WATER AND SANITATION PROGRAM: RESEARCH BRIEF 98062 Scaling Up Rural Sanitation and Hygiene Management of Child Feces: Current Disposal Practices June 2015 KEY FINDINGS INTRODUCTION Safe disposal of children’s feces is as essential as that of • In most countries analyzed, over 50 percent of adults’ feces. The Joint Monitoring Program for Water Supply households with children under age three reported and Sanitation (JMP) tracks progress toward the Millennium that the feces of their children were unsafely Development Goal 7 target to halve, by 2015, the proportion disposed.3 of people without sustainable access to safe drinking water • Even among households with improved toilets or and basic sanitation. The JMP standardized definition for an latrines, some unsafe child feces disposal behavior improved sanitation facility is one that hygienically separates was reported. human excreta from human contact.1 The latest JMP report • In almost every country, feces of children under age stated that 64 percent of the global population had access three are less likely to be safely disposed of than to improved sanitation in 2012.2 This means that 2.5 billion those of the general population. individuals lacked improved sanitation; of these, 1 billion • Higher rates of unsafe child feces disposal were practiced open defecation. However, these estimates are found in poor, rural households with the youngest based on the household’s primary sanitation facility, and may children and where other household members defecate in the open. overlook the disposal practices of young children feces. In • Although there is a common belief that children’s many cases, children may not be able to use an improved feces are not harmful, exposure to children’s feces toilet or latrine—because of their age and stage of physical could be more risky than exposure to adults’ feces. development or the safety concerns of their caregivers— even if their household has access to one. PROBLEM STATEMENT Although the impact of poor sanitation and hygiene is WHaT IS “SaFE DISpoSal” oF a CHIlD’S FECES? often measured by the effects on children, most sanitation The safest way to dispose of a child’s feces is to and hygiene interventions target adults. In order to reach help the child use a toilet or latrine or, for very young children, to put or rinse their feces into a toilet or latrine. For the purposes of this brief, these disposal 1 The JMP has established a set of standardized definitions to categorize improved sanitation, which are used to track progress toward Millennium methods are referred to as “safe,” whether the feces Development Goal 7. However, these definitions are not always the same as is deposited into an unimproved or an improved those used by national governments. See Progress on Drinking Water and toilet or latrine. Other methods are considered Sanitation: Update 2014. 2 WHO/UNICEF Joint Monitoring Program. 2014. Progress on Drinking Water “unsafe.” When a child’s feces are put or rinsed and Sanitation: Update 2014. Geneva: World Health Organization. into an “improved” toilet or latrine, this is termed 3 Data analysis was conducted for Afghanistan, Bangladesh, Burkina “improved child feces disposal.”4 Faso, Cambodia, Chad, Ethiopia, Egypt, India, Indonesia, Haiti, Kenya, Lao, Madagascar, Malawi, Mozambique, Nepal, Niger, Nigeria, Pakistan– Balochistan Province, Pakistan–Punjab Province, Philippines, Senegal, Sierra Leone, Tanzania, Uganda, and Zambia. 4 Bain, R., and R. Luyendijk. 2015 (in press). “Are Burial or Disposal with Garbage Safe Forms of Child Faeces Disposal? An Expert Consultation.” Waterlines. 2 Management of Child Feces: Current Disposal Practices Scaling Up Rural Sanitation and Hygiene with child feces disposal data for each country were analyzed (see regional maps in Figure 1). Responses to the survey question, “The last time your child defecated, where were the stools disposed of?” were examined to determine what the current practices were. In both data sets the questions were part of a survey targeted at women and 100 percent of the answers were supplied by females. In order to increase the comparability of the two datasets, analyses were usually restricted to children under three, except analyses where age was the background characteristic of interest. In addition, a literature review was conducted and experts in study countries contacted in order to document what methods current programs have tried to promote safe sanitation for children in each country. The documentation of programs and individual country profiles can be found at: www.wsp.org/childfecesdisposal. This research brief provides a summary of the analysis included in the individual country profiles as it relates to child feces disposal practices. KEY LESSONS Several patterns emerged with respect to children’s feces Emily Christensen Rand/World Bank disposal among the 26 locations researched related to the the proposed sustainable development goals of universal wealth, age, location, and toilet type of the household. coverage or end open defecation by 2030, we must ensure More than 50 percent of households with children under children’s feces are safely disposed of. While there is some age three in 15 of the 26 locations reported that the feces data on how children’s feces are being disposed of, in of their youngest child under age three were not deposited general, sanitation for children has been a neglected area into any kind of improved or unimproved toilet or latrine—i.e., of research, policy, and program intervention, and there is they were unsafely disposed of. However, an even greater very little evidence of effective strategies for increasing the proportion reported that the child’s feces were not disposed safe disposal of children’s feces. Significant knowledge gaps must be filled before comprehensive, practical, evidence- based policy and program guidance can be made available. ACTION To improve the evidence base, the World Bank Group’s Water and Sanitation Program (WSP) and the United Nations Children’s Fund (UNICEF) partnered to develop profiles outlining the current child feces disposal practices of caregivers and existing interventions to improve those practices for 26 locations. To develop the country profiles, Multiple Indicator Cluster Survey (MICS) Child Module or Demographic and Health Survey (DHS) Individual Module UNICEF/UKLA 2012–01117/Kurzen www.wsp.org Scaling Up Rural Sanitation and Hygiene Management of Child Feces: Current Disposal Practices 3 Figure 1: In 10 locations, less than 20 percent of children’s feces are safely disposed of. Percentage of households with available comparable Multiple Indicator Cluster Survey (MICS) or Demographic and Health Survey (DHS) data reporting safe feces disposal for their youngest child under age three for Africa, South Asia, and Southeast Asia.5 5 The latest available MICS/DHS survey with data for each country, as of March 2014. Survey years range from 2006–2012. Please see the”Related Reading” section. www.wsp.org 4 Management of Child Feces: Current Disposal Practices Scaling Up Rural Sanitation and Hygiene Figure 2: The rate of improved sanitation is lower among children than the broader population. Percentage of households with available comparable Multiple Indicator Cluster Survey (MICS) or Demographic and Health Survey (DHS) data reporting safe feces disposal for their youngest child under age three for select countries and JMP estimate of the percentage of the population with improved sanitation.6 100 90 80 70 60 50 40 30 20 10 0 Afghanistan Bangladesh Burkina Faso Cambodia Chad Egypt Ethiopia Haiti India Indonesia Kenya Lao Madagascar Malawi Mozambique Nepal Niger Nigeria Pakistan Balochistan* Pakistan Punjab* Philippines Senegal Sierra Leone Tanzania Uganda Zambia Improved household sanitation Safe child feces disposal into an improved toilet Unimproved household sanitation (excluding open defecation) Safe child feces disposal into an unimproved toilet Household open defecation Unsafe child feces disposal * Pakistan Household data based on Country wide data of into an improved sanitation facility. In all but three locations, Although the severity differed, in every location, households the feces of children are more likely to be unsafely disposed with younger children were more likely to report unsafe of than the country’s general population (see Figure 2). disposal methods. Figure 4 shows that in Haiti, among households with children under the age of 12 months, Not surprisingly, the highest levels of unsafe child feces 59 percent reported safe disposal, compared to 72 percent disposal can be found among households practicing open of those with children aged four. This shift in safe disposal defecation. However, all countries reported some unsafe child practices as children grow is seen in many countries: children feces disposal behavior, even among those households with are increasingly likely to use a toilet or latrine themselves. At improved sanitation. In the countries examined, between 11 these young ages, the behavior of the children’s caregiver and 64 percent of households with improved sanitation still is critical to disposing of their feces safely and shaping the unsafely disposed of their children’s feces (also see regional child’s toilet training. maps in Figure 1. For example, in India, over 54 percent of households with improved sanitation still unsafely disposed of their children’s feces with 23 percent of those with improved sanitation simply leaving children’s feces in the open and not 6 Child Feces disposal data was taken from the latest available MICS/DHS disposing of them in any way (see Figure 3). survey with data from each country, as of March 2014. Survey years range from 2006–2012. Household sanitation data was taken from the JMP 2012 data. Please see the “Related Reading” section. www.wsp.org Scaling Up Rural Sanitation and Hygiene Management of Child Feces: Current Disposal Practices 5 Figure 3: Even among households using improved Figure 4: Households with younger children were sanitation in India, more than half (56 percent) more likely to report unsafe disposal methods. reported unsafe child feces disposal behaviors. Reported feces disposal practice for children of different Reported feces disposal practice for households’ youngest ages (Haiti, 2012). child under age three, by household sanitation facility type (India, 2005–2006). 100 2% 2% 2% 2% 100 3% 1% 1% 12% 15% 17% 16% 17% 24% 23% 2% 3% 80 35% 80 12% 6% 5% 5% 1% 5% 1% 2% 2% 51% 1% 9% 10% 9% 14% 1% 12% % of children % of children 60 60 1% 13% 21% 34% 1% 55% 8% 30% 40 40 1% 63% 31% 59% 25% 58% 20 36% 16% 20 38% 10% 19% 13% 20% 1% 1% 7% 1% 2% 7% 0 0 Open Unimproved Shared Improved 0 1 2 3 4 defecation (5% of HHs) (10% of HHs) (23% of HHs) Child age (years) (62% of HHs) Type of sanitation facility used by household (HH) Other Put/rinsed into drain or ditch Left in the open Put/rinsed into toilet/latrine Other Put/rinsed into drain or ditch Buried Child used toilet/latrine Left in the open Put/rinsed into toilet/latrine Thrown into garbage Buried Child used toilet/latrine Thrown into garbage WSP Laos/World Bank www.wsp.org 6 Management of Child Feces: Current Disposal Practices Scaling Up Rural Sanitation and Hygiene Figure 5: Safe disposal differs across the wealth Figure 6: Safe disposal remains less prevalent among quintiles, with safe disposal somewhat more likely rural households than among urban households. among the wealthiest 40 percent of households than Percent of households reporting safe feces disposal for among the least wealthy 60 percent.7 Reported feces their youngest child under age three, by urban and rural disposal practice for households’ youngest child under age residence (Lao PDR, 2011–2012).8 three, by household wealth quintile (Niger, 2012). 1% 100 % children with safe feces disposal 100 2% 2% 2% 1% 6% 1% 2% 1% 8% 1% 9% 1% 8% 1% 1% 2% 2% 2% 1% 80 21% 80 60 % of children 60 41% 43% 70% 40 85% 84% 84% 73% 40 20 12% 5% 20 0 Urban Rural Urban Rural 20% 2% 2% 3% 1% 1% 2006 2011–2012 0 Poorest Poorer Middle Richer Richest Wealth quintile of child’s household Other Thrown into garbage Left in the open/not disposed of Put/rinsed into toilet/latrine sanitation for children. The primary questions that researchers Put/rinsed into drain or ditch Child used toilet/latrine Buried could examine next are what improved behaviors exist and what factors influence those behaviors. In order to determine Safe disposal differs across the wealth quintiles, with safe the answer to that question researchers could start to explore disposal somewhat more likely among the wealthiest other questions such as: 40 percent of households than among the least wealthy • How do safe collection, transport, disposal, and cleaning 60 percent. For example, in the poorest quintile in Niger, only differ as children age and their diet and mobility change? 2 percent of households reported safe feces disposal for their youngest children under age three, compared to three- • What is known about the intra household dynamics and quarters (74 percent) of the richest households (see Figure 5). the roles of men and women in assuring safe disposal of child feces? Safe disposal remains less prevalent among rural households • What safe options exist for households with limited water than urban households in every location analyzed except or other resources? the Philippines and Egypt. Lao PDR is similar to many other • What programs and practices can improve management countries, which shows the difference between rural and of child feces? urban safe feces disposal as well as improvement over time • How do practices differ at different times of the day or in (see Figure 6). This same improvement over time is seen in different seasons? the general household sanitation coverage as well. • How are children learning sanitation habits? WHAT ELSE DO WE NEED TO KNOW • How is hand hygiene after linked to the disposal of child Given the widespread practice of unsafe disposal of child feces? feces, further research is needed so that governments, organizations and caregivers can start to ensure safe 8 Lao PDR Ministry of Health and Lao Statistics Bureau, Ministry of Education and Sports. 2012. Lao Social Indicator Survey (LSIS) 2011–12, Multiple Indicator Cluster Survey / Demographic And Health Survey. Vientiane, Lao PDR: Ministry of Health; Lao PDR Department of Statistics and UNICEF. 2008. 7 The asset indices used to classify households into wealth quintiles have not Lao PDR Multiple Indicator Cluster Survey 2006: Final Report. Vientiane, Lao been adjusted to remove drinking water or sanitation variables. PDR: Department of Statistics and UNICEF. Scaling Up Rural Sanitation and Hygiene Management of Child Feces: Current Disposal Practices 7 Why Ensuring Safe Disposal of Child Feces Matters There is a common belief that the feces of infants and young children are not harmful,9 but this is not necessarily true. In fact, there is evidence that children’s feces could be more risky than adults’ feces, due to a higher prevalence of diarrhea and pathogens—such as hepatitis A, rotavirus, and E. coli—in children than in adults.10 Therefore, children’s feces should be treated with the same concern as adult feces, using safe disposal methods that ensure separation from human contact and household contamination. In particular, the unsafe disposal of children’s feces may be an important contaminant in household environments, posing a high risk of exposure to young infants.11 A 2005 study among children under age five in Mauche and Nessuit, Kenya, found that 37 percent of children ingest earth occasionally (less than a handful per day), and 12 percent ingest a lot (a handful or more per day).12 In locations where children’s feces are not being safely disposed of, feces and the accompanying pathogens may also be ingested. Poor child feces management can result in substantial health impacts in children, including a higher prevalence of diarrheal disease, intestinal worms, enteropathy, malnutrition, and death. A 1989 study in Cebu, Philippines, found unsanitary disposal of young children’s feces to be associated with a 34 percent increase in clinically diagnosed diarrheas and a 63 percent increase in pathogen positive diarrheas, compared to those who were following sanitary practices.13 A study in Burkina Faso found “evidence of an association between where the mother reported disposing of the child’s stools and hospital admission with diarrhoea or dysentery.”14 Similarly, a 1994 study in South Sumatra, Indonesia, found that disposing of children’s feces in open places rather than in a latrine was significantly associated with diarrheal disease incidence among children under age three.15 In addition, in Ethiopia a bivariate and multivariate data analysis found that along with a few other characteristics, improper child stool disposal methods increased the risk of childhood diarrhoea when adjusting for other variables.16 As a result of these and other studies, the Child Health Epidemiology Reference Group (CHERG) has concluded the data was “strongly suggestive” that safe stool disposal has a protective effect.17 According to the World Health Organization (WHO), most diarrheal deaths in the world (88 percent) are caused by unsafe water, sanitation, or hygiene.18 More than 99 percent of these deaths are in developing countries, and about eight in every 10 deaths are children.19 Diarrhea obliges households to spend significant sums on medicine, transportation, health facility fees, and more, and can mean lost work, wages, and productivity among working household members.20 Stunting and worm infestation can reduce children’s intellectual capacity, which affects productivity later in life. The WHO estimates that the average IQ loss per worm infection is around 3.75 points.”21 9 Gil, A., C. Lanata, E. Kleinau, and M. Penny. 2004. Children’s Feces Disposal Practices in Developing Countries and Interventions to Prevent Diarrheal Diseases: A Literature Review. Strategic Report 11. Peru: Environmental Health Project (EHP). Washington, DC: United States Agency for International Development (USAID); A. M. Almedom. 1996. “Recent Developments in Hygiene Behaviour Research: An Emphasis on Methods and Meaning.” Tropical Medicine & International Health 1(2):171–182; C. Bessenecker. 1994. A Study of Child-Related Excreta Disposal Practices and Beliefs in a Peri-Urban Community of Ciudad Juarez, Mexico. MPH Project. Houston: School of Public Health. The University of Texas Health Science Center at Houston; O. Rauyajin, V. Pasandhanatorn, V. Rauyajin, S. Na-nakorn, J. Ngarmyithayapong, and C. Varothai. 1994. “Mothers’ Hygiene Behaviours and Their Determinants in Suphanburi, Thailand.” Journal of Diarrhoeal Diseases Research 12(1):25–34; S. Zeitlyn and F. Islam. 1991. “The Use of Soap and Water in Two Bangladeshi Communities: Implications for the Transmission of Diarrhoea.” Reviews of Infectious Diseases 13(suppl 4):S259–264. 10 Feachem, R., D. Bradley, H. Garelick, et al. 1983. Sanitation and Disease: Health Aspects of Excreta and Wastewater Management. World Bank Studies in Water Supply and Sanitation 3. Chichester, UK: John Wiley & Sons. 11 Gil, A., C. Lanata, E. Kleinau, and M. Penny. 2004. Children’s Feces Disposal Practices in Developing Countries and Interventions to Prevent Diarrheal Diseases: A Literature Review. Strategic Report 11. Peru: Environmental Health Project (EHP). Washington, DC: U.S. Agency for International Development (USAID). 12 Shivoga, W. A., and W. N. Moturi. 2009. “Geophagia as a Risk Factor for Diarrhea.” Journal of Infection in Developing Countries 3(2):94–98. 13 Baltazar J. C., and F. S. Solon. 1989. “Disposal of Faeces of Children under Two Years Old and Diarrhoea Incidence: A Case-Control Study.” International Journal of Epidemiology 18(4 Suppl 2):S16–S19. 14 Curtis, Valerie, et al. 2011. “Hygiene: New Hopes, New Horizons.” The Lancet Infectious Diseases 11(4):312–321; Curtis, Valerie, et al. 1995. “Potties, Pits and Pipes: Explaining Hygiene Behaviour in Burkina Faso.” Social Science & Medicine 41(3):383–393. 15 Aulia, H., S. C. Surapaty, E. Bahar, et al. 1994. “Personal and Domestic Hygiene and Its Relationship to the Incidence of Diarrhea in South Sumatera.” Journal of Diarrheal Diseases Research 12(1):42–48. 16 Mihrete, T., G. Alemie, and A. Teferra. 2014. “Determinants of Childhood Diarrhea among Underfive Children in Benishangul Gumuz Regional State, North West Ethiopia.” BMC Pediatrics 14:102. http://www.biomedcentral.com/1471-2431/14/102 17 Scott, B. Children’s Stool Disposal—A Review of Prevalence of Practice and its Relationship with Health, and Recommendations for Filling the Evidence Gaps. Unpublished. London: London School of Hygiene and Tropical Medicine. 18 Prüss–Üstun, A., A. Bartram, T. Clasen, et al. 2014. “Burden of Disease from Inadequate Water, Sanitation and Hygiene in Low- and Middle-Income Settings: A Retrospective Analysis of Data from 145 Countries.” Tropical Medicine & International Health 19(8):894–905. 19 WHO. 2009. WHO Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva: World Health Organization, 23. 20 Favin, M., G. Miaoli, and L. Sherburne. 2004. Improving Health through Behavior Change: A Process Guide on Hygiene Promotion. Environmental Health Project. Washington, DC: USAID. 21 WHO. 2005. Deworming for Health and Development. Report of the Third Global Meeting of the Partners for Parasite Control. Geneva: World Health Organization, 15. 8 Management of Child Feces: Current Disposal Practices Scaling Up Rural Sanitation and Hygiene About the program Today, 2.5 billion people live without access to improved sanitation. Of these, 71 percent live in rural communities. To address this challenge, WSP is working with governments and local private sectors to build capacity and strengthen performance monitoring, policy, financing, and other components needed to develop and institutionalize large scale, sustainable rural sanitation programs. With a focus on building a rigorous evidence base to support replication, WSP combines Community-Led Total UNICEF/NYHQ2007–0487/Nesbitt Sanitation, behavior change communication, and sanitation ACKNOWLEDGEMENTS RELATED READING marketing to generate sanitation This research brief was written by Emily The individual child feces disposal demand and strengthen the supply of sanitation products and Christensen Rand, Libbet Loughnan, country profiles created in this services, leading to improved Louise Maule, and Heather Reese. The series are available to download at health for people in rural authors would like to thank Susanna www.wsp.org/childfecesdisposal. areas. For more information, Smets, Jane Bevan, Yolande Coombes, please visit www.wsp.org/ Jacqueline Devine, Craig Kullmann, and scalingupsanitation. Eduardo Perez for review comments. Contact us If you have thoughts to share, ABOUT WSP or know of a program that is The Water and Sanitation Program is a multi-donor partnership, part of the World Bank Group’s encouraging the safe disposal of Water Global Practice, supporting poor people in obtaining affordable, safe, and sustainable access children’s feces, please contact WSP to water and sanitation services. at worldbankwater@worldbank.org or UNICEF at WASH@unicef.org so that ABOUT UNICEF we can integrate your information into The United Nations Children’s Fund (UNICEF) was established by the United Nations on 11 December future program guidance. 1946 to meet the emergency needs of children in post-war Europe and China. In 1950, its mandate was broadened to address the long-term needs of children and women in developing countries everywhere. This brief was developed jointly by WSP and UNICEF as part of a series of country profiles about sanitation for children under age three. The findings, interpretations, and conclusions expressed herein are those of the author(s), and do not necessarily reflect the views of the International Bank for Reconstruction and Development / The World Bank and its affiliated organizations, or those of the Executive Directors of The World Bank or the governments they represent, or of UNICEF. © 2015 International Bank for Reconstruction and Development / The World Bank and UNICEF.