Date Published: April 18, 2019
Publisher: The American Society of Tropical Medicine and Hygiene
Author(s): Valerie Bauza, Heather Reese, Parimita Routray, Thomas Clasen.
Latrine access alone may be insufficient to encourage households to dispose of young children’s feces safely in a latrine, and little is known about the determinants of improved child feces disposal. We used longitudinal data collected at up to three timepoints for children less than 5 years of age from households in Odisha, India, which received a combined household-level piped water supply and sanitation intervention, but did not specifically promote the safe disposal of child feces. Among the 85% of intervention households who reported access to improved sanitation, we characterized child defecation and feces disposal practices by age, across time, and season, and assessed determinants of improved disposal. Feces from children less than 3 years of age was commonly picked up by caregivers but disposed of unsafely with garbage into open areas (56.3% of households) or in a drain/ditch (6.2%). Although children 3 and 4 years were more likely to use a latrine than younger children, their feces was also more likely to be left in the open if they did not defecate in a latrine. For children less than 5 years of age, most (84.7%) children’s feces that was safely disposed of in a latrine was because of the children defecating in the latrine directly. Significant predictors for disposing of child feces in an improved latrine were the primary female caregiver reporting using a latrine to defecate, the child’s age, and water observed at place for handwashing. These findings suggest that child feces interventions should focus on encouraging children to begin using a toilet at a younger age and changing the common behavior of disposing of young child’s feces into open areas.
Globally, an estimated 2.3 billion people lack access to a basic (improved and unshared) sanitation facility, with 892 million people estimated to practice open defecation.1 In addition, many households with access to sanitation facilities do not dispose of their young children’s feces in the latrine.2–4 Poor child feces management (CFM) presents a particular health risk because young children often have the highest incidence of enteric infections5 and poorly developed immune systems, so their feces likely contain higher quantities of transmissible pathogens.6 Young children also tend to defecate in areas closer to households, where susceptible children could be exposed,7 because young children spend large amounts of time on the ground and commonly engage in exploratory behaviors that include putting fingers, fomites, and soil in their mouths.8–12 Consistent with these concerns, unhygienic child feces disposal has been found to be associated with diarrhea,13 soil-transmitted helminth infection,14 stunting,3 and environment enteric dysfunction.15
This work found evidence that children’s defecation and feces disposal practices change with age, that most children’s feces that was disposed of in a toilet originated from children defecating there, that feces disposal practices are inconsistent over time, and that there were minimal differences in child defecation or feces disposal practices across season in this rural India setting. These findings have implications for the design of future interventions to encourage child feces disposal and suggest that interventions which encourage children to use the latrine directly may be potentially beneficial interventions that are often overlooked when discussing CFM. This study also evaluated potential determinants of improved child feces disposal among households in villages following an intervention for household piped water and pour-flush toilets, and no obvious determinants were identified that can be targeted in future interventions. Consistent with several other studies,2,3,19,25,32,33 we also found that many households with access to a toilet still do not dispose of their children’s feces in the toilet, providing additional support for the necessity of separate interventions which may include targeted behavior change and CFM hardware to improve CFM that go beyond toilet and water access.
Disposal of child feces into a latrine was uncommon, even among households with access to an improved pour-flush latrine that was used by adults in the household. Two important findings were that the feces from children less than 3 years of age was commonly picked up by caregivers but disposed of unsafely with garbage into open areas and that most children’s feces that was safely disposed of in a toilet was because of children defecating in the toilet directly. These findings suggest there may be a need to rethink traditional child feces interventions of scoops, diapers/nappies, and potties for children less than 3 years of age, as these may fail to alter the current practices of disposing of feces with garbage, a common practice for children less than 3 years of age in this setting in rural India. These findings also suggest that interventions which are effective at encouraging children to begin using a toilet at a younger age could improve child feces disposal practices. More research is needed to evaluate the most effective interventions for promoting safe CFM practices in ways that will achieve sustained uptake, with a focus on practices that encourage use of latrines earlier by children and shift from disposal of feces in garbage to disposal in a toilet.