Latrine Utilization and Associated Factors in Rural Community of Chencha District, Southern Ethiopia: A Community Based Cross-Sectional Study

The use of sanitation facilities is known to interrupt the transmission of fecal-to-oral related disease. Health improvement comes from the proper use of sanitation facilities, not simply their physical presence. This is best achieved through regular use of clean and well maintained latrines. A community based cross-sectional study was conducted to assess latrine utilization and associated factors in the rural community of Chencha district, Gamo Goffa Zone in February 2013. Sample population of 420 households with latrine facilities were selected from 5 sub districts (Kebeles). Multistage systematic random sampling method was used. The structured questionnaire was used for data collection. All types of available latrines were pit latrines. Of which 67.4% latrines were functional and from which 46.4% required maintenance. Among 415 households, overall latrine use was 60% and the remaining 40% households were not using latrine. However, over all persistent utilization was 31.08%. Main reasons for non-use or non-persistent use of latrine were lack of functional latrine, stay out for farming and lack of supra structure of latrine. self-initiation (AOR (95% CI) = 6.480(2.772-15.379), p<0.001), peer influence (AOR (95% CI)= 3.111(1.4706.584), p= 0.003), length of years since latrine was constructed ((AOR (95% CI) = 0.219(0.133-0.362) P<0.001), and educational status of the heads of households ((AOR (95% CI) = 3.293 (1.969-5.506) P<0.001) were the major predictors affecting utilization of latrines. In conclusion, Latrine status and utilization in rural community of Chencha district was found to be very low and needed attention to promote hygiene and sanitation behavior in the community.


Background
Over 50 different infections are potentially transmitted from an infected person to a healthy one by various routes involving excreta. Lack of sanitation facilities compels people to practice open defecation and this increases the risk of transmission of diseases. The disease burden associated with poor water, sanitation, and hygiene is estimated to account for 4.0% of all deaths and 5.7% of the total disease burden in disability-adjusted life year (DALYs) in worldwide, principally through diarrheal diseases, schistosomiasis, trachoma, ascariasis, trichuriasis, and hookworm infection. The use of sanitation facilities is known to interrupt the transmission of fecal-to-oral related disease [1,2,3,4].
The global Millennium Development Goal (MDG) target for sanitation has been missed by almost 700 million people and 68% of the global population now uses an improved sanitation facility. The only developing regions to meet the sanitation target were the Caucasus and Central Asia, Eastern Asia, Northern Africa and Western Asia. About 2.1 billion people have gained access to an improved sanitation facility since 1990 and 82% of the global urban population and 51% of the rural population, uses improved sanitation facilities. Seven out of ten people without improved sanitation facilities, and nine out of ten people still practicing open defecation, live in rural areas. The least developed countries did not meet the sanitation target, and only 27 % of their current population has gained access to improved sanitation since 1990. In 2015, 2.4 billion people still lack improved sanitation facilities [5].
Even though, Ethiopia had established the National Sanitation Strategy the goal of 100% latrine coverage to improve sanitation and hygiene in 2005, it was reported there was little improvement (less than 50%) coverage in 2015 [5,6].
Health improvement comes from the proper use of sanitation facilities, not simply their physical presence [2]. This is best achieved through regular use of clean and well maintained latrines. The proper use of latrines can reduce the risk of diarrhea to almost the same extent as improved water supplies, but the greatest benefit occurs when improvements in sanitation and water supply are combined and education is given on hygienic practices [7,8].
The hygienic disposal of excreta is important because the infective organisms for many diseases leave through feces and some through urine [8]. One gram of feces may contain 10 million viruses, 1 million bacteria, a 1000 parasite cysts and a 100 worm eggs [9]. It seems clear therefore, that human excreta should be managed as a potentially dangerous material [10]. Young children are frequently infected with enteric pathogens and their stools are actually an important source of infection. Therefore, hygienic disposal of all feces including young children is an important aspect of disease prevention [7].
In Ethiopia, according to Demographic and Health Survey 2011, overall 38 percent of households have no toilet facility, 16 percent in urban areas and 45 percent in rural areas. The same data source indicated the proportion of households with private improved sanitation that are not shared with other households was only 8%, 14 percent in urban areas and 7 percent in rural areas. This is highly unacceptable given the national prevalence of diarrhea diseases 18%, among under-five children whose mortality is one of the decisive indicators in the MDG goals. Overall child mortality could be reduced by 55% with the provision of safe water, sanitation and hygiene [8,11].
However, the consistent utilization and associated factors of consistent latrine utilization on the community, particularly in rural community has not been assessed. This study has shown at what extent the study community has been using latrine and what affect their use.

Study Area and Period
A community based cross-sectional study was conducted in February 2013 in Chencha district Gamo Goffa Zone, Southern Ethiopia. The district is found in Gamo Goffa Zone of Southern Nations Nationalities and Peoples Regional State and located about 560 Km from Addis Ababa, and 60Km from Arbaminch town. Its climatic condition is cool zone (Dega). According census 2007 which was conducted by central statistics agency of Ethiopia, the total population of the district was about 111,686 and the district has 5 urban and 45 rural Sub districts (Kebeles) with a total of 50 Sub districts (Kebeles). There are 2 Health Extension workers in each Sub districts (Kebeles) of the district assigned in the Health Post. There is one preparatory school, 2 high schools and 50 elementary and primary schools in the district.

Operational Definitions
Latrine utilization: using latrine for excretion purpose of feces and urine including disposal of children excreta.
Functional latrine -latrine that provided services at the time of data collection even if the latrine required maintenance.
Latrine maintenance: maintaining the existing functional latrine in case of broken sub or superstructures without digging new hole.
Self-initiation: construction of latrine without any external influence by already aware households.

Sample Size Determination and Sampling Procedure
The sample size was determined by using the single population proportion formula based on the assumption of 50% proportion (p) that all latrine owners are utilizing latrines, at a confidence level of 95% and margin of sampling error tolerated 5%, minimum sample sizes was 384and with 10% increase to allow non-response rate a total of 422 households with latrines.
Five Sub districts (11%) of 45 rural Sub districts (Kebeles) of the district were selected by systematic random sampling and included in the study. Once the study Sub districts (Kebeles) was identified, 422 households with latrines were selected by systematic random sampling after proportional allocation to the size of each Sub districts (Kebeles).

Data Collection
Structured questionnaire in which close ended questions with multiple options were developed reviewing relevant similar studies. Ten health extension workers for data collection and two sanitarians for supervision were selected and trained before data collection. Pre-test was conducted by 5% of the sample populations in 21 households with latrines in one of non-selected Sub districts (Kebeles) of the district which has similar backgrounds as selected Sub districts (Kebeles). During pre-test some respondents assumed latrine utilization for defecation only and this gap was solved during main data collection by informing that latrine utilization was both for defecation and urination. Heads of households who were considered as such by the members of the households were selected for interview. Face to face interview with individual respondents was carried out to assess whether all family members use or not use latrine and if use whether consistently or non-consistently and how they dispose excreta of under five children. In addition observation checklist was used for indicators of latrine utilization such as fresh feces around squat hole, footpaths to latrine; and observed feces and urine smell in the compound.

Data Quality
The questionnaire was prepared originally in English and then translated in to Amharic and back to English to ensure reliable information. Data collection guideline was prepared and given for data collectors and supervisors. Pre-test of questionnaire and training of data collectors and supervisors were conducted to ensure the quality of data. Pre-test feedback was given for data collectors and supervisors before the start of actual data collection. Data collectors and supervisors were reviewed every questionnaire for completeness and for logical consistency, and counter checked by the principal investigator at the end of each day in the field.

Ethical Consideration
The ethical approval and clearance was obtained from Ethical clearance committee of regional Ethical review Board. Permission was also obtained from the concerned bodies of Gamo Goffa Zonal Health Department and Chencha Woreda Health Office. Oral informed consent was taken from each respondent. Information collected from each household was kept confidential and used only for the purpose of research.

Data Analysis
Data were double entered in to SPSS software version 20, cleaned and analyzed. Frequency distribution and percentages were calculated as appropriate and displayed using tables and figures. Logistic regression for association was carried out to identify association of latrine utilization with predictor variables.

Type of Latrine and Status
Promotion of Latrine construction was facilitated in the district by the district Health Office with the help of UNICE. All types of available latrines were pit latrines. The superstructure and the floor ( slab) of the pit latrine was designed to be constructed by locally available materials like wood and mud that initiate the acceptance, affordability and sustainability of the project by the community (Photo 1). The pit of the latrine was circular with a diameter of 1 meter and a depth of 3 meters. Height of the superstructure was 2 meters with 1.5 meters X 1.5 meters width and length. Size of the squat hole was designed to be 25cms width and 30cms length. From 280 functional latrines only 25(8.92%) had cover for squatting hole and 219(78.21%) of the covering slab (sanitation platform) were difficult to clean. There was no Hand washing facilities from locally available materials like gourd, pot, Jerry can etc. near to latrines to remind users to wash their hands after visiting latrines.  Table 2). The remaining non-functional 135 (32.6%) latrines required reconstruction. Three hundred thirty (77.1%) of latrines were > 6 meters far away from houses and remaining were ≤6 meters. Half of latrines were constructed uphill from water well ( Table 2).

Perceived Reasons of Latrine Construction by Respondents
Two hundred thirty nine (57.59%) of the respondents who had latrines explained that they were advised by health workers to construct latrines but only 53 (12.7%) respondents said that they were imposed by other bodies like local administrators (Table 3).

Use of Latrines by Family Members
Among 415 households, 249(60%) use latrine in some frequency and the remaining 40% households were not using latrine. Over all consistent latrine utilization was found to be only 120 (31.08%). There were fresh feces at squat hole indicating the recent use of latrines in 187 (66.78%) of households with functional latrine. However, in households with functional latrine 49 (17.5%) foot-paths to the latrines were covered with grasses (Photo 3). There were also observable feces in the compound of 90 (32.14%) households and 31 (11.07%) bad smell of frequent open urination in the compound in households with functional latrine.
Major reasons for not-using latrine by family members ≥5 years old were non-functional latrine, stay out for farming and no superstructures for latrine. Other minor reasons were convenience of open filed, societal habit and large family size.

Latrine Use by <5 children
Among households with under-five children only 4 (2.7%) heads of households responded their children were using latrines and the starting age of latrine use was at age of four years. The major reasons given by respondents for why <5 children did not use the latrines were large squat hole and floor was not safe to stand on (Table 4). From 146 households whose under-five children do not use latrine only 52(35.61%) of households dispose excreta of children who cannot use latrine by themselves at Pit latrine (Table 5).

Perceived Reasons for Latrine Use
Majority of the respondents, 278(67%) explained that use of latrines was because they knew that excreta are dangerous to the health followed by no other place for excretion (20.35%) ( Table 6).

Predictors of Latrine Utilization
The predictors of latrine utilization as presented below at Table 7 Table 8).  COR=Crude odds ratio, AOR = Adjusted odds ratio.

Type of Latrine and Status
All types of available latrines at study area were pit latrines. From 280(67.47%) functional latrines, 130 (46.42%) required maintenance. From total 135 (32.53%) non-functional latrines required reconstruction. This finding is lower when compared with study conducted in northern Ethiopia in which functional latrines were 86.7%, need reconstruction were only 13.3% and need maintenance were 47.2% [12]. However, it was better than a study in Indian in which 47% latrine were functional even though type of latrine are not similar [13]. Latrines that need maintenance of supra-structure were 76(58.46%) and roof were 50(38.4%). Latrines without roof might imply that the economic situation of the people and environmental sanitation awareness. Since latrines without a roof causes problems during the wet season, more emphasis should be given to convince the community about roofing their latrines in order to keep the water flow to the latrines as low as possible.
Majority of the functional latrines 219(78.21%) in the selected Sub districts (Kebeles) had covering slab (sanitation platform) which were not suitable to clean and 255(91.07%) of latrines do not have squat hole cover. Also there is no any kind of hand washing material after utilization. Despite all these problems, considerable numbers of the latrines were constructed very near to house. However, it was recommended to build latrine with a minimum of 6 meters distance from the home in order to avoid the associated health risk and inconvenience [14]. On top of that 12(50.00%) of the latrines were constructed uphill from water well ( Table 2). This will give good opportunity for breading of houseflies and can harm the health of community by contaminating food and drinking water [7,8].

Latrine Utilization
The findings of this study revealed that reported over all usage of latrine by family members above age of 5 was found to be 60.00% and only 129(31.08%) of total assessed households consistently use latrine. This is lower than two studies conducted in Northern Ethiopia (61%) and rural community of Bangladesh (57.4%) [12,15,16].
In this study, family whose children were using latrine reported that they began to use latrine at the age of 4 years. However, only 4(2.74%) of households under five children were using latrine. The majority of households with under-five children had unhealthy disposal of child excreta. From 146 households whose under five children do not use latrine, 35(23.97%) threw away from the house either in the bush or in the garden and 56(37.67%) burying in the compound which is too shallow to protect contamination. Only 52(35.61%) correctly dispose in pit latrine ( Table 5). The use of latrine for safe disposal of children feces lower when compared with study in Northwest Ethiopia in which 8.8% of children aged 3-5 use latrine and 68.3% had sanitary disposal of child excreta [16]. However, it is better than study conducted in India in which less than 21% of children excreta disposed safely [17].

Perceived Benefits of Latrine Utilization
Even though, majority 278(66.98%) of respondents knew that excreta are dangerous to health, significant number of respondents do not have awareness about danger of excreta. Forty seven (11.32%) responded latrine utilization was due to it is a convenient place for defecation, particularly for girls and women in a community that defecation during day time is dishonor and 84(20.24%) considered latrine utilization is due to in absence of other place to defecate. This clearly shows that there is gap on awareness in community about importance of latrine utilization. This gap is higher compared study conducted in Gojam in which 84.2% respondents use latrines because of their understanding about the danger of excreta to health [12].
Major reasons that deter latrine use by the households were non-functional latrines, stay out for farming and no superstructure; which is similar to the study conducted in Ethiopia by Ministry of Health in 1997 except staying out for farming [18] and study in Gojam in which nonfunctionality of latrines and staying out for work were the main reasons for not utilizing a latrine [12]. However, study in Northwest Ethiopia and India reported different reason in both of which the major reasons for not using latrine by the households were long live habit and considering open defecation is comfortable [13,16].

Predictors of Latrine Utilization
The extent of latrine utilization was associated with self-initiation, peer influence, length of years which latrine was constructed and educational status of the heads of households. Self initiation for larine construction was 6.5 times more likely to use latrine than mere education given by health education workers. Observation of models from their neighbors also 3 times more likely to use latrine and imposition from others was 51% less likely than mere education given by health extension workers. Hence rather imposing individuals and simply informing what to do, it is better to provide and promote role models from whom community adopt and reshape their health behavior like 1-to-5 organization. This result is similar with a study result in Gojam [12]. The recent (<2 years) since latrine constructed to data collection period was 78% less likely to use latrine than the households owning latrines for >2 years. The study conducted in India supports this result that when years since latrine was constructed increase the utilization of latrine was being increased [13]. This may be due to behavioral change in community may take some period of time. Hence, education, support and monitoring of sanitary activity need maintained until community behavioral change observed rather informing in short intermittent campaigns. The likely hood of latrine utilization in households with literate head was found to be 3.3 times more than households with illiterate head. Similar result was reported by study in India [15]. We did not find significant association between presence of school children in household and extent of latrine utilization when adjusted to other factors. This may be due to only 46(6.16%) of children are above grade 8 to influence family (Table 1). Family size also not associated with latrine utilization.
The limitations of the study were as being cross-sectional study in nature, it may not address actual situation of the seasonal difference in consistent latrine utilization and there might have tendency of respondents to over report positive hygiene behavior in the interview.

Conclusions and Recommendations
This study concluded that latrine utilization was found unsatisfactory. Self-initiation and peer influence for construction of latrine, length of years since households owned latrine and educational status of the heads of households were the major predictors affecting utilization of latrines. Since inconsistency of latrine use and un-functionality of latrine were the major problems, sustainable and model approach needed to promote hygiene and sanitation behavior in the community.