Latrine use and Determinant Factors in Southwest Ethiopia

Copyright: © 2016 Oljira D, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. *Corresponding author: Berkessa T S, Department of Public Health, Faculty of Public Health and Medical Sciences, Mettu University, Mettu, Ethiopia, PO Box 318, Tel: (+251) 911068413; E-mail: tsegayebtola@gmail.com


Background
Despite encouraging progress on sanitation, most of Sub-Saharan Africa did not meet the MDG sanitation target.In 2015 it is estimated that 2.4 billion people globally still use unimproved sanitation facilities.Of these, an estimated 1 in 8 (946 million) people still practice open defecation worldwide [1].Ethiopia achieved the largest decrease in the proportion of the population practicing open defecation, from 44.3 million Ethiopians in 1990 to 28.3 million in 2015, or an average reduction of over 4 percentage points per year over 25 years [1].
In developing countries, 47 % of the population has living in unhygienic environment, while in developed countries the proportion is only 1% [2].The sanitation coverage of rural and urban was 39% and 71%respectively in developing countries [2].Nowadays, globally 80% users of unhygienic sanitation facilities and 85.7% who practice open defecation were live in rural areas [3].The Ethiopian DHS survey in 2014 estimated that 82.5% of the urban and 97.5% of the rural population had no access to improved sanitation, and that 8.7% of urban and 37.5% of the rural population practiced open defecation [4].Poor sanitation has great impact on public heath because it facilitates transmission of infectious pathogens in the human excreta [2].Globally about 1.5 million children die due to diarrheal diseases each year, 88% of these deaths occurring due inadequate sanitation, improper hygiene, and unsafe drinking water [2].
Ethiopia is one of Sub-Saharan countries in which still significant numbers of people are still living in unimproved hygiene and need rapid improvement of sanitation which call for detail research [5].To improve sanitation and hygiene throughout the country, federal ministry of health setted the goal that every households should have access to latrine and large-scale interventions were implemented to increase sanitation coverage [6].However, the strategy gives emphasis to the coverage without focusing on its use.To address the rapidly increasing demand for sanitation, identifying current level of use and its predictors is the most important issue.Therefore, one major objective of this study was to assess latrine use and associated factors in southwest Ethiopia, where the Health Extension Program has been implemented.Open Access

Sample size and Sampling technique
The sample size for the survey was calculated by using the formula for a single population proportion, including a 95 % CI, 5% margin of error, and estimate of 58.4% of households using latrines, based on a previous study in Ethiopia [7].With a 10% adjustment for non-response rate and a design effect of 2, the resulting calculation for a total sample size was 823 households.The study employed a multi-stage sampling technique, taking into consideration that socio-demographic factors affecting latrine use might differ based on the household's distance from the town.The 24 districts were first stratified into three groups (urban, semi-urban, and rural districts), and then seven districts (Bedelle town, Bedelle rural district, Gachi district, Dabo hana district, Bure district, Algie district and Darimu district) were randomly selected by lottery method by proportional allocation to size (1 from the first, 2 from the second and 4 from the third stratum).Then, a proportional sample size was allocated according to the number of kebeles in each district.Accordingly 60, 140, 120, 84, 86, 107 and 226 households were selected from Bedelle town, Bedelle rural, Gachi, Dabo hana, Bure, Algie and Darimu districts respectively.Households were randomly selected from a list provided by the district administration.Intervals (K th ) for selecting households were determined by dividing the number of households with the sample size allocated for each districts.After determining the K th interval, the first household was selected randomly.The next households were identified systematically onwards by adding cumulatively K th intervals to the first selected household.

Data collection method and analysis
Data were collected by diploma health professionals after training using a pretested, structured questionnaire prepared in English and then translated into the local language of Afan Oromo.Data collectors administered the questionnaire through household visits.Information was primarily collected from the head of households (father or mother), or if this was not possible, from another adult household member selected randomly by lottery method.Information related to socio-demographic characteristics was collected by questionnaire while latrine availability, latrine condition and its use was collected by checklist through observation.Data was entered into Epidata version 3.1, and Stata version 11.0 was used for analysis.Descriptive statistics provided means and percentages related to socio-demographic characteristics, latrine use, and condition.Univariate logistic regression was used to analyze the association of each variable with latrine use.Multi-logistic regression model was developed to further assess the impact of variables on the latrine use.

Operational definitions
Pit latrine: Is the simplest form of dry latrine and consists of a pit dug in the ground and a cover slab or floor above the hole.
Functional latrine: Is defined as a latrine which has super structure, some type of closure over the pit/slab and currently in use.

Consistent latrine use:
Was assumed when all family members used the latrines as reported by the respondents, and no faeces were observed to be present in the vicinity.

Availability of hand washing facility:
This is usually a plastic container hung from a tree which can be tilted or tipped to release a small amount of water for washing hands.

Availability of water:
This is presence of water in the plastic container hung from a tree which can be tilted or tipped to release a small amount of water for washing hands during the observation.

Ethical clearance was obtained from the Mettu University Faculty of Public Health and Medical Sciences Institutional Research Ethics
Review Committee, as well as from the zonal and district-level health offices.Before each interview, researchers sought consent from each respondent.

Socio-demographic characteristics
In total, 823 households were interviewed with a response rate of 100%.The respondents were either the head of the household or adult household member.The mean ± standard error (S.E) age of the respondents was 36.1 ± 12.2 years with an average household family size of 5.2.The majority of the respondents were married (727, 88.3% and 518 (62.9%) had a family size of five or more.About 202 (25.7%) fathers and 389 (47.7%) mothers were literate (at least can read and write).Among the households, 337 (40.9%) had children attending at primary or junior high school.The majority of the respondents (710, 86.3%) were engaged in farming, and 713 (86.6%) households had an income of less than 5,000 Ethiopian Birr per year (Table 1).Open Access

Latrine coverage and use
Of the households, 726 (88.2%) had latrines and the majority were pit latrines 661(91%).More than half of the latrines (441, 60.7%) were constructed 2 or more years prior to the time of the study.At the time of data collection, 220 (62.0%) latrines were functional.
The health extension workers had the construction and supervised the work to make proper dry pit latrines, but for different reasons some households did not construct the latrines as instructed.Wood slab with a plastic sheet super structure was the most common material used for the construction of the latrine.Furthermore, per the observational checklist, 296 (40.8%) of the latrines needed repair and maintenance of slabs, walls, roofs or dug.
Out of the interviewed 726 households with latrines, about one third of the respondents (32.8%) did not use them at all, only 261 (36%) reported their consistent use, and 227 (31.3%) used them occasionally.Consistent use was assumed when all family members used the latrines as reported by the respondents, and no feces were observed to be present in the vicinity.Of the available latrines, 34 (4.7%) were located at a distance of less than 6 meters from the home.Of the households with latrines, only 82 (11.3%) had hand-washing facilities, among them only 25 (30.5%) had water and 7(8.5%) had detergents available during data collection (Table 2).

Variables
Frequency Percent

Factors associated with latrine use
Bivariate analysis was carried out to examine the associated factors for latrine use at the household level.Many variables were explored to test association of Adjustment of variables using logistic regression was carried out to predict variables that were associated with latrine use during the crude analysis.Factors associated with the use of latrine by households were presence of a child attending formal education in the household (Adjusted OR=2.30, 95% CI: 1.15-4.59),heard information about latrines (Adjusted OR=3.34, 95% CI: 1.59-7.02),presence of a hand washing facility Adjusted OR=4.08, 95% CI: 1.62-10.27),yearly household income (Adjusted OR=9.90, 95% CI: 2.66-36.82)and age of latrine (Adjusted OR=2.85, 95% CI: 1.54-5.26)(Table 3).

Discussion
Out of the 726 households interviewed that had latrines, 32.7% of the respondents did not use them at all; only 36% reported using them  Open Access 4 latrines constructed from locally available material, needing repair maintenance and were not used properly by the households.Therefore, economic or material support that enables households to construct and maintain latrine, health and sanitation education, and encouragement to households to consistently use latrines is crucial.consistently, and 31.3% reported using them occasionally.Consistent use was assumed when all family members used the latrines as reported by the respondents, and no faeces were observed to be present in the vicinity.The consistent use of latrines in this study was lower than that of Tigray in northern Ethiopia [8], and rural Msongora in Tanzania [9].The variations might be due to different demographic characteristics, their perceptions and economic status of the three groups.
This study found that only 11.8% of the households lacked pit latrines, a low proportion compared to the 45% of households in rural areas lacking latrine facilities per the 2011 Ethiopia DHS and 32.3% in a study in rural North Shewa zone in Amahara region [10,11].Despite high latrine coverage in this study, consistent latrine use was very low.The health extension workers promote the awareness among the rural communities of the benefits from constructing latrines, but have been less active in teaching proper use and maintenance.
At the time of data collection, nearly all latrines (98.9%) were functional (able to be used); this is higher than that reported in a study conducted in rural Zinder in Niger [12] and (86.7%) reported from study done in Hulet Ejju Enessie district of Ethiopia [13].Among the available pit latrines, 40.8% required maintenance; a lower proportion compared to the 47.2% found in the Hulet Ejju Enessie study [13].In order to avoid inconvenience and the related health risks literatures recommend building a latrine with a minimum of 6 meters far away from the home [14,15], 4.7% of the available latrines were located at distance less than 6 meters from the home.
In this study only 11.3% latrine facilities had hand washing facilities.This is higher with the findings from Kersa Woreda, Eastern Ethiopia, which indicated that about 5.1% of households had a habit of hand washing after defecation [16].In this study, the likelihood of latrine use was 4-fold higher among households that had a latrine with a hand washing facility compared to those with no hand washing facility.
Households with very high yearly income were 9.90 times more likely to use latrines than their counterparts with low incomes.This finding is in line with the results of a study conducted in Tigray, northern Ethiopia,[8].This might be due to higher income rural households being more likely to accept health extension programme packages and adopt the promoted behaviors.
Latrine use was also affected by the age of the latrine, with households 2.85 times more likely to use latrines constructed two or more years ago compared to recently constructed latrines.It may be that households having a latrine for a longer period of time were more accustomed to using them.Latrine use was significantly associated with latrines needing maintenance.This may be due to more frequently used latrines needing maintenance after a certain period of use compared to unused ones.Respondents who had heard information about latrines were more likely to use them compared to their counterparts.This may be related to the difference in the knowledge and awareness levels of the two groups regarding human waste management and human health.
Finally, this study shares the limitations of cross-sectional studies and hence it might suffer from temporal relationship establishment with some variables and might not provide much stronger evidence of causality.However, this study identified some important factors which affect latrine use by households and the level of latrine use in the study setting.

Conclusions
Though latrine coverage was high in this study compared to other recent studies and surveys in similar rural areas, most of the latrines were dry pit Open Access n H U B f o r S c i e n t i f i c R e s e a r c h Citation: Oljira D, Berkessa T S (2016) Latrine use and Determinant Factors in Southwest Ethiopia.J Epidemiol Public Health 1(6): doi http://dx.doi.org/10.16966/2471-8211.133 n H U B f o r S c i e n t i f i c R e s e a r c h Citation: Oljira D, Berkessa T S (2016) Latrine use and Determinant Factors in Southwest Ethiopia.J Epidemiol Public Health Rev 1(6): doi http://dx.doi.org/10.16966/2471-8211.133 This cross sectional survey was conducted in Ilu Aba Bor Zone, located approximately 600 km from Addis Ababa in the Southwest Oromia Region of Ethiopia.It has a total population of 1,503,733, with people residing in 22 rural districts and 2 town districts.It is bounded by East Wollega and West Wollega zone in the north, West Wollega zone and Kellem Wollega zone in the West, Jimma zone in the east and Gambella region in the south.The study zone has 2 hospitals, 56 health centers, and 481 health posts (Ilu Aba Bor annual zonal office report, unpublished).

Table 3 :
Final logistic regression model for household's latrine use in Ilu Aba Bor zone, South West Ethiopia, 2015 *