Open defecation: risk factors for adverse outcomes in Indonesia


 The increasing number of Indonesian population has caused serious issue of open defecation. Indonesia ranks the second large of open defecation prevalence in the world, after India. Human’s excrement was disposed in trench, drain, terrace, grassland, backwoods, forest, river, lake or other open spaces, thus, contaminates the water system. Open defecation can lead to the increasing risk of transmission of water-boene diseases of child morbidity in Indonesia. This study aimed at exploring different socio-economic and demographic factors of Indonesians who practice open defecation. Data were obtained from 49,627 female respondents of the 2017 Indonesia Demographic and Health Survey. The data were examined utilizing descriptive and logistic regression. The results reveal that the practice of open defecation is significantly influenced by place of residence, household’s wealth quintile, and household’s water supply. The findings suggest the needs for toilet construction and water supply sustainability in public area as well as in poor neighbourhood to eliminate open defecation in the country.


Introduction
The signi cance of eliminate open defecation to safeguard human health is indisputable and has critical public health concerns. Access to sanitation has been essential for the environment, human health, dignity and welfare. Open defecation is unsafely managed human excreta or fecal contamination in the environment (i.e. elds, forests, bushes, trench, drain, terrace, grassland, backwoords or other space for human disposal) rather than into a toilet, which leads to potential for exposure to enteric pathogens (Bhatt et al., 2019;Abebe and Tucho, 2020;Rakotomanana et al., 2020).
Open defecation could cause a trachoma, an acute visual disorder, which spread over ies that breed on unprotected human feces (Macleod et al., 2019). Moreover, open defecation can cause snail fever, known as schistosomiasis, an enduring parasitical illness spread through skin contact with an infection freshwater snail or drinking of excreta contaminated water (Colley et al., 2014;Osakunor, Woolhouse and Mutapi, 2018). Cholera is also linked to consuming contaminated water due to human excreta (Diaconu et al., 2018;Goswami et al., 2019). Open human excreta contain ovas of herminths that live in land until the next two years and can caused infectious such as ascariasis, trichuriasis, and hookworm (Bethony et al., 2006;McKay, Shute and Lopes, 2017). Hepatitis illness also occur within feces-contaminated drinking water supply (Junaid, Agina and Abubakar, 2014;Himmelsbach, Bender and Hildt, 2018).
The Sustainable Development Goals (SDGs) 6.2 has targeted open defecation to be eliminated by 2030 (Mara and Evans, 2017;Odagiri et al., 2017). However, open human excrement disposal is still major challenge for Indonesia since Indonesia has been identi ed as the second largest number of open defecation in the world, after India (Cameron, Olivia and Shah, 2019;Cameron et al., 2021). A study of drinking water in Yogyakarta in 2017 has revealed that 67 per cent of household drinking water and 89 per cent of water supplies were infected by part of human excreta (Aidan A . Many studies have studied various factors associated open defecation in Nepal (Budhathoki et al., 2017), Kenya (Njuguna and Muruka, 2017), and Ethiopia (Tessema, 2017). Most of open human excrement disposal practices occur in rural areas (Sara and Graham, 2014;Vyas et al., 2019) and in low-income families (Njuguna, 2019;Chakrabarti, Singh and Bruckner, 2020). Place of residence (Vyas and Spears, 2018), region of residence (Aidan A ; head of household , head of household's age (Njuguna and Muruka, 2017), head of household's educational level (Sinharoy et al., 2019), household's water supply (Vyas et al., 2019;Deshpande et al., 2020) and household's wealth quintile (Biran et al., 2011)  and environment indicators such as household ownership, sanitation, water-supply, maternal and child health variables (USAID, 2020). This study employed weighted-household-dataset of the 2017 IDHS because sanitary decisions (particularly constructing a toilet) is generated mostly at household level (Rutstein and Rojas, 2006;Croft et all, 2018). A two-stage sample study-design has been conducted to screen respondents of the study. Data on 49,627 respondents were generated from the interviewed women of reproductive age (15-49 years) in the primary questionnaire. Entire information on household ownership were collected including sanitary history. These sanitary data were used to identify the open defecation practice in a household.

The Study Variables
The dependent variable of this study is open defecation in which a household undertake open human excrement disposal or not (binary), de ned as respondents reporting not having any form of septic tanksanitary facility or disposing of human feces in open land, river, stream, creek, pit, yard, forest, backwoods, farmland for open defecation. The variable was measured utilizing the IDHS questionnaire on: "what kind of toilet facility do members of your household usually use?" (toilet with septic tank, toilet with no septic tank, shared/public toilet, river/stream/creek, pit or yard/bush/forest). The open defecation status categorised as 0 = septic tank-closed toilet for a house that that utilize all other types of septic tank-closed system toilet facilities and 1 = open defecation for a house without septic tank toilet facility or use open land/river/ stream/creek/ pit/bush/forest/ eld for disposing human excreta. The independent variables considered in this study include place of residence, region of residence, head of household, head of household's age, head of household's educational level, household's wealth quintile    (Njuguna, 2016;Osumanu, Kosoe and Ategeeng, 2019) and Asia (Spears, Ghosh and Cumming, 2013;McMichael, 2018) countries. The result of this study reveals that those household in rural areas, Java Bali, poor-poorest and utilizing unprotected water supply are linked with increased probabilities of open human excrement disposal. This study reveals evidence that open defecation is relatively common in the rural area (Bhatt et al., 2019), despite SDG's target that suggest universal access to sanitation. A study conducted by Jain et al. (2020) rea rmed that 69% of households in rural Bihar, India did not own a latrine in 2011 (Jain et al., 2020). Majority of poor households cannot build a septic tank toilet and without nancial and technical support (Abebe and Tucho, 2020). Open defecation practice contributes to and increased jeopardy of infected, gastrointestinal, respiratory, neurocognitive, and psychological diseases (Macleod et al., 2019).
All these variables are related to poverty and limited access of health.
The practice of open defecation may result in morbidity and mortality as well. Also, increase in open defecation could result in lack of productivity of household members as morbidity level within household increased (Thakur et al., 2018).
Open defecation has caused Kenya loses $88 million per year for health care, medicines, and treatment of their population (Abebe and Tucho, 2020). Furthermore, open defecation has caused in the loss of several productive working days (Njuguna, 2016). Open human excrement disposal also increases school absence, which lead to low academic achievement, failure to pass classes, increase drop-out rates, and delays in social improvement (Muluneh, Hailu and Alemu, 2020). The abstinence of toilet causes many women to walk long distances from their home to nd isolated-unexposed places to dispose, cope their menstrual issues which causes them exposed to encounter verbal, physical and sexual violence (Saleem, Burdett and Heaslip, 2019). The discriminating anxiety, embarrassment and weakness are prevalent in the girls and women of countries where open defecation still occurred (Saleem, Burdett and Heaslip, 2019).
A reduction in the likelihood of open defecation among wealthier families suggests that improving economic condition of households through community empowerment will improve the likelihood of household's healthy life issues, which is related to earlier studies (Cassivi et al., 2020). This is predicted since advancements in economic level of household will lead to better sanitary system and healthier life of the parents, their children and the community (A A . For instance, upper-middle households have higher privilages to evolve better sanitation and water supply facilities for their households' members needs, particularly employment of protected water supply practices which in turn will result in better health outcomes for both parents and their children (Aluko et al., 2018). Thus, the wealth condition of households could modify the utilization of curative health services (McCullough and Jonathon P Leider, 2017). The expected nding that the risk of open defecation decreased with increase in the wealth quintile in household, which is consistent with previous studies (Smith et al., 2015). Java-Bali's residences have increased risk of open defecation compared to outer Java-Bali residences.
This study is consistent with previous ndings that high density of Java-Bali islands is correlate with increasing numbers of home-less families and in uences their health outcomes particularly in open defecation issues (Cameron, Olivia and Shah, 2019). In fact, high-economic gap in Java-Bali areas largely in uence the socio-economic resources and health conditions of populations at the local, regional and national levels .
This study is persistent with earlier ndings that high density of Java-Bali islands is correlate with increasing numbers of home-less families and in uences their health outcomes particularly in open human excrement disposal issues Cameron, Olivia and Shah, 2019). In fact, higheconomic gap in Java Bali areas largely in uence the socio-economic resources and living conditions of populations  In country, there is a continual regional gaps in the distribution of socio-economic resources, particularly health care delivery, health services and wealth among the vulnerable and the poor households with inadequate health services and poor living conditions of households (Hosseinpoor et al., 2018). The likelihood of open human excrement disposal decreased among urban households compared to their rural counterparts (Boisson et al., 2014). A plausible explanation could be that urban households are more likely to earn more economic resources, that is very crucial to develop healthy sanitation unlike their rural counterparts (Boisson et al., 2014;Sara and Graham, 2014;Bhatt et al., 2019).
This study used the 2017 IDHS that is a nationally representative population-based study on household which contain an immense sample size in 34 provinces of Indonesia, which had been selected randomly.
Hence, the ndings of this study can be generalise to the Indonesian households and to other similar populations. The study's limitation is its potentially recall bias and social desirability to declare the actual practice of open defecation due to self-reporting measurement. Nevertheless, due to the cross-sectional nature of the study, this nding is incapability to measure fundamental consequences of open defecation. Other socio-cultural nor economic habituate of households, such as cultural beliefs, could be associated with open defecation. Furthermore, there are de cient data on some crucial variables such as working status, hence, were not included in the analysis.

Conclusion
The unseen of open defecation has been acknowledged as a decisive public health issue in Indonesia.
This study has emphasised crucial strategies for eliminating open defecation in the country through providing healthy sanitary system and increasing access to clean water supply. Eliminating open defecation has been an urge to decrease the spread of intestinal parasites and enteric pathogens to combat the child morbidity and mortality. Government and community should focus on increasing the economic level of household to increase the health status of household members as well as to improve the prevailing standard of living among Indonesians households.

Declarations
Author contribution. DKI contributed to the initial idea, conception, analysis, writing and approved the nal version of the manuscript and agreed to be responsible for the quality and accuracy of all parts of the work. WU contributed to the cleaning data, statistical analysis, interpretation of data result and agreed to be responsible for the quality and accuracy of all parts of the work. Con ict of interest. The authors declare no competing interests.