Authors: Lidetu Demoze, Awrajaw Dessie, Jember Azanaw, Gelila Yitageasu, Kidist Asrat, Zemichael Gizaw
Categories: Research, Comorbidity, Diarrhea, Respiratory infection symptoms, Gondar, Ethiopia
Source: Italian Journal of Pediatrics
Authors: Lidetu Demoze, Awrajaw Dessie, Jember Azanaw, Gelila Yitageasu, Kidist Asrat, Zemichael Gizaw
Childhood morbidity is frequently characterized by more than one health condition. Children under the age of five in low- and middle-income countries including Ethiopia experience multiple episodes of diarrhea and respiratory infection symptoms. However, there have been limited studies on comorbidities of diarrhea and respiratory infection symptoms. In addition, most studies conducted in Ethiopia seek separate outcomes for diarrhea and respiratory infection symptoms. Therefore, this study aimed to determine the prevalence of diarrhea and respiratory infection symptoms comorbidity, and associated factors among under-five children in Gondar City.
Community-based cross-sectional study was conducted in Gondar City among under-five children from April 05 – May 04, 2023. Multi-stage sampling technique was used to collect a sample of 836. A structured questionnaire was employed through an interview-administered method for data collection at participants’ homes. Bivariable and multivariable binary logistic regression analyses were undertaken to identify predictors of childhood comorbidity of diarrhea and respiratory infection symptoms.
The comorbidity prevalence of diarrhea and respiratory infection symptoms in under-five children was 17.22% [CI: 14.8%-19.9%]. Mothers/caretaker age < 25 years (AOR = 3.52 at 95% CI:1.64,7.5), mothers/caretakers who had no formal education (AOR = 4.42 at 95% CI: 2.08,9.9.40), family size > 5 (AOR = 4.52 at 95% CI: 2.13,9.61), second birth order (AOR = 2.67 at 95% CI: 1.31,5.41), children playground not clean(AOR = 2.19 at 95% CI:1.01,4.71), started supplementary feeding at age > 6 months (AOR = 4.51 at 95% CI:1.50,13.58), mothers/caretakers who didn’t wash their hands after visiting latrine (AOR = 2.03 at 95% CI: 1.03,4.03), mothers/caretakers who didn’t wash their hands with soap and water (AOR = 1.92 at 95% CI: 1.00,3.69) were significantly associated factors with under five children comorbidity of diarrhea and respiratory infection symptoms.
According to the findings, the prevalence of diarrhea and respiratory infection symptoms comorbidity was higher and variation in the amount of comorbidity is explained by maternal and child predictors. Educating mothers/caregivers about hand washing, sanitation, hygiene, and supplementary feeding is a key approach for the prevention and control of comorbidities in children.
Childhood morbidity is frequently characterized by more than one health condition [1]. Globally, pneumonia which is the main complication of Acute respiratory infection (14%) and diarrhea (14%) kills more children under the age of five than Human Immunodeficiency Virus (4%), malaria (16%), and measles (1%), combined [2]. Around 40 and 60 percent of children worldwide receive adequate treatment for the symptoms of diarrhea and acute respiratory infections (ARIs), respectively; nonetheless, diarrhea and ARI continue to be the leading causes of death for under five children [3]. According to World Health Organization reports, each year diarrhea takes the lives of more than 525,000 children under five years worldwide [4]. According to a systematic analysis conducted in 2015, approximately 4.4 million children under the age of five will die from infectious diseases such as diarrhea and ARI by 2030, with Sub-Saharan Africa accounting for 60% of these deaths [5]. In addition around 3 billion people use biomass [6] which is attributed to Indoor air pollution causing 1.5 to 2 million deaths per year worldwide, with 1 million occurring in children under the age of five due to ARI [7].
Acute respiratory infections in Sub-Saharan Africa, account for 42% of child fatalities [8] exposure to indoor air pollution during early childhood, impairs lung function and aggravates pre-existing conditions such as asthma [9]. Ethiopian Demographic and Health Survey 2016 found a 4.3 per cent childhood comorbidity of diarrhea and ARI among 9917 under-five children and residence, vaccination, and mother’s education were factors associated with comorbidity [10]. 50,320 infant deaths each year in Ethiopia due to IAP which represents 4.9% of the country’s overall illness burden [11]. EDHS 2016 report says 12% of under-five children experienced diarrhea in the two weeks preceding the survey [12]. Malnutrition and failure to thrive are also well-known risk factors for ARI therefore a causal link between diarrhea and subsequent risk of ARI is biologically plausible [13]. Confections of diarrhea and ARI were extremely common among children under five years of age seeking care due to overlapping risk factors such as poor indoor air environment, inadequate provision of water, hygiene, sanitation, overcrowding, breastfeeding for the first 6 months, socioeconomic status, the type of house the child lived in, the maternal occupation, are common risk factors for two diseases [2, 14]. Due to this factors comorbidity of diarrhea and respiratory infection symptoms diseases are common in under-five children in Africa and specifically, in Ethiopia. Therefore, this study provides insights for healthcare providers, highlighting the specific risks associated with ignoring comorbidities, which can lead to correct prioritization of public health interventions. There is limited evidence on the comorbidity of these two conditions, as most studies examine each condition separately. Accordingly, this study aimed to identify the prevalence of diarrhea and respiratory infection symptoms comorbidity, and associated factors among children under five children in Gondar City, Ethiopia, 2023.
A community-based cross-sectional study was conducted in Gondar City among under-five children between April 05 – May 04, 2023. Gondar City is approximately 734.3 km, from Addis Ababa and about 180 km from Bahir Dar City the capital of the Amhara region [15, 16]. According to the most recent administration report, Gondar has an estimated population of more than 454,446, with 218,378 men and 236,068 women. In the City, there are a total of 41,623 under-five children 20,191 males and 21,432 females. It has six sub-City administration areas comprised of 36 kebeles. The City has nine health centers, one referral hospital, and one general hospital that serves the people of Gondar City and the surrounding area (Fig. 1).Fig. 1Map of the Gondar City, Northwest Ethiopia
The sample size was calculated using a single population proportion formula while keeping the following assumptions in P = 50% of children with comorbidity of diarrhea and respiratory infection symptoms and (no previous study in the study area at the time of the study), 95% confidence interval, 5% margin of error (d), and design effect 2.
\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ n;=\frac{\left({\displaystyle\frac{Z\alpha}2}\right)^2;P(1-P)}{d^2};=;\frac{\left(1.96\right)^{2\ast}0.5^\ast0.5}{0.05^2};=384
By taking 10% of the non-response rate, then the total sample size was 845. The target populations were included in the study using multi-stage sampling technique with a total of two stages (Fig. 2).Fig. 2A Flow chart of the sampling procedures for the selection of study participants in Gondar City, northwest Ethiopia, 2023 ### Data collection tools and procedures Structured and pretested questionnaires were used to collect data. The questionnaire was prepared based on a review of relevant literature [17–20]. The questionnaire was first prepared in English language and translated to the local Amharic language, and back-translated into English to check consistency. Data were collected from mothers/primary caretakers using an interviewer-administered method. The questionnaire includes a total of four parts which include the socio-demographic characteristics, the child’s diarrhea and respiratory infection symptoms, environmental, household and behavioral factors respectively. Data collectors were given two-day training on the tool & exercise it. The questionnaire discussed thoroughly question by question. The data collection process and completeness of data were closely supervised. ### Measurement of study variables Comorbidity was defined as the mother/caretaker self-reported that a child had the occurrence of diarrhea and respiratory infection symptoms together or in a sequential manner [2]. Respiratory infection symptoms were defined as the mother/caretaker self-reported the child had been suffering from cough, shortness of breath, wheezing, phlegm and blocked or running nose in the past two weeks [21]. Diarrhea was defined as the mother/caretaker self-reported that the child had three or more loose or watery stools in 24 h, in the past two weeks before data collection [22]. ### Data processing and analysis All the questionnaires were checked manually for completeness, coded, and entered into EPI info version 7.1.5.2 and exported to Stata version 14.1 software for further analyses. Descriptive analyses were done to describe variables using summary measures, frequencies, figures & tables. Comorbidity of diarrhea and respiratory infection symptoms evaluated by running binary logistic regression. Then explanatory variables with a *P*-value < 0.20 in bivariable logistic regression were analyzed in multivariable regression. The degree of association between outcome & explanatory variables was assessed using odds ratios and a 95% confidence interval. Independent Variables with a *p*-value < 0.05 in multivariable regression are considered statistically significant. Finally, the multi-collinearity of variables was assessed by calculating the Variance Inflation Factor (VIF). Additionally, the Goodness of fit of the model was checked by Hosmer and Lemeshow. ## Results ### Socio-demographic characteristics of mothers/caretakers A total of 836 participants were enrolled in this study, with a response rate of 98.93%. Seven hundred seventy-nine (93.18%) were female caretakers and fifty-seven were male caretakers (6. 82%), the median age is 29. The majority (87.44%) of study participants were Orthodox Christian in religion followed by Muslims (9.69%). Five hundred eighteen (61.96%) of caretakers were housewives (Table 1). Table 1Socio-demographic characteristics of mothers/caretakers in Gondar City between March –April 2023(*n* = 836)**Variable ****Category**** Frequency(n)****Percent(%)****Sex **Female77993.18Male576.82 **Age **<2519122.8525-2719323.0928-3115218.18≥3230035.89**The median age of the mother/caretaker is 29 ± 7.63(SD)****Religion **Orthodox73187.44Muslim819.69Other*242.87**Marital status **Married71986.00Divorced465.50Other **718.50**Educational status **No12314.71Primary26331.46Secondary and above45053.83**Education status of the spouse**No9111.65Primary21627.66Secondary and above47460.69**Average monthly ****Income(Ethiopian Birr)**1000-487621325.484877-564320624.645644-800024329.07≥800117420.81**Occupation of mother **Housewife51861.96Farmer80.96Student242.87Private11213.40Government13215.79Merchant313.71Other***111.32**Occupation of spouse**Farmer111.42Student70.90Private48662.71Government19024.52Merchant536.84Other***283.61**House ownership**Private/owned22927.39Rent from kebele718.49Rent from private53063.40Neither60.72**Family size **≤5 persons63876.32> 5 persons19823.68**Relation of the Respondent to the child**Mother74889.47Caretaker8810.53**Number of rooms **One51361.36Two19122.85Three and above13215.79**Separate bedroom**No60772.61Yes22927.39**Separate kitchen **No59871.53Yes23828.47Others* = Protestant, Jewish, or CatholicOther**=single, separated, widowedOthers*** = daily laborer, driver, or priest ### Child-related socio-demographic factors Of the 836 under five children, the majority, 255 (30.50%), were between 48 and 59 months old, while 243 (29.07%) were between 24 and 35 months. Four hundred thirty (51.44%) were males and four hundred six (48.56%) were females (Table 2). Table 2Child-related socio-demographic factors in Gondar City between March–April 2023(*n* = 836)VariableCategoryFrequency(n)Percent (%)**Age in month** < 128710.4112–23799.4524–3524329.0736–4717220.5748–5925530.50**Sex**Male43051.44Female40648.56**Birth order of a child**First33039.47Second26932.18Third11213.40Fourth819.69Fifth and above445.26**Number of under-five children in the household**One57168.30Two24629.43Three or more192.27 ### Housing characteristics and latrine facility status Only a few households (6.94%) have kitchen exhaust and the majority of the households six hundred seventy-one (80.26%) constructed their house with mud and less than one-fifth (19.14%) constructed their house with the concert. More than three-fourths (88.28%) of the households have latrine facilities from this majority of facilities were pit latrines with slab (79.89%) and (85.77%) households have shared latrine facilities and less than one-fifth (18.78%) of the household have hand washing facilities. (79.19%) household practice cooking inside the house (Table 3). Table 3Housing characteristics and latrine facility status in Gondar City between March –April 2023(*n* = 836)VariableCategoryFrequency(n)Percent (%)**Kitchen exhaust**No77893.06Yes586.94**No functional windows**None809.57One56467.46Two14717.58 ≥ Three455.38**Floor construction mud**No16519.74Yes67180.26**Floor construction materials concrete**No67680.86Yes16019.14**Floor construction brick**No81597.49Yes212.51**Wall surface water base paint**No34040.67Yes49659.33**Ceiling surface**Wooden66279.19Painted17420.81**Damp stains**No27833.25Yes55866.75**Visible mold**No35141.99Yes48558.01**Cooking**Inside66279.19Outside17420.81**Hand washing facility**No67981.22Yes15718.78**Latrine**No9811.72Yes73888.28**Type of latrine**Flush to septic tank516.93Flush to pit latrine253.40VIP719.65Pit with slab58178.94Pit without slab81.09**The proximity of the latrine from home**1–9 m55074.46 ≥ 10 m18825.54**Faeces around the pit hole**No21328.92Yes52571.08**Faeces around the compound**No52763.04Yes30936.96**If the household has no latrine where do they dispose of the human waste**Open field8687.76Other*1212.24**Ownership of latrine**Private10514.23Shared63385.77**Child playground**Not clean61573.56Clean22126.44Other* = Buried underground, plastic bags ### Waste disposal and water-related characteristics of the respondents More than half (58.37%) of household uses a garbage can for waste disposal and eight hundred (95.69%) have improved water source (Table 4). Table 4Waste disposal and water-related characteristics in Gondar City between March –April 2023(*n* = 836)VariableCategoryFrequency(n)Percent (%)**Waste disposal**Pit141.67Open26832.06Burning495.86Garbage48858.37Other*172.03**Waste Collection container**Plastic78593.90Iron20.24Jerry can404.78Other**91.08**Source of water supply**Improved80095.69Unimproved364.31**Daily requirements of water**< 20 litters526.22≥ 20 litters78493.78**How long it takes to reach the water source(round trip)**< 15 min76591.51≥ 15 min718.49Other* = Dispose into the riverOther** = pot ### Childhood diarrheal diseases and respiratory infection symptoms comorbidity in Gondar City The prevalence of diarrhea among under-five children was 24.64% and the prevalence of respiratory infection symptoms among under-five children was 35.29%. ### The comorbidity prevalence of diarrhea and respiratory infection symptoms among under-five children The comorbidity prevalence of diarrhea and respiratory infection symptoms at a 95% confidence interval was 17.22% [CI: 14.8%-19.9%] (Fig. 3).Fig. 3The comorbidity prevalence of diarrhea and respiratory infection symptoms (cough, phlegm, shortness of breath, wheezing and runny nose) among under-five children in Gondar City, northwest Ethiopia, 2023 ### Determinants of comorbidity among under-five children On bivariable analysis, the age of the mother/caretakers, educational status of mother/caretaker, educational status of spouse, average monthly income, family size, number of rooms, birth order, separate bedroom, child sex, kitchen cleanse, a father with asthma, charcoal, smoking in the building, cleaning frequency, hand washing facility, kitchen floor, flies observed around the latrine facilities, refuse disposal, child playground, uncollected garbage, exposure to animal allergens in past, supplementary feeding, breastfeeding status, feed powder milk, feeding with hand, wash hand before food preparation and eating, wash hand after feeding child, wash hand after visiting latrine, wash with soap and water and wash hand with only water were significantly associated with comorbidity of diarrhea and respiratory infection symptoms. Finally, on multivariable analysis, the age of mothers/caretakers < 25 years, educational status of mothers/caretakers, birth order, family size, child playground, supplementary feeding, hand washing with soap and water, and hand washing after visiting latrine were significantly associated with under-five children’s comorbidity of diarrhea and respiratory infection symptoms. Under-five children whose mothers/caretakers age < 25 years were 3.52 times more likely to develop comorbidity than those whose age was higher and more mature (AOR = 3.52 at 95% CI: 1.64, 7.55). Under-five children whose mothers/caretakers had no education were 4.42 times more likely to encounter comorbidity than those who enrolled in secondary and above formal educations (AOR = 4.42 at 95% CI: 2.08, 9.40). Households with family size greater than five were 4.52 times more likely to develop comorbidity of children under five years than their counterparts (AOR = 4.52 at 95% CI: 2.13,9.61). Under five children whose birth order is second were 2.67 times more likely to encounter comorbidity than those with first orders (AOR = 2.67 at 95% CI: 1.31, 5.41). Under five children whose playground is not clean were 2.19 times more likely to develop comorbidity than their counterparts (AOR = 2.19 at 95% CI: 1.01, 4.71). Under-five children who started supplementary feeding at an age greater than 6 months were 4.51 times more likely to develop comorbidity than their under-five children who started supplementary feeding at 6 months and lower (AOR = 4.51 at 95% CI:1.50,13.58). Under five children whose mothers/caretakers didn’t wash their hands after visiting latrine regular basis, their children were 2.03 times more likely to develop comorbidity than their counterparts (AOR = 2.03 at 95% CI: 1.03,4.03). Under five children whose mothers/caretakers didn’t wash their hands with soap and water their children were at 1.92 times higher risk of encountering comorbidity than those who wash their hands with soap and water regularly (AOR = 1.92 at 95% CI: 1.00,3.69) (Table 5). ## Bi-variable and multi-variable binary logistic regression analysis of associated factors with comorbidity Table 5Factors associated with under-five children comorbidity of diarrhea and respiratory infection symptoms in Gondar City northwest Ethiopia, 2023Child with ComorbidCOR (CI%95)AOR (CI%95)VariablesCategoriesNoYesAge of mother/caretaker < 2525–2728–31 ≥ 32132170126264592326363.27(2.06,5.21)0.99(0.56,1.80)1.51(0.87,2.61)13.52(1.64,7.55) *1.54(0.66,3.63)2.03(0.94,4.38)1Educational status of mother/caretakerNoPrimarySecondary and above692134105450403.33(2.08,5.33)10.41(0.26,0.65)4.42(2.08,9.40)*10.85(0.42,1.72)Educational status of spouseNoPrimarySecondary and above721684081948660.92(0.50,1.68)10.56(0.37,0.85)0.87(0.34,2.19)11.29(0.66,2.50)Average monthly income (Ethiopian Birr)1000–48764877–56435644–8000 ≥ 8001166156213157475030172.61(1.44,4.74)2.96(1.63,5.35)1.30(0.69,2.44)10.75(0.30,1.86)1.74(0.72,4.16)1.46(0.61,3.46)1Family size ≤ 5 > 5557135816313.20(2.19,4.68)14.52(2.13,9.61) *Number of under fiveOneTwoThree and more4692101310236610.78(0.52,1.19)2.12(0.79,5.71)10.56(0.30,1.07)1.51(0.33,6.82)Number of roomOneTwoThree and above41316111810030141.29(.83,2.03)10.63(0.32,1.25)0.76(0.33,1.74)11.42(0.52,3.92)Birth orderFirstSecondThirdFourthFifth and above28420793693946621912511.84(1.21,2.81)1.26(0.70,2.26)1.07(0.53,2.13)0.79(0.29,2.11)12.67(1.31,5.41) *1.23(0.46,3.31)0.32(0.09,1.09)0.25(0.05,1.14)Separate bedroomNoYes493299114301.53(0.99,2.36)11.42(0.60,3.39)1Child sexMaleFemale34734583611.35(0.94,1.94)11.41(0.81,2.46)1Kitchen cleanseCleanNot clean488204697512.60(1.80,3.74)11.62(0.86,3.04)Father with asthmaNoYes665271321212.23(1.10,4.53)12.04(0.63,6.55)CharcoalNoYes1925002312112.02(1.25,3.25)11.06(0.46,2.46)Smoking in the buildingNoYes637551152912.92(1.78,4.77)11.78(0.78,4.09)Cleaning frequencyOne timeTwo timesThree times > 3 times331279641874462131.35(0.90,2.02)11.99(1.11,3.56)1.01(0.28,3.56)1.03(0.53,2.02)12.01(0.79,5.10)1.72(0.24,12.3)Hand washing facilityNoYes552140127171.89(1.10,3.24)10.78(0.32,1.86)1Kitchen floorClay & mudCementOther576104121221571.34(0.76,2.36)13.75(1.28,10.9)0.83(0.32,2.12)12.15(0.40,11.57)Flies observed around the latrine facilitiesNoYes2264391512214.18(2.39,7.39)12.15(0.95,4.86)Refuse disposalPitOpenBurningGarbage canOther1221239419102561069711.58(0.34,7.28)1.53(0.29,8.01)0.98(0.21,4.51)4.2(0.70,24.94)10.21(0.03,1.40)0.26(0.03,2.19)0.31(0.05,1.91)0.54(0.05,5.38)Child playgroundNot cleanClean484208131134.33(2.39,7.83)12.19(1.01,4.71) *1Uncollected garbage/solid wasteNoYes1795131113314.21(2.22,7.98)11.43(0.58,3.54)Exposure to animal allergens in pastNoYes641511261811.79(1.01,3.17)11.12(0.44,2.87)Supplementary feeding < 6 month = 6 month > 6 month11144813311458811.01(0.50,2.02)6.67(3.39,13.1)11.40(0.47,4.18)4.51(1.50,13.58) *Breastfeeding statusExclusivePartialNot21214457565741.47(0.53,4.02)1.87(1.29,2.71)11.87(0.32,10.75)1.69(0.94,3.02)1Feeding the child powder milkNoYes551141126181.79(1.05,3.03)10.91(0.40,2.06)1Feeding the child with a handNoYes1605321213213.30(1.78,6.13)11.30(0.44,3.80)Wash hands before food preparation and eatingNoYes6762546984.37(2.84,6.74)11.86(0.80,4.29)1Wash hands after feeding the childNoYes143549421021.58(1.05,2.36)11.92(0.85,4.35)1Wash hands after visiting the latrineNoYes257435101433.97(2.69,5.86)12.03(1.03,4.03) *1Wash hands with soap and waterNoYes13655661833.00(2.05,4.39)11.92(1.00,3.69) *1Wash hands with only waterNoYes3193732611813.68(2.36,5.74)11.74(0.95,3.21)*AOR* adjusted odds ratio, *CI* confidence interval, *COR* crude odds ratioHosmer and Lemeshow test = 0.7502 showed that the model was fitted well * = statistically significant at *p* < 0.05 * = statistically significant at *p* < 0.01 * = statistically significant at *p* < 0.001 ### Discussion A community-based cross-sectional study was conducted to determine the prevalence and factors associated with comorbidity of diarrhea and respiratory infection symptoms among under-five children in Gondar City. Children who experienced both diarrhea and respiratory infection symptoms have a prevalence of 17.22% which is higher than the previous study conducted in Ethiopia EDHS 4.6% [10] and Kenya DHS(2.2%) [2] children had comorbidity from diarrhea and ARI respectively. Similarly, the prevalence was higher than Ghana and Congo DHS having a comorbidity of diarrhea and ARI was 11% and 3.9% consecutively [23, 24]. Similarly, Adedokun’s [25] Nigerian study found that 9% of under-five children had comorbidity. In addition, the prevalence was higher than the study conducted in Myanmar which was 3.7% [26]. Our finding was comparable with a scoping review from 6 studies stating that the prevalence of multimorbidity among under-five children in sub-Saharan African countries ranged from 1.2% to 24.8%. The overall prevalence in our finding shows a higher burden of experiencing both diarrhea and respiratory infection symptoms than the previously done research. This could be because the current study mainly includes City inhabitants since City slum areas are often characterized by poor sanitation, overcrowding, and limited access to clean water and healthcare [27]. Furthermore, there is a difference in sociodemographic characteristics, and environmental factors such as climate and geographical differences because most of them are based on country-wide surveys [28]. Finally, a recall period of 2 weeks for diarrhea and 12 months for respiratory infection symptoms would lead the child to experience an enormous amount of respiratory infection symptoms which increases the chance of the child having comorbidity. The prevalence of diarrhea and respiratory infection symptoms was 24.28% and 35.29% respectively. Diarrhea and respiratory infection symptoms prevalence were comparable with the study conducted in eastern and northern Ethiopia at 22.5% and 22.1% [29, 30] and the study conducted in Gondar City at 37.5% respectively [31]. The prevalence of diarrhea was lower in comparison to a study conducted in the Southern part of Ethiopia 30.5% [32] and Northern part of Ethiopia almost half or 54% [33] of under-five children have diarrhea and higher in comparison to the studies conducted in other Ethiopia regions kamashi, farta and Addis Ababa 14.5%,16.7% and 11.9% respectively [34–36]. The prevalence of respiratory infection symptoms was lower in comparison to the studies conducted in India [37, 38] and higher than the study conducted previously in Gondar University Hospital pediatrics ward and Addis Ababa consecutively [11, 39]. We observed that children whose mothers/caretakers had no education their children more likely they have both conditions many findings also suggest this [2, 10, 25, 32, 40]. This is most likely due to a combination of circumstances like mothers/caretakers who had no formal education may be unaware of how to prevent diarrhea and ARI. For example, she/he is unaware of the significance of nursing, basic hygiene, and vaccination. Children whose mothers/caretakers age between < 25 years are more likely to have morbidity of the two conditions than 25 years and above which is consistent with the finding from Kenya, Iran, and Nigeria [2, 25, 41]. This is due to the reason that older mothers/caretakers have more experience in preventing and managing childhood diseases and taking responsibility than the younger ones for their children. In addition, young women are believed to be fresh to childcare methods and hence lack such experience. Children with second birth order are significantly associated with both conditions. Studies also showed that diarrhea occurrence is related to their birth order [42, 43]. Possible explanations for this association, first, later-born children may not receive as much attention from their parents, which could lead to poorer health outcomes. Secondly, later-born children may be less likely to be breastfed, which is protective against diarrhea and ARI. Children who started supplementary feeding greater than six months high likely to develop these conditions than those who started at 6 months and below, this finding also supported by Feachem published in the Bulletin of the World Health Organization reviews the evidence on the effectiveness of supplementary feeding programs in reducing the incidence and severity of diarrhea diseases in young children [44]. The explanation for this is starting supplementary feeding at 6 months can Improve the immune system and reduce the risk of malnutrition which will lead to a lower chance of getting diarrhea and respiratory infection symptoms than their counterparts. Children with playgrounds not clean have odds of comorbidity much higher than those who have clean playgrounds. This is because filthy surfaces contain infectious germs and this is corroborated by studies that found that poor sanitation and hygiene are linked to intestinal protozoa infections and diarrhea in those under-five in northern Ethiopia, it was also supported by findings from Bangladesh and Côte d’Ivoire [20, 45, 46]. The odds of comorbidity were higher among households that have a family size greater than five and this was consistent with studies from Uganda and Tanzania [47, 48]. The main reason for this is that larger families are more likely to live in crowded conditions, which can increase the risk of infection. Additionally, larger families may have fewer resources to invest in preventive measures, such as hand washing and access to clean water. Mothers/caretakers who didn’t wash their hands after visiting the latrine and those who didn’t wash their hands with soap and water regularly their children were associated with higher odds of experiencing both diarrhea and respiratory infection symptoms. The explanation for this is washing your hands properly with soap and water can help to prevent the spread of germs (like bacteria and viruses) and can help to break the chain of infection and prevent the spread of germs that cause these diseases. Other findings from developing countries like Bangladesh, Benin, Burkina, Faso Cambodia, Ghana, India, and Kenya also claim that hand hygiene interventions can reduce the incidence of diarrhea by 23% to 48% and the incidence of respiratory infections by 15% to 35% in schoolchildren in developing countries [49]. Studies from the University of Gondar Comprehensive Specialized Hospital and Lao People’s Democratic Republic supported this evidence stating that effective hand washing can prevent both diarrhea and ARI incidence [39, 50]. Even though this study did not find a significant relationship between income level breastfeeding status, kitchen floor, latrine availability, ownership of a latrine, the number of under-five, waste disposal method, and water source, other studies found that there is a significant association between getting sick for children with diarrhea and ARI with these factors [22, 42, 51–53]. ## Conclusion In this study, the prevalence of diarrhea and respiratory infection symptoms was relatively high in Gondar City. The independent predictors for comorbidity of diarrhea and respiratory infection symptoms are the mother/caretaker’s age, mother/caretaker’s education, child age, birth order, family size, supplementary feeding, and child playground, kitchen cleanses and hand hygiene practice. Preventive measures targeting both conditions simultaneously offer significant healthcare benefits for under-five populations.