Background

Many infectious diseases have been related to human excreta and a lack of sanitation, including cholera, typhoid, hepatitis, polio, cryptosporidiosis, ascariasis, and schistosomiasis.¹ Sanitation is a critical basis for the protection of public health and human welfare, and it has risen to prominence as a basic human right on the worldwide development agenda.^2–4 Sanitation seeks to keep human excrement out of the environment and protect people from fecal-oral disease transmission. More than 2.4 billion people in the globe do not have access to better sanitation, and nearly 1 billion individuals defecate in open fields.⁵ Globally, 45% of CFD is unsafe. Unhygienic disposal of child feces has also been described as a widespread sanitation problem in Sub-Saharan African countries; primarily in rural areas.^6,7 Children’s feces left out in the open, excrement thrown in the trash, feces buried or left on the ground, and feces poured or rinsed into drains or ditches are all unsafe CFD practices practiced by homes in low- and middle-income countries (LMICs), with more than half of households disposing of child feces in an unsafe manner.^8,9

Sustainable Development Goal (SDG) 6 aspires to provide all people with equitable access to safely managed water and appropriate sanitation, as well as to eliminate open defecation.^10,11 Apart from SDG 6,¹² large-scale projects in some countries have expanded latrine coverage, although they do not always assure appropriate latrine use, such as the safe disposal of children excrement, which is a substantial source of fecal pathogen exposure.¹³

So far, no country’s sanitation initiatives have paid much attention to children’s feces, and in many nations, newborn babies’ and children’s stools are regarded as harmless and not dirty.¹⁴ Surprisingly, most sanitation programs focus on household sanitation and ignore children’s stool disposal practices. People, especially children, are more likely to come into close contact with fecal pathogens when feces are left out in the open.¹⁵ Because they play on the ground and put their hands near their faces and into their mouths, children are more likely to be exposed to fecal-oral infections.¹⁶ Fecal-oral infections can induce diarrheal illnesses, which can lead to stunting. The association with hazardous CFD and stunting exemplifies the serious and long-term consequences of this behavior, as stunting results in impaired cognitive and physical development, lower productive ability, and other negative health consequences.¹⁷

Since 2003, Ethiopia has made significant progress in providing better latrines through the execution of health extension packages, reducing open defecation from 61% to 32.3% between 2005 and 2016.¹⁸ Due to a higher prevalence of diarrhea and infections such as hepatitis A, rotavirus, and E. coli in children than in adults, the feces of newborns and small children are 5 times more harmful than that of adults.¹⁹ As a result, children’s feces should be handled with the same care as adults’ feces, using safe disposal procedures that assure sanitary separation from human touch and contamination in the home. The improper disposal of children’s feces, in particular, may be a significant pollutant in family surroundings, offering a significant risk of exposure to newborn infants.²⁰

According to a survey conducted in 15 SSA countries, 58.73% of pregnant women securely disposed of their children’s feces, with CFD levels ranging from 85.90% in Rwanda to 26.38% in Chad.²¹ In line with studies of different settings, safe CFD is still uncommon in Ethiopia, and there is a high disparity of unsafe disposal practice ranging from 26% to 78% from region to region.²²

Demographic characteristics are the most well-known drivers of safe CFD. Ownership of improved latrine, wealth, education and/or literacy, urban rural disparities, age of the child, number of children within the household, marital status of the woman, and water and sanitation infrastructure were related to safe CFD compared to their counterparts.^19,21–24 Evidence is critical for making well-informed decisions and intervening. Consistent and mutually supported results are indispensable to influence policy makers. Factors that influence safe CFD practice are not yet well investigated in Ethiopia. Better yet, it is recommended by a previous study to conduct further research to generate sufficient evidence regarding CFD.²² Therefore, the goal of this study was to determine the level of children’s safe disposal practices and associated factors in West Armachho district, Northwest Ethiopia, in order to develop effective interventions by directing policy makers.

Methods

Sample size determination and sampling methods

The sample size was calculated using a single population proportion formula by considering the following assumptions. The proportion of safe CFD practice (P = 34%) from the previous study done in Ethiopia,²² the Margin of error as 4%, confidence level of 95%, non-response rate of 10%, and design effect of 1.5.

Therefore;

After taking in to account a design effect of 1.5, and a 10% non-response rate;

The final sample size was 888.

Study variables

Operational definition

Safe/Hygienic CFD practice: Defecation into a latrine, put/rinsed feces into latrine or buried.²⁵

Basic latrine: Use of improved facilities that are not shared with other households.²⁶

Improved latrine: excreta disposal facilities that can guarantee the hygienic separation of human excreta from human and insect contact.²⁷

Unimproved latrine: Any latrine, whether a pit without a slab, a platform, a hanging, or a bucket latrine.²⁵

Improved water source: Water sources that have the potential to deliver safe water by nature of their design and construction, and include: piped water, boreholes or tube wells, protected dug wells, protected springs, rainwater, and packaged or delivered water.²⁸

Kebele: The smallest administrative unit in Ethiopia.

Data Collection Tool and Procedure

Data was collected using a pretested structured questionnaire and an observational checklist of household latrines for indicators of usage and of the compound for the presence of human stools. The survey was written in English first, and then translated into Amharic and back to English to check its consistency. The data was collected by eight (08) diploma nurses and supervised by two (02) health officer.

Data Quality Control

The data collection instrument was pretested in areas away from the areas of actual data collection. The data collectors and supervisors were given 2 days of training on how to collect data (questioning techniques and ethical issues). The lead investigator and supervisors routinely supervised the data collection process, and any ambiguities in the questionnaire handling and questioning process were corrected on the spot. Every day, a completed questionnaire was double-checked for accuracy, consistency, and completeness. Before starting the next day’s work, the data collectors, supervisors, and lead investigator discuss the previous day’s data gathering process and any issues that arose.

Data Management and Analysis

Data was entered into Epi Info™ version 7.2, and exported to SPSS version 23 statistical software for analysis. The study variables were summarized using descriptive statistics such as frequencies and proportions. To find parameters linked to the safe disposal of children’s feces, researchers employed a binary logistic regression model. To control the likely effect of confounders, variables with a P-value of .2 in the binary logistic regression analysis were incorporated into the multivariable analysis. In the multivariable analysis, the adjusted odds ratio (AOR) with a 95% confidence interval was calculated to assess the strength of the association, and a P-value of ⩽.05 was used to declare statistical significance. The model’s fitness was further tested using the Hosmer and lemeshow goodness of fit-test(P-value = .621).

Results

Socio demographic characteristics of study subjects

This study had received responses from 873 mothers out of 888 samples, resulting in a response rate of 98.31%. The mothers’/caregivers’ median age was 30 years. Almost all (859, 98.4%) were Orthodox, and (14, 1.6%) others were Muslims in religion. About two-third of the respondents; (572, 65.52%) were living in urban residence, while (301, 34.48%) were living in rural. Most of the mothers; (847, 97.02%) were married. The assessment of the educational status of the study participants revealed that 354 (40.55%) were unable to read and write. It was also found that most of the mothers 751 (86.02(%) were a housewife. Six hundred sixty-four (76.05%) of the households studied had one child whereas the sex ratio of the children was almost similar; (50.28%) male and (49.71%) female (Table 1).

Table 1.

Socio-demographic characteristics of households in West Armachiho district North West Ethiopia, 2019 (n = 873).

Household environmental factors associated with safe CFD practice

The common sources of drinking water for most of the households were improved public stand pipe; 805 (92.21%), and most of them (842, 96.44%) had a total fetching time of 30 minutes or less for a round-trip including the queue. The majority of the respondents; 676 (77.43%) reported that they had a latrine. Most of the latrines were; 480 (71%) were an unimproved type. Only 123 (14.08%) of the households have water within their dwelling compound. The proportion of improved latrine coverage was 83 (12.27%). Seventy-one (10.5%) of the study participants had no their own latrine. A significant number of study participants 220 (32.55%) do not know the last time when they cleaned their latrine (Table 2).

Table 2.

Household environmental factors associated with safe CFD practice in West Armachiho district, North West Ethiopia, May 2019 (n = 873).

Health related (behavioral) factors associated with safe CFD practice

The results of this study showed that most of the respondents 710 (81.32%) had visited health institution in the last 12 months. Majority of the respondents 528 (60.48%) do not had health education about CFD practices. Five hundred fourteen (58.88) of the study participants have knowledge of disposal technology options. Only 26.68% of the study participants have media exposure regarding CFD (Figure 1).

Figure 1.

Institutional factors associated with safe CFD practice in West Armachiho district, North West Ethiopia, 2019 (n = 873).

*watching TV and listening radio.

Level of safe disposal practice of children feces

The magnitude of safe CFD was found to be 37.85% (95% CI: 34.6-40.895). The study participants reported that 61 (7%) their child used the latrine for defecation; 265 (30.35%) children’s stools were put/ rinsed into latrine/latrine, and a very small proportion (0.5%) of children’s stools was buried. The remaining was unsafe CFD practices (Figure 2).

Figure 2.

Proportion of methods practiced for CFD in West Armachiho district, North West Ethiopia, 2019.

Factors affecting safe disposal practice of children feces

Residence of the respondents, age of mother, educational status of children mothers and fathers, their fathers and mothers occupation, age of children, media exposure, (availability, type, and cleaning time) of latrine, water source and distance from it, location of water source, visited health institution in the last 12 months, defecation site, getting health education about CFD practices and listening CFD technology options were fulfilled the criteria and were included in multivariable analysis.

In multivariable logistic regression analysis, the age of children, media exposure, getting health education about CFD practices, fathers’ educational status, households having the basic type of latrine and knowledge of technology options were significantly associated with safe CFD practices. Those households whose child aged 48 to 59 months were 5.07 times more likely practice safe disposal than those households whose child aged <12 months (AOR = 5.07, 95%CI = 2.52-10.21). Children whose father’s educational status was in the category between 9 and 12 were 2.34 times more likely to practice safe disposal compared to those born from unable to read and write father (AOR = 2.34,95% CI: 1.05-5.25). Households who had basic sanitary facilities were 2.79 times more likely to have a safe CFD practice (AOR = 2.79, 95% CI = 1.55-5.02) than those household without basic sanitary facility. Similarly, Households who had got health education about safe CFD practices were 2.77 times more likely to comply to safe CFD practices (AOR = 2.77, 95% CI: 1.84-4.16) as compared to households who did not get health education. Households who had got media exposure about safe CFD practices were 1.88 times more likely to practice safe CFD (AOR = 1.88, 95%CI = (1.22-2.99) as compared to non-exposed households. Households who know disposal technology options were 2.58 times more likely to practice safe disposal of child feces (AOR = 2.58, 95% CI = 11.68-3.96) as compared to those who did not know disposal technology options (Table 3).

Table 3.

Bivariate and multivariable regression for factors affecting CFD practice in West Armachiho district, Northwest Ethiopia, 2019 (n = 873).

Discussion

For a healthy environment and human health, excreta disposal that does not pollute the environment, water, food, or fingertips is essential. The feces of babies and small children are more dangerous than that of adults, but there is a misconception that the feces of babies and younger children aren’t harmful. This contradicts the fact, and proper precautions must be taken to protect residents.¹⁴

Safe CFD techniques were found to be used by 37.8% of research participants in this study. This indicates that residents might face a significant risk of illness exposure and environmental contamination. Children may be vulnerable to diarrhea, parasite infection, and environmental enteropathy if their feces are not properly disposed of. So, proper CFD may be especially important in preventing fecal-oral transmission. Diarrhea is the greatest cause of death among children under the age of 5 in Ethiopia, accounting for 23% of all under-five deaths, and over 70 000 children per year.²⁹ Through evidence-based strategic planning, coordination, and implementation of development actions; the water, sanitation and hygiene(WASH) sector need to be strengthened. A major focus should be on improving knowledge management by using data to improve and strengthen service delivery, policies, procedures, monitoring, and evaluation. Herewith, due attention should be given for safe disposal of child feces in West Armachiho district as the magnitude of safe disposal practice is low.

The level of safe CFD revealed in this study is comparable to that found in a study conducted in Madagascar (38%),³⁰ and Ethiopia.²¹ However, the proportion of CFD practice in the current study was lower than studies of Zambia (77.81%),²¹ Nigeria (56.95%),²¹ Malawi (84.67%),²¹ Kenya (70%),³¹ Malawi (79%),³² Mali (63.5),²¹ Cambodia (70.73%),³³ and Uganda (75%).³⁴ This difference might be due to socio-demographic, environmental, cultural, institutional, economic, and individual livelihood factors of the current study compared to the previous settings.

On the other hand, the proportion of safe CFD in this study was higher compared to studies done in Bangladesh(20%),³⁵ Anglola (32.69%),²¹ Benin (34.13%),²¹ India (21%),¹⁹ the rural block of West Bengal in India (27.6%),³⁶ and Ethiopia (33.68%).²² The presence of open defecation-free declared kebeles in the study area could be a feasible rationale for the differences. Another reason could be that, over time, community knowledge grows as a result of media, and the implementation of health extension program due to sensitization of achieving sustainable development goals in the case of the current study.

According to the findings of this study, households with a basic facility/improved latrine were more likely to practice safe feces disposal than those with an unimproved latrine, which is similar to a study done in Zambia.³⁷ CFD habits vary widely, with a higher frequency of unsafe practices in households lacking access to adequate sanitation.³⁷ Another study conducted in Ethiopia and South Africa found that mothers (caregivers) who lived in a home with a better latrine were more likely to practice safe CFD.^16,22,36 However, a study conducted in India found that the opposite of this study is true, indicating that even in households with improved latrines, 54% of children’s stools were disposed of unsafely. This shows that simply having better latrines does not guarantee that the latrine facility will be used to dispose of the children’s feces.¹⁹

Fathers with a high school, a college diploma, or a higher level of education were found to be more likely than fathers with no formal education to have safe CFD practices. This finding is supported by research conducted in Bangladesh, South Africa, and Ethiopia.^22,38,39 This could be due to a father’s educational attainment, which could lead to a greater role in the safe disposal of child feces by assisting the child during defecation and by buying sanitary pans for his children. Furthermore, educated fathers were more aware of sanitary issues and tend to provide a better care for their children.

These findings suggest that media exposure and health education about correct children’s feces disposal could help avoid improper feces disposal. This observation is in line with the findings of a research conducted in Kenya.⁴⁰ Health promotion efforts should make extensive use of information, education, and communication as well as mass media. Village Health, Sanitation, and Nutrition Committees established under the National Rural Health Mission (NRHM) must be strengthened, trained, and made operational in order to raise community awareness about proper stools disposal.¹⁹ Another study conducted in South Africa found that improved communication channels to reach members of rural communities, particularly home visits, small group meetings, and community meetings, were cited as motivating factors to practice safe CFD.³⁹ Also, health promotion programs involving health education and the media resulted in a 4% increase in the safe disposal of children’s feces in Burkina Faso.⁴⁰

The age of the children was also one of the factors linked to safe CFD in this study. Research in Bangladesh, India, and Ethiopia had found similar results.^22,38,40 This result was also supported by research undertaken in West Nigeria and Kenya.^41,42 When a child reaches a certain age, his or her feces will have a terrible odor and visible food remnants, making the feces more disgusting.²⁰ Another possible justification is that as children get older, especially between the ages of 48 and 59 months, they can practice using the latrine without assistance, and that the pattern of child defecation and the location of defecation in these communities vary with age.

Knowing about children’s excrement disposal technology options was found to be strongly related with safe CFD practices in this study. This finding was further supported by a study conducted in Cambodia.³⁸ The primary reasons reported by caregivers for their satisfaction with existing products included that they were easy to use to dispose of feces and clean; they saved time, especially at night; they were safe and hygienic; they kept the household clean; they were multipurpose, and they were cheap.³⁸ This suggests that community lobbying and advocacy efforts are essential for enabling people to become dependent on better sanitation technology and for providing them with affordable costs associated with using them.

Conclusion

In conclusion, practice of safely disposing of child excrement was found to be poor in the West Armachiho district. Children’s age, media exposure, fathers’ educational status, and health education about children’s feces disposal practices, as well as the type of latrine facility available and knowledge of disposal technology options, were factors associated to safe CFD practices. These findings highlighted the need for a sustained intervention to be designed targeting CFD practices, taking into account different media outlets and advocacy of improved sanitation technology use by policy makers.