Open defecation-free slippage and its associated factors in Ethiopia: a systematic review

Spatial distribution and determinants of improved shared sanitation facilities among households in Ethiopia: Using 2019 mini-Ethiopian Demographic and Health Survey

INTRODUCTION

Limited or shared sanitation services are considered improved sanitation facilities, but they are shared between two or more households. Globally, 600 million people use shared toilet facilities. Although shared facilities are not classified as improved sanitation due to potential infection risks, inaccessibility, and safety concerns, this is a significant issue in developing countries like Ethiopia. Evidence on the distribution of shared sanitation services and their determinants in Ethiopia is limited. Therefore, this study aimed to assess the extent of shared toilet facilities and their determinants among households in Ethiopia.

METHODS

The 2019 Ethiopian Demographic and Health Survey (EDHS) served as the basis for the cross-sectional secondary data analysis. The analysis included a total of 7,770 households from the weighted sample. STATA 14 software was used to clean, weigh, and analyze the data. To explore the distribution and determine the factors associated with shared toilet facilities in Ethiopia, both spatial and mixed-effect analyses were utilized. A p-value of less than 0.05 was used to display the relationships between the dependent and independent variables, employing adjusted odds ratios and 95% confidence intervals.

RESULTS

The magnitude of improved shared sanitation facilities among households in Ethiopia, according to the EDHS 2019, was 10.5% (95% CI: 9.88, 11.24). The prevalence was highest in Addis Ababa at 70.2% and lowest in the Southern Nations, Nationalities, and Peoples' Region at 2.4%. Individual-level variables significantly associated with the use of improved shared toilet facilities included being a household head aged 55 years or older [AOR = 0.48; 95% CI: 0.33, 0.71], having secondary education or higher [AOR = 2.43; 95% CI: 1.80, 3.28], and belonging to middle or rich wealth status [middle: AOR = 2.32; 95% CI: 1.35, 3.96; rich: AOR = 6.23; 95% CI: 3.84, 10.11]. Community-level characteristics such as residing in urban areas [AOR = 7.60; 95% CI: 3.47, 16.67], the metropolitan region [AOR = 25.83; 95% CI: 10.1, 66.3], and periphery regions [AOR = 5.01; 95% CI: 2.40, 10.48] were also associated with the use of shared toilet facilities.

CONCLUSION

The usage of improved shared toilet facilities among households in Ethiopia is relatively low. Significant factors related to the use of shared toilet facilities were being 55 years of age or older, possessing secondary or higher education, having a middle or rich wealth status, living in urban areas, and residing in metropolitan or peripheral regions. To improve access to and utilization of shared sanitation facilities, Ethiopian policy should emphasize user education and awareness.

Assessing fecal contamination from human and environmental sources using Escherichia coli as an indicator in rural eastern Ethiopian households-a cross-sectional study from the EXCAM project

Introduction

Enteric pathogens are a leading causes of diarrheal deaths in low-and middle-income countries. The Exposure Assessment of Campylobacter Infections in Rural Ethiopia (EXCAM) project, aims to identify potential sources of bacteria in the genus Campylobacter and, more generally, fecal contamination of infants during the first 1.5 years of life using Escherichia coli as indicator.

Methods

A total of 1,310 samples (i.e., hand rinses from the infant, sibling and mother, drinking and bathing water, food and fomite provided to or touched by the infants, areola swabs, breast milk and soil) were collected from 76 households between May 2021 and June 2022. Samples were assigned to two groups by infant age: TP1 (time point 1), infants between 4 and 8 months of age, and TP2, infants between 11 and 15 months of age. Fluorometric and semi-selective colorimetric approaches were used to quantify E. coli in the field samples.

Results

Overall, E. coli was ubiquitous within selected households (56.8% across the study). E. coli was more frequently detected than average (>53%) with high concentration (>2-log CFU) in soil (g) and per pair of hand, while the opposite trend (<33%; <1.5-log CFU) was observed in food provided to the infants (g or mL), per areola, and breast milk (mL; p < 0.01). E. coli was frequently detected in fomites touched by the infants, drinking and bathing water (>51%), but at low concentration (<1.5-log CFU). Correlation analysis between E. coli concentration in different sample types suggested that the mother's hands and fomites might play a key role in the transmission of E. coli to the infants (p < 0.01; r 2 > 0.3).

Discussion

Using E. coli as surrogate, our study identified mother (hands and areola) as reservoirs likely to be involved in frequent transmission of fecal contaminants to infants within rural Ethiopian households.

Barriers to transition to resource-oriented sanitation in rural Ethiopia

Recycling excreta resources through resource-oriented toilet systems (ROTS) holds transformative potential, yet adoption remains limited, especially where benefits could be high. This study aims to understand constraints hindering the adoption of ROTS in one such area in Ethiopia. Based on a survey among 476 households comprising 2393 individuals, we examine the plans to use ROTS and willingness to pay for ROTS and apply structural equation modelling to analyze the drivers of these two outcomes while comparing the explanative power of the extended technology acceptance model, extended theory of planned behaviour, and their combined model. While 40% of households expressed a plan to use ROTS and 20% reported willingness to pay for a subsidized ROTS with a biogas unit, merely 7% revealed both the plan to use and sufficient willingness to pay, highlighting the need to target both these complementary outcomes concurrently. The theory of planned behaviour showed the best explanative power, also revealing that these two outcomes are influenced by partly distinct sets of factors. Findings imply that common efforts to ease objective constraints through subsidies, which incentivize willingness to pay, are necessary but not sufficient for facilitating the adoption of ROTS. To simultaneously enhance intentions to use, it is also recommended to target psychosocial drivers, such as perceived behavioural control and perceived community support, through awareness creation, behaviour change activities, and community engagement techniques.

The Right to Healthcare Must Include the Right to Ease of Physical Access: Exploring Geography-Health Nexus in GIDA Communities in the Philippines

Using the United Nations' 'leave no one behind' framework for the achievement of sustainable development goals, this article underscores the key role of geography as one of the core factors why certain people are left behind, deprived, and continue to experience inequality in terms of access to (quality) health care facilities and services. This article specifically examines the consequences of physical inaccessibility to health outcomes and health-seeking behavior in geographically isolated and disadvantaged areas (GIDAs) in the Philippines. This article illustrates that physical accessibility is an ignored aspect of the public health paradigm. For that reason, public health facilities, no matter how critical the facility is to a person's care, are not an immediate option for GIDA residents who seek medical aid. Responsive policy measures are vital to address this seemingly paradigmatic error. Subsidizing transportation costs and allocating funds for road improvements are called for, among other changes. The government must act on the people's right to ease of access as part of fulfilling fundamental health-related state obligations. But for the government to act, it will be crucial for claimants to health rights to proactively demand these changes. The latter is key for the fulfillment of the affected people's right to get easier access to meaningful health care.

Assessing fecal contamination from human and environmental sources using Escherichia coli as an indicator in rural eastern Ethiopian households - a study from the EXCAM project

Enteric pathogens are a leading causes of diarrheal deaths in low- and middle-income countries. The Exposure Assessment of Campylobacter Infections in Rural Ethiopia (EXCAM) project, aims to identify potential sources of bacteria in the genus Campylobacter and, more generally, fecal contamination of infants during the first 1.5 years of life using Escherichia coli as indicator. A total of 1,310 samples (i.e., hand rinses from the infant, sibling and mother, drinking and bathing water, food and fomite provided to or touched by the infants, areola swabs, breast milk and soil) were collected from 76 households between May 2021 and June 2022. Samples were assigned to two groups by infant age: TP1 (time point 1), infants between 4 and 8 months of age, and TP2, infants between 11 and 15 months of age. Fluorometric and semi-selective colorimetric approaches were used to quantify E. coli in the field samples. Overall, E. coli was ubiquitous within selected households (56.8% across the study). E. coli was more frequently detected than average (>53%) with high concentration (>2-log CFU) in soil (g) and per pair of hand, while the opposite trend (<33%; <1.5-log CFU) was observed in food provided to the infants (g or ml), per areola, and breast milk (ml; P<0.01). E. coli was frequently detected in fomites touched by the infants, drinking and bathing water (>51%), but at low concentration (<1.5-log CFU). Correlation analysis between E. coli concentration in different sample types suggested that the mother's hands might play a key role in the transmission of E. coli between the environment (i.e., soil, bathing water and fomites) and other family members (i.e., infant and sibling; P<0.04; r2>0.3). Using E. coli as surrogate, our study identified mother (hands and areola) as reservoirs likely to be involved in frequent transmission of fecal contaminants to infants within rural Ethiopian households.

Spatial variation and geographical weighted regression analysis to explore open defecation practice and its determinants among households in Ethiopia

BACKGROUND

In Ethiopia, recent evidence revealed that over a quarter (27%) of households (HHs) defecated openly in bush or fields, which play a central role as the source of many water-borne infectious diseases, including cholera. Ethiopia is not on the best track to achieve the SDG of being open-defecation-free by 2030. Therefore, this study aimed to explore the spatial variation and geographical inequalities of open defecation (OD) among HHs in Ethiopia.

METHODS

This was a country-wide community-based cross-sectional study among a weighted sample of 8663 HHs in Ethiopia. The global spatial autocorrelation was explored using the global Moran's-I, and the local spatial autocorrelation was presented by Anselin Local Moran's-I to evaluate the spatial patterns of OD practice in Ethiopia. Hot spot and cold spot areas of OD were detected using ArcGIS 10.8. The most likely high and low rates of clusters with OD were explored using SaTScan 10.1. Geographical weighted regression analysis (GWR) was fitted to explore the geographically varying coefficients of factors associated with OD.

RESULTS

The prevalence of OD in Ethiopia was 27.10% (95% CI: 22.85-31.79). It was clustered across enumeration areas (Global Moran's I = 0.45, Z-score = 9.88, P-value ≤ 0.001). Anselin Local Moran's I analysis showed that there was high-high clustering of OD at Tigray, Afar, Northern Amhara, Somali, and Gambela regions, while low-low clustering of OD was observed at Addis Ababa, Dire-Dawa, Harari, SNNPR, and Southwest Oromia. Hotspot areas of OD were detected in the Tigray, Afar, eastern Amhara, Gambela, and Somali regions. Tigray, Afar, northern Amhara, eastern Oromia, and Somali regions were explored as having high rates of OD. The GWR model explained 75.20% of the geographical variation of OD among HHs in Ethiopia. It revealed that as the coefficients of being rural residents, female HH heads, having no educational attainment, having no radio, and being the poorest HHs increased, the prevalence of OD also increased.

CONCLUSION

The prevalence of OD in Ethiopia was higher than the pooled prevalence in sub-Saharan Africa. Tigray, Afar, northern Amhara, eastern Oromia, and Somali regions had high rates of OD. Rural residents, being female HH heads, HHs with no educational attainment, HHs with no radio, and the poorest HHs were spatially varying determinants that affected OD. Therefore, the government of Ethiopia and stakeholders need to design interventions in hot spots and high-risk clusters. The program managers should plan interventions and strategies like encouraging health extension programs, which aid in facilitating basic sanitation facilities in rural areas and the poorest HHs, including female HHs, as well as community mobilization with awareness creation, especially for those who are uneducated and who do not have radios.

Mapping and predicting open defecation in Ethiopia: 2021 PMA-ET study

INTRODUCTION

There has been extensive research conducted on open defecation in Ethiopia, but a notable gap persists in comprehensively understanding the spatial variation and predictors at the household level. This study utilizes data from the 2021 Performance Monitoring for Action Ethiopia (PMA-ET) to address this gap by identifying hotspots and predictors of open defecation. Employing geographically weighted regression analysis, it goes beyond traditional models to account for spatial heterogeneity, offering a nuanced understanding of geographical variations in open defecation prevalence and its determinants. This research pinpoints hotspot areas and significant predictors, aiding policymakers and practitioners in tailoring interventions effectively. It not only fills the knowledge gap in Ethiopia but also informs global sanitation initiatives.

METHODS

The study comprised a total weighted sample of 24,747 household participants. ArcGIS version 10.7 and SaT Scan version 9.6 were used to handle mapping, hotspots, ordinary least squares, Bernoulli model analysis, and Spatial regression. Bernoulli-based model was used to analyze the purely spatial cluster detection of open defecation at the household level in Ethiopia. Ordinary Least Square (OLS) analysis and geographically weighted regression analysis were employed to assess the association between an open defecation and explanatory variables.

RESULTS

The spatial distribution of open defecation at the household level exhibited clustering (global Moran's I index value of 4.540385, coupled with a p-value of less than 0.001), with significant hotspots identified in Amhara, Afar, Harari, and parts of Dire Dawa. Spatial analysis using Kuldorff's Scan identified six clusters, with four showing statistical significance (P-value < 0.05) in Amhara, Afar, Harari, Tigray, and southwest Ethiopia. In the geographically weighted regression model, being male [coefficient = 0.87, P-value < 0.05] and having no media exposure (not watching TV or listening to the radio) [coefficient = 0.47, P-value < 0.05] emerged as statistically significant predictors of household-level open defecation in Ethiopia.

CONCLUSION

The study revealed that open defecation at the household level in Ethiopia varies across the regions, with significant hotspots identified in Amhara, Afar, Harari, and parts of Dire Dawa. Geographically weighted regression analysis highlights male participants lacking media exposure as substantial predictors of open defecation. Targeted interventions in Ethiopia should improve media exposure among males in hotspot regions, tailored sanitation programs, and region-specific awareness campaigns. Collaboration with local communities is crucial.

Prevalence of Open Defecation Practice and Associated Factors Among Households in Geshiyaro Project Implementation Sites in Ethiopia: A Cross-Sectional Study

Background

Open defecation is a significant global challenge, impacting public health, environmental sanitation, and social well-being, especially in low- and middle-income countries like Ethiopia. It is the second-largest cause of disease burden worldwide by facilitating the spread of germs that cause diarrhea diseases. Studies examining open defecation practices are insufficient, especially in areas implementing Ethiopia's Geshiyaro project. Therefore, this study aimed to assess the status of open defecation practice and associated factors in the study area.

Method

A community-based cross-sectional study was conducted from June to July 2023. The total number of households included in this study was 7995. A structured questionnaire and observational checklist were used to collect data. Descriptive and multivariate logistic regression analyses were performed using STATA version 16.

Results

The study found that 16.5% of households practiced open defecation. The following factors were significantly associated with the occurrence of open defecation: residence (AOR = 1.56, 95% CI: 1.26-1.92), education (AOR = 0.59, 95% CI: 0.49-0.72), age (AOR = 0.53, 95% CI: 0.41-0.69), knowledge on diarrhea prevention (AOR = 1.32, 95% CI: 1.17-1.50), marital status (AOR = 1.61, 95% CI: 1.32-1.97), and awareness creation about WASH services (AOR = 1.96, 95% CI: 1.71-2.25). On the other hand, no significant association was observed between the occurrence of open defecation and the household's income (AOR = 1.07, 95% CI: 0.93-1.23) or the head of household sex (AOR = 0.94, 95% CI: 0.78-1.12).

Conclusion

Open defecation remains a critical public health concern in Ethiopia's Geshiyaro project sites. Various factors influencing this practice have been identified. Targeted interventions are needed to enhance access to safe sanitation facilities and promote awareness of WASH services, aligning with SDG 3 target 3, and SDG 6 target 2.

Assessment of the surface water quality and primary health risk in urban wastewater and its receiving river Kathajodi, Cuttack of eastern India

Kathajodi, the principal southern distributary of the Mahanadi River, is the vital source of irrigation and domestic water use for densely populated Cuttack city which receives anthropogenic wastes abundantly. This study assesses the contamination level and primary health status of urban wastewater, and its receiving river Kathajodi based on the physicochemical quality indices employing inductively coupled plasma mass spectroscopy and aligning with guidelines from the United States Environmental Protection Agency (USEPA) and WHO. The high WQI, HPI, and HEI in the catchment area (KJ2, KJ3, and KJ4) indicate poor water quality due to the influx of domestic waste through the primary drainage system and effluents of healthcare units. A high BOD (4.33-19.66 mg L-1) in the catchment indicates high organic matter, animal waste, bacteriological contamination, and low DO, resulting in deterioration of water quality. CR values beyond limits (1.00E - 06 to 1.00E - 04) in three locations of catchment due to higher Cd, Pb, and As indicate significant carcinogenic risk, while high Mn, Cu, and Al content is responsible for several non-carcinogenic ailments and arsenic-induced physiological disorders. The elevated heavy metals Cd, Cu, Fe, Mn, Ni, and Zn, in Kathajodi, could be due to heavy coal combustion, vehicle exhaust, and industrial waste. On the other hand, Cu, Fe, K, and Al could be from agricultural practices, weathered rocks, and crustal materials. Positive significant (p ≤ 0.05) Pearson correlations between physicochemical parameters indicate their common anthropogenic origin and similar chemical characteristics. A strong correlation of PCA between elements and physiological parameters indicates their role in water quality deterioration. Assessing the surface water quality and heavy metal contents from this study will offer critical data to policymakers for monitoring and managing public health concerns.

Open Defecation Practice and Its Determinants Among Households Owned Toilet Facilities in Gambela Town, South West Ethiopia

The use of toilet facilities is a major sanitation intervention, as it reduces the spread of diarrheal diseases. In areas where toilets are misused, human excreta may be disposed of in open fields, bushes, and other open places. However, information about the level of utilization of toilet facilities in developing regions of Ethiopia is limited. Therefore, this study aimed to identify open defecation (OD) levels and determinants of OD among household-owned toilets in Gambella town, Ethiopia. A cross-sectional survey was conducted among 561 households in Gambela Town, using systematic random sampling and questionnaires. The level of OD was analyzed using frequency and percentage. The determinants of OD were assessed using binary logistic regression. Variables with a P-value less than .25 in univariable logistic regression were entered into the multivariable logistic regression model, and statistical significance was declared at a P-value less than .05. The model's fit was tested using Hosmer and Lemeshow's goodness of fit. The study found that OD was 47.2% [95% CI: 43.2%-51.4%] among those who owned toilet facilities. The determinants of OD were: occupation of household head [AOR: 5.27, 95% CI: 3.08-9.00], toilet facilities lacking a superstructure [AOR: 2.0, 95% CI: 1.16-3.43], toilet facilities lacking doors [AOR: 3.23, 95% CI: 1.97-5.27], large family size [AOR: 2.16, 95% CI: 1.29-3.60], knowledge of the respondents [AOR: 2.40, 95% CI: 1.50-3.99], and respondents with negative attitude [AOR: 1.76, 95% CI: 1.12-2.74]. Therefore, key stakeholders should focus on improving toilet utilization, considering those factors in their interventions.

Promotion of market-based sanitation in Ethiopia: a case study from Wolaita zone

Ethiopia increased the availability of latrines notably, but the sanitation facilities rarely meet hygienic standards. Therefore, the market-based sanitation (MBS) programme has been implemented across the country for nearly a decade to expand the market and boost the demand for hygienic sanitation products and services. While it does not seem that the MBS would bring any notable change in sanitation conditions so far, its implementation challenges are not adequately understood. To address this gap, this article delves into the grassroots-level implementation of MBS in the Wolaita zone. The study relies on qualitative data gathered through interviews with various stakeholders, examining both demand- and supply-side challenges. Some issues identified were external to MBS implementation, such as high inflation and an unstable political and security situation in Ethiopia. Additionally, the study reveals that more general deficiencies of the Ethiopian health extension program, including the stress and discouragement of local change agents (health extension workers, health development army members) due to workloads and low remuneration, have adversely impacted MBS delivery. The implementation of MBS has also not effectively addressed the affordability of hygienic sanitation products. On the supply side, economic constraints and organizational inefficiencies have hindered the development of the sanitation market, preventing it from reaching a critical mass. Our research suggests that MBS alone will not suffice to improve sanitation in Ethiopia.

Determinants of Open Defecation Among Rural Women in Ghana: Analysis of Demographic and Health Surveys

Open defecation continuously remains a major global sanitation challenge, contributing to an estimated 1.6 million deaths per year. Ghana ranks second in Africa for open defecation and had the fourth-lowest sanitation coverage in 2010. Evidence indicates that about 32% of the rural Ghanaian population still practice open defecation due to lack of access to basic sanitation facilities, drifting the country from achieving universal access to sanitation by 2030. Women, particularly those in rural areas, are disproportionately affected by open defecation, facing heightened health risks, harassment, and a loss of dignity. Even though previous studies on open defecation in Ghana exist, they lack national representation and neglect women in rural residents who are disproportionally affected by the repercussions of open defecation. Examining that rural women will contribute to heightening their own vulnerability to health risks by practising open defecation is essential to bridging the literature gap on open defecation practices among rural women. The study investigated determinants of open defecation among rural women in Ghana using data from the female files of the 2003, 2008 and 2014 Demographic and Health Surveys (DHS). A total of 4,284 rural women with complete information on variables of interest were included in the study. The outcome variable was 'open defecation', whilst 14 key explanatory variables (e.g., age, education, wealth status, among others) were used. Two logistic regression models were built, and the outputs were reported in odds ratio. Descriptively, 42 in every 100 women aged 15 to 49 practiced open defecation (n = 1811, 95% CI = 49-52). Open defecation (OD) significantly correlated with educational attainment, wealth status, religion, access to mass media, partner's education, and zone of residence. The likelihood of practicing open defecation reduced among those with formal education [aOR = 0.69, CI = 0.56-0.85], those whose partners had formal education [aOR = 0.64, CI = 0.52-0.80], women in the rich wealth quintile [aOR = 0.12, CI = 0.07-0.20], the traditionalist [aOR = 0.33, CI = 0.19-0.57], and those who had access to mass media [aOR = 0.70, CI = 0.57-0.85]. Residents in the Savannah zone had higher odds of openly defecating [aOR = 21.06, CI = 15.97-27.77]. The prevalence of open defecation is disproportionately pro-poor, which indicates that impoverished rural women are more likely to perform it. Public health initiatives should aim to close the rich-poor divide in OD practice among rural women.

Factors influencing community-led total sanitation (CLTS) implementation abandonment before achieving open defecation-free (ODF) status: case study of the Central-Western region of Burkina Faso

Access to sanitation has become an important element for improving the health of populations in developing countries. In Burkina Faso, 12% of the population in rural areas has access to latrine and 65% practice open defecation (OD). In a bid to eliminate this unsanitary practice and enhance sanitation access in rural areas, the government embraced community-led total sanitation (CLTS) as a national strategy in 2014. However, more than 6 years later, a notable observation is the high abandonment rate, with only a small fraction of rural communities successfully eradicating OD. Out of the 8892 villages in the country, 3546 underwent a CLTS triggering from 2014 to 2020. Nevertheless, in 787 of these villages, the implementation of the CLTS approach was abandoned, indicating a substantial abandonment rate of 22.19%. Until now, most studies on CLTS have focused on the post-ODF phase, emphasizing the question of the sustainability of the results generated by the approach, as if the process from triggering to obtaining ODF certification was not subject to any problems. However, cases of abandonment of the CLTS process after triggering do exist, although poorly documented in the literature, and there are no studies that clearly assign responsibilities to the actors when CLTS implementation comes to be abandoned. This research aims to bridge these gaps by identifying the root causes of these abandonment cases while delineating the distinct responsibilities associated with these instances. To achieve this, the study was conducted in the Central-Western region of Burkina Faso, where all stakeholders involved in CLTS implementation, including target communities, were identified, their different roles in the process defined, and data collected through household surveys, interviews, and focus groups. The content analysis method was used to analyze the data. The research findings indicate that the abandonment of the CLTS implementation process is due to four categories of factors: sociocultural and economic aspects (39.78%), physical conditions (17.52%), governance aspects (26.28%), and the quality of approach implementation (16.42%). Moreover, these factors highlight a shared accountability for abandonment involving the government, implementing organizations, and target communities. These findings have significant implications for the future design of sanitation programs using the CLTS approach. To mitigate abandonment rates in the CLTS implementation process across rural communities, it is imperative for policymakers to attentively consider these factors and integrate the recommendations delineated in this study.

Socio-economic factors associated with open defecation among agricultural households: a cross-sectional study in Haiti

Background

Open defecation (OD) is recognised as an important public health challenge in low-income and middle-income countries. Although agriculture is the main occupation in these countries, few if any study on OD has focused on agricultural households. In order to enhance the prevention of OD and contribute to a better understanding of this health-threatening behaviour, this paper analyses the socio-economic factors associated with OD practice among agricultural households in Haiti.

Methods

The study used primary data from 1269 households selected in 5 out of 10 geographic departments of Haiti surveyed in 2020-2021. Descriptive statistics and bivariate analysis were used to identify households' characteristics that were significantly associated with OD. In addition, a multivariate analysis was performed using binary logistic regression to study the factors associated with the probability to defecate in the open.

Results

Findings show that one out of five (20.1%) agricultural households in Haiti practices OD. More than 26% of the households did not have any member with secondary school education level. Multivariate analysis revealed that in addition to the location, the probability of OD practices among agricultural households was correlated with socio-economic factors such as education, access to the media, plot number and livestock, level of specialisation in the agriculture, agricultural income and participation in local organisations.

Conclusion

While Haiti is struggling with cholera among other health issues, this paper sheds light on factors associated with OD, a health-threatening and unsustainable sanitation behaviour. According to the results, in addition to toilet acquisition subsidies, awareness campaigns need to make use of mass media and local organisations particularly women and community ones. Elimination of OD among agricultural households is of great significance for better quality of foods and vegetables at watershed level.

Influence of social factors on adoption of sanitation practices in rural areas: a mixed methods study in Nzaui, Kenya

Introduction

provision of adequate sanitation is among the common strategies of preventing sanitation-related diseases. However, provision of sanitation facilities may only be a sustainable solution if the population´s behavior changes and positive perception is embraced. This paper highlights the influence of social factors on adoption of sanitation practices.

Methods

convergent mixed methods design was employed. Quantitative data was gathered using structured questionnaires from 100 household heads selected using cluster and simple random techniques. Logistic regression analysis was performed to explore factors that influenced adoption of sanitation practices. Qualitative data was gathered from a purposively selected focus group and analyzed thematically.

Results

many (57%) of the participants were males. The average age for participants was 39 years, standard deviation (SD)=0.20. From the multivariable regression analysis with adjusted odds, household heads being aged 18-33 years (OR 1.76, 95% CI: 0.62-3.02, p=0.015) and safety of latrines (OR 1.72, 95% CI: 0.70-5.15, p<0.001) was associated with increased open defecation chances; whereas being a female (OR 0.16 95% CI: 0.06-1.81, P=0.01), availability of open spaces near households (OR 0.12, 95% CI: 0.05-1.13, p=0.30), and mason skills (OR 0.29, 95% CI: 0.13-1.65) were associated with reduced likelihood of open defecation practices. Further, being a female (OR 1.06, 95% CI: 0.18-3.16, p=0.043), having knowledge on safe sanitation (OR 1.01, 95% CI: 0.74-3.08, p=0.02), engaging skilled masons for toilet construction (OR 1.299, 95% CI: 1.01-8.95, p=0.005) and financial stability (OR 1.95, 95% CI: 0.98-23.40, P=0.032<0.001) were positively associated with adoption of improved toilets.

Conclusion

the sanitation status in the study area was mainly poor due to the influence of multiple factors like gender, absence of toilets, knowledge on safe sanitation, poverty, mason skills and toilet location in relation to safety. The findings showed the need for innovative planning approaches based on the social aspects of communities for progress in sanitation standards in rural areas. Such approaches should adhere to the sanitation hardware versus software components of communities to promote active utilization of the available toilets, construction of improved toilets and reduction of open defecation.

Latrine utilization and associated factors among districts implementing and not-implementing community-led total sanitation and hygiene in East Wollega, Western Ethiopia: A comparative cross-sectional study

INTRODUCTION

Discharge of excreta to the environment lead to surface and groundwater contamination and human exposure to disease-causing micro-organisms. There is limitation of evidences regarding the latrine utilization among community-led total sanitation and hygiene implemented and non-implemented districts of the East Wollega Zone. Hence, this study aimed to determine the magnitude and associated factors of latrine utilization among households in community-led total sanitation and hygiene implemented and non-implemented Districts in East Wollega Zone, Western Ethiopia.

METHODS

A cross-sectional study was conducted. A Multi-stage sampling technique was applied to select the 461 households. Data were collected using interviews and observations guided by a pre-structured questionnaire. Data were entered using Epi Data and exported to SPSS software version 25 for data recording, cleaning, and statistical analysis. Bivariable logistic regression was run to identify the candidate variables at p-value <0.25. Variables that had associations with latrine utilization in the bi-variable analysis were entered together into multivariable logistic regression. An Adjusted odds ratio with a 95% confidence interval was calculated and P-value< 0.05 was used to declare a statistically significant association.

RESULT

The overall prevalence of latrine utilization was found to be 52.7% (95%CI:48%, 57.3%). Religion (AOR = 0.149;95%CI:0.044,0.506), education (AOR = 3.861;95%CI:1.642,9.077), occupation, absence of children <5 years (AOR = 4.724;95%CI:2.313,9.648), toilet cleaning (AOR = 10.662;95%CI:5.571,20.403), frequency of latrine construction (AOR = 6.441;95%CI:2.203,18.826), maintenance need (AOR = 6.446; 95%CI:3.023,13.744), distance from health institution (AOR = 0.987; 95%CI:0.978, 0.996), distance from kebele office (AOR = 6.478; 95%CI:2.137,19.635), and latrine distance from dwelling (AOR = 11.656; 95%CI:2.108, 64.44) were the factors associated with latrine use.

CONCLUSION

The latrine utilization in this study is low as compared to other studies. Religion, education, occupation, absence of children <5 years, toilet cleaning, frequency of latrine construction, maintenance need of the toilet, distance from health institution, distance from kebele, and latrine distance from dwelling are the associated factors of latrine utilization. Both households and health workers have to work together to improve latrine utilization and the safe disposal of children's feces.

Review of the slippage factors from open defecation-free (ODF) status towards open defecation (OD) after the Community-Led Total Sanitation (CLTS) approach implementation

Open-defecation (OD) is one of the most widespread sanitation practices in low-income countries. This practice often causes diarrheal diseases and 760,000 deaths per year. To eradicate OD, several approaches have been developed, including Community-Led-Total Sanitation (CLTS) which is a participatory and community approach. The specificity of CLTS is that it is managed by the community itself, as its name implies, and that no subsidies or financial contributions from outside the community are used in the construction of the facilities. Although, the CLTS is effective in the short-term for eradicating OD, the long-term results are not encouraging: Open-Defecation-Free (ODF) communities revert to OD or partially use latrines. The present research is based on literature review and authors investigation in Burkina Faso. It was conducted to provide a comprehensive understanding of the factors that affect the sustainability of ODF-status leading to slippage in communities. It was found that these factors can be grouped into five categories: behavioral and social, technological, organizational, and vulnerability factors. The last one, socio-political factors, is a contribution from the authors as it was not reported in the literature yet. The authors have proposed graphical synthesis of all the slippage factors and their associated categories in the ODF-communities. Finally, authors have suggested that to sustain ODF-status of communities: include all stages of the sanitation value chain (SVC) in the CLTS, the follow-up activities after achieving ODF-status must be planned well in advance, sanitation marketing should be developed and the sanctions against the practice of OD have to be reinforced. Governments and donors should pay particular attention to the following options: raising awareness and regular monitoring after ODF certification, encouraging research on sustainable and pro-poor sanitation technologies, and building the capacity of implementing actors including facilitators. While obtaining ODF status is materialized by a sign with the status on it, this paper drew the attention of CLTS implementers to the lack of materialization of slippage when it occurs, and the absence of studies on the evolution of the community sanitation scale after ODF-status.

Socio-economic and demographic factors influencing open defecation in Haiti: a cross-sectional study

BACKGROUND

Open defecation (OD) remains an important public health challenge in Haiti. The practice poses a significantly high risk of disease transmission. Considering these negative health consequences, this paper aims to identify socio-economic and demographic factors that influence OD practice among households in Haiti.

METHODS

The study used secondary data from 13,405 households from the Haiti Demographic and Health Survey 2016-2017. Descriptive statistics and bivariate analysis were used to find the preliminary results. Further, multivariate analysis was performed to confirm the findings.

RESULTS

Around one quarter (25.3%) of Haitian households still defecate in the open, almost 10% in urban areas, and nearly 36% in rural areas. Multivariate analysis revealed that the age and sex of the household head, household size, number of children aged 1-14 years old in the household, education level, wealth index, access to mass media, place of residence, and region were significant predictors of OD practice among households in Haiti.

CONCLUSION

To accelerate the elimination of OD by 2030 and therefore achieve sustainable open defecation-free status, the government of Haiti and its partners should consider wealth disparities among regions and mobilize mass media and community-based networks to raise awareness and promote education about sane sanitation practices. Furthermore, because the possibilities to build toilets differ between rural and urban areas, specific interventions must be spearheaded for each of these regions. The public program can subsidize individual toilets in rural areas with room to collect dry excreta for the preparation of fertilizers, while in urban areas collective toilets can be built in slums. Interventions should also prioritize households headed by women and young people, two underpriviledged socioeconomic groups in Haiti.

Effect of Schooling on Anemia and Nutritional Status Among Women: A Natural Experiment in Ethiopia

This study estimates the effect of length of schooling on anemia and nutritional status and evaluates the cost-effectiveness of primary schooling as an anemia intervention for women of childbearing age in Ethiopia. In 1994-1995, Ethiopia abolished primary school tuition fees and embarked on a large-scale educational investment program, which increased primary school enrollment and retention. An instrumented regression-discontinuity design was used to examine the effect on anemia risk and body mass index (BMI) of an increase in length of schooling resulting from the reforms, as a natural experiment. Anemia and BMI biomarkers and demographic data for 13,984 women were obtained from the 2011 and 2016 Ethiopia Demographic and Health Surveys, with the 2019 Mini Demographic and Health Survey used for robustness checks. Results indicate that each additional year of schooling reduced anemia risk by 3 percentage points (9.2%-11.2% reduction) and increased BMI (weight (kg)/height (m)2) by 0.26-0.42. Primary education was cost-effective-based on World Health Organization cost-effectiveness thresholds-as an anemia intervention, with a cost per anemia case averted of US$1,654. The findings suggest that investment in education reduces anemia risk later in life.

Assessing the Sustainability of an Integrated Rural Sanitation and Hygiene Approach: A Repeated Cross-Sectional Evaluation in 10 Countries

An evaluation of area-wide sanitation interventions in 10 countries found that 6 of the 12 program areas had sustained similar levels of basic sanitation 1–2 years post-implementation, with varying levels of slippage in the other program areas.

Introduction:

While many studies have implemented programs to increase sanitation coverage throughout the world, there are limited rigorous studies on the sustainability of these sanitation programs.

Methods:

Between 2014 and 2018, the rural Sustainable Sanitation and Hygiene for All (SSH4A) approach was implemented by SNV in sub-Saharan Africa and Asia. Repeated cross-sectional household surveys were administered annually throughout program implementation and 1 to 2 years following completion of program activities. We characterize to what extent sanitation coverage was sustained 1 to 2 years after implementation of this SSH4A intervention.

Results:

Surveys were conducted in 12 program areas in 10 countries, with 22,666 households receiving a post-implementation survey. Six of 12 program areas (Bhutan, Ghana, Kenya, both Nepal sites, Tanzania) had similar coverage levels of basic sanitation 1–2 years post-implementation, whereas there were varying levels of slippage in the other program areas (both Ethiopia sites, Indonesia, Mozambique, Uganda, Zambia), ranging from a drop of 63 percentage points in coverage in Ethiopia to a drop of only 4 percentage points in Indonesia. In countries that experienced losses in the coverage of household sanitation, sanitation sharing among neighbors generally did not increase, whereas open defecation did increase. In each of the areas where slippage occurred, the sanitation coverage levels at the final time point were all still higher than the initial time point before SNV started working in these areas. We found several factors to be associated with the sustainability of sanitation coverage, including household socioeconomic status, having household members with disabilities, baseline sanitation coverage levels of the program areas, and rate of change of coverage during program activities.

Conclusions:

Data revealed sustained gains in sanitation coverage in some program areas, yet slippage in other areas. This work may serve to benchmark the sustainability of sanitation interventions in sub-Saharan Africa and Asia.

Household-level sanitation in Ethiopia and its influencing factors: a systematic review

BACKGROUND

Within the past two decades, Ethiopia has achieved one of the fastest reductions of open defecation worldwide. This change can be attributed to the implementation of a national sanitation strategy that focused on facilitating community demand for latrine adoption and use of basic self-constructed latrines but less on other preconditions of hygienic sanitation. Recognition of sanitation by policymakers also catalyzed primary research in this area. As such, the synthesis of the available evidence is both warranted and possible. In this article, we thus decided to assess available primary evidence on the household-level sanitation in Ethiopia and its influencing factors.

METHODS

We searched primary studies that present findings on the role of factors influencing household-level sanitation outcomes in Ethiopia. We typologically classified sanitation outcomes analyzed in identified literature and computed pooled estimates for the most prevalent ones (measures of latrine availability and use). We characterized thematic types (themes and sub-themes) of influential sanitation drivers and used network analysis to examine the relational patterns between sanitation outcomes and their influencing factors.

FINDINGS

We identified 37 studies that met our inclusion criteria-all but one published after 2009. The general latrine coverage pooled across 23 studies was 70% (95% CI: 62-77%), the share of improved latrines pooled across 15 studies was 55% (95% CI: 41-68%), and latrine use pooled across 22 studies was 72% (95% CI: 64-79%). Between-study heterogeneity was high, and no time trends were identified. The identified sanitation outcomes were classified into eight types and factors reported to influence these outcomes were classified into 11 broader themes and 43 more specific sub-themes. Factors around the quality of latrines represented the most frequent sub-theme of consequential drivers. We found that the available research focused predominantly on outcomes concerning the initial adoption and use of basic latrines, emulating the main focus of national sanitation strategy. By contrast, research on drivers of the sustainability of sanitation change and, in particular, on the upgrading of latrines, has been rare despite its urgency. There is a high need to redirect the focus of sanitation research in Ethiopia towards understanding these factors on both the demand and supply side.

The Impact of Pro-Poor Sanitation Subsidies in Open Defecation-Free Communities: A Randomized, Controlled Trial in Rural Ghana

BACKGROUND

According to the World Health Organization/United Nations International Children's Fund Joint Monitoring Program, 494 million people practice open defecation globally. After achieving open defecation-free (ODF) status through efforts such as Community-Led Total Sanitation (CLTS), communities (particularly vulnerable households) may revert to open defecation, especially when toilet collapse is common and durable toilets are unaffordable. Accordingly, there is increasing interest in pro-poor sanitation subsidies.

OBJECTIVES

This study determined the impacts of a pro-poor sanitation subsidy program on sanitation conditions among the most vulnerable households and others in the community.

METHODS

In 109 post-ODF communities in Northern Ghana, we conducted a cluster randomized controlled trial to evaluate a pro-poor subsidy program that identified the most vulnerable households through community consultation to receive vouchers for durable toilet substructures. We surveyed households to assess toilet coverage, quality, and use before and after the intervention and tracked program costs.

RESULTS

Overall, sanitation conditions deteriorated substantially from baseline to endline (average of 21 months). In control communities (not receiving the pro-poor subsidy), open defecation increased from 25% (baseline) to 69% (endline). The subsidy intervention attenuated this deterioration (open defecation increased from 25% to only 54% in subsidy communities), with the greatest impacts among voucher-eligible households. Noneligible households in compounds with subsidized toilets also exhibited lower open defecation levels owing to in-compound sharing (common in this context). CLTS followed by the subsidy program would benefit more households than CLTS alone but would cost 21-37% more per household that no longer practiced open defecation or upgraded to a durable toilet.

DISCUSSION

Sanitation declines, often due to toilet collapse, suggest a need for approaches beyond CLTS alone. This subsidy program attenuated declines, but durable toilets likely remained unaffordable for noneligible households. Targeting criteria more closely aligned with sanitation inequities, such as household heads who are female or did not complete primary education, may help to generate greater and more sustainable impacts in Northern Ghana and, potentially, other contexts facing toilet collapse and limited market access. https://doi.org/10.1289/EHP10443.

Spatiotemporal distribution and determinants of open defecation among households in Ethiopia: A Mixed effect and spatial analysis

Background

Open defecation is the disposal of human faeces in the fields, forests, bushes, and open bodies of water. It is practiced more in sub-Saharan African countries and is considered a sign of underdevelopment. Open defecation facilitates the transmission of pathogens that cause diarrheal diseases which is the second leading contributor to the global burden of disease. In Ethiopia, it kills half a million under-five children annually. Even though open defecation practice is a major cause of childhood mortality and morbidity in Ethiopia, there is minimal evidence on the trend, spatiotemporal distribution, wealth-related inequalities, and other determinates of open defecation practice.

Objectives

Therefore, this study aimed to investigate the trend, spatiotemporal distribution, and determinants of open defecation among households in Ethiopia.

Methods

Cross-sectionally collected secondary data analysis was conducted based on 2016 Ethiopian Demographic and Health Survey (EDHS). A total weighted sample of 16,554 households was included. We assessed the 16 years (2000–2016) trend of open defecation with 95% confidence intervals. Data were weighted, recoded, cleaned, and analyzed using STATA version 14.2 software. A mixed-effect analysis was employed to identify factors contributing to open defecation practice in Ethiopia. In the final multivariable analysis, the associations between dependent and independent variables were presented using adjusted odds ratios and 95% confidence intervals with a p-value of <0.05. The concentration index was used to assess wealth-related inequalities, while spatial analysis was used to explore the spatial distribution and significant windows of open defecation practice.

Results

The trend of open defecation practice in Ethiopia was significantly decreased from 81.96% (95% CI: 81.08, 82.8) in 2000 EDHS, to 32.23% (95% CI: 31.16, 33.31) in 2016 EDHS. Individual-level factors such as; age, educational attainment, marital status, media exposure, wealth status, and source of drinking water, as well as community-level factors such as residence, region, community-level poverty, and community level media usage, had a significant association. Open defecation practice was significantly and disproportionately concentrated on the poor households [C = -0.669; 95% CI: -0.716, -0.622]. A non-random open defecation practice was observed in Ethiopia. Among the 11 regions, primary clusters were identified in only 3 regions (Afar, Somali, and Eastern Amhara)

Conclusion

Open defecation practice remains a public health problem irrespective of the significant decrease seen in Ethiopia for the past 16 years. Individual and community-level factors had a significant association with this problem. Since it is a leading cause of under-five children mortality and morbidity, the Ethiopian ministry of health should plan and work on basic sanitation programs that focus on the poorest communities, rural societies, and small peripheral regions. These programs should include regional planning for sanitation, and translation of materials into local languages to prevent under-five mortality and morbidity due to diarrheal diseases caused by open defecation.

Pooled prevalence and associated factors of diarrhea among under-five years children in East Africa: A multilevel logistic regression analysis

Background

Worldwide, diarrhea is the second most common cause of death and morbidity among under -five years’ children. In sub-saran Africa, access to water, sanitation, and hygiene are very scanty and the burden of diarrhea diseases is countless relative to the rest of the world. Prior studies conducted in East Africa vary in design, sample size, and other data collection tools. Through those studies, it is hard to make regional comparisons. Combining datasets that are studied on similar people and having common variable identified enhances statistical power due to the large sample size, advance the ability to compare outcomes, and create the opportunity to develop new indicators. Hence, this study aimed to assess the prevalence and associated factors of diarrhea among under five years’ children using the most recent national representative Demographic and Health Surveys from 12 East African countries. The information generated from this pooled datasets will give good insight into the sub-regional prevalence of diarrhea.

Methods

This study utilized secondary data from 12 East African countries’ most recent demographic health survey. Variables were extracted and appended together to assess the pooled prevalence of diarrhea and associated factors. A total of 90,263 under-five years of age children were encompassed in this study. STATA version was used to cross-tabulate and fit the models. To account for the hierarchical nature of the demographic health survey, multilevel logistic regression was calibrated. BIC, AIC, deviance, and LLR were used as Model comparison parameters. Variables with a p-value of <0.2 were considered for multivariable analysis. Adjusted odds ratio with 95% CI and p-value <0.05 were used to declare statistical significances of factors.

Results

The pooled prevalence of diarrhea in under five years children was 14.28% [95%CI; 14.06%, 14.51%]. Being child whose mother age is 15–24 years [AOR = 1.41, 95% CI; 1.33, 1.49], 25–34 years[AOR = 1.17, 95%CI; 1.10, 1.23], being 7–12 months child [AOR = 3.10, 95%CI; 2.86, 3.35], being 12–24 months child [AOR = 2.56, 95%CI; 2.38, 3.75], being 25–59 months child [AOR = 0.88, 95%CI; 0.82, 0.95], being child from poor household [AOR = 1.16, 95%CI; 1.09, 1.23], delayed breast feeding initiation (initiated after an hour of birth) [AOR = 1.15, 95%CI; 1.10, 1.20], and being a child from community with low educational status [AOR = 1.10, 95%CI; 1.03, 1.18] were factors associated with diarrheal diseases.

Conclusion

The pooled prevalence of diarrhea among under five years of children in East African countries is high. Maternal age, child’s age, wealth status of the household, the timing of breast feeding initiation, sex of the child, community level of educational status, working status of the mother, and the number of under five children were factors that were associated with diarrheal diseases. Scaling up of maternal and child health services by government and other concerned bodies should consider those economically marginalized communities. Additionally, awareness should be created for those uneducated mothers concerning the nature of childhood diarrhea.

Latrine Utilization and Its Associated Factors Among Community Led Total Sanitation Implemented and Non-Implemented Kebeles of Tullo District, West Hararge, Eastern Ethiopia

BACKGROUND

Improper human waste management is a major health problem in most developing countries, including Ethiopia. In Ethiopia, the majority of the population used unimproved sanitation facilities and practiced open defecation. This problem is significantly higher in the rural parts of the country.

OBJECTIVE

The aim of this study was to assess latrine utilization and associated factors among Community Led Total Sanitation (CLTS) implemented and non-implemented kebeles in Tullo District, West Hararghe, and Eastern Ethiopia.

METHODS

A community-based comparative cross-sectional study design was conducted in 740 households in 3 kebeles Community Led Total Sanitation implemented and 3 kebeles non-Community Lead Total Sanitation implemented for comparison. Study units were selected using a multi-stage sampling technique. The data was cleaned and coded before being entered into Epi-data version 3.1 and analyzed with the Statistical Package for the Social Sciences version 20. Logistic regression analysis was used to assess the association between dependent and independent variables.

RESULT

In this study, the overall prevalence of latrine utilization in the study area was 415 (56.1%) (95% CI = 52.6%, 59.9%). Of them, 243 (65.7%) (95% CI = 60.4%, 70.3%) and 172 (46.5%) (95% CI = 41.3%, 51.7%) of participants in the CLTS and non CLTS kebeles were utilized latrine, respectively. In CLTS implemented kebeles, literate (AOR = 3.66; 95% CI: 1.53, 8.73), households being visited by health extension worker (AOR = 11.72; 95% CI: 4.01, 34.31), households being graduated as model family(AOR = 7.56, 95% CI: 2.79, 20.44), ⩾2 years by years of latrine owning (AOR = 12.10, 95% CI: 3.21, 45.64), >6 meters distance of toilet to home (AOR = 27.43, 95%CI: 8.43, 89.29),Latrine with hand washing (AOR = 2.93, 95%CI: 1.19, 7.17), latrine with superstructure (AOR = 6.54, 95% CI: 2.04, 20.98) were significantly associated with latrine utilization, while in non CLTS implemented kebeles, literate (AOR = 25.78, 95% CI: 13.35, 49.78), medium wealth status(AOR = 4.87, 95% CI: 2.10, 11.29), poor wealth status(AOR = 2.51, 95% CI: 1.26, 5.01) were significantly associated with latrine utilization.

CONCLUSION

The findings of this study revealed that more of the rural households had utilized latrines in CLTS implemented kebeles than non-CLTS implemented' kebeles. So, it is recommended that the district health office increase the latrine utilization rate through the effective and sustainable implementation of the CLTS approach.

Open defecation practice and its determinants among households in sub-Saharan Africa: pooled prevalence and multilevel analysis of 33 sub-Saharan Africa countries demographic and health survey

BACKGROUND

Open defecation facilitates the transmission of pathogens that cause diarrheal diseases, which is the second leading contributor to the global burden of disease. It also exposed hundreds of millions of girls and women around the world to increased sexual exploitation. Open defecation is more practice in sub-Saharan African (SSA) countries and is considered an indicator of low socioeconomic status. However, there is little evidence on the pooled prevalence and factors contributing to open defecation practice among households in SSA.

OBJECTIVES

This study aimed to assess the pooled prevalence, wealth-related inequalities, and other determinants of open defecation practice among households in sub-Saharan Africa.

METHODS

Demographic and Health Survey data sets of 33 SSA countries with a total sample of 452,281 households were used for this study. Data were weighted, cleaned, and analyzed using STATA 14 software. Meta analyses were used to determine the pooled prevalence of open defecation practice among households in SSA. Multilevel analysis was employed to identify factors contributing to open defecation practice among households in SSA. Moreover, concentration index and graph were used to assess wealth-related inequalities of open defecation practice. The associations between dependent and independent variables were presented using adjusted odds ratios and 95% confidence intervals with a p value of < 0.05.

RESULTS

The pooled prevalence of open defecation practice among households in sub-Saharan African countries was 22.55% (95%CI: 17.49%, 27.61%) with I2 = 99.9% and ranges from 0.81% in Comoros to 72.75% in Niger. Individual level factors, such as age, educational attainment, media exposure, wealth status, and access to drinking water, as well community level factors, such as residence, country income status, and region in SSA, had a significant association with open defecation practice. The concentration index value [C = - 0.55; 95% CI: - 0.54, - 0.56] showed that open defecation practice was significantly disproportionately concentrated on the poor households (pro-poor distribution).

CONCLUSIONS

Open defecation practice remains a public health problem in sub-Saharan Africa. Individual level factors, such as age, educational attainment, media exposure, household wealth status, and access to drinking water had an association with open defecation practice. Moreover, community level factors such as residence, country income status and region in SSA have a significant effect on open defecation. There is a significantly disproportional pro-poor distribution of open defecation practice in SSA. Each country should prioritize eliminating open defecation practices that focused poorest communities, rural societies, and limited water access areas. Media exposure and education should be strengthened. Moreover, public health interventions should target to narrow the poor-rich gap in the open defecation practice among households including provisions of subsidies to the poor. Policymakers and program planners better use this evidence as preliminary evidence to plan and decide accordingly.

Contextual and psychological factors influencing open defecation free status: an exploratory qualitative study in rural South Western Uganda

INTRODUCTION

Achieving the Open defecation free (ODF) status remains a major challenge in Uganda, yet it contributes significantly to child health improvement. Literature on social, cultural and behavioral aspects that influence the ODF status in rural Uganda is limited. The study therefore, explored perceived factors influencing the ODF status in rural South Western Uganda.

METHODS

An exploratory study employing qualitative techniques and based on deductive analysis between month December 2020 and January 2021 was conducted. Seven Focus Group Discussions (FGDs and three Key Informant Interviews (KIs) were conducted in Kabale District, southwestern Uganda. Focus Group Discussion participants were mothers and fathers having children of 2 years and below while KIIs included local community leaders and health extension workers. Data was analyzed using a categorization matrix derived from the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) model which is comprised of contextual and psychological factors. Text was further categorized into high and low statements for attainment of ODF status.

RESULTS

The contextual factors influencing the Open Defecation Free status behavior included; farming activities far from home, financial constraints, rainy seasons, collapsible soft soils, and alcohol use. Psychological factors influencing ODF status included; perceived health risk for typhoid disease, low perceived severity for lack of ODF components, negative attitude of less value attached to ODF components, and a feeling of time wastage practicing ODF status behavior. The perception that the community has the ability to attain the ODF status was high. Although, the capability to maintain ODF was low when it comes to replacement of ODF component if stolen or destroyed.

CONCLUSION

Open Defecation Free status is influenced by contextual and psychological factors. Therefore, it's crucial for sanitation promotors to always identify such context specific factors in order to design sanitation and hygiene promotion interventions to address the ODF free status related challenges.

Latrine utilization and associated factors in East Gojjam Zone, North-West Ethiopia: A community-based cross-sectional study

Objective

This research was aimed at assessing latrine utilization and associated factors in East Gojjam Zone, North West Ethiopia.

Methods

A community-based cross-sectional study was conducted on households of East Gojjam Zone, from 1 February to 30 May 2021. Multistage cluster sampling technique was used to select 806 study participants into the study. Data were collected through pretested structured interview questionnaires and direct observation. Collected data were entered and cleaned using EPI info version 7.2 and analysed using SPSS version 23 software package. Bivariable and multivariable logistic regression was employed to assess association of the variables and controlling the effect of confounders, respectively. P value less than 0.05 was taken as statistically significant.

Results

The overall latrine utilization in East Gojjam Zone was found to be 45.4% (95% confidence interval = 42.2-49.1). Occupation (adjusted odds ratio = 2.248, 95% confidence interval = 1.037-4.876), participating in model family training (adjusted odds ratio = 2.481, 95% confidence interval = 1.802-3.415), water availability (adjusted odds ratio = 2.456, 95% confidence interval = 1.514-3.983), and type of latrine (adjusted odds ratio = 2.013, 95% confidence interval 1.648-2.972) had statistically significant association with latrine utilization.

Conclusion

Latrine utilization in East Gojjam Zone was found to be low relative to other studies and the country's plan. It is very far apart from the Ethiopian latrine coverage and utilization plan (100%). Occupational status, participated in the model family training, water availability, and type of toilet were significantly associated with toilet utilization. Encouraging private latrine construction with accessibility of water and all households participating in model family training may increase latrine utilization in East Gojjam Zone. Further observational study triangulated with qualitative research should be conducted to provide more strong evidence for further improvement of household latrine utilization status in East Gojjam Zone.

Can open-defecation free (ODF) communities be sustained? A cross-sectional study in rural Ghana

Community-led total sanitation (CLTS) is a widely used approach to reduce open defecation in rural areas of low-income countries. Following CLTS programs, communities are designated as open defecation free (ODF) when household-level toilet coverage reaches the threshold specified by national guidelines (e.g., 80% in Ghana). However, because sanitation conditions are rarely monitored after communities are declared ODF, the ability of CLTS to generate lasting reductions in open defecation is poorly understood. In this study, we examined the extent to which levels of toilet ownership and use were sustained in 109 communities in rural Northern Ghana up to two and a half years after they had obtained ODF status. We found that the majority of communities (75%) did not meet Ghana’s ODF requirements. Over a third of households had either never owned (16%) or no longer owned (24%) a functional toilet, and 25% reported practicing open defecation regularly. Toilet pit and superstructure collapse were the primary causes of reversion to open defecation. Multivariate regression analysis indicated that communities had higher toilet coverage when they were located further from major roads, were not located on rocky soil, reported having a system of fines to punish open defecation, and when less time had elapsed since ODF status achievement. Households were more likely to own a functional toilet if they were larger, wealthier, had a male household head who had not completed primary education, had no children under the age of five, and benefitted from the national Livelihood Empowerment Against Poverty (LEAP) program. Wealthier households were also more likely to use a toilet for defecation and to rebuild their toilet when it collapsed. Our findings suggest that interventions that address toilet collapse and the difficulty of rebuilding, particularly among the poorest and most vulnerable households, will improve the longevity of CLTS-driven sanitation improvements in rural Ghana.

The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial

Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.

Having a latrine facility is not a guarantee for eliminating open defecation owing to socio-demographic and environmental factors: The case of Machakel district in Ethiopia

Background

Open defecation practice problem is rampant in most rural areas of developing countries, including Ethiopia. To combat this problem, the Ethiopian government implemented different sanitation interventions including Community-Led Total Sanitation and Hygiene (CLTSH). The CLTSH approach is mainly aimed to eradicate open defecation practice through mobilizing the community to construct a latrine facility and utilize it. Although this intervention has significantly improved households’ access to a latrine facility, its impact on bringing behavioral change such as avoiding open defecation is not well studied.

Objective

Our study aimed to assess the prevalence of open defecation among households having their latrine and its determinant factors in rural settings in Northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted in Machakal district from September 1 to 30, 2019. A total of 472 household heads who had a latrine facility and systematically selected from six rural Kebeles of the district, were involved in the study. The data were collected using a structured questionnaire and observational checklist tools through face-to-face interviews and observation methods. Bivariate and multivariable logistic regression models were run to identify the factors that influence open defecation practice. During the multivariable analysis, statistical significance was declared at the p-value of <0.05 with 95% CI.

Results

The prevalence of open defecation practice among household heads who had latrine facility was 27.8% (95% CI, [23.1–32.8]). Female gender (AOR = 2.94, 95% CI [1.13–7.68]), not attending of formal education (AOR = 3.10, CI 95% [1.34–7.13]), having >5 family members (AOR = 1.72, CI 95% [1.05–2.80]), presence of under-five child (AOR = 3.64 CI 95% [2.14–6.21]), preferring leaf as anal cleaning material (AOR = 3.18, CI 95% [1.67–6.08]), having unclean latrine (AOR = 2.15, CI 95% [1.34–3.44]), and having latrine that needs maintenance (AOR = 2.50 CI 95% [1.52–4.11]) variables were associated with open defecation practice.

Conclusions

Among the total respondents, finding more than a quarter of open defecators is concerning for a district that achieved greatly in terms of latrine coverage. This indicates the above-mentioned factors contributed to influence household heads to defecate openly despite having latrines. Therefore, the government and partners need to focus on designing strategies that effectively address determinant factors of open defecation.

The impact of access to water supply and sanitation on the prevalence of active trachoma in Ethiopia: A systematic review and meta-analysis

Background

Trachoma is a worldwide infectious disease causing blindness. Trachoma continued as a public health problem in Ethiopia due to a lack of sanitation and inadequate prevention strategies. This study aimed to identify the impact of water supply and sanitation intervention on preventing active trachoma among children.

Methods

Systematic literature searches were performed from 4 international databases. The search involved articles published from January 1995 up to March 2019. The Cochran Q and I² statistical tests were used to check heterogeneity among the studies. A random-effect meta-analysis was employed to determine the pooled estimates with a 95% confidence interval (CI). Data analysis was performed using the CMA V.3 and RevMan 5 software program, and the result of the systematic review was reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Findings

Out of 211 studies screened for the analysis, only 29 studies were finally included in this systematic review and meta-analysis. The result revealed factors that are significantly associated with increased odds of active trachoma. Accordingly, households with no access to toilet facilities (odds ratio [OR]: 2.04, 95% CI: 1.75–2.38), no access to improved water (OR: 1.58, 95% CI: 1.27–1.96), and do not practice regular face washing for children (OR: 4.19, 95% CI: 3.02–5.81) have shown increased odds of active trachoma. Besides, the results show a higher prevalence of active trachoma among children who did not wash their faces with soap and frequently.

Conclusions

The study found strong evidence that lack of access to water, sanitation, and hygiene (WASH) was associated with increased prevalence of active trachoma among children. Therefore, a comprehensive and partnership-oriented program is needed to tackle the problem, but further study will be required to strengthen its implementation.

Environmental characteristics around the household and their association with hookworm infection in rural communities from Bahir Dar, Amhara Region, Ethiopia

Soil-Transmitted Helminths (STH) are highly prevalent Neglected Tropical Disease in Ethiopia, an estimated 26 million are infected. Geographic Information Systems and Remote Sensing (RS) technologies assist data mapping and analysis, and the prediction of the spatial distribution of infection in relation to environmental variables. The influence of socioeconomic, environmental and soil characteristics on hookworm infection at the individual and household level is explored in order to identify spatial patterns of infection in rural villages from Zenzelema (Amhara region). Inhabitants greater than 5 years old were recruited in order to assess the presence of STH. Socioeconomic and hookworm infection variables at the household level and environmental variables and soil characteristics using RS were obtained. The dominant STH found was hookworm. Individuals which practiced open defecation and those without electricity had a significant higher number of hookworm eggs in their stool. Additionally, adults showed statistically higher hookworm egg counts than children. Nonetheless, the probability of hookworm infection was not determined by socioeconomic conditions but by environmental characteristics surrounding the households, including a combination of vigorous vegetation and bare soil, high temperatures, and compacted soils (high bulk density) with more acidic pH, given a pH of 6.0 is optimal for hatching of hookworm eggs. The identification of high-risk environmental areas provides a useful tool for planning, targeting and monitoring of control measures, including not only children but also adults when hookworm is concerned.

The Applications of Implementation Science in Water, Sanitation, and Hygiene (WASH) Research and Practice

BACKGROUND

Delivery of high quality, at-scale, and sustained services is a major challenge in the water, sanitation, and hygiene (WASH) sector, made more challenging by a dearth of evidence-based models for adaption across contexts in low- and middle-income countries.

OBJECTIVE

We aim to describe the value of implementation science (IS) for the WASH sector and provide recommendations for its application.

METHODS

We review concepts from the growing field of IS-defined as the "scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and hence, to improve the quality and effectiveness of health services"-and we translate their relevance to WASH research, learning, and delivery.

DISCUSSION

IS provides a suite of methods and theories to systematically develop, evaluate, and scale evidence-based interventions. Though IS thinking has been applied most notably in health services delivery in high-income countries, there have been applications in low-income settings in fields such as HIV/AIDS and nutrition. Expanding the application of IS to environmental health, specifically WASH interventions, would respond to the complexity of sustainable service delivery. WASH researchers may want to consider applying IS guidelines to their work, including adapting pragmatic research models, using established IS frameworks, and cocreating knowledge with local stakeholders. https://doi.org/10.1289/EHP7762.

Selection of Optimum Pollution Load Reduction and Water Quality Improvement Approaches Using Scenario Based Water Quality Modeling in Little Akaki River, Ethiopia

The collective impacts of rapid urbanization, poor pollution management practices and insufficient sanitation infrastructure have driven the water quality deterioration in Little Akaki River (LAR), Ethiopia. Water quality modeling using QUAL2Kw was conducted in the LAR aimed at selecting the optimal water quality improvement and pollution load reduction approaches based on the evaluation of five scenarios: modification of point sources (PS) load (S1), modification of nonpoint sources (NPS) load (S2), simultaneous modification of PS and NPS load (S3), application of local oxygenators and fish passages using cascaded rock ramps (S4), and an integrated scenario (S5). Despite the evaluation of S1 resulting in an average load reduction of Biochemical Oxygen Demand (BOD) (17.72%), PO4-P (37.47%), NO3-N (19.63%), the water quality objective (WQO) in LAR could not be attained. Similarly, though significant improvement of pollution load was found by S2 and S3 evaluation, it did not secure the permissible BOD and PO4-P pollution load in the LAR. Besides, as part of an instream measure, a scenario evaluated using the application of rock ramps (S4) resulted in significant reduction of BOD load. All the individual scenarios were not successful and hence an integration of scenarios (S5) was evaluated in LAR that gave a relatively higher pollutant load reduction rate and ultimately was found a better approach to improve pollution loads in the river. In conclusion, pollution load management and control strategy integrally incorporating the use of source-based wastewater treatment, control of diffuse pollution sources through the application of best management practices and the application of instream measures such as the use of cascaded rock ramps could be a feasible approach for better river water quality management, pollution reduction, aquatic life protection and secure sustainable development in the LAR catchment.