarrhea than public water source. This observation is consistent with the prevalence of diarrhea has been reported to be associated with water source [29, 50]. Studies in Central America, South Africa, Kuwait and India have also revealed a high peak incidence of diarrhea in using public tap water [51, 52]. The same trend was observed in eastern Ethiopia [53].

In our study, lacking basic sanitation like washing feeding materials of twice and above were 0.08 times less affected by diarrhea than less frequently washing and also those were not hand washing were affected by diarrhea.

There was reported WHO and UNICEF 2006, Africa leads the world in terms of the disease burden arising from unclean water and poor sanitation, as almost a quarter of Sub-Saharan African people lack access to safe drinking water, and the number of people lacking basic sanitation has increased by over 30 %.

Infant weaning was found to be significantly associated with diarrhea morbidity that infants who were correctly weaned were at lower odds of experiencing diarrhea than those who were weaned incorrectly. This is consistent with a study done in Philippines where infants under six month who were given non-nutritive additives were three times at higher risk of diarrhea morbidity than exclusively breast fed infants and the risk was thirteen times higher among infants who were non-breast-fed. Moreover it was consistent with a study done in India where exclusively breast fed infants were at a lower risk of developing diarrhea compared to spoon and bottle fed infants P<0.01 [54]. In addition, it was consistent with studies done in USA, England, Peru and Thailand: where infants with better breast-milk intake had a lower risk of diarrheal morbidity and mortality compared to infants with lower breast milk intake [50-52, 55]. Moreover, Diarrhea morbidity was lower by half among those infants who were exclusively breast-fed compared to those early-weaned infants. This could be because infant’s who were weaned too early will lack the antibodies and nutrients supplied by breast milk, which could be exposed to different pathogens. On weaning time and those infants who are lately weaned will suffer of inadequacy of nutrient from breast milk because unless the infant is supported with weaning diet the breast milk will gradually lack it’s ingredients to supply the ever increasing nutrient demand of the growing infant. Additionally, there was significant difference in the likelihood of acquiring diarrhea in infants under different age categories. This could be because infants within the age range 6-12 months have almost similar rate of exposure because this is the age at which infants are weaned and are exposed to different pathogens for it is the time when the infant starts to crawl on the ground and put sever thing at hand to its mouth.

In our study, the risk of diarrhea among children whose mothers had the two poor hand related practices and children that don’t wash their hands before eating are higher than that among those whose mothers paid attention to washing their hands after going to toilet and before feeding children respectively and also hand washing by mothers with soap and water. Studies showed the importance of hand washing in reducing the occurrence of childhood diarrhea [24, 25]. However, monitoring correct hand washing behavior at critical times is challenging. Hygiene behavior related observational studies showed wide discrepancy between what people said and did and suggested that reported hand washing behavior over estimate observed behavior [26-28] and supported the availability of water and soap in places of hand washing as indicator of hand washing behavior [29]. In this study, there was a significant positive association between the availability of hand washing facility with childhood diarrhea. Similarly in Childhood Diarrhea in Sub-Saharan Africa reported that Methods of food handling and storage, source, storage and use of safe water, and personal hygiene all contribute to the potential risk of developing acute diarrhea [46].

According to this study, washing feeding utensils twice or more frequently, children born to government employed fathers and government employed mothers, using private tap as source of water and incorrect weaning practice were found to be significant determinants of diarrhea morbidity so that to prevent this diseases with a focus on breast-feeding and safe weaning foods, better personal and domestic hygiene, and the provision of safe water supplies are being gradually must introduced. These are all more important to effect. Measuring the impact of water supply, improvements in sanitation, and public health education on diarrheal disease is mandatory. The long-term solution for decreasing morbidity from diarrhea may include the delivery of improved sanitation and hygiene through efficient educational programs that concentrate on personal hygiene which lead to full sanitation. This should be reinforced in combination with health workers educating households on sanitation. Longitudinal studies can be the best designs to provide data on the changing prevalence of diarrhea and address seasonality by including relevant factors.