Childhood Sanitation Practices and Incidence of Diarrhea in Slum Communities With Implications for Community-Based Education in Less Developed Countries

Diarrhoea is a major cause of mortality among under-five children, especially in less developed countries. Previous studies on childhood diarrhoea have largely focused on biomedical methods with little attention given to community-based approach to reduce the prevalence of the disease in the slums, classified in literature among areas of high diarrhoea incidence. The key question is does childhood sanitation practices influence the incidence of diarrhea? This study, was therefore, designed to examine the association between childhood sanitation practices and incidence of diarrhea using community-based approach. 57 influence unhygienic toilet practices in the slums. This has negative health implications on the lives of low-income and vulnerable slum dwellers. Thus, community-based education on improved sanitary practices is necessary to reduce diarrhoea prevalence. 50 51 53


Abstract Background
Diarrhoea is a major cause of mortality among under-five children, especially in less developed 28 countries. Previous studies on childhood diarrhoea have largely focused on biomedical methods 31 with little attention given to community-based approach to reduce the prevalence of the disease in 32 the slums, classified in literature among areas of high diarrhoea incidence. The key question is does 33 childhood sanitation practices influence the incidence of diarrhea? This study, was therefore, 34 designed to examine the association between childhood sanitation practices and incidence of 36 diarrhea using community-based approach. 37

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The value beliefs and planned behavior theories were 39 adopted as framework, while cross-sectional survey was use to elicit data from 900 mothers of 40 under-five children who had lived in the study locations for at least 12 months preceding the 41 research and 10 In-depth interviews was conducted.

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However, the challenges associated with poor sanitation still lingers as reports indicate that 2.5 22 billion people still do not have access to improved toilet facilities, resulting in widespread open 24 defecation [12, 22,30]. This has health implications as research 27 shows that for every 20 seconds, a child dies due to poor sanitation [30]. The situation is precarious in less developed   Studies on sanitation practices in Nigeria have largely focused on adult and household facilities 30 31 [16,24] . There is a paucity of information on the 32 33 relationship between childhood toilet practices and diarrhea, especially in the slums. In addition,

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little is known on the contributions of community based education to reduction of diarrhea 36 incidence. This has implications on the success of achieving the Sustainable Development Goals.

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This gap in the literature has effects on the human development index, typified by under-five 39 40 mortality in Nigeria. Therefore, this study was designed to examine the relationship between 41 42 childhood sanitation practices and incidence of diarrhea in the slums of Nigeria in order to make 43 44 context-specific recommendations.
1. What are the associations between childhood sanitation practices and incidence of diarrhoea? The study is anchored on two theoretical perspectives, namely; the value belief norms and planned personal interest and societal values shape human behaviour within a community. The thrust of 11 the theory is that pro-social attitudes and personal norms are significant predictors of human to actions or inactions are strong determinants of acceptable and non-acceptable behaviors.

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However, acceptable behavior varies within space and time. In this study, societal norms, community perception and parental financial capability influence 24 children toilet behaviour and practices. Wealth is a significant factor that shape household facilities. The situation is precarious in the slums due to limited finance to care for children.

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Therefore, the risk of child morbidity is higher is the slums than non-slums. Further, [ 2 1 ] 31 had earlier explained how the belief and perception of 33 a society shape behavior and attitude. Behavioral response to hygiene practices are associated with 35 perception and beliefs that community has towards such actions. People in the community are 36 37 more likely to obliged to a particular hygiene practices if they perceive or belief that such practices 38 39 will yield positive outcome. This theory, however, did not highlight the intra-personal connections 40 41 between human attitude, behavior and actions. Thus, the need for the theory of planned behavior. outcome. If an individual perceive that the outcome of his action will be negative, he/she is more 51 52 likely to reframe from such act. Thus, human attitude relies on rational choices. Subjective norms 53 explains that human action is generated from interaction with friends, family members, neighbors, In addition, the theory predict how individuals will behave based on their pre-existing attitudes 11 and behavioural intentions. The World Health Organisation has suggested that children toilet 13 practices should be safely managed. However, adherence to this practice is subject to parent's 14 15 beliefs that such action will produce positive health outcome or benefit to their children.

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This study was conducted in Nigeria, which is the 32 nd largest country in the world in term of land 7 8 space. The country has six geopolitical zone: South-west, South-south, South-east, North-central, Nigeria. South-west region was purposively chosen for this study because of the prevalence of  in epidemiological survey involving children [13,19] . 36 37 This entails the systematic selection of 30 clusters for a study. In each cluster, 30 households were 38 39 selected. Therefore, 30 clusters makes up 900 households were a questionnaire was randomly 40 41 administer to mothers that met the inclusion criterion. In this case, 30 slum clusters were selected Organization WASH instrument that focused on childhood sanitation was adapted for this study 53 [30]. Households 55 eligible for inclusion in the study were households with mothers or care-givers of under-five 57 children that were 18 years and above, who have been living in the study locations for at least 12 58 59 months prior to the study.
Interview (IDI) for the qualitative method. The questionnaire was used to collect information on mothers' social 9 10 characteristics, child's health, toilet practices, and incidence of diarrhea in each of the selected 11 households in the 4 weeks preceding the survey. The questions were close-ended and was adapted from a questionnaire developed by the Joint Monitoring Programme of the World Health Organization and UNICEF on water and sanitation, which had been used in a similar study [1]. A segment of the adapted questionnaire can be found at the World Health Organization website https://washdata.org/monitoring/methods/core-questions. A pre-test of the questionnaire was conducted with 15 respondents in the study location to determine its suitability on childhood sanitation practices.
After the pre-test, the questionnaire was adjusted to suite childhood sanitation practices within the contexts of the study location. Data was collected within the month of February and July 2018. In addition, ten In-depth Interviews were 13 conducted with caregivers to gain insight into the interpretative understanding of childhood toilet  The dependent variable was childhood diarrhea. This was measured by asking mothers whether after defecating, and faeces disposal site. Table 1 illustrates the measurement variables of the 27 28 study. The classification of variables aligned with the WHO/UNICEF joint monitoring programme 29 30 for toilet practices [30]. The quantitative data were analyzed using descriptive and inferential statistics, while the 33 qualitative data was content analyzed. Chi-square was used to test the relationship between the 35 independent and dependent variables. A logistic regression model was used to examine the 36 37 influence of childhood toilet practices on the risk of diarrhea among under-five children that lives

Ethics
Ethical approval to conduct this research was obtained from the Social Sciences and Humanities Research Ethics Committee at University of Ibadan, Nigeria with assigned number UI/SSHEC/2017/0025, issued on 31 st October, 2017. All participants provided written informed consent for the study, assured of their anonymity, informed that data was purely for academic publications, voluntary and were free to leave the study at any time.  Almost all respondents (97%) who had experienced diarrhoea within the last four week defecates 7 8

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with unimproved toilet facilities. In addition, children whose faeces were disposed within 9 household environments were more susceptible to diarrhea (χ 2 =10.542, P<0.05). About 74% of 11 respondents that disposed faeces around household environment had experienced diarrhea in the 13 last 4 weeks before the survey. Further, there is a significant association between using    68.854, P<0.05), and mothers education. Children whose mothers had no education were more 29 30 likely to defecate with unhygienic toilet facilities (100%), clean their buttocks with unimproved 31 32 toilet materials (100%), and faeces were disposed (78%) around residential homes.

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Further, there is a significant positive relationship between mothers' marital status and under-five  The norms and perception of people within the slums influence childhood toilet practices. Open 7 8 defecation is a bane to children's development and survival, yet many people practice unhygienic 9 10 toilet behavior due widely held perception and practices. A respondent in an In-depth Interview The community perception and neighbourhood norms influence toilet practices of children less 22 23 than five years old. Another respondent buttressed this when she said: 24 25 It is not our tradition for children to defecate in the toilet, especially The responses of respondents shows that community perception interact with poverty to influence

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The unadjusted model on table 4 shows that the odds of getting diarrhea was high among under-7 8 five children whose mothers' were older than 24 years, with no education, poor and without 9 10 husband (single or widow). Model 2 shows that the odds of experiencing diarrhea was high among children that defecate using 5 6 unimproved toilet facilities (OR = 6.964; P<0.05). The odds increased in model 3 as children that 7 8 defecates using unimproved toilet facilities were 8 times more likely to experience diarrhea than 9 10 those using improved toilet facilities. In summary, there is a significant relationship between 11 mother's age, education, marital status, poverty, unimproved toilet practices and the risk of 13 experiencing diarrhea among children less than five years in the slums.  water is mainly used for washing children buttocks. In a similar study conducted in Nigeria, [3] reported that 85% of care-givers use 29 30 water for anal cleansing after children defecate. The use of water to wash anal were perceived as 31 better than any other materials. In addition, children defecate on their mothers body due to belief 33 that children faeces were not harmful. Contrary to widely held beliefs in that children faeces were 35 not harmful, [7] debunked such beliefs and associated the death 36 37 of 151,700 children per annum to diarrhea, which is mainly caused by unhygienic water and faeces on the floor to diarrhea due to the presence of flies around household's environment. 42 Further, these reports support the finding of an earlier study conducted in Ondo State, Nigeria by  What this study adds 11 This study shows that despite national progress on the use of improved toilet facilities, there remain will stall or retard efforts made nationally to reduce morbidity among children less than five. Slum 16 17 communities' perception of diarrhoea, which is influence by ignorance and poverty, is the major 18 19 constraint limiting the use of improve toilet facilities. Toilet practices in the slums is precarious 20 21 and children in the slums suffer from preventable illnesses due to poverty, ignorance and slum 22 practices. Therefore, to achieve the Sustainable Development Goal 6 by year 2030, community 24 education on improved sanitary practices should be integrated to slum inhabitants.

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Limitation of the study 29 30 The limitation of this study relate mainly to the constraints involved with primary data. The 31 responses were self-reported and accuracy of the data depends on the respondents.

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Conclusion 36 37 Childhood sanitation practices remains a major health challenge, especially, in the slums with 38 39 precarious toilet facilities. This situation increases the prevalence of morbidity and mortality 40 41 among children less than five. Poor perception, poverty and ignorance has been implicated for the 42 persistent use of unhygienic toilet facilities and children from poor household were more 44 predisposed to experience diarrhea. Therefore, to achieve the Sustainable Development Goal 6 by 46 2030, community education should be use to increase the sanitary consciousness of slum dwellers.

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Health intervention programmes should be integrated with community education to promote 49 50 improve health practices in the slums and reduce death among children less than five years.

Ethical approval and consent to participate
Ethical approval was sought from the University of Ibadan Social Science and Humanities Research Ethics Committee, University of Ibadan, Nigeria with assigned number I/SSHEC/2017/0025. In addition, the international standard ethical issues bordering on respondent's confidentiality, beneficence to participants, non-maleficence and justice as it affects the study was considered and respected. All

Consent for publication
Not applicable

Availability of data and materials
The datasets generated and analysed during the present study are available from the corresponding author on reasonable request.

Competent interest
We have no conflict to disclose

Funding
No funding was received toward completing this work Author's contribution OSC Conceptualized, designed and carried out data collection, data analysis/interpretation and wrote the first draft of the paper. AO edited, improved and revised all version of the manuscript. All authors read and approved the final version of the manuscript.