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Influence of socio-demographic and environmental factors on childhood diarrhea in Cambodia

[version 1; peer review: 1 approved with reservations]

Pisey

Vong

Conceptualization Data Curation Investigation Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0001-6500-6532 1 2 Banchonhattakit

Pannee

Conceptualization Methodology Supervision Validation https://orcid.org/0000-0001-5204-0213 a 3 1Doctor of Public Health Program, Faculty of Public Health, Khon Kaen University, Khon Kaen, 40002, Thailand 2Office of Rural Health Care, Pursat Provincial Department of Rural Development, Ministry of Rural Development, Cambodia 3Faculty of Public Health, Khon Kaen University, Khon Kaen, 40002, Thailand

a panban@kku.ac.th

No competing interests were disclosed.

28 4 2020

2020

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2020

This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: Diarrhea is still the leading cause of childhood death worldwide, as well as a major cause for concern in developing countries. This study was conducted to investigate the factors related to childhood diarrhea in Cambodia.

Methods: A cross-sectional study was conducted using the combination of two datasets from the Cambodia Demographic and Health Survey 2014. A generalized linear mixed model was used to analyze the determinant factors of childhood diarrhea.

Results: The surveys included 2,828 children, aged 12 to 35 months. The prevalence of diarrhea was 16.44% (95% CI: 14.72%-18.31%). Factors with statistically significant associations with childhood diarrhea in Cambodia were: maternal unemployment, compared with being in employment (AOR = 1.43; 95% CI: 1.14-1.78); the child being male (AOR = 1.25; 95%CI: 1.02-1.53); the presence of unimproved toilet facilities (AOR = 1.17; 95%CI: 1.05-1.31) compared with improved toilet facilities; and unhygienic disposal of children’s stools (AOR = 1.32; 95%CI: 1.06-1.64) compared with hygienic disposal of children’s stools when controlling for other covariates. Both maternal age (one year older; AOR = 0.85; 95%CI: 0.78– 0.93) and child age (one month older; AOR = 0.86; 95%CI: 0.78-0.94) had significant negative associations with the occurrence of childhood diarrhea.

Conclusion: Childhood diarrhea remains a public health concern in Cambodia. The probability of diarrhea occurring is shown to be increased by maternal unemployment, the sex of the child being male, lack of provision of improved toilet facilities, and the unhygienic disposal of children’s stools; whereas increasing maternal age and child’s age were associated with a reduced chance of diarrhea occurring. On the basis of these results, we recommend provision of programs focusing on reducing diarrhea through the construction of improved toilet facilities and the promotion of behavior to improve hygiene, specifically targeting younger mothers.

Socio-demographic environmental childhood diarrhea generalized linear mixed model Cambodia

The author(s) declared that no grants were involved in supporting this work.

Introduction

Diarrhea is defined as the passage of loose or watery stools, three or more times each day, or more frequent passage than is normal for an individual ¹. Diarrhea remains a leading cause of child mortality and morbidity in the world, with an estimated 1.7 billion cases of childhood diarrhea and 525,000 deaths of children under five caused by diarrhea each year. Diarrhea is the second leading cause of death in children under the age of five years ^{1,
2}. 88% of diarrhea cases globally are attributable to poor water, poor sanitation or poor hygiene ³. There is not just the one single factor associated with childhood diarrhea but multiple factors, including unimproved drinking water sources ^{4–
7}, untreated water ^{8–
10}, unimproved toilet facilities ^{6,
8,
9,
11}, unhygienic disposal of children’s stools ^{12–
14}, lack of hand washing facilities ^{15,
16}, type and location of residence ^{11,
16}, the child’s age ^{4,
13,
16}, the child’s sex (male) ¹³, maternal illiteracy ^{12,
13,
17}, the mother’s occupation ^{9,
12}, maternal age ^{14,
18}, wealth index ^{4,
19}, and whether or not the child is breastfed ^{10,
15}.

In 2014, Cambodia still had one of the highest prevalence levels of diarrhea among children under the age of five amongst countries in South-East Asia, at 12.8% ²⁰. By comparison, Myanmar had a prevalence of 10.4% in 2015–16 ²¹, Malaysia 4.4% in 2016 ⁷, Laos 6.5% in 2017 ²², Philippines 6.1% in 2017 ²³, and Indonesia 14.1% in 2017 ²⁴. According to 2016 data from UNICEF, Cambodia had 5,947 total neonatal deaths, of which 20 were due to diarrhea; 5,248 post-neonatal deaths, of which 672 were due to diarrhea (13%); and 692 deaths of children under five due to diarrhea (6%) ²⁵. High rates of diarrhea alone account for one fifth of the deaths of children under the age of five in Cambodia, and an estimated 10,000 deaths overall each year ²⁶. This demonstrates that diarrhea is the most common cause of death in Cambodian children. According to the Cambodia Demographic and Health Survey (CDHS) 2014, the prevalence of diarrhea among children aged 12 to 35 months was high, which is known to affect for child development and growth ²⁰.

It is of great importance to understand the factors related to the prevalence of diarrhea among children aged 12 to 35 months. There are no existing studies on the association in this age group, and no national studies on childhood diarrhea in Cambodia have yet been published.

Methods Ethical statement

This research project received approval from the Khon Kean University Ethics Committee in Human Research (HE632097). This study uses existing CDHS data and re-analysis was done under the original consent provided by the participants.

CDHS 2014

The CDHS 2014 collected data nationally across the country, which is subdivided into 19 province domains. Its sampling frame consisted of 28,455 eligible enumeration areas (EAs), which comprised the 2008 Cambodian General Population Census (GPC). The sample considered any domain with a power allocation, including both urban and rural areas. The stratified sample was selected in two stages. In the first stage, a fixed number of EAs were chosen using probabilities weighted proportional to the size of the EA. In the second stage, 24 and 28 households were picked up from every urban cluster and rural cluster, respectively, through a systematic sampling process with equal probability weighting. 15,825 households, 17,578 women, and 5,190 men were interviewed between the 2 ^nd June and the 12 ^th December 2014; further details can be found in the CDHS 2014 report ²⁰. The final sample size comprised 2,828 children aged 12 to 35 months, providing a suitable degree of power (0.9627, 0.9682).

Data use

Two raw CDHS 2014 datasets, comprising household data and children’s data were combined for use in this study. All entries and variables in these datasets were included in this study.

Dependent variable

The prevalence of diarrhea is the dependent variable considered in this study. This is referred to the questionnaire thus: “Has (NAME) had diarrhea in the last 2 weeks?” The dichotomous variable childhood diarrhea can take values “1” representing a response of “yes” or “0” representing “no” and “don’t know” responses.

Independent variables

Socio-demographic characteristics take the form of continuous variables such as maternal age, child’s age, and number of household members and categorical variables such as maternal education (no education/primary/secondary/higher), maternal occupation (employed/unemployed), mother’s knowledge of oral rehydration salts (ORS) (good/poor) ²⁷, exposure to media (yes/no) ²⁸, sex of the child, breastfeeding (ever/never), deworming (yes/no) ²⁷, vaccination (ever/never), residence (urban/rural) and wealth index (poorest/poorer/middle/richer/richest) ²⁷. CDHS data were organized in 19 province domains, which we regrouped into four regions: Central Plain; Tonle Sap; Coastal and Sea; and Plateau and Mountains ²⁹. Environmental characteristics were also treated as categorical variables, including drinking water source (improved/unimproved) ³⁰, whether or not the same source of drinking water was used during wet and dry seasons (same/different), whether or not water was treated before drinking (always/no), type of toilet facility (improved/unimproved) ³⁰, hygiene (adequate/inadequate) ³⁰, and disposal of children’s stools (sanitary/unsanitary) ³¹.

Statistical analysis

Statistical data analyses were performed using STATA/SE 14.0 ³² as follows.

Categorical data were analyzed to provide frequency and percentage. Continuous data were treated as means, standard deviations, and ranges for analysis. A weighting variable was used in the form of the woman’s individual sample weighting. Cross-tabulations were run with the appropriate sample weights to provide nationally representative results ¹⁹. The svyset command was used to test for complex survey sampling methods used in the original surveys, in order to adjust for differences in the probabilities of sample selection and to avoid using over-sampled strata within the survey data ²⁷.

The prevalence of diarrhea was estimated as a percentage. The numerator was the number of living children aged 12 to 35 months with an occurrence of diarrhea during the two weeks preceding the interview (i.e. an answer “yes” to, “Has (NAME) had diarrhea in the last 2 weeks?”) and the denominator was the number of living children aged 12 to 35 months.

A bivariate analysis with simple logistic regression was performed using the svyset ( svy command). A linearity test was conducted between the continuous variable and dependent variable. Any independent variables significant at p<0.25 were entered into the initial model ^{33,
34}. Multicollinearity was performed with the independent variables-variance inflation factor (VIF) ³⁵. Finally, a multivariate analysis was performed using a generalized mixed linear model with four regions picked as ‘random effects’ corresponding to the various clusters in the sampling design ³⁶. The backward stepwise procedure was applied as the model fitting strategy. Statistical significance was considered at a threshold of p<0.05 and the adjusted odds ratio (AOR) with 95% confidence intervals (CI) was considered as the magnitude of the effect.

Results

A total of 2,828 children were included in the study. The majority of the children (84.12%) lived in rural areas. Nearly half (44.03%) lived in Central Plain and one third (33.32%) in Tonle Sap. The average maternal age was 28.27±5.89 years old. More than half the mothers (51.08%) attended primary school. Three quarters (75.10%) of the mothers were employed and the average number of household members was five. More than half (51.18%) of the children were male and the mean age was 23.33±6.79 months. Almost all (96.17%) children had been breastfed; 59.60% had received deworming treatment; and 77.97% of them had never been vaccinated. Out of 2,828 households, more than half (54.07%) always had treated water to drink; 57.97% had an unimproved toilet facility; while 68.01% used adequate hygiene; and 70.25% used sanitary disposal of children’s stool ( Table 1).

Table 1. Socio-demographic and environmental characteristics of households in Cambodia, 2014 (n=2,828).

Variables	Frequency	Percentage
Maternal characteristics
Age (years)
16–24	397	14.04
25–34	1591	56.26
35–49	840	29.70
Mean±SD	28.27±5.89
Range	16 to 49
Education
No education	366	12.96
Primary	1445	51.08
Secondary	921	32.58
Higher	96	3.38
Occupation
Employed	2124	75.10
Unemployed	704	24.90
Knowledge of oral rehydration salts
Good	2717	96.05
Poor	111	3.95
Exposure to media
Yes	1808	63.92
No	1020	36.08
Children’s characteristics
Age (months)
12–23	1460	51.64
24–35	1368	48.36
Mean±SD	23.33±6.79
Range	12 to 35
Sex
Male	1448	51.18
Female	1381	48.82
Breastfeeding status
Ever	2720	96.17
Never	108	3.83
Deworming
Yes	1686	59.60
No	1142	40.40
Vaccination
Ever	623	22.03
Never	2205	77.97
Household characteristics
Residence
Urban	449	15.88
Rural	2379	84.12
Region
Coastal and Sea	169	5.98
Tonle Sap	942	33.32
Central Plain	1245	44.03
Plateau and Mountains	472	16.67
Number of household members
1–4	969	34.28
>4	1859	65.72
Mean±SD	5.73±2.31
Range	1 to 22
Wealth index
Poorest	672	23.76
Poorer	523	18.49
Middle	550	19.44
Richer	493	17.45
Richest	590	20.86
Environmental characteristics
Drinking water during dry season
Improved	1745	61.71
Unimproved	1083	38.29
Drinking water during wet season
Improved	2320	82.02
Unimproved	508	17.98
Same source of drinking water during wet and dry season
Same	1955	69.11
Different	873	30.89
Treating water to drink
Yes, always	1529	54.07
No	1299	45.93
Toilet facility
Improved	1189	42.03
Unimproved	1640	57.97
Hygiene
Adequate	1923	68.01
Inadequate	905	31.99
Disposal of children’s stool
Sanitary	1987	70.25
Unsanitary	841	29.75

SD, standard deviation.

Bivariate analysis of factors associated with childhood diarrhea in Cambodia

Factors with a significant association with childhood diarrhea (p<0.05) were maternal age, maternal occupation, the child’s age, available toilet facilities, and the method of stool disposal ( Table 2). Further, the factors of the child’s sex, their vaccination history, the number of household members, wealth index, source of drinking water during dry season, whether or not the same source of drinking water is used during wet and dry seasons, and the treatment/non-treatment of drinking water did not reach significance but did meet the pre-determined threshold of p<0.25 for inclusion in the initial model. Finally, region (p<0.25) also met the criteria for inclusion in the initial model and was used as a random effect. As such, the multivariate analysis was conducted using a generalized mixed linear model with each of the four regions of Cambodia treated as random effects.

Table 2. Bivariate analysis of factors associated with childhood diarrhea in Cambodia, 2014 (n=2,828).

Variables	Number	Diarrhea %	COR	95% CI	p-value
Overall	2828	16.44		14.72-18.31
Maternal age (years)	2828	N/A	0.82	0.73-0.92	<0.001
Maternal education					0.681
Literate	2462	16.29	1
Illiterate	366	17.46	1.09	0.73-1.62
Maternal occupation					0.007
Employed	2124	15.00	1
Unemployed	704	20.78	1.49	1.11-1.98
Mother’s knowledge of oral rehydration salts					0.481
Good	2717	16.61	1
Poor	111	12.21	0.69	0.25-1.90
Mother’s exposure to media					0.502
Yes	1808	15.99	1
No	1020	17.23	1.09	0.84-1.42
Child’s age (months)	2828	N/A	0.83	0.75-0.92	<0.001
Child’s sex					0.075
Female	1381	14.86	1
Male	1448	17.94	1.25	0.97-1.61
Breastfeeding status					0.268
Ever	2720	16.64	1
Never	108	11.42	0.64	0.29-1.40
Deworming					0.504
Yes	1686	16.91	1
No	1142	15.75	0.91	0.71-1.17
Vaccination					0.232
Ever	623	14.44	1
Never	2205	17.00	1.21	0.88-1.66
Residence					0.561
Urban	449	15.39	1
Rural	2379	16.64	1.10	0.80-1.50
Region					0.203
Coastal and Sea	169	12.36	1
Tonle Sap	942	15.55	1.31	0.82-2.07
Central Plain	1245	16.92	1.44	0.92-2.25
Plateau and Mountains	472	18.40	1.60	1.02-2.51
Number of household members					0.095
>4	1859	15.38	1
1–4	969	18.47	1.25	0.96- 1.62
Wealth index					0.128
Richest	590	14.44	1
Richer	493	17.40	1.25	0.82-1.90
Middle	550	14.65	1.02	0.67-1.55
Poorer	523	14.50	1.00	0.67-1.50
Poorest	672	20.46	1.52	1.03-2.26
Drinking water during dry season					0.065
Improved	1745	15.12	1
Unimproved	1083	18.56	1.28	0.98-1.66
Drinking water during wet season					0.676
Improved	2320	16.27	1
Unimproved	508	17.22	1.07	0.78-1.48
Same source of drinking water during wet and dry season					0.161
Same	1955	15.56	1
Different	873	18.40	1.22	0.92-1.62
Treating water to drink					0.139
Yes, always	1529	15.28	1
No	1299	17.81	1.20	0.94-1.53
Toilet facility					0.013
Improved	1189	13.61	1
Unimproved	1640	18.49	1.20	1.04-1.39
Hygiene					0.995
Adequate	1923	16.44	1
Inadequate	905	16.43	0.99	0.74-1.34
Disposal of children’s stool					0.020
Sanitary	1987	14.99	1
Unsanitary	841	19.85	1.40	1.05-1.87

COR, crude odds ratio; CI, confidence interval.

Multivariate analysis of factors associated with childhood diarrhea in Cambodia

The multivariate analysis ( Table 3) showed that as maternal age increased by a year, the odds of the child suffering from diarrhea decreased 15% (AOR = 0.85; 95%CI: 0.78– 0.93; p=0.001). The odds of suffering from diarrhea was 43% higher (AOR = 1.43; 95% CI: 1.14-1.78; p=0.002) in children whose mother was unemployed compared to employed. As the child’s age increased by a month, the odds of the child suffering from diarrhea decreased 14% (AOR = 0.86; 95%CI: 0.78-0.94; p=0.001). The odds of suffering from diarrhea was 25% higher (AOR = 1.25; 95%CI: 1.02-1.53; p=0.031) in males compared to females. The odds of suffering from diarrhea was 17% higher (AOR = 1.17; 95%CI: 1.05-1.31; p=0.004) in children living in a household with unimproved toilet facilities compared with those with improved toilet facilities. The odds of suffering from diarrhea was 32% higher (AOR = 1.32; 95%CI: 1.06-1.64; p=0.011) in children whose stools were disposed of unhygienically compared to children whose stools were disposed of hygienically.

Table 3. Multivariate analysis of factors associated with childhood diarrhea in Cambodia, 2014 using generalized mixed linear model (n=2,828).

Variables	Number	Diarrhea %	AOR	95% CI	p-value
Maternal age (years)	2828	N/A	0.85	0.78-0.93	0.001
Maternal occupation					0.002
Employed	2124	15.00	1
Unemployed	704	20.78	1.43	1.14-1.78
Child’s age (months)	2828	N/A	0.86	0.78-0.94	0.001
Child’s sex					0.031
Female	1381	14.86	1
Male	1448	17.94	1.25	1.02-1.53
Toilet facility					0.004
Improved	1189	13.61	1
Unimproved	1640	18.49	1.17	1.05-1.31
Disposal of children’s stool					0.011
Sanitary	1987	14.99	1
Unsanitary	841	19.85	1.32	1.06-1.64

AOR, adjusted odds ratio; CI, confidence interval.

Discussion

This is the first study to report factors associated with diarrhea in children aged 12 to 35 months at the national level in Cambodia. Younger maternal age, maternal unemployment, younger child age, being male, lack of unimprovement to toilet facilities, and unhygienic disposal of children’s stools were found to be associated with childhood diarrhea.

Socio-demographic characteristics such as maternal age were significantly associated with reduced incidence of diarrhea, in line with studies conducted in Brazil and Tanzania ^{14,
18}, and perhaps due to the mother having more experience in childcare and feeding. The association of maternal unemployment with the incidence of diarrhea is consistent with a study in Senegal ⁹. The child’s age had a significant, negative association with incidence of diarrhea, in line with many studies in Ethiopia and Tanzania ^{4,
14,
16}, and potentially due to the development of the immune system throughout childhood. Males were more likely to suffer from diarrhea than females, which may simply reflect a natural predisposition of males to develop diarrhea more frequently than females ³⁷, but is also supported by a previous study conducted in India ¹³.

Environmental characteristics such as the lack of improvements to toilet facilities were significantly associated with the incidence of diarrhea, consistent with many studies including a systematic review ^{4,
6,
8,
11}. Finally, disposal of children’s stools was significantly associated with the incidence of diarrhea, consistent with previous studies in Ethiopia, India, and Tanzania ^{12–
14}. These findings demonstrate that the quality of sanitation facilities strongly influences the prevalence of childhood diarrhea in Cambodia.

A limitation of this research study was that it used a cross-sectional design with just one outcome measure (diarrhea prevalence) taken as a snapshot at a given point in time. Future longitudinal studies may improve on this. The CDHS 2014 was not fully comprehensive in that it did not cover the WASH factors of hand washing before preparing meals and after defecating. The inclusion of these questions in the survey would give a more comprehensive analysis of hygiene practices in the population. Further, the CDHS 2014 captured data by household, rather than by individual person, which may introduce a confound in that it has a tendency to under-estimate the quality of both drinking water source and sanitation facility available.

Conclusion

Diarrhea still remains a public health concern among children in Cambodia. The probability of developing diarrhea is strongly associated with maternal unemployment, being male, not having access to improved toilet facilities, or practicing hygienic disposal of children’s stools. Conversely, increasing maternal and child age is associated with a reduction in the probability of developing diarrhea.

Recommendations

Based on this finding, the authors provide the following recommendations.

National level: The WASH program managed by the Ministry of Rural Development in Cambodia should focus on delivering guidance to younger mothers with younger children and also to unemployed mothers. Guidance should include sanitary disposal of children’s stools in addition to water treatment, sanitation and health. Health policy decision makers should design appropriate intervention programs focusing on reducing diarrhea through the construction of improved toilet facilities in addition to promoting hygienic behaviors.

Community level: Younger mothers should be encouraged to enroll in health education for the prevention of childhood diarrhea. Improvements should be made to the general community sanitation facilities as well as the construction of additional toilet facilities.

Future study: Longitudinal studies on childhood diarrhea need to be conducted in order to measure the impact of interventions.

Data availability

Our study used raw children’s and household data from DHS, Cambodia 2014. Data are free to access for research purposes and can be obtained through the DHS Program after registering and obtaining an approval letter from the Inner City Fund (ICF) ( https://dhsprogram.com/data/Access-Instructions.cfm).

Acknowledgements

The authors would like to express sincere thanks and appreciation to:

Dr. Kavin Thinkhamrop, Health and Epidemiology Geoinformatics Research (HEGER), Faculty of Public Health, Khon Kaen University; Dr. Wilaiphorn Thinkhamrop, Data Management and Statistical Analysis Center (DAMASAC), Faculty of Public Health, Khon Kaen University for their statistical support; and Rebecca S Dewey, University of Nottingham for language editing.

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10.5256/f1000research.25665.r64014

Reviewer response for version 1

Siyan

1 2 3 Referee https://orcid.org/0000-0002-3045-5386 1Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore 2Center for Global Health Research, Touro University California, Vallejo, CA, USA 3KHANA Center for Population Health Research, Phnom Penh, Cambodia

Competing interests: No competing interests were disclosed.

15 6 2020

2020

This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

recommendation

approve-with-reservations

General comments: This study used data from Cambodia Demographic and Health Surveys to identify risk factors associated with diarrhea in children aged 12 to 35 months. Overall, the study findings are interesting and may contribute to the literature in this area given the scarcity of data in low- and middle-income countries. The analyses appeared appropriate. The quality of the writing is acceptable, although more careful proofreading is required before the paper can be published.

Here are my specific comments:

Title:

The term 'influence' may not be appropriate for this study as it can only tell the associations of variables, not causal relationships.

Abstract:

Methods: The first sentence "A cross-sectional study was conducted using the combination of two datasets from the Cambodia Demographic and Health Survey 2014" is hard to understand. The authors may want to make it clear that this study used secondary data from CDHS. What are the two data sets?

What was the time frame for the prevalence of diarrhea - past month or lifetime?

Introduction:

Please provide a reference for the statement in the second sentence, paragraph 1.

Avoid starting sentences with numbers.

It would be helpful for readers if authors could define some terminology; e.g., neonatal deaths, post-neonatal deaths, under-five deaths, etc.

Paragraph 2:

- "...and 692 deaths of children under five due to diarrhea (6%)." What is the denominator of the 6%? In the following sentence, the authors stated that 'diarrhea alone account for one fifth of the deaths of children under the age of five in Cambodia." Please clarify these.

- "High rates of diarrhea alone account for...' Diarrhea alone?

- It is confusing that this study used data from CDHS 2014, but also cited the prevalence of diarrhea in the same population and from the same data, while claiming that no national studies on childhood diarrhea in Cambodia have yet been published. - The rationale of the study needs improvement.

Methods:

What 'province domains' mean?

What does this mean: '...,which comprised the 2008 Cambodian General Population Census (GPC)?'

'The sample considered any domain...' is not understandable.

Although the CDHS 2014 was referred to, some variables require a clear definition; e.g., improved/unimproved water sources, toilet facilities, adequate/inadequate hygiene, sanitary/unsanitary disposal of children's stools, etc.

Data analyses:

- It is not accurate to state this "Continuous data were treated as means, standard deviations, and ranges for analysis." Perhaps something like 'For continuous variables, mean and standard deviations were calculated..."

- I am not sure what authors wanted to tell by this "A weighting variable was used in the form of the woman’s individual sample weighting."

- Any independent variables significant at p<0.25 in bivariate analyses were entered into the initial model.

-Multicolinearity assessment was performed...

Results:

...and one third (33.32%) in Tonle Sap region?

It should be mean (SD xx).

"More than half the mothers (51.08%) attended primary school." Did this include mothers who had no education?

Any details to define the breastfeeding - duration, exclusivity...?

Please check this data: "...and 77.97% of them had never been vaccinated." This could be very wrong as the immunization coverage in Cambodia has been globally recognized as very high.

Discussion:

This section can be improved by extending more in-depth literature in this area and link to the policy implication of the findings.

Further limitations of the study should also be included (e.g., self-reporting measures, recall bias...).

Conclusions and recommendations can be combined.

Recommendations can be summarized.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

If applicable, is the statistical analysis and its interpretation appropriate?

Yes

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

Partly

Reviewer Expertise:

Epidemiology, community-based intervention and evaluation, infectious diseases

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

VONG

PISEY

Ministry of Rural Development, Cambodia, Cambodia

Competing interests: No competing interests

29 6 2020

Review1

Title:

The term 'influence' may not be appropriate for this study as it can only tell the associations of variables, not causal relationships.

A: Agree with the reviewer. As suggested, we have revised the term to “The association”. See title, para 1 on page 1

Abstract:

1. Methods: The first sentence "A cross-sectional study was conducted using the combination of two datasets from the Cambodia Demographic and Health Survey 2014" is hard to understand. The authors may want to make it clear that this study used secondary data from CDHS. What are the two data sets?

A: Taken care. "A cross-sectional study of the secondary data from the Cambodia Demographic and Health Survey (CDHS) 2014 was conducted using the combination of household data and children’s data. See Abstract, 1 ^st sentence, para 2 on page 1

2. What was the time frame for the prevalence of diarrhea - past month or lifetime?

A: Taken care. The authors added the text “in the last 2 weeks”. See Abstract, 2 ^nd sentence, para 3 on page 1

Introduction:

1. Please provide a reference for the statement in the second sentence, paragraph

A: Taken care. “1,2”. See 2 ^nd sentence, para 1 on page 3.

2. Avoid starting sentences with numbers.

A: Taken care. Globally, 88% of diarrhea cases are attributable…… See 4 ^th sentence, para 1 on page 3.

3. It would be helpful for readers if authors could define some terminology; e.g., neonatal deaths, post-neonatal deaths, under-five deaths, etc.

A: We are sorry, we do not agree with the peer reviewer on this. Authors have retained our original because we think it is not much helpful to add terminology of neonatal deaths, post-neonatal deaths, under-five deaths.

4. Paragraph 2:

- "High rates of diarrhea alone account for...’Diarrhea alone?

A: The denominator of the 6% is the “number of under five children”, however in the data from UNICEF, they do not put it. They just put only “under five deaths due to diarrhea: 692”; and “% underfive deaths due to diarrhoea: (6%)”. According to calculation by the authors, denominator of (6%) is about 11,533.

A: Please, see the reference on number 26 which mentioned as “High incidences of diarrhoeal diseases alone account for one fifth of the deaths of children age five and under in Cambodia, and an estimated 10,000 overall deaths annually, largely owing to lack of sanitation and poor hygiene practices”.

A: Agree with the reviewer. As suggested, we have revised the text to “There are no existing studies on the association in this age group, and no national studies on the associated factors with childhood diarrhea in Cambodia have yet been published”. See 2 ^nd sentence, para 3 on page 3.

Methods:

1.What 'province domains' mean?

A. Province domains means the 19 sampling domains of provinces. There are 24 provinces in Cambodia in CDHS 2014, of which fourteen individual provinces (Banteay Meanchey, Kampong Cham, Kampong Chhnang, Kampong Speu, Kampong Thom, Kandal, Kratie, Phnom Penh, Prey Veng, Pursat, Siem Reap, Svay Rieng, Takeo, and Otdar Meanchey); and five groups of provinces (Battambang and Pailin, Kampot and Kep, Preah Sihanouk and Koh Kong, Preah Vihear and Stung Treng, and Mondul Kiri and Ratanak Kiri)

2. What does this mean: '..., which comprised the 2008 Cambodian General Population Census (GPC)?'

A. It means “which used the 2008 Cambodian General Population Census”

That has been mentioned in CDHS 2014 as “The sampling frame used for the 2014 CDHS was derived from the list of all enumeration areas (EAs) created for the 2008 Cambodia General Population Census (GPC), provided by NIS

3. The sample considered any domain...' is not understandable.

A: Taken care. We have revised the text to “The sample was allocated into urban and rural in each domain with a power allocation preventing oversample urban, and can represent Cambodia is mainly rural. See 3 ^rd sentence, para 3 on page 3.

4. Although the CDHS 2014 was referred to, some variables require a clear definition; e.g., improved/unimproved water sources, toilet facilities, adequate/inadequate hygiene, sanitary/unsanitary disposal of children's stools, etc.

A: Agree with the reviewer. As suggested, we have added the text “World Health Organization (WHO) guidelines on water, sanitation and hygiene (WASH) were used to classify WASH as either improved or unimproved according to the WHO/UNICEF Joint Monitoring Programme (Table1 and Table 2). See 3 ^rd sentence, para 2 on page 4; and we also added the Table 1 and Table 2. See on page 11 and 12.

5. Data analyses:

- I am not sure what authors wanted to tell by this "A weighting variable was used in the form of the woman’s individual sample weighting."

- Any independent variables significant at p<0.25 in bivariate analyses were entered into the initial model.

-Multicolinearity assessment was performed...

A: Agree with the reviewer. As suggested, we have revised the text “Categorical variable were analyzed to provide frequency and percentage. Continuous variable were calculated as means, standard deviations, and ranges”. See 1 ^st sentence, para 3 on page 4.

A: Because it is survey data, by providing national representative, we used Woman’s individual weighting because child data was accessed by asking for their mother.

A: Yes, please see in the “Result” on 2 ^nd sentence, para 2 on page 6.

A: Taken care “Multicolinearity assessment was performed...”

Results:

...and one third (33.32%) in Tonle Sap region?

A. Taken care. We have revised by adding “lived”. See on 2nd sentence, para 1 page 5

2. It should be mean (SD xx).

A. Taken care.

3."More than half the mothers (51.08%) attended primary school." Did this include mothers who had no education?

A: No, It did not include mothers who had no education

4. Any details to define the breastfeeding - duration, exclusivity...?

A: No, in the data showing only “ever breastfed (not currently breastfeed, never breastfed, still breastfeeding”; so we group as “ever and never”.

5. Please check this data: "...and 77.97% of them had never been vaccinated." This could be very wrong as the immunization coverage in Cambodia has been globally recognized as very high.

A: Agree with the reviewer. As in the data of 2828 showed that 2.15% was no, 22.03% was yes, 0.27% was don’t know, and 75.55 was missing. The authors request to delete this variable since it is too much missing, moreover according to literature review this variable is not related with childhood diarrhea, only rotavirus vaccination is associated.

Discussion:

1. This section can be improved by extending more in-depth literature in this area and link to the policy implication of the findings.

A: Agree with the reviewer. However, we do not extending more in-depth literature. We have retained our original.

2. Further limitations of the study should also be included (e.g., self-reporting measures, recall bias...).

A. Taken care. See 4th sentence, para 3 on page 7.

3. Conclusions and recommendations can be combined.

A: Authors have retained our original because it will be a good idea to separate the limitation, recommendations and conclusion. Moreover, conclusion is an important part of the paper.

4. Recommendations can be summarized.

A: Taken care. As suggested, the authors have summarized the text in Recommendations part. See page 8.