Spatial variation and associated factors of deworming among children aged 24 to 59 months in Ethiopia: spatial and multilevel logistic analysis

Intestinal parasitic infections are one of the neglected tropical diseases (NTD) which is mainly concentrated in developing countries [1]. Soil-transmitted helminths like roundworms, whipworms and hookworms are among the most familiar infections to human beings and which found mainly in areas with warm and moist climates where sanitation and hygiene are poor [2, 3]. Those soil-transmitted helminths occupy the intestine of human beings and their eggs are passed in the feces of infected persons [3]. If an infected person defecates outside (near bushes, in a garden, or field) or if the faeces of an infected person are used as fertilizer, eggs are deposited on the soil [3]. Among the most common cause of intestinal parasitic infections are worms, Enterobius vermicularis, Amebiasis trichuriasis, Giardia lamblia, Ancylostoma duodenale, Necator americanus, and Entamoeba histolytica are the most common species [4, 5]. Gastrointestinal parasitic infections are diseases of poverty, which mainly affects children living in tropical and subtropical regions like Ethiopia [6]. Worldwide, more than one billion people are influenced by gastrointestinal parasitic infections and majority of them are children [7]. Children under the age of 5 years are more prone to intestinal parasitosis because of their delicate immunity system and mouthing of contaminated soil or object [8]. Those infections are more common in countries with low level of Water, Sanitation and Hygiene (WASH). In Ethiopia, the availability of WASH services are poor. For example, research done using the 2016 Ethiopian demographic health survey’s datasets revealed that the proportion of households having access to improved drinking water sources and toilet facilities were relatively low(i.e.70% for drinking water and 25.4% for toilet facilities) [9]. Another pocket study done in the Tigray region of Ethiopia also showed a similar occasion (i.e. Poor quality of WASH in the country) that revealed that only 53, 42.4 and 36.2% households utilize latrine, hand washing, and water facilities properly [10].

Additionally, the prevalence of gastrointestinal parasitic infection is still high in Ethiopia. A systematic review in Ethiopia showed that the pooled prevalence of intestinal parasitosis was 48%. Intestinal parasitic infection can lead to under-five mortality by inducing bloody diarrhea, chronic loss of blood that ends up with anemia, impair intestinal food absorption, and loss of appetite [11, 12]. The influence of helminthic infections goes beyond these obvious health effects to include economic and social effects resulting from lost school attendance and effective work time. Deworming to children aged 24–59 months of age is one of the strategic initiatives to halt the global burden of intestinal parasitosis among under-five children. Deworming (sometimes called Preventive chemotherapy) is the administration of albendazole or mebendazole drug to a high-risk group of population to treat soil-transmitted helminthiases (STH) and is also administrated to minimize future parasitic related morbidity [13]. Besides, a drug like praziquantel is used to treat schistosomiasis [14]. World Health Organization (WHO) recommended annual single-dose administration of either Albendazole (400 mg)or Mebendazole (500 mg) to regions that have a baseline prevalence of any soil-transmitted infection of 20% and Biannual if the baseline prevalence raised above 50% [2]. Despite Ethiopia is launching deworming programs to intervene against the burden of intestinal parasitic infection among preschool-age children and the coverage of preventive chemotherapy (deworming) is still not satisfactory.

Existing studies are believed to embody different limitations, which this paper is designed to address. Firstly, prior research in Ethiopia was conducted by the standard binary logistic regression to find factors associated with deworming uptake among children aged 24–59 months. Ordinary/standard binary logistic regression doesn’t account for the hierarchical nature of Demographic Health Survey (DHS) data, and this might have biased the model estimation. But this study applied multivariable multilevel logistic analysis for such kind of hierarchical data to increase the statistical power and to get the appropriate estimation. Secondly, previous studies in Ethiopia didn’t take into consideration the spatial pattern of deworming uptake among children aged 24–59 months. Sub-regional estimates of poor deworming uptake using spatial modeling could give information to local decision-makers about what is happening at local (geographic) and administrative levels. The information generated at local levels like hotspot areas (clusters with a high proportion of poor deworming uptake) could help decision-makers to develop location-based interventional strategies. Therefore, this study was aimed to assess the spatial variation and factors associated with poor deworming uptake among children aged 24–59 months in Ethiopia using evidence from the 2016 Ethiopian Demographic Health Survey (EDHS).

A total of 5609 children aged 24 to 59 months was included in this study. The median age of the study participants was 41 months ((Inter Quartile Range (IQR) = 32, 50)). The majority of the study participants were born to uneducated mothers (69.4%) and were males (86%). More than three-fourths of the children were born at health facilities (Table 1).

The overall prevalence of poor deworming uptake in Ethiopia was 85% [95% CI: 83.0–86.8]. Regional variation of poor deworming uptake was observed in Ethiopia. Region like Afar (96.3%), Somali (95.6%), Harari (90.3%), SNNP (24.6%) and Gambela (89%) and Amhara (86%) had unfavorable (high) proportion of poor deworming medication uptake relative to pooled national prevalence i.e. 85%. However, a relatively lower proportion of poor deworming medication uptake among children aged 24–59 months were noted in Tigray (66.82%), Benishangul (71.5%) and Dire Dawa (74.6%) provinces (Fig. 1).

The overall magnitude of poor deworming uptake among children aged 24–59 months was high (i.e. 85%). The spatial pattern of poor deworming uptake among children in Ethiopia is not random (clustered). Employment status, perceived distance, mother’s education, place of delivery, region of residency and diarrhea were the main factors associated with deworming uptake among children. The spatial analysis identified five clusters of poor deworming uptake in eastern Ethiopia.

The most likely cluster occurred in the Somali regional state (area: 153.22 km, RR: 1.17 and p-value< 0.0001) (Table 3). This high proportion of poor deworming uptake in Somali and Afar region might be related to low maternal and child service utilization rate [19]. There were also documented higher perceived health care access challenges in Somali and Afar regions [20]. Those two regions are also among the regions with the lowest Human Development Index [21]. Besides, the observed cluster of poor deworming uptake in Somali region might be explained by poor health-seeking behavior toward child health [22]. Relative to other regions, Gambela, Addis Ababa and Benishangul gumuz region have good deworming medication uptake (i.e. no clustering of cases was observed there) [23]. This might be due to good maternal health uptake in those areas. Having good maternal health services uptake might lay the foundation to take deworming medication for their children. Focused interventions in these high-burden clusters (high proportion of poor deworming uptake areas) can optimize resources and achieve the WHO targeted soil-transmitted helminthiases coverage, i.e. reaching up to 75% of preschool children in need of treatment [24].

The spatial Kriging interpolation assured that a higher proportion of predicted poor uptake of deworming was found, concentrated mainly in Afar and Somali regions (Fig. 5). This can be explained by the pastoralist’s nature of the people in those areas might lead theme to confront difficulty to access health facilities because of no permanent residency [25]. Another reason for this finding might be related to the shortage of trained health professionals in those areas [22]. In Somali, prior research documented that husbands were reported as the predominant decision-maker with regard to children’s health [26]. This restricted autonomy of power over their child’s health has been reported as a major barrier to women’s ability to access child health care services [27, 28]. The interpolated poor deworming uptake could help decision-makers and local authorities in evaluating the performance of prior installed deworming programs, allocate resources and develop targeted intervention plans without conducting additional research.

The multivariable multilevel logistic analysis revealed that employment status, perceived distance, mother’s education, place of delivery and diarrhea were the individual-level factors associated with poor deworming uptake. In addition to this, the region of residency was the only significant variable among the community-level factors. This study showed that children born to uneducated mothers are more likely not to take the deworming drugs. This result is in agreement with another study [29]. Another research in Pakistan [30] also support this finding, which found that the odds of child health care practice were lower among children born to not educated mother. This might be explained by; educational status is more likely to correlate with wealth status, which leads to lack of money to afford cost of transportation and cost of health services.

The current study revealed that regardless of other variables, being a child born to not working/unemployed mother increases the odds ratio of not deworming to children from working women. This finding is in line with a study conducted in Ghana [29], which disclosed that employed women are more likely to utilize deworming for their children compared to unemployed women. This might be due to not working women are less granted to afford child health services and cost of transformation.

This study revealed that being a child born at home was associated with higher odds of not taking deworming medication. A supportive study in Kenya [31] reached a similar conclusion to this finding. This might be justified by; women who deliver at home are expected to have unfavorable awareness towards the health of their child compared to their counterparts. In addition to this, women who were not given birth at health facilities are less likely to receive advice about their future health of the child specifically advice about the importance of deworming drug supplementation during early childhood.

Furthermore, children who had diarrhea 2 weeks before the survey were less likely to take deworming drugs compared to those who had no diarrhea episode. This might be the relationship between diarrhea and intestinal parasitic infection [32]. Children who had encountered diarrhea are more likely to seek health services, and the diarrhea episode could have created an opportunity to take deworming tablets.

From the community level factors, group regions of residency have increased the odds of not taking deworming drugs. Children residing in regions Afar, Somali, Harari, SNNP and Amhara has found increased odds of not taking deworming tablets. A similar supportive study from Ghana revealed that, residents from the western part of the country were less likely to take deworming tablets [29]. This might be justified by the unequal distribution of health services and other Infrastructures throughout the country.

To conclude, the distribution of not taking deworming drug among 24–59 months of children was unevenly distributed across space and major public health concern in Ethiopia. Maternal education, perceived distance to health facility, and place of delivery to the last child, maternal working/employment status, region of living and diarrhea in the last 2 weeks prior to date of interview were statistically significant factors associated with unfavorable deworming drug uptake in Ethiopia. Developing targeted interventional programs towards the clusters identified by scan statistics are recommended to minimize this unfavorable deworming uptake. Additionally, enhancing mothers through education and employment, and increasing access towards facility delivery are also recommended to halt this public health problem.