Abstract
Background
Using sanitary facilities is proven to enhance health and halt the spread of fecal-to-oral disease. Despite efforts to improve the availability of latrine facilities in developing countries like Ethiopia, finding a village that is entirely free of open defecation remains difficult. To determine the need for intervention programs and promote regular latrine usage, local data is essential.
Objectives
This study aimed to assess latrine utilization and associated factors among households in East Meskan District, Southern Ethiopia.
Methods
A community-based cross-sectional study was conducted among 630 households from April 15 to May 30, 2022. A simple random sampling technique was used to select the study households. Data were collected using an interviewer-administered structured questionnaire and an observational checklist. The collected data were then entered into Epi-Info version 7.1 and analyzed using SPSS version 21. In binary logistic regression analysis, independent variables with a P-value < .25 were considered candidates for multiple logistic regression analysis. The association was expressed in odds ratio with a 95% confidence interval (CI), and significance was declared at P-value < .05 in the final model.
Results
The magnitude of latrine utilization was 73.3% (95% CI: 69.7, 76.8) in the study district. Husband being family head (adjusted odds ratio [AOR] = 12.9; 95% CI: 5.78 ,28.90), being female (AOR = 16.4; 95% CI: 6.52, 41.27), family size less than 5 (AOR = 24.2; 95% CI: 11.49, 51.09), absence of school children (AOR = 0.3; 95% CI: 0.13, 0.51), and greater than 2 years since latrine was constructed (AOR = 14; 95% CI: 7.18, 27.41) had a significant association with latrine utilization.
Conclusion
In this study, utilization of latrines was low compared to the national target plan. Family head, sex, family size, presence of school children, and length of years in which the latrine was constructed were factors associated with latrine utilization. Thus, regular supervision of early latrine construction and utilization in communities is essential.
Background
Latrines are excreta disposal facilities that can safely separate human excreta from human and insect contact. The use of sanitation facilities is known to halt the spread of fecal-to-oral disease. In addition to their physical presence, effective sanitation facility utilization enhances health (Tamene & Afework, 2021).
More than 2.5 billion people worldwide lack access to sanitation and hygienic facilities, particularly in South Asia and Sub-Saharan Africa (SSA) have the highest percentages of these people. Diseases attributed to inadequate water, sanitation, and hygiene account for more than 4% of all disease burdens and deaths (Abebe et al., 2020; Garn et al., 2017). In SSA countries like Ethiopia, 76% of the rural population did not have access to proper sanitary facilities, and a high burden of diarrheal infections existed (Nunbogu et al., 2019). The percentage of households with latrine facilities increased nationwide from 55% in 2011 to 61% in 2016, according to the Ethiopian Demographic and Health Surveys (EDHS) report. In rural areas, 59% of families utilize unimproved toilet facilities (Girma et al., 2018; Tamene & Afework, 2021). The progress, however, fell far short of the national target, which was set at 100% (Gebremariam & Tsehaye, 2019).
According to the World Health Organization (WHO), 1.5 million children die each year from diarrhea, which is caused by a combination of poor sanitation and poor personal hygiene (Farah et al., 2015). In developing nations, 88% of all deaths from diarrheal diseases are caused by inadequate access to sanitation, the use of contaminated drinking water, and poor hygiene combined. Improvements in sanitation alone, according to sanitation and health experts, have the potential to reduce parasite infections that harm children’s development and the global prevalence of diarrheal disease, which is a primary cause of death for children, by one-third (Beyene et al., 2015; Islam et al., 2018). Because of inadequate sanitation, 15% of all fatalities result from diarrhea, primarily among a large number of children under the age of five. In addition to diarrheal illnesses, worm infestations are very common and significantly increase malnutrition levels (Godana & Mengistie, 2017; Ssekamatte et al., 2019).
Review of Literature
The combined global economic loss in 2015 attributed to early deaths connected to sanitation, medical costs for diseases related to sanitation, output lost due to illness, and time lost to use sanitation facilities was projected to be 222.9 billion dollars (Godana & Mengistie, 2017; Nyanza et al., 2018; Tamene & Afework, 2021).
Studies conducted in several regions of Ethiopia to evaluate latrine utilization and associated factors indicated that the prevalence of latrine utilization is unsatisfactory and ranges from 60% to 71% in various settings (Asnake & Adane, 2020; Koyra et al., 2017). The use of latrines can be affected by a range of behavioral, cultural, social, geographic, and economic factors differing across communities (Leshargie et al., 2018).
Despite years of effort to increase the availability of latrine facilities, it is still difficult to find a village that is completely free from open defecation. The country's report points out a large discrepancy between the availability and utilization of latrine facilities in rural communities (Beyene et al., 2015). It is necessary to conduct such studies because the government's regular report on both latrine coverage and utilization has indicated a gap between what is real and what is desired. Open defecation and unsafe excreta disposal continue to be widespread in the study area, with major public health and economic consequences. Data on the utilization of latrines is still inadequate. Therefore, this study aimed to assess the utilization of latrine facilities and identify the associated factors that are helpful strategies to fill the identified gaps. Moreover, the findings of this study will help the health sectors at different levels, communities, and local decision-makers for health intervention programs with a view of adding to the existing body of knowledge to improve sanitation facilities in the study area in particular and reduce open defecation through different strategies.
Methods
Design
A community-based cross-sectional study was conducted from April 15 to May 30, 2022. East Meskan district is located 155 kilometers southeast of Addis Ababa, 90 kilometers east of Wolkite town, the administrative center of the Gurage zone, and 20 kilometers east of Butajira town. In 2021, the district administration office reports a total population of approximately 67,891 people, 34,624 females, and 33,267 males. The district has 15 kebeles (a small administrative unit in Ethiopia), (one urban and 14 rural), and the total number of households is 13,855. There are three health centers and 14 health posts in the district. The current study was conducted on seven rural kebeles namely Elle, Bati Legano, Waja Bati, Bati futo, Ensenousme, Bamo, and Yemrwach.
Research Questions
What is the magnitude of latrine utilization and associated factors among the rural community of East Meskan District, Gurage Zone, Southern Ethiopia?
What are the factors that are associated with latrine utilization and associated factors among the rural community of East Meskan District, Gurage Zone, Southern Ethiopia?
Sample
An independent sample size was calculated for the two specific objectives of the current study and the largest sample was taken. The largest sample size was the one calculated using the single population proportion formula with the following assumptions: Based on a similar study done in Chencha District, SNNPR state where 60% of rural communities utilized latrines (Koyra et al., 2017), with margin of error of 4% at the 95% confidence level, and with a 10% non-response rate, thus the total sample size required is 640 households.
Using a simple random sampling technique, seven kebeles were chosen at random from a total of 14 kebeles. Each of the selected kebeles received a consecutive sample size based on a proportional allocation to household number. Following that, study households were chosen from each selected kebele using simple random sampling from lists of households obtained from each kebele office executed via the lottery method. The household heads were then interviewed in the selected households, and observations were made (Figure 1).
Schematic presentation of sampling procedure to assess latrine utilization and associated factors in East Meskan district Gurage zone, Southern, Ethiopia, 2022.
Inclusion/Exclusion Criteria
The study populations were all households that have latrines in the selected kebeles of East Meskan District. Household heads that had lived for more than 6 months were included in the study. Members of each household who were less than 18 years old during the data collection period were excluded as study participants.
Data Collection
The data were collected by using an interviewer-administered structured questionnaire and observational checklist, which were developed after reviewing previous studies and different literature (Asnake & Adane, 2020; Beyene et al., 2015). The questionnaire was initially prepared in English then translated into Amharic and then translated back into English by different experienced persons to check the consistency of meaning. Data were collected by seven diploma nurses and supervised by two BSc Environmental Health professionals. The questionnaires were pre-tested on 5% of the total sample size of the study households in non-selected Beche bulchano kebele to ensure consistency in terms of easy understandability, coherence, and completeness to households. Data collectors and supervisors received one-day training on the data collection process. Supervisors reviewed and checked the collected data every day for completeness and consistency.
Study Variables
In the present study, the dependent variable is latrine utilization, and the independent variables are age, sex, religion, ethnicity, occupational status, educational status, marital status, average, monthly income, family size, presence of under-five children, and presence of schoolchildren.
Operational Definitions
Latrine utilization: Households with functioning latrines of any design must exhibit at least these indicators of use: a functional footpath to the toilet or pavement covered in grass, the presence of fresh feces near the squat hole, the absence of a spider web in the gate, wetness of the slab, visible anal cleansing materials, and the presence of flies (Asnake & Adane, 2020; Omer et al., 2022).
School children: Refers to whether there are any children in the household who are enrolled in formal education at the elementary school level or higher (Woyessa et al., 2022).
Latrine maintenance: Maintaining the existing functional latrine in case of broken sub or superstructures without digging a new hole (Koyra et al., 2017).
Shared latrines: Sanitation facilities shared between two or more households. Shared facilities include public toilets.
Statistical Analysis
The collected data were entered into Epi-Info version 7 and then exported to SPSS version 21 for analysis. Before analysis, data processing activities such as cleaning and coding were performed. Normality for continuous variables was checked using the Shapiro–Wilk test. Descriptive statistics were used to determine the magnitude of latrine utilization. Binary logistic regression was used to model the relationship between the dependent variable and the independent variable. The statistical assumptions for binary logistic regression (adequacy of sample in each cross-tabulated result, expected count in each cell) were assessed, and multi-collinearity was checked using variation inflation factor (VIF) at VIF > 10 indicating the presence of multi-collinearity. Simple logistic regression analysis was used to identify independent variables with a P-value < .25 considered a candidate for the multiple logistic regression analysis. Multiple logistic regression was applied to estimate the effects of independent variables on latrine utilization after adjusting for the effects of possible confounding effects. The regression model was fitted using the standard model-building approach. In the process of fitting the model, variables that didn’t have a significant association with latrine utilization at P-value < .05 were excluded from the model. The odds of latrine utilization were estimated using an adjusted odds ratio (AOR) with 95% confidence intervals (CIs). At this level, the significance of associations was declared at a P-value of .05. The model fitness test was checked by the Hosmer and Lemeshow goodness of fit test at P-value ≥ .05.
Results
Socio-Demographic Characteristics
In this study, a total of 630 households participated, giving a 98.4% response rate. Of these 504 (80%) respondents were female, 546 (86%) respondents were Gurage by ethnicity, and 567 (89.4%) respondents were Muslim. Regarding marital status, 589 (89%) of respondents were married. The study showed that a family size less than 5 was 357 (56.7%) and 420 (66%) of households have under-five children. About 301 (47.6%) of heads of household were farmers and 357 (56.7%) of them were unable to read and write (Table 1).
Socio-Demographic Characteristics of Respondents in a Rural Community of East Meskan District, 2022 (n = 630).
Note. HHs = households; ETB = Ethiopian birr.
Behavioral Factors
Five hundred and forty-six (86.7%) of the respondents who had latrines explained that they were advised by health extension workers to construct latrines. All 100% of respondents explained that the importance of having a latrine is to prevent disease and to keep a clean village. In this study, 323 (70%) respondents washed their hands after using the latrine and 267 (82.8%) of them washed their hands after using the latrine with only water (Table 2).
Behavioral Factors of the Rural Households in East Meskan District 2022 (n = 630).
Characteristics of Latrine Facilities
Among the household latrines, 441 (70%) of them needed maintenance. Latrine superstructures made of wood and plastic accounted for 231 (36.7%), while wood and cloth accounted for 169 (26.8%). A total of 567 latrines (90%) were privately owned, 441 (70%) of latrines had a door and in 147 (23.3%) of latrines, feces were observed on the floor. 525 (83.3%) had been more than two years since the construction of the latrine (Table 3).
Characteristics of Latrine Facilities in Rural Households of East Meskan District, 2022 (n = 630).
Research Question Results
Latrine Utilization
The result of this study showed that the magnitude of latrine utilization among the East Meskan district rural community was 73.3% (95% CI: 69.7, 76) (Figure 2). Of those who did not practice latrine utilization 105 (62.5%) participants claimed that the unreasonable unpleasant odor was their reason (Figure 3).
Latrine utilization in a rural community of East Meskan district, Gurage zone, Southern, Ethiopia, 2022.
Study participant's reasons for not practicing latrine utilization in a rural community of East Meskan district, Gurage zone, Southern, Ethiopia, 2022 (n = 168).
Factors Associated with Latrine Utilization
Family head, sex, occupation, educational status, family size, under-five children, presence of school children, privately owned latrine, the component of latrine, years since latrine was constructed, and status of latrine were the variables that fulfilled the criteria P < .25 and transferred to multivariable analysis. After adjusting for confounder variables in the multivariable analysis, family head, sex of respondent, family size, presence of school children, and years since the latrine was constructed were significantly associated with latrine utilization.
Accordingly, in the multivariable analysis respondents with a family head being a husband were 12.9 (AOR = 12.9, 95% CI: 5.78, 28.90) times more likely to utilize a latrine than a family head being a wife. Regarding the sex of respondents, females were 16.4 (AOR = 16.4, 95% CI: 6.52, 41.27) times more likely to utilize latrines than males. Regarding family size, those households who had a family size of less than five were 24 (AOR = 24.2, 95% CI: 11.49, 51.09) times more likely to utilize a latrine than a family size more than and equal to five. Households who do not have school children were 70% (AOR = 0.3, 95% CI: 0.13, 0.51) less likely to utilize a latrine than Households who have school children. Households with more than two years since the construction of the latrine were 14 (AOR = 14, 95% CI: 7.18, 27.41) times more likely to utilize a latrine than those who constructed their latrine less than or equal to two years (Table 4).
Factors Associated with Latrine Utilization in a Rural Community of East Meskan District, 2022.
Abbreviations: COR = crude odds ratio; CI = confidence interval; AOR = adjusted odds ratio.
Note. *Significant at P-value < .25 in unadjusted logistic regression analysis, **significant at P < .05 in adjusted logistic regression analysis, 1 = Reference.
Discussion
The main objective of this study was to assess the level of latrine utilization and its associated factors in the East Meskan District. Accordingly, the present study revealed that the level of latrine utilization in the community of the study area was 73.3% [(95% CI: 69.6–76.97)]. This study's findings were higher than those of Chencha District (60%) (Koyra et al., 2017), Dembia District (61.2%) (Yimam et al., 2014), and Aneded District (63%) in North West Ethiopia (Chanie et al., 2016). However, it was lower than the finding in Derashe District (88.7%) (Godana & Mengistie, 2017), Mahal Meda (91.2%) (Abebe et al., 2020), and a report from the rural village of Vietnam (79.2%) (Le & Makarchev, 2020).
This variation could be explained by the fact that the study population of these areas could have socioeconomic and cultural differences and may also be due to sample size and study period differences. The relatively higher prevalence of latrine utilization could be attributed to the fact that the majority of residents in this area are Muslim; Muslims in general have extremely high personal hygiene standards, as Islam places a high value on both physical and spiritual cleanliness and purification. While humankind in general usually considers cleanliness to be a pleasing attribute, Islam insists on it.
The study revealed that respondents with the head of the family being the husband were 12.9 times more likely to utilize a latrine compared to the head of the family the wife. The result was supported by a similar study conducted in a rural village in Vietnam (Le & Makarchev, 2020). The reason could be that in many female-headed households, low income combined with a lack of technical expertise or physical ability to dig soil and erect latrines severely limits the sanitation options available to them.
According to this study, females were 16.4 times more likely to utilize a latrine than males. This could be because many of the men and a few of the women work in their farm fields from dawn to dusk. For many, the lack of community-level public latrines near their farms encouraged open defecation. They do not return to their residence to use the latrine when they are on the farm because it is too far away.
Households with a family size of less than five were 24 times more likely to utilize a latrine than households with a family size greater and equal to five. This result was supported by a similar study conducted in semi-urban areas of northeastern Ethiopia (Asnake & Adane, 2020). This could be because the family size is too large, and if there aren't enough squat holes, the chances of finding a latrine that isn't already occupied by another member decrease. Sharing a latrine among a small number of family size results in less frequent latrine usage, which increases the chance of the latrine being cleaner, this in turn increases latrine utilization. Sharing a latrine with a large family, on the other hand, increases the number of times the latrine is used daily and puts a person's sense of responsibility to use the latrine properly in danger, resulting in the latrine being dirty, which may decrease latrine utilization. Furthermore, because latrines in rural areas are built at a shallow depth, they will be out of service sooner (Asnake & Adane, 2020).
Households who do not have school children were 70% less likely to utilize latrines than households who have school children. This study was supported by other studies Achefer District Amhara Region (Kishiru et al., 2019) and Hulet Ejju Enessie Woreda (Anteneh & Kumie, 2010). The justification could be school children may have gotten information from the school about sanitation and implemented it with their parents and developed awareness in the community (Koyra et al., 2017).
Households with more than two years since the construction of the latrine were 14 times more likely to utilize a latrine than their counterpart. This result was supported by other studies done Mahal Meda (Abebe et al., 2020) and Hulet Ejju Enessie Woreda (Anteneh & Kumie, 2010). This could be because behavioral changes in the community require a lot of time. The longer they use the latrine, the more comfortable they become with it and the more they notice the positive effects of using it (Asnake & Adane, 2020).
Strengths and Limitations of the Study
The main strength of this study was its attempt to address a neglected health concern in the study area by obtaining data from primary sources. As a limitation, the study was cross-sectional; therefore, it is difficult to establish a temporal relationship between the dependent and independent variables. In the absence of follow-up, the magnitude of latrine utilization and other independent variables may be greatly underestimated or overestimated in this study. Although on-the-spot observation was used to determine latrine utilization during the study period, it was difficult to determine whether there was the consistent use of the latrine using.
Conclusion
This study concluded that latrine utilization was found to be low. Family head, sex, family size, presence of school children, and the length of years in which the latrine was constructed were the major predictors affecting the utilization of latrines. East Meskan District Health Office should conduct regular supervision of early latrine construction and use in the communities.
Implications for Practice and Research
Open defecation and inadequate sanitation are frequently connected to diarrhea and other communicable diseases. Increased open defecation rates are also linked to serious economic, environmental, and substantial public health effects that have an impact on the general well-being and dignity of mankind. Regular supervision of early latrine construction and utilization in communities should be conducted. Households with latrines should have enough latrines to accommodate the number of people living in the same household and adapt to latrine usage.
To enhance knowledge regarding the causes, modes of transmission, and contribution of human waste to the incidence of infectious illnesses, a variety of diverse actions, strategies, and programs must be implemented. Having said that, nurses design initiatives to promote community health and educate people about the risks associated with not using latrines. Changing habits that can significantly affect someone's health is the ultimate goal. Researchers should further investigate with qualitative research to understand the behavioral aspects of the community and the effective utilization of latrines and associated factors.
Footnotes
Acknowledgments
The authors would like to express their gratitude to the East Meskan District Health Office and the kebele administrative for their invaluable assistance in providing necessary information and facilitating data collection. We are extremely grateful to the participants and data collectors.
Authors’ Contributions
ENZ worked on the conception and design of the study, training and supervising the data collectors, data analysis, and interpretation of the data. NTB redid the statistical analysis and drafted the manuscript. NTB and YMN critically reviewed the draft manuscript and wrote the final version. MSG and AMG advised the study. All authors read and approved the final manuscript.
Data Availability
The data that support the findings of this study are available upon reasonable request.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics Approval and Consent to Participate
Ethical approval and clearance were obtained from the Institutional Review Board (IRB) of Adama Hospital Medical College, and a letter was submitted to the Gurage Zone health department and East Meskan District Health office, and respective Kebele administrators. Respondents were informed about the purpose of the study, the importance, and the duration of the study to get their free time. The information sheet and consent were provided for respondents for those who can read and the interviewer read for those who can’t read. Verbal consent from all study subjects was obtained before data collection. Participants were informed that they have the full right to discontinue or refuse to participate in the study or to be interviewed. To ensure confidentiality, the name of the interviewee was not written on the questionnaire.
