Child feces disposal practice and associated factors: a dilemma in Tigray, northern Ethiopia

Proper excreta disposal and minimum levels of personal and domestic hygiene are known to protect public health. Safe excreta disposal and handling acts as the primary barrier for preventing excreted pathogens from entering the environment (Richard 2001). However, improper human excreta disposal and lack of adequate personal and domestic hygiene have been implicated in the transmission of many infectious diseases in sub-Saharan Africa. This is because knowledge about the health benefits of sanitation is low accounting for only 2.5% of mothers associated with it. Feces were disposed of and removed for esthetic reasons, not for the prevention of spread of diarrhea as mothers are not aware of that (Nielsen et al. 2001). The Joint Monitoring Program (JMP) standardized definition for an improved sanitation facility is one that hygienically separates human excreta from human contact (WHO/UNICEF 2014). In general, the world has fallen short on the sanitation target, leaving 2.4 billion without access to improved sanitation facilities. Almost 700 million people who would have been served in the MDG target for sanitation are waiting for the sustainable development goal in sub-Saharan Africa (WHO/UNICEF 2015). Ethiopia achieved the largest decrease in the proportion of the population practicing open defecation (from 92% in 1990 to 29% in 2015), a reduction over five times greater than the regional average for the same period (WHO/UNICEF 2015). In line with this, 8.8% of households are using improved toilet facilities that are not shared with other households, 14% in urban areas and 7% in rural areas. One in ten households (32% in urban areas and 3% in rural areas) use shared toilet facilities. The large majority of households (82%) use non-improved toilet facilities (91% in rural areas and 54% in urban areas). The most common type of non-improved toilet facility is an open pit latrine or pit latrine without slabs, used by 45% of households in rural areas and 37% of households in urban areas. Overall, 38% of households have no toilet facility (16% in urban areas and 45% in rural areas) (Central Statistical Agency 2012). However, the existing latrines in developing countries are not proper for the use of small children. Defecation on the floor is common and potentially seen as the most practical option until the child is potty trained (Gil et al. 2004; Brown et al. 2013). However, proper excreta disposal in the study area is not mainly due to the nature of the latrine per se, rather the perceived safety of child feces among the communities at large. According to the Central Statistical Agency (March 2012), in Ethiopia only 36% of children's feces are safely disposed of, that is, 6% of children use a toilet or latrine, 29% of children's feces is placed in the toilet or latrine, and 1% buried. These studies are too general to give clues about the malignancy of the problem in the region. Therefore, this study was undertaken to provide evidence on the experience of child feces disposal practice and associated factors in the region, which is a neglected issue due to the perception of mothers that child feces do not have health consequences.

A community-based cross-sectional study design was employed to collect quantitative data from a total of 456 randomly selected households in October 2015. Data were customized and cleaned using EPI data and SPSS version 16 software package was used for analysis. Descriptive statistics like frequencies and percentages were calculated for all variables and binary logistic regression was used to test the association between explanatory and outcome variables with 95% confidence interval (CI), and crude odds ratio (COR) and adjusted odds ratio (AOR) were also computed to identify statistically significant associations between child feces disposal practice and associated factors. All variables having a p value ≤0.2 in the binary logistic regression were included in the final multivariable logistic regression model to identify the independent predictor of child feces disposal of the mother or caregiver. Those variables with a p value <0.05 in the final multivariable logistic regression model were considered as associated factors for safe child feces disposal. Both COR and AOR were calculated with a 95% CI.

Variables for the cross-sectional study like place of residence, women's occupation, women's educational status, religion, monthly income, father's educational status, father's occupation, information access (media exposure), women's age and child's age, knowledge on safe disposal of child feces, intention toward child feces disposal, child feces defecation site, feces disposal site, time contact with child feces, cleaning materials used after defecation, hand washing after child feces disposal, availability of latrine, functionality of latrine, type of latrine, feces visibility in the compound, hand-washing materials, flies in the latrine, and smell of the latrine were included.

The outcome variable for this study was child feces disposal practices. Child feces disposal practice was assessed based on the JMP for water supply and sanitation definition by asking ‘The last time child passed feces (indexed for youngest under five years old child), what was done to dispose of the feces?’ The list of disposal options include: did the child use potty, used diaper, bury feces, latrine, garbage pit, and used water and soap/ash to wash. Before calculating the overall knowledge and attitude, item reliability test was checked for Likert scale items that measure the knowledge and attitude using the Cronbach's alpha coefficient, and according to George & Mallery (2003), the result is acceptable and indicates the set of items were internally consistent. After checking, the reliability knowledge and attitude of respondents towards child feces disposal practice was measured by dichotomizing the overall knowledge and attitude questions into ‘satisfactory’ or ‘unsatisfactory’ knowledge and ‘supportive’ or ‘non-supportive’ attitude based on the mean knowledge and attitude of individual responses, respectively. Finally, child feces disposal practices were recoded into a binary outcome, ‘safe’ and ‘unsafe’ (household floor, went in yard, went outside premises, outside/open air/bush, went on his or her cloths, and did not wash).

Data were collected after getting ethical clearance from Mekelle University, College of Health Sciences, and Research and Community Services office. Written consent was obtained from mothers/caregivers and data were recorded anonymously. The participants were further informed of the reasons for using a recording device for data collection and they were assured that the recording was entirely for the purpose of verifying and clarifying the information they provided.

The study was carried out in Hintalo Wajerat district, one of the 46 districts of Tigray region, located 45 km south of Mekelle, the capital city of Tigray regional state, Ethiopia. It has a total of 23 kebeles (five semi-urban and 18 rural) for administrative purposes. Based on the 2014 Hintalo Wajerat District Health Office report, the total population estimated was 185,466 of which 27,078 are under five years of age. There are seven governmental health centers and 23 health posts in the district. Latrine coverage of 80% was reported with 67% utilization and 60% water access (Hintalo Wajerat Woreda Health Office 2014). From the district a total of 456 participants with under children under five were recruited in this study.

Of the total 456 participant mothers, 445 responded, with a response rate of 97.6%. Of these, 98.2% were biological mothers, while the other 1.8% were grandmothers and sisters. The median age of mothers was 29 years with interquartile range (IQR) of eight. Two hundred and fifty-six (57%) of the mothers were in the age range of 25–34. Sixty-seven percent of mothers did not attend formal school and 212 (47.6%) were illiterate. As well, 263 (65.1%) of husbands did not attend formal education and 178 (40%) of mothers were housewives by occupation. The median age of children was also assessed and was found to be 14 months with an IQR of 16 (Table 1).

Caregivers having satisfactory knowledge and a supportive attitude about child feces disposal practice were 59.3% and 42.7%, respectively (Table 2).

Two hundred and thirteen (47.9%) children were reported to defecate on the household floor followed by potty (108, 24.3%), and 264 (59.1%) mothers used a latrine for final disposal. Two hundred and seventy-six mothers (62%) reported that they used water only and 112 (30.4%) used soap. Most caregivers reported they had contact with child feces during cleaning their child's bottom (230, 51.7%), with only 369 of them reporting washing their hands after handling feces (Table 3).

During the data collection time, 400 (89.9%) had latrines and 378 (94.5%) were functional. From the total available latrines, 300 (75%) were traditional pit latrines and most of them were located (197, 49%) within a distance of 6–10 m. Of the observed functional latrines, there were no visible feces in 166 (37.3%) of the compounds of caregivers.

Fathers' education, mothers' occupation, mothers' age, attitude towards child feces disposal, child feces defecation site, residence, latrine functionality, cleaning material of child bottom's after defecation, and distance of latrine were significant predictors of child feces disposal at p < 0.2. Of the significant predictors of child feces disposal only, caregivers' occupation, age of caregiver, child defecation site, and residence of caregivers were found to be independent predictors of child feces disposal practice in the bivariate and multivariate analysis (shown in Table 3).

Caregivers in the age category of 25–34, were 3.7 times more likely to practice safe child feces disposal than the younger age caregivers in the age range of 15–24 [AOR (95% C.I.) = 3.73 (1.06, 13.10)]. Government employed caregivers were 99.92% less likely to practice safe child feces disposal compared to housewives [AOR (95% C.I.) = 0.08 (0.01, 0.60)]. Respondents living in urban areas were 3.5 times more likely to practice safe child feces disposal than caregivers living in rural areas with [AOR (95% C.I.) = 3.51 (1.24, 9.99)]. The logistic analysis also revealed that children defecating on the household floor were 89% less likely to practice safe child feces disposal compared to those who used a potty [AOR (95% C.I.) = 0.11 (0.02, 0.75)] (Table 4).

Safe disposal of children's feces is as essential as that of adults' feces. Nevertheless, feces of children under the age of five are less likely to be safely disposed of compared to the general population. Therefore, this study is one of the few studies that have attempted to assess child feces disposal practice and associated factors among mothers having children under five years in Hintalo Wajerat district, Tigray region, Ethiopia. Defecation of children in the open is customary among the residents of the study area. Of all 445 caregivers interviewed, only 34.2% had safe child feces disposal practice, while the rest of the caregivers reported that the feces of their children under age five were not deposited into any kind of latrine or buried, i.e., they were unsafely disposed of. This result was more or less similar with the EDHS national survey result and the Tigray region's prevalence which is 36% and 34.7%, respectively (Central Statistical Agency 2012) and also similar to a study in Madagascar (38%). This could be due to the common belief or dilemma, that the feces of infants and young children are not harmful, in the region. However, literature has indicated the risk nature of child feces compared to adult. This is because the prevalence of child diarrhea and pathogens like hepatitis A, rotavirus, and Escherichia coli are by far higher in children than adults (UNICEF & World Bank 2010). Additionally, unsanitary disposal of child feces and garbage are also significant predictors of severe diarrheal disease (ORs = 2.69 and 2.92, respectively; p = 0.001) (UNICEF 2009). Nevertheless, compared to the studies conducted in India (22.8%), Cambodia (25%), Bangladesh (22%), and Niger (19%) (Gil et al. 2004; UNICEF Bank & WSP 2010; UNICEF & World Bank 2010; UNICEF, WSP & Bank 2012), the prevalence in this study was relatively higher generally, irrespective of the context of the study areas. On the other hand, our findings were lower than reports from Ghana, Sierra Leone, and Uganda (76%, 72%, and 75%), respectively (UNICEF, WSP & Bank 2011, 2013; Majorin et al. 2014a). The variations might be due to different demographic characteristics, economic status of the different groups, and parents' perception that child feces are harmless. In agreement with this, disposal of child feces and household garbage and mothers' knowledge and poor mothers' cleanliness was a cause of diarrhea in children and showed strong associations with risk of diarrhea (UNICEF 2009). Moreover, a study in East Africa indicated that diarrhea morbidity is associated with poor hygiene (unsafe disposal of feces and wastewater), and education level of household head (Tumwine et al. 2002). Furthermore, this could be further explained by child feces not being considered in different sanitation promotion approaches to realize open defecation free (ODF) communities, and the status of health extension workers in promoting this practice and behavior may not be the same in the study areas. However, a strategic report on child feces disposal indicated no significant difference by region or type of methods used in the studies reviewed, although the variability of the estimates was high, with very wide 95% C.I. The inconsistency of behavior was further reported (Gil et al. 2004). This study also found 47.9% of children defecates on the household floor. This could be due to the perception of caregivers that feces from infants or small children are not considered as dirty, repulsive, or hazardous as the feces of older children or adults. Anthropological studies have indicated open defecation as a preferred site by mothers for child defecation. This may be because, in rural areas, defecation directly onto the ground is considered natural, and for some mothers, allowing their child to do so is a way of continuing their cultural pattern of behavior (Yeager et al. 1999). It has been postulated that children's feces deposited in the household soil constitute the greatest risk for diarrheal diseases in younger children (Lanata et al. 1998). In contrast, 59% of the interviewed mothers reported that they disposed of child feces in a latrine. This is higher in comparison to the average safe practice of child feces disposal in Ethiopia (UNICEF 2009; Azage & Haile 2015). However, there was variation among the age groups of mothers practicing safe child feces practice; in this regard, mothers with the age range of 25–34 made a significant contribution to safe disposal than mothers below and above this category, as indicated in Table 4. Government employed caregivers were 99.92% less likely to practice safe child feces disposal as compared to housewives. This result is consistent with studies in India and Peru (Brown et al. 2013; Ravindra et al. 2014). The reason could be that housewives might have enough time to care for their children than government employed caregivers. They may also have frequent contact with voluntary community health workers and health extension workers (HEWs), which leads to more exposure to health messages. Caregivers in the age category of 25–34 were 3.73 times more likely to practice safe child feces disposal than the younger age caregivers, which are in the age range 15–24. A similar finding was reported from Cambodia in a study that showed mothers of older age had the highest odds of hygienic child feces disposal (Miller-Petrie et al. 2016). This could be due to better experience of child caring and awareness of waste management and its impact on health as compared to the younger inexperienced caregivers in the studies [AOR = 3.73 (1.06, 13.10)] (Table 4). This was supported by a study done by Azage & Haile (2015), in which the odds of practicing safe child feces disposal was higher among mothers with age >35 [AOR = 1.18 (0.99, 1.42)]. The finding of this study also revealed that caregivers of children defecating on the household floor were 99.89% less likely to practice safe child feces disposal as compared to those who used a potty. A similar finding was reported from Cambodia in a study that showed where children defecated in a potty the feces were more likely to be disposed of in the toilet (Miller-Petrie et al. 2016). This may signify that mothers who use a potty were aware of the risk of inappropriate child feces disposal. Concerning residence, caregivers living in an urban area were 3.51 times more likely to practice safe child feces disposal than caregivers living in a rural area. A similar explanation was given by a study conducted using secondary EDHS data in Ethiopia (Azage & Haile 2015). Moreover, safe child feces disposal was reported to be less prevalent among rural households than among urban households (UNICEF, WSP & Bank 2009; UNICEF & World Bank 2010; UNICEF et al. 2010, 2011, 2012, 2013; Libbet & Rand 2014a, 2014b; Sykes et al. 2015; WSP & UNICEF 2015). This is in line with the disparity in sanitation coverage between rural and urban areas, where rural areas are comparatively underserved. The disparities between sanitary feces disposal in urban and rural settings could be further explained by disparities of socioeconomic status between urban and rural populations as well as the higher population density and more limited courtyard space present in urban areas. As well, caregivers in an urban set up might have better access to health information. Income was not significantly associated with child feces disposal practice but different studies also indicate marginalized people dispose of their children's feces unsafely (Libbet & Rand 2014a; Sykes et al. 2015; WSP & UNICEF 2015). This may be due to poor access to child defecation materials and marginalized people may not prioritize child feces disposal as a priority. They may not have, for instance, the income to buy potties, nappies, and latrines favorable for children's use. Child age was not significantly associated in this study, but a study by Azage & Haile (2015) indicated significance with safe child feces disposal. Similarly, many other findings including Majorin et al. (2014), Miller-Petrie et al. (2016), WSP & UNICEF (2015) concluded the significance of age with respect to the hygienic disposal of child feces. The caregiver's education was insignificant in this study, although it has a significant association with safe child feces disposal practice due to knowledge and awareness levels regarding human waste management and human health. In this study, we relied on reported practices via a survey rather than direct observation, thus, it can be difficult to ascertain whether the explained behaviors varied over time. Also, the study was conducted in one district, so the overall findings may not be representative of all the districts in the country with different ethnic groups and cultures. Thus, an inclusive study on a large scale is needed to provide evidence on the dilemma of child feces disposal and associated problems in the country.

Child feces disposal practice was generally low in the study area. Thus, this study challenges the effectiveness of health extension programs in the country involving thousands of health extension workers in every corner of the country including Hintalo Wajerat. Given the child feces disposal practice in the area, emphasis is required on child feces similar to adult feces in the hygiene and sanitation programs being run in the district. On the other hand, caregivers in a relatively higher age category, housewives, urban residence, and those who use a potty were factors associated with safe child feces disposal practices. Based on the findings, it is necessary to strengthen efforts focusing on lower age category caregivers, government employees, rural dwellers, and those who defecate on the floor to minimize adverse health outcomes. Moreover, the health extension program should further enhance factors associated with safe disposal of child feces and improve the poor practices of safe child feces among the identified factors. The authors are convinced that this study is inconclusive methodologically in relating poor child feces disposal and associated factors as it uses a cross-sectional study design. Thus, interventional studies are recommended to assess the relationship between poor child feces disposal and associated factors in the study area.

We are grateful to Mekelle University, School of Public Health, College of Health Sciences for offering us such an opportunity to conduct this research. We would like to thank all the respondents who participated in this study, data collectors, and Hintalo Wajerat District Office. We also thank the anonymous reviewers for their great help, and the editor for constant support. No potential conflict of interest was reported by the authors. Yisfalem Ayele conceived and designed the study, collected data, performed analysis and interpretation of data. Ergib Mekibib participated in the research topic preparation process, research design process, data analysis, and interpretation process of results. Dejen Yemane assisted with the design, conception, analysis, and interpretation of data and critically reviewed the manuscript. Getachew Redae drafted the manuscript, reviewed the manuscript. All authors read and approved the final manuscript.