This study reported the safe and improved child stool disposal practices of 4145 children under age two living with the mother in Ethiopia, together with the factors associated with these practices. Overall, the stool of 36.9 and 5.3% of children below two years of age was disposed of safely and with improved sanitation, respectively. Variables such as region, place of residence, household wealth index, the age of the child and age of the mother were the main factors associated with child stool disposal.
The prevalence of safe child stool disposal practice found in this study is almost similar to the prevalence reported by Azage et al., 33.68% [8] and other low-income settings, such as Madagascar [26] and Nepal [27]. Additionally, studies conducted in India and Bangladeshi also reported a similar low prevalence of safe child stool disposal [28,29,30]. The finding implies the majority of cases children’s stool was disposed of unsafely, which may possibly put a child at risk of infection through multiple pathways. And, when there is improper child’s stool disposal in the community, both adults and children are at risk of enteric infection and not just the children alone. There are also evidence regarding the association between unsafe excreta disposal and a high burden of diarrhea, soil-transmitted helminth infections, trachoma and other enteric diseases [12, 25]. In connection, a study conducted by Bawankule et al. reported children whose stools were disposed of unsafely were more likely to suffer from diarrhea than children whose stools were disposed of safely [9].
However, the present study did not detect such association, safe child stool disposal and decreased odds of diarrheal prevalence. Likewise, a study by Islam et al. also reported unsafe child feces disposal was not significantly associated with presences of diarrhea among children under age three [29]. The absence of such an association might be explained in a number of ways. The first reason might be due to the age category of children. This age category of children (age < 2 years) may not be able to use a toilet facility because of their age and stage of physical development. In addition, children under age 6 months and those 6–11 months were not beginning walking and less likely to exposed to a contaminated environment. Although the prevalence of diarrhea may not only depend on unsafe stool disposal but also psychosocial factors (feeding practice and nurturing), mother personal hygiene, and environmental sanitation. To overcome, such phenomenon improving access to sanitation facilities alone is not enough, however context-specific behavior change strategies equally important. Countries like Ethiopia, where the burden of childhood diarrhea is prevalent should explore opportunities to integrate child stool management into existing sanitation intervention programs that target mothers and caregivers of young children. Sanitation strategies such as educating mothers or caregivers on safe disposal of children’s stools along with building sanitation facilities are also essential in curbing the high prevalence of unsafe child stool disposal. Furthermore, the promotions of behavior change strategies to prevail over barriers to disposal of child stool and water used for child bathing after defecation should be considered [25].
In this study, the most common type of unsafe child stool disposal method was left child feces in the open or not disposed of (25.5%). Meaning a significant number of children stools were disposed of unsafely in open field, and if feces are left uncontained, diseases may spread by direct contact or animal contact [1, 25, 31]. Systematic studies also plainly indicated that diarrheal diseases were highly prevalent in areas where poor hygiene and lack of sanitation is widespread [11, 32]. In connection, literature documented that the practice of unsafe child stool disposal can cause environmental contamination by fecal pathogens that can cause enteric diseases among young children’s [10, 29, 30, 33, 34].
In this study, the odds of practicing safe disposal of child stool were increased with the increased level of household wealth index. Households from a higher wealth quintile were more likely to practice safe disposal of child stool than those households from the poorest wealth quintile. This finding is consistent with the studies from Ethiopia [8], India [9], South Africa [35] and Burkina Faso [36].
Place of residence was another factor that significantly associated with safe child stool disposal. Children’s stools are more likely to be disposed of safely in urban households than in rural households. Similar higher safe child stool disposal practice among urban residents was reported from a similar study from Ethiopia [8], and Kenya [37].
Ages of the child and mother’s age were the other factors that positively associated safe child stool disposal. This finding is consistent with the finding of a similar study conducted in Ethiopia [8] and Bangladesh [30, 31]. This could be explained by a shift in safe disposal practices seen as children grow; children are increasingly likely to use a toilet/latrine themselves, rather than have their feces put or rinsed into one [13]. And the old age mothers and caregivers may be more conscious and observant about disposing of child feces safely and are more likely to understand the causes of childhood illness.
In multivariable logistic regression analysis, the presence of an improved sanitation facility was not associated with safe child stool disposal. The comparable finding was reported from rural Bangladesh [30]. Rand et al. also reported, in 15 out of 26 locations more than 50% of households reported that the feces of their youngest child under three years were disposed of unsafely; even the percentage of feces ending up in improved sanitation facilities is much lower [14]. These findings suggested that even those with access to improved sanitation facilities often fail to use them for disposal of child feces [25, 31]. Meaning, people who are having improved toilets at their house are disposing of the child stool in a risky way.
In fact, access to sanitation facilities is a pre-requisite to ending open defecation as well as unsafe child stool disposal, but it is not always a sufficient condition to overcome unsafe child stool disposal [25, 38, 39]. A study by Phaswana-Mafuya et al. identified improvement and presence of physical sanitation infrastructure alone is not sufficient to ensure safe hygienic practices [35]. In overcome such situation, robust sanitation promotion and strong behavior change program that targeted on the determinants of behaviors is important.
The prevalence of improved child stool disposal found in this study (5.3%) is almost close to the prevalence reported in the last EDHS-3 (2011) 3.0% [13]. In fact, according to the most recent EDHS-4 report overall 6% of Ethiopian households use improved toilet facilities (16% in urban areas and 4% in rural areas) [1]. Subsequently, improved child stool disposal is only possible where there is access to improved sanitation facilities [13]. According to the recent WHO sanitation and health guideline, disposal of child feces in a toilet connected to a safe sanitation chain is the only safe method where solid waste management systems for children’s absorbent underclothes (nappies) disposal are not safe [25]. The association between place of residence and improved disposal of child feces in this study is not surprising since there is a significant variation in improved sanitation coverage among urban and rural residents in Ethiopia. In the present study, the household wealth index was a strong predictive factor for having improved child stool disposal. The finding is in line with other related studies [35, 40, 41].
This study has several limitations. First, it has all the disadvantages of any cross-sectional study; the temporal relationship between the outcome and independent variables could not be established. Second, mothers’ knowledge and perception towards safe and improved disposal of child feces were not assessed in this study. Moreover, the study may be susceptible to social desirability and recall bias, as the data dealt with reported practices rather than direct observation. The other limitation of this study was lack of exhaustiveness to include all the relevant variables, such as child stool collection practice that may influence the practice of safe and improved disposal of child stool. Furthermore, some of the regions had a small sample size, which questions the accuracy of prevalence estimates per region, so that it should be interpreted with caution.
