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

Child feces disposal practices in humanitarian and non-humanitarian settings across 34 low- and middle-income countries

Globally, safe sanitation has improved significantly in the last two decades, but unsafe child feces disposal remains a growing challenge in many regions, exposing household members and communities to infectious pathogens. The drivers associated with child feces disposal in several contexts including humanitarian settings are not well understood. This study investigated child feces disposal (CFD) practices and associated factors in low- and middle-income countries, including in humanitarian settings. Data from 352,173 women in 34 countries, collected between 2012 and 2021 through Demographic and Health Surveys (DHS), were used. We utilized multivariate logistic regression to assess CFD practices among children under two years old and the factors linked to these practices. We incorporated data from the United Nations High Commissioner for Refugees (UNHCR) regarding refugee camps' locations in the analysis. Time series and local spatial autocorrelation analyses were run to examine changes in safe CFD practices over time and space, respectively. Results showed minimal improvement in safe child feces disposal over the past decade, with 55.6 % of respondents in non-humanitarian settings and 38.1 % in humanitarian settings improperly disposing of feces. Improper CFD significantly correlated with increased odds of diarrhea in non-humanitarian settings (OR 1.09 95 % CI: 1.05-1.13) but not in humanitarian settings (OR 1.14 95 % CI: 0.53-2.49). The most significant factors (p < 0.05) associated with safe CFD included being in the richest wealth quintile (OR 3.27 95 % CI: 3.06-3.49), having basic education (OR 1.28 95 % CI: 1.22-1.33), children eating solid food (OR 1.53 95 % CI: 1.48-1.57), improved sanitation access (OR 1.88 95 % CI: 1.81-1.96), and listening to radio at least weekly (OR 1.40 95 % CI: 135-1.46). Policymakers and development partners must include safe CFD guidelines in national policies and programs, as well as prioritize investments in household-level sanitation and educate caregivers about safe CFD practices.

Does owning improved latrine facilities enhance the safe disposal of child feces in Africa? a systematic review and meta-analysis

INTRODUCTION

Improved sanitation refers to those that effectively avoid human contact with excreta in a hygienic manner. Having improved latrines is a key factor in adopting safe ways of disposing of child feces. However, previous studies in Africa that examined how owning improved latrine facilities associated with household child feces disposal practices has shown inconsistent results, and no systematic review of these findings has been done. Therefore, this study aims to synthesize the evidence on the significance of households having improved latrine facilities for safe child feces disposal practices among households with under five-year-old children in Africa.

METHODS

The searched databases include: PubMed/Medline, Ovid/Embase, ScienceDirect, AJOL and the Cochrane Library. In the search process, Google Scholar and references of other studies were considered. This review included studies that were published in English without any time restrictions. The outcome of this study was an estimate of the association between the ownership of an improved latrine and the disposal practices of children's feces. Two reviewers used the Excel data extraction tool to extract the relevant data from the studies that were included in the review. Using Stata version 16, a meta-analysis was performed with a random effects statistical model. The inverse index of variance (I2) was used to assess heterogeneity. Forest plots were used to show the pooled estimate with a 95% confidence interval. Publication bias was assessed using Egger's test and a funnel plot.

RESULTS

Out of the 616 studies that were retrieved, 15 were included in the systematic review analysis and 10 were included in the meta-analysis. All studies that were included are cross-sectional studies done in Ethiopia, Nigeria, Gambia, Malawi, Eswatini, Ghana, Zambia, and a study used data from sub-Saharan Africa. Improved latrine facilities significantly enhanced the practice of safe child feces disposal, as shown by the overall effect size (OR = 2.74; 95% CI = 1.24-1.35, I2  =  99.95%). In the subgroup analysis by sample size, the presence of improved latrines significantly enhanced safe child feces disposal in studies with sample sizes less than 1000 (OR = 3.24; 95% CI = 2.86-3.62, I2  =  61.38%), while there was no significant difference in studies with sample sizes greater than 1000 (OR = 2.67; 95% CI = 0.69-4.64, I2  =  99.97%). However, studies that involved children under 5 years old indicated that improved latrine facilities significantly enhanced the practice of safe child feces disposal (OR = 4.02; 95% CI = 2.03-6.09; I2  =  99.96%).

CONCLUSIONS

In this research study, we examined the ownership of improved latrine facilities among households with five-year-old children to enhance the disposal of child feces in a safer manner in Africa. The high heterogeneity among the studies and the cross-sectional design of the included studies limit the causal inference and generalizability of the findings. Therefore, meta-analyses of longitudinal and experimental studies are needed to confirm the causal relationship between improved latrine facilities and safe child feces disposal practices in Africa.

Decomposing rural-urban gap in unsafe disposal practice of child stool in India using nationwide sample survey data

A significant rural-urban disparity in unsafe child stool disposal practices exists in India, yet existing research falls short in identifying the contributing factors to this gap. This study addresses the research gap by contextualizing the rural-urban divide in unsafe child stool disposal using data from the fifth round of the National Family Health Survey (NFHS-5, 2019-21). In particular, the study examines the prevalence and predictors of unsafe disposal practices, exploring associated contributing factors to this gap. The study involves a sample of 78,074 women aged 15-49 with a living child under 2 years, without any missing data related to the study interest. Employing descriptive statistics, the Pearson chi-square test, multilevel logistic regression, and the Fairlie decomposition model, the research aims to fulfill its objectives. The rural-urban gap in unsafe child stool disposal practices among the study participants was 22.3 percentage points (pp), with a more pronounced gap among the Scheduled Tribes (ST). Notably, the gap was particularly wide in Madhya Pradesh (33.9 pp), Telangana (27.5 pp), Gujarat (26.1 pp), and Rajasthan (25.8 pp). Predictors such as mother's education, mass media exposure, household wealth quintile, and sanitation facilities proved significant irrespective of residence. However, religion, social group, and water facility on household premises emerged as significant factors in rural areas only. The study identified that 67% of the explained gap in unsafe child stool disposal practices was attributed to the rural-urban difference in household wealth. Other noteworthy contributors were 'household sanitation facility' (21.3%), 'mother's education level' (3.9%), and 'water facility on household premises' (3.9%). These findings underscore the need for population and area-specific policy interventions, especially for individuals from socio-economically disadvantaged backgrounds, those with lower education levels, and limited exposure to mass media, particularly in states with a high prevalence of unsafe disposal practices. Such interventions are crucial to mitigating the existing rural-urban gap in unsafe child stool disposal practices.

Exploring drivers of unsafe disposal of child stool in India using hierarchical regression model

BACKGROUND

Disposal of children's stools is often neglected in Indian sanitation programs, putting them at higher risk of diseases transmitted through the fecal-oral route. Therefore, the current study aims to identify the socioeconomic and demographic factors associated with the unsafe disposal of child stool in India and to estimate the geographical variation in unsafe disposal.

METHODS

The study used 78,074 births under two years from the fifth round of the National Family Health Survey (2019-21). Descriptive statistics, bivariate analysis with the chi-square test, and a four-level hierarchical logistic regression model were applied to accomplish the study objectives.

RESULTS

Findings revealed a 61.3% prevalence of unsafe stool disposal nationwide, significantly varying between rural (45%) and urban (67%) areas. Multilevel logistic regression highlighted that mother's education, wealth quintile, and sanitation facility were significant predictors of unsafe disposal of child stools. Random intercept statistics revealed a substantial geographical unit-level variance in unsafe stool practice in India.

CONCLUSION

The study emphasizes the widespread unsafe disposal of child stool among Indian mothers with young children below two years, and the study underscores a range of contributing factors, including education, media exposure, prosperity, water availability, and sanitation. It also accentuates the significance of the geographical variance in the unsafe disposal of child stool in India, particularly at the household level, followed by the community level. Hence, the findings underscore the importance of focused interventions, including targeted household-level poverty alleviation programs, initiatives to enhance sanitation and water facilities, and community-level public health awareness programs.

Factors associated with rural-urban safe disposal of children stools in Ghana

INTRODUCTION

The burden of children's disease in many low-and middle-income countries is associated with poor sanitation, including unsafe disposal of children's stool. Infants and toddler stools pose a greater public health risk than adults. Studies on stool disposal in Sub-Saharan Africa (SSA) and Ghana have focused on prevalence, patterns, and associated factors. Nevertheless, these studies have not focused on factors that independently influence rural and/or urban child stool disposal. This study, therefore, examines factors associated with safe child stool disposal in rural areas separately from urban areas towards Ghana's readiness for ending open defaecation by 2030.

METHODOLOGY

We examined young children's faecal disposal drawing on the sixth round of the nationally-representative Ghana Multiple Indicator Cluster Survey (MICS) conducted in 2017/18. This study was restricted to children under two years, yielding a sub-sample of 3,476. Responses of caregivers or mothers who disposed of children less than two years faecal matter, their characteristics in addition to the child's age in months were analysed. A binary logistic regression was used to examine the factors associated with the safe disposal of young children's stools.

RESULTS

In the aggregated data, only 22% of households, regardless of their residence, dispose of their young children less than two years stools safely. From the disaggregated data, the rural analysis shows that 26% of young children's stools were safely disposed of, compared to 16% in the urban analysis. The urban analysis shows that the child's age, sex and caregiver's marital status were significantly associated with safe disposal of stools. On the other hand, child's age, caregiver listening to radio and household access to improved toilet facilities were significant in the rural analysis.

CONCLUSION

The safe practice of stool disposal was very low. The results of this study show that urgent and different policies and strategies are needed to address child stool disposal in urban residences compared to rural residences if we are to meet SDG targets of ending open defaecation.

No Child's Play: Under-five Child Feces Management in a Rural Area of Bengaluru Urban District, India

Background

Inappropriate feces disposal leads to environmental contamination, and increases the risk of exposure to children. We aimed to estimate the proportion of rural households with knowledge and practice of safe management of feces (SMoF) among under-five children and to identify associated factors.

Materials and Methods

A cross-sectional study was conducted in eight villages in Bengaluru Urban district over 2 months, using a face-validated semi-structured interview schedule. SMoF was defined based on five criteria - defecation site, transport tool, feces disposal, cleaning of transport tool, and hand washing.

Results

Out of 320 under-five children surveyed, 15.7% were pre-ambulatory and 84.3% were ambulatory. The majority of the caregivers (92.5%) felt that children should defecate in the latrine and only 23.7% were aware that child feces were more infectious than adult feces. SMoF was only practiced by caregivers of ambulatory children (52.6%). Households with older caregivers (P = 0.01) and those living in a pucca house (P = 0.02) with a latrine inside (P = 0.04) were found to practice SMoF. Children of households that practiced unsafe disposal of child feces experienced more diarrheal episodes (P = 0.04). Caregivers >20 years were found to have better odds of SMoF [20-25 years (adjusted odds ratio, aOR: 9.02), 26-30 years (aOR: 12.17), >30 years (aOR: 8.93)] compared to those <20 years.

Conclusion

The proportion of households with knowledge and practice of SMoF was low. Awareness of SMoF is essential to reduce the incidence of diarrheal diseases and improve sanitation. Our findings also call for awareness building at schools and colleges.

Effect of Positive Deviance Approach on Promotion of Safe Disposal of Child's Feces in Rural Tamil Nadu: A Community-Based Quasi-Experimental Study

Introduction

Safe disposal of feces is ensured when it is deposited into a toilet, whereas unsafe disposal of child's feces plays a crucial role in disease transmission and environmental pollution. These areas are overlooked by many sanitation promotion interventions.

Objective

To determine the effect of positive deviance (PD) approach on safe disposal of child's feces among households who owned a toilet.

Materials and Methods

A community-based quasi-experimental study was conducted in the four field practice villages of the Urban Health Training Center, Villupuram, for 18 months. Households who owned a toilet and had a child less than 5 years old were included. After IEC clearance, information was collected from a representative sample of 100 households before intervention and another 100 households after intervention. PD approach was applied for 6 months to promote safe disposal practices in the study villages. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software (version 24). The Chi-square test was used to determine the significance of difference between baseline and endline data. The effect size was calculated to estimate the magnitude of difference between baseline and endline data.

Results

Before intervention, only 3% of households disposed the feces into a toilet, while after intervention, almost 38% of households disposed in the toilet (χ2 = 37.39; df = 1; P = 0.001). The effect size (Cramer's V) was found to be 0.43.

Conclusion

PD approach demonstrated considerable improvements in safe disposal of child's feces in rural settings. Further, to sustain the behavior change, frequent reinforcement of key messages at frequent intervals needs to be emphasized.

Using intersectionality to study gender and antimicrobial resistance in low- and middle-income countries

Different sexes and genders experience differentiated risks of acquiring infections, including drug-resistant infections, and of becoming ill. Different genders also have different health-seeking behaviours that shape their likelihood of having access to and appropriately using and administering antimicrobials. Consequently, they are distinctly affected by antimicrobial resistance (AMR). As such, it is crucial to incorporate perspectives on sex and gender in the study of both AMR and antimicrobial use in order to present a full picture of AMR's drivers and impact. An intersectional approach to understanding gender and AMR can display how gender and other components 'intersect' to shape the experiences of individuals and groups affected by AMR. However, there are insufficient data on the burden of AMR disaggregated by gender and other socio-economic characteristics, and where available, it is fragmented. For example, to date, the best estimate of the global burden of bacterial AMR published in The Lancet does not consider gender or other social stratifiers in its analysis. To address this evidence gap, we undertook a scoping review to examine how sex and gender compounded by other axes of marginalization influence one's vulnerability and exposure to AMR as well as one's access to and use of antimicrobials. We undertook a gendered analysis of AMR, using intersectionality as a concept to help us understand the multiple and overlapping ways in which different people experience exposure vulnerability to AMR. This approach is crucial in informing a more nuanced view of the burden and drivers of AMR. The intersectional gender lens should be taken into account in AMR surveillance, antimicrobial stewardship, infection prevention and control and public and professional awareness efforts, both donor and government funded, as well as national and international policies and programmes tackling AMR such as through national action plans.

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

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.

Associated factors of safe child feces disposal in sub-Saharan Africa: Evidence from recent demographic and health surveys of 34 sub-Saharan countries

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.

Safe stool disposal and associated factors among mothers of children aged under-two years in Gambia: Evidence from Gambia Demographic Health Survey 2019/20

BACKGROUND

Appropriate disposal of child stool is vital in preventing the spread of faecal-oral diseases. According to WHO/ UNICEF Joint Monitoring Program, Safe child stool disposal includes disposing a stool in a Flush or pour-flush toilet/latrine (to a piped sewer system, septic tank, pit latrine), Ventilated improved pit (VIP) latrine or a Pit latrine with slab.

OBJECTIVE

The study aimed to assess safe child stool disposal practice and associated factors among mothers with children aged under-two years in Gambia.

METHODS

This study was based on a large community-based cross-sectional survey, conducted from 21 November 2019 to 30 March 2020 in Gambia. The survey employed a two-staged stratified cluster sampling technique to recruit study participants. Descriptive statistics and logistic regression models were used to summarize descriptive data and identify factors associated with safe waste disposal, respectively. A p-value of less than 0.05 and 95% confidence interval were used to determine statistical significance.

RESULTS

The prevalence of safe stool disposal among mothers with children aged under-two years were 56.3% (95% CI: 54.6%, 58.1%). Mothers aged 25-34 (AOR = 0.78 (95%CI: 0.62, 0.98)), the highest wealth quintile (AOR = 0.43 (95%CI: 0.33, 0.56)), being exposed to media (AOR = 1.37 (95%CI: 1.07, 1.76)), increasing age of children (AOR = 1.06 (1.05, 1.07)), Being employed (AOR = 1.31 (1.11, 1.55)) and Geographic region were significantly associated with safe child disposal practice.

CONCLUSION

The prevalence of safe child stool disposal was low in Gambia. Age of the mother, age of the child, region, wealth index, media exposure and occupational status of the mother were significantly associated with safe child stool disposal. Public health intervention strategies designed to promote safe child stools disposal need to conduct thorough community assessments to identify community-specific facilitators, needs and barriers. Additionally, public health experts and policy makers should take into consideration the geographical and wealth inequalities when designing programs aimed to improve safe child stool disposal practice.

A Community-Based Cross-Sectional Study on Latrine Utilization and Associated Factors Among Rural Community of East Meskan District, Gurage Zone, Southern Ethiopia

Background

Using sanitary facilities is proven to enhance health and halt the spread of fecal-to-oral disease. Despite efforts to improve the availability of latrine facilities in developing countries like Ethiopia, finding a village that is entirely free of open defecation remains difficult. To determine the need for intervention programs and promote regular latrine usage, local data is essential.

Objectives

This study aimed to assess latrine utilization and associated factors among households in East Meskan District, Southern Ethiopia.

Methods

A community-based cross-sectional study was conducted among 630 households from April 15 to May 30, 2022. A simple random sampling technique was used to select the study households. Data were collected using an interviewer-administered structured questionnaire and an observational checklist. The collected data were then entered into Epi-Info version 7.1 and analyzed using SPSS version 21. In binary logistic regression analysis, independent variables with a P-value < .25 were considered candidates for multiple logistic regression analysis. The association was expressed in odds ratio with a 95% confidence interval (CI), and significance was declared at P-value < .05 in the final model.

Results

The magnitude of latrine utilization was 73.3% (95% CI: 69.7, 76.8) in the study district. Husband being family head (adjusted odds ratio [AOR] = 12.9; 95% CI: 5.78 ,28.90), being female (AOR = 16.4; 95% CI: 6.52, 41.27), family size less than 5 (AOR = 24.2; 95% CI: 11.49, 51.09), absence of school children (AOR = 0.3; 95% CI: 0.13, 0.51), and greater than 2 years since latrine was constructed (AOR = 14; 95% CI: 7.18, 27.41) had a significant association with latrine utilization.

Conclusion

In this study, utilization of latrines was low compared to the national target plan. Family head, sex, family size, presence of school children, and length of years in which the latrine was constructed were factors associated with latrine utilization. Thus, regular supervision of early latrine construction and utilization in communities is essential.

Contextual and psychosocial factors influencing caregiver safe disposal of child feces and child latrine training in rural Odisha, India

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.

Formative Research Using Settings and Motives to Explore Child Faeces Disposal and Management in Rural Solomon Islands

Unsafe child faeces management can lead to adverse health and wellbeing outcomes for children. In Solomon Islands, diarrhoeal disease is a leading cause of under-5 mortality, though there is limited research into CFM practices and promotion of safe behaviours. The formative research applied a Behaviour-Centred Design framework to investigate the habits, motives and settings related to child faeces management in rural Solomon Islands villages. Data were collected through structured recall demonstrations by caregivers (n = 61), household infrastructure observations (n = 57), semi-structured interviews with caregivers (n = 121) and community leaders (n = 30), focus group discussions (n = 26), and three participatory activities with caregivers. The findings identified a range of CFM-related behaviours, some of which would be considered safe and some, such as outside defecation and disposal to a waterway, as unsafe. Convenience is important in shaping CFM practice and may help health benefits to be achieved without women bearing the cost of an increased work burden. Nurture and disgust may provide the basis for behaviour change communication in SI as they have elsewhere. Critically, the participation in and promotion of safe CFM by fathers in households should be promoted, and motivating such behaviours might be achieved through focus on nurture as a motive.

Hygienic Child Feces Disposal Practice and Its Associated Factors among Mothers/Caregivers of Under Five Children in West Armachiho District, Northwest Ethiopia

BACKGROUND

Children's feces are 5 times more dangerous than that of adults. Unhygienic disposal of child feces has been reported as one of the major sanitation problems in Sub-Saharan African countries. However, there is a scanty of information in the study area and evidences are insufficient in Ethiopia. Therefore, this study intends to assess child feces disposal practices and associated factors among Mothers/Caregivers of Under Five Children in West Armachiho District, Northwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted in the West Armachho district from March 10, 2019 to April 10, 2019 by using a multistage cluster sampling method. Binary and multivariable logistic regression models were employed to identify factors associated to child faces disposal practice. The adjusted odds ratio with a 95% confidence interval and a P-value of ⩽.05 were used to declare statistical significance.

RESULT

The proportion of safe child feces disposal practice was 37.8% (95% CI: 34.6-40.89). Child feces disposal practice was significantly associated with the age of the child (AOR = 5.07, 95% CI: 2.52-10.21), the educational status of fathers (AOR = 2.34, 95% CI: 1.05-5.25), getting health education (AOR = 2.77, 95% CI: 1.84-4.16), utilization of basic type of latrine (AOR = 2.79, 95% CI: 1.55-5.02), knowledge of feces disposal technology options (AOR = 2.58, 95% CI: 1.88-3.96), and media exposure about child feces (AOR = 1.88, 95% CI: 1.22-2.99).

CONCLUSION

The practice of safe CFD was low. Age of the child, fathers' educational status, receiving health education, basic type of latrine, feces disposal technology options used, and media exposure were independent predictors of safe CFD practice. Interventions need to be designed targeting safe CFD practices taking into account different media outlets and advocacy of improved sanitation technology use by policy makers.

A review of rural and peri-urban sanitation infrastructure in South-East Asia and the Western Pacific: Highlighting regional inequalities and limited data

Rural and peri-urban communities in developing countries rely on sanitation systems which are often unsafely managed. One of the major barriers to assess safely managed sanitation is a lack of data about the existing sanitation infrastructure and levels of containment safety. The aim was to review rural and peri-urban on-site sanitation studies in order to understand different infrastructure types, associated management practices and any impacts on human health. The scope was limited to South-East Asia and Western Pacific regions in order to better identify regional inequalities. Among the 155 reviewed articles, 73 studies (47%) linked sanitation infrastructure to poor human health. Nearly all articles reported latrine ownership (n = 149, 96%) while sanitation infrastructure types were covered less frequently (n = 104, 67%). In particular, there was a lack of published literature describing back-end characteristics (dimension and materials) (n = 12, 8%) and/or management practices (n = 4, 3%). This stems from a limited application of research methodologies that characterise sanitation infrastructure and faecal sludge management (containment, emptying and on-site treatment). Inequality between regions was prevalent with three quarters of the studies on latrine back-end infrastructure from Bangladesh and India in South-East Asia. A strategic research approach is needed to address the current knowledge gaps regarding sanitation infrastructure and safe faecal sludge management.

Formative Research to Design a Child-Friendly Latrine in Bangladesh

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.

A multilevel analysis of individual and contextual factors associated with the practice of safe disposal of children's faeces in sub-Saharan Africa

Background

Over the years, sanitation programs over the world have focused more on household sanitation, with limited attention towards the disposal of children’s stools. This lack of attention could be due to the misconception that children’s stools are harmless. The current study examined the individual and contextual predictors of safe disposal of children’s faeces among women in sub-Saharan Africa (SSA).

Methods

The study used secondary data involving 128,096 mother-child pairs of under-five children from the current Demographic and Health Surveys (DHS) in 15 sub-Saharan African countries from 2015 to 2018. Multilevel logistic analysis was used to assess the individual and contextual factors associated with the practice of safe disposal of children’s faeces. We presented the results as adjusted odds ratios (aOR) at a statistical significance of p< 0.05.

Results

The results show that 58.73% (57.79–59.68) of childbearing women in the 15 countries in SSA included in our study safely disposed off their children’s stools. This varied from as high as 85.90% (84.57–87.14) in Rwanda to as low as 26.38% (24.01–28.91) in Chad. At the individual level, the practice of safe disposal of children’s stools was more likely to occur among children aged 1, compared to those aged 0 [aOR = 1.74; 95% CI: 1.68–1.80] and those with diarrhoea compared to those without diarrhoea [aOR = 1.17, 95% CI: 1.13–1.21]. Mothers with primary level of education [aOR = 1.42, 95% CI: 1.30–1.5], those aged 35–39 [aOR = 1.20, 95% CI: 1.12–1.28], and those exposed to radio [aOR = 1.23, 95% CI: 1.20–1.27] were more likely to practice safe disposal of children’s stools. Conversely, the odds of safe disposal of children’s stool were lower among mothers who were married [aOR = 0.74, 95% CI: 0.69–0.80] and those who belonged to the Traditional African Religion [aOR = 0.64, 95% CI: 0.51–0.80]. With the contextual factors, women with improved water [aOR = 1.13, 95% CI: 1.10–1.16] and improved toilet facility [aOR = 5.75 95% CI: 5.55–5.95] had higher odds of safe disposal of children’s stool. On the other hand, mothers who lived in households with 5 or more children [aOR = 0.89, 95% CI: 0.86–0.93], those in rural areas [aOR = 0.86, 95% CI: 0.82–0.89], and those who lived in Central Africa [aOR = 0.19, 95% CI: 0.18–0.21] were less likely to practice safe disposal of children’s stools.

Conclusion

The findings indicate that between- and within-country contextual variations and commonalities need to be acknowledged in designing interventions to enhance safe disposal of children’s faeces. Audio-visual education on safe faecal disposal among rural women and large households can help enhance safe disposal. In light of the strong association between safe stool disposal and improved latrine use in SSA, governments need to develop feasible and cost-effective strategies to increase the number of households with access to improved toilet facilities.

Effect of sanitation improvements on soil-transmitted helminth eggs in courtyard soil from rural Bangladesh: Evidence from a cluster-randomized controlled trial

Improved sanitation has been hypothesized to reduce soil-transmitted helminth (STH) infections by reducing the prevalence and concentration of STH eggs/larvae in soil. We evaluated the effect of a randomized sanitation program (providing households with an improved dual-pit latrine, tools for child/animal feces management, and behavioral messaging) on reducing the prevalence and concentration of STH eggs in soil from household courtyards. We collected soil samples from 1405 households enrolled in the sanitation intervention (n = 419) and control (n = 914) groups of a cluster-randomized controlled trial (WASH Benefits) in rural Bangladesh approximately 2 years after the initiation of the interventions. We analyzed samples for Ascaris lumbricoides, Trichuris trichiura, and hookworm eggs by microscopy. We estimated prevalence ratios (PR) and egg count ratio (ECR) to compare the prevalence of STH eggs and arithmetic and geometric mean egg counts for STH eggs per gram of soil in the sanitation and control arms. Among intervention households, latrines achieved high and sustained user uptake by adults while child open defecation remained common and most households did not dispose of child feces hygienically. In courtyard soil from control households, the prevalence of any STH eggs was 75.7% and the prevalence of any larvated STH eggs was 67.3%. A. lumbricoides was detected in 63.0% of control samples and T. trichiura in 55.7% of control samples; hookworm was not detected in any sample. In the control arm, the arithmetic mean egg count for any STH was 3.96 eggs/dry gram, while the geometric mean was 1.58 eggs/dry gram. There was no difference between the intervention and control groups in the prevalence of any STH eggs (PR = 0.98 (95% CI: 0.91, 1.05)) or mean egg counts (ECR = 0.08 (95% CI: -0.10, 0.26) for geometric mean and 0.07 (95% CI: -0.22, 0.37) for arithmetic mean). Adjusted models gave similar results. A compound-level sanitation intervention that provided improved latrines and tools for disposal of child and animal feces did not have an impact on STH eggs in soil. In order to effectively reduce the prevalence and concentration of STH eggs in the environment, sustained, widespread use of sanitation strategies to isolate and hygienically dispose of child and animal feces may need to complement traditional strategies for containment of adult human feces. Trial Registration: NCT01590095.

Unhygienic stool-disposal practices among mothers of children under five in Cambodia: Evidence from a demographic and health survey

Background

Unhygienic disposal of children’s stools affects children’s health in terms of their susceptibility to many diseases. However, there are no existing studies into the impact of unhygienic stool disposal in Cambodia. Therefore, this study aimed to identify factors associated with the unhygienic disposal of children’s stools among children under the age of five in Cambodia.

Methods

An analytical cross-sectional study was conducted using data from the Cambodia Demographic and Health Survey (CDHS) 2014. A multivariable binary logistic regression was conducted using Stata to analyze factors associated with the unhygienic disposal of children’s stools.

Results

Overall, the prevalence of practicing unhygienic disposal of children’s stools was 29.27% (95%CI: 27.51%- 31.09%). Factors statistically associated with this practice were: living in the Central Plain, Plateau and Mountains, Coastal and Sea regions (AOR = 1.65; 95% CI: 1.33–2.04), (AOR = 2.53; 95% CI: 1.98–3.24) and (AOR = 4.16; 95% CI: 3.15–5.48) respectively, poor household wealth (AOR = 1.58; 95% CI: 1.31–1.91), the mother having no education (AOR = 1.45; 95% CI: 1.14–1.85), a high number of children aged under five (AOR = 1.11; 95% CI: 1.03–1.20), being in the “other” religious category (AOR = 1.77; 95% CI: 1.25–2.51), living in a household with unimproved toilet facilities (AOR = 1.22; 95% CI: 1.11–1.34), living in a household with inadequate hygiene (AOR = 1.33; 95% CI: 1.12–1.59), and the household not being visited by a family planning worker in the last year (AOR = 1.45; 95% CI: 1.19–1.77). However, an increase in the child’s age by even a month had significant negative associations with unhygienic practice (AOR = 0.65; 95% CI: 0.60–0.70), even when controlling for other covariates.

Conclusion

Almost one third of the mothers do not practice hygienic disposal of children’s stools in Cambodia. Unhygienic practices were more prevalent in certain regions, and were also associated with low wealth, lack of education, an increase in the number of children under five in the household, religion, lack of sanitation and access to healthcare professionals. Conversely, the child’s age was found to be positively associated with the hygienic disposal of children’s stools.

Geographical variation and factors associated with unsafe child stool disposal in Ethiopia: A spatial and multilevel analysis

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.

Associations Between Improved Water Supply and Sanitation Usage and Childhood Diarrhea in Ethiopia: An Analysis of the 2016 Demographic and Health Survey

BACKGROUND

Diarrheal disease is one of the leading causes of death in children under the age of 5. Access to and use of improved water and sanitation services is associated with this, but there is little country-level evidence for this relationship in Ethiopia. Therefore, associations between improved water supply and sanitation usage and childhood diarrhea in Ethiopia have been identified as the objective of this study.

METHODS

This study was a cross-sectional study using data from Ethiopia's 2016 Demographic and Health Survey. Through interviews with mothers/caregivers who had children under the age of 5 years, data was collected. The outcome of this study was the response of the mothers/caregivers interviewed to the 2-week occurrence of diarrhea. Logistic regression analysis was used to examine the relationship between dependent and independent variables.

RESULTS

The survey results found that the use of improved drinking water and latrine facilities was 59.3% (95% CI: 58.36-60.31) and 17.3% (95% CI: 16.59-18.09), respectively. With respect to the handling practices of child feces, 24.8% (95% CI: 23.8-25.70) of the child feces of the interviewed mothers/caregivers were disposed of safely. The prevalence of childhood diarrhea in the preceding 2 weeks was 11% (95% CI: 10.36-11.61). Residence of Somali Region (AOR = 1.81, 95% CI: 1.25-2.61), having more than 2 under-5 children (AOR = 1.21, 95% CI: 1.01-1.46), having more than 5 family members (AOR = 1.18, 95% CI: 1.03-1.36), sex of the indexed child (AOR = 0.88, 95% CI: 0.77-0.99) and unsafe child feces disposal practices (AOR: 1.32; 95% CI: 1.14-1.54) were significantly associated with childhood diarrhea.

CONCLUSION

Residing in the Somali region, having more than 2 children under the age of 5 and having more than 5 household members, indexed child sex, and safe disposal of child feces were significantly associated with diarrhea. Therefore, in Ethiopia, the prevention of childhood diarrhea should concentrate on eliminating household crowding and encouraging the safe disposal of child feces.

Are children's stools in Ghana disposed of safely? Evidence from the 2014 Ghana demographic and health survey

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.

Shared bacterial communities between soil, stored drinking water, and hands in rural Bangladeshi households

Understanding household-level transmission pathways of fecal pathogens can provide insight for developing effective strategies to reduce diarrheal illness in low- and middle-income countries. We applied whole bacterial community analysis to investigate pathways of bacterial transmission in 50 rural Bangladeshi households. SourceTracker was used to quantify the shared microbial community in household reservoirs (stored drinking water, soil, and hands) and estimate the percentage of fecal-associated bacteria from child and mothers' feces in these reservoirs. Among the reservoirs studied, most bacterial transfer occurred between mothers' and children's hands and between mothers' hands and stored water. The relative percentage of human fecal-associated bacteria in all household reservoirs was low. We also quantified the number of identical amplicon sequence variants within and between individual households to assess bacterial community exchange in the domestic environment. Intra-household sharing of bacteria between mothers' and children's hands and between hands and soil was significantly greater than inter-household sharing.

Assessing the prevalence trend of childhood pneumonia associated with indoor air pollution in Pakistan

The indoor air pollution (IAP) is one of the leading risk factors of childhood pneumonia in developing countries. This study makes the first attempt to examine the prevalence trend of pneumonia among under-five children in Pakistan in association with IAP-related factors, using bivariate and multivariate statistical methods. Three waves of Pakistan Demographic Health Survey for 2006-2007, 2012-2013, and 2017-2018 were used. Our study findings showed a steady decline in the prevalence of pneumonia synchronized with the decreased use of polluting fuel during the last decade (2006-2017). In bivariate regression, odd ratios of childhood pneumonia were 1.27 and 1.21 times higher in overcrowded houses in 2006-2007 and 2012-2013, respectively, and 1.25 times higher in families relying on biomass for cooking in 2017-2018. In the multivariate model, polluting fuel and overcrowded homes had higher adjusted odd ratios of pneumonia in all survey years, and children age 37-48 months, older mothers, and large birth sized children had lower AOR of pneumonia in 2006-2007 and 2012-2013. Countrywide promotion of IAP mitigation measures such as sponsoring cleaner fuels, separate place for cooking, and lessening home overcrowding may play a vital role in alleviating the prevalence of childhood pneumonia.

Individual and contextual factors associated with disposal of children's stools in Papua New Guinea: evidence from the 2016-2018 demographic and health survey

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.

Overweight and obesity among urban women with iron deficiency anaemia in Bangladesh

In this study, we aimed to determine the prevalence and factors associated with overweight and obesity among nonpregnant and nonlactating (NPNL) women of reproductive age with iron deficiency anaemia (IDA) in urban Bangladesh. We obtained data from the baseline assessment of a randomized control trial conducted among 525 women of reproductive age (18–49 years) with IDA (Hb < 12 gdl⁻¹ and serum ferritin <30 μg L⁻¹). The study was carried out in Mirpur, Dhaka, Bangladesh, between December 2017 and January 2019. We collected information on women's socio‐demographic characteristics and anthropometry. Body mass index (BMI) was calculated using the following formula: weight in kilograms per height in square metres. BMI ≥ 25–29.9 kg m⁻² was considered as overweight, whereas BMI ≥ 30 kg m⁻² as obese. A multivariable logistic regression model was used to ascertain the risk factors of overweight and obesity. The prevalence of overweight and obesity was 29.9% (95% CI: 26.0–34.0) and 13.1% (95% CI: 10.4–16.3), respectively. The combined prevalence of overweight and obesity was 43.0% (95% CI: 38.7–47.4). The multivariable analysis showed married women (aOR: 4.4; CI: 1.8–11.1), women aged 30–49 years (aOR: 7.6; CI: 2.4–24.1), unemployed women (aOR 1.5; CI: 1.0–2.4) and women from the wealthier households (aOR 3.9; CI: 2.3–6.8) had the highest risk of being overweight and obese compared with their counterparts. Both age and household wealth statuses showed dose–response relationships. Combination of overweight and obesity with IDA poses a particular challenge for public health interventions. The policymakers should consider what new interventions and policy initiatives are needed to address this combination of overweight and obesity with IDA.

Assessment of Knowledge, Attitudes, and Practices on Water, Sanitation, and Hygiene in Some Selected LGAs in Kaduna State, Northwestern Nigeria

Access to safe water, sanitation, and hygiene (WASH) facilities is a basic necessity for human livelihood, survival, and well-being. Adequate WASH facilities provision is a critical issue to most developing countries around the world including Nigeria. Knowledge, attitudes, and practices regarding WASH are integral to effective and sustainable WASH facilities provision. This study assessed the level of knowledge, behavior, and practices towards water, sanitation, and hygiene in Kaduna state, Nigeria, with a view to ensuring sustainable WASH facilities intervention in the region. Data collection tools included spot check observation and questionnaire involving 854 participants, selected from five local government areas (LGAs): Chikun, Kajuru, Soba, Kachia, and Zango Kataf. From the results, major drinking water sources were surface waters (52.5%) and unprotected hand dug wells (44.8%); only 46.2% treated their water supply and few (16.6%) used chlorination method. Pit latrine toilets were the major (76.5%) excreta disposal means, and open defecation practices were widespread (41.4%). Level of personal and environmental hygiene understanding was fairly good in all the local government areas, and 65.4% claimed to use water and soap for washing hands after defecation. Incidence of water related diseases is generally low in the area. Despite the commendable findings in the study areas, communities are still at risk due to lack of safe water supply and poor practices of home treatment and excreta disposal. Therefore provision of WASH facilities and WASH education is fundamental for ensuring public health in the study area.

Determinants of disposal of child faeces in latrines in urban slums of Odisha, India: a cross-sectional study

BACKGROUND

Even among households that have access to improved sanitation, children's faeces often do not end up in a latrine, the international criterion for safe disposal of child faeces.

METHODS

We collected data on possible determinants of safe child faeces disposal in a cross-sectional study of 851 children <5 y of age from 694 households in 42 slums in two cities in Odisha, India. Caregivers were asked about defecation and faeces disposal practices for all the children <5 y of age in the household.

RESULTS

Only a quarter (25.5%) of the 851 children's faeces were reported to be disposed of in a latrine. Even fewer (22.3%) of the 694 households reported that the faeces of all children <5 y of age in the home ended up in the latrine the last time the child defecated. In multivariate analysis, factors associated with being a safe disposal household were education and religion of the primary caregiver, number of children <5 y of age in the household, wealth, type and location of the latrine used by the household, household members >5 y of age using the latrine for defecation and mobility of children <5 y of age in the household.

CONCLUSIONS

Few households reported disposing of all of their children's faeces in a latrine. Improving latrine access and specific behaviour change interventions may improve this practice.

Child defecation and feces management practices in rural Bangladesh: Associations with fecal contamination, observed hand cleanliness and child diarrhea

Child open defecation is common in low-income countries and can lead to fecal exposure in the domestic environment. We assessed associations between child feces management practices vs. measures of contamination and child diarrhea among households with children <5 years in rural Bangladesh. We visited 360 households quarterly and recorded caregiver-reported diarrhea prevalence, and defecation and feces disposal practices for children <5 years. We examined caregiver and child hands for visible dirt and enumerated E. coli in child and caregiver hand rinse and stored drinking water samples. Safe child defecation (in latrine/potty) and safe feces disposal (in latrine) was reported by 21% and 23% of households, respectively. Controlling for potential confounders, households reporting unsafe child defecation had higher E. coli prevalence on child hands (prevalence ratio [PR] = 1.12, 1.04-1.20) and in stored water (PR = 1.12,1.03-1.21). Similarly, households reporting unsafe feces disposal had higher E. coli prevalence on child hands (PR = 1.11, 1.02-1.21) and in stored water (PR = 1.10, 1.03-1.18). Effects on E. coli levels were similar. Children in households with unsafe defecation and feces disposal had higher diarrhea prevalence but the associations were not statistically significant. Our findings suggest that unsafe child feces management may present a source of fecal exposure for young children.

Unsafe child feces disposal status in Ethiopia: what factors matter? Analysis of pooled data from four demographic and health surveys

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.

Impact of an intervention to improve pit latrine emptying practices in low income urban neighborhoods of Maputo, Mozambique

Safe fecal sludge management (FSM) – the hygienic emptying, transport, and treatment for reuse or disposal of fecal sludge – is an essential part of safely managed sanitation, especially in towns and cities in low- and middle-income countries with limited sewer coverage. The need for safe and affordable FSM services has become more acute as cities grow and densify. Hygienic pit-emptying uses equipment that limits direct human exposure with fecal sludge and hygienic transport conveys fecal sludge offsite for treatment. We evaluated whether a program of on-site sanitation infrastructure upgrades and FSM capacity development in urban Maputo, Mozambique resulted in more hygienic pit-emptying and safe transportation of fecal sludge. We compared reported emptying practices among multi-household compounds receiving sanitation upgrades with control compounds, both from the Maputo Sanitation (MapSan) trial at 24–36 months after the intervention. Intervention compounds (comprising 1–40 households, median = 3) received a subsidized pour-flush latrine to septic tank system that replaced an existing shared latrine; control compounds continued using existing shared latrines. We surveyed compound residents and analyzed available municipal data on FSM in the city. Due to the recent construction of the intervention, emptying was more frequent in control compounds: 5.6% (15/270) of intervention compounds and 30% (74/247) of controls had emptied their on-site sanitation system in the previous year. Among those compounds which had emptied a sanitation facility in the previous year, intervention compounds were 3.8 (95% CI: 1.4, 10) times more likely to have to done so hygienically. Results suggest that the construction of subsidized pour-flush sanitation systems increased hygienic emptying of fecal sludge in this setting. Further gains in hygienic emptying in urban Maputo may be limited by affordability and physical accessibility.

Interventions to improve disposal of child faeces for preventing diarrhoea and soil-transmitted helminth infection

BACKGROUND

Diarrhoea and soil-transmitted helminth (STH) infections represent a large disease burden worldwide, particularly in low-income countries. As the aetiological agents associated with diarrhoea and STHs are transmitted through faeces, the safe containment and management of human excreta has the potential to reduce exposure and disease. Child faeces may be an important source of exposure even among households with improved sanitation.

OBJECTIVES

To assess the effectiveness of interventions to improve the disposal of child faeces for preventing diarrhoea and STH infections.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, and 10 other databases. We also searched relevant conference proceedings, contacted researchers, searched websites for organizations, and checked references from identified studies. The date of last search was 27 September 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and non-randomized controlled studies (NRS) that compared interventions aiming to improve the disposal of faeces of children aged below five years in order to decrease direct or indirect human contact with such faeces with no intervention or a different intervention in children and adults.

DATA COLLECTION AND ANALYSIS

Two review authors selected eligible studies, extracted data, and assessed the risk of bias. We used meta-analyses to estimate pooled measures of effect where appropriate, or described the study results narratively. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Sixty-three studies covering more than 222,800 participants met the inclusion criteria. Twenty-two studies were cluster RCTs, four were controlled before-and-after studies (CBA), and 37 were NRS (27 case-control studies (one that included seven study sites), three controlled cohort studies, and seven controlled cross-sectional studies). Most study sites (56/69) were in low- or lower middle-income settings. Among studies using experimental study designs, most interventions included child faeces disposal messages along with other health education messages or other water, sanitation, and hygiene (WASH) hardware and software components. Among observational studies, the main risk factors relevant to this review were safe disposal of faeces in the latrine or defecation of children under five years of age in a latrine.Education and hygiene promotion interventions, including child faeces disposal messages (no hardware provision)Four RCTs found that diarrhoea incidence was lower, reducing the risk by an estimated 30% in children under six years old (rate ratio 0.71, 95% confidence interval (CI) 0.59 to 0.86; 2 trials, low-certainty evidence). Diarrhoea prevalence measured in two other RCTs in children under five years of age was lower, but evidence was low-certainty (risk ratio (RR) 0.93, 95% CI 0.84 to 1.04; low-certainty evidence).Two controlled cohort studies that evaluated such an intervention in Bangladesh did not detect a difference on diarrhoea prevalence (RR 0.91, 95% CI 0.64 to 1.28; very low-certainty evidence). Two controlled cross-sectional studies that evaluated the Health Extension Package in Ethiopia were associated with a lower two-week diarrhoea prevalence in 'model' households than in 'non-model households' (odds ratio (OR) 0.26, 95% CI 0.16 to 0.42; very low-certainty evidence).Programmes to end open defecation by all (termed community-led total sanitation (CLTS) interventions plus adaptations)Four RCTs measured diarrhoea prevalence and did not detect an effect in children under five years of age (RR 0.92, 95% CI 0.79 to 1.07; moderate-certainty evidence). The analysis of two trials did not demonstrate an effect of the interventions on STH infection prevalence in children (pooled RR 1.03, 95% CI 0.64 to 1.65; low-certainty evidence).One controlled cross-sectional study compared the prevalence of STH infection in open defecation-free (ODF) villages that had received a CLTS intervention with control villages and reported a higher level of STH infection in the intervention villages (RR 2.51, 95% CI 1.74 to 3.62; very low-certainty evidence).Sanitation hardware and behaviour change interventions, that included child faeces disposal hardware and messagingTwo RCTs had mixed results, with no overall effect on diarrhoea prevalence demonstrated in the pooled analysis (RR 0.79, 95% CI 0.49 to 1.26; very low-certainty evidence).WASH hardware and education/behaviour change interventionsOne RCT did not demonstrate an effect on diarrhoea prevalence (RR 1.15, 95% CI 0.93 to 1.41; very low-certainty evidence).Two CBAs reported that the intervention reduced diarrhoea incidence by about a quarter in children under five years of age, but evidence was very low-certainty (rate ratio 0.77, 95% CI 0.71 to 0.84). Another CBA reported that the intervention reduced the prevalence of STH in an intervention village compared to a control village, again with GRADE assessed at very low-certainty (OR 0.17, 95% CI 0.02 to 0.73).Case-control studiesPooled results from case-control studies that presented data for child faeces disposal indicated that disposal of faeces in the latrine was associated with lower odds of diarrhoea among all ages (OR 0.73, 95% CI: 0.62 to 0.85; 23 comparisons; very low-certainty evidence). Pooled results from case-control studies that presented data for children defecating in the latrine indicated that children using the latrine was associated with lower odds of diarrhoea in all ages (OR 0.54, 95% CI 0.33 to 0.90; 7 studies; very low-certainty evidence).

AUTHORS' CONCLUSIONS

Evidence suggests that the safe disposal of child faeces may be effective in preventing diarrhoea. However, the evidence is limited and of low certainty. The limited research on STH infections provides only low and very-low certainty evidence around effects, which means there is currently no reliable evidence that interventions to improve safe disposal of child faeces are effective in preventing such STH infections.While child faeces may represent a source of exposure to young children, interventions generally only address it as part of a broader sanitation initiative. There is a need for RCTs and other rigorous studies to assess the effectiveness and sustainability of different hardware and software interventions to improve the safe disposal of faeces of children of different age groups.

Prevalence and associated factors of safe and improved infant and young children stool disposal in Ethiopia: evidence from demographic and health survey

BACKGROUND

Infant and young children stools are often considered innocuous, and are not disposed of safely despite having a higher pathogen load than adult feces. In Ethiopia, sanitary management of young children's stool is often overlooked and transmission of fecal-oral diseases is still a significant health burden. The study, therefore, describes the prevalence and associated factors of safe and improved child stool disposal.

METHODS

Data from the fourth round of the Ethiopian Health and Demographic Survey (EDHS) conducted in 2016 was used for this analysis. Descriptive statistics were computed. Bivariate and multivariable logistic regression analyses were performed to identify factors associated with safe and improved child stool disposal.

RESULTS

The prevalence of safe and improved child stool disposal in Ethiopia was 36.9% (95%CI: 33.4-40.5%) and 5.3% (95%CI: 4.3-6.5%) respectively. There was regional variation in the prevalence of safe and improved child stool disposal. The odds of safe stool disposal among households with richest wealth index had 4.54 (AOR: 4.54; 95%CI: 2.89-7.12), richer 3.64 (AOR: 3.64; 95%CI: 2.46-5.38), middle 3.26 (AOR: 2.26; 95%CI: 2.27-4.68), and poorer 1.93 (AOR: 1.93; 95%CI: 1.39-2.68) times higher odds of practicing safe child stool disposal than households with poorest wealth index. Similarly, households found in richest, richer, middle, and poorer wealth index had also (AOR: 20.23; 95%CI: 8.59-47.66), (AOR: 12.53; 95%CI: 5.59-28.10) (AOR: 4.91; 95%CI: 1.92-12.55), and (AOR: 4.50; 95%CI: 2.06-9.84) higher odds of practicing improved child stool disposal than households from poorest wealth index respectively. The odds of safe child stool disposal were higher among households whose children age between 6 and 11 months (AOR: 1.57; 95%CI: 1.17-2.09), 12-17 months (AOR: 1.39; 95%CI: 1.00-1.95), and 18-23 months (AOR: 1.43; 95%CI: 1.03-1.99) than households whose children age between 0 and 5 months. The odds of safe child stool disposal were 1.31 (AOR: 1.31; 95%CI: 1.00-1.72) and 1.44 (AOR: 1.44; 95%CI: 1.04-2.01) times higher among mothers whose age between 25 and 34 and greater than 34 years compared to mothers whose age between 15 and 24 years, respectively. In addition, children's stools are more likely to be disposed of safely in urban households than in rural households (AOR: 3.12; 95%CI: 1.86-5.22). The present study also revealed households with access to improved sanitation facilities fail to use them for disposal of child stool (AOR: 0.99; 95% CI: 0.67-1.45).

CONCLUSIONS

The prevalence of safe and improved child stool disposal in Ethiopia was found to be very low. Household socio-demographic and economic determinate were the key factors associated with child stool disposal. Appropriate strategic interventions to ensure safe and improved child stool disposal in Ethiopia is necessary. In addition, integrating child stool management into the existing sanitation interventions programs should be strongly recommended.

Child Defecation and Feces Disposal Practices and Determinants among Households after a Combined Household-Level Piped Water and Sanitation Intervention in Rural Odisha, India

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.

Do Sanitation Improvements Reduce Fecal Contamination of Water, Hands, Food, Soil, and Flies? Evidence from a Cluster-Randomized Controlled Trial in Rural Bangladesh

Sanitation improvements have had limited effectiveness in reducing the spread of fecal pathogens into the environment. We conducted environmental measurements within a randomized controlled trial in Bangladesh that implemented individual and combined water treatment, sanitation, handwashing (WSH) and nutrition interventions (WASH Benefits, NCT01590095). Following approximately 4 months of intervention, we enrolled households in the trial's control, sanitation and combined WSH arms to assess whether sanitation improvements, alone and coupled with water treatment and handwashing, reduce fecal contamination in the domestic environment. We quantified fecal indicator bacteria in samples of drinking and ambient waters, child hands, food given to young children, courtyard soil and flies. In the WSH arm, Escherichia coli prevalence in stored drinking water was reduced by 62% (prevalence ratio = 0.38 (0.32, 0.44)) and E. coli concentration by 1-log (Δlog10 = -0.88 (-1.01, -0.75)). The interventions did not reduce E. coli along other sampled pathways. Ambient contamination remained high among intervention households. Potential reasons include noncommunity-level sanitation coverage, child open defecation, animal fecal sources, or naturalized E. coli in the environment. Future studies should explore potential threshold effects of different levels of community sanitation coverage on environmental contamination.

Cost and effectiveness of water, sanitation and hygiene promotion intervention in Ghana: the case of four communities in the Brong Ahafo region

Knowledge of cost and effectiveness of Ghana's main hygiene promotion intervention (HPI), Community-Led Total Sanitation (CLTS), is critical for policy direction. Cost and resultant effect of HPI is examined using a case study of four communities. Surveys were conducted with 300 households, CLTS implementers and relevant agencies during the study period (May 2012 to February 2014). The HPI produced marginal but statistically significant effect (8%, p < 0.001). Improvement in hygiene behaviour was statistically associated with both government investments (p < 0.001) and household investments (p < 0.001). Actual HPI cost is US$ 90 per household: US$ 51 and 39 from government and households respectively. Cost-effectiveness of the HPI is US$ 106.42 per capita of improved hygiene behaviour.

Animal Feces Contribute to Domestic Fecal Contamination: Evidence from E. coli Measured in Water, Hands, Food, Flies, and Soil in Bangladesh

Fecal-oral pathogens are transmitted through complex, environmentally mediated pathways. Sanitation interventions that isolate human feces from the environment may reduce transmission but have shown limited impact on environmental contamination. We conducted a study in rural Bangladesh to (1) quantify domestic fecal contamination in settings with high on-site sanitation coverage; (2) determine how domestic animals affect fecal contamination; and (3) assess how each environmental pathway affects others. We collected water, hand rinse, food, soil, and fly samples from 608 households. We analyzed samples with IDEXX Quantitray for the most probable number (MPN) of E. coli. We detected E. coli in source water (25%), stored water (77%), child hands (43%), food (58%), flies (50%), ponds (97%), and soil (95%). Soil had >120 000 mean MPN E. coli per gram. In compounds with vs without animals, E. coli was higher by 0.54 log10 in soil, 0.40 log10 in stored water and 0.61 log10 in food (p < 0.05). E. coli in stored water and food increased with increasing E. coli in soil, ponds, source water and hands. We provide empirical evidence of fecal transmission in the domestic environment despite on-site sanitation. Animal feces contribute to fecal contamination, and fecal indicator bacteria do not strictly indicate human fecal contamination when animals are present.