Latrine utilization and its associated factors among Rural Communities of North Achefer District, Amhara Region, Northwest Ethiopia

Abstract Objective: In Ethiopia, there has been progress on construction of latrine facilities in all parts of the country through health extension program since 2003. However, there were limited evidence whether the household are using properly or not. Therefore, the aims of this study were to decide level of latrine use and to explore the reasons for latrine use in rural community of North Achefer District, Ethiopia. Result: The proportion of latrine utilization was 44.5 % (95% CI: 441%, 48%) among rural communities. Presence of student in household (AOR=4.3, 95%CI: 2.25, 8.26), father’s able to read and write (AOR=1.5, 95%CI: 1.03, 2.2), duration of latrine (AOR=3.04, 95%CI: 1.88, 4.9), latrine need maintenance (AOR=0.5, 95% CI: 0.36, 0.75), short distance of latrine (AOR=0.32, 95% CI: 0.19, 0.55), self-initiation of latrine use (AOR=0.22, 95%CI: 0.1, 0.46) and peer pressure for latrine use (AOR=2.07, 95%CI: 1.04, 4.13) were factors associated with increased latrine use. Poor quality of latrines, methods of mobilizing community, infrequent supervision and follow up, poor commitment of health extension workers, inadequate knowledge and unfavorable attitudes & motivations of latrine uses were challenges to use latrine. Key words: Latrine utilization, Hand facilities, Ethiopia years were positively associated with latrine utilization. However, Latrine use by self-initiation, latrine needs maintenance and distance of latrine from home greater than 10 meters were factors negatively associated with latrine utilization. Poor quality of latrines, incorrect methods of mobilization, infrequent supervision and follow up, poor knowledge and attitudes of the community on latrine utilization, poor participation of concerned bodies on motivating the community, poor commitment of health extension workers, absence of strong school health for latrine utilization were mentioned challenges for latrine utilization.

Data were collected using pretested semi-structured questionnaire, observational check list and focus group discussion guide. The questionnaire was rst prepared in English and translated into local language (Amharic version) and nally back translated into English to ensure consistency of questions.
One day training was given for data collectors and supervisors. During the discussion, data was collected using note taking and a tape recorder and transcribe by rst author and moderators.

Data management and analysis
Data were entered using Epi info version 7 and export into SPSS version 23 for analysis. Descriptive statistics like frequency tables, gures, percentages and texts were performed. Variable which have p-value<0. 25 in binary logistic regression analysis was included in the multi-variable analysis. 95% con dence interval and p-value<0.05 was used to identify signi cant variables.

Qualitative Data analysis
Before transcribing the data repeated listening of the tap recorded data was done to capture the information and written note line by line was done to transcribe data from Amharic to English. Responses arranged in general categories using discussion guide and was analyzed manually using a content thematic approach.

Results
Socio-Demographic characteristics of respondent A total of 810 households were included in the study with a response rate of 96%. The mean (±SD) age of respondents was 46.3 (12.5) years. Most, 660(81.5%) study respondents reside in sub-tropical. About 215(28%) fathers and 86(11%) mothers were literate. Among the households, 695(85.8%) had children attending at primary or secondary school (Table 1).

Sanitation Facilities
Of the total households, 771(95.3%) had functional latrines and 739(91%), and ve hundred forty-nine (67.7%) required maintenance. Above half household's used grass and wood to superstructure of the latrine facilities (Table 2).

Behavioral factors
Over all latrine utilization in the study area was 44.5%. Above half 526(65%) respondents explained open defecation causes diarrheal disease and 78% of the respondents were satis ed with the latrine utilization (see additional le1). The main reasons to construct and utilize latrines was because of getting advice from health extension workers about its bene t (see additional le2).

Predictors of latrine utilization
In binary logistic regression analysis, presence of school aged children in the households 4 times more likely to use latrine compared to those who don't have (AOR= 4.3, 95% CI: 2.25, 8.26). Households having fathers who can read and write were about 1.5 times more likely utilized its counterpart (AOR=1.5, 95% CI: 1.03, 2.2). Households owning latrine >=2 years were 3 times more likely utilize it than <2 years (AOR=3.0, 95% CI: 1.88, 4.92). Households that had latrine >10 meters away from home were 68% less likely to utilize latrine than <6 meters away (AOR= 0.32, 95% CI: 0.19, 0.55). Household that had latrines which need maintenance were 50% less likely to utilize than which don't need (AOR= 0.5, (95% CI: 0.36, 0.75). Those households who learn the bene t of latrine from peer group were 2 times more consistently utilize it than those enforced by other bodies (AOR=2.11, 95% CI: 1.05, 4.22). The extent of latrine utilization 77% less likely in the households who construct and use by themselves than households advised by health extension workers (AOR=0.23, 95%CI: 0.11, 0.502) ( Table 3).
Qualitative results: Most of the discussants explained that the presence of barriers and negligence on community and health sectors for the consistent latrine utilization. Lack of awareness, the poor quality of constructed latrines, absence of detail understanding on importance of latrine utilization, infrequent supervision and follow up by concerned bodies, shortage of necessary materials for latrine construction, latrines constructed with enforcement without communities will.
Poor quality of latrines (Them 1) Discussants raised that majority of constructed latrines had a quality problem. 35 years' health personnel explain that "most of the communities had substandard latrine facilities which needs frequent maintenance and majority served only for dry seasons because of the material they constructed.." Poor methods of community mobilization (Them2) The discussants explain the presence of poor method of community mobilization to construct and use latrine facilities.
One FGD participants indicates that, "most of latrines constructed with campaign with fear of punishment without teaching the importance of utilizing latrine"

Lack of frequent Supervision and follow up (Them 3)
From district health o ce to community level, problems were not solved and no supportive supervision and follow up concerning latrine utilization.
Male FGD participant explained that, "the practice of communities of latrine utilization is different. Some of them practice what is taught by health extension workers. Another did what they understand when they are learning, this categories need follow up. The rest group had poor attitude and do not respond what the health providers saying and the health development army also." Poor knowledge and attitudes on latrine use (Them 4) The majority of FGD participants reported that, "generally latrine utilization was high among those who know latrines as diarrheal disease prevention compared. For example, majority believed that: someone is at risk of getting diarrhea if neighbor practiced open defecation."

Discussion
This study found that the proportion of latrine utilization among the study area was 44.5%. This nding is lower than the Awoble District [7], Dembia district [6] and but higher than the study in southeastern Ethiopia [12] and southern Ethiopia [20], in northern Ethiopia Hawzien district [9]. It also less than a study conducted in Eastern Nepal [21] and 2017 JMP report [2]. This difference might be the study period variation (2013 vs 2018) and study area socio demographic and economic status difference.
In this study only few households had hand washing facilities near the latrines. This is higher than the nding from EDHS 2016 report of rural areas [5], rural Tanzania [22] and Kenya [23]. This could be due to scarcity of water, lack of awareness about the importance of hand washing.
Though many knew the bene t of latrine utilization, signi cant number of them use latrine because it is convenient particularly for females as compared with open defecation. This nding is similar with the result of South Ethiopia, but higher than Northwest Ethiopia [20,24]. This might be because of lack of awareness.
On the other hand, households who had primary/secondary students more utilize latrine than who didn't. This nding is consistent with the study conducted in Awobel district, Southeast Ethiopia and Eastern Nepal [12,21,25]. This might be due to school age children were more exposed to hygiene related information in the school. Literate husband household heads more utilize latrine than the illiterate. This nding is inconsistent with the study conducted in the North Ethiopia [9]. This difference could be attributed to the difference in the knowledge and awareness levels of the communities.
Long time of owning latrine encourages latrine utilization. This nding is similar with the study conducted in the gulomekeda district, Northern Ethiopia and Kenya [26,27]. This could be associated on focus group discussion if the household members visited frequently and supervised by HEWs and teach them the importance of latrine utilization; this would motivate households to use latrines constantly. Households who had latrines which need maintenance 67% times less likely to utilize latrine. This result is greater than the study conducted in Awobel district [7]. The reason might be, poor quality of latrine facility construction affects proper utilization.
Households constructing latrine far from home 68% times less likely to utilize latrine than nearest. This could be because of as latrine is far from home it is di cult to use it at night and during illnesses. Similar ndings were reported from North Ethiopia, southeast Ethiopia and study around Addis Ababa city a study [9,12,28].
Households constructing and using latrine by peer in uence were more utilize it than enforced by other bodies. But perceived reason of self-initiation was 77% less likely to utilize than being advised by health extension workers. This result is consistent with the study conducted in Hult Ejju Enessie and Chencha district [8,20]. This is also explained in national health extension program which implemented for the provision and promotion of model activities, which serve as trigger for public health intervention.

Conclusions
This study found that the proportion of latrine utilization among the study area was 44.5%. This nding is lower than the Awoble District [7], Dembia district[6] and but higher than the study in southeastern Ethiopia [12] and southern Ethiopia [20], in northern Ethiopia Hawzien district [9]. It also less than a study conducted in Eastern Nepal [21] and 2017 JMP report [2]. This difference might be the study period variation (2013 vs 2018) and study area socio demographic and economic status difference.
In this study only few households had hand washing facilities near the latrines. This is higher than the nding from EDHS 2016 report of rural areas [5], rural Tanzania [22] and Kenya [23]. This could be due to scarcity of water, lack of awareness about the importance of hand washing.
Though many knew the bene t of latrine utilization, signi cant number of them use latrine because it is convenient particularly for females as compared with open defecation. This nding is similar with the result of South Ethiopia, but higher than Northwest Ethiopia [20,24]. This might be because of lack of awareness.
On the other hand, households who had primary/secondary students more utilize latrine than who didn't. This nding is consistent with the study conducted in Awobel district, Southeast Ethiopia and Eastern Nepal [12,21,25]. This might be due to school age children were more exposed to hygiene related information in the school. Literate husband household heads more utilize latrine than the illiterate. This nding is inconsistent with the study conducted in the North Ethiopia [9]. This difference could be attributed to the difference in the knowledge and awareness levels of the communities.
Long time of owning latrine encourages latrine utilization. This nding is similar with the study conducted in the gulomekeda district, Northern Ethiopia and Kenya [26,27]. This could be associated on focus group discussion if the household members visited frequently and supervised by HEWs and teach them the importance of latrine utilization; this would motivate households to use latrines constantly. Households who had latrines which need maintenance 67% times less likely to utilize latrine. This result is greater than the study conducted in Awobel district [7]. The reason might be, poor quality of latrine facility construction affects proper utilization.
Households constructing latrine far from home 68% times less likely to utilize latrine than nearest. This could be because of as latrine is far from home it is di cult to use it at night and during illnesses. Similar ndings were reported from North Ethiopia, southeast Ethiopia and study around Addis Ababa city a study [9,12,28].
Households constructing and using latrine by peer in uence were more utilize it than enforced by other bodies. But perceived reason of self-initiation was 77% less likely to utilize than being advised by health extension workers. This result is consistent with the study conducted in Hult Ejju Enessie and Chencha district [8,20]. This is also explained in national health extension program which implemented for the provision and promotion of model activities, which serve as trigger for public health intervention.

Conclusion
In the study, latrine utilization was found to be low. Presence of primary or secondary school students in the household, father's level of education, latrine use by peer in uence and duration of latrines two or more years were positively associated with latrine utilization. However, Latrine use by self-initiation, latrine needs maintenance and distance of latrine from home greater than 10 meters were factors negatively associated with latrine utilization.
Poor quality of latrines, incorrect methods of mobilization, infrequent supervision and follow up, poor knowledge and attitudes of the community on latrine utilization, poor participation of concerned bodies on motivating the community, poor commitment of health extension workers, absence of strong school health for latrine utilization were mentioned challenges for latrine utilization.

Limitations
Since the study is cross sectional, the ability to establish cause and effect relationships is impossible. In addition, there may be professional bias.

Consent for publication
Not applicable.

Availability of data and materials
All the data sets used for this study are available from the corresponding author and can be given with a reasonable request.

Competing Interest
The authors declare that they don't have any con ict of interest in any aspect of the article Funding Not applicable, there was no sources of funding for this study.
AK designed the study, collected, analyzed and interpreted the data, and also drafted the manuscript. Dr. MA Participated in conceptualization the study, design, analyses and interpretation of results as well as editing & critical review the manuscript. TA and KA conceptualization and designed the study, editing & critical review the manuscript. All authors read and approved the nal manuscript.