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Background  Diarrheal disease is still one of the most common causes of mortality and morbidity in children under five in developing countries, including Ethiopia. Lack of specific data on the prevalence of acute diarrhea and associated factors among under-five children in the semi-urban areas of Gelsha, found in northeastern Ethiopia’s South Wollo zone, remains a major gap. Therefore, this study was designed to provide data that is important for proper planning of intervention measures to reduce the problem in this area.    Methods  A community-based cross-sectional study was conducted among 340 systematically selected children under five in semi-urban areas of Gelsha from January to March 2019. The data was collected using a structured questionnaire and an observational checklist. Bivariable (crude odds ratio [COR]) and multivariable analysis (adjusted odds ratio [AOR]) were employed using binary logistic regression model with 95% CI (confidence interval). Variables with a  p- value < 0.05 from the multivariable analysis were declared as factors significantly associated with acute diarrhea.    Result  The prevalence of acute diarrhea among children under five in the study area was 11% (95%CI: 7.8–14.3%). About two-thirds (63.60%) of study participants used water from improved sources. About half (54.90%) of study participants practiced poor handwashing and 45.10% practiced good handwashing. We found that factors significantly associated with acute diarrhea were a child’s age of 12–23 months (AOR = 4.68, 95% CI: 1.45–1.50), the presence of two or more under-five children in the house (AOR = 2.84, 95% CI: 1.19–6.81), unimproved water sources (AOR = 2.97, 95% CI: 1.28–6.87) and presence of feces around the pit hole/slab/floor of the latrine (AOR = 3.34, 95% CI: 1.34–8.31).    Conclusion  The prevalence of acute diarrhea among children under five was relatively high. To reduce the problem, various prevention strategies are essential, such as the provision of health education to mothers/caregivers that focuses on keeping sanitation facilities clean and child care, and construction of improved water sources. Furthermore, implementing a strong health extension program, advocating an open defecation-free environment, and practicing a community-led total sanitation and hygiene approach might be helpful to sustainably reduce childhood diarrhea.    Supplementary Information  The online version contains supplementary material available at 10.1186/s12887-021-02762-5.

Prevalence of acute diarrhea and associated factors among children under five in semi-urban areas of northeastern Ethiopia