Associated factors of safe child feces disposal in sub-Saharan Africa: Evidence from recent demographic and health surveys of 34 sub-Saharan countries

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Study Justification:
This study aimed to determine the associated factors of safe child feces disposal among children under two years of age in sub-Saharan Africa. Children’s feces pose a greater public health risk due to higher concentrations of pathogens. Understanding the factors that influence safe child feces disposal is crucial for improving public health outcomes in the region.
Highlights:
– The study analyzed data from the most recent demographic and health surveys of 34 sub-Saharan countries.
– A total weighted sample of 78,151 mothers/caregivers of under two children were included in the study.
– Factors associated with safe child feces disposal included urban residence, primary education of mothers, higher wealth quintiles, family size

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a secondary data analysis of recent demographic and health surveys conducted in 34 sub-Saharan countries. The study used a large weighted sample size and employed both bivariable and multivariable multilevel logistic regression. The odds ratios and confidence intervals were calculated for each independent variable. The study identified several factors associated with safe child feces disposal, providing actionable steps to improve the practice. To improve the evidence, the study could have included a discussion of limitations and potential biases in the data collection process. Additionally, it would have been helpful to provide more details on the specific methods used for data extraction, recoding, and analysis.

Introduction Children’s feces are thought to pose a greater public health risk than those of adults’ due to higher concentrations of pathogens. The aim of this study was to determine the associated factors of safe child feces disposal among children under two years of age in Sub-Saharan Africa. Methods The most recent demographic and health survey datasets of 34 sub-Saharan countries were used. A total weighted sample of 78, 151 mothers/caregivers of under two children were included in the study. Both bivariable and multivariable multilevel logistic regression were done. The Odds Ratio (OR) with a 95% Confidence Interval (CI) was calculated for each independent variables included in the model. Results Those mothers/caregivers from urban residence (AOR = 1.42; CI: 1.36, 1.48), mothers with primary education (AOR = 1.49; CI: 1.44, 1.56), richer (AOR = 1.78; CI: 1.69, 1.88) and richest wealth quintiles (AOR = 2.17; CI: 2.01, 2.31), family size <5 (AOR = 1.06; CI: 1.02–1.09), access to improved water source (AOR = 1.29; CI: 1.25, 1.34), mothers who owned toilet (AOR = 3.09; 2.99–3.19) and who had media exposure (AOR = 1.19; CI: 1.15, 1.24) had higher odds of practicing safe child feces disposal than their counter parts. However, mothers/care givers who are not currently working (AOR = 0.83; CI: 0.80, 0.86), higher education (AOR = 0.85; CI: 0.76–0.94) and from Western region of Africa (AOR = 0.82; CI: 0.79–0.86) had reduced chance of safe child feces disposal as compared to their counter parts. Conclusion Residence, mothers’ level of education, wealth index, water source, toilet ownership and media exposure were factors associated with safe child feces disposal. It is advisable to implement health promotion and behavioral change intervention measures especially for those women /caregivers from rural residence, poor economic status, who cannot access improved water and for those with no media exposure to improve the practice of safe child feces disposal.

This study was a secondary data analysis from the most recent appended demographic and health surveys (KR data sets) conducted in 34 sub-Saharan countries from 2009 to 2018. The DHS is a nationally representative survey that collects data on basic health indicators like morbidity, mortality, fertility, maternal and child health. The DHS used two stage stratified sampling technique to select the study participants. A pretested and standard DHS questionnaires were used for data collection of the DHS surveys. The questionnaire was conceptualized to the different countries context and the data were collected by trained data collectors. The datasets of each sub- Saharan country were obtained at https://dhsprogram.com/data/dataset_admin/index.cfm.Those countries which have data on feces disposal among under two children were included in the analysis. We removed those cases which were incomplete from the analysis to handle missing data. Each country was given a code and then appended together to create a single data set that represents the SSA countries. In this study, a total weighted sample of 78,151 under-two children were included (Table 1). The dependent variable for this study was safe child feces disposal. Safe child feces disposal is a binary outcome (yes or no) and a child is said to have safe child feces disposal if they used latrine’ and if they ‘put/rinsed child feces into latrine [18]. The independent variables considered for this study were both individual and community level variables. The individual level variables were age of child, age of mothers, education level of mothers, education level of partners, wealth index, occupational status of mothers, family size, number of under five children, water source, toilet ownership and media exposure (a composite variable generated by the aggregation of listening radio, reading newspaper and watching television and it was dichotomized as yes “if the mother had exposure to either of the above three mentioned media sources” and no “if she had no exposure to all of the three media sources). SSA region and residence were considered as the community level variables. Data extraction, recoding and analysis were done using STATA version 14 software. Before the analysis sampling weight was applied to produce reliable estimates by adjusting the over and under-sampled region. Sample weights were calculated to six decimals but are presented in the standard recode files without the decimal point. They need to be divided by 1,000,000 before use to approximate the number of cases. The whole procedure of weighting and its rationale is found on the guide of DHS statistics [24]. Measures of community variation/random effects such as Median Odds Ratio (MOR), Proportional Change in Variance (PCV) and Interclass Correlation Coefficient (ICC) were calculated due to the correlated nature of DHS data. Accordingly, the values of these measures were found to be significant and hence the use of multilevel logistic regression model is more appropriate than ordinary logistic regression. To choose the best fitted model, first we developed four models and compared them with deviance. The first one is the null-model; a model with no independent variable, the second model is model I; a model that has individual-level factors only, model II; a model with community-level factors only and model III; a model that contain both individual and community level independent variables. Of the four models fitted, model III was selected as the best fitted model (it had the lowest deviance). Then after, both bivariable and multivariable multilevel logistic regression was conducted to determine the associated factors of safe child feces disposal in SSA. All variables with a p value < 0.2 at bi-variable analysis were entered into the multivariable logistic regression model. In the final model p value ≤ 0.05 was used to declare statistically significant variables.

Based on the description provided, the study identified several factors associated with safe child feces disposal in Sub-Saharan Africa. These factors include:

1. Residence: Mothers/caregivers from urban areas had higher odds of practicing safe child feces disposal compared to those from rural areas.

2. Education: Mothers with primary education had higher odds of safe child feces disposal compared to those with higher education.

3. Wealth index: Mothers/caregivers from richer and richest wealth quintiles had higher odds of practicing safe child feces disposal compared to those from poorer wealth quintiles.

4. Family size: Families with fewer than 5 members had higher odds of safe child feces disposal compared to larger families.

5. Access to improved water source: Mothers/caregivers with access to improved water sources had higher odds of safe child feces disposal.

6. Toilet ownership: Mothers who owned a toilet had higher odds of safe child feces disposal.

7. Media exposure: Mothers/caregivers with media exposure (e.g., radio, newspaper, television) had higher odds of safe child feces disposal.

8. Employment status: Mothers/caregivers who were not currently working had reduced chances of safe child feces disposal.

9. Region: Mothers/caregivers from the Western region of Africa had reduced chances of safe child feces disposal compared to other regions.

Based on these findings, it is recommended to implement health promotion and behavioral change intervention measures, especially targeting women/caregivers from rural areas, those with poor economic status, and those who cannot access improved water sources or media exposure. These interventions can help improve the practice of safe child feces disposal and ultimately improve maternal and child health outcomes.
AI Innovations Description
Based on the description provided, the study identified several factors associated with safe child feces disposal in Sub-Saharan Africa. These factors include:

1. Residence: Mothers/caregivers from urban areas had higher odds of practicing safe child feces disposal compared to those from rural areas.

2. Education: Mothers with primary education had higher odds of safe child feces disposal compared to those with higher education.

3. Wealth index: Mothers/caregivers from richer and richest wealth quintiles had higher odds of practicing safe child feces disposal.

4. Family size: Families with fewer than 5 members had higher odds of safe child feces disposal.

5. Access to improved water source: Mothers/caregivers with access to improved water sources had higher odds of safe child feces disposal.

6. Toilet ownership: Mothers who owned a toilet had higher odds of safe child feces disposal.

7. Media exposure: Mothers/caregivers with media exposure (radio, newspaper, television) had higher odds of safe child feces disposal.

However, there were also factors associated with reduced chances of safe child feces disposal:

1. Employment status: Mothers/caregivers who were not currently working had reduced odds of safe child feces disposal.

2. Higher education: Mothers with higher education had reduced odds of safe child feces disposal.

3. Western region of Africa: Mothers/caregivers from the Western region of Africa had reduced odds of safe child feces disposal.

Based on these findings, the study recommends implementing health promotion and behavioral change intervention measures to improve the practice of safe child feces disposal. Specifically, targeting women/caregivers from rural areas, those with poor economic status, limited access to improved water sources, and no media exposure can help improve safe child feces disposal practices.
AI Innovations Methodology
Based on the provided description, the study aims to determine the associated factors of safe child feces disposal among children under two years of age in Sub-Saharan Africa. The methodology used in the study involves analyzing the most recent demographic and health survey datasets of 34 sub-Saharan countries. Here is a brief description of the methodology used:

1. Data Source: The study utilizes the most recent demographic and health survey datasets from 34 sub-Saharan countries. These surveys are nationally representative and collect data on various health indicators, including maternal and child health.

2. Sampling Technique: The surveys used a two-stage stratified sampling technique to select study participants. The sampling was designed to ensure representation at both the national and regional levels.

3. Data Collection: Trained data collectors used pretested and standardized questionnaires to collect data from mothers/caregivers of children under two years of age. The questionnaires were adapted to the specific context of each country.

4. Data Analysis: The datasets from each country were obtained from the DHS program website and appended together to create a single dataset representing the sub-Saharan African countries included in the study. Incomplete cases were removed to handle missing data.

5. Sample Size: The study included a total weighted sample of 78,151 mothers/caregivers of under two children.

6. Dependent Variable: The dependent variable for the study is safe child feces disposal, which is a binary outcome (yes or no). Safe child feces disposal is defined as using a latrine and putting/rinsing child feces into the latrine.

7. Independent Variables: The study considered both individual and community-level variables as independent variables. Individual-level variables included age of child, age of mothers, education level of mothers, education level of partners, wealth index, occupational status of mothers, family size, number of under-five children, water source, toilet ownership, and media exposure. Community-level variables included SSA region and residence.

8. Statistical Analysis: The study used both bivariable and multivariable multilevel logistic regression analysis. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for each independent variable included in the model. The analysis accounted for the correlated nature of the DHS data by using measures of community variation/random effects such as Median Odds Ratio (MOR), Proportional Change in Variance (PCV), and Interclass Correlation Coefficient (ICC).

9. Model Selection: Four models were developed and compared based on deviance. The null model (no independent variables), model I (individual-level factors only), model II (community-level factors only), and model III (both individual and community-level factors). Model III, which had the lowest deviance, was selected as the best-fitted model.

10. Variable Selection: Variables with a p-value < 0.2 in the bivariable analysis were entered into the multivariable logistic regression model. In the final model, variables with a p-value ≤ 0.05 were considered statistically significant.

In conclusion, the study used secondary data analysis from demographic and health surveys to identify the associated factors of safe child feces disposal in sub-Saharan Africa. The methodology involved data collection, data analysis using multilevel logistic regression, and model selection based on deviance.

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