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]. Similarly, high prevalence of unsafe child stool disposal was reported from studies conducted elsewhere, 84% in rural Bangladesh [21], 81.4% in rural Orissa (India) [43], 79% in Malawi [44], and 75% in Uganda [45]. A study conducted in 26 locations showed that more than 50 percent of households with children under age three in 15 of the 26 locations reported that the feces of their youngest child under age three were not deposited into any kind of improved or unimproved toilet or latrine. That is, they were unsafely disposed of. The finding has important implications for interventions, as it indicates the high prevalence of unsafe child stool disposal in Ethiopia. As a result, those ongoing sanitation and hygiene programs should consider child stool disposal as an innermost component of an intervention to end open defecation, by extension to achieve the SGD goal.
The present study also revealed that most child stools ended up in the household waste disposal site or throw outside the yard 18.9%. Meaning a considerable number of children stools were disposed of unsafely in open field, which may put children's at high risk of acquiring fecal-oral diseases. Studies indicated that environmental contamination, as a result, unsafe child stool disposal can cause enteric diseases among young children's [25, 46]. A review also showed that diarrheal diseases were prevalent in areas where poor hygiene and sanitation is widespread [12].
The results also revealed that the proportion of unsafe child stool disposal in Ethiopia dropped from 90.8% in 2000 to 63.1% in 2016. Likewise, the trend showed a considerable decline in unsafe child stool disposal in rural areas (95.6% and 66.2% in 2000 and 2016, respectively); whereas in the urban areas a slow reduction of unsafe disposal was noted, from 51.9% in 2000 to 40.4% in 2016. Moreover, the pace in decline of unsafe child disposal was encouraging between the year 2000 and 2011 in Ethiopia however it becomes steady in the following five years between 2011 to 2016. The possible reason for a significant decline in unsafe child stool disposal between the year 2000 and 2011 may be due to the promotion of hygiene and sanitation through the well-known countrywide health extension program, which has been active since 2003. And the frequency of visitation by health extension workers might have increased the implementation of safe child stool disposal by households in Ethiopia, particularly in rural areas. Existing evidence also showed that between 2000 and 2011, reported latrine coverage and safe disposal of child feces improved in Ethiopia [6]. Despite the efforts through different approaches, still, 63.1% of children stool unsafely disposed of according to the recent EDHS report [24]. This finding, therefore, embodies an important message for the ongoing WASH, CLTSH, and other sanitation-related projects in the country that should be strengthened with particular emphasis on young children excreta management practices.
These findings have also important implications for the design of future sanitation interventions and call urgent attention to reducing the high burden of unsafe child stool disposal. First, interventions which encourage children to use the latrine directly may be potentially beneficial. Second, enhancing the behavior of the children's mothers/caregiver 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 environmental sanitation and show poor hygiene behavior [50]. Similarly, studies from Ethiopia, Kenya, and India found that the odds of practicing safe disposal of child feces increased with the level of mothers' education [22-24, 51]. Again, this association can be easily explained by the fact that educated mothers are more likely aware of the negative effects of unsafe child stool disposal and therefore practice safe disposal.
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 [6]. Past studies have also found child feces disposal to be associated with the child's age [22, 25, 52]. Behavioral interventions that encourage greater use of toilets by young children and encourage children to use a toilet consistently at a younger age may have a meaningful impact on improving child feces disposal practices. Hussain et al also suggested four behaviors that should be promoted in a child potty behavior change intervention for safe disposal of children's feces: 1) acquisition of a potty, 2) potty training, 3) regular emptying of the potty into a latrine, and 4) cleaning and maintenance for continued use [49]. And studies conducted in Nigeria [53], Burkina Faso (54), and Bangladesh (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 higher levels of pathogens and helminth eggs [55, 56]. The present study also identified a strong association between unsafe child stool disposal and high prevalence of childhood diarrhea in the bivariate analysis; though somewhat surprisingly this association disappears in the multivariable analysis. However, another Ethiopian study showed evidence of childhood diarrheal risks from unsafe child stool disposal [16]. These findings are similar to those from Nepal [10], Indonesia [11], Thailand [13], India [14], and in Burkina Faso [18]. Gil et al in their meta-analysis also found that unsafe disposal of young children's stools was associated with a 23% increased risk of diarrhea [risk ratio (RR): 1.23, 95% CI (1.15–1.32)] [12]. 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 cross-sectional 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.