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Terefe B, Assimamaw NT, Chekole B. Individual and community level factors of safe child feces disposal among youngest children in East Africa: a multilevel modeling analysis using recent national demography and health survey data. Arch Public Health 2024; 82:109. [PMID: 39026362 PMCID: PMC11256366 DOI: 10.1186/s13690-024-01335-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 06/29/2024] [Indexed: 07/20/2024] Open
Abstract
BACKGROUND The Joint Monitoring Program (JMP) for water supply and sanitation developed by the WHO and UNICEF defines safe child feces disposal practices as either burial or defecation into a toilet. Children become exposed to fecal-oral illnesses when their stools are not disposed of appropriately, and this vulnerability persists until all children's stools are properly disposed of. Data on the elements influencing child feces disposal in East Africa is scarce. Hence, this study aimed to assess the prevalence and associated factors of safe child feces disposal in East Africa. METHODS Data from the Demographic and Health Surveys, which were collected between 2015 and 2022 in 10 East African nations, were used in this analysis. For a weighted 44,821 children under the age of two, we examined additional features as well as how child feces were disposed of. Both bivariable and multivariable multilevel logistic regression were carried out to choose potential components and identify important explanatory variables connected to the outcome variable. With 95% confidence intervals, adjusted odd ratios (AORs) were used to present the results. P values of ≤ 0.2 and < 0.05 were used to investigate significant factors in the binary and multivariable multilevel logistic regression models respectively. RESULTS Approximately 65.54% (95% CI: 65.10, 65.98) of children's waste was disposed of properly. Women age from 35 to 49 years (AOR = 1.12, 95% CI: 1.05-1.19) 15-24 years old, primary (AOR = 1.62, 95% CI, 1.53,1.72), and secondary/higher education (AOR = 1.22, 95% CI, 1.14,1.31), women from highly educated community (AOR = 1.33, 95% CI, 1.22,1.46), employed (AOR = 1.29, 95% CI, 1.24,1.35), poorer(AOR = 1.51,95% CI, 1.42,1.61), middle(AOR = 1.67, 95% CI, 1.56,1.78), richer(AOR = 1.96,95% CI, 1.82,2.11), and richest(AOR = 2.08, 95% CI, 1.91,2.27), mass media exposure (AOR = 1.37,95% CI,1.31,1.44), community level mass media exposure (AOR = 1.23, 95% CI, 1.34,1.34), had ANC visit(AOR = 1.71, 95% CI, 1.55,1.88), modern contraceptive(AOR = 1.17, 95% CI, 1.12,1.23), health institution delivery (AOR = 2.22, 95% CI, 2.09,2.34), had an improved toilet facility (AOR = 1.12, 95% CI, 1.07,1.17), children who's their age group from 6 to 11 months old, (AOR = 2.12, 95% CI, 2.01,2.25) and 12-23 months old (AOR = 3.10,95% CI, 2.94,3.27) were the factors associated with higher odds of safe child feces disposal as compared to less than six months old children respectively. Finally, women from high community poverty level (AOR = 0.87, 95% CI, 0.79,0.95), and rural women were the factors associated with lower odds of safe child feces disposal (AOR = 0.91, 95% CI 0.85-0.98) compared to their counterparts respectively. CONCLUSIONS East Africa has a Slightly lower proportion of properly disposing of child feces. There was a strong correlation between characteristics such as residence, mother's age, education level, work status, place of delivery, ANC visit, child's age, wealth index, media exposure, and poverty. Acting on these factors and strengthening and using links between mother and child health care is, thus, strongly advocated.
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Affiliation(s)
- Bewuketu Terefe
- Department of Community Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Nega Tezera Assimamaw
- Department of Pediatric and Child Health, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Bogale Chekole
- Department of Comprehensive Nursing, College of Medicine and Health Sciences, Wolkite University, Southern, Ethiopia
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Essuman MA, Storph RP, Ahinkorah BO, Budu E, Yaya S. Hygienic Disposal of Children's Stools Practices Among Women of Children With Diarrhoea in Sub-Saharan Africa. ENVIRONMENTAL HEALTH INSIGHTS 2023; 17:11786302231204764. [PMID: 37899844 PMCID: PMC10605691 DOI: 10.1177/11786302231204764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 09/13/2023] [Indexed: 10/31/2023]
Abstract
Background Diarrhoea stools contain infectious agents and pose a public health threat to children and members of the entire family when exposed to them. Therefore, their hygienic disposal is essential. Empirical data are needed to stir the needed public health interventions to encourage or enforce proper disposal practices to curb associated clinical issues. This study assessed the prevalence and correlates of hygienic stool disposal practices by mothers of children with diarrhoea in sub-Saharan Africa (SSA). Methods The Demographic and Health Surveys (DHS) data of 16 sub-Saharan African countries from 2015 to 2021 involving 22 590 mother-child pairs were analysed. Multilevel binary logistic analysis was conducted to assess the individual- and household-level factors associated with the hygienic disposal of stool practices by mothers of children with diarrhoea. The results were presented using adjusted odds ratios (AOR) and 95% confidence intervals (CI) at a statistical significance of P < .05. Results The overall prevalence of hygienic disposal of children's stools among women of children with diarrhoea was 49.01% (95% CI: 48.40-49.62) and ranged from 15.70% in Liberia to 86.6% in Rwanda. The practice of hygienic disposal of stools of children with diarrhoea was likely to increase among mothers who are working (AOR: 1.19; 95% CI: 1.09-1.30), those with partners with primary level of education (AOR: 1.18; 95% CI: 1.06-1.31), Muslims (AOR: 1.69; 95% CI: 1.49-1.91) and widowed/divorced (AOR: 8.94, 95% CI: 3.55-22.53). Again, mothers in the richer (AOR: 1.23; 95% CI: 1.08-1.39) wealth index had increased odds of disposing of stools hygienically compared to those in the poorest wealth index. Women who were 20 years and above, to who belonged to Traditional Religions (AOR: 0.57; 95% CI: 0.43-0.74), and those with unimproved sources of water (AOR: 0.89; 95% CI: 0.82-0.98) and toilet facilities (AOR: 0.63; 95% CI: 0.58-0.69) were less likely to dispose of child's diarrhoea stool hygienically than their counterparts. Conclusion The study reveals that the unhygienic disposal of the stool of children with diarrhoea is prevalent in SSA and requires a concerted effort to curb it. Sanitation practices such as educating mothers about hygienic disposal of children's stool and improving water and sanitation facilities are crucial in lowering the high prevalence of unhygienic disposal of the diarrhoeic stool of children. Additional country-level research is needed to assess children's defecation behaviours and the disposal of diarrhoeic stools using different methodologies.
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Affiliation(s)
- Mainprice Akuoko Essuman
- Department of Medical Laboratory Science, School of Allied Health Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Central, Ghana
| | | | - Bright Opoku Ahinkorah
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Eugene Budu
- Korle Bu Teaching Hospital, Accra, Greater Accra, Ghana
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, ON, Canada
- The George Institute for Global Health, Imperial College London, London, UK
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Islam M, Rahman M, Kafi MAH, Unicomb L, Rahman M, Mertens A, Benjamin-Chung J, Arnold BF, Colford JM, Luby SP, Ercumen A. Assessing sustained uptake of latrine and child feces management interventions: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh 1-3.5 years after intervention initiation. Int J Hyg Environ Health 2023; 250:114149. [PMID: 36913791 PMCID: PMC10186382 DOI: 10.1016/j.ijheh.2023.114149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 01/27/2023] [Accepted: 03/07/2023] [Indexed: 03/15/2023]
Abstract
BACKGROUND Sanitation interventions typically result in modest increases in latrine access, and any gains in latrine access and use are often not sustained over time. Sanitation programs also rarely include child-focused interventions such as potties. We aimed to assess the sustained effect of a multi-component sanitation intervention on access to and use of latrines and child feces management tools in rural Bangladesh. METHODS We conducted a longitudinal substudy nested within the WASH Benefits randomized controlled trial. The trial provided latrine upgrades, child potties and sani-scoops for feces removal, along with behavior change promotion to encourage use of the delivered hardware. Promotion visits to intervention recipients were frequent during the first 2 years after intervention initiation, decreased in frequency between years 2-3, and ceased after 3 years. We enrolled a random subset of 720 households from the sanitation and control arms of the trial in a substudy and visited them quarterly between 1 and 3.5 years after intervention initiation. At each visit, field staff recorded sanitation-related behaviors through spot-check observations and structured questionnaires. We assessed intervention effects on observed indicators of hygienic latrine access, potty use and sani-scoop use and investigated whether these effects were modified by duration of follow-up, ongoing behavior change promotion and household characteristics. RESULTS The intervention increased hygienic latrine access from 37% among controls to 94% in the sanitation arm (p < 0.001). Access among intervention recipients remained high 3.5 years after intervention initiation, including periods with no active promotion. Gains in access were higher among households with less education, less wealth and larger number of residents. The intervention increased availability of child potties from 29% among controls to 98% in the sanitation arm (p < 0.001). However, fewer than 25% of intervention households reported exclusive child defecation in a potty or had observed indicators of potty and sani-scoop use, and gains in potty use declined over the follow-up period, even with ongoing promotion. CONCLUSION Our findings from an intervention that provided free products and intensive initial behavior change promotion suggest a sustained increase in hygienic latrine access up to 3.5 years after intervention initiation but infrequent use of child feces management tools. Studies should investigate strategies to ensure sustained adoption of safe child feces management practices.
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Affiliation(s)
- Mahfuza Islam
- Environmental Intervention Unit, Infectious Disease Division, icddr,b, Dhaka, Bangladesh.
| | - Mahbubur Rahman
- Environmental Intervention Unit, Infectious Disease Division, icddr,b, Dhaka, Bangladesh
| | | | - Leanne Unicomb
- Environmental Intervention Unit, Infectious Disease Division, icddr,b, Dhaka, Bangladesh
| | - Mostafizur Rahman
- Environmental Intervention Unit, Infectious Disease Division, icddr,b, Dhaka, Bangladesh
| | - Andrew Mertens
- Division of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, CA, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, University of California, Berkeley, CA, USA
| | - Stephen P Luby
- Woods Institute for the Environment, Stanford University, Stanford, USA
| | - Ayse Ercumen
- Department of Forestry and Environmental Resources, North Carolina State University, Raleigh, NC, USA
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Demissie GD, Zerihun MF, Ekubagewargies DT, Yeshaw Y, Jemere T, Misganaw B, Tariku A, Atnafu A. Associated factors of safe child feces disposal in sub-Saharan Africa: Evidence from recent demographic and health surveys of 34 sub-Saharan countries. PLoS One 2023; 18:e0281451. [PMID: 36758034 PMCID: PMC9910663 DOI: 10.1371/journal.pone.0281451] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 01/23/2023] [Indexed: 02/10/2023] Open
Abstract
INTRODUCTION Children's feces are thought to pose a greater public health risk than those of adults' due to higher concentrations of pathogens. The aim of this study was to determine the associated factors of safe child feces disposal among children under two years of age in Sub-Saharan Africa. METHODS The most recent demographic and health survey datasets of 34 sub-Saharan countries were used. A total weighted sample of 78, 151 mothers/caregivers of under two children were included in the study. Both bivariable and multivariable multilevel logistic regression were done. The Odds Ratio (OR) with a 95% Confidence Interval (CI) was calculated for each independent variables included in the model. RESULTS Those mothers/caregivers from urban residence (AOR = 1.42; CI: 1.36, 1.48), mothers with primary education (AOR = 1.49; CI: 1.44, 1.56), richer (AOR = 1.78; CI: 1.69, 1.88) and richest wealth quintiles (AOR = 2.17; CI: 2.01, 2.31), family size <5 (AOR = 1.06; CI: 1.02-1.09), access to improved water source (AOR = 1.29; CI: 1.25, 1.34), mothers who owned toilet (AOR = 3.09; 2.99-3.19) and who had media exposure (AOR = 1.19; CI: 1.15, 1.24) had higher odds of practicing safe child feces disposal than their counter parts. However, mothers/care givers who are not currently working (AOR = 0.83; CI: 0.80, 0.86), higher education (AOR = 0.85; CI: 0.76-0.94) and from Western region of Africa (AOR = 0.82; CI: 0.79-0.86) had reduced chance of safe child feces disposal as compared to their counter parts. CONCLUSION Residence, mothers' level of education, wealth index, water source, toilet ownership and media exposure were factors associated with safe child feces disposal. It is advisable to implement health promotion and behavioral change intervention measures especially for those women /caregivers from rural residence, poor economic status, who cannot access improved water and for those with no media exposure to improve the practice of safe child feces disposal.
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Affiliation(s)
- Getu Debalkie Demissie
- Department of Health Education and Behavioral Sciences, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- * E-mail:
| | - Muluken Fekadie Zerihun
- Department of Biochemistry, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Daniale Tekelia Ekubagewargies
- Department of Pediatrics and Child Health Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yigizie Yeshaw
- Department of Human Physiology, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tadeg Jemere
- Department of Biomedical Sciences, College of Health Sciences, Debretabor University, Debretabor, Ethiopia
| | - Bisrat Misganaw
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Tariku
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Asmamaw Atnafu
- Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Formative Research to Design a Child-Friendly Latrine in Bangladesh. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111092. [PMID: 34769612 PMCID: PMC8583528 DOI: 10.3390/ijerph182111092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 11/20/2022]
Abstract
In low- and middle-income countries, most latrines are not accessible to young children. We explored how to modify existing pit latrines to make them child friendly. We conducted four focus group discussions with mothers to explore barriers to child latrine use. We then enrolled 20 households with a child aged 3–7 years old to test six enabling technologies developed based on the identified barriers. Two to three weeks after installing the selected enabling technologies in each household, researchers conducted 19 in-depth interviews with caregivers to explore the technologies’ acceptance and feasibility. Common barriers included the discomfort of squatting on a large pan, fear of darkness, and fear of a slippery floor. Of the potential solutions, a ring to stabilize the child while squatting in the latrine was preferred by children and was affordable and available. A wooden board with a smaller hole than the usual pan reduced fears of falling and helped eliminate discomfort but was inconvenient to handle and clean. A transparent fiberglass roof tile was affordable, available, increased visibility, and kept the latrine floor dry. In conclusion, the fiberglass roof tile and stability ring were two affordable and locally available technologies that facilitated latrine use by children aged 3–7 years.
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Sultana R, Luby SP, Gurley ES, Rimi NA, Swarna ST, Khan JAM, Nahar N, Ghosh PK, Howlader SR, Kabir H, Khan S, Jensen PKM. Cost of illness for severe and non-severe diarrhea borne by households in a low-income urban community of Bangladesh: A cross-sectional study. PLoS Negl Trop Dis 2021; 15:e0009439. [PMID: 34115764 PMCID: PMC8221788 DOI: 10.1371/journal.pntd.0009439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 06/23/2021] [Accepted: 05/03/2021] [Indexed: 01/08/2023] Open
Abstract
The illness cost borne by households, known as out-of-pocket expenditure, was 74% of the total health expenditure in Bangladesh in 2017. Calculating economic burden of diarrhea of low-income urban community is important to identify potential cost savings strategies and prioritize policy decision to improve the quality of life of this population. This study aimed to estimate cost of illness and monthly percent expenditure borne by households due diarrhea in a low-income urban settlement of Dhaka, Bangladesh. We conducted this study in East Arichpur area of Tongi township in Dhaka, Bangladesh from September 17, 2015 to July 26, 2016. We used the World Health Organization (WHO) definition of three or more loose stool in 24 hours to enroll patients and enrolled 106 severe patients and 158 non-severe patients from Tongi General Hospital, local pharmacy and study community. The team enrolled patients between the first to third day of the illness (≤ 72 hours) and continued daily follow-up by phone until recovery. We considered direct and indirect costs to calculate cost-per-episode. We applied the published incidence rate to estimate the annual cost of diarrhea. The estimated average cost of illness for patient with severe diarrhea was US$ 27.39 [95% CI: 24.55, 30.23] (2,147 BDT), 17% of the average monthly income of the households. The average cost of illness for patient with non-severe diarrhea was US$ 6.36 [95% CI: 5.19, 7.55] (499 BDT), 4% of the average monthly income of households. A single diarrheal episode substantially affects financial condition of low-income urban community residents: a severe episode can cost almost equivalent to 4.35 days (17%) and a non-severe episode can cost almost equivalent to 1 day (4%) of household’s income. Preventing diarrhea preserves health and supports financial livelihoods. The illness cost borne by households, known as out-of-pocket expenditure was 74% of the total health expenditure in Bangladesh in 2017. Most of the studies in Bangladesh that estimated the cost of diarrheal illness collected data from hospital patients and mostly targeted under-five children. Information on economic burden of diarrhea borne by households of low-income urban communities who commonly had ≤ 2 US$ dollar income per capita per day still remained unknown. We conducted this study in East Arichpur area of Tongi township in Dhaka, Bangladesh from September 2015 to July 2016 to estimate cost of illness and monthly percent expenditure borne by households due diarrhea in a low-income urban settlement of Dhaka, Bangladesh. The estimated average cost of illness for patient with severe diarrhea was US$ 27.39 (2,147 BDT) and non-severe diarrhea was US$ 6.36 (499 BDT). A single diarrheal episode substantially affects financial capability of the low-income urban community: a severe episode can cost 4.35 days (17%) and a non-severe episode can cost 1 day (4%) of income of a households. Preventing diarrhea preserves health and supports financial livelihoods.
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Affiliation(s)
- Rebeca Sultana
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
- Institute of Health Economics, University of Dhaka, Dhaka, Bangladesh
- icddr,b, Dhaka, Bangladesh
- * E-mail:
| | - Stephen P. Luby
- Stanford University, Stanford, California, United States of America
| | - Emily S. Gurley
- icddr,b, Dhaka, Bangladesh
- John Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | | | | | - Nazmun Nahar
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Sahiledengle B, Teferu Z, Tekalegn Y, Awoke T, Zenbaba D, Bekele K, Tesemma A, Seyoum F, Woldeyohannes D. Geographical variation and factors associated with unsafe child stool disposal in Ethiopia: A spatial and multilevel analysis. PLoS One 2021; 16:e0250814. [PMID: 33914836 PMCID: PMC8084221 DOI: 10.1371/journal.pone.0250814] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 04/14/2021] [Indexed: 11/19/2022] Open
Abstract
Background Unsafe disposal of children’s stool makes children susceptible to fecal-oral diseases and children remain vulnerable till the stools of all children are disposed of safely. There is a paucity of data on spatial distribution and factors associated with unsafe child stool disposal in Ethiopia. Previous estimates, however, do not include information regarding individual and community-level factors associated with unsafe child stool disposal. Hence, the current study aimed (i) to explore the spatial distribution and (ii) to identify factors associated with unsafe child stool disposal in Ethiopia. Methods A secondary data analysis was conducted using the recent 2016 Ethiopian demographic and health survey data. A total of 4145 children aged 0–23 months with their mother were included in this analysis. The Getis-Ord spatial statistical tool was used to identify high and low hotspots areas of unsafe child stool disposal. The Bernoulli model was applied using Kilduff SaTScan version 9.6 software to identify significant spatial clusters. A multilevel multivariable logistic regression model was fitted to identify factors associated with unsafe child stool disposal. Results Unsafe child stool disposal was spatially clustered in Ethiopia (Moran’s Index = 0.211, p-value< 0.0001), and significant spatial SaTScan clusters of areas with a high rate of unsafe child stool disposal were detected. The most likely primary SaTScan cluster was detected in Tigray, Amhara, Afar (north), and Benishangul-Gumuz (north) regions (LLR: 41.62, p<0.0001). Unsafe child stool disposal is more prevalent among households that had unimproved toilet facility (AOR = 1.54, 95%CI: 1.17–2.02) and those with high community poorer level (AOR: 1.74, 95%CI: 1.23–2.46). Higher prevalence of unsafe child stool disposal was also found in households with poor wealth quintiles. Children belong to agrarian regions (AOR: 0.62, 95%CI 0.42–0.91), children 6–11 months of age (AOR: 0.65, 95%CI: 0.52–0.83), 12–17 months of age (AOR: 0.68, 95%CI: 0.54–0.86), and 18–23 months of age (AOR: 0.58, 95%CI: 0.45–0.75) had lower odds of unsafe child stool disposal. Conclusions Unsafe child stool disposal was spatially clustered. Higher odds of unsafe child stool disposal were found in households with high community poverty level, poor, unimproved toilet facility, and with the youngest children. Hence, the health authorities could tailor effective child stool management programs to mitigate the inequalities identified in this study. It is also better to consider child stool management intervention in existing sanitation activities considering the identified factors.
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Affiliation(s)
- Biniyam Sahiledengle
- Department of Public Health, Madda Walabu University Goba Referral Hospital, Bale-Goba, Ethiopia
- * E-mail:
| | - Zinash Teferu
- Department of Public Health, Madda Walabu University Goba Referral Hospital, Bale-Goba, Ethiopia
| | - Yohannes Tekalegn
- Department of Public Health, Madda Walabu University Goba Referral Hospital, Bale-Goba, Ethiopia
| | - Tadesse Awoke
- Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Demisu Zenbaba
- Department of Public Health, Madda Walabu University Goba Referral Hospital, Bale-Goba, Ethiopia
| | - Kebebe Bekele
- Department of Surgery, Madda Walabu University Goba Referral Hospital, Bale-Goba, Ethiopia
| | - Abdi Tesemma
- Department of Surgery, Madda Walabu University Goba Referral Hospital, Bale-Goba, Ethiopia
| | - Fikadu Seyoum
- Department of Pediatrics, Madda Walabu University Goba Referral Hospital, Bale-Goba, Ethiopia
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Seidu AA. Are children's stools in Ghana disposed of safely? Evidence from the 2014 Ghana demographic and health survey. BMC Public Health 2021; 21:113. [PMID: 33422043 PMCID: PMC7797132 DOI: 10.1186/s12889-021-10155-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 01/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background Safe disposal of children’s faeces has always been one of the main challenges to good hygiene in Ghana. Although it has been proven that children’s faeces are more likely to spread diseases than adults’ faeces, people usually mistake them for harmlessness. This study, therefore, sought to determine the prevalence and factors associated with safe disposal of children’s faeces in Ghana. Methods Data from the 2014 Ghana Demographic and Health Survey was used for the analysis. A sample size of 2228 mother-child pairs were used for the study. The outcome variable was disposal of children stools. Both bivariate and multivariable logistic regression analyses were performed to identify the factors with safe child stool disposal. Results The prevalence of safe child stool disposal in Ghana was 24.5%. Women in the middle [Adjusted odds ratio (AOR) = 4.62; Confidence Interval (CI) = 3.00–7.10], Coastal Zone [AOR = 4.52; CI = 2.82–7.22], mothers whose children were aged 12–17 [AOR = 1.56; CI = 1.15–2.13] and 18–23 months [AOR = 1.75; CI = 1.29–2.39], and mothers whose household had improved type of toilet facility [AOR = 2.04; CI = 1.53–2.73] had higher odds of practicing safe children’s faeces disposal. However, women from households with access to improved source of drinking water [AOR = 0.62; CI = 0.45–2.7] had lower odds of practicing safe children’s faeces disposal. Conclusion Approximately only about 25 out of 100 women practice safe disposal of their children’s faeces in Ghana. The age of the child, ecological zone, the type of toilet facilities, and the type of drinking water source are associated with the disposal of child faeces. These findings have proven that only improved sanitation (i.e. drinking water and toilet facilities) are not enough for women to safely dispose of their children’s faeces. Therefore, in addition to provision of toilet facilities especially in the northern zone of Ghana, there is also the need to motivate and educate mothers on safe disposal of children’s stools especially those with children below 12 months. More so, mothers without access to improved toilet facility should also be educated on the appropriate ways to bury their children’s stools safely. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-10155-7.
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Affiliation(s)
- Abdul-Aziz Seidu
- Department of Population and Health, College of Humanities and Legal Studies, University of Cape Coast, Cape Coast, Ghana. .,College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland, Australia.
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Seidu AA, Agbaglo E, Ahinkorah BO, Dadzie LK, Bukari I, Ameyaw EK, Yaya S. Individual and contextual factors associated with disposal of children's stools in Papua New Guinea: evidence from the 2016-2018 demographic and health survey. BMC Public Health 2020; 20:1762. [PMID: 33228606 PMCID: PMC7686747 DOI: 10.1186/s12889-020-09852-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 11/08/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Proper sanitation has been one of the topmost priorities on the global public health agenda. In the past few decades, sanitation programs targeting households have often paid little attention to the disposal of children's stools. We assessed the individual and contextual factors associated with disposal of children's faeces in Papua New Guinea. METHODS The data used for this study forms part of the 2016-2018 Papua New Guinea Demographic and Health Survey (PDHS). For this study, we focused on women with children less than five years (n = 2095). Both descriptive and inferential analyses were carried out. Descriptive statistics were used to summarize the data, using frequency counts and percentages. The inferential analysis used multilevel logistic regression models to investigate the individual and contextual factors associated with disposal of children's stools. These models were presented as adjusted odds ratio (AORs), together with their corresponding 95% confidence intervals. Statistical significance was set at p < 0.05. RESULTS More than half (56%) of the women had disposed of their children's stools unsafely. With the individual level factors, the results showed that women with children < 12 months [AOR =1.71; CI = 1.28-2.29] and women aged 20-24 [AOR =2.58; CI = 1.24-5.37], 35-39 [AOR =2.34; CI = 1.09-5.04], and 40 years and above [AOR =2.51; CI = 1.09-5.79] were more likely to practice unsafe disposal of children's stool. The odds of unsafe disposal of faeces was also higher among women who visited the health facility for child diarrhea [AOR =1.69; CI = 1.25-2.28]. With the contextual factors, the odds of unsafe disposal of children's stool was higher among women who lived in the Southern region [AOR =4.82; CI = 2.08-11.18], those who lived in male-headed households [AOR =1.79; CI = 1.19-2.70], and those who had unimproved toilet facilities [AOR =1.96; CI = 1.39-2.76]. On the contrary, women with unimproved source of drinking water were less likely to dispose of their children's stool unsafely [AOR =0.54; CI = 0.35-0.83]. CONCLUSION Both individual and contextual factors predict unsafe disposal of children's faeces in Papua New Guinea. It is recommended that sanitation programs should focus on behavioral change and not only on the extension of water and improved toilet facilities. Such programs should also focus on both individual and contextual factors of women.
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Affiliation(s)
- Abdul-Aziz Seidu
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Queensland Australia
| | - Ebenezer Agbaglo
- Department of English, University of Cape Coast, Cape Coast, Ghana
| | - Bright Opoku Ahinkorah
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Louis Kobina Dadzie
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
| | | | - Edward Kwabena Ameyaw
- School of Public Health, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, Canada
- The George Institute for Global Health, The University of Oxford, Oxford, UK
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Ellis A, McClintic EE, Awino EO, Caruso BA, Arriola KRJ, Ventura SG, Kowalski AJ, Linabarger M, Wodnik BK, Webb-Girard A, Muga R, Freeman MC. Practices and Perspectives on Latrine Use, Child Feces Disposal, and Clean Play Environments in Western Kenya. Am J Trop Med Hyg 2020; 102:1094-1103. [PMID: 32124727 PMCID: PMC7204574 DOI: 10.4269/ajtmh.19-0389] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Exposure to fecal pathogens contributes to childhood diarrhea and stunting, causing harmful short- and long-term impacts to health. Understanding pathways of child fecal exposure and nutritional deficiencies is critical to informing interventions to reduce stunting. Our aim was to explore determinants of latrine use, disposal of child feces, and perceptions and provisions of a safe and clean child play environment among families with children under two (CU2) years to inform the design of a behavior change intervention to address water, sanitation, and hygiene (WASH), and nutrition behaviors. In 2016, we conducted a mixed-methods formative research in western Kenya. We conducted 29 key informant interviews with community leaders, health workers, and project staff; 18 focus group discussions with caregivers of CU2 years; and 24 semi-structured household observations of feeding, hygiene, and sanitation behaviors. We used the capability, opportunity, motivation, and behavior model as our theoretical framework to map caregiver behavioral determinants. Latrine use barriers were lack of latrines, affordability of lasting materials, and social acceptability of unobserved open defecation. Barriers to safe disposal of child feces were lack of latrines, time associated with safe disposal practices, beliefs that infant feces were not harmful, and not knowing where children had defecated. Primary barriers of clean play environments were associated with creating and maintaining play spaces, and shared human and animal compounds. The immediate cost to practicing behaviors was perceived as greater than the long-term potential benefits. Intervention design must address these barriers and emphasize facilitators to enable optimal WASH behaviors in this context.
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Affiliation(s)
- Anna Ellis
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Emilie E McClintic
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Emily O Awino
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Bethany A Caruso
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kimberly R J Arriola
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Sandra Gomez Ventura
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Alysse J Kowalski
- Nutrition and Health Sciences, Laney Graduate School, Emory University, Atlanta, Georgia
| | - Molly Linabarger
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Breanna K Wodnik
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Amy Webb-Girard
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Matthew C Freeman
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
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11
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Sahiledengle B. Unsafe child feces disposal status in Ethiopia: what factors matter? Analysis of pooled data from four demographic and health surveys. BMC Public Health 2020; 20:800. [PMID: 32460735 PMCID: PMC7254708 DOI: 10.1186/s12889-020-08945-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 05/18/2020] [Indexed: 12/21/2022] Open
Abstract
Background The only safest way to dispose of a child’s feces is to help the child use a toilet or, for very young children, to put or rinse their feces into a toilet, whereas other methods are considered unsafe. This study aimed to determine the magnitude and factors associated with unsafe child feces disposal in Ethiopia. Methods This was a cross-sectional study using pooled data from the four rounds of Demographic and Health Surveys (DHS) conducted in Ethiopia (2000, 2005, 2011, and 2016). Data on child feces disposal practice was collected for all children born during the 5 years preceding survey. Mothers were asked for the youngest child born, “The last time child passed stools, what was done to dispose of the stools?”.Descriptive statistics were computed to illustrate the given data. Multivariable logistic regression was performed to identify factors associated with unsafe child feces disposal. Results The pooled dataset contains data for 40,520 children younger than 5 years, male accounts 20,629 (50.9%). Overall, 77.7% (95%CI: 76.3–79.0) of children feces disposed of unsafely. In the multivariable logistic regression model, those mothers whose child was 13–24 months [AOR: 0.68, 95% CI: (0.60–0.78)] and ≥ 25 months [AOR: 0.66, 95% CI: (0.60–0.72)] were lower odds of unsafe child’s feces disposal. Children born into households having two or fewer children were 33% lower [AOR: 0.67, 95% CI: (0.56–0.79)] odds of unsafe child’s feces disposal than their counterparts. The odds of disposing of feces unsafely among households having improved toilet facility was 76% lower [AOR: 0.24, 95% CI: (0.19–0.29)] that of households lacking such facilities. Further, being an urban resident, having improved drinking water facility, a high level of maternal and paternal education, paternal occupational status (work in non-agriculture), and maternal age (25–34 and ≥ 35 years) were factors that associated with lower odds of unsafe child’s feces disposal. Conclusions Three in four Ethiopian children feces disposed of unsafely. Household and socio-demographic factors, such as access to improved toilet facility, the child’s age (older age), and both higher maternal and paternal education levels were important factors that significantly associated with lower odds of unsafe child feces disposal.
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Affiliation(s)
- Biniyam Sahiledengle
- School of Health Science, Department of Public Health, Madda Walabu University Goba Referral hospital, Bale-Goba, Ethiopia.
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12
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Aliyu AA, Dahiru T. Factors Associated with Safe Disposal Practices of Child's Faeces in Nigeria: Evidence from 2013 Nigeria Demographic and Health Survey. Niger Med J 2019; 60:198-204. [PMID: 31831940 PMCID: PMC6892328 DOI: 10.4103/nmj.nmj_3_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 06/15/2019] [Accepted: 09/02/2019] [Indexed: 11/16/2022] Open
Abstract
Background: Stool disposal practices have been shown to be associated with childhood diarrhea. There exist variations in explanatory variables of safe child's faecal disposal practices depending on the context of the study. Thus, the need for this study to assess factors associated with safe disposal practices of children's faeces in Nigeria. Methods: This study utilized the 2013 Nigeria Demographic and Health Survey data. Child's faecal disposal practice was classified as safe and unsafe as defined by the World Health Organization/UNICEF Joint Monitoring Program. Binary and multivariate logistic regression models were used to identify factors associated with safe faecal disposal practices. The analysis was restricted to a weighted sample of 19, 288 youngest children in the households. Results: Overall, the prevalence of safe disposal of child's faeces was 59.4%. Safe child's faeces disposal was the highest among older women (64.4%), highly educated women and their husbands (67.1%) and (66.4%), respectively; among rich households (72.3%), Muslim (68.7%), urban areas (68.8%), and in North West zone (78.4%). In multivariate analysis, safe faecal disposal was significantly associated with the age of mother, maternal education level, wealth index, religion, source of water, and type of toilet facility. Marital status, geopolitical zone, having diarrhea in the past 2 weeks before the survey and sex of the child were not significant determinants of safe faecal disposal practice. Conclusion: Understanding the prevailing faecal disposal practices is a prerequisite to the formulation of effective intervention strategies. It is pertinent, therefore, that programs and interventions designed to improve safe child's faecal disposal practices need to take into consideration the factors identified in this study.
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Affiliation(s)
- Alhaji A Aliyu
- Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
| | - Tukur Dahiru
- Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
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13
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Lin A, Ercumen A, Benjamin-Chung J, Arnold BF, Das S, Haque R, Ashraf S, Parvez SM, Unicomb L, Rahman M, Hubbard AE, Stewart CP, Colford JM, Luby SP. Effects of Water, Sanitation, Handwashing, and Nutritional Interventions on Child Enteric Protozoan Infections in Rural Bangladesh: A Cluster-Randomized Controlled Trial. Clin Infect Dis 2019; 67:1515-1522. [PMID: 29669039 PMCID: PMC6206106 DOI: 10.1093/cid/ciy320] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 04/11/2018] [Indexed: 12/19/2022] Open
Abstract
Background We evaluated effects of individual and combined water, sanitation, handwashing (WSH), and nutritional interventions on protozoan infections in children. Methods We randomized geographical clusters of pregnant women in rural Bangladesh into chlorinated drinking water, hygienic sanitation, handwashing, nutrition, combined WSH, nutrition plus WSH (N+WSH), or control arms. Participants were not masked. After approximately 2.5 years of intervention, we measured Giardia, Cryptosporidium, and Entamoeba histolytica prevalence and infection intensity by multiplex real-time polymerase chain reaction of child stool. Analysis was intention-to-treat. Results Between May 2012 and July 2013, we randomized 5551 pregnant women. At follow-up, among 4102 available women, we enrolled 6694 children into the protozoan assessment. We analyzed stool from 5933 children (aged ~31 months) for protozoan infections. Compared with 35.5% prevalence among controls, Giardia infection prevalence was lower in the sanitation (26.5%; prevalence ratio [PR], 0.75 [95% confidence interval {CI}, .64-.88]), handwashing (28.2%; PR, 0.80 [95% CI, .66-.96]), WSH (29.7%; PR, 0.83 [95% CI, .72-.96]), and N+WSH (26.7%; PR, 0.75 [95% CI, .64-.88]) arms. Water and nutrition interventions had no effect. Low prevalence of E. histolytica and Cryptosporidium (<2%) resulted in imprecise effect estimates. Conclusions Individual handwashing and hygienic sanitation interventions significantly reduced childhood Giardia infections, and there were no effects of chlorinated drinking water and nutrition improvements in this context. Combined WSH interventions provided no additional benefit. To reduce Giardia infection, individual WSH interventions may be more feasible and cost-effective than combined interventions in similar rural, low-income settings. Clinical Trials Registration NCT01590095.
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Affiliation(s)
- Audrie Lin
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley
| | - Ayse Ercumen
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley
| | - Jade Benjamin-Chung
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley
| | - Benjamin F Arnold
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley
| | - Shimul Das
- Enteric and Respiratory Infections Programme, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Rashidul Haque
- Enteric and Respiratory Infections Programme, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Sania Ashraf
- Enteric and Respiratory Infections Programme, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Sarker M Parvez
- Enteric and Respiratory Infections Programme, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Leanne Unicomb
- Enteric and Respiratory Infections Programme, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Mahbubur Rahman
- Enteric and Respiratory Infections Programme, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley
| | | | - John M Colford
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley
| | - Stephen P Luby
- Infectious Diseases and Geographic Medicine, Stanford University, California
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14
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Parvez SM, Azad R, Pickering AJ, Kwong LH, Arnold BF, Rahman MJ, Rahman MZ, Alam M, Sen D, Islam S, Rahman M, Colford JM, Luby SP, Unicomb L, Ercumen A. Microbiological contamination of young children's hands in rural Bangladesh: Associations with child age and observed hand cleanliness as proxy. PLoS One 2019; 14:e0222355. [PMID: 31504064 PMCID: PMC6736272 DOI: 10.1371/journal.pone.0222355] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 08/27/2019] [Indexed: 11/29/2022] Open
Abstract
Background Hands are a route of transmission for fecal-oral pathogens. This analysis aimed to assess associations between hand E. coli contamination and child age and determine if observed hand cleanliness can serve as a proxy for E. coli contamination on young children’s hands. Methods Trained field workers collected hand rinse samples from children aged 1–14 months in 584 households in rural Bangladesh and assessed the visual cleanliness of child hands (fingernails, finger pads and palms). Samples were analyzed using the IDEXX most probable number (MPN) methodto enumerate E. coli. We assessed if child age (immobile children aged 1–4 months vs. mobile children aged 5–14 months) is associated with log10E. coli counts on hands using generalized estimating equations (GEE). We estimated the log10 difference in hand E. coli counts associated with the cleanliness of different hand parts using a multivariable GEE model.We calculated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for dirty fingernails, fingerpads, palms and overall hands (the three observed parts combined) against binary E. coli presence on hands. Results E. coli was detected on 43% of child hands. Children in the mobile age range had 0.17 log10 MPN higher E. coli on hands than those in the immobile age range (Δlog10 = 0.17, 95% CI = 0.02, 0.32, p = 0.03). Children with visible dirt particles on finger pads had 0.46 log10 MPN higher E. coli on hands than those with clean finger pads (Δlog10 = 0.46, 95% CI = 0.05, 0.87, p = 0.03). Dirty fingernails indicated binary E. coli presence with 81% sensitivity and 26% specificity while dirty fingerpads and palms indicated E. coli presence with 29% sensitivity and 75–77% specificity. The PPV was 45–48% and NPV 59–65% for all three types of observations. Conclusion Hand contamination with E. coli was prevalent among young children in rural Bangladesh, with higher levels of contamination among mobile children. Studies should assess if strategies to remove animal feces from the courtyard, provide designated hygienic play spaces for children and deliver targeted messaging to mothers to wipe or wash children’s hands after contact with animals and animal feces reduce child hand contamination. Visible hand cleanliness was a poor predictor of E. coli presence on young children’s hands so other low-cost field measurements are needed to accurately detect fecal contamination on hands.
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Affiliation(s)
- Sarker Masud Parvez
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
- * E-mail:
| | - Rashidul Azad
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Amy J. Pickering
- School of Engineering, Tufts University, Medford, MA, United States of America
| | - Laura H. Kwong
- Stanford University, Stanford, CA, United States of America
| | - Benjamin F. Arnold
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, United States of America
| | - Musarrat Jabeen Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md. Zahidur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mahfuja Alam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Debashis Sen
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sharmin Islam
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mahbubur Rahman
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - John M. Colford
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, United States of America
| | | | - Leanne Unicomb
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ayse Ercumen
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, CA, United States of America
- North Carolina State University, Raleigh, NC, United States of America
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15
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Bauza V, Reese H, Routray P, Clasen T. Child Defecation and Feces Disposal Practices and Determinants among Households after a Combined Household-Level Piped Water and Sanitation Intervention in Rural Odisha, India. Am J Trop Med Hyg 2019; 100:1013-1021. [PMID: 30793682 PMCID: PMC6447099 DOI: 10.4269/ajtmh.18-0840] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/14/2018] [Indexed: 12/29/2022] Open
Abstract
Latrine access alone may be insufficient to encourage households to dispose of young children's feces safely in a latrine, and little is known about the determinants of improved child feces disposal. We used longitudinal data collected at up to three timepoints for children less than 5 years of age from households in Odisha, India, which received a combined household-level piped water supply and sanitation intervention, but did not specifically promote the safe disposal of child feces. Among the 85% of intervention households who reported access to improved sanitation, we characterized child defecation and feces disposal practices by age, across time, and season, and assessed determinants of improved disposal. Feces from children less than 3 years of age was commonly picked up by caregivers but disposed of unsafely with garbage into open areas (56.3% of households) or in a drain/ditch (6.2%). Although children 3 and 4 years were more likely to use a latrine than younger children, their feces was also more likely to be left in the open if they did not defecate in a latrine. For children less than 5 years of age, most (84.7%) children's feces that was safely disposed of in a latrine was because of the children defecating in the latrine directly. Significant predictors for disposing of child feces in an improved latrine were the primary female caregiver reporting using a latrine to defecate, the child's age, and water observed at place for handwashing. These findings suggest that child feces interventions should focus on encouraging children to begin using a toilet at a younger age and changing the common behavior of disposing of young child's feces into open areas.
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Affiliation(s)
- Valerie Bauza
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Heather Reese
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Parimita Routray
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Thomas Clasen
- Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Benjamin-Chung J, Amin N, Ercumen A, Arnold BF, Hubbard AE, Unicomb L, Rahman M, Luby SP, Colford JM. A Randomized Controlled Trial to Measure Spillover Effects of a Combined Water, Sanitation, and Handwashing Intervention in Rural Bangladesh. Am J Epidemiol 2018; 187:1733-1744. [PMID: 29596644 PMCID: PMC6070113 DOI: 10.1093/aje/kwy046] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 02/27/2018] [Indexed: 12/17/2022] Open
Abstract
Water, sanitation, and handwashing interventions may confer spillover effects on intervention recipients’ neighbors by interrupting pathogen transmission. We measured geographically local spillovers in the Water Quality, Sanitation, and Handwashing (WASH) Benefits Study, a cluster-randomized trial in rural Bangladesh, by comparing outcomes among neighbors of intervention versus those of control participants. Geographically defined clusters were randomly allocated to a compound-level intervention (i.e., chlorinated drinking water, upgraded sanitation, and handwashing promotion) or control arm. From January 2015 to August 2015, in 180 clusters, we enrolled 1,799 neighboring children who were age matched to trial participants who would have been eligible for the study had they been conceived slightly earlier or later. After 28 months of intervention, we quantified fecal indicator bacteria in toy rinse and drinking water samples and measured soil-transmitted helminth infections and caregiver-reported diarrhea and respiratory illness. Neighbors’ characteristics were balanced across arms. Detectable Escherichia coli prevalence in tubewell samples was lower for intervention participants’ neighbors than control participants’ (prevalence ratio = 0.83; 95% confidence interval: 0.73, 0.95). Fecal indicator bacteria prevalence did not differ between arms for other environmental samples. Prevalence was similar in neighbors of intervention participants versus those of control participants for soil-transmitted helminth infection, diarrhea, and respiratory illness. A compound-level water, sanitation, and handwashing intervention reduced neighbors’ tubewell water contamination but did not affect neighboring children’s health.
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Affiliation(s)
- Jade Benjamin-Chung
- School of Public Health, University of California, Berkeley, Berkeley, California
| | - Nuhu Amin
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Ayse Ercumen
- School of Public Health, University of California, Berkeley, Berkeley, California
| | - Benjamin F Arnold
- School of Public Health, University of California, Berkeley, Berkeley, California
| | - Alan E Hubbard
- School of Public Health, University of California, Berkeley, Berkeley, California
| | - Leanne Unicomb
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Mahbubur Rahman
- Infectious Disease Division, International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
| | - Stephen P Luby
- Infectious Diseases & Geographic Medicine, Stanford University, Stanford, California
| | - John M Colford
- School of Public Health, University of California, Berkeley, Berkeley, California
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Unicomb L, Begum F, Leontsini E, Rahman M, Ashraf S, Naser AM, Nizame FA, Jannat K, Hussain F, Parvez SM, Arman S, Mobashara M, Luby SP, Winch PJ. WASH Benefits Bangladesh trial: management structure for achieving high coverage in an efficacy trial. Trials 2018; 19:359. [PMID: 29976247 PMCID: PMC6034218 DOI: 10.1186/s13063-018-2709-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 05/25/2018] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Water, sanitation, and hygiene (WASH) efficacy trials deliver interventions to the target population under optimal conditions to estimate their effects on outcomes of interest, to inform subsequent selection for inclusion in routine programs. A systematic and intensive approach to intervention delivery is required to achieve the high-level uptake necessary to measure efficacy. We describe the intervention delivery system adopted in the WASH Benefits Bangladesh study, as part of a three-paper series on WASH Benefits Intervention Delivery and Performance. METHODS Community Health Workers (CHWs) delivered individual and combined WASH and nutrition interventions to 4169 enrolled households in geographically matched clusters. Households were provided with free enabling technologies and supplies, integrated with parallel behaviour-change promotion. Behavioural objectives were drinking treated, safely stored water, safe feces disposal, handwashing with soap at key times, and age-appropriate nutrition behaviours (birth to 24 months). The intervention delivery system built on lessons learned from prior WASH intervention effectiveness, implementation, and formative research studies. We recruited local CHWs, residents of the study villages, through transparent merit-based selection methods, and consultation with community leaders. CHW supervisors received training on direct intervention delivery, then trained their assigned CHWs. CHWs in turn used the technologies in their own homes. Each CHW counseled six to eight intervention households spread across a 0.2-2.2-km radius, with a 1:12 supervisor-to-CHW ratio. CHWs met monthly with supervisor-trainers to exchange experiences and adapt technology and behaviour-change approaches to evolving conditions. Intervention uptake was tracked through fidelity measures, with a priori benchmarks necessary for an efficacy study. RESULTS Sufficient levels of uptake were attained by the fourth intervention assessment month and sustained throughout the intervention period. Periodic internal CHW monitoring resulted in discontinuation of a small number of low performers. CONCLUSIONS The intensive intervention delivery system required for an efficacy trial differs in many respects from the system for a routine program. To implement a routine program at scale requires further research on how to optimize the supervisor-to-CHW-to-intervention household ratios, as well as other program costs without compromising program effectiveness. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCC01590095 . Registered on 2 May 2012.
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Affiliation(s)
- Leanne Unicomb
- Infectious Disease Division, Environmental Intervention Unit, Enteric and Respiratory Disease Program, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Farzana Begum
- Infectious Disease Division, Environmental Intervention Unit, Enteric and Respiratory Disease Program, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Elli Leontsini
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Mahbubur Rahman
- Infectious Disease Division, Environmental Intervention Unit, Enteric and Respiratory Disease Program, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Sania Ashraf
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Abu Mohd Naser
- Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Fosiul A. Nizame
- Infectious Disease Division, Environmental Intervention Unit, Enteric and Respiratory Disease Program, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Kaniz Jannat
- Infectious Disease Division, Environmental Intervention Unit, Enteric and Respiratory Disease Program, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Faruqe Hussain
- Infectious Disease Division, Environmental Intervention Unit, Enteric and Respiratory Disease Program, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Sarker Masud Parvez
- Infectious Disease Division, Environmental Intervention Unit, Enteric and Respiratory Disease Program, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Shaila Arman
- Infectious Disease Division, Environmental Intervention Unit, Enteric and Respiratory Disease Program, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212 Bangladesh
| | - Moshammot Mobashara
- Infectious Disease Division, Environmental Intervention Unit, Enteric and Respiratory Disease Program, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shahed Tajuddin Ahmed Sarani, Mohakhali, Dhaka, 1212 Bangladesh
| | | | - Peter J. Winch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Parvez SM, Azad R, Rahman M, Unicomb L, Ram PK, Naser AM, Stewart CP, Jannat K, Rahman MJ, Leontsini E, Winch PJ, Luby SP. Achieving optimal technology and behavioral uptake of single and combined interventions of water, sanitation hygiene and nutrition, in an efficacy trial (WASH benefits) in rural Bangladesh. Trials 2018; 19:358. [PMID: 29976251 PMCID: PMC6034207 DOI: 10.1186/s13063-018-2710-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 05/25/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Uptake matters for evaluating the health impact of water, sanitation and hygiene (WASH) interventions. Many large-scale WASH interventions have been plagued by low uptake. For the WASH Benefits Bangladesh efficacy trial, high uptake was a prerequisite. We assessed the degree of technology and behavioral uptake among participants in the trial, as part of a three-paper series on WASH Benefits Intervention Delivery and Performance. METHODS This study is a cluster randomized trial comprised of geographically matched clusters among four districts in rural Bangladesh. We randomly allocated 720 clusters of 5551 pregnant women to individual or combined water, sanitation, handwashing, and nutrition interventions, or a control group. Behavioral objectives included; drinking chlorine-treated, safely stored water; use of a hygienic latrine and safe feces disposal at the compound level; handwashing with soap at key times; and age-appropriate nutrition behaviors (pregnancy to 24 months) including a lipid-based nutrition supplement (LNS). Enabling technologies and behavior change were promoted by trained local community health workers through periodic household visits. To monitor technology and behavioral uptake, we conducted surveys and spot checks in 30-35 households per intervention arm per month, over a 20-month period, and structured observations in 324 intervention and 108 control households, approximately 15 months after interventions commenced. RESULTS In the sanitation arms, observed adult use of a hygienic latrine was high (94-97% of events) while child sanitation practices were moderate (37-54%). In the handwashing arms, handwashing with soap was more common after toilet use (67-74%) than nonintervention arms (18-40%), and after cleaning a child's anus (61-72%), but was still low before food handling. In the water intervention arms, more than 65% of mothers and index children were observed drinking chlorine-treated water from a safe container. Reported LNS feeding was > 80% in nutrition arms. There was little difference in uptake between single and combined intervention arms. CONCLUSIONS Rigorous implementation of interventions deployed at large scale in the context of an efficacy trial achieved high levels of technology and behavioral uptake in individual and combined WASH and nutrition intervention households. Further work should assess how to achieve similar uptake levels under programmatic conditions. TRIAL REGISTRATION WASH Benefits Bangladesh: ClinicalTrials.gov, identifier: NCT01590095 . Registered on April 30, 2012.
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Affiliation(s)
- Sarker Masud Parvez
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr.b), Dhaka, Bangladesh
| | - Rashidul Azad
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr.b), Dhaka, Bangladesh
| | - Mahbubur Rahman
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr.b), Dhaka, Bangladesh
| | - Leanne Unicomb
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr.b), Dhaka, Bangladesh
| | - Pavani K. Ram
- School of Public Health and Health Professions, University of Buffalo, Buffalo, NY USA
| | - Abu Mohd Naser
- Rollins School of Public Health, Emory University, Atlanta, GA USA
| | | | - Kaniz Jannat
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr.b), Dhaka, Bangladesh
| | - Musarrat Jabeen Rahman
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Diseases Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr.b), Dhaka, Bangladesh
| | - Elli Leontsini
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Peter J. Winch
- Department of International Health, Social and Behavioral Interventions Program, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Stephen P. Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA USA
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Rahman M, Ashraf S, Unicomb L, Mainuddin AKM, Parvez SM, Begum F, Das KK, Naser AM, Hussain F, Clasen T, Luby SP, Leontsini E, Winch PJ. WASH Benefits Bangladesh trial: system for monitoring coverage and quality in an efficacy trial. Trials 2018; 19:360. [PMID: 29976234 PMCID: PMC6034300 DOI: 10.1186/s13063-018-2708-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 05/25/2018] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Researchers typically report more on the impact of public health interventions and less on the degree to which interventions were followed implementation fidelity. We developed and measured fidelity indicators for the WASH Benefits Bangladesh study, a large-scale efficacy trial, in order to identify gaps between intended and actual implementation. METHODS Community health workers (CHWs) delivered individual and combined water, sanitation, handwashing (WSH) and child nutrition interventions to 4169 enrolled households in geographically matched clusters. Households received free enabling technologies (insulated water storage container; sani-scoop, potty, double-pit, pour-flush latrine; handwashing station, soapy-water storage bottle), and supplies (chlorine tablets, lipid-based nutrient supplements, laundry detergent sachets) integrated with parallel behavior-change promotion. Behavioral objectives were drinking treated, safely stored water, safe feces disposal, handwashing with soap at key times, and age-appropriate nutrition behaviors. We administered monthly surveys and spot-checks to households from randomly selected clusters for 6 months early in the trial. If any fidelity measures fell below set benchmarks, a rapid response mechanism was triggered. RESULTS In the first 3 months, functional water seals were detected in 33% (14/42) of latrines in the sanitation only arm; 35% (14/40) for the combined WSH arm; and 60% (34/57) for the combined WSH and Nutrition arm, all falling below the pre-set benchmark of 80%. Other fidelity indicators met the 65 to 80% uptake benchmarks. Rapid qualitative investigations determined that households concurrently used their own latrines with broken water seals in parallel with those provided by the trial. In consultation with the households, we closed pre-existing latrines without water seals, increased the CHWs' visit frequency to encourage correct maintenance of latrines with water seals, and discouraged water-seal removal or breakage. At the sixth assessment, 86% (51/59) of households were in sanitation only; 92% (72/78) in the combined WSH; and 93% (71/76) in the combined WSH and Nutrition arms had latrines with functional water seals. CONCLUSIONS An intensive implementation fidelity monitoring and rapid response system proved beneficial for this efficacy trial. To implement a routine program at scale requires further research into an adaptation of fidelity monitoring that supports program effectiveness. TRIAL REGISTRATION WASH Benefits Bangladesh: ClinicalTrials.gov, ID: NCT01590095 . Registered on 30 April 2012.
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Affiliation(s)
- Mahbubur Rahman
- Environmental Intervention Unit, Enteric and Respiratory Disease Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sania Ashraf
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Leanne Unicomb
- Environmental Intervention Unit, Enteric and Respiratory Disease Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - A. K. M. Mainuddin
- Environmental Intervention Unit, Enteric and Respiratory Disease Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Sarker Masud Parvez
- Environmental Intervention Unit, Enteric and Respiratory Disease Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Farzana Begum
- Environmental Intervention Unit, Enteric and Respiratory Disease Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Kishor Kumar Das
- Environmental Intervention Unit, Enteric and Respiratory Disease Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abu Mohd. Naser
- Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Faruqe Hussain
- Environmental Intervention Unit, Enteric and Respiratory Disease Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Thomas Clasen
- Rollins School of Public Health, Emory University, Atlanta, GA USA
| | - Stephen P. Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA USA
| | - Elli Leontsini
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Peter J. Winch
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Islam M, Ercumen A, Ashraf S, Rahman M, Shoab AK, Luby SP, Unicomb L. Unsafe disposal of feces of children <3 years among households with latrine access in rural Bangladesh: Association with household characteristics, fly presence and child diarrhea. PLoS One 2018; 13:e0195218. [PMID: 29621289 PMCID: PMC5886761 DOI: 10.1371/journal.pone.0195218] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 03/02/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Young children frequently defecate in the living environment in low-income countries. Unsafe child feces disposal has been associated with risk of diarrhea. Additionally, reported practices can underestimate socially undesirable unhygienic behaviors. This analysis aimed to assess (1) the sensitivity of reported child feces disposal practices as an indicator for observed presence of human feces in the domestic environment, (2) household characteristics associated with reported unsafe feces disposal and (3) whether unsafe feces disposal is associated with fly presence and diarrhea among children <3 years. METHODS We recorded caregiver-reported feces disposal practices for children <3 years; unsafe disposal was defined as feces put/rinsed into a drain, ditch, bush or garbage heap or left on the ground and safe disposal as feces put/rinsed into latrine or specific pit or buried. We conducted spot checks for human feces, counted flies in the compound and recorded caregiver-reported child diarrhea prevalence among 803 rural Bangladeshi households. We assessed associations using generalized estimating equations (GEE) and generalized linear models (GLM) with robust standard errors. RESULTS Unsafe disposal of child feces was reported by 80% of households. Reported disposal practices had high sensitivity (91%) but low positive predictive value (15%) as an indicator of observed feces in the compound. Unsafe disposal was more common among households that reported daily adult open defecation (PR: 1.13, 1.02-1.24) and had children defecating in a nappy or on the ground versus in a potty (PR: 2.92, 1.98-4.32), and less common in households where adults reported always defecating in latrines (PR: 0.91, 0.84-0.98). The presence of observed human feces was similarly associated with these household characteristics. Reported unsafe feces disposal or observed human feces were not associated with fly detection or child diarrhea. CONCLUSION Despite access to on-site sanitation, unsafe child feces disposal was reported by the majority of households. However, this practices was not associated with diarrhea; suggesting that child feces may not be the most important fecal exposure. Before resources are invested to improve child feces management practices, studies should explore whether these contribute meaningfully to risk of enteric disease.
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Affiliation(s)
- Mahfuza Islam
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Ayse Ercumen
- University of California, Berkeley, CA, United States of America
| | - Sania Ashraf
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Mahbubur Rahman
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Abul K. Shoab
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Stephen P. Luby
- Woods Institute for the Environment, Stanford University, Stanford, United States of America
| | - Leanne Unicomb
- Environmental Intervention Unit, Enteric and Respiratory Infections Program, Infectious Disease Division, International Centre for Diarrheal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
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Luby SP, Rahman M, Arnold BF, Unicomb L, Ashraf S, Winch PJ, Stewart CP, Begum F, Hussain F, Benjamin-Chung J, Leontsini E, Naser AM, Parvez SM, Hubbard AE, Lin A, Nizame FA, Jannat K, Ercumen A, Ram PK, Das KK, Abedin J, Clasen TF, Dewey KG, Fernald LC, Null C, Ahmed T, Colford JM. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Bangladesh: a cluster randomised controlled trial. LANCET GLOBAL HEALTH 2018; 6:e302-e315. [PMID: 29396217 PMCID: PMC5809718 DOI: 10.1016/s2214-109x(17)30490-4] [Citation(s) in RCA: 394] [Impact Index Per Article: 65.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 12/04/2017] [Indexed: 12/16/2022]
Abstract
Background Diarrhoea and growth faltering in early childhood are associated with subsequent adverse outcomes. We aimed to assess whether water quality, sanitation, and handwashing interventions alone or combined with nutrition interventions reduced diarrhoea or growth faltering. Methods The WASH Benefits Bangladesh cluster-randomised trial enrolled pregnant women from villages in rural Bangladesh and evaluated outcomes at 1-year and 2-years' follow-up. Pregnant women in geographically adjacent clusters were block-randomised to one of seven clusters: chlorinated drinking water (water); upgraded sanitation (sanitation); promotion of handwashing with soap (handwashing); combined water, sanitation, and handwashing; counselling on appropriate child nutrition plus lipid-based nutrient supplements (nutrition); combined water, sanitation, handwashing, and nutrition; and control (data collection only). Primary outcomes were caregiver-reported diarrhoea in the past 7 days among children who were in utero or younger than 3 years at enrolment and length-for-age Z score among children born to enrolled pregnant women. Masking was not possible for data collection, but analyses were masked. Analysis was by intention to treat. This trial is registered at ClinicalTrials.gov, number NCC01590095. Findings Between May 31, 2012, and July 7, 2013, 5551 pregnant women in 720 clusters were randomly allocated to one of seven groups. 1382 women were assigned to the control group; 698 to water; 696 to sanitation; 688 to handwashing; 702 to water, sanitation, and handwashing; 699 to nutrition; and 686 to water, sanitation, handwashing, and nutrition. 331 (6%) women were lost to follow-up. Data on diarrhoea at year 1 or year 2 (combined) were available for 14 425 children (7331 in year 1, 7094 in year 2) and data on length-for-age Z score in year 2 were available for 4584 children (92% of living children were measured at year 2). All interventions had high adherence. Compared with a prevalence of 5·7% (200 of 3517 child weeks) in the control group, 7-day diarrhoea prevalence was lower among index children and children under 3 years at enrolment who received sanitation (61 [3·5%] of 1760; prevalence ratio 0·61, 95% CI 0·46–0·81), handwashing (62 [3·5%] of 1795; 0·60, 0·45–0·80), combined water, sanitation, and handwashing (74 [3·9%] of 1902; 0·69, 0·53–0·90), nutrition (62 [3·5%] of 1766; 0·64, 0·49–0·85), and combined water, sanitation, handwashing, and nutrition (66 [3·5%] of 1861; 0·62, 0·47–0·81); diarrhoea prevalence was not significantly lower in children receiving water treatment (90 [4·9%] of 1824; 0·89, 0·70–1·13). Compared with control (mean length-for-age Z score −1·79), children were taller by year 2 in the nutrition group (mean difference 0·25 [95% CI 0·15–0·36]) and in the combined water, sanitation, handwashing, and nutrition group (0·13 [0·02–0·24]). The individual water, sanitation, and handwashing groups, and combined water, sanitation, and handwashing group had no effect on linear growth. Interpretation Nutrient supplementation and counselling modestly improved linear growth, but there was no benefit to the integration of water, sanitation, and handwashing with nutrition. Adherence was high in all groups and diarrhoea prevalence was reduced in all intervention groups except water treatment. Combined water, sanitation, and handwashing interventions provided no additive benefit over single interventions. Funding Bill & Melinda Gates Foundation.
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Affiliation(s)
- Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA.
| | - Mahbubur Rahman
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Benjamin F Arnold
- School of Public Health University of California Berkeley, Berkeley, CA, USA
| | - Leanne Unicomb
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sania Ashraf
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Peter J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Farzana Begum
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Faruqe Hussain
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Jade Benjamin-Chung
- School of Public Health University of California Berkeley, Berkeley, CA, USA
| | - Elli Leontsini
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Abu M Naser
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Sarker M Parvez
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Alan E Hubbard
- School of Public Health University of California Berkeley, Berkeley, CA, USA
| | - Audrie Lin
- School of Public Health University of California Berkeley, Berkeley, CA, USA
| | - Fosiul A Nizame
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Kaniz Jannat
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Ayse Ercumen
- School of Public Health University of California Berkeley, Berkeley, CA, USA
| | - Pavani K Ram
- School of Public Health and Health Professions, University of Buffalo, Buffalo, NY, USA
| | - Kishor K Das
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Jaynal Abedin
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Thomas F Clasen
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kathryn G Dewey
- Department of Nutrition, University of California Davis, Davis, CA, USA
| | - Lia C Fernald
- School of Public Health University of California Berkeley, Berkeley, CA, USA
| | - Clair Null
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - John M Colford
- School of Public Health University of California Berkeley, Berkeley, CA, USA
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Bauza V, Guest JS. The effect of young children's faeces disposal practices on child growth: evidence from 34 countries. Trop Med Int Health 2017; 22:1233-1248. [DOI: 10.1111/tmi.12930] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Valerie Bauza
- Department of Civil and Environmental Engineering University of Illinois at Urbana‐Champaign Urbana IL USA
| | - Jeremy S. Guest
- Department of Civil and Environmental Engineering University of Illinois at Urbana‐Champaign Urbana IL USA
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Hussain F, Luby SP, Unicomb L, Leontsini E, Naushin T, Buckland AJ, Winch PJ. Assessment of the Acceptability and Feasibility of Child Potties for Safe Child Feces Disposal in Rural Bangladesh. Am J Trop Med Hyg 2017; 97:469-476. [PMID: 28722606 PMCID: PMC5544061 DOI: 10.4269/ajtmh.15-0932] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Indiscriminate defecation among young children and the unsafe disposal of their feces increases fecal contamination in the household environment and the risk of diarrheal disease transmission. Improved sanitary technology for children too young to use a latrine may facilitate safe feces disposal and reduce fecal contamination in the household environment. We assessed the acceptability and feasibility of child potties in rural Bangladesh in 2010. Our team introduced child potties into 26 households for 30 days, and conducted semistructured interviews, group discussions, and observations to assess the acceptability and feasibility of their use for parents and children. Residents of this rural Bangladeshi community accepted the child potties and caregivers found them to be a feasible means of managing child feces. The color, shape, design, and size of the potty influenced its acceptability and use. These residents reported that regular use of the potty improved the household’s physical environment and caregiver and child personal hygiene. Regular potty use also reduced caregivers’ work load by making feces collection and disposal easier. Primary caregivers viewed 4–6 months as the appropriate age to initiate potty training. Sanitation interventions should integrate and emphasize potties for children’s feces management to reduce household environmental contamination.
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Affiliation(s)
- Faruqe Hussain
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Stephen P Luby
- Stanford University, Stanford, California.,International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Leanne Unicomb
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Elli Leontsini
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Tania Naushin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Audrey J Buckland
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Peter J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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George CM, Oldja L, Biswas S, Perin J, Sack RB, Ahmed S, Shahnaij M, Haque R, Parvin T, Azmi IJ, Bhuyian SI, Talukder KA, Faruque AG. Unsafe Child Feces Disposal is Associated with Environmental Enteropathy and Impaired Growth. J Pediatr 2016; 176:43-9. [PMID: 27318380 DOI: 10.1016/j.jpeds.2016.05.035] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Revised: 03/28/2016] [Accepted: 05/11/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To investigate the relationship between unsafe child feces disposal, environmental enteropathy, and impaired growth, we conducted a prospective cohort study of 216 young children in rural Bangladesh. STUDY DESIGN Using a prospective cohort study design in rural Bangladesh, unsafe child feces disposal, using the Joint Monitoring Program definition, was assessed using 5-hour structured observation by trained study personnel as well as caregiver reports. Anthropometric measurements were collected at baseline and at a 9-month follow-up. Stool was analyzed for fecal markers of environmental enteropathy: alpha-1-antitrypsin, myeloperoxidase, neopterin (combined to form an environmental enteropathy disease activity score), and calprotectin. FINDINGS Among 216 households with young children, 84% had an unsafe child feces disposal event during structured observation and 75% had caregiver reported events. There was no significant difference in observed unsafe child feces disposal events for households with or without an improved sanitation option (82% vs 85%, P = .72) or by child's age (P = .96). Children in households where caregivers reported unsafe child feces disposal had significantly higher environmental enteropathy scores (0.82-point difference, 95% CI 0.11-1.53), and significantly greater odds of being wasted (weight-for-height z score <-2 SDs) (9% vs 0%, P = .024). In addition, children in households with observed unsafe feces disposal had significantly reduced change in weight-for-age z-score (-0.34 [95% CI -0.68, -0.01] and weight-for-height z score (-0.52 [95% CI -0.98, -0.06]). CONCLUSION Unsafe child feces disposal was significantly associated with environmental enteropathy and impaired growth in a pediatric population in rural Bangladesh. Interventions are needed to reduce this high-risk behavior to protect the health of susceptible pediatric populations.
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Affiliation(s)
- Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
| | - Lauren Oldja
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Shwapon Biswas
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Dhaka, Bangladesh
| | - Jamie Perin
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - R Bradley Sack
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Shahnawaz Ahmed
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Dhaka, Bangladesh
| | - Mohammad Shahnaij
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Dhaka, Bangladesh
| | - Rashidul Haque
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Dhaka, Bangladesh
| | - Tahmina Parvin
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Dhaka, Bangladesh
| | - Ishrat J Azmi
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Dhaka, Bangladesh
| | - Sazzadul Islam Bhuyian
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Dhaka, Bangladesh
| | - Kaisar A Talukder
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Dhaka, Bangladesh
| | - Abu G Faruque
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Dhaka, Bangladesh
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Cronin AA, Sebayang SK, Torlesse H, Nandy R. Association of Safe Disposal of Child Feces and Reported Diarrhea in Indonesia: Need for Stronger Focus on a Neglected Risk. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:E310. [PMID: 26978379 PMCID: PMC4808973 DOI: 10.3390/ijerph13030310] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Revised: 01/18/2016] [Accepted: 01/19/2016] [Indexed: 11/17/2022]
Abstract
Indonesia still faces several challenges in the areas of water, sanitation, and hygiene (WASH). Diarrhea remains a major killer of children and it is important to understand the local diarrhea transmission pathways to prioritise appropriate WASH interventions to reduce diarrhea burden. This study used a cross-sectional data set from a recent national household survey (the 2012 Indonesia Demographic and Health Survey) to examine the associations between diarrhea in children aged less than 24 months with WASH interventions and population characteristics. Unsafe disposal of child feces was strongly associated with an increased odds of child diarrhea (OR: 1.46; 95% CI: 1.18-1.82, p = 0.001). However, other WASH practices were not found to be associated. The findings underline the dangers of unsafe disposal of child feces and highlight the need for strengthening the related policies and program strategies and their implementation.
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Affiliation(s)
- Aidan A Cronin
- UNICEF Indonesia, World Trade Center 6, Jalan Jenderal Sudirman Kav. 31, Jakarta 12920, Indonesia.
| | - Susy Katikana Sebayang
- Faculty of Public Health, Universitas Airlangga, Banyuwangi Campus, Jalan Wijaya Kusuma No 113, Banyuwangi 68414, Indonesia.
| | - Harriet Torlesse
- UNICEF Indonesia, World Trade Center 6, Jalan Jenderal Sudirman Kav. 31, Jakarta 12920, Indonesia.
| | - Robin Nandy
- UNICEF Indonesia, World Trade Center 6, Jalan Jenderal Sudirman Kav. 31, Jakarta 12920, Indonesia.
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Miller-Petrie MK, Voigt L, McLennan L, Cairncross S, Jenkins MW. Infant and Young Child Feces Management and Enabling Products for Their Hygienic Collection, Transport, and Disposal in Cambodia. Am J Trop Med Hyg 2015; 94:456-465. [PMID: 26598568 PMCID: PMC4751965 DOI: 10.4269/ajtmh.15-0423] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/16/2015] [Indexed: 12/04/2022] Open
Abstract
In Cambodia, children's feces are rarely disposed of in an improved sanitation facility. This study examines current practices and the role that enabling products may play in increasing hygienic management of infant and young child (IYC) feces in households with access to improved sanitation. A survey was conducted with the primary caregiver of a child under 5 years of age in 130 homes with an improved latrine in 21 villages across two provinces in Cambodia. Two focus group discussions per province were conducted after the survey to obtain caregiver feedback on new enabling products for hygienic management. Among caregivers, 63% reported child feces disposal in an improved latrine but only 36% reported doing so consistently. Besides child age, years of latrine ownership, caregiver age, consistency of adult latrine use, and presence of child feces management tools in the latrine were associated with hygienic disposal. The youngest caretakers with the newest latrines and youngest children were least likely to dispose of IYC feces hygienically, representing a key target group for interventions to improve hygienic disposal in Cambodia. Reusable diapers, child-friendly potties, and possibly latrine seats, that offer child safety, time and cost savings, and easy disposal and cleaning could potentially facilitate hygienic disposal for these ages.
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Affiliation(s)
- Molly K. Miller-Petrie
- *Address correspondence to Molly K. Miller-Petrie, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Kepple Street, London, WC1E 7HT, United Kingdom. E-mail:
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Azage M, Haile D. Factors associated with safe child feces disposal practices in Ethiopia: evidence from demographic and health survey. Arch Public Health 2015; 73:40. [PMID: 26504520 PMCID: PMC4620604 DOI: 10.1186/s13690-015-0090-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 08/24/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND According to the WHO/UNICEF Joint Monitoring Programme (JMP) for water supply and Sanitation definition, safe child feces disposal practices include: children defecation into a latrine, disposal of child stools in a latrine or burial. Inappropriate disposal of human feces including unsafe child feces disposal facilitates the transmission of pathogens. However, the factors associated with safe child feces disposal practices have not been yet well explored in Ethiopia. This study aimed to identify factors associated with safe child feces disposal practices in Ethiopia. METHODS This study analyzed data from Ethiopian Demographic and Health Survey (EDHS) 2011. The practice of child's feces disposal was categorized into 'safe' and 'unsafe' based on the WHO/ UNICEF JMP for water supply & Sanitation definition. Binary and multivariable logistic regression models were employed to identify factors associated with safe child feces disposal practices. RESULT The prevalence of safe child feces disposal was 33.68 % (95 % CI: 32.82-34.55). In the final multivariable logistic regression model, the practice of safe disposal of child feces was significantly associated with urban residency (AOR = 1.25, 95 % CI: 1.01-1.55) and having access to an improved latrine (AOR = 1.92, 95 % CI: 1.56-2.36). Households found in the poorer, middle, richer and richest wealth quintile had (AOR = 2.22, 95 % CI: 1.70-2.89), (AOR = 2.94, 95 % CI: 2.27-3.81), (AOR = 4.20, 95 % CI: 3.42-5.72) and (AOR = 8.06, 95 % CI: 5.91-10.99) times higher odds to practice safe child feces disposal respectively as compared households from poorest wealth quintile. Mothers/caregivers with primary, secondary and higher educational status had (AOR = 1.29, 95 % CI: 1.10-1.50), (AOR = 1. 64, 95 % CI: 1.12-2.41) and (AOR = 2.16, 95 % CI: 1.25-3.72) times higher odds to practice safe child feces disposal respectively than those mothers who had no education. Those mothers/caregivers whose child was 48-59 months old had (AOR = 2.21, 95 % CI: 1.82-2.68) times higher odds to practice safe child feces disposal as compared to mothers/caregivers who had a child with age less than 12 months old. The odds of safe child feces disposal among households who had one two and three under five years old children were (AOR = 3.11, 95 % CI: 1.87-5.19),(AOR = 2.55, 95 % CI: 1.53-4.24) and (AOR = 1.92, 95 % CI: 1.13-3.24) times higher respectively than households with four and more children of under five years old. CONCLUSION Only one third of the mothers practiced safe child feces disposal in Ethiopia. Being an urban resident, having a higher wealth quintile, high levels of maternal education, older child age, having a lower number of under five years old children, and the presence of an improved latrine were factors associated with safe child feces disposal practices. Therefore interventions designed to improve safe child feces disposal practices should consider those factors identified. Further research is also needed to design intervention that will aim to improve safe child feces disposal.
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Affiliation(s)
- Muluken Azage
- />Department of Public Health, College of Medicine and Health Sciences, Bahir Dar University, P.O.Box 79, Bahir Dar, Ethiopia
| | - Demewoz Haile
- />Department of Reproductive Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
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Christensen G, Dentz HN, Pickering AJ, Bourdier T, Arnold BF, Colford JM, Null C. Pilot cluster randomized controlled trials to evaluate adoption of water, sanitation, and hygiene interventions and their combination in rural western Kenya. Am J Trop Med Hyg 2014; 92:437-47. [PMID: 25422394 DOI: 10.4269/ajtmh.14-0138] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In preparation for a larger trial, the Water, Sanitation, and Hygiene (WASH) Benefits pilot study enrolled 72 villages and 499 subjects in two closely related randomized trials of WASH interventions in rural western Kenya. Intervention households received hardware and promotion for one of the following: water treatment, sanitation and latrine improvements, handwashing with soap, or the combination of all three. Interventions were clustered by village. A follow-up survey was conducted 4 months after intervention delivery to assess uptake. Intervention households were significantly more likely than controls to have chlorinated stored water (36-60 percentage point increases), covers over latrine drop holes (55-75 percentage point increases), less stool visible on latrine floors (16-47 percentage point reductions), and a place for handwashing (71-85 percentage point increases) with soap available (49-66 percentage point increases). The high uptake in all arms shows that combined interventions can achieve high short-term adoption rates if well-designed.
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Affiliation(s)
- Garret Christensen
- Rollins School of Public Health, Emory University, Atlanta, Georgia; Innovations for Poverty Action, Busia, Kenya; Department of Civil and Environmental Engineering, Stanford University, Stanford, California; Division of Epidemiology, University of California, Berkeley, California
| | - Holly N Dentz
- Rollins School of Public Health, Emory University, Atlanta, Georgia; Innovations for Poverty Action, Busia, Kenya; Department of Civil and Environmental Engineering, Stanford University, Stanford, California; Division of Epidemiology, University of California, Berkeley, California
| | - Amy J Pickering
- Rollins School of Public Health, Emory University, Atlanta, Georgia; Innovations for Poverty Action, Busia, Kenya; Department of Civil and Environmental Engineering, Stanford University, Stanford, California; Division of Epidemiology, University of California, Berkeley, California
| | - Tomoé Bourdier
- Rollins School of Public Health, Emory University, Atlanta, Georgia; Innovations for Poverty Action, Busia, Kenya; Department of Civil and Environmental Engineering, Stanford University, Stanford, California; Division of Epidemiology, University of California, Berkeley, California
| | - Benjamin F Arnold
- Rollins School of Public Health, Emory University, Atlanta, Georgia; Innovations for Poverty Action, Busia, Kenya; Department of Civil and Environmental Engineering, Stanford University, Stanford, California; Division of Epidemiology, University of California, Berkeley, California
| | - John M Colford
- Rollins School of Public Health, Emory University, Atlanta, Georgia; Innovations for Poverty Action, Busia, Kenya; Department of Civil and Environmental Engineering, Stanford University, Stanford, California; Division of Epidemiology, University of California, Berkeley, California
| | - Clair Null
- Rollins School of Public Health, Emory University, Atlanta, Georgia; Innovations for Poverty Action, Busia, Kenya; Department of Civil and Environmental Engineering, Stanford University, Stanford, California; Division of Epidemiology, University of California, Berkeley, California
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Dreibelbis R, Winch PJ, Leontsini E, Hulland KRS, Ram PK, Unicomb L, Luby SP. The Integrated Behavioural Model for Water, Sanitation, and Hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings. BMC Public Health 2013; 13:1015. [PMID: 24160869 PMCID: PMC4231350 DOI: 10.1186/1471-2458-13-1015] [Citation(s) in RCA: 206] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 10/04/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Promotion and provision of low-cost technologies that enable improved water, sanitation, and hygiene (WASH) practices are seen as viable solutions for reducing high rates of morbidity and mortality due to enteric illnesses in low-income countries. A number of theoretical models, explanatory frameworks, and decision-making models have emerged which attempt to guide behaviour change interventions related to WASH. The design and evaluation of such interventions would benefit from a synthesis of this body of theory informing WASH behaviour change and maintenance. METHODS We completed a systematic review of existing models and frameworks through a search of related articles available in PubMed and in the grey literature. Information on the organization of behavioural determinants was extracted from the references that fulfilled the selection criteria and synthesized. Results from this synthesis were combined with other relevant literature, and from feedback through concurrent formative and pilot research conducted in the context of two cluster-randomized trials on the efficacy of WASH behaviour change interventions to inform the development of a framework to guide the development and evaluation of WASH interventions: the Integrated Behavioural Model for Water, Sanitation, and Hygiene (IBM-WASH). RESULTS We identified 15 WASH-specific theoretical models, behaviour change frameworks, or programmatic models, of which 9 addressed our review questions. Existing models under-represented the potential role of technology in influencing behavioural outcomes, focused on individual-level behavioural determinants, and had largely ignored the role of the physical and natural environment. IBM-WASH attempts to correct this by acknowledging three dimensions (Contextual Factors, Psychosocial Factors, and Technology Factors) that operate on five-levels (structural, community, household, individual, and habitual). CONCLUSIONS A number of WASH-specific models and frameworks exist, yet with some limitations. The IBM-WASH model aims to provide both a conceptual and practical tool for improving our understanding and evaluation of the multi-level multi-dimensional factors that influence water, sanitation, and hygiene practices in infrastructure-constrained settings. We outline future applications of our proposed model as well as future research priorities needed to advance our understanding of the sustained adoption of water, sanitation, and hygiene technologies and practices.
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Affiliation(s)
- Robert Dreibelbis
- Social and Behavioural Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Arnold BF, Null C, Luby SP, Unicomb L, Stewart CP, Dewey KG, Ahmed T, Ashraf S, Christensen G, Clasen T, Dentz HN, Fernald LCH, Haque R, Hubbard AE, Kariger P, Leontsini E, Lin A, Njenga SM, Pickering AJ, Ram PK, Tofail F, Winch PJ, Colford JM. Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale. BMJ Open 2013; 3:e003476. [PMID: 23996605 PMCID: PMC3758977 DOI: 10.1136/bmjopen-2013-003476] [Citation(s) in RCA: 158] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Enteric infections are common during the first years of life in low-income countries and contribute to growth faltering with long-term impairment of health and development. Water quality, sanitation, handwashing and nutritional interventions can independently reduce enteric infections and growth faltering. There is little evidence that directly compares the effects of these individual and combined interventions on diarrhoea and growth when delivered to infants and young children. The objective of the WASH Benefits study is to help fill this knowledge gap. METHODS AND ANALYSIS WASH Benefits includes two cluster-randomised trials to assess improvements in water quality, sanitation, handwashing and child nutrition-alone and in combination-to rural households with pregnant women in Kenya and Bangladesh. Geographically matched clusters (groups of household compounds in Bangladesh and villages in Kenya) will be randomised to one of six intervention arms or control. Intervention arms include water quality, sanitation, handwashing, nutrition, combined water+sanitation+handwashing (WSH) and WSH+nutrition. The studies will enrol newborn children (N=5760 in Bangladesh and N=8000 in Kenya) and measure outcomes at 12 and 24 months after intervention delivery. Primary outcomes include child length-for-age Z-scores and caregiver-reported diarrhoea. Secondary outcomes include stunting prevalence, markers of environmental enteropathy and child development scores (verbal, motor and personal/social). We will estimate unadjusted and adjusted intention-to-treat effects using semiparametric estimators and permutation tests. ETHICS AND DISSEMINATION Study protocols have been reviewed and approved by human subjects review boards at the University of California, Berkeley, Stanford University, the International Centre for Diarrheal Disease Research, Bangladesh, the Kenya Medical Research Institute, and Innovations for Poverty Action. Independent data safety monitoring boards in each country oversee the trials. This study is funded by a grant from the Bill & Melinda Gates Foundation to the University of California, Berkeley. REGISTRATION Trial registration identifiers (http://www.clinicaltrials.gov): NCT01590095 (Bangladesh), NCT01704105 (Kenya).
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Affiliation(s)
- Benjamin F Arnold
- School of Public Health, University of California, Berkeley, California, USA
| | - Clair Null
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Innovations for Poverty Action, New Haven, Connecticut, USA
| | - Stephen P Luby
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Stanford University, Stanford, California, USA
| | - Leanne Unicomb
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Christine P Stewart
- Program in International and Community Nutrition, University of California, Davis, California, USA
| | - Kathryn G Dewey
- Program in International and Community Nutrition, University of California, Davis, California, USA
| | - Tahmeed Ahmed
- Centre for Nutrition & Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- BRAC University, James P Grant School of Public Health, Dhaka, Bangladesh
| | - Sania Ashraf
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Garret Christensen
- Innovations for Poverty Action, New Haven, Connecticut, USA
- Department of Economics, Swarthmore College, Swarthmore, Pennsylvania, USA
| | - Thomas Clasen
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Holly N Dentz
- Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Innovations for Poverty Action, New Haven, Connecticut, USA
| | - Lia C H Fernald
- School of Public Health, University of California, Berkeley, California, USA
| | - Rashidul Haque
- Centre for Communicable Diseases, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
- Centre for Communicable Diseases and Centre for Vaccine Sciences, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Alan E Hubbard
- School of Public Health, University of California, Berkeley, California, USA
| | - Patricia Kariger
- School of Public Health, University of California, Berkeley, California, USA
| | - Elli Leontsini
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Audrie Lin
- School of Public Health, University of California, Berkeley, California, USA
| | - Sammy M Njenga
- Eastern & Southern Africa Centre of International Parasite Control, Kenya Medical Research Institute, Nairobi, Kenya
| | - Amy J Pickering
- Civil and Environmental Engineering, Stanford University, Stanford, California, USA
| | - Pavani K Ram
- School of Public Health and Health Professions, State University of New York at Buffalo, Buffalo, New York, USA
| | - Fahmida Tofail
- Centre for Nutrition & Food Security, International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Peter J Winch
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - John M Colford
- School of Public Health, University of California, Berkeley, California, USA
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