Date Published: May 19, 2018
Publisher: The American Society of Tropical Medicine and Hygiene
Author(s): Rebecca Lyn Ritter, Dorothy Peprah, Clair Null, Christine L. Moe, George Armah, Joseph Ampofo, Nii Wellington, Habib Yakubu, Katharine Robb, Amy E. Kirby, Yuke Wang, Katherine Roguski, Heather Reese, Chantal A. Agbemabiese, Lady Asantewa B. Adomako, Matthew C. Freeman, Kelly K. Baker.
In crowded urban settlements in low-income countries, many households rely on shared sanitation facilities. Shared facilities are not currently considered “improved sanitation” because of concerns about whether hygiene conditions sufficiently protect users from the feces of others. Prevention of fecal exposure at a latrine is only one aspect of sanitary safety. Ensuring consistent use of latrines for feces disposal, especially child feces, is required to reduce fecal contamination in households and communities. Household crowding and shared latrine access are correlated in these settings, rendering latrine use by neighbors sharing communal living areas as critically important for protecting one’s own household. This study in Accra, Ghana, found that household access to a within-compound basic latrine was associated with higher latrine use by children of ages 5–12 years and for disposal of feces of children < 5 years, compared with households using public latrines. However, within-compound access was not associated with improved child feces disposal by other caregivers in the compound. Feces was rarely observed in household compounds but was observed more often in compounds with latrines versus compounds relying on public latrines. Escherichia coli and human adenovirus were detected frequently on household surfaces, but concentrations did not differ when compared by latrine access or usage practices. The differences in latrine use for households sharing within-compound versus public latrines in Accra suggest that disaggregated shared sanitation categories may be useful in monitoring global progress in sanitation coverage. However, compound access did not completely ensure that households were protected from feces and microbial contamination.
An estimated 1.7 billion episodes of diarrhea occur in children less than 5 years of age globally each year, 437 million of which occur in sub-Saharan Africa alone.1 Furthermore, 10% of all deaths worldwide in this age group are attributed to this diarrheal disease burden.2 The greatest risk factors for diarrheal diseases in low-income countries are poor sanitation, water, and hygiene conditions.3,4 Interventions that improve household sanitation access are considered cost-effective strategies for reducing fecal contamination in the environment and preventing the spread of gastrointestinal disease.5,6 The Sustainable Development Goals (SDGs) have targeted the elimination of open defecation by 2025, with all people using adequate household sanitation facilities by 2040.7 Progress toward these goals is measured by the World Health Organization and UNICEF Joint Monitoring Program (JMP) through the percentage of the population living in households where “improved” sanitation facilities protect users from exposure to the feces of other individuals by installing a barrier between users and human excreta.8 “Safely managed” and “basic” household access to a private improved facility is considered to be the safest approach for protecting users, whereas “limited” access to a shared facility of improved design is considered less safe. Shared latrines have historically been considered unimproved, based on the premise that accessibility, hygiene maintenance, and safety may be of low quality and may not elicit sufficient use to prevent environmental fecal contamination.9 Consistent with this policy, sharing a sanitation facility with just a few other households has been repeatedly associated with increased diarrhea risk in children and adults, compared with the use of private sanitation facilities.10,11 Based on this classification system, an estimated 638 million people using shared facilities of an otherwise improved design lacked access to an improved sanitation facility in 2015.8 Shifting these people from shared to household sanitation is unlikely to change quickly as lack of space and cost are key barriers to owning a private household latrine in poor urban areas.12
To our knowledge, this is the first study to compare reported child feces disposal practices, based on household access to compound versus public shared latrines. In addition, the examination of perceived feces disposal practices for within-compound neighbors with compound or public latrine access was novel. Low rates of latrine use for child feces disposal were expected overall because of low global levels of latrine use for child feces in similar settings.28 However, we hypothesized that latrine usage for child feces disposal would be more common in households with within-compound versus public latrine access because of potential contextual differences in convenience of access, safety, cost, and privacy.12 After adjusting for potential socioeconomic confounders and neighborhood,10,15 we observed that self-reported use of latrines by older children (5–12 years) and disposal of the feces of young children (< 5 years) were more common in households with a within-compound latrine than in households relying on public latrines. Although reported latrine usage was greater in households with minimally shared compound latrines versus public latrine access, feces were observed on the ground more often within households with latrines in the compound versus households with public latrine access. Observation of human feces on the ground in compounds was uncommon, making it difficult to draw further conclusions about whether access to within-compound sanitation better prevents human fecal contamination of the household environment compared with public latrines. Source: http://doi.org/10.4269/ajtmh.17-0654