Beardsley2020.docx

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Factors associated with safe child feces disposal: evidence across

Ethiopia, India, and Zambia

By

Rachel Beardsley

Honors Thesis Public Policy Department

University of North Carolina at Chapel Hill

March 25, 2020

Approved:

______________________ (Student’s Chair)

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Acknowledgements

I would first like to thank my thesis advisor Dr. Benjamin Mason Meier of the Public

Policy Department. I would like to thank Dr. Musa Manga, Ryan Cronk, and Wren Tracy of the

Water Institute at UNC for guiding me through this process. I would like to express my gratitude

for the Water Institute as a whole for allowing me to work with them and providing a place for

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Abstract

Over 50% of households with children under three report that their children’s feces were

unsafely disposed. Unsafe child feces disposal (CFD)leaves many people at risk of exposure to

fecal-oral pathogens. I analyzed data from a cross-sectional survey of water, sanitation, and

hygiene programming in rural Ethiopia, India, and Zambia. Binary and multivariable logistic

regression models were used to identify factors associated with safe CFD in Ethiopia, India, and

Zambia. Sixty-two percent of households did not dispose of child feces safely. In India and

Zambia, there was a significant association between a household member open defecating and

unsafe child feces disposal (India: OR=0.29, Zambia: p=0.004; OR=0.37, p=0.001. In India,

there was a significant association between the female head of household attending primary

school and households practicing safe CFD (OR=2.20, p=0.012). If a respondent spoke to

someone (such as a community health worker or community leader) about cleanliness was

significantly associated with safe CFD practices in Ethiopia (OR=2.15, p=0.001). In Zambia, if a

respondent washed hands after cleaning a baby they were significantly more likely to practice

safe CFD (OR=1.81, p=0.050). Safe CFD needs to be incorporated into more programs and

should be explicitly mentioned in information about healthy behaviors. More studies should be

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Introduction

Unsanitary CFD poses a substantial health risk for those exposed, as unsafe CFD is

associated with higher environmental enteropathy1_{, increased diarrheal disease, and stunting}

(Bawankule, Singh, Kumar, & Pedgaonkar, 2017; George et al., 2016). Safe CFD is defined as a

child or caregiver placing or rinsing child feces into a sanitation facility. Unsafe disposal

methods include leaving the feces out in the open, throwing feces into the garbage, and

placing/rinsing the feces into drains or ditches (UNICEF, 2015d). When feces are left out in the

open, people are at risk for direct contact with fecal pathogens. Unsafe practices may result in

child feces disposal into the environment (i.e. open drains, canals, etc.), ultimately increasing the

likelihood of pathogens leaching into soil and water sources exposing people to hazardous

pathogens (Majorin, Torondel, Routray, Rout, & Clasen, 2017).

Many infrastructural and societal factors influence child feces disposal practices. Some

cultures believe that child feces are cleaner than adult feces as their size and odor are less

repulsive (Bawankule et al., 2017). However, evidence suggests that children’s feces pose a

higher health risk than that of adults, due to higher prevalence of certain pathogens such as

hepatitis A, rotavirus, and E. coli (Bawankule et al., 2017). Children are at higher risk of

exposure to fecal-oral pathogens because children play on the ground and put their hands near

their face and mouth which, if feces are left out in the open, facilitates the transmission of

fecal-oral pathogens (Bawankule et al., 2017). These fecal-fecal-oral pathogens can cause diarrheal illnesses

which, if reoccurring, can lead to stunting. Unsanitary CFD’s link to stunting illustrates the

1_{Environmental Enteropathy is defined by “reduced intestinal barrier function, and increased}

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severe and lasting effects of this unsafe behavior. Stunting2_{is a condition that effects 30% of}

children and contributes to half of all deaths under 5 (World Health Organization, 2014; Worley,

2014). Stunting affects the immediate health of children but also leads to diminished cognitive

and physical development, reduced productive capacity, and worse health outcomes (World

Health Organization, 2014).

Literature review

CFD is influenced by open defecation and available sanitation infrastructure (Bauza & Guest,

2017). Without sanitation infrastructure, safe CFD is impossible, and when households open

defecate they normalize keeping feces out in the open. Thus, households that open defecate are

more likely to dispose of child feces unsafely. For example, 7% of households in Ethiopia that

open defecate safely dispose of child feces compared to the 45% of households that own an

improved latrine where child feces can be disposed safely (UNICEF, 2015a). However, open

defecation and unsafe child feces disposal does occur even when facilities are accessible

(Standing Commitee on Rural Development, 2017; UNICEF, 2015c, 2017).

Health effects of unsafe child feces disposal

There is substantial evidence linking unsafe child feces disposal to negative health

effects. Bawankule et al (2017) found that children whose feces were disposed of unsafely were

11% more likely to get diarrhea than those whose feces were disposed of safely. Those with

frequent diarrheal disease can lead to environmental enteropathy and are more likely to be

stunted. Environmental enteropathy, significantly reduced weight-for-age, and significantly

reduced weight-for-height z-scores were more likely in children in households whose caregivers

reported unsafe child feces disposal (George et al., 2016). All of these are indicators of

2_{Stunting is defined as “a height that is more than two standard deviations below the World}

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undernutrition – which severely impacts development and is responsible for around half the

deaths of children under 5 in developing countries (World Health Organization, 2014).

Management options for children’s feces

In Ethiopia, many latrines are not easily accessible by children (Asfaw, Azage, &

Gebregergs, 2016). Thus, instead of latrines, potties are occasionally used to dispose of feces.

African households use more potties than Asian households. 25% of Asian households use

potties and 75% of African households use potties (Gil, Lanata, Kleinau, & Penny, 2004).

Diapers are a tool used to manage child feces. However, their use is less prevalent. Respondents

from a study by Majorin et al. (2017) noted that many care-giver thought diapers were too

expensive to use.

Reasons for unsafe child feces disposal

A reason why child’s feces are left out in the open is because their feces are not

considered as harmful as adult feces due to their smaller size and less offensive odor. This was

consistent across all countries where defecating in the open is seen as natural (Ayele, Yemane,

Redae, & Mekibib, 2018; Bawankule et al., 2017). Not only is it the norm, but in Ethiopia,

mothers preferred children defecating in the open as it was perceived as the practical

option (Ayele et al., 2018).

Determinants of safe CFD

Because of insufficient literature, most known determinants of safe CFD are demographic

factors. Income was significantly associated with safe CFD in a majority of studies as was

urbanity (Azage & Haile, 2015; Bawankule et al., 2017; Preeti, Sahoo, Biswas, & Dasgupta,

2016). Many reports found a significant positive association with mothers’ education and/or

literacy (Ayele et al., 2018; Azage & Haile, 2015; Bawankule et al., 2017; George et al., 2016;

Preeti et al., 2016). However, Bauza and Guest found no association with mothers’

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literate being able to benefit from sanitation campaigns’ use of posters or other media to

communicate proper behaviors.

Child defecation in potties was strongly associated with safe CFD in Bangladesh and

Ethiopia (Islam et al., 2018). Children defecating in the open were 89% less likely to safely

dispose of feces compared to those who used a potty. Ayele et al. (2018) that this indicates that

mothers who use a potty are aware of the risks of unsafe CFD.

It is unclear whether the presence of an improved latrine is associated with safe child

feces disposal. Bawankule et al. and Azage & Haile found that households with an improved

latrine were twice as likely to dispose of child feces safely. George et al. did not find such

association (George et al., 2016). Preeti et al found that an improved water source was

significantly associated with safe CFD (Preeti et al., 2016). In India, most households that safely

disposed of child feces had water on the compound (Majorin et al., 2014). However, a study in

Ethiopia found no such association (Azage & Haile, 2015). The association between improved

infrastructure and safe CFD may be because those who invest in sanitation understand and care

about sanitation and sanitary behaviors (Curtis et al., 1995).

Health behavior

Even if sanitation infrastructure is available, people still open defecate. In Ethiopia, after

a community-led total sanitation (CLTS) intervention in the Diretiyara district, 11% of

respondents with a latrine still defecated out in the open after the intervention (Tessema, 2017).

As of 2018, 84% of India had access to an improved sanitation facility, yet around half the

population still practiced open defecation due to broken or unclean sanitation facilities, water

access or reliability, religious reasons, convenience, or cultural norms (Standing Committee on

Rural Development, 2017). Likewise, in Zambia, many people prefer open defecation to using

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providing latrines. However, child feces are more likely to be disposed of unsafely in households

that practice open defecation (Bauza & Guest, 2017; Islam et al., 2018). Thus, sanitation access

is an important tool in eliminating unsafe CFD, but it cannot be the only method.

Community health workers

One method used by all countries to promote healthy behavior are community healthcare

workers. These workers are links to both the community they serve and the healthcare system

and critically important in rural areas where healthcare is less accessible. In addition to linking

people to health services, CHWs provide health information to their communities.

The effectiveness of CHW programs in inspiring WaSH-related behavior change differs

in magnitude. In Tamil Nadu, CHWs in an experimental program taught villagers both

the reasons clean drinking water is a necessity in addition to how to treat water. After this

program ended, villagers were significantly more likely to know when drinking water was

contaminated. However, compared to the control village, treated villagers were not significantly

more likely to treat water. In general, greater awareness was observed, but it was not

accompanied by behavior change (Gupta, Mutukkanu, Nadimuthu, Thiyagaran, &

Sullivan-Marx, 2012). In India, there were few studies examining CHWs effect on sanitation-related

behavior change. This is likely because although ASHAs are meant to teach sanitary behaviors,

maternal and child health roles comprise dominate their duties, and none of their financial

incentives are WaSH related (Scott, George, & Ved, 2019).

In southeast Africa, CHWs often inspire change too. In Ethiopia, an experiment

compared model families, families that undergoes training by Health Extension Workers

(HEWs) to be the standard of good behavior in the community, to non-model families. Proper

latrine utilization was practiced by 100% of model households and 83.1 % of non-model

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of non-model households. This indicates that HEWs have proper knowledge of safe child feces

disposal, this information is covered in official training, and HEWs can effectively communicate

this knowledge (Gebru, Taha, & Kassahun, 2014). Another study in Ethiopia discovered that the

odds of a child from a poor household having diarrhea were 1.72 times higher if

the HEW’s house revisit interval was less than 1.7 times in comparison to those who were visited

by HEWs every three months (Azage, Kumie, Worku, & Bagtzoglou, 2016). Likewise,

households visited by HEWs every 3 months decreased cases of diarrheal illness compared

to household visited every 6 months (Azage & Haile, 2015).

In Zambia, there are few reports of community health assistants’ effect on sanitary

behaviors. However, there is evidence that CHWs do encourage behavior change as mothers

seeking vaccination for their children increased by 7.5% after a CHW program advocating for

maternal and child health was implemented (Biemba et al., 2016).

Ethiopia’s sanitary practices and healthcare infrastructure

Access to sanitation infrastructure is a problem, with only 68% of rural Ethiopia having

accessible sanitation facilities (CSA, 2011). Additionally, access is particularly a problem for

children as many toilets are not built in a way that children can easily use them. In a baseline

survey, 42% of caregivers reported that their latrine is not easily accessible to children.

Additionally, caregivers often fail to dispose of child feces into sanitation facilities even when

the facility is available and accessible (UNICEF, 2015a).

Ethiopia’s ONEWASHT Nation Program (OWNP) was established in 2013 and adopted

a multi-sectoral program that brings together four ministries (Health, Finance, Water Resources,

and Education) together along with private and nongovernmental stakeholders. Ethiopia’s

National Hygiene and Sanitation strategy has three pillars. The first is enabling a favorable

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sanitation protocol and health extension workers (Federal Democratic Republic of Ethiopia

Ministry of Health(FMOH), 2017). The second pillar is promoting sanitary and hygienic

behavior through communication, social marketing, and incentives. The final pillar is to improve

access and affordability of necessary products and services. Ethiopia’s “Baby and Mother

WASH Implementation Guideline” (BabyWaSH) is meant to be integrated into the pillars of this

overall strategy. Child feces disposal is a central target of the BabyWaSH protocol, and

BabyWaSH is meant to be integrated into each administrative level.

Ethiopia’s CHW program is the most likely to include policies on safe CFD as part of

BabyWaSH guidelines were to integrate the policies into the curriculum under Ethiopia’s Health

Extension Program (HEP). The HEP is a community-based healthcare delivery system dedicated

to providing equitable access to health services and encourage healthy behavior. There are three

main CHW schemes that make up the HEP: HEWS, the Health Development Army (HDA), and

"Model Families" (Zulliger, n.d.). HEWs have education requirementsand formal training and

provide essential services with an emphasis on maternal and child health. The HDA are

volunteers whose role is to increase utilization of primary health services. Model families are

families looked up to in the community that are trained in maternal health, malaria prevention

and control, and hygiene and environmental sanitation. In Ethiopia, an experiment

compared model families to non-model families. Safe child feces disposal was practiced by

93.2% of model families and 58.1% of non-model households. This indicates that HEWs have

proper knowledge of safe child feces disposal, this information is covered in official training, and

HEWs can effectively communicate this knowledge (Gebru et al., 2014).

India’s sanitary practices and healthcare infrastructure

Child feces disposal is widespread in India due to both cultural and infrastructure factors.

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infrastructure for safe disposal. However, infrastructure is not the only barrier to sanitary CFD,

as evidenced by open defecation practices surpassing the number of households that do not have

a latrine. As of 2018, 84% of Indian households have access to an improved sanitation facility,

yet around half the population still practices open defecation due to broken or unclean sanitation

facilities, water access or reliability, religious reasons, convenience, or cultural norms. 16% of

households dispose of child feces safely, suggesting that it is largely behavior, rather than

infrastructure that is the cause of unsafe CFD (Standing Commitee on Rural Development, 2017;

UNICEF, 2015b).

India’s national sanitation campaign, Swachh Bharat Mission (SBM), began in 2014 and

improved upon its former program, the Total Sanitation Campaign by focusing on

community-centered, collective behavioral change, instead of concentrating on ensuring improved sanitation

facilities were available to all. SBM is split into urban and rural missions named SBM (Urban)

and SBM (Gramin), respectively. SBM(G) has two methods to improve sanitation in India:

providing and facilitating access to resources whether in-kind or monetary, and encouraging

behavior change through information, education, and communication (IEC) programs. Safe

disposal of child feces is still overlooked in programming and national emphasis. Child feces

disposal is not mentioned in the SBM(G) guidelines, and there are no programming, information

campaigns, or guidelines specifically focusing on reducing unsafe CFD (Ministry of Drinking

Water and Sanitation, 2017; Standing Commitee on Rural Development, 2017).

In India, there are three main types of community health workers in India: Accredited

Social Health Activists (ASHAs), Anganwadi Workers (AWW), and Auxilary Nurse Midwives

(ANMs). These workers focus on maternal and child health, vaccinations, and encouraging

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to promote Maternal and Child health. Their main roles are to educate and inform on proper

health behaviors and resources, refer villagers to the proper health facility, and assist AWWS

(Tripathy et al., 2011). AWWs focus on supplying nutritional supplements to children,

adolescent girls, and lactating women in addition to manning the Anganwadi centers (AWCs).

AWCs are community health centers with services comprising health nutrition, and

informational packages for pregnant women, lactating mothers, and children under six years of

age (Saprii, Richards, Kokho, & Theobald, 2015). Though these workers are dedicated to

encouraging healthy behaviors in mother and children, sanitary CFD is not specifically

mentioned in their duties and health talk topics, nor do they report educating on CFD in their

service logs (Ministry of Drinking Water and Sanitation, 2017).

Zambia’s sanitary practices and healthcare infrastructure

There are no studies examining CFD in Zambia. 33% of Zambian households safely

dispose of child feces, and rates are much higher in rural areas. 52% of rural households reported

safe disposal in comparison to 87% of urban households. Households with sanitation facilities

were much more likely to dispose of child feces. Of households with an improved sanitation

facility, 89% safely disposed of child feces. 67% of households with unimproved facilities

practiced safe CFD, and 29% of households that practice open defecation practice safe CFD.

In Zambia, the Ministry of Local Government and Housing (MLGH) developed the

National Rural Water Supply and Sanitation Programme (NRWSSP). This program focuses on

decentralization, creating an enabling environment, and strengthening organizational and

individual capacity (Government of the Republic of Zambia, 2015). The sanitation strategy

works across ministries, local authorities, civil society organizations and non-governmental

organizations, and private sector partners. While specifically executed under the MoLGH but

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General Education. The NRWSSP ended in 2016. In 2016, the Ministry of Water, Development,

Sanitation, and Environmental Protection was created. Its goal is to increase water security,

improve management and provision of water and sanitation services, improve resource

mobilization and management, and build operational capacity and a productive operational

environment (2018-2021 Strategic Plan, n.d.).

There are no known studies on safe child feces disposal in Zambia (UNICEF, 2015c).

However, in an impact evaluation report commissioned by UNICEF, both appropriate disposal of

child feces and handwashing after disposing of child feces were indicators. This suggests that

some specific attention to child feces disposal exists (Yeboah-Antwi et al., 2017).

In Zambia, Community Health Actors (CHAs) are paid employees that work underneath

nurses. CHAs split their time between health posts and their community. The health information

and services provided reflect the disease burden of the country. Thus, they predominately

provide services related to maternal health, child health, environmental health, and HIV/AIDs.

Their WaSH-related roles include promoting hand washing, inspecting construction of latrines,

promotion of proper sanitary behavior, providing information, education, and communication

activities on clean water and water purification techniques, and participating in community-led

total sanitation efforts (Katharine Shelley & Worku, 2015).

Methods

Summary

Binary and multivariable logistic regression models were used to identify factors

associated with safe child feces disposal (CFD) in rural Ethiopia, India, and Zambia. This study

used secondary data from a survey conducted by World Vision (WV) and the Water Institute

(WI) at the University of North Carolina at Chapel Hill. This survey sampled both areas where

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study design was used across WV program areas and comparison areas. The WI created the

evaluation design, methods, sampling plan, ethical review, data collection plan, data collection

tools, water quality testing parameters, and data analysis plan. This study examined the data from

the household surveys from Ethiopia, India, and Zambia.

Study population

The survey sampled 14 countries decided by WV on the basis of their activity in the

country. Around 56 comparative area clusters and 56 WV program clusters were randomly

selected in each country. The population is restricted to the 3,737 households that answered the

survey question on child feces disposal.

Sample selection and design

Selected countries

Ethiopia, India, and Zambia countries were chosen because of their high rates of unsafe

child feces disposal, high rates of open defecation, and relatively expansive community health

worker programs. India was specifically chosen because of its extensive national sanitation

program that has little to no emphasis on safe child feces disposal. Ethiopia was chosen because

it has a national sanitation program that does entail guidelines on safe child feces disposal.

Zambia was chosen because of the aforementioned factors and its proximity to and similar size

in comparison to Ethiopia.

Sampling design

The study used a cluster-randomized, population-based design. The process of identifying

clusters for Zambia and Ethiopia differed from identifying clusters for India. For Zambia and

Ethiopia, enumeration areas (EAs) were collected from national statistic offices’ lists of

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programs and comparison areas. Primary-sampling units (PSUs) were randomly selected from

each stratum using a probability-proportional-to-size method (PPS)3_.

PSUs were overlaid with a map of WV program areas and then areas were selected.

Comparison areas were selected from any district outside the WV program area boundaries.

India differed in that a list with administrative units was not collected. Thus, districts containing

World Vision programs were identified and collected. WV administrative blocks and non-WV

administrative blocks within these districts were selected and used as clusters. A list of blocks,

both non-WV and WV, was composed and then sampled using a PPS to select the PSUs. 56

comparative area clusters and 56 WV program clusters were randomly selected from all clusters

in each country.

PSUs were randomly selected and further divided if there were more than 200 households

in the unit. This division resulted in secondary sampling units (SSUs) which were randomly

sampled. Clusters contained 100-200 households.

Survey instruments and personnel

The survey instrument contained questions on water, sanitation, and hygiene. The WI led

workshops to train research supervisors who then used this material to train enumerators with

previous experience in mobile surveys and survey data collection. The surveys were translated

into the local languages and then authenticated by either research personnel or WV staff in

country. The surveys included WaSH-related interview questions and direct observations.

Survey answers were logged using mWater, a mobile survey tool.

3_{PPS method is a sampling method by which a size measure is available for each population unit within a finite}

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Data collection

Survey questions were both observational and posed directly to householders. Female

heads of households were interviewed unless unavailable. If unavailable, an available adult was

interviewed. If no adult was available, another household from the same cluster was selected.

Data entry, processing, and analysis

Descriptive statistics and indicators were created using survey questions in Table 1.

Indicators were calculated for “at the time of survey” responses and were adjusted to account for

year-round differences in responses.

Data analysis

Multivariate and binary logit regression was used to examine factors associated with

unsafe disposal of children’s stool. Stata 15.1 was used to conduct this analysis. Independent

variables were tested for possible multicollinearity before putting those into the regression

models. The logit regression will be used to identify odds ratios for sanitary child feces disposal

for demographic factors, sanitation infrastructure, health behaviors, contact with community

health workers, and household’s participation in the community. In all models, controls are

wealth quintile, female head of household’s education, if any household member open defecates,

and improved vs unimproved sanitation facility.

Variables

Table 1: Variables and respective survey questions and answers

Variable topic Variable definition or survey question Categorization of survey responses Child feces disposal How do you dispose of your child’s feces?

Put/rinsed into toilet or latrine was coded as safe. Put/rinsed into drain or ditch, thrown into garbage bin or pile, Buried, Left in the open, and Other was coded as unsafe.

 Unsafe disposal  Safe disposal

Wealth quintile Wealth indexes were created separately for each country using variables for household services and possessions, such as electricity, vehicles, and electronics, as well as housing construction materials, such as flooring, roof, and walls. The principal components analysis method outlined by the Demographic and Health Surveys Program was employed for wealth index construction (Rutstein, 2015).

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Female head of household education level

Has the female head of household finished primary

school?  Yes No

Open defecation Does at least one member of your household defecate in the open?

 Yes  No Talked about

Cleanliness Can you remember the last time someone talked to you about cleanliness?  Yes  No WaSH committee -

activity

Has the water/WaSH committee held a community

meeting in the past year?  YesNo

Sanitation facility –

shared Is this facility shared with other families who are not _relatives?  YesNo

Handwash – defecation

Does the respondent wash their hands after defecating?  Yes

 No

Handwash-cleaning

baby Does the respondent wash their hands after cleaning _{their baby?}  YesNo

Main water source

improved What is the main type of water point that your _{household uses to get drinking?}

Responses then coded into improved/unimproved drinking water source

 Unimproved

 Improved

Additionally, there were some problems with questions about WaSH committees in India.

Those who had piped-water in their yards as their main water source were excluded from

questions about committees which decreased the number of respondents. There were particularly

few responses in India since for the ‘Water point and community’ survey. Community water

points were available in each of the PSU and people were available to look after the points and

report in case of malfunctioning to appropriate authorities. However, they were not organized

into any water committees. As a result, in most of the PSUs, respondents could not properly

answer the questions related to water committee.

Results

Table 2 shows the percentage of unsafe CFD by selected demographic characteristics

foreach country and collectively. The highest prevalence of unsafe child feces disposal was in

India (83%), followed by Ethiopia (60%), and Zambia (46%). The prevalence of unsafe child

feces disposal was 75% among poorest wealth quintile households and 41% among the richest

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school. Twenty-seven percent of households had an improved sanitation facility. In Ethiopia,

India, and Zambia, households that had an improved sanitation facility practiced safe CFD at

rates of 29%, 57%, 21% respectively.Fourteen percent of Indian households recalling such talks,

and 42% and 37% of Ethiopian and Zambian households recalling such talks respectively. There

were few active WaSH committees in India – with only 2% holding meetings within the year.

Ethiopia and Zambia had more active committees with 31% to 24% holding meetings within the

year.

Table 2: Unsafe disposal of children’s feces by socioeconomic and demographic characteristics

Ethiopia India Zambia

Characteristics _{Safe (%)} _Number _{Safe (%)} _Number _{Safe (%)} _Number Wealth quintile

Poorest 29.7 63 2.1 5 43.5 101

Poor 32.0 93 15.3 37 46.7 121

Middle 35.7 97 14.4 31 48.3 130

Wealth 41.3 123 24.2 44 55.9 152

Wealthiest 59.4 165 36.2 68 73.3 200

Female head of household finished primary school

No 33.2 213 11.8 80 46.0 103

Yes 46.3 328 26.4 107 55.6 601

At least one household member open

defecates

No 71.3 361 46.7 147 80.2 595

Yes 21.3 180 5.2 40 19.3 108

Respondent can recall when someone last spoke to them about cleanliness

No 31.4 238 15.8 144 49.2 389

Yes 52.8 288 23.0 35 61.5 283

WaSH committee has held a meeting in past year

No 37.2 294 52.7 328

Yes 51.2 178 56.4 194

Closest sanitation facility is shared with non-family members

No 72.8 397 43.0 119 80.2 446

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Washes hands after defecation

No 30.3 168 11.5 9 40.4 76

Yes 46.9 373 17.8 178 56.2 628

Washes hands after cleaning baby

No 35.6 273 18.1 115 52.2 530

Yes 45.8 268 16.18 72 60.2 174

Improved year-round main water point

Unimproved 26.0 58 12.2 12 58.6 190

Improved 43.2 435 1838.0 172 52.3 487

Binary logistic regression analysis

In the three countries, female heads of households finishing primary school, any household

member open defecating, and recalling the last time they talked to someone about cleanliness were all

significantly associated with safe CFD. In Ethiopia and Zambia, washing hands after defecation, washing

hands after cleaning a baby, and if the main water source was improved were all significantly associated

with practicing safe disposal of child feces. In Ethiopia, there was a significant association between safe

CFD practices and if the WaSH committee had met in the past year.

Table #3 Binary logistic regression of safe child feces disposal

Variables

OR (CI) p-value OR (CI) p-value OR (CI) p-value

Wealth Quintile (vs. Poorest)

Poor 1.11 (0.89-1.33) 0.592 8.59 (4.42-12.76) 0.000 1.13 (0.92-1.34) 0.479

Middle 1.31 (1.05-1.57) 0.168 8.02 (4.08-11.96) 0.000 1.21 (0.99-1.43) 0.283 Wealthy 1.66

(1.49-1.83) 0.008 * 1.64(1.34-1.94) 0.006

Wealthiest 3.45 (2.78-4.12)

0.000 * 3.55

(2.87-4.23) 0.000 Female attended Primary school 1.73 (1.54-1.93) 0.000 2.68 (2.235-3.12) 0.000 1.47 (1.25-1.69) 0.009

Any member of the household open defecates 0.11 (0.09-0.12) 0.000 0.06 (0.05-0.07) 0.000 0.06 (0.05-0.07) 0.000

Can recall last time someone talked to them about

2.44

(2.16-2.72) 0.000 1.60(1.26-1.94)

*

0.028 1.65

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cleanliness Whether WaSH committee has met in past year 1.77 (1.54-2.00) 0.000 1.16 (1-1.32) 0.263 Closest sanitation facility shared with non-family members 1.28 (0.90-1.67) 0.408 0.46 (0.26-0.66) 0.071 0.66 (0.51-0.81) 0.070

Washes hands after defecation 2.03 (1.79-2.27) 0.000 1.65 (1.05-2.25) 0.167 1.89 (1.59-2.19) 0.000

Washes hands after cleaning baby 1.53 (1.36-1.70) 0.000 0.87 (0.73-1.01) 0.416 1.39 (1.2-1.58) 0.016

Main water source is improved 2.16 (1.80-2.52) 0.000 1.61 (1.09-2.13) 0.134 0.77 (0.67-0.87) 0.049

*Removed due to multicollinearity Multivariable analysis

All wealth quintiles for India are significantly associated with safe CFD. In Ethiopia,

those in the poor were significantly more likely to practice safe CFD than the poorest households

(OR=2.63, p=0.099). The middle quintile were significantly less likely to practice safe CFD than

the poorest households (OR=.0.36, p=0.023). In Zambia, all quintiles were significant relative to

the poorest quintile except for the poor quintile. In India and Zambia, whether a member of the

household open defecates was also significant (India: OR=0.29, p=0.004; Zambia: OR=0.37,

p=0.001. In India, females who finished primary school were significantly more likely to practice

safe CFD (OR=2.20, p=0.012). In Ethiopia, if a respondent can recall speaking to someone about

cleanliness they are significantly more likely to dispose of feces safely (OR=2.15, p=0.001). In

Zambia, if a respondent reported to wash hands after cleaning a baby they are significantly more

likely to practice safe CFD in Zambia (OR=1.81, p=0.050).

Table #4 Multivariable logistic regression of safe child feces disposal

Variables

OR (CI) p-value OR (CI) p-value OR (CI) p-value

Wealth Quintile (vs. Poorest)

Poor 2.63 (1.09-4.17) 0.099 6.79 (1.12-12.46) 0.022 1.81 (1.15-2.47) 0.103

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(0.2-0.52) (1.01-11.69) (-0.85-1.45) Wealthy 0.35 (0.2-0.5) 0.160 7.29 (1.08-13.5) 0.020 2.69 (1.68-3.7) 0.008

Wealthiest 0.64 (0.35-0.93) 0.327 6.95 (1.21-12.69) 0.019 3.22 (2.05-4.39) 0.001 Female attended

Primary school 1.24(0.96-1.52) 0.347 2.20(1.51-2.89) 0.012 1.74(1.20-2.28) 0.073

Any member of the household open defecates

0.68

(0.51-0.85) 0.123 0.29(0.17-0.41) 0.004 0.37(0.26-0.48) 0.001

Can recall last time someone talked to them about cleanliness

2.15

(1.67-2.63) 0.001 1.17(0.67-1.67) 0.707 1.28(0.96-1.6) 0.323

Whether WaSH committee has met in past year

1.38

(1.03-1.73) 0.203 0.84(0.62-1.06) 0.500

Closest sanitation facility shared with non-family members 1.55 (0.97-2.13) 0.240 0.50 (0.21-0.79) 0.236 0.6 (0.43-0.77) 0.073

Washes hands after

defecation 0.92(0.68-1.16) 0.753 0.46(0.1-0.82) 0.322 0.97(0.60-1.34) 0.945

Washes hands after

cleaning baby 0.82(0.62-1.02) 0.418 0.64(0.44-0.84) 0.145 1.81(1.26-2.36) 0.050

Main water source is improved 1.75 (1.216-2.284) 0.065 0.94 (0.46-1.42) 0.900 1.04 (0.75-1.33) 0.902

Discussion

Sixty-two percent of all respondents did not dispose of child feces safely which means

that three-fifths of the population is at an increased risk for pathogen exposure from coming into

contact with child feces

India had the highest rates of unsafe child feces disposal by far. Rates of sanitation

coverage are similar across countries, so the high rate is not an issue of infrastructure. It is

possible that the higher rates of open defecation normalize feces being out in the open and thus it

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In India and Zambia, if the household had a family member that open defecated they

were significantly less likely to practice with safe CFD. This association may occur because if a

member open defecates they are likely to be more comfortable with feces out in the open. This

association could be caused by the persisting norm of open defecation.

In Zambia, those who washed their hands after cleaning their baby were 87% more likely

to dispose of child feces safely. Handwashing is most likely an indication that those who do it

recognize that child feces are dangerous. This suggests that if caregivers are made to understand

the harms of child feces- they will be more likely to dispose of them safely.

Respondents are more likely to dispose of child feces safely if they can recall someone

talking to them about cleanliness. In Ethiopia, respondents are 83% more likely to practice safe

CFD if they've talked to someone about cleanliness. As seen in other studies, talking to someone

about cleanliness, namely a CHW, increases greater awareness of risky health behaviors and can

encourage behavior change (Biemba et al., 2016; Gupta et al., 2012).

There were no significant associations for WaSH committees which suggests that the

WaSH committees either play no role in encouraging healthy behaviors or that WaSH

committees do not mention CFD when detailing healthy behaviors.

The association between wealth and safe CFD mainly in the middle and wealthy quintiles

is in line with many other studies (Azage & Haile, 2015; Bawankule et al., 2017; Preeti, Sahoo,

Biswas, & Dasgupta, 2016). Those with in higher wealth quintiles are more likely to have

improved sanitation facilities making safe CFD possible (Azage & Haile, 2015). Similarly, there

are many sources cited with the association between females attending primary school and

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Azage & Haile, 2015; Bawankule et al., 2017; George et al., 2016; Preeti et al., 2016). However,

Bauza & Guest did not find this association to hold in their study across 34 countries.

Limitations

The data are representative of most rural areas in most countries, but generalizations

cannot be made for all rural areas of all countries. All household survey results were unweighted

because the data needed for households weighting was not collected in all countries. There are

several potential sources of bias in the survey questionnaire. Survey questions that asked about

year-round water use are subject to recall bias.. However, our method of asking this was

consistent with another study (Elliott et al., 2017). Additionally, households may not have had

the technical ability to answer some questions. Another problem is that this survey was not

dedicated to CFD, and there are some questions that would have given a richer analysis into

CFD. Additional questions include reasons for the way they dispose of child feces or including

their understanding of the whether child feces is dangerous. This would help us understand the

motivations behind the practice of unsafe CFD.

Implications

In India and Zambia, households that had at least one household member who open

defecates were significantly less likely to dispose of children's feces safely. Efforts should be

made to reduce open defecation and these measures should also include specific information on

disposing of children’s feces safely.

In Zambia, there was a significant association between washing your hands after cleaning

a baby and practicing safe CFD. Likely, those that wash their hands after cleaning a baby do so

because they understand that feces are dangerous. This leads me to believe that if people are

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Thus, more effort should be put into communicating the risks of children’s feces specifically

whether this be through certain programs or media campaigns.

Ethiopia may be the only country to show an association with the respondent talking to

someone about cleanliness because of their program seems to include information on safe child

feces disposal. This is determined from the BabyWash policy and the study by Gebru et al.

(2014) which found that model families, families taught by HEWs and serve as role models for

the community, are more likely to dispose of child feces safely than non-model families. If other

countries included safe CFD protocols in the CHW health talks, similar results could be seen in

other countries.

Conclusions

Sixty-two percent of households did not dispose of child feces safely. In India and

Zambia, there was a significant association between a household member open defecating and

unsafe child feces disposal (India: OR=0.29, Zambia: p=0.004; OR=0.37, p=0.001. In India,

there was a significant association between the female head of household attending primary

school and households practicing safe CFD (OR=2.20, p=0.012). If a respondent spoke to

someone (such as a community health worker or community leader) about cleanliness was

significantly associated with safe CFD practices in Ethiopia (OR=2.15, p=0.001). In Zambia, if a

respondent washed hands after cleaning a baby they were significantly more likely to practice

safe CFD (OR=1.81, p=0.050).

This study raises a number of questions about the role of feces disposal in sanitation

policies and the effectiveness of sanitation policies on safe CFD. Safe child feces disposal should

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Additionally, further research on safe CFD is necessary to better understand the problem and to

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