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

Vong Pisey; Pannee Banchonhattakit; Wongsa Laohasiriwong

doi:10.12688/f1000research.23246.3

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Research Article

Revised

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

[version 3; peer review: 1 approved with reservations]

Vong Pisey^1,2, Pannee Banchonhattakit ³, Wongsa Laohasiriwong³

PUBLISHED 12 Apr 2021

Author details Author details

¹ Doctor of Public Health Program, Faculty of Public Health, Khon Kaen University, Khon Kaen, 40002, Thailand
² Office of Rural Health Care, Pursat Provincial Department of Rural Development, Ministry of Rural Development, Cambodia
³ Faculty of Public Health, Khon Kaen University, Khon Kaen, 40002, Thailand

Vong Pisey
Roles: Conceptualization, Data Curation, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing

Pannee Banchonhattakit
Roles: Conceptualization, Methodology, Supervision, Validation

Wongsa Laohasiriwong
Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing

OPEN PEER REVIEW

REVIEWER STATUS

This article is included in the Global Public Health gateway.

Abstract

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 of the secondary data from the Cambodia Demographic and Health Survey 2014 was conducted using the combination of household data and children’s data. 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 in the last 2 weeks 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.

Keywords

Socio-demographic, environmental, childhood diarrhea, generalized linear mixed model, Cambodia

Corresponding author: Pannee Banchonhattakit

Competing interests: No competing interests were disclosed.

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

Copyright: © 2021 Pisey V et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Pisey V, Banchonhattakit P and Laohasiriwong W. The association of socio-demographic and environmental factors on childhood diarrhea in Cambodia [version 3; peer review: 1 approved with reservations]. F1000Research 2021, 9:303 (https://doi.org/10.12688/f1000research.23246.3) First published: 28 Apr 2020, 9:303 (https://doi.org/10.12688/f1000research.23246.1) Latest published: 23 Sep 2021, 9:303 (https://doi.org/10.12688/f1000research.23246.5)

Revised Amendments from Version 2

We have updated the authorship of article by adding Wonga Laohasiriwong as last author

See the authors' detailed response to the review by Siyan Yi
See the authors' detailed response to the review by Okechukwu S. Chukwudeh

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 individual¹. 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^1,2. Diarrhea is the second leading cause of death in children under the age of five years^1,2. Globally, 88% of diarrhea cases are attributable to poor water, poor sanitation or poor hygiene³. 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 2015–16²¹, Malaysia 4.4% in 2016⁷, Laos 6.5% in 2017²², Philippines 6.1% in 2017²³, and Indonesia 14.1% in 2017²⁴. 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 year²⁶. 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 growth²⁰.

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 the associated factors with 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 was allocated into urban and rural in each domain with a power allocation preventing oversample urban, and can represent Cambodia is mainly rural. 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 report²⁰. 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 Mountains²⁹. 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. World Health Organization (WHO) guidelines on water, sanitation and hygiene (WASH) were used to classify WASH as either improved or unimproved, and sanitary or unsanitary according to the WHO/UNICEF Joint Monitoring Programme (Table 1 and Table 2)^30,31

Table 1. Joint Monitoring Programme classification of improved and unimproved water, sanitation and hygiene (WASH)³⁰.

Service	Improved	Unimproved
Drinking water	Piped water, boreholes or tube wells, protected dug wells, protected springs, rainwater, and packaged or delivered water, and provided collection time is not more than 30 minutes for a round trip, including queuing	Unprotected dug well, unprotected spring, surface water (river, reservoirs, lakes, ponds, streams, canals, and irrigation channels).
Sanitation	Flush and pour flush connected to piped sewer, septic tanks or pit latrines; ventilated improved pit (VIP) latrine, composting toilets or pit latrines with slabs, and that are not shared with other households	Flush and pour flush not to sewer/septic tank/pit latrine, pit latrine without slab/open pit, bucket, hanging toilet/hanging latrine, no facility/bush/field
Hygiene	Availability of a handwashing facility on premises with soap and water	No handwashing facility on premises

Table 2. Joint Monitoring Programme classification of sanitary and unsanitary disposal of children stool³¹.

Sanitary	Unsanitary
Child used toilet or latrine Put or rinsed in the toilet or latrine Buried	Put or rinsed into drain or ditch Throw into the garbage Left in the open or not disposed of Other

Statistical analysis

Statistical data analyses were performed using STATA/SE 14.0³² as follows.

Categorical variables were analyzed to provide frequency and percentage. Continuous variables were calculated as means, standard deviations, and ranges. 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 results¹⁹. 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 data²⁷.

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 assessment 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 design³⁶. 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%) lived in Tonle Sap. The mean of 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. 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 3).

Table 3. 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
*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 4). Further, the factors of the child’s sex, 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 4. 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
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 5) 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 5. 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 Senegal⁹. 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 females³⁷, but is also supported by a previous study conducted in India¹³.

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. Moreover, self-reporting measures and recall bias could happened and considered in the study. 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: The WASH program should focus on younger mothers, mothers of younger children and unemployed mothers. Guidance should include sanitary methods of stool disposal, water treatment, sanitation, and health. Intervention programs should focus on the construction of improved toilet facilities and promoting hygienic behaviors.

Local: Younger mothers should be encouraged to enroll in health education. Additional community sanitation facilities should be constructed and existing facilities should be improved/maintained.

Future study: Longitudinal studies are needed to measure the impact of these 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.

Faculty Opinions recommended

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18. Vasconcelos MJOB, Rissin A, Figueiroa JN, et al.: Factors associated with diarrhea in children under five years old in the state of Pernambuco, according to surveys conducted in 1997 and 2006. Rev Saude Publica. 2018; 52: 48. PubMed Abstract | Publisher Full Text | Free Full Text
19. Rutstein SO, Staveteig S, Winter R, et al.: Urban Child Poverty, Health, and Survival in Low- and Middle-Income Countries. DHS Comparative Reports No. 40. Rockville, Maryland, USA; 2016. Reference Source
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Comments on this article Comments (0)

Version 5

VERSION 5 PUBLISHED 28 Apr 2020

Author details Author details

Vong Pisey
Roles: Conceptualization, Data Curation, Investigation, Writing – Original Draft Preparation, Writing – Review & Editing

Pannee Banchonhattakit
Roles: Conceptualization, Methodology, Supervision, Validation

Wongsa Laohasiriwong
Roles: Conceptualization, Methodology, Supervision, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

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

Article Versions (5)

version 5

Revised

Published: 23 Sep 2021, 9:303

https://doi.org/10.12688/f1000research.23246.5

version 4

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Published: 04 Aug 2021, 9:303

https://doi.org/10.12688/f1000research.23246.4

version 3

Revised

Published: 12 Apr 2021, 9:303

https://doi.org/10.12688/f1000research.23246.3

version 2

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Published: 03 Jul 2020, 9:303

https://doi.org/10.12688/f1000research.23246.2

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Published: 28 Apr 2020, 9:303

https://doi.org/10.12688/f1000research.23246.1

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Pisey V, Banchonhattakit P and Laohasiriwong W. The association of socio-demographic and environmental factors on childhood diarrhea in Cambodia [version 3; peer review: 1 approved with reservations]. F1000Research 2021, 9:303 (https://doi.org/10.12688/f1000research.23246.3)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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Reviewer Report 15 Jun 2020

Siyan Yi, Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore; KHANA Center for Population Health Research, Phnom Penh, Cambodia; Center for Global Health Research, Touro University California, Vallejo, CA, USA

Approved with Reservations

https://doi.org/10.5256/f1000research.25665.r64014

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

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

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
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

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.

CITE

Report a concern

Author Response 03 Jul 2020

PISEY VONG, Office of Rural Health Care, Pursat Provincial Department of Rural Development, Ministry of Rural Development, Cambodia

03 Jul 2020

Author Response

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. ... Continue reading 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:
- "...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.

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:
- 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...

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.
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:
- "...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.

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:
- 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...

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.
Competing Interests: No competing interests Close
Report a concern
Respond or Comment

COMMENTS ON THIS REPORT

Author Response 03 Jul 2020

PISEY VONG, Office of Rural Health Care, Pursat Provincial Department of Rural Development, Ministry of Rural Development, Cambodia

03 Jul 2020

Author Response

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. ... Continue reading 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:
- "...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.

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:
- 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...

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.
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:
- "...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.

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:
- 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...

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.
Competing Interests: No competing interests Close
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Siyan Yi, National University of Singapore, Singapore, Singapore; KHANA Center for Population Health Research, Phnom Penh, Cambodia; Touro University California, Vallejo, USA
Okechukwu S. Chukwudeh, North-West University, Mahikeng, South Africa

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07 Oct 2021 | for Version 5

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Approved

The authors have addressed all the critical points. I have no further comments.

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Epidemiology, community-based intervention and evaluation, infectious diseases

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Okechukwu S. Chukwudeh, North-West University, Mahikeng, South Africa

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Approved

The article is a topical issue especially in less developed countries. It is presumed it will make meaningful impact to scholars and policy makers.

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Sociology (Demography and Population Studies)

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26 Aug 2021 | for Version 4

Okechukwu S. Chukwudeh, North-West University, Mahikeng, South Africa

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Approved With Reservations

Report on the manuscript titled “The association of socio-demographic and environmental factors on childhood diarrhea in Cambodia”

Abstract
The abstract should be filtered to avoid repetition of points

Methods

Study design and setting: The design, settings, location and relevant dates was not clearly stated. This should be stated in the methodology section. Where is Central Plain, and Tonle Sap? These were not described in the methodology. Are they cities or communities in rural or urban clusters?
Participants: Eligibility criteria was totally missing in this study. Kindly fulfil this requirement. The Author should provide the population size. What is the total number of under-five children (0-5 years) in the country? What is the total number of children 12 to 35 months in the country? What is significant about 12 to 35 months in Cambodia?
Variables: The variables, indicators, predictors and confounders for the study are not clearly outline. Kindly outline this in alignment with recent WASH analyses pattern e.g Water ladder scale, and Sanitation ladder services (this should be added to what author have on the work).
Data: The data for each variable of measurement is entirely missing. Kindly provide sources of data for each variables and indicators.
Bias: Kindly provide efforts to address potential bias
Study size: kindly explain how the sample size was arrived at. How did you arrive at the sample of 2,828? You selected 2,828 sample which represent 565 households based on five persons per household. Recall that you stated that the total number of households was 15,825. This means you selected 4% of the entire household in the study location. This is small and this affects the generalization of the study. Kindly review this along side the eligibility criteria. Also, how were 15,825 households, 17,578 women, and 5,190 men interviewed? What is the significant of interviewing men? The study sample size is clumsy. Kindly review.
Statistical method: How were variables handled in the analyses. The statistical method was not well explained. What is the meaning of improve and unimproved sanitation? Describe the statistical method and sampling strategy used for the study. How were data handled? What kind of technique was used to calculate the prevalence of diarrhea (see abstract)?

Conclusion: The method for the study is not sufficiently detailed to understand the approach. The author is advised to provide detailed approach and statistical techniques applied.

Results

The demographics of the respondents was not sufficiently reported.
Descriptive statistics was used for the study. Recall in the methodology, under the 2^nd stage of the sampling technique, 24 and 28 households were picked from urban and rural clusters, respectively using equal probability weighting. However, result shows that 84% of the children live in rural areas. Kindly align this narrative.
Kindly explain the result succinctly.

Conclusion: The result should be aligned with the methodology and conclusion

Interpretations/Discussion

Contextually, why are male more susceptible to diarrhea when other studies such as Nwokocha, Chukwudeh, and Damian (2020) have found otherwise. Kindly justify this contextually, this makes the work unique.
If male gender is uniquely susceptible to diarrhea as stated in this study, why was it not included in the conclusion and its implications reflected in the recommendation. However, gender status and disease prevalence are contextual and highly contested in literature.
Validity of the results was not included.
The results were not engaged with other studies to know the gap that was filled in this study.
The contribution to knowledge of the study is not clearly outline in the body of the work.
The implication and contribution of findings to the body of knowledge is missing.

Conclusion: Author should derive conclusion from the results

Recommendation: Invitation to revise (more work is required to satisfy all criteria)

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

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

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

No
If applicable, is the statistical analysis and its interpretation appropriate?

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

No
Are the conclusions drawn adequately supported by the results?

No

References

1. E. Nwokocha E, S. Chukwudeh O, Ukwandu D: Prevalence and the social contexts of childhood diarrhea in Ibadan slums, Southwest Nigeria. African Journal of Gender, Society and Development (formerly Journal of Gender, Information and Development in Africa). 2020; 9 (3): 11-34 Publisher Full Text

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Sociology (Demography and Population Studies)

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Author Response

23 Sep 2021

PISEY VONG, Doctor of Public Health Program, Faculty of Public Health, Khon Kaen University, Khon Kaen, 40002, Thailand

Thank you for your valuable comments to improve the quality of our paper.
#Response to reviewer: Okechukwu S. Chukwudeh

Abstract
The abstract should be filtered to avoid repetition of points
Reply: Taken care.

Methods
1. Study design and setting: The design, settings, location and relevant dates was not clearly stated. This should be stated in the methodology section. Where is Central Plain, and Tonle Sap? These were not described in the methodology. Are they cities or communities in rural or urban clusters?
Reply: Taken care. Please, see Figure 1 as well as please, kindly see the CDHS 2014 and Data use.

2. Participants: Eligibility criteria was totally missing in this study. Kindly fulfil this requirement. The Author should provide the population size. What is the total number of under-five children (0-5 years) in the country? What is the total number of children 12 to 35 months in the country? What is significant about 12 to 35 months in Cambodia?
Reply: Taken care.

3. Variables: The variables, indicators, predictors and confounders for the study are not
clearly outline. Kindly outline this in alignment with recent WASH analyses pattern e.g Water ladder scale, and Sanitation ladder services (this should be added to what author have on the work).
Reply: The authors have retained our originals. Please feel free to check it in limitation.

4. Data: The data for each variable of measurement is entirely missing. Kindly provide sources of data for each variables and indicators.
Reply: Some of the variable is not provided the sources because it is the secondary data which has been grouped or categorized already. i.e. source of drinking water during wet and dry seasons (same/different), residence (urban/rural), etc.

5. Bias: Kindly provide efforts to address potential bias
Reply: The authors have retained our originals. Please feel free to check it in limitation.

6. Study size: kindly explain how the sample size was arrived at. How did you arrive at the sample of 2,828? You selected 2,828 sample which represent 565 households based on five persons per household. Recall that you stated that the total number of households was 15,825. This means you selected 4% of the entire household in the study location. This is small and this affects the generalization of the study. Kindly review this along side the eligibility criteria. Also, how were 15,825 households, 17,578 women, and 5,190 men interviewed? What is the significant of interviewing men? The study sample size is clumsy. Kindly review.
Reply: DHS used large survey which is not only interviewing for only one outcome. It provides information related to fertility, family planning, maternal and child health, gender, HIV/AIDS, malaria, and nutrition. Therefore, you will get the answer. Please, kindly understand the DHS/CDHS report.

7. Statistical method: How were variables handled in the analyses. The statistical method was not well explained. What is the meaning of improve and unimproved sanitation? Describe the statistical method and sampling strategy used for the study. How were data handled? What kind of technique was used to calculate the prevalence of diarrhea (see abstract)?
Reply: Our statistical method is already explained. The meaning of improved and unimproved sanitation was outlined in Table 1 and Table 2. Please, kindly see. Our outcome calculation was also outline there. Please, see it carefully.

Conclusion: The method for the study is not sufficiently detailed to understand the approach. The author is advised to provide detailed approach and statistical techniques applied.
Reply: As we explain above in statistical method, the authors have retained our originals in this point.

Interpretations/Discussion
1. Contextually, why are male more susceptible to diarrhea when other studies such as Nwokocha, Chukwudeh, and Damian (2020) have found otherwise. Kindly justify this contextually, this makes the work unique.
Reply: The authors confirm that our analysis is correct. We also outline in Discussion that “…. may simply reflect a natural predisposition of males to develop diarrhea more frequently than females³⁷)” as well as a study published in PMC Public Health by Bawankule, R., Singh, A., Kumar, K. et al. found the same as our study.

2. If male gender is uniquely susceptible to diarrhea as stated in this study, why was it not included in the conclusion and its implications reflected in the recommendation. However, gender status and disease prevalence are contextual and highly contested in literature.
Reply: Taken care.

3. Validity of the results was not included.
Reply: Please, feel free to check it carefully.

4. The results were not engaged with other studies to know the gap that was filled in this study.
Reply: Please, feel free to check it carefully.

5. The contribution to knowledge of the study is not clearly outline in the body of the work.
Reply: Please, feel free to check it carefully.

6. The implication and contribution of findings to the body of knowledge is missing.
Reply: Please, feel free to check it carefully.

Conclusion: Author should derive conclusion from the results.
Reply: Please, feel free to check it carefully.

Recommendation: Invitation to revise (more work is required to satisfy all criteria)
Reply: Taken care.

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13 Aug 2021 | for Version 4

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Approved With Reservations

General comments:
This is an interesting study of an important health topic in low-income countries using large datasets from the Cambodia Demographic and Health Survey (CDHS) 2014. These data are often under use in many resource-limited countries, despite their large scope and scale with standardized methods. Despite its significant contribution to the literature, the manuscript requires substantial improvement in the writing quality and careful proofreading to eliminate several grammatical errors, misuse of punctuations, and complex sentences easily found throughout the text for improving its accuracy and readability. Below are some suggestions that are not exhaustive.

Abstract

When talking about health-related issues in children, please be specific about age groups. The term ‘childhood diarrhea’ is too broad, while diarrheal diseases commonly affect younger children.
The first sentence in background is not very accurate and can be simplified as follows: “Diarrheal diseases remain the leading cause of death among under-five children in lower- and lower-middle-income countries.”
Methods: “We analyzed cross-sectional data from the Cambodia Demographic and Health Survey 2014 using combined household and children’s datasets.”
Results: The 1^st sentence: “The survey included 2,828 children aged 12 to 35 months.” and the 3^rd sentence: “Factors significantly associated with childhood diarrhea were…” - Please correct the misuse and inconsistent use of punctuation.
Conclusions: The 2^nd sentence only repeats the results. Please summarize the key findings without redundancies. Recommendations can be simplified, avoiding unnecessary wording: “Intervention programs should focus on reducing diarrheal diseases by constructing improved toilet facilities and promoting behavior to improve hygiene, specifically targeting younger mothers.”
Keywords can also be improved.

Introduction
The writing quality of the introduction needs substantial improvement. I am trying to help, but it is difficult and time-consuming. Here are some examples:

The 1^st sentence: the definition of diarrhea is not very important in the background as everyone is familiar with the basic definitions, and it takes unnecessary space. However, the authors should provide its operational definition specific to this study in methods. This would ensure the reader that the measurement of the outcome variable was valid.
The 2^nd and 3^rd sentences, paragraph 1, tell almost the same thing and should be combined.
The 5^th sentence, paragraph 1: consider, “Childhood diarrhea is associated with multiple factors, including…”
The writing quality makes the background very confusing. For example, the authors stated that, in 2016, 20/5,947 (0.34%) total neonatal deaths were due to diarrhea; 672/5,248 post-neonatal deaths were due to diarrhea (13%); and 692 deaths of children under five due to diarrhea (6%). These are hard to understand – how were ‘neonatal deaths, post-neonatal deaths, and under-five child deaths’ defined? Was it possible that the age groups can be overlapping? The authors continued by stating that “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.” One-fifth means 20%, which is much higher than any percentages mentioned above.
The rationale of study is also relatively weak. For example, the authors stated that, “It is of great importance to understand the factors related to the prevalence of diarrhea among children aged 12 to 35 months.” Please elaborate why it is important to study diarrhea among children in this age group. This should also be explained in the methods (study population).
The study’s objective is missing. Please provide a clear objective at the end of the introduction.

Methods

Sampling procedures: it is great that the authors described the CDHS-2014’s sampling methods. However, the reader needs the information on how the research team reached children aged 12 to 35 months, this study’s population.
Please provide operational definition of diarrhea used in the CDHS 2014. This would ensure the reader that the measurement of the outcome variable was valid.
I understand that the sample size was sufficiently large to address the research question. However, it would make more sense to mention minimum required sample size calculation, rather than saying that “The final sample size comprised 2,828 children aged 12 to 35 months, providing a suitable degree of power (0.9627, 0.9682),” which was not understandable.
Statistical analyses: The sentence, “Any independent variables significant at p<0.25 were entered into the initial model” is inaccurate and incomplete. Consider: “Variables associated with diarrhea in bivariate analyses at a level of p<0.25 were included in the initial model.”

Also, what did ‘the initial model mean?’

Later, the authors mentioned, “Finally, a multivariable analysis was performed using…” This confused the reader – was the earlier-mentioned model different from the multivariable analysis (model)?

Results

The 1^st sentence is redundant with that in methods (CDHS 2014 description).
The result presentation style (mean ± SD) has not been recommended for use since long ago. Please use ‘mean (SD xx)’ format.
Much of the bivariate results presentation only repeated the data analysis methods. The authors better keep the space to clarify the direction of the bivariate associations.
The way p-values are presented in tables does not follow a standardized format in scientific/academic papers.

Discussion

The discussion section is superficial, mostly only compared this study’s findings to those from the literature without in-depth discussions of the key findings and their policy implication.
Conclusions and recommendations should be combined. The recommendations can be summarized to the extent to which this study’s findings can support.

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Epidemiology, community-based intervention and evaluation, infectious diseases

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Author Response

23 Sep 2021

PISEY VONG, Doctor of Public Health Program, Faculty of Public Health, Khon Kaen University, Khon Kaen, 40002, Thailand

Thank you so much for your valuable comments to improve the quality of our paper.
#Response to reviewer: Siyan Yi

Abstract
1. When talking about health-related issues in children, please be specific about age groups.
The term ‘childhood diarrhea’ is too broad, while diarrheal diseases commonly affect younger children.
Reply: Taken care

2. The first sentence in background is not very accurate and can be simplified as follows:
“Diarrheal diseases remain the leading cause of death among under-five children in lower and lower-middle-income countries.”
Reply: Taken care

3. Methods: “We analyzed cross-sectional data from the Cambodia Demographic and Health Survey 2014 using combined household and children’s datasets.”
Reply: Taken care

4. Results: The 1st sentence: “The survey included 2,828 children aged 12 to 35 months.” and the 3rd sentence: “Factors significantly associated with childhood diarrhea were…” - Please correct the misuse and inconsistent use of punctuation.
Reply: Taken care

5. Conclusions: The 2^nd sentence only repeats the results. Please summarize the key findings without redundancies. Recommendations can be simplified, avoiding unnecessary wording: “Intervention programs should focus on reducing diarrheal diseases by constructing improved toilet facilities and promoting behavior to improve hygiene, specifically targeting younger mothers.”
Reply: Taken care

6. Keywords can also be improved.
Reply: Taken care: Prevalence, Child, Diarrhea, Cross-Sectional Study, Cambodia

Introduction
The writing quality of the introduction needs substantial improvement. I am trying to help, but it is difficult and time-consuming. Here are some examples:

1. The 1^st sentence: the definition of diarrhea is not very important in the background as everyone is familiar with the basic definitions, and it takes unnecessary space. However, the authors should provide its operational definition specific to this study in methods. This would ensure the reader that the measurement of the outcome variable was valid.
Reply: Taken care.

2. The 2^nd and 3^rd sentences, paragraph 1, tell almost the same thing and should be combined.
A: Taken care

3. The 5^th sentence, paragraph 1: consider, “Childhood diarrhea is associated with multiple factors, including…”
Reply: Taken care

4. The writing quality makes the background very confusing. For example, the authors stated that, in 2016, 20/5,947 (0.34%) total neonatal deaths were due to diarrhea; 672/5,248 postneonatal deaths were due to diarrhea (13%); and 692 deaths of children under five due to diarrhea (6%). These are hard to understand – how were ‘neonatal deaths, post-neonatal deaths, and under-five child deaths’ defined? Was it possible that the age groups can be overlapping? The authors continued by stating that “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.” One-fifth means 20%, which is much higher than any percentages mentioned above.

Reply: Taken care

4.1. Neonatal death: Probability of dying during the first 28 days of life
Post-neonatal deaths: Probability of dying between 28 and 364 days of age
Under-five death: Probability of dying between birth and exactly 5 years of age
Sources: https://data.unicef.org/topic/child-survival/neonatal-mortality/ and
https://www-doh.state.nj.us/doh-shad/view/sharedstatic/PostneonatalMortalityRate.pdf

4.2. The authors can confirm that the age groups cannot be overlapping.

4.3. “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.” is the report from UNICEF year 2014; however, “in 2016, 20/5,947 (0.34%) total neonatal deaths….” is the report from UNICEF year 2018. Therefore, the authors would like to reverse the sentence as following:

“According to report from UNICEF Cambodia year 2014, 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. However, according to report from UNICEF year 2018, by year 2016 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%).”

5. The rationale of study is also relatively weak. For example, the authors stated that, “It is of great importance to understand the factors related to the prevalence of diarrhea among children aged 12 to 35 months.” Please elaborate why it is important to study diarrhea among children in this age group. This should also be explained in the methods (study population).
Reply: Taken care

6. The study’s objective is missing. Please provide a clear objective at the end of the introduction.
Reply: Taken care

Methods
1. Sampling procedures: it is great that the authors described the CDHS-2014’s sampling methods. However, the reader needs the information on how the research team reached children aged 12 to 35 months, this study’s population.
Reply: Taken care: In our analysis, we included only children aged 12 to 35 months (n=2,828) due to the high prevalence of diarrhea among this aged group while comparing with other age groups and this age period is known to affect for child development and growth.”

2. Please provide operational definition of diarrhea used in the CDHS 2014. This would ensure the reader that the measurement of the outcome variable was valid.
Reply: Taken care.

3. I understand that the sample size was sufficiently large to address the research question. However, it would make more sense to mention minimum required sample size calculation,
rather than saying that “The final sample size comprised 2,828 children aged 12 to 35
months, providing a suitable degree of power (0.9627, 0.9682),” which was not
understandable.
Reply: The authors used secondary data for this study; so, authors should test for the power of its sample size whether it is sufficient for this study analysis. This following paper is also performed https://bmjpaedsopen.bmj.com/content/5/1/e000992 the power to clarify its sufficiency. According to our analysis it is unable to show how minimum the sample size is.

4. Statistical analyses: The sentence, “Any independent variables significant at p<0.25 were entered into the initial model” is inaccurate and incomplete. Consider: “Variables associated with diarrhea in bivariate analyses at a level of p<0.25 were included in the initial model.”
Reply: Taken care
Also, what did ‘the initial model mean?’
Reply: Taken care. Multivariable model
Later, the authors mentioned, “Finally, a multivariable analysis was performed using…” This confused the reader – was the earlier-mentioned model different from the multivariable analysis (model)?
Reply: Taken care. It is the same

Results
1. The 1^st sentence is redundant with that in methods (CDHS 2014 description).
Reply: Taken care

2. The result presentation style (mean ± SD) has not been recommended for use since long ago. Please use ‘mean (SD xx)’ format.
Reply: Taken care

3. Much of the bivariate results presentation only repeated the data analysis methods. The authors better keep the space to clarify the direction of the bivariate associations.
Reply: Taken care

4. The way p-values are presented in tables does not follow a standardized format in scientific/academic papers.
Reply: We think reviewer suggest to present p-value in each group. We agree with the reviewer if our research question in which the variable has stratified group i.e. Whether age group of each gender associated on Outcome (Y) or not. Then, we must stratify group of each age group and gender; after that we will present each p-value in each group. In our research question, we better to present p-value of each factor because we would like to know each factor. Therefore, the authors have retained our originals.

Discussion

1. The discussion section is superficial, mostly only compared this study’s findings to those from the literature without in-depth discussions of the key findings and their policy implication.
Reply: Taken care

2. Conclusions and recommendations should be combined. The recommendations can be summarized to the extent to which this study’s findings can support.
Reply: Taken care

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

45 Views

15 Jun 2020 | for Version 1

45 Views Cite this report Responses(1)

Approved With Reservations

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

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

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
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Epidemiology, community-based intervention and evaluation, infectious diseases

Respond to this report

Responses (1)

Author Response

03 Jul 2020

PISEY VONG, Office of Rural Health Care, Pursat Provincial Department of Rural Development, Ministry of Rural Development, Cambodia

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:
- "...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.

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:
- 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...

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.

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Competing Interests

No competing interests

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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

Abstract

Keywords

Revised Amendments from Version 2

Introduction

Methods

Ethical statement

CDHS 2014

Data use

Dependent variable

Independent variables

Table 1. Joint Monitoring Programme classification of improved and unimproved water, sanitation and hygiene (WASH)30.

Table 2. Joint Monitoring Programme classification of sanitary and unsanitary disposal of children stool31.

Statistical analysis

Results

Table 3. Socio-demographic and environmental characteristics of households in Cambodia, 2014 (n=2,828).

Bivariate analysis of factors associated with childhood diarrhea in Cambodia

Table 4. Bivariate analysis of factors associated with childhood diarrhea in Cambodia, 2014 (n=2,828).

Multivariate analysis of factors associated with childhood diarrhea in Cambodia

Table 5. Multivariate analysis of factors associated with childhood diarrhea in Cambodia, 2014 using generalized mixed linear model (n=2,828).

Discussion

Conclusion

Recommendations

Data availability

Acknowledgements

References

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Table 1. Joint Monitoring Programme classification of improved and unimproved water, sanitation and hygiene (WASH)³⁰.

Table 2. Joint Monitoring Programme classification of sanitary and unsanitary disposal of children stool³¹.