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Background Over the years, sanitation programs over the world have focused more on household sanitation, with limited attention towards the disposal of children’s stools. This lack of attention could be due to the misconception that children’s stools are harmless. The current study examined the individual and contextual predictors of safe disposal of children’s faeces among women in sub-Saharan Africa (SSA). Methods The study used secondary data involving 128,096 mother-child pairs of under-five children from the current Demographic and Health Surveys (DHS) in 15 sub-Saharan African countries from 2015 to 2018. Multilevel logistic analysis was used to assess the individual and contextual factors associated with the practice of safe disposal of children’s faeces. We presented the results as adjusted odds ratios (aOR) at a statistical significance of p< 0.05. Results The results show that 58.73% (57.79-59.68) of childbearing women in the 15 countries in SSA included in our study safely disposed off their children's stools. This varied from as high as 85.90% (84.57-87.14) in Rwanda to as low as 26.38% (24.01-28.91) in Chad. At the individual level, the practice of safe disposal of children's stools was more likely to occur among children aged 1, compared to those aged 0 [aOR = 1.74; 95% CI: 1.68-1.80] and those with diarrhoea compared to those without diarrhoea [aOR = 1.17, 95% CI: 1.13-1.21]. Mothers with primary level of education [aOR = 1.42, 95% CI: 1.30-1.5], those aged 35-39 [aOR = 1.20, 95% CI: 1.12-1.28], and those exposed to radio [aOR = 1.23, 95% CI: 1.20-1.27] were more likely to practice safe disposal of children's stools. Conversely, the odds of safe disposal of children's stool were lower among mothers who were married [aOR = 0.74, 95% CI: 0.69-0.80] and those who belonged to the Traditional African Religion [aOR = 0.64, 95% CI: 0.51-0.80]. With the contextual factors, women with improved water [aOR = 1.13, 95% CI: 1.10-1.16] and improved toilet facility [aOR = 5.75 95% CI: 5.55-5.95] had higher odds of safe disposal of children's stool. On the other hand, mothers who lived in households with 5 or more children [aOR = 0.89, 95% CI: 0.86-0.93], those in rural areas [aOR = 0.86, 95% CI: 0.82-0.89], and those who lived in Central Africa [aOR = 0.19, 95% CI: 0.18-0.21] were less likely to practice safe disposal of children's stools. Conclusion The findings indicate that between- and within-country contextual variations and commonalities need to be acknowledged in designing interventions to enhance safe disposal of children's faeces. Audio-visual education on safe faecal disposal among rural women and large households can help enhance safe disposal. In light of the strong association between safe stool disposal and improved latrine use in SSA, governments need to develop feasible and cost-effective strategies to increase the number of households with access to improved toilet facilities.
Data for this study were obtained from current Demographic and Health Surveys (DHS) conducted between 2015 and 2019 in 15 sub-Saharan African countries (Table 1). The 15 countries were those that had recent DHS datasets and all the variables of interest in the study in their datasets. DHS is a nationwide survey undertaken across low- and middle-income countries every five-year period [24]. The survey is representative of each of these countries and targets core maternal and child health indicators such as unintended pregnancy, contraceptive use, skilled birth attendance, immunisation among under-fives, intimate partner violence, and issues regarding men’s health such as tobacco and contraceptive use. Children’s files (Kids Recode–KR files) were used for our study. aSample size at design bWomen with complete information on children’s stool disposal cWomen with complete information on all variables of interest In selecting the sample for each survey, stratified dual-stage sampling approach was employed. The first step of this sampling approach involved the selection of clusters (i.e., enumeration areas [EAs]), followed by systematic household sampling within the selected EAs. The sample size in the current study consisted of 128,096 mother-child pairs of under-five children with complete information on all the variables of interest. The respondents were mothers. Table 1 provides a description of the study sample. A detailed methodology of the DHS procedures has been discussed extensively elsewhere [24]. The dataset is freely available at www.measuredhs.com. We followed the “Strengthening the Reporting of Observational Studies in Epidemiology” (STROBE) statement in conducting this study and writing the manuscript (S1 Table). The outcome variable was safe disposal of children’s stool, captured as “safe” or “unsafe”. The variable was derived from the question “The last time [Name] passed stools, what was done to dispose of the stools?” The responses included “child used the toilet or latrine”, “put/rinsed into toilet or latrine,” “put/rinsed into drain/ditch,” “thrown into the garbage”, “buried”, “left in the open”, and “other”. Following the WHO’s [11] definition of safe and unsafe stool disposal, and previous studies [12, 15–17, 19, 25–28], these responses were recoded as follows: “Child used toilet or latrine”, buried and “put/rinsed into toilet or latrine” were combined and coded as “safe disposal of child stool” (coded as ‘1’) whereas the others were coded as “unsafe disposal of child stool” (coded as ‘0’). Hence, in this study, safe disposal of stool includes “child used toilet or latrine”, buried and “put/rinsed into toilet or latrine” while “thrown into the garbage,” “left in the open,” and “other” were considered as unsafe disposal of child stool. Selected variables were included based on their association with safe disposal of children’s stool in previous studies [12, 15–17, 19, 20, 25–28] and availability of variables in the data. Seventeen explanatory variables were included in the study and were grouped into two: The datasets were pooled by recoding the variables in the respective countries and using the ‘append’ command to pool them together as a single file. Data were analysed at the univariate, bivariate, and multivariate levels. Prevalence of safe disposal of children’s faeces and socio-demographic characteristics were described using frequencies and percentages. At the bivariate level, a chi-square test was carried out between the independent and dependent variable at p<0.05. We selected all the variables that showed statistical significance for the multilevel binary logistic regression model which was used due to the hierarchical nature of the data [30, 31]. A two-level multilevel binary logistic regression analysis was done to assess the individual and contextual factors associated with disposal of children stools. Per the two-level modelling, women were nested within clusters to account for the variance in primary sampling units (PSUs). Clusters were regarded as random effect to take care of the unexplained variability at the contextual level. We fitted four models. First, we fitted the empty model, Model 0, that had no predictors (random intercept). This procedure was followed by Model 1, which contained only the individual level variables (child and maternal factors), Model 2 with only contextual level variables, and Model 3, with both individual and contextual level variables. For all models, we presented the adjusted odds ratios (aOR) and associated 95% confidence intervals. For model comparison, we used the Akaike information criterion (AIC) test [32, 33]. Model adequacy was checked using the LR test. Using the variance inflation factor (VIF), the multicollinearity test showed that there was no evidence of collinearity among the independent variables (Mean VIF 1.24, Maximum VIF = 1.62, Minimum VIF = 1.03). The choice of reference categories was informed by previous studies [12, 15–17, 19, 20, 25–28] and practical significance. Sample weight was applied in all the analysis to correct for over- and under-sampling while the “svy” command was used to account for the complex survey design and generalizability of the findings. According to Hatt and Waters [34], pooling data can reveal broader results that are ‘‘often obscured by the noise of individual data sets.” To calculate the pooled values, an additional adjustment is needed to account for the variability in the number of individuals sampled in each country. This method was accomplished using the weighting factor 1/(A*nc /nt), where A refers to the number of countries where a particular question was asked, nc denotes the number of respondents for the country c, and nt indicates the total number of respondents over all countries where that question was asked. All the analyses were carried out using Stata Version 14.2 for MacOS. Statistical significance was set at p < 0.05. Ethical clearance for DHS surveys is usually obtained from the Ethics Committee called Inner City Fund Institutional Review Board (IRB) as well as Ethics Boards of partner organisations of the various countries such as the Ministries of Health. During the surveys, either written or verbal consent was provided by the targeted women. Since the data were not collected by the authors of this manuscript, permission was sought from MEASURE DHS website and access to the data was provided after our intent for the request was assessed and approved on 3rd April, 2019. The data is available on https://dhsprogram.com/data/available-datasets.cfm.
