Trend and predictors of unsafe child stool disposal in Ethiopia (2000-2016): pooled evidence from demographic and health survey

Exposure to children's stool may present a greater health risk. But, in many settings including Ethiopia children's stools often considered not harmful, and do not end up in a toilet. Even those with access to sanitation facilities often fail to use them for disposal of child feces. Importantly, Ethiopia ranked among the worst third of 38 African countries whose children feces are safely disposed of.Therefore, the study aims to determine the pooled prevalence of unsafe disposal of children's stools in Ethiopia, the predictive factors associated with it and finally it examines the trend of child stool disposal in Ethiopia.Methods The pooled data for this study obtained from the demographic and health survey (DHS) done in Ethiopia between 2000 and 2016. Descriptive statistics were computed to illustrate the given data. Binary multivariable logistic regression was employed to identify the predictors of unsafe child

In Ethiopia, almost three in four children's stool disposed unsafely, and maternal education and working status, children age,and type of sanitation facility were found to be predictive of unsafe child stool disposal. Thus, it is necessary to strengthen efforts focusing on child stool disposal behavioral to reduce the significant burden of unsafe child stool disposal and through careful consideration of these identified factors. The safe disposal of human excreta is of paramount importance for the health and welfare of populations as well as the prevention of environment pollution [1]. Despite this fact, there is a common belief that child stool is often considered innocuous and not harmful in many societies, therefore not disposed of safely [2][3][4]. Interestingly, child feces may have higher pathogen loads than those of adults and exposure to children's stool may present a greater health risk [5]; as a result safe disposal of children's feces is as essential as that of adults' and should be treated with the same concern using safe disposal methods [2,6]. diarrheal prevalence.
In developing countries, in every location, unsafe disposal of children's stool represents a particular challenge [2,11,26,27]. The latest available Multiple Indicator Cluster Survey (MICS) or Demographic data showed that in 10 locations (Africa, South Asia, and Southeast Asia), greater than 80 percent of children's feces are disposed of unsafely [2]. Even among households that have access to improved sanitation facilities, children's stool often does not end up in a toilet [2,4,24,26,28]. In Ethiopia, 63.1% and 94.7% of the households had unsafe and unimproved child stool disposal practice, respectively [24]; even among households with access to improved sanitation facilities fail to use them for disposal of child stool [24]. Interestingly, Ethiopia ranked among the worst third of 38 African countries whose children feces are safely disposed of [6].
So far, efforts to reduce and end open defecation have mainly targeted adults, with only a limited focus on the management of child stool in many low-and middle-income countries (LMIC) [19], and how children's feces are being disposed of, in general, has been a neglected area of research, policy, and program intervention [2,5,30,31]. In effect, the Sustainable Development Goal (SDG) target 6.2 calls for elimination of open defection, aiming to "achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations by 2030" [32], and the United Nations (UN) declares access to sanitation, as a human right [33]. In light of this, the World Health Organization (WHO) Director-General stated that "After decades of neglect, the importance of access to safe sanitation for everyone, everywhere, is now rightly recognized as an essential component of universal health coverage" [3].
At present, irrefutable evidence suggested that sanitation for everyone everywhere has been accelerated throughout the globe, of which Ethiopia is no exception, as part of the overall drive to achieve the SDG. In Ethiopia, over the past two decades a significant effort has been made, to create an enabling environment for the disposal of human excreta and to enable 100 percent adoption of improved hygiene and sanitation by Despite the efforts to date, the extent of unsafe child stool disposal in Ethiopia remains unclear and it is doubtful how progress in WASH has affected the practice of child stool disposal. Also, there is no nationally representative study that has investigated the trends, as well as the factors associated with unsafe child stool disposal; the existing studies [24, 30], provides limited information as they are survey specific and focuses on safe disposal. Furthermore, using a pooled dataset to explore the predictive factors associated with the behavior of the children's mothers/caregiver is critically important, at these young ages; they are responsible for disposing of their children feces. Therefore, the purpose of this study is (1) to determine the pooled prevalence of unsafe child stool disposal practice (2), to identify the predictive factors associated with unsafe child stool disposal and (3) lastly, to look at the trends on unsafe child stool disposal (by urban/rural residence).

Study design and data source
The study design for the present study was a cross-sectional study design with pooled Demographic and Health Survey (DHS) data. Pooled data are very important because of the characteristics of the blend of both cross-sectional and time-series data. Datasets used in this study were collected from the Ethiopian Demographic and Health Survey age five living with the mother from each household and mothers were asked about the disposal practice of the last passed stool for the youngest child. All respondents who responded to the outcome variable were included in the analysis for this study.

Outcome variables
Mothers reported unsafe child stool disposal were considered for analysis as an outcome of interest. The outcome variables were constructed based on the recent WHO definition, response categories such as 'child used toilet or latrine' and 'put/rinsed into toilet or latrine' were combined and coded as "safe disposal of child stool (coded as '0')". And the others were coded as "unsafe disposal of child stool (coded as '1')". Unsafe disposal of child stool was defined as the disposal of stool in any site other than a latrine, such as ''put/rinsed into drain/ditch" ''thrown into the garbage, ''buried, ''left in the open,' and 'other' [3].

Exposure variables
The explanatory variables include; sex of children, age of the child (0-12 months, 13-24 months, ≥ 25 months), mother's age (< 24, 24-34, ≥ 34), mother educational level (no education, primary, secondary, higher), marital status (married, divorced/separated, widowed, living with partner, and single), mother's working status (not working, working), sex of household head (male, female), place of residence (urban, rural), mother's exposure to media (yes, no), latrine type (improved, unimproved), sources of drinking water (improve, unimproved) and presence of diarrhea in the last two weeks (yes, no). The variable on media exposure includes exposure to the radio. The mothers who were not exposed to radio were coded as "no" and those who have frequent exposure were coded as "yes". Also, the toilet facility and source of drinking water were categorized into 'improved' and 'unimproved' following the WHO/UNICEF definition [39].

Statistical analysis
Statistical analysis was carried out using SPSS version 20.0 (IBM Corp., Armonk, NY, USA).
A pooled cross-sectional study was conducted by using all datasets of the EDHS, 1st, 2nd, 3rd and 4th round datasets. After pooled the four datasets and data cleaning for missing information was performed before the study begins. Appropriate sampling weights were used in the estimations for the adjustment of cluster sampling design. Weighted frequency, percentage and descriptive summaries used to explain the number of study participants in the analysis. Chi-square test also used to describe child stool disposal practice by the explanatory variables. Line graph was used to display and compare the trend of child stool disposal practice in the specified period. A complex sample binary logistic regression model was employed to assess the association between the outcome variables and explanatory variables. First, bivariate logistic regression was performed and explanatory variables that were significant in the binary logistic regression analysis with a cut-off point of p-value less than 0.25 were candidate factors for the multivariable binary logistic regression analysis to identify the predictor of unsafe child stool disposal. In the multivariable model measures of strength of association were reported as odds ratio (OR) with 95% confidence intervals (CIs), by controlling the effect of other factors. P-value of less than 0.05 was used to ascertain significant association. Multicollinearity effect was assessed with a cut of off point of variation inflation factor (VIF) of greater than ten [40] and finally, to check the correctness of the final formulated model, the Hosmer-Lemeshow test for overall goodness of fit was used [41]. Table 1 presents the background characteristics of the children, their mothers and households across the entire pooled data set. Overall, in this study, 26,014 young children under age five living with the mother were included. Of these, half of the children's were male, a great majority of children (88.6%) were from the rural area of residence, and one out of five children had diarrhea in past two weeks before the survey.

Trends in child stool disposal
Despite the improvement, important regional variations were noted in the prevalence of unsafe child stool disposal, in all waves of EDHS including in the pooled data. Over three fourth of the rural households (80.2%) still had unsafe child stool disposal as evidenced from the poled data, while that is true only for 44.4% of the urban households. Also, the urban-rural gap in the unsafe disposal of stool was wide in all-round of the survey (

Results of bivariate and multivariable analysis
The results of bivariate and multivariable binary logistic regression assessing the factors associated with unsafe disposal of the stool are presented in Table 8. In the bivariate regression analysis, socio-demographic and sanitation characteristics of households such as sex of the child, sex of the household head, age of the child, age of mother, marital status, mother's education, place of residence, presence of diarrhea in past two weeks prior to the survey, water sources, latrine type, and media exposure were associated with unsafe child stool disposal.
In the multivariable logistic regression model, the odds of disposing of stools unsafely Unsafe disposal of stool was also statistically associated with place of residence. The odds of unsafe disposal were 2.27 times higher [AOR: 2.27, 95% CI: (1.79-2.89)] among rural households than urban dwellers. Lack of access to improved toilet facility was statistically associated with the unsafe disposal of stool. The odds of disposing of stools unsafely among households having a lack of access to improved toilets were three times [AOR: 3.23, 95% CI: (2.75-3.79)] that of households having access to improved toilets. Moreover, unsafe disposal of stool also significantly associated with the mother's exposure to media.
The odds of unsafe stool disposal were 1.52 times higher [AOR: 1.52, 95% CI: (1.34-1.73)] in mothers who were not exposed to media than in mothers who were exposed to media.
However, the presence of diarrhea in the past two weeks before the survey [AOR: 1.05, 95%CI (0.92-1.20)] were significant at bivariate but insignificant in multivariable logistic regression analysis.

Discussion
The pooled data contained 26,014 children's with their mother. Of these, 76.1% of them had unsafe child stool disposal. The trend confirms that the prevalence of unsafe child stool disposal was falling from 90.8% in 2000 to 63.1% in 2016. Factors such as maternal education and working status, children age, media exposure, and type of sanitation facility were the most important variables that significantly associated with unsafe child stool disposal. The prevalence of unsafe child stool disposal found in this study is reasonably higher than the prevalence reported in the latest EDHS 2016, which reported that 63.1% of child stool were disposed of unsafely [24]. However, the finding was in line with a survey report from India, which also reported 79.0% of child feces were disposed of unsafely [14,42].  is essential, since in many cases they are responsible for disposing of their children feces and shaping the child's toilet training. Third, access to a latrine is a necessary condition to have a positive effect on the reduction of unsafe child stool disposal. From this perspective, it must be noted that the presence of physical sanitation infrastructure alone is not sufficient to ensure safe hygienic practice [47]. Besides, the common barriers and perception that young child's feces are not harmful should be addressed to achieve safe child feces disposal. Curtis et al [48] identified in some cases, parents may discourage children from using a latrine with a squatting slab because they believe that children will dirty the latrine. In light of this, there may be a need to rethink safe child stool disposal measures and a child-friendly and socially acceptable method for feces disposal that would encourage caregivers to adopt consistent hygienic disposal of child feces [49].
In the multivariable logistic regression analysis; mothers' educational status appeared to be significantly associated with unsafe child stool disposal. The odds of disposing of the stools unsafely were higher in mothers who were no education than those who had higher education. These observations are quite as expected because less-educated parents are more likely to be unaware of the health risks associated with unsafe excreta disposal and It also appeared that the age of a child was strongly associated with unsafe child stool disposal; the odds of disposing of the stools unsafely were lower in children aged between 13-24 months and ≥ 25 months than children age between 0-12 months. Meaning households with younger children; particularly households with children in their first year of life were more likely to report unsafe child stool disposal practice. This strong association can be satisfactorily explained by the fact that a shift in safe disposal practices is usually seen as children grow: children being more likely to use a toilet/latrine themselves as they get older, rather than have their feces put or rinsed into one  (49) showed that child defecation in potties was strongly associated with safe child feces disposal.
Also, studies have found child feces disposal to be associated with the mother/caregiver's age, mother's education, media exposure, residence, and toilet/latrine access [22-24, 49, 52, 54] which is generally consistent with the present study results.
Indiscriminate disposal of stools was one of the risky behaviors of mothers causing diarrhea in children [24]. There is evidence that children's feces could be riskier than adults' feces, due to a higher prevalence of diarrheal disease and their feces may contain . In this particular case, children whose stools were put in a toilet were less likely to suffer from diarrhea than those whose stools were left in the open [23]. These in general translate to mounting challenges for the health of a child in Ethiopia. As noted, this finding clearly indicates that the focus of safe child stool disposal interventions must consider sanitation coverage as well as behavioral changes, such as efforts to change the behavior of mothers/caregivers that encourage cleaning children after defecation, potty training at early age, and using proper methods to transport child stool to a sanitation facility. In support of this assertion, in this study, among households that lack improved toilets or latrines, higher odds of unsafe child stool disposal behavior was reported. This finding is consistent with other studies and that have similarly reported unsafe child stool disposal among households that lacked improved toilet facility [22,24,47].

Limitations of the study
Although the study uses a nationally representative population-based dataset for examining the trend, and factors associated with unsafe child stool disposal in Ethiopia.
This study has several limitations. First, the study suffers from the disadvantages of crosssectional study; the temporal relationship between the outcome and explanatory variables could not be established. Second, the study did not record how feces were transported for disposal in study households. This would have added understanding of the relationship between unsafe child stool disposal and child stool transportation mechanisms. Third, reporting bias is likely to over-report child stool disposal behavior. Fourth, the study may be susceptible to recall bias, as the data dealt with reported practices rather than direct observation of the actual practice. Fifth, the measurement of the prevalence of diarrhea in all EDHS is based on a two weeks recall period, which may introduce a recall and reporting bias in childhood diarrhea prevalence. Finally, despite there were similar trends for many of the countries in the practice of child stool disposal, I would suggest caution against applying the results to countries located in other regions of the world, as cultural differences may affect child stool disposal practices.

Conclusion
In conclusion, the findings indicate that the prevalence of unsafe child stool disposal remains a significant health burden in Ethiopia; almost three in four children's stool disposed of unsafely. Overall, the pace in decrease of unsafe child stool disposal was encouraging between 2000 and 2016, dropped from 90.8% in 2000 to 63.1% in 2016. A closer look into the trends of unsafe child stool disposal revealed that a steady decrement in unsafe disposal was observed in urban-rural households. In multivariate analysis, predictive factors associated with being unsafe child stool disposal were age, working status, education and media exposure of the mother/primary caregiver, place of residence, age of the child, and type of the latrine used by the household. The study emphasizes the need for urgent specific measures to reduce the significant burden of