Child feces disposal practices in rural Orissa: a cross sectional study

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.

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.

Hygienic Disposal of Children's Stools Practices Among Women of Children With Diarrhoea in Sub-Saharan Africa

Background

Diarrhoea stools contain infectious agents and pose a public health threat to children and members of the entire family when exposed to them. Therefore, their hygienic disposal is essential. Empirical data are needed to stir the needed public health interventions to encourage or enforce proper disposal practices to curb associated clinical issues. This study assessed the prevalence and correlates of hygienic stool disposal practices by mothers of children with diarrhoea in sub-Saharan Africa (SSA).

Methods

The Demographic and Health Surveys (DHS) data of 16 sub-Saharan African countries from 2015 to 2021 involving 22 590 mother-child pairs were analysed. Multilevel binary logistic analysis was conducted to assess the individual- and household-level factors associated with the hygienic disposal of stool practices by mothers of children with diarrhoea. The results were presented using adjusted odds ratios (AOR) and 95% confidence intervals (CI) at a statistical significance of P < .05.

Results

The overall prevalence of hygienic disposal of children's stools among women of children with diarrhoea was 49.01% (95% CI: 48.40-49.62) and ranged from 15.70% in Liberia to 86.6% in Rwanda. The practice of hygienic disposal of stools of children with diarrhoea was likely to increase among mothers who are working (AOR: 1.19; 95% CI: 1.09-1.30), those with partners with primary level of education (AOR: 1.18; 95% CI: 1.06-1.31), Muslims (AOR: 1.69; 95% CI: 1.49-1.91) and widowed/divorced (AOR: 8.94, 95% CI: 3.55-22.53). Again, mothers in the richer (AOR: 1.23; 95% CI: 1.08-1.39) wealth index had increased odds of disposing of stools hygienically compared to those in the poorest wealth index. Women who were 20 years and above, to who belonged to Traditional Religions (AOR: 0.57; 95% CI: 0.43-0.74), and those with unimproved sources of water (AOR: 0.89; 95% CI: 0.82-0.98) and toilet facilities (AOR: 0.63; 95% CI: 0.58-0.69) were less likely to dispose of child's diarrhoea stool hygienically than their counterparts.

Conclusion

The study reveals that the unhygienic disposal of the stool of children with diarrhoea is prevalent in SSA and requires a concerted effort to curb it. Sanitation practices such as educating mothers about hygienic disposal of children's stool and improving water and sanitation facilities are crucial in lowering the high prevalence of unhygienic disposal of the diarrhoeic stool of children. Additional country-level research is needed to assess children's defecation behaviours and the disposal of diarrhoeic stools using different methodologies.

Assessment of sanitation and drinking water facilities among slum households in Bhubaneswar, Odisha - A cross-sectional study

Aim

The study aims to assess the practice of using unsafe drinking water and sanitary practices among the population dwelling in slum settings of Bhubaneswar city, Odisha, India.

Subjects and Methods

A cross-sectional study was conducted among 288 households in the Bhubaneswar slums of Chandrasekharpur, Neeladri Vihar, and Trinatha basti. A questionnaire was administered face to face. Descriptive statistics were used to define the participants' sociodemographic characteristics, household information, drinking water, latrine characteristics, and waste disposal.

Results

The majority (59.7%) resided in kutcha households in notified slum areas, and 89.6% were reportedly illiterate. About 92.7% resided in a deplorable condition, relying on piped water (79.5%) from the community sources and 20.5% used it for drinking and household purposes. Around 83% of the respondents stated they did not treat water before consumption. Bathroom facilities were found to be inadequate, and 74.3% used pit latrines. The majority of household wastes (83%) were managed by directly letting them to the drainage system untreated. As a consequence, 91% reported breeding of flies and mosquitoes near their household premises and 70.5% stated having fever in the past 6 months.

Conclusion

Despite the government's initiatives to improve water, sanitation, and hygiene (WASH) strategies, an extensive gap in practice was observed. As a result, Bhubaneswar municipality must strictly enforce policy and regulatory guidelines concerning WASH to improve the sanitation practices, particularly in the areas of drinking water and household waste management.

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.

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.

Global practices, geographic variation, and determinants of child feces disposal in 42 low- and middle-income countries: An analysis of standardized cross-sectional national surveys from 2016 - 2020

Background

Despite considerable progress improving water and sanitation access globally, unsafe child feces disposal remains common in many low- and middle-income countries (LMICs), posing an important health risk. The present study characterizes the current prevalence of child feces disposal practices and child latrine use across low- and middle-income countries and investigates determinants associated with appropriate disposal practices.

Methods

Data for children ranging from 0 through 4 years of age were analyzed from standardized and nationally-representative surveys of 42 LMICs collected from 2016 to 2020 to assess child feces disposal practices. We report child feces disposal in three categories: disposal in any type of latrine, disposal in an improved latrine, and disposal through means other than in a latrine. Survey weighted multiple Poisson regression models were used to explore factors associated with these practices.

Results

Data on 403,036 children (weighted N = 191 million) demonstrated that a minority (40.3%) of children have their feces disposed of in a latrine of any kind, and just 29% have feces disposed of in an improved latrine. Prevalence varied considerably by country and region. In adjusted analyses, both child feces disposal in any latrine and disposal in an improved latrine increased with child age, higher intra-country relative wealth, and urban living, and decreased with breastfeeding and shared sanitation facilities. Disposal in improved latrines additionally increased with access to higher levels of service for drinking water and higher mother's education. Nevertheless, the role of facility access alone was insufficient, as only about half of children with household access to any latrine or improved latrines had their feces disposed of in these facilities. Child latrine use among households with latrine access was also low and highly variable across countries.

Conclusions

Children's feces in LMICs are infrequently disposed of in any latrine type, and even less frequently in improved latrines. In order to minimize health risks in LMICs, increased effort must be undertaken not just to increase sanitation coverage but to address these common barriers to safe child feces disposal and child latrine use.

•

Global child feces disposal in latrines is low and variable between countries.

•

Latrine access is insufficient to explain low use for child feces management.

•

Household relative wealth is associated with increased disposal in latrines.

•

Child latrine use increases with age but remains low and varied between countries.

Hygienic disposal of stools and risk of diarrheal episodes among children aged under two years: Evidence from the Ghana Demographic Health Survey, 2003–2014

Background

Most childhood diarrheal illnesses are a result of the faeco-oral transmission of infected food, water, and unclean fingers. The present paper was conducted to estimate the prevalence of hygienic disposal of stools (HDS) and its associated factors, and further quantify the impact of HDS on diarrheal diseases among children under two years.

Methods

A cross-sectional design was used to evaluate three rounds of the Ghana Demographic Health Survey (GDHS) from 2003–2014 involving 4869 women with children aged under two years. The outcomes were prevalence of HDS and diarrheal diseases. Poisson regression model was employed to assess risk factors associated with HDS and dominance analysis was used to rank the important risk factors. Inverse Probability Weighting Poisson Regression Adjustment (IPWPRA) with Propensity Score 1:1 density kernel-based matching was employed to assess impact.

Results

The pooled prevalence rate of HDS was 26.5%(95%CI = 24.6–28.4) and it ranged from 18.7% (95%CI = 16.4–21.2) in 2014 to 38.8%(95%CI = 35.3–42.4) in 2003. Diarrhea diseases pooled prevalence was 17.9%(95%CI = 16.4–19.5) and ranged from 13.3%(95%CI = 11.1–15.9) in 2014 to 25.4%(95%CI = 22.2–28.9) in 2003. The overall growth rate for HDS and prevalence of diarrhea diseases, decreased by 21.6% and 11.4% respectively. The most important risk factors of HDS from dominance analysis included; age of the child, wealth index, and differences in region. From pooled data wealth index, increasing age of the child, and regional disparity constituted approximately 72% of the overall impact (Weighted Standardized Dominance Statistics (WSDS) = 0.30, 0.24, and 0.19 respectively). In 2014, they constituted approximately 79% (WSDS = 0.139, 0.177 and 0.471 respectively). The average prevalence of diarrheal diseases among children of women who practiced HDS reduced over the period of the GDHS compared to those whose mothers did not practice HDS [2008 ATE(95%CI) = -0.09(-0.16–0.02), 2014 ATE(95%CI) = -0.05(-0.09–0.01) and Pooled data ATE(95%CI) = -0.05(-0.09–0.02)].

Conclusion

This analysis has provided empirical evidence of the impact of practicing HDS in Ghana from a national household survey. Implementation of the WASH agenda in this low-income setting requires a synergy of interventions and collaborations of actors (government, private and development partners) to improve water and sanitation facilities and to increase hygiene education to prevent the spread of diseases including diarrhea by 2025.

Study design and rationale for a cluster randomized trial of a safe child feces management intervention in rural Odisha, India

BACKGROUND

Poor child feces management (CFM) is believed to be an important source of exposure to enteric pathogens that contribute to a large disease burden in low-income settings. While access to sanitation facilities is improving, national surveys indicate that even households with latrines often do not safely dispose of their child's feces. Working with caregivers in rural Odisha, India, we co-developed an intervention aimed at improving safe disposal of child feces and encouraging child latrine use at an earlier age. We describe the rationale for the intervention and summarize the protocol for a cluster randomized trial (CRT) to evaluate its effectiveness at changing CFM practices.

METHODS

The intervention consists of six behavior change strategies together with hardware provision: wash basin and bucket with lid to aid safe management of soiled nappies and a novel latrine training mat to aid safe disposal and latrine training. The intervention will be offered at the village level to interested caregivers of children < 5 years of age by a community-based organization. Following a baseline survey, 74 villages were randomly allocated to either intervention or control arm. The primary outcome is caregiver reported safe disposal of child feces after last defecation, either by the caregiver disposing of the child's feces into the latrine or the child using the latrine, measured approximately four to six months following intervention delivery. Secondary outcomes include fecal contamination of household drinking water and the childs' hands. A process evaluation will also be conducted to assess intervention fidelity and reach, and explore implementer and participant feedback.

DISCUSSION

This study addresses a crucial knowledge gap in sanitation by developing a scalable intervention to improve safe management of child feces. The behavior change strategies were designed following the Risks, Attitudes, Norms, Abilities and Self-Regulation (RANAS) approach, which has shown to be effective for other environmental behavior change interventions in low-income settings. The latrine training mat hardware is a novel design developed cooperatively and manufactured locally. The evaluation follows a rigorous CRT study design assessing the impact of the intervention on CFM behavior change, as well as fecal contamination of two sources of potential exposure.

TRIAL REGISTRATION

This trial is registered at ISRCTN: ISRCTN15831099.

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.

Caregiver social support and child toilet training in rural Odisha, India: What types of support facilitate training and how?

Studies show positive impacts of social support on childcare practices, but there is limited research on child toilet training. Social support with toilet training may be especially important for rural Indian caregivers as this is a new childcare practice for many and mothers face an already demanding workload. The aim of this study was to examine the role of social support in toilet training using mediation and conditional process analyses. We surveyed 570 caregivers of children <5 years old living in rural Odisha, India. We found certain types of support aid toilet training through three mechanisms: directly, by improving self‐efficacy, and by buffering against stress. Informational and instrumental support had a positive direct effect on toilet training while emotional support had no effect. Instrumental support also aided toilet training indirectly through bolstering a caregiver's perceived self‐efficacy. These effects of instrumental support were not moderated by the caregiver's support network size. Additionally, we found perceived stress had a negative indirect effect on caregivers' toilet training efforts through diminishing self‐efficacy, but this effect was buffered (i.e. moderated) by social support. These findings offer useful programmatic insights and expand the evidence‐base on how social support functions to another childcare practice and cultural context.

Handwashing Knowledge, Attitudes, and Practices among Students in Eastern Province Schools, Saudi Arabia

Background. Lack of knowledge about appropriate handwashing practices has caused great concerns for human health, especially in the risk of many communicable diseases. The objective of the current study is to determine the level of handwashing knowledge, attitudes, and practices among school students in Eastern Province Schools, Saudi Arabia. A cross-sectional survey was recruited from November 2019 to March 2020 to assess the level of the students' handwashing knowledge. A reliable questionnaire was prepared (Cronbach's alpha = 0.608) and conducted using a two-stage sampling technique. A total of 271 students participated in the study from primary, middle, and high schools; 80% were boys, most of whom displayed an acceptable level of knowledge on hand hygiene. Nearly 75% and 74% of boys and girls, respectively, gained knowledge about hand hygiene practices from their parents. Only 46% of the students thought that handwashing is a potential protective measure against diseases, whereas 34% thought it only removes dirt. Prevalence of handwashing with soap after using the toilet was recognized among 52% of the students. Additionally, 93% of the students used water and soap to wash their hands (p value < 0.001) and 97% suggested that soap and water are the best methods to wash their hands (p value < 0.001). There was a positive correlation between the mother's education and hand hygiene practices (p value = 0.044). Results collectively indicated that handwashing knowledge and practices among school students in the Eastern Province are acceptable interventions in preventing the transmission of infectious diseases such as COVID-19. Indeed, further improvement conducted through specific health education programs to emphasize the role of handwashing in health hygiene is highly recommended.

Factors associated with safe child feces disposal in Ethiopia, India, and Zambia

Safe child feces disposal (CFD) is defined as a child or caregiver placing or rinsing child feces into an improved sanitation facility. In low- and middle-income countries (LMICs), 48% of households with children under five report that child feces were safely disposed. Despite its widespread prevalence and harmful health effects, little is known about the determinants of safe CFD. We analyzed determinants of CFD across three countries that differently address safe CFD in their policies. We used data from a cross-sectional survey of 3737 households in rural areas of Ethiopia, India, and Zambia. Multivariable logistic regression models were used to identify factors associated with safe child feces disposal (CFD) in these countries. Safe CFD was positively associated with whether a female head of household attended primary school in Zambia and India, whether someone spoke to households about cleanliness in Ethiopia, and whether a community had a WaSH committee that met in the past year in Ethiopia. In all three countries, households with a member who practiced open defecation were significantly less likely to practice safe CFD. Increasing the education level of female head of households, reducing open defecation, speaking to a household, and having an active WaSH committee are important programmatic considerations for actors who seek to address CFD in low resource settings. Unsafe CFD is a substantial challenge to transformative WaSH, and more studies should be conducted to evaluate the causes, determinants, and behaviors of CFD.

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.

Impact of a demand-side integrated WASH and nutrition community-based care group intervention on behavioural change: a randomised controlled trial in western Kenya

INTRODUCTION

Growth shortfalls and diarrhoeal diseases remain a major cause of morbidity and mortality in low-income settings. Due to the multifaceted causes of undernutrition and the identified limitations of siloed nutrition programmes, improving the delivery of integrated water, sanitation, hygiene (WASH) and nutrition programming could improve child health.

METHODS

We conducted a cluster randomised trial in western Kenya to assess the impact on household behaviours of a novel, theory-informed and integrated WASH and nutrition intervention delivered through care groups as compared with the standard care group approach. We developed an intervention targeting practices relating to food hygiene, mealtime and feeding, and compound cleanliness, each using various behavioural change techniques to influence the uptake of targeted behaviours. Prespecified behavioural outcomes were verified through direct observation, 24 hours recall, and self-reported picture-based methods.

RESULTS

Compared with control households, a greater proportion of intervention households had a hygienic food preparation area (Risk double difference (RDD) 0.81, 95% CI 0.68 to 0.96), had stored food hygienically (RDD 0.76, 95% CI 0.58 to 1.00), had a functional handwashing station (RDD 0.64, 95% CI 0.56 to 0.74), provided a safe space for their child to play (RDD 0.73, 95% CI 0.56 to 0.96), and who fed their children thickened porridge (RDD 0.56, 95% CI 0.51 to 0.63) at endline. The proportion of children 6-24 months in intervention households consuming a sufficient diversity of foods (RDD 0.81, 95% CI 0.64 to 1.04) was higher than in control households; however, there was a non-significant increase in the percentage of pregnant and lactating women receiving an adequate diversity of foods in their diets (RDD 0.86, 95% CI 0.70 to 1.05) among intervention compared with control households at endline.

CONCLUSION

Our integrated WASH and nutrition intervention resulted in important changes in behaviours. This theory-informed intervention could be added to existing care group programmes to considerable advantage.

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.

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.

Prevalence and risk factors of geohelminthiasis among the rural village children in Kota Marudu, Sabah, Malaysia

Geohelminthiasis is a worldwide problem, especially in low-income countries. Children from rural areas and those living in poverty, lacking basic health amenities and having poor environmental sanitation are likely to be affected. Adverse effects such as anemia, protein malnutrition, colitis are common which can affect both the children's physical and mental growing development. A cross-sectional study on geohelminthiasis was conducted among children from 238 households in 13 villages in Kota Marudu of northern Sabah, East Malaysia. The study involved interviewing villagers using questionnaires to collect demographic and socio-economic data, getting faecal samples from the children, collecting soil samples and identifying parasite eggs with microscopy and molecular methods. A total of 407 children (6 months-17 years old) enrolled in the study. Geohelminthiasis was detected in the faecal samples of children from 54% (7/13) of the villages with mean prevalence of infection per village of 9.0% (0%-34.9%). On a household basis, 18% (43/238) of the households sampled had infected children, with mean prevalence rate per household of 11% (0%-43%). The prevalence was for Ascaris lumbricoides: 9.6% (39/407), Trichuris trichiura: 2.7% (11/407) and hookworms (Necator americanus and Ancylostoma sp.): 2.7% (11/407). The overall mean infection rate of the children examined was 14.3%. Significantly higher prevalence was recorded for the children of mothers who did not have any formal education (p = 0.003); household income of less than USD119 (RM500) (p<0.001); children from homes without proper sanitation facilities (p<0.001); children who usually go about barefoot (p<0.001) and not washing feet before entering the house (p = 0.017). Soil samples were found to have geohelminth eggs or larvae which could be due to unhygienic sanitation practices. This study shows the geohelminthiasis is prevalent in the villages, and the risk factors are lack of maternal education, low income, poor sanitation facilities and irregular deworming practice. Expanding deworming coverage in the study region may help reduce the worm infections in these communities, so that the mental and physical development of the children would not be affected by geohelminthiasis. The data on the prevalence of geohelminthiasis in this study would contribute to better public health monitoring and operation to reduce the infection in rural areas.

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.

Practices and Perspectives on Latrine Use, Child Feces Disposal, and Clean Play Environments in Western Kenya

Exposure to fecal pathogens contributes to childhood diarrhea and stunting, causing harmful short- and long-term impacts to health. Understanding pathways of child fecal exposure and nutritional deficiencies is critical to informing interventions to reduce stunting. Our aim was to explore determinants of latrine use, disposal of child feces, and perceptions and provisions of a safe and clean child play environment among families with children under two (CU2) years to inform the design of a behavior change intervention to address water, sanitation, and hygiene (WASH), and nutrition behaviors. In 2016, we conducted a mixed-methods formative research in western Kenya. We conducted 29 key informant interviews with community leaders, health workers, and project staff; 18 focus group discussions with caregivers of CU2 years; and 24 semi-structured household observations of feeding, hygiene, and sanitation behaviors. We used the capability, opportunity, motivation, and behavior model as our theoretical framework to map caregiver behavioral determinants. Latrine use barriers were lack of latrines, affordability of lasting materials, and social acceptability of unobserved open defecation. Barriers to safe disposal of child feces were lack of latrines, time associated with safe disposal practices, beliefs that infant feces were not harmful, and not knowing where children had defecated. Primary barriers of clean play environments were associated with creating and maintaining play spaces, and shared human and animal compounds. The immediate cost to practicing behaviors was perceived as greater than the long-term potential benefits. Intervention design must address these barriers and emphasize facilitators to enable optimal WASH behaviors in this context.

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.

Correlates of appropriate disposal of children's stools in Malawi: a multilevel analysis

BACKGROUND

Management of children's stools is an important aspect of achieving open defecation free communities and reduction of diarrhea. However, information regarding individual- and community- level factors associated with safe child stool disposal in Malawi is limited. The current study aimed to assess the prevalence of safe child stool disposal and the associated individual- and community- level factors in Malawi.

METHODS

The cross-sectional study used data from the 2015-16 Malawi Demographic Health Survey in which 6326 children aged under 2 years, nested within 850 communities, were analyzed. Individual- and community- level factors were tested for association with safe child stool disposal practice using multilevel logistic regression models.

RESULTS

Results revealed that 85.6% of the women reported to have safely disposed of their children's stools. Women from households with improved sanitation had 36.0% greater odds of safely disposing of their children's stools compared with those from households with unimproved sanitation [(adjusted odds ratio (aOR): 1.36; 95% confidence interval (CI): 1.12-1.65). Further, women from communities with a middle (aOR: 1.62; 95% CI: 1.18-2.21) and high (aOR: 1.45; 95% CI: 1.14-1.84) percentage of educated women were more likely to have their children's stools safely disposed of than those from communities with a low percentage of educated women. Children's age, media exposure, and region were significantly associated with safe stool disposal.

CONCLUSION

Both Individual- and community-level factors were revealed to be important factors for child stool disposal. Public health strategies designed to promote sanitation/safe child stools disposal need to conduct thorough community assessments to identify community-specific needs/barriers. Additionally, public health practitioners should take into consideration the geographical and wealth inequalities when designing programs aimed to improve safe child stood disposal.

Local Perceptions, Cultural Beliefs, Practices and Changing Perspectives of Handling Infant Feces: A Case Study in a Rural Geita District, North-Western Tanzania

We report on the management of infant feces in a rural village in Geita region, Tanzania. Findings discussed here emerged incidentally from a qualitative study aimed at investigating vulnerability and resilience to health challenges in rural settings. Data was gathered through semi-structured focus group discussions (FDGs) with women (n = 4; 32 participants), men (n = 2; 16 participants), and community leaders (n = 1; 8 participants). All FDGs were audio recorded, transcribed verbatim and thematically analyzed using Atlas.ti. Respondents reported feces of a child under the age of six months were considered pure compared to those of older children. Infant feces were seen as transitioning to harmful at the point when the child began to eat solid food, resulting in their stool visually changing in appearance. Caregivers reportedly used soft implements to handle infant feces due to the belief that tools with hard surfaces would physically harm the child. Infant feces were disposed in environments around the house due to the belief that disposal in latrines would prevent developmental milestones and result in other perceived negative health outcomes for the child. Changing views expressed by participants suggest a window of opportunity to implement evidence-based and culturally relevant interventions to encourage the safe disposal of infant feces.

Child feces management practices and fecal contamination: A cross-sectional study in rural Odisha, India

Safe child feces management (CFM) is likely critical for reducing exposure to fecal pathogens in and around the home, but the effectiveness of different CFM practices in reducing fecal contamination is not well understood. We conducted a cross-sectional study of households with children <6 years in rural Odisha, India, using household surveys (188 households), environmental sample analysis (373 samples for 80 child defecation events), and unstructured observation (33 households) to characterize practices and measure fecal contamination resulting from CFM-related practices, including defecation, feces handling and disposal, defecation area or tool cleaning, anal cleansing, and handwashing. For environmental sampling, we developed a sampling strategy that involved collecting samples at the time and place of child defecation to capture activity-level fecal contamination for CFM practices. Defecating on the floor or ground, which was practiced by 63.7% of children <6 years, was found to increase E. coli contamination on finished floors (p < 0.001) or earthen ground surfaces (p = 0.008) after feces were removed, even if paper was laid down prior to defecation. Use of unsafe tools (e.g., paper, plastic bag, straw/hay) to pick up child feces increased E. coli contamination on caregiver hands after feces handling (p < 0.0001), whereas the use of safe tools (e.g., potty, hoe, scoop) did not increase hand contamination. Points of contamination from cleaning CFM hardware and anal cleansing were also identified. The most common disposal location for feces of children <6 years was to throw feces into an open field (41.6%), with only 32.3% disposed in a latrine. Several households owned scoops or potties, but use was low and we identified shortcomings of these CFM tools and proposed alternative interventions that may be more effective. Overall, our results demonstrate the need for CFM interventions that move beyond focusing solely on feces disposal to address CFM as a holistic set of practices.

Enteric pathogens from water, hands, surface, soil, drainage ditch, and stream exposure points in a low-income neighborhood of Nairobi, Kenya

Child exposure to fecal-oral pathogens occurs through several transmission pathways. However, the relative importance of different exposure points for pathogen transmission both inside and outside households is not well understood. We conducted a cross-sectional study in the urban slum of Kibera in Nairobi, Kenya, collecting 237 environmental samples from 40 households from source water, stored drinking water, caregiver hands, child hands, household surfaces, soil, standing water, open drainage ditches, and streams. We quantified the fecal indicator Escherichia coli and the enteric pathogens of adenovirus, Campylobacter jejuni, Shigella spp./enteroinvasive E. coli (EIEC), and Vibrio cholerae. At least one enteric pathogens was detected in 13% of household stored water, 47% of hand, 46% of table surface, 26% of plate surface, 75% of floor surface, 96% of soil, 56% of standing water, 77% of drainage ditch, and 100% of stream samples despite all households having access to a toilet or latrine. Our results provide evidence that children may be exposed to enteric pathogens from several exposure points, that domestic hygiene practices related to water treatment and child handwashing were associated with reduced pathogen detection in this setting, but household table and floor cleaning practices were not, that ownership or presence of chickens in the compound was associated with increased detection of C. jejuni inside households and on soil, that there were interactions among different transmission pathways for enteric pathogens, and that there were differential correlations between E. coli and enteric pathogens for different pathogens and environmental sample types. Additionally, V. cholerae was detected at several exposure points during a cholera outbreak. Overall, these results suggest that interventions that can disrupt many transmission pathways may be needed to reduce enteric pathogen exposure in this urban slum setting.

Hygiene and Sanitation Practices and the Risk of Morbidity among Children 6–23 Months of Age in Kumbungu District, Ghana

Background. Poor hygiene and sanitation (WASH) practices are characterised by the manifestation of disease and infections, notably diarrhoea and respiratory tract infections (RTIs) among children. This study aimed to assess the influence of WASH practices on the occurrence of diarrhoea and RTIs among children 6–23 months of age.Methods. An analytical cross-sectional study design was conducted in June 2017. Systematic random sampling technique was used to select 300 mothers/caregivers with children aged 6–23 months from 9 communities in the Kumbungu District. We assessed the WASH practices, socio-demographic characteristics of the households and the occurrence of diarrhoea and RTIs among the children with a semi-structured questionnaire. The Hygiene Improvement Framework observational guide was adapted for household sanitation. Backward binary multiple logistic regression was used to determine the WASH practices that significantly predicted morbidity.Results. About 53% and 55.3% of the children reportedly experienced diarrhoea and RTIs, respectively, two weeks before the survey. Caregiver handwashing with soap after defecation [OR = 0.32 (95% C.I: 0.19, 0.52)] and before feeding [OR = 0.50 (95% C.I: 0.30, 0.84)] as well as washing the child’s hands with or without soap before feeding [OR = 0.21 (95% C.I: 0.04, 1.01)] were associated with lower odds of diarrhoea morbidity. The main determinants of RTI morbidity included caregiver handwashing with or without soap after defecation [OR = 0.29 (95% C.I: 0.10, 0.81)] and washing of the child’s hands with soap before feeding [OR = 0.60 (95% C.I: 0.37, 0.99)] However, we found no association between household sanitation and diarrhoea as well as RTI among the children.Conclusion. About a half each of the children had diarrhoea and RTI 2 weeks before the survey. The results emphasise the need for urgent targeting of handwashing and waste disposal programmes to avert the high burden of diarrhoea and RTIs among children.

Factors Associated with Safe Disposal Practices of Child's Faeces in Nigeria: Evidence from 2013 Nigeria Demographic and Health Survey

Background:

Stool disposal practices have been shown to be associated with childhood diarrhea. There exist variations in explanatory variables of safe child's faecal disposal practices depending on the context of the study. Thus, the need for this study to assess factors associated with safe disposal practices of children's faeces in Nigeria.

Methods:

This study utilized the 2013 Nigeria Demographic and Health Survey data. Child's faecal disposal practice was classified as safe and unsafe as defined by the World Health Organization/UNICEF Joint Monitoring Program. Binary and multivariate logistic regression models were used to identify factors associated with safe faecal disposal practices. The analysis was restricted to a weighted sample of 19, 288 youngest children in the households.

Results:

Overall, the prevalence of safe disposal of child's faeces was 59.4%. Safe child's faeces disposal was the highest among older women (64.4%), highly educated women and their husbands (67.1%) and (66.4%), respectively; among rich households (72.3%), Muslim (68.7%), urban areas (68.8%), and in North West zone (78.4%). In multivariate analysis, safe faecal disposal was significantly associated with the age of mother, maternal education level, wealth index, religion, source of water, and type of toilet facility. Marital status, geopolitical zone, having diarrhea in the past 2 weeks before the survey and sex of the child were not significant determinants of safe faecal disposal practice.

Conclusion:

Understanding the prevailing faecal disposal practices is a prerequisite to the formulation of effective intervention strategies. It is pertinent, therefore, that programs and interventions designed to improve safe child's faecal disposal practices need to take into consideration the factors identified in this study.

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.

A cluster-randomized multi-level intervention to increase latrine use and safe disposal of child feces in rural Odisha, India: the Sundara Grama research protocol

Background

Despite health benefits of sanitation, an estimated 12% of the global population practices open defecation, including an estimated 50% of the population of India. Current estimates, however, do not include households that own toilets but do not use them, suggesting that the actual number of people defecating in the open is underestimated. This protocol describes a cluster randomized controlled trial to evaluate an intervention specifically designed to increase latrine use, including the safe disposal of child feces, in rural Odisha, India.

Methods

The trial engages 66 villages in Puri district, 33 randomly allocated to receive the intervention and 33 to serve as controls. The primary outcome is latrine use and is recorded at baseline and endline for all members of all households that own latrines in all trial vilalges. Additional data on determinants of latrine use and safe child feces disposal are also collected to assess change based on the intervetntion. A process evaluation assesses the delivery of the intervention and qualiative research takes place in non-trial villages as well as post-endline in trial villages to help explain trial findings.

Discussion

This is one of four trials taking place simultaneously in rural India with latrine use as the primary outcome. All four studies use the same outcome to gerenate comparable data across sites that can serve the government of India. The trial in Odisha is unique in that it collects latrine use data from all potential users in all households that own latrines, enabling a thorough view of the sanitation situation and factors that influence use at the community level. That latrine use is collected via self-report is a limitation, however any bias in reporting should be the same across villages and not impact the overall assessment of intervention impact.

Trial registration

This trial is registered at clinicaltrials.gov: NCT03274245.

Does safe disposal of child faeces matter? An assessment of access to improved sanitation and child faeces disposal behaviour and diarrhoea in rural Nepal

Background

Improper disposal of child faeces is a major source of faecal pathogens that cause diarrhoeal disease. However, this has received relatively less attention in sanitation evaluation literature, which has tended to focus on sanitation provision, implicitly assuming that child faeces disposal behaviour also improves with sanitation. We examined the impact of improved sanitation without safe disposal (households with improved sanitation but not disposing of child faeces in improved sanitation) and improved sanitation with safe disposal (households with improved sanitation and disposal of child faeces in improved sanitation) on diarrhoeal prevalence in rural Nepal.

Methods

Data from the Nepal Demographic Health Survey 2011 for 3377 children <5 y of age were used to answer the research question using quasi-experimental methods.

Results

Improved sanitation with safe disposal was associated with a 3.3 percentage point (standard error [SE] 0.016) to 6.6 percentage point (SE 0.023) lower prevalence of diarrhoea among children <5 y of age compared with matched households without access to improved sanitation. No effect was observed for households having improved sanitation without safe disposal compared with matched households without access to improved sanitation. Improved sanitation with safe disposal was also associated with a 4.0 percentage point (SE 0.023) lower prevalence of diarrhoea in low economic status households (bottom two quintiles).

Conclusions

Our results suggest that sanitation programmes need to focus on behavioural interventions as well as increasing access to sanitation facilities.

Identification of Human and Animal Fecal Contamination in Drinking Water Sources in the Kathmandu Valley, Nepal, Using Host-Associated Bacteroidales Quantitative PCR Assays

This study identified the sources of fecal contamination in the groundwater of different land covers. A total of 300 groundwater samples were collected in the Kathmandu Valley, Nepal, in the dry (n = 152) and wet (n = 148) seasons of 2016. Fecal indicator bacteria were initially enumerated, and then fecal contamination sources were identified using human (BacHum), ruminant (BacR), and pig-associated (Pig2Bac) Bacteroidales quantitative polymerase chain reaction assays. Sixty-six percent (197/300) of the tested groundwater samples had Escherichia coli concentrations higher than the World Health Organization threshold for drinking (<1 most probable number/100 mL). The fecal contamination of the groundwater was of human (22%, 55/250), ruminant (11%, 28/250), and pig (3%, 8/250) origin. Deep tube wells were less likely to be positive for E. coli and fecal markers compared to shallow dug wells. The human fecal marker was more likely to be detected in sources from built-up as compared to agricultural areas (Adjusted odds ratio (AOR) = 3.60, p = 0.002). Likewise, the ruminant fecal marker was more likely to be detected in sources from agricultural as compared to built-up areas (AOR = 2.90, p = 0.018). These findings suggest the preparation of mitigation strategies for controlling fecal pollution based on land cover and well types.

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

BACKGROUND

Young children frequently defecate in the living environment in low-income countries. Unsafe child feces disposal has been associated with risk of diarrhea. Additionally, reported practices can underestimate socially undesirable unhygienic behaviors. This analysis aimed to assess (1) the sensitivity of reported child feces disposal practices as an indicator for observed presence of human feces in the domestic environment, (2) household characteristics associated with reported unsafe feces disposal and (3) whether unsafe feces disposal is associated with fly presence and diarrhea among children <3 years.

METHODS

We recorded caregiver-reported feces disposal practices for children <3 years; unsafe disposal was defined as feces put/rinsed into a drain, ditch, bush or garbage heap or left on the ground and safe disposal as feces put/rinsed into latrine or specific pit or buried. We conducted spot checks for human feces, counted flies in the compound and recorded caregiver-reported child diarrhea prevalence among 803 rural Bangladeshi households. We assessed associations using generalized estimating equations (GEE) and generalized linear models (GLM) with robust standard errors.

RESULTS

Unsafe disposal of child feces was reported by 80% of households. Reported disposal practices had high sensitivity (91%) but low positive predictive value (15%) as an indicator of observed feces in the compound. Unsafe disposal was more common among households that reported daily adult open defecation (PR: 1.13, 1.02-1.24) and had children defecating in a nappy or on the ground versus in a potty (PR: 2.92, 1.98-4.32), and less common in households where adults reported always defecating in latrines (PR: 0.91, 0.84-0.98). The presence of observed human feces was similarly associated with these household characteristics. Reported unsafe feces disposal or observed human feces were not associated with fly detection or child diarrhea.

CONCLUSION

Despite access to on-site sanitation, unsafe child feces disposal was reported by the majority of households. However, this practices was not associated with diarrhea; suggesting that child feces may not be the most important fecal exposure. Before resources are invested to improve child feces management practices, studies should explore whether these contribute meaningfully to risk of enteric disease.

Within-Compound Versus Public Latrine Access and Child Feces Disposal Practices in Low-Income Neighborhoods of Accra, Ghana

In crowded urban settlements in low-income countries, many households rely on shared sanitation facilities. Shared facilities are not currently considered "improved sanitation" because of concerns about whether hygiene conditions sufficiently protect users from the feces of others. Prevention of fecal exposure at a latrine is only one aspect of sanitary safety. Ensuring consistent use of latrines for feces disposal, especially child feces, is required to reduce fecal contamination in households and communities. Household crowding and shared latrine access are correlated in these settings, rendering latrine use by neighbors sharing communal living areas as critically important for protecting one's own household. This study in Accra, Ghana, found that household access to a within-compound basic latrine was associated with higher latrine use by children of ages 5-12 years and for disposal of feces of children < 5 years, compared with households using public latrines. However, within-compound access was not associated with improved child feces disposal by other caregivers in the compound. Feces was rarely observed in household compounds but was observed more often in compounds with latrines versus compounds relying on public latrines. Escherichia coli and human adenovirus were detected frequently on household surfaces, but concentrations did not differ when compared by latrine access or usage practices. The differences in latrine use for households sharing within-compound versus public latrines in Accra suggest that disaggregated shared sanitation categories may be useful in monitoring global progress in sanitation coverage. However, compound access did not completely ensure that households were protected from feces and microbial contamination.

A Cross Sectional Study of the Association between Sanitation Type and Fecal Contamination of the Household Environment in Rural Bangladesh

We conducted a cross sectional study to assess 1) the association between access to basic sanitation and fecal contamination of sentinel toy balls and 2) if other sanitation factors such as shared use and cleanliness are associated with fecal contamination of sentinel toy balls. We assessed sanitation facilities in 454 households with a child aged 6-24 months in rural Bangladesh. We defined "basic" sanitation as access to improved sanitation facilities (pit latrine with a slab or better) not shared with other households. In each household, an identical toy ball was given to the target child. After 24 hours, the balls were rinsed to enumerate fecal coliforms as an indicator of household fecal contamination. Households with basic sanitation had lower fecal coliform contamination than households with no access to basic sanitation (adjusted difference in means: -0.31 log₁₀ colony forming units [CFU]/toy ball; 95% confidence interval [CI]: -0.61, -0.01). Shared sanitation facilities of otherwise improved type were more likely to have visible feces on the latrine slab compared with private facilities. Among households with access to improved sanitation, households with no visible feces on the latrine slab had less toy ball contamination than households with visible feces on the latrine slab (adjusted difference in means: -0.38 log₁₀ CFU/toy ball; 95% CI: -0.77, 0.02). Access to basic sanitation may prevent fecal contamination of the household environment. An Improved sanitation facility used by an individual household may be better in preventing household fecal contamination compared with improved facilities shared with other households.

A socio-ecological analysis of barriers to the adoption, sustainablity and consistent use of sanitation facilities in rural Ethiopia

BACKGROUND

Despite evidence showing that access to and use of improved sanitation is associated with healthier households and communities, barriers influencing the adoption and sustainablity of sanitation facilities remain unclear. We conducted a qualitative case study to explore barriers influencing the adoption, sustainablity and consistent use of sanitation facilities in rural Ethiopia.

METHODS

A qualitative study was conducted in the rural district of Becho, in central Ethiopia, from June to August 2016. A socio-ecological model and Integrated Behavioural Model (IBM) for a Water Hygiene and Sanitation (WASH) framework were employed to design the study and analyse data. A total of 10 in-depth interviews (IDI) were conducted with latrine adopters (n = 3), latrine non-adopters (n = 3), health extension workers (n = 3) and the district WASH coordinator (n = 1). Eight Focus Group Discussions (FGD) were undertaken with 75 participants, of which 31 were women. The FGDs and IDIs were tape-recorded, transcribed verbatim and translated into English. The analysis was supported using Nvivo version 10 software.

RESULTS

Barriers to sustained adoption and use of sanitation facilities were categorized into 1) individual level factors (e.g., past latrine experience, lack of demand and perceived high cost to improved latrines), 2) household level factors (e.g., unaffordability, lack of space and absence of a physically strong family member), 3) community level factors (e.g., lack of access to public latrines, lack of shared rules against open defecation, lack of financial access for the poor), and 4) societal level factors (e.g., lack of strong local leadership, flooding, soil conditions, lack of appropriate sanitation technology, lack of promotion and demand creation for improved latrines).

CONCLUSION

The use of the socio-ecological model and IBM-WASH framework helped to achieve a better understanding of multi-level and multi-dimensional barriers to sustained latrine adoption. The results indicate that there is a need to consider interventions that address multi-level factors concurrently.

Identifying Potential Sources of Exposure Along the Child Feces Management Pathway: A Cross-Sectional Study Among Urban Slums in Odisha, India

Child feces represent a particular health risk to children due to increased prevalence of enteric agents and a higher risk of exposure owing to exploratory behaviors of young children. The safe management of such feces presents a significant challenge, not only for the 2.4 billion who lack access to improved sanitation, but also due to unhygienic feces collection and disposal and poor subsequent handwashing practices. We assessed potential sources of fecal exposure by documenting child feces management practices in a cross-sectional study of 851 children < 5 years of age from 694 households in 42 slums in two cities in Odisha, India. No preambulatory children and only 27.4% of ambulatory children defecated directly in the latrine. Children that did not defecate in a latrine mainly defecated on the ground, whether they were preambulatory or ambulatory. Use of diapers (1.2%) or potties (2.8%) was low. If the feces were removed from the ground, the defecation area was usually cleaned, if at all, only with water. Most children’s feces were disposed of in surrounding environment, with only 6.5% deposited into any kind of latrine, including unimproved. Handwashing with soap of the caregiver after child feces disposal and child anal cleaning with soap after defecation was also uncommon. While proper disposal of child feces in an improved latrine still represents a major challenge, control of the risks presented requires attention to the full range of exposures associated to the management of child feces, and not simply the place of disposal.

Assessment of the Acceptability and Feasibility of Child Potties for Safe Child Feces Disposal in Rural Bangladesh

Indiscriminate defecation among young children and the unsafe disposal of their feces increases fecal contamination in the household environment and the risk of diarrheal disease transmission. Improved sanitary technology for children too young to use a latrine may facilitate safe feces disposal and reduce fecal contamination in the household environment. We assessed the acceptability and feasibility of child potties in rural Bangladesh in 2010. Our team introduced child potties into 26 households for 30 days, and conducted semistructured interviews, group discussions, and observations to assess the acceptability and feasibility of their use for parents and children. Residents of this rural Bangladeshi community accepted the child potties and caregivers found them to be a feasible means of managing child feces. The color, shape, design, and size of the potty influenced its acceptability and use. These residents reported that regular use of the potty improved the household’s physical environment and caregiver and child personal hygiene. Regular potty use also reduced caregivers’ work load by making feces collection and disposal easier. Primary caregivers viewed 4–6 months as the appropriate age to initiate potty training. Sanitation interventions should integrate and emphasize potties for children’s feces management to reduce household environmental contamination.

The management of the faeces passed by under five children: an exploratory, cross-sectional research in an urban community in Southwest Nigeria

Background

Safe management of faeces (SMoF) and environmental contamination by faecal pathogens have been extensively researched although the SMoF in under-five children has been perennially neglected perhaps due to the misconception that it is harmless. This research, therefore, studied the situation, to determine the magnitude and dimensions of the problem aimed at making policy level stakeholders aware of child faeces management systems and so, inform evidence-based implementation of child and health-related programmes in Nigeria.

Methods

The study utilized an exploratory cross-sectional design and a multi-stage sampling technique to identify 300 respondents from 12 randomly selected streets from 4 wards in Ife central local government area. The study collected data with a pretested questionnaire which included direct observations of child defecation practices and existing toilet facilities. Cleaned data were analyzed by IBM-SPSS version 20 with child faeces management outcomes as the dependent variable.

Results

The mean age of respondents’ and monthly income (mode) were 30.8 ± 7.5 years and ₦10,000.00 ($28.60). Most respondents were mothers to the under five children (84.7%), had a secondary education (72.0%) and were semi-skilled (57.0%). The caregivers had access to improved water sources (93.7%), improved toilets (64.3%), with 64% and 53.7% having above average scores in knowledge and attitudes, respectively. In the study, 19.7% and 69.0% of caregivers practiced safe disposal of faeces passed by the under five child during the day and at night respectively, though most caregivers (94.3%) omitted steps in the safe management of child faeces chain. The under five diarrhoea prevalence rate was 13.7% and unsanitary passage of child faeces is associated with four folds likelihood of having diarrhoea (p = 0.001). The caregivers whose under five children practiced safe sanitation were rich (p = 0.009) and knowledge was significantly associated with ownership of household toilet (P = 0.037), night faeces management chain practice (P < 0.001) and disposal of anal cleaning materials (P = 0.002). Handwashing was significantly associated with household toilet (P < 0.001), wealth (P < 0.001), under five child defecation preferences during the day (P < 0.001) and at night (P = 0.008).

Conclusion

The high knowledge and positive attitudes exhibited by the caregivers were at variance with practice. Where under five children defecate during the day were influenced by the disposal of their anal cleaning materials, distance to the toilet and caregivers’ education. The findings highlight the dangers of unsanitary disposal of child faeces and the need to strengthen the related policies that can increase caregivers awareness and practice at all levels and in all livelihood domains.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4078-1) contains supplementary material, which is available to authorized users.

Disposal of children's stools and its association with childhood diarrhea in India

BACKGROUND

Children's stool disposal is often overlooked in sanitation programs of any country. Unsafe disposal of children's stool makes children susceptible to many diseases that transmit through faecal-oral route. Therefore, the study aims to examine the magnitude of unsafe disposal of children's stools in India, the factors associated with it and finally its association with childhood diarrhea.

METHODS

Data from the third round of the National Family Health Survey (NFHS-3) conducted in 2005-06 is used to carry out the analysis. The binary logistic regression model is used to examine the factors associated with unsafe disposal of children's stool. Binary logistic regression is also used to examine the association between unsafe disposal of children's stool and childhood diarrhea.

RESULT

Overall, stools of 79% of children in India were disposed of unsafely. The urban-rural gap in the unsafe disposal of children's stool was wide. Mother's illiteracy and lack of exposure to media, the age of the child, religion and caste/tribe of the household head, wealth index, access to toilet facility and urban-rural residence were statistically associated with unsafe disposal of stool. The odds of diarrhea in children whose stools were disposed of unsafely was estimated to be 11% higher (95% CI: 1.01-1.21) than that of children whose stools were disposed of safely. An increase in the unsafe disposal of children's stool in the community also increased the risk of diarrhea in children.

CONCLUSION

We found significant statistical association between children's stool disposal and diarrhea. Therefore, gains in reduction of childhood diarrhea can be achieved in India through the complete elimination of unsafe disposal of children's stools. The sanitation programmes currently being run in India must also focus on safe disposal of children's stool.

Faecal contamination of household drinking water in Rwanda: A national cross-sectional study

Unsafe drinking water is a leading cause of morbidity and mortality, especially among young children in low-income settings. We conducted a national survey in Rwanda to determine the level of faecal contamination of household drinking water and risk factors associated therewith. Drinking water samples were collected from a nationally representative sample of 870 households and assessed for thermotolerant coliforms (TTC), a World Health Organization (WHO)-approved indicator of faecal contamination. Potential household and community-level determinants of household drinking water quality derived from household surveys, the 2012 Rwanda Population and Housing Census, and a precipitation dataset were assessed using multivariate logistic regression. Widespread faecal contamination was present, and only 24.9% (95% CI 20.9-29.4%, n=217) of household samples met WHO Guidelines of having no detectable TTC contamination, while 42.5% (95% CI 38.0-47.1%, n=361) of samples had >100TTC/100mL and considered high risk. Sub-national differences were observed, with poorer water quality in rural areas and Eastern province. In multivariate analyses, there was evidence for an association between detectable contamination and increased open waste disposal in a sector, lower elevation, and water sources other than piped to household or rainwater/bottled. Risk factors for intermediate/high risk contamination (>10TTC/100mL) included low population density, increased open waste disposal, lower elevation, water sources other than piped to household or rainwater/bottled, and occurrence of an extreme rain event the previous day. Modelling suggests non-household-based risk factors are determinants of water quality in this setting, and these results suggest a substantial proportion of Rwanda's population are exposed to faecal contamination through drinking water.

Systematic review of evidence on the effectiveness of safe child faeces disposal interventions

OBJECTIVES

To review and synthesise the available evidence on the effectiveness of interventions targeting unsafe child faeces disposal in reducing this behaviour and improving child health in low- and middle-income countries.

METHODS

PubMed and EMBASE were systematically searched. Studies meeting the inclusion criteria were reviewed and key information on study methodologies and outcomes were extracted.

RESULTS

A total of 1048 articles were screened, and eight studies representing five countries were included for the review. Three were randomised controlled trials, and five were prospective cohort studies. There was wide variability across studies in the definition of 'safe disposal' of child faeces. Six studies reported the change in child faeces disposal practices associated with safe child faeces disposal interventions. However, only one study found a significant improvement in this behaviour. Two of the six studies that evaluated the health impact of delivered interventions found significant reductions in childhood diarrhoea associated with safe faeces disposal practices, and one study reported a positive effect on child growth and ascariasis. Only one study was identified that delivered a single intervention solely focused on safe child faeces disposal. Unfortunately, this study did not investigate the impact of this intervention on child health.

CONCLUSIONS

There are major methodological limitations in studies that assessed the impact of safe child faeces disposal interventions. The health impact of these interventions is inconclusive because the quality of the current evidence is poor. Randomised controlled trials are urgently needed to assess the impact of safe faeces disposal interventions on child health.

Unsafe Disposal of Child Faeces: A Community-based Study in a Rural Block in West Bengal, India

Objectives

A clean India is the responsibility of all Indians. One of the objectives of the Swachh Bharat Abhiyan (Clean India Initiative) is to bring about behavioural changes regarding healthy sanitation practices. While large-scale programs in India have increased latrine coverage, they have to some extent failed to bring behavioural changes ensuring optimal latrine use, including the safe disposal of child faeces, which is a significant source of exposure to faecal pathogens. Hence, this study was done to explore child faeces disposal practices in rural West Bengal and to elicit the determinants of unhygienic faeces disposal.

Methods

Data collection was done using an interview method among the mothers of 502 under-5 children, following a pre-designed, semi-structured schedule during house-to-house visits in a set of villages in the Hooghly district of West Bengal.

Results

The prevalence of unsafe disposal of child faeces was 72.4%, and maternal education, per capita income, and water source were found to be significantly associated with unsafe child faeces disposal.

Conclusions

This study draws attention to the unsafe disposal of child faeces in this area of India and raises questions about the efficiency of sanitation campaigns in rural India that focus on expanding coverage rather than emphasizing behavioural changes, which are crucial to ensure the safe disposal of child faeces. Thus, it is urgently necessary to strengthen efforts focusing on behavioural changes regarding the safe disposal of child faeces in order to minimise adverse health outcomes.

Unsafe Child Feces Disposal is Associated with Environmental Enteropathy and Impaired Growth

OBJECTIVE

To investigate the relationship between unsafe child feces disposal, environmental enteropathy, and impaired growth, we conducted a prospective cohort study of 216 young children in rural Bangladesh.

STUDY DESIGN

Using a prospective cohort study design in rural Bangladesh, unsafe child feces disposal, using the Joint Monitoring Program definition, was assessed using 5-hour structured observation by trained study personnel as well as caregiver reports. Anthropometric measurements were collected at baseline and at a 9-month follow-up. Stool was analyzed for fecal markers of environmental enteropathy: alpha-1-antitrypsin, myeloperoxidase, neopterin (combined to form an environmental enteropathy disease activity score), and calprotectin.

FINDINGS

Among 216 households with young children, 84% had an unsafe child feces disposal event during structured observation and 75% had caregiver reported events. There was no significant difference in observed unsafe child feces disposal events for households with or without an improved sanitation option (82% vs 85%, P = .72) or by child's age (P = .96). Children in households where caregivers reported unsafe child feces disposal had significantly higher environmental enteropathy scores (0.82-point difference, 95% CI 0.11-1.53), and significantly greater odds of being wasted (weight-for-height z score <-2 SDs) (9% vs 0%, P = .024). In addition, children in households with observed unsafe feces disposal had significantly reduced change in weight-for-age z-score (-0.34 [95% CI -0.68, -0.01] and weight-for-height z score (-0.52 [95% CI -0.98, -0.06]).

CONCLUSION

Unsafe child feces disposal was significantly associated with environmental enteropathy and impaired growth in a pediatric population in rural Bangladesh. Interventions are needed to reduce this high-risk behavior to protect the health of susceptible pediatric populations.

The impact of a rural sanitation programme on safe disposal of child faeces: a cluster randomised trial in Odisha, India

BACKGROUND

Unsafe disposal of child faeces is persistent and may lead to considerable impact on the health of young children. Research is limited on the impact of sanitation or hygiene interventions to improve child faeces disposal practices.

METHODS

In the context of a randomised controlled trial to assess the health impact of a programme in Odisha, India, to promote rural sanitation under the Government of India's Total Sanitation Campaign, we explored whether the intervention affected the safe disposal of faeces of children under-5 years of age.

RESULTS

At baseline, 1.1% of households practised 'safe' disposal of child faeces, either disposing it in a toilet or by burial. The intervention increased safe disposal of child faeces to 10.4% in intervention households, compared to 3.1% in the control households (RR 3.34; 95% CI 1.99-5.59). This increase in safe disposal is attributable to increases in latrine presence in the intervention communities; the intervention did not change safe disposal practices above and beyond the increase in latrine coverage.

CONCLUSIONS

The very modest increase in safe disposal, while statistically significant, is not likely to have consequential health benefit. To achieve open defecation free communities, sanitation interventions will need to develop behaviour change approaches to explicitly target safe disposal behaviours.