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Sclar GD, Bauza V, Bisoyi A, Majorin F, Mosler HJ, Clasen TF. Effect of a behavior change and hardware intervention on safe child feces management practices in rural Odisha, India: a cluster-randomized controlled trial. BMC Public Health 2024; 24:2327. [PMID: 39192252 DOI: 10.1186/s12889-024-19272-5] [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: 11/14/2023] [Accepted: 06/25/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Poor child feces management contributes to enteropathogen exposure and, consequently, is associated with diarrheal disease and negative impacts on child growth. Despite high latrine coverage, only 37% of Indian households safely dispose of their child's feces into a latrine or have the child use the latrine, with the lowest rate in the state of Odisha at 12%. We evaluated a behavior change and hardware intervention designed to improve caregiver safe disposal of child feces and child latrine use. METHODS We conducted a cluster-randomized controlled trial among 74 villages in rural Odisha, India. Eligible villages previously participated in a water and sanitation infrastructure program. Following a baseline survey, half the villages were assigned to intervention and half to control. Caregivers of children < 5 years old from households with a latrine were eligible to participate. The intervention included five behavior change activities. Hardware was provided at the first activity, based on child age, to aid safe disposal and latrine training (wash basin and bucket with lid for children < 7 months old; latrine training mat platform with removable tray for children 7 to 48 months old). The primary outcome was caregiver reported 'safe disposal' as defined by the WHO/UNICEF Joint Monitoring Programme (JMP) which encompasses two behaviors: caregiver disposal of child's feces into a latrine and child latrine use. Safe disposal was measured four to six months after intervention delivery (endline). RESULTS Endline analysis included 665 intervention caregivers (840 children) and 634 control caregivers (785 children). Prevalence of JMP-defined safe disposal was 1.16 times greater in the intervention arm compared to control (77.7% vs. 65.9%; prevalence ratio [PR] 1.16, 95% CI 1.04-1.29), with higher prevalence of caregiver safe disposal (18.6% vs. 13.6%; PR 1.46, 95% CI 1.12-1.92) but no significant difference in child latrine use (59.0% vs. 52.2%; PR 1.06, 95% CI 0.95-1.18). When restricted to children < 3 years old, JMP-defined safe disposal was 1.42 times greater (67.5% vs. 46.7%; PR 1.42 95% CI 1.21-1.67) with higher prevalence of both caregiver safe disposal (34.6% vs. 25.7%; PR 1.44, 95% CI 1.11-1.86) and child latrine use (32.9% vs. 20.9%; PR 1.41, 95% CI 1.08-1.83). CONCLUSIONS The intervention increased JMP-defined safe disposal, with substantial improvements in both caregiver safe disposal and child latrine use among children < 3 years old. While future research is needed to demonstrate sustainability of these effects, our results suggest a potentially scalable intervention for improving child feces disposal and reducing disease. TRIAL REGISTRATION This trial was retrospectively registered at ISRCTN15831099 on 18/02/2020, which was approximately two months after the first participant was recruited for the baseline survey on 02/12/2019.
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Affiliation(s)
- Gloria D Sclar
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
- Department of Psychology, University of Zürich, Zürich, Switzerland.
| | - Valerie Bauza
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Fiona Majorin
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Thomas F Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Contreras JD, Islam M, Mertens A, Pickering AJ, Arnold BF, Benjamin-Chung J, Hubbard AE, Rahman M, Unicomb L, Luby SP, Colford JM, Ercumen A. Improved Child Feces Management Mediates Reductions in Childhood Diarrhea from an On-Site Sanitation Intervention: Causal Mediation Analysis of a Cluster-Randomized Trial in Rural Bangladesh. J Epidemiol Glob Health 2024:10.1007/s44197-024-00210-y. [PMID: 38507184 DOI: 10.1007/s44197-024-00210-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/14/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND The WASH benefits Bangladesh trial multi-component sanitation intervention reduced diarrheal disease among children < 5 years. Intervention components included latrine upgrades, child feces management tools, and behavioral promotion. It remains unclear which components most impacted diarrhea. METHODS We conducted mediation analysis within a subset of households (n = 720) from the sanitation and control arms. Potential mediators were categorized into indicators of latrine quality, latrine use practices, and feces management practices. We estimated average causal mediation effects (ACME) as prevalence differences (PD), defined as the intervention's effect on diarrhea through its effect on the mediator. RESULTS The intervention improved all indicators compared to controls. We found significant mediation through multiple latrine use and feces management practice indicators. The strongest mediators during monsoon seasons were reduced open defecation among children aged < 3 and 3-8 years, and increased disposal of child feces into latrines. The strongest mediators during dry seasons were access to a flush/pour-flush latrine, reduced open defecation among children aged 3-8 years, and increased disposal of child feces into latrines. Individual mediation effects were small (PD = 0.5-2 percentage points) compared to the overall intervention effect but collectively describe significant mediation pathways. DISCUSSION The effect of the WASH Benefits Bangladesh sanitation intervention on diarrheal disease was mediated through improved child feces management and reduced child open defecation. Although the intervention significantly improved latrine quality, relatively high latrine quality at baseline may have limited benefits from additional improvements. Targeting safe child feces management may increase the health benefits of rural sanitation interventions.
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Affiliation(s)
- Jesse D Contreras
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, 48103, USA
| | - Mahfuza Islam
- Department of Environmental Health Sciences, School of Public Health, University of California, Berkeley, Berkeley, CA, 94720, USA
| | - Andrew Mertens
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, CA, 94720, USA
| | - Amy J Pickering
- Department of Civil and Environmental Engineering, University of California, Berkeley, Berkeley, CA, 94720, USA
- Chan Zuckerberg Biohub, San Francisco, CA, 94158, USA
| | - Benjamin F Arnold
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, CA, 94158, USA
| | - Jade Benjamin-Chung
- Chan Zuckerberg Biohub, San Francisco, CA, 94158, USA
- Department of Epidemiology and Population Health, Stanford University, Palo Alto, CA, 94304, USA
| | - Alan E Hubbard
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, CA, 94720, USA
| | - Mahbubur Rahman
- Environmental Health and WASH, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, 1212, Bangladesh
| | - Leanne Unicomb
- Environmental Health and WASH, Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), Dhaka, 1212, Bangladesh
| | - Stephen P Luby
- Woods Institute for the Environment, Stanford University, Stanford, CA, 94305, USA
| | - John M Colford
- Division of Epidemiology and Biostatistics, School of Public Health, University of California, Berkeley, Berkeley, CA, 94720, USA
| | - Ayse Ercumen
- Department of Forestry and Environmental Resources, North Carolina State University, Raleigh, NC, 27695, USA.
- Jordan Hall Addition 2225, Raleigh, NC, 27606, USA.
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Behera D, Mohanta N, Behera MR, Tripathy S, Kumar A. Examining toilet use and menstrual hygiene practices among beneficiary households of Swachh Bharat Abhiyaan (Clean India Mission) in rural areas of Mayurbhanj district of Odisha, India. J Family Med Prim Care 2024; 13:971-976. [PMID: 38736784 PMCID: PMC11086773 DOI: 10.4103/jfmpc.jfmpc_1424_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 05/14/2024] Open
Abstract
Background Basic sanitation and waste management have always remained a central issue in India. The country launched its flagship sanitation program - Swachh Bharat Abhiyan (SBA) (Clean India Mission) in 2014 to abolish open defecation and achieve universal sanitation coverage. Objective This study aimed to examine barriers to toilet use and women's menstrual hygiene practices in relation to the availability of toilets among rural residents. Materials and Methods Using a cross-sectional design and multi-stage sampling method, 120 households were selected from rural villages of the Mayurbhanj district of Odisha. Structured questionnaires and direct observation methods were used for data collection. Results All the houses had SBA latrines, yet 25% population defecated outside. About 40% households reportedly never cleaned their toilets. Most menstruating women (86.2%) preferred to change their menstrual pads/cloths in their bedroom instead of bathrooms. Incomplete construction was reported as the major reason for not using toilets. Large family size and low caste were found to be other predictors of non-use of toilets. Rural women did not use toilets for menstrual purposes as they do not consider these places as clean and safe. Conclusion This study clearly suggests that constructing toilets without adequate behaviour change interventions would not solve the problem of hygiene and sanitation in India, particularly in rural areas. There must be adequate monitoring of SBA scheme and utilization of funds for toilet usage. Development and implementation of suitable behaviour change strategies for toilet use in rural areas are essential to achieve the goal of open defaecation-free India.
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Affiliation(s)
- Deepanjali Behera
- School of Public Health, Kalinga Institute of Industrial Technology (KIIT) Deemed to be University, Bhubaneswar, Odisha, India
| | - Namrata Mohanta
- Centre for Stem Cell Research, Christian Medical College (CMC), Vellore, Tamil Nadu, India
| | - Manas R. Behera
- School of Public Health, Kalinga Institute of Industrial Technology (KIIT) Deemed to be University, Bhubaneswar, Odisha, India
| | - Snehasish Tripathy
- Department of Dental Research Cell, Dr. D. Y. Patil Dental College and Hospital, Dr. D. Y. Patil Vidyapeeth, Pune, India
| | - Abhishek Kumar
- Department of Business Consulting - Transformation Delivery, Ernst and Young LLP, Bhubaneswar, Odisha, India
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Nazar SZA, Narayanappa C, Daniel D. Perception and Disposal Practices of Toddler Feces by Mothers in Suburban Area of Kendari, Indonesia. WHO South East Asia J Public Health 2024; 13:29-34. [PMID: 39167133 DOI: 10.4103/who-seajph.who-seajph_198_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/29/2024] [Indexed: 08/23/2024]
Abstract
Unsafe child feces disposal (CFD) is another form of open defecation and can pose a risk of disease in children. More than 30% of Indonesian households practice unsafe CFD, yet, its determinants are unknown. This study aims to identify the contextual and behavioral determinants of CFD through the lens of the Risk, Attitude, Norm, Ability, and Self-regulation (RANAS) framework. The cross-sectional study was conducted in 349 households in the suburbs of Kendari City, Southeast Sulawesi Province, Indonesia, in mid-2023. About 64% of the respondents practiced unsafe CFD. Most respondents used diapers that were immediately thrown into the trash without cleaning (i.e., 60.2%). Logistic regression analysis found two significant contextual factors associated with safe CFD: having received sanitation-related information and toddler age, i.e., children below 5 years old. Perceived severity was the most influential psychological factor behind the CFD practice, followed by knowledge. This study suggests that informing caregivers about the negative health effects of practicing unsafe CFD, especially on their children, can be a positive trigger for them to practice safe CFD. In addition, the promotion of early toilet initiation and recycling programs for used diaper waste should also be conducted to ensure comprehensive CFD management.
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Affiliation(s)
| | - Chandana Narayanappa
- Center for Emerging Technologies for Sustainable Development, Indian Institute of Technology, Jodhpur, Rajasthan, India
| | - D Daniel
- Department of Health Behaviour Environment and Social Medicine, Faculty of Medicine, Public Health and Nursing, Gadjah Mada University, Yogyakarta, Indonesia
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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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Anderson DM, Bear AB, Zacher T, Endres K, Saxton R, Richards F, Robe LB, Harvey D, Best LG, Cloud RR, Thomas ED, Gittelsohn J, O’Leary M, Navas-Acien A, George CM. Implementing a Community-Led Arsenic Mitigation Intervention for Private Well Users in American Indian Communities: A Qualitative Evaluation of the Strong Heart Water Study Program. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:2681. [PMID: 36768048 PMCID: PMC9915175 DOI: 10.3390/ijerph20032681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/22/2023] [Accepted: 01/25/2023] [Indexed: 06/18/2023]
Abstract
Arsenic is a naturally occurring toxicant in groundwater, which increases cancer and cardiovascular disease risk. American Indian populations are disproportionately exposed to arsenic in drinking water. The Strong Heart Water Study (SHWS), through a community-centered approach for intervention development and implementation, delivered an arsenic mitigation program for private well users in American Indian communities. The SHWS program comprised community-led water arsenic testing, point-of-use arsenic filter installation, and a mobile health program to promote sustained filter use and maintenance (i.e., changing the filter cartridge). Half of enrolled households received additional in-person behavior change communication and videos. Our objectives for this study were to assess successes, barriers, and facilitators in the implementation, use, and maintenance of the program among implementers and recipients. We conducted 45 semi-structured interviews with implementers and SHWS program recipients. We analyzed barriers and facilitators using the Consolidated Framework for Implementation Research and the Risks, Attitudes, Norms, Abilities, and Self-regulation model. At the implementer level, facilitators included building rapport and trust between implementers and participating households. Barriers included the remoteness of households, coordinating with community plumbers for arsenic filter installation, and difficulty securing a local supplier for replacement filter cartridges. At the recipient level, facilitators included knowledge of the arsenic health risks, perceived effectiveness of the filter, and visual cues to promote habit formation. Barriers included attitudes towards water taste and temperature and inability to procure or install replacement filter cartridges. This study offers insights into the successes and challenges of implementing an arsenic mitigation program tailored to American Indian households, which can inform future programs in partnership with these and potentially similar affected communities. Our study suggests that building credibility and trust between implementers and participants is important for the success of arsenic mitigation programs.
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Affiliation(s)
- Darcy M. Anderson
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Annabelle Black Bear
- Missouri Breaks Industries Research, Cheyenne River Sioux Tribe, Eagle Butte, SD 57625, USA
| | - Tracy Zacher
- Missouri Breaks Industries Research, Cheyenne River Sioux Tribe, Eagle Butte, SD 57625, USA
| | - Kelly Endres
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Ronald Saxton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Francine Richards
- Missouri Breaks Industries Research, Cheyenne River Sioux Tribe, Eagle Butte, SD 57625, USA
| | - Lisa Bear Robe
- Missouri Breaks Industries Research, Cheyenne River Sioux Tribe, Eagle Butte, SD 57625, USA
| | - David Harvey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
- Indian Health Service, Rockville, MD 20857, USA
| | - Lyle G. Best
- Missouri Breaks Industries Research, Cheyenne River Sioux Tribe, Eagle Butte, SD 57625, USA
| | - Reno Red Cloud
- Environmental Resource Department, Oglala Sioux Tribe, Pine Ridge, SD 57770, USA
| | - Elizabeth D. Thomas
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Joel Gittelsohn
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Marcia O’Leary
- Missouri Breaks Industries Research, Cheyenne River Sioux Tribe, Eagle Butte, SD 57625, USA
| | - Ana Navas-Acien
- Department of Environmental Health Science, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Christine Marie George
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
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Sclar GD, Bauza V, Bisoyi A, Clasen TF, Mosler HJ. Contextual and psychosocial factors influencing caregiver safe disposal of child feces and child latrine training in rural Odisha, India. PLoS One 2022; 17:e0274069. [PMID: 36083872 PMCID: PMC9462565 DOI: 10.1371/journal.pone.0274069] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 08/21/2022] [Indexed: 11/25/2022] Open
Abstract
Child feces are an important source of fecal exposure in household environments. Typically, one of two behaviors is necessary to mitigate this risk: either caregivers dispose of their children's feces into a latrine or children learn how to use a latrine. Although past studies have examined factors associated with these two behaviors collectively (i.e. "safe disposal"), there is a need to separately analyze these distinctive practices to better inform programming. This study aims to quantitatively examine contextual and psychosocial factors influencing caregiver safe disposal and, separately, child latrine training. We surveyed 791 primary female caregivers, who reported on 906 children <5 years old, across 74 villages in rural Odisha, India. At their last defecation event, 38% of children used the latrine and another 10% had their feces safely disposed of into the latrine. Since caregiver safe disposal was rare, we instead assessed safe disposal intention. We used linear regression and multilevel mixed effects models to examine contextual and psychosocial factors. For contextual factors, we found caregivers had stronger safe disposal intention when they came from wealthier households and had greater informational support, but weaker intention when their latrine was near the household. Caregivers more intensely practiced latrine training with their child when they themselves used the latrine for defecation, the latrine was fully intact, and they had greater instrumental support. For psychosocial factors, caregivers had stronger safe disposal intention when their households expected them to practice safe disposal, they felt strongly committed to the behavior, and had a plan for what to do when faced with a water shortage. Caregivers more intensely taught their child how to use the latrine when they believed their child was at risk of becoming sick if they practiced open defecation (OD); viewed child OD as unbeneficial; liked teaching their child; personally felt it was important for the child's father to help; felt confident in their ability to teach their child; and had greater action control over their training practice. Interestingly, caregivers put less effort into latrine training when they felt more concerned for their child's safety when the child defecated outside. These findings underscore the critical need to separately assess unique child feces management (CFM) practices and also provide a road map for practitioners on the types of behavior change strategies to consider in their CFM programming.
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Affiliation(s)
- Gloria D. Sclar
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- Department of Psychology, University of Zürich, Zürich, Switzerland
| | - Valerie Bauza
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | | | - Thomas F. Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
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Global practices, geographic variation, and determinants of child feces disposal in 42 low- and middle-income countries: An analysis of standardized cross-sectional national surveys from 2016 - 2020. Int J Hyg Environ Health 2022; 245:114024. [PMID: 36029740 PMCID: PMC9489922 DOI: 10.1016/j.ijheh.2022.114024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022]
Abstract
Background Despite considerable progress improving water and sanitation access globally, unsafe child feces disposal remains common in many low- and middle-income countries (LMICs), posing an important health risk. The present study characterizes the current prevalence of child feces disposal practices and child latrine use across low- and middle-income countries and investigates determinants associated with appropriate disposal practices. Methods Data for children ranging from 0 through 4 years of age were analyzed from standardized and nationally-representative surveys of 42 LMICs collected from 2016 to 2020 to assess child feces disposal practices. We report child feces disposal in three categories: disposal in any type of latrine, disposal in an improved latrine, and disposal through means other than in a latrine. Survey weighted multiple Poisson regression models were used to explore factors associated with these practices. Results Data on 403,036 children (weighted N = 191 million) demonstrated that a minority (40.3%) of children have their feces disposed of in a latrine of any kind, and just 29% have feces disposed of in an improved latrine. Prevalence varied considerably by country and region. In adjusted analyses, both child feces disposal in any latrine and disposal in an improved latrine increased with child age, higher intra-country relative wealth, and urban living, and decreased with breastfeeding and shared sanitation facilities. Disposal in improved latrines additionally increased with access to higher levels of service for drinking water and higher mother's education. Nevertheless, the role of facility access alone was insufficient, as only about half of children with household access to any latrine or improved latrines had their feces disposed of in these facilities. Child latrine use among households with latrine access was also low and highly variable across countries. Conclusions Children's feces in LMICs are infrequently disposed of in any latrine type, and even less frequently in improved latrines. In order to minimize health risks in LMICs, increased effort must be undertaken not just to increase sanitation coverage but to address these common barriers to safe child feces disposal and child latrine use. Global child feces disposal in latrines is low and variable between countries. Latrine access is insufficient to explain low use for child feces management. Household relative wealth is associated with increased disposal in latrines. Child latrine use increases with age but remains low and varied between countries.
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