Latrine Utilization and Associated Factors in Mehal Meda Town in North Shewa Zone, Amhara Region, Ethiopia, 2019

Background Worldwide lack of sanitation is a serious health risk, affecting billions of people around the world, particularly the poor and disadvantaged of people around the world. In Sub-Saharan Africa, the number of people who defecate remains the open field 215 million. According to the 2016 Ethiopian Demographic and Health Surveys report, 56% of the rural households use unimproved toilet facilities. One in every three households in the country has no toilet facility. However, achieving real gains in increasing latrine use and quality remained as a challenge. This study was used to assess the latrine utilization and associated factors in Mehal Meda town in North Shewa zone, Amhara region, Ethiopia, 2019. Result In this study, a total of 558 participants were included. Out of households, 509 (91.2%) utilized their latrine facility. On the other way, 503 (98.8%) households utilized latrine regularly. Significant variables that were associated to latrine utilization were the occupational status of head of households, observing feces around the compound/latrine, duration of latrine utilization, shape and structure of latrine facility, latrine status during observation, and distance between water well and latrine. According to this study, the magnitude of latrine utilization in Mehal Meda district was 91.2%. It was lower than Ethiopia national expected target of MDGs (100%). Significant variables that were associated to latrine utilization were occupational status of head of households, observing feces around the compound/latrine, shape and structure of latrine facility, latrine status during observation, and distance between water well and latrine facility. Therefore, health education about latrine utilization and its advantage should be given for community in the study area.


Background
Latrine utilization is defined as the use of the latrine by all the family members in the households [1]. Approximately, 1.1 billion people did not use any facility at all and practiced open-defecation [1,2]. Globally, about 2.3 billion people who still have no basic sanitation service either practice open defecation (892 million) [3][4][5]. Moreover, billions of people have continued their life without the basic sanitation services in the world [6][7][8].
In Sub-Saharan Africa (SAA) like Ethiopia, 76% of the rural population did not use a better-quality hygiene facility, and people were exposed for diarrheal diseases in high burden especially under five children [9][10][11][12]. The majority of households, 91% rural and 54% urban, use nonimproved latrine facilities [13,14]. Based on other studies, the number of people practicing open defecation in southern Asia has declined moderately from 1990, but in Sub-Saharan Africa, the number of people practicing open defecate increased from then in 1990 (increased by 26%) [15,16].
In Ethiopia, there was progress in reducing child mortality from 123 deaths of less than five years of children per 1,000 live births in 2005 [17]. In other rural studies, 56% of the rural households in Ethiopia use unimproved toilet facilities [18][19][20]. The recent data Mini EDHS indicates that, in Ethiopia, more than half 55% of households (56.7% in rural and 4.4% in urban areas) access to unimproved sanitation [21]. The government of Ethiopia had set to achieve a national target of 100 percent sanitation coverage in both rural and urban areas and made different effort to achieve it by 2015 [22][23][24].
As 2011 EDHS finding, the coverage latrine utilization in SNNP, Amhara, Tigray, and Oromia was 56%, 46%, 41%, and 40%, respectively [25]. Similarly, in the study done in Aneded district, the level of latrine utilization was 63% [26]. Also, in the study done in Laelai Maichew Woreda, the age categories ranges from 36 to 50 years had shown significant association to the use of latrine [27].
On the other side, in a study done SNNPRS, participants who had clean latrine facilities were 1.2 fold higher to use than those with unclean once [28] and 1.5 times more likely to have a larger family than nonadopting neighbors [29]. Similarly, a study conducted in Hulet Ejju revealed that 20% of the households have utilized latrine [30]. But there is no previous study in this study area about latrine utilization. Therefore, this study is aimed to assess latrine utilization and associated factors in Mehal Meda town in North Shewa zone, Amhara region, Ethiopia, 2019.

Methods and Materials
2.1. Study Area and Study Period. This cross-sectional study was conducted in Mehal Meda town district is located at 361 km north east of Addis Ababa and about 180 km north of the Debre Birhan town from January 15 to January 30, 2019. There are 4 kebeles in the district. In 2011, the town administration office report total population is about 40394, and the total number of households is 10,069. All households that had latrine facilities in Mehal Meda town were the source of population.

Sample
Size. Sample size was calculated using a single population proportion formula. The following assumption was taken to calculate the sample: P = 67:4% [31], confidence interval ðCIÞ = 95%, and marginal error ðDÞ = 5%.
The sample size was 558 by using 1.5 design effect and adding 10% nonresponse rate.
2.3. Sampling Procedure. The multistage sampling method was employed. Mehal Meda town has 4 kebeles. Then, by using a simple random sampling technique, two kebeles were selected from those kebeles. Households selected using systematic random sampling. The sampling interval (K) was gained by dividing each selected Kebele's household number to the sample size, so k = N/n = every 6th household visited until we got 558 Households ( Figure 1).

Schematic Presentation of
Sampling Procedure 3.1. Data Collection Tool and Procedure. An interview using a structured questionnaire was used by adapted from previous similar literatures [16,28,32]. Pretest was done on 5% (n = 28) in nonselected kebeles. Data collectors and supervisors had got training for one day on how they collect the data. The principal investigators were strictly following the data collection every day.

Discussion
According to this study, the latrine utilization of Mehal Meda town was 91.2%. It was a little bit more than the result of community-based cross-sectional studies in Hulet Ejju Enessie, Aneded district, and in SNNPRS, Southern Ethiopia [26,28,30]. The reason could be attributed to the method and areas of the study.
According to this study, five hundred thirty-four households (95.7%) lived near to health center with a distance of below 5 kms. Five hundred thirty-four (95.7%) households had latrine with a distance of below 6 meter. Similarly, in Aneded district study, 55.6% participants lived near to health center with a distance of below 5 km [26]. The possible reason may be due to participants who have enough water sources and who were nearest to the health center/post were used latrine clearly than far from health center/health post/low water source.
Base on this study, 250 (44.8%) heads of households claimed to wash their hands after toilet use, whereas 72 (12.9%) heads of households washed their hands during at four critical times. This finding was lower than the studies done in different parts of Ethiopia [26,32,33].
According to this study, the illiterate household heads were 21 [AOR = 20:65, 95% CI: 1.382 78.479] times more likely to use than those who have diploma and above educational status. This result was not supported with the studies done in Aneded district, Laelai Maichew Woreda, and  Based on this study, the duration of latrine utilizing was 1-3 years were 78.2% less likely to use than those who have 3 years and above duration of use [AOR = 0:218, 95% CI: 0.061, 0.771]. This variable had not shown its association in other studies.
According to our study, the participants who have clean latrines were 9 [AOR = 8:846, 95% CI: 2.919, 26.802] times more likely to use latrine than the counters. This study was in lined with a study done in SNNPRS [27]. The possible reason may be due to the clean latrine more attractive and comfortable to use than the unclean toilets.
According to this study, households that had good and fair latrine facilities were 25 [AOR = 25:486, 95% CI: 6.268, 103.633] and 14 [AOR = 14:440, 95% CI: 4.233, 49.253] times more likely to utilize latrine than those who had bad latrine facilities. This study was supported by the study done in Aneded district in Ethiopia [26]. This may be due to the reason that the good and fair latrine was attractive and clean to use by families than the counters.
This study revealed that the households that have water well with a distance of below 15 meters from latrine facility were 5 [AOR = 4:469, 95% CI: 1.622, 12.312] times more likely used than the counter. This variable was not shown its association in other studies. The possible reason may be due to participants who have enough water sources.

Conclusion
Based on this study, the latrine utilization of Mehal Meda district was 91.2%. It was lower than Ethiopia national expected target of MDGs (100%). Occupational status of head of households, observing feces around the compound/latrine, duration of latrine utilization, shape and structure of latrine facility, latrine status during observation, and distance between water well and latrine facility had a significant association with latrine utilization. Therefore, health education should be given on associated findings to get full coverage latrine utilization in this woreda.
6.1. Limitation of the Study. The study design is crosssectional. So, it has its drawback (this does not show which one was come first effect or cause).

AOR:
Adjusted odds ratio CI: Confidence interval DALYs: Disability -adjusted life years EDHS: Ethiopian demographic health survey MDG's: Millennium development goal OD: Open defecation OR: Odds ratio SNNP: Southern nations, nationalities, and people SPSS: Statistical package for social science SSA: Sub Sahara Africa UNICEF: United nation international Children's emergency fund WASH: Water, sanitation and hygiene WHO: World Health Organization.

Data Availability
All data are accessed in this manuscript.

Ethical Approval
Ethical clearance gained from Debre Birhan health science college research committee. Supportive Letter gained from Zonal health office to all selected kebeles administrative office to get their cooperative letter to show for selected mother during the data collection. Each study participant adequately informed about the purpose, method, and anticipated benefit and risk of the study by their data collector. Respondents had the right to respond or refuse to interview. Written consent found from study participants. All the information given by respondents was used for research purposes only and confidentiality and privacy kept by omitting the name of the respondents during the data collection procedure.

Conflicts of Interest
The authors declare that they have no competing interests.