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Research Latrine utilization and associated factors among people living in rural areas of Denbia district, Northwest Ethiopia, 2013, a cross-sectional study Yimam Tadesse Yimam1, Kassahun Alemu Gelaye1, Daniel Haile Chercos1,& 1
Department of Environmental and Occupational Health and Safety, Institute of Public Health, University of Gondar, Ethiopia
Corresponding author: Daniel Haile Chercos, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Ethiopia
Key words: Latrine utilization, hand washing facility, hygiene, sanitation Received: 18/03/2014 - Accepted: 23/07/2014 - Published: 26/08/2014 Abstract Introduction: In Ethiopia up to 60% of the current disease burden is attributable to poor sanitation. Latrine facility coverage is increasing since Health Extension Program started, whereas less attention to quality and utilization of latrine facilities in rural Ethiopia. Methods: A community based cross-sectional study design with multistage sampling technique was employed to collect data from total of 806 households. Results: A total of 801 households with latrines were assessed for their latrine utilization status. The extent of latrine utilization among 490 (61.2%) households was satisfactory. Presence of ≤5 children (AOR: 0.379, 95% CI :( 0.196, 0.732)), job of mothers (being farmer) (AOR: 0.321, 95%CI :( 0.136, 0.757)) and rare cleaning frequency (AOR: 0.055, 95% CI :( 0.005, 0.620)) were a factor negatively associated with latrine utilization. Whereas the presence of secondary school children (AOR: 3.739, 95% CI (1.884, 7.419), educational status of mothers (AOR: 2.437, 95% CI (1.032, 5.756), latrine constructed for the second time (AOR: 2.676, 95% CI :( 1.352, 5.299)), presence of door (AOR: 3.201, 95% CI: (1.437, 7.130)), the hygienic condition of latrine (AOR: 4.327, 95% CI: (2.05, 9.134)) were factors positively associated with latrine utilization. Conclusion: Latrine utilization rate of household latrines was satisfactory. The presence of ≤ 5 years children, job of mother (farmer), educational status of mothers, presence of secondary school student, the presence of the door, frequency of latrine construction, and hygienic condition of latrine were significant predictors of latrine utilization.
Pan African Medical Journal – ISSN: 1937- 8688 (www.panafrican-med-journal.com) Published in partnership with the African Field Epidemiology Network (AFENET). (www.afenet.net) Page number not for citation purposes
campaign with less effort to change the attitudes of the households
and most of the effort of health extension workers mainly focuses Globally over 2.5 billion people are still without access to improved sanitation. In 2010, 15% of the population still practice open defecation . In developing regions almost half the population does not have access to sanitary facilities an estimated 1.1 billion
on new construction with less follow-up to utilization of existing latrine facilities. Therefore, it was necessary to carry out this study so as to establish baseline information on latrine utilization and factors affecting the proper utilization of latrine in Denbia district.
people practice open defecation, exposing themselves and their communities to major health risks [1,2]. In sub-Saharan Africa, only 24% of the rural population was using an improved sanitation
facility . In Ethiopia up to 60% of the current disease burden is attributable to poor sanitation where 15% of total deaths are from
diarrhoea, mainly among the large population of under-five year's children. In addition to diarrheal diseases, there is a high prevalence
The study conducted in Denbia district, which is found in North
of worm infestations causing contributing to the high levels of
Gondar Zone, ANRS. The District is located 781 km away from Addis
malnutrition . According to Ethiopia Demographic and Health
Ababa, the capital of Ethiopia and 216 km from Bahr Dar. From on
Survey 2011 report 62% of households have toilet facility, 84%
2007 National Housing & Population Census, the population
urban and 55% rural households. The majority of households, 82%
projected by CSA for the year 2012 is 295,423 of which 147,850 are
(91% rural and 54% urban) use non-improved latrine facilities. The
males and 147,573 are females. The district comprises 45 kebeles
coverage falls short of meeting the Millennium Development Goal
(40 rural and 5 urban) with a total area of 1261.96 km2 and per
target. In addition to that, level of handling and utilization status of
km2 234.1 persons live in the district . According to the 2011/12
existing latrines is not known [5, 6].
annual report of the district health office more than 94% of the households have latrine facility .
Study in the Kersa district in households with latrine, the habit of hand-washing after defecation was reported to be only about 5.1%.
Only 8.3% had hand washing facilities near the latrine. The habit of hand washing after defecation is significantly allied with the
The sample size was determined by using a single population
educational status of the respondents . From an individual point
proportion formula considering the following assumptions of latrine
of view, any latrine is better than no latrine where as from a
utilization 61% , 95%CI, level of significance to be 5% which
community point of view; a high level of coverage with hygienic
gives 806 study households.
latrines appears to have modest health advantages , A study done in Hulet Ejju Enessie district showed that the duration of
utilization was a strong predictor of occurrence of childhood diarrheal diseases .
A community based cross-sectional study collected by interviewing randomly selected sample household spouses preferably mothers in
A poor practice such as limited utilization of sanitary facilities
households using a structured questionnaire and by using an
contaminates the environment and water sources. This suggests
observational checklist from February to April 2013. Multistage
that efforts to increase access to safe water and improved sanitation
sampling technique was undertaken. Eight kebeles and respective
have to be joined with strategies to promote appropriate utilization
'gots' were randomly selected by simple random sampling and 806
of sanitary facilities .
study households selected from each 'got' through systematic sampling.
Provision of sanitation facilities initiated in all parts of Ethiopia with interventions
investments to increase access to safe water and improved sanitation . The increasing coverage mainly achieved by
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Operational definitions Satisfactory latrine utilization: is a households having functional latrines, safe disposal of child faeces, no observable faeces in the compound and show at least one sign of use (foot path to the latrine not covered by grass, the latrine is smelly, spider weave in squatting hole, presence of anal cleansing material, fresh faeces in the squatting hole, and the slab is wet). Hygienic: means no faecal matter presents inside the facility on floor or walls, which are not full and not smell bad. Functional latrine: is a latrine that provided services at the time of data collection even if the latrine required maintenance. Access to hand washing facilities: is availability of hand washing facilities at the entry or adjacent to the latrine. A Child friendly feature of latrine facility: means availability of at least one of the following features; small squatting hole, lower seat and presence of potty. Data processing and analysis Data was checked visually, coded and entered into Epi Info version 3.5.1 and exported to SPSS version 20.0 software package for further statistical analysis. The data analysed using bivariate and multivariate logistic regression to determine the effect of various factors on the outcome variable. The degree of association between independent and dependent variables were assessed using odds ratio with 95% confidence interval and p-value ≤0.05. Ethical consideration Ethical clearance was obtained from the Institutional Review Board (IRB) of the University of Gondar, Institute of Public Health. Formal letter of cooperation was written for Denbia district Health Office. Consent of district health office and respective kebeles were obtained. Informed consent was obtained from each study subject. Any involvement in the study was carried out with the full consent of the person being interviewed. Finally after collection of the necessary data, identified problems during an evaluation process were discussed with health office so as to improve utilization of the latrine facilities in the district.
Results Socio-demographic characteristics A total of 806 households with latrines were planned to participate in the study, out of which 801 were included in the study a response rate of 99.4%. The majority of the respondents 756 (94.4%) were mothers and the remaining 45 (5.6%) were their spouse. The mean age of the respondents was 37.22 years (±10.736 SD). The majority, (98.5 %) of respondents were Orthodox Christians. The majority (89.5%) of respondents were married and 602 (75%) had a family size of five or more with a mean family size of 5.95 (±1.944 SD) persons. There were ≤5 children in 420 (52.4%) households. Two hundred forty-four (39.4 %) under-five children were within 3-5 years age category. Five hundred eighty-eight (73.4%) mothers and 458 (66.1%) fathers were illiterate. Six hundred eleven (76.3%) households had children attending either primary or secondary school. Six hundred ninetythree (86.5%) households were headed by fathers. Characteristics of latrine facilities Types of available latrines in the district were 100% simple pit latrines. About 764 (95.4%) latrines were privately owned and the rest 37 (4.6%) was shared with their neighbours. Five hundred forty six (68.2%) of latrines was constructed two years and longer prior the study and the mean duration of having a latrine was 2.39 (±1.34) years. Most 710 (88.6%) of the respondents who had latrines explained that they were advised by extension health workers or community health agents to construct latrines. Only 42 (5.2%) respondents complained that they were imposed by other bodies like local administrators and fear of punishment. Regarding the frequency of latrine construction 414 (51.1%) of the current latrine was the first ever latrine, while 340 (42.4%) reported that it was their second and only 47 (5.9%) noted that it was their third latrine that they had constructed. For those who built for the second time or more, the main reason attributed to the building of the new one was because the old one got flooded were 49.4%, while 38.5% damaged and only 10.9% were due to filling up of latrine. From the functional latrines almost all of latrine slabs were made of mainly wood and mud from this 464 (76.1%) were sealed with mud
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and the remaining 144 (23.6%) have no properly constructed slab
for not utilizing a latrine. The reasons given by respondents for why
and only 1 cemented. About 290 (52.4%) of latrines had no cover
children not using latrines were: large squatting hole 112 (54.4%),
on the squatting hole (Table 1).
being just a child 54 (26.2%), and floor was not safe to stand on 40 (19.4%).
Hand washing practices were measured through proxy indicators that focus on the existence of hand washing devices near the
Factors affecting latrine utilization
latrine. Only 164 (26.9%) latrines have hand washing devices. Water was observed in 124 (75.6%) households and among this
soap, ash was observed only in 42 (25.6%) and 23 (14.0%) hand washing stations respectively. Among all functional latrines only 65
From socio-demographic factors, marital status, educational status
(10.7%) of households with access to a place to wash hands that
of the women and men, presence of primary and secondary school
has all essential supplies (Table 1).
children in the household, job of mother and father, family income, presence of ≤5 children and presence of radio had showed a
Latrine Utilization The use of the latrine was assessed based on
significant association with satisfactory latrine utilization in the
self- reporting, and the observation of proxy indicators. The majority
bivariate analysis at p ≤ 0.05.
695 (86.8%) of latrines was reported as used by the respondents and the rest 106 (13.2%) latrines were never used at all. Whereas
After adjusting for other confounders in the multivariate analysis,
based on observation 609 (76.0%) households were observed with
presence of ≤ 5 children, presence of secondary school student,
the presence of at least one sign of use as an indication of
educational status and job of mother remained significant predictors
utilization and 192 (24%) have no any sign of use. In the compound
of latrine utilization. Households with secondary school children
faeces were physically observed in 84 (13.8%) of households which
were 3.739 times more likely to utilize latrine compared to
have functional latrine. The extents of latrine utilization among 490
households without secondary school children (AOR: 3.739, 95% CI
(61.2%) households with latrines were satisfactory.
(1.884,7.419)). The extent of latrine utilization were 2.437 times more likely for mothers who can read and write than those unable
Among the 226 households which have 3-5 years children only 20
to read and write (AOR: 2.437, 95%CI :( 1.032,5.756)).
(8.8%) children were using latrines. Of those households which have ≤5 children 133 (31.7%) households disposed their children's
On the other hand farmer mothers were 67.9% less likely to utilize
faeces improperly by disposing out of houses somewhere either in
latrine as compared to housewife's (AOR: 0.321, 95%CI :( 0.136,
the backyard or in the nearby bush (Table 2). Concerning the
0.757)). The extent of latrine utilization were 62.1% less likely for
frequency of cleaning the latrine majority 79.5% of households
households having ≤ 5 years children than those without ≤ 5
clean their latrine when get dirty, only 1.7% clean daily and only
children (AOR: 0.379, 95%CI :( 0.196, 0.732)).
400 (65.7%) latrines were founded in a hygienic condition (Table 2).
Reasons of latrine utilization The majority of the respondents
Among environmental factors distance of latrine from the house,
reported to use latrines because of their understanding about the
latrine service year, squatting hole cover, presence of the door,
danger of excreta to health 653 (94%), to keep the environment
frequency of latrine construction, need of maintenance, number of
clean 191 (27.5%), for privacy purpose, access and no other place
households use latrine well constructed slab and superstructure
to defecate were 50(7.2%).
showed a significant association in the bivariate analysis at a p value ≤ 0.05 significant point. After adjusting for other confounder
Reasons of not using the latrine
variables in the multivariate analysis, the only presence of door, frequency of latrine construction were significant predictors of
Among the reasons given by the respondents for not use of latrine
satisfactory latrine utilization. Households who construct latrines for
facilities by adults were long live habit (60.4%) and considering
the second time were 2.676 times more likely to utilize their latrine
open defecation comfortable (18.9%) had been the main reasons
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compared with households having first ever latrine ((AOR: 2.676, 95% CI :( 1.352, 5.299)).
The methods of handling of faeces of children varied among respondents: from children 3-5 age only 8.8% children who used
Concerning the presence of the door, households which have
latrines and among those households which have ≤5 children
latrines with door were 3.201 times more likely to utilize latrine
31.7% households disposed their children's faeces improperly by
compared with latrines which have no door (AOR: 3.201, 95% CI:
disposing out of houses somewhere either in the backyard or in the
nearby bush. The use of the latrine for safe disposal of children´s faeces in the present study was higher than the study kintampo,
Northern Ghana (66.5%) similar when compared with the reports in Hulet Ejju Enessie. This behaviour is entirely unacceptable practice
Among behavioural factors frequency of cleaning and hygienic
of handling faeces of children [10, 14]. Almost half of latrines were
condition of latrine showed a significant association in the bivariate
built for the second time or more, the main reason attributed to the
analysis at a p value ≤ 0.05 significant point.
building of the new one was the old one got flooded (49.4%) and damaged (38.5%), while only 9.7% in Alaba and 2.5% in Mirab
After adjusting for other confounder variables in the multivariate
Abaya . This may indicate that the study area was more
analysis, both frequency of cleaning and hygienic condition of latrine
exposed to erosion or using inappropriate latrine construction
materials which lead to problems during flooding, in loose soils.
Households who clean the latrine rarely were 94.5% less likely to utilize their latrine as compared with households clean latrine daily
Concerning hand washing facilities near latrine, only 26.9% latrines
(AOR: 0.055, 95% CI :( 0.005, 0.620)). Whereas households which
have a hand washing facility. Which is more than three times higher
have hygienic latrines were 4.327 times more likely to utilize latrine
than the study done in Baher Dar Zuria (6.2%), Kersa (8.3%) This
compared with latrines not hygienic (AOR: 4.327, 95% CI: (2.05,
difference may be due to the fact that recently there has been high
9.134)) (Table 3).
mobilization of the community on hygiene and sanitation which increases hand washing facility coverage of the study area. But this study result was lower than Hulet Ejju Enessie (30.8%) this
difference might be due to effort difference in mobilizing the community to use hand washing facilities [8, 10, 12].
The study found that the extent of latrine utilization among 61.2% households with latrines was satisfactory which is similar to the report in Hulet Ejju Enessie (60.7%) . It was also established that hygienic condition of latrine, presence of secondary school student, presence of the door, latrine constructed for the second time and educational status of mothers were significant predictors of satisfactory latrine utilization. The majority 695 (86.8%) of latrines was reported as used by the respondents, lower than Mirab Abaya and Alaba (100%). Whereas based on proxy indicators only 76.0% of latrines were giving service which was 10.8% lower than reported as used by the respondents. The discrepancy between self report and observation might be a tendency of respondents to over report positive hygiene behaviour in the interview. This result is lower than the finding in Mirab Abaya and Alaba (93%), higher than study in Bahr Dar Zuria (62%) and similar to study in Hulet Ejju Enessie district (86.7%) [10, 12, 13].
The major reasons of latrines use were their understanding about the danger of excreta to health, to keep the environment clean, privacy and convenience. This finding also supported by focus group discussion, reasons were to prevent from diseases related with excreta, to keep the environment clean and for privacy. The most common reason for not utilizing of latrine by the households was long live habit (60.4%) and considering open defecation comfortable (18.9%). Study in Hultu Ejju Enessie identified that non functionality of latrine and staying out for work . Supporting the quantitative finding, participants of the focus group discussion also mentioned long live habit, staying out for work and low awareness on use of latrine were major reasons for non utilization of latrines. The reasons given by respondents for not using latrines by ≤5 children were: large squatting hole (54.4%), being just a child (26.2%) and (19.4%) floor was not safe to stand. This shows that
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latrines constructed without considering child friendly features like
households' clean latrine daily. Latrines should be cleaned daily to
small squatting hole, small foot rest and presence of the potty. The
prevent disease transmission through contact with faeces and flies
findings of this study were similar to the study in Hulet Ejju Enessie
and, perhaps more crucially, insanitary conditions and odour which
district . However, the use of latrines by children in the study
may deter people from using them . But there is no any
area was not encouraging; study in Tanzania showed that children's
significant difference between those clean their latrine daily and
use of latrines was associated with a significant decrease in risk of
clean when dirty. Moreover, households which have hygienic latrines
were 4.327 times more likely to utilize latrine compared with latrines not hygienic. The strong association between hygienic condition of
Based on the result of multivariate analysis from socio-demographic
latrine and utilization could be attributed to fear of contamination,
factors as similar to the study in Hulet Ejju Enessie households with
odour and flies that are major problems of unhygienic latrines.
secondary school children were 3.739 times more likely to utilize
Strong association also seen between improved latrine use by all
latrine compared to households without secondary school children
household members and conducive and hygienic latrine in Tanzania
. This might be due to the fact that secondary school students
were more exposed to hygiene information in the school environment. The extents of latrine utilization were 2.437 times more likely for mothers who can read and write than those unable
to read and write. The presence secondary school student and educational status of mother positively favoured the improvement of latrine utilization in the home environment.
the household latrines utilization rate was satisfactory and on the
Farmer mothers were 67.9% less likely to utilize latrine as compared to housewives. This might be due to the fact that housewife's have a higher chance of staying in and around their home for a long time, which have great contribution for use of household latrine. The extents of latrine utilization were 62.1% less likely for households having ≤5 years children than those without ≤ 5 children. This might be due to open defecation practice of children and improper disposal of child faeces by parents.
for the second time were 2.676 times more likely to utilize their latrine compared with households having first ever latrine. This utilization difference might be due to those first ever latrine users received new knowledge about sanitation recently and the habit of not
way to reach 82% plan of HSDP IV of Ethiopia. Whereas hand washing facility near the latrine with access to all essential supplies were very low. From this study, we conclude that presence of ≤ 5 years children, job of mother farmer] and rare cleaning of latrine were factors negatively associated with latrine utilization and educational status of mothers, presence of secondary school student, the presence of the door, frequency of latrine construction, and hygienic condition of latrine were positively associated with latrine utilization.
From the environmental factors households who construct latrines
Based on the findings of this study we can conclude that generally
reconstructs their latrine after the first full. Concerning the presence of the door, households which have latrines with door were 3.201 times more likely to utilize their latrine compared with latrines which have no door. This might be due to the fact that latrines which have
Based on the study attention must be given to expand latrine facilities accompanying with the hand washing device, incorporating child friendly features, superstructure which insures privacy, encouraging people to keep their latrine hygienic and Improving women's educational status and encouraging children to continue their education above primary school is very important in improving latrine utilization status of households. Therefore, in general it is recommended that integration of hygiene behavioural change with construction of sanitation facilities is crucial.
door can insure privacy that can encourage people to use the latrine.
The association was observed between cleaning frequency and utilization of latrine. Households who clean the latrine rarely were
The authors declare no competing interests.
94.5% less likely to utilize their latrine as compared with
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