Content uploaded by Negasa Eshete Soboksa
Author content
All content in this area was uploaded by Negasa Eshete Soboksa on Nov 30, 2022
Content may be subject to copyright.
Review Paper
Unsafe fecal disposal practices in children and the nexus with childhood diarrhea
in low- and middle-income countries: a systematic review and meta-analysis
Negasa Eshete Soboksa a,*, Beekam Kebede Olkebab, Belay Negassa a, Habtamu Endashaw Hareru c
and Dinkinesh Begna Gudetad
a
Department of Environmental Health, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
b
Department of Environmental Health Science, College of Medicine and Health Science, Hawassa University, Hawassa, Ethiopia
c
School of Public Health, College of Health Sciences and Medicine, Dilla University, Dilla, Ethiopia
d
Department of Nursing, College of Health and Medical Sciences, Arsi University, Asalla, Ethiopia
*Corresponding author. E-mail: yeroosaa@gmail.com
NES, 0000–0003-3451-175X; BN, 0000-0002-6212-8064; HEH, 0000-0002-0591-0893
ABSTRACT
In household environments, the improper handling of children’s feces can be a significant contaminant, raising a high risk of child exposure.
Thus, the objective of this study was to pool the available evidence on the prevalence of safe child feces disposal practices and their associ-
ation with reported childhood diarrhea in low-income and middle-income countries. PubMed, Science Direct, Cochrane Library databases,
Ovid Medline, Google Scholar, and references of other studies were searched. The search was limited to studies published in English-
language literature. Two independent reviewers used an appropriate tool to critically appraise the selected studies. Stata version 16 was
used for the analysis. The pooled prevalence of unsafe disposal of children’s feces among 20 studies was 52.63% (95% CI: 0.43–0.62). Overall,
the meta-analysis found that unsafe disposal practices insignificantly increased the risk of diarrhea by 4% (OR: 1.04, 95% CI: 0.84–1.24). In the
subgroup analysis, unsafe disposal of children’s feces decreased the risk of diarrhea in Oceania (OR ¼0.75, 95% CI ¼0.62–0.88) and
increased in Asia (OR ¼1.33, 95% CI ¼1.25–1.41). In conclusion, the prevalence of unsafe child feces disposal practices was high. There
was no significant association between unsafe child feces disposal practices and diarrhea.
Key words: association, child, diarrhea, feces disposal, low-income, middle-income countries, pooled prevalence
HIGHLIGHTS
•This study aimed to pool the extent of disposal of children’s feces and its association with diarrhea in children.
•This systematic review and meta-analysis included 19 published articles and 1 unpublished study.
•The pooled prevalence of unsafe maternal/guardian disposal practices for child feces in this study was high.
•Unsafe disposal practices for children’s feces insignificantly increased the likelihood of diarrhea in children.
BACKGROUND
Each year, 829,000 people in low- and middle-income countries die as a result of inadequate water, sanitation, and hygiene,
accounting for 60% of all diarrhoeal deaths (WHO 2022). Unsafe sanitation is one of the world’s most serious health and
environmental problems, particularly for the poorest people. In 2017, an estimated 775,000 people died as a result of
unsafe sanitation. This accounted for 1.4% of all deaths worldwide. Unsafe sanitation also accounts for 5% of deaths in
low-income countries (Hannah & Roser 2021). It is estimated to cause 432,000 diarrheal deaths each year and is also a
major contributor to numerous neglected tropical diseases such as intestinal worms, schistosomiasis, and trachoma, as
well as contributing to malnutrition (WHO 2019).
Globally, over 1.7 billion people do not have access to basic sanitation services such as private toilets and latrines. Of these,
494 million continue to defecate in the open, such as in street gutters, behind bushes, or in open bodies of water (WHO 2022).
Adopting safe child feces disposal practices necessitates the availability of improved latrines (Majorin et al. 2014;Sara &
This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence (CC BY 4.0), which permits copying, adaptation and
redistribution, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/).
© 2022 The Authors Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 742 doi: 10.2166/washdev.2022.040
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
Graham 2014). A previous study, however, showed that some respondents who had a latrine practiced unsafe child feces dis-
posal, suggesting that improvement and the provision of physical infrastructure are insufficient to ensure the adoption of
appropriate hygiene practices (Sahiledengle 2020).
Fecal contamination from children aged 3 months to 5 years old in the home environment was widespread both inside and
outside the home, according to studies conducted in an urban slum in Nairobi, Kenya, and rural Odisha, India (Bauza et al.
2017,2020). According to studies, leaving child feces out in the open or failing to dispose of it is a common child feces dis-
posal practice (Sultana et al. 2013;Majorin et al. 2014). Findings showed that the prevalence of unsafe child feces disposal
varies from country to country. The highest prevalence was reported in Nigeria (80.33%) (Aluko et al. 2017), Bangladesh
(80.33%) (Islam et al. 2020), and India (79.00%) (Bawankule et al. 2017). In contrast, studies from Ethiopia (9.20%)
(Alemayehu et al. 2021), Kenya (30%) (World Bank/UNICEF 2015), and Cambodia (29.27%) (Vong et al. 2021) reported
the lowest prevalence.
Improper disposal of children’s feces can be a major contaminant in household settings and pose a high risk of exposure to
infants. The study reported from Indonesia showed that households that do not dispose of children’s feces safely are signifi-
cantly more likely to have diarrhea than households that practice safe disposal (Cronin et al. 2016;Majorin et al. 2019).
According to a meta-analysis study, unsafe child feces disposal practices like open defecation, stool disposal in the open,
stools not removed from soil, and feces observed on the ground increased the risk of diarrheal diseases by 23% (Gil et al.
2004). Several studies done in Nepal (Lamichhane et al. 2018), Indonesia (Cronin et al. 2016), Thailand (Wilunda & Alessio
2009), Cambodia (Vong et al. 2021), India (Bawankule et al. 2017), and Kenya (World Bank/UNICEF 2015) have linked
unsafe fecal disposal to an increased risk of childhood diarrhea. However, studies conducted in Ethiopia (Sahiledengle
2020), Papua New Guinea (Seidu et al. 2020), Nigeria (Aluko et al. 2017), and Eswatini (Simelane et al. 2020) found that
unsafe fecal disposal in children reduces the risk of childhood diarrhea. It might be that the availability of physical infrastruc-
ture alone is insufficient to assure the adoption of safe child feces disposal practices.
Previously conducted studies in various low- and middle-income countries revealed that the prevalence of unsafe practices
for disposing of children’s feces, as well as the association of unsafe fecal disposal with diarrhea, had conflicting results, and
no attempts have been made to systematically review this. Thus, the current study aimed to synthesize the available evidence
on unsafe fecal disposal practices in children and its association with diarrhea in children in low- and middle-income
countries based on this evidence. In this study, the research questions addressed in this review were: (1) What is the
extent of unsafe practices for disposal of child feces in low- and middle-income countries? (2) Is there a link between
unsafe child feces disposal practices and diarrhea in low- and middle-income countries?
METHODS AND ANALYSIS
Study design and protocol
This systematic review and meta-analysis was written following the reporting guidelines in the PRISMA guidelines (Preferred
Reporting Items for Systematic Reviews and Meta-analyses) (Moher et al. 2009). The four phases drawn from the PRISMA
flowchart were documented in the results to show the study selection process from the initially identified records to the even-
tually included studies (Moher et al. 2009). The review protocol was registered in the PROSPERO database (Registration ID:
CRD42020189034).
Eligibility criteria
The systematic review and meta-analysis included published and unpublished observational studies conducted in low- and
middle-income countries that examined the magnitude of unsafe child feces disposal practices and its association with
reported diarrhea. Our population of interest were mothers/guardians with children under 5 years of age, regardless of
gender, race, and socio-economic status. The outcome of interest was the pooled prevalence of unsafe disposal practices
for children’s feces and its association with reported diarrhea. The review includes only reports prepared in English, regard-
less of the year of publication. Previously published systematic reviews and qualitative studies were not included.
Information sources and search strategy
PubMed, Science Direct, Cochrane Library databases, and Ovid Medline electronic resources were used to find relevant lit-
erature for this review. In addition, we searched Google Scholar and references from other studies. The literature search was
carried out by the first author in July 2021. The search strategy was limited to studies published in English literature. We used
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 743
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
terms from Medical Subject Headings (MeSH) from PubMed and combined keywords to identify studies in the databases
(‘unsafe’and ‘child’and ‘feces disposal’and ‘association’and ‘diarrhea’and ‘low-income and middle-income countries’).
A complete search strategy for PubMed is given in Supplementary Material, Table S1.
Study selection process
The search results were exported to Mendeley Desktop reference management software, version 1.19.5 (Mendeley Ltd,
Elsevier, The Netherlands) and then duplicates were eliminated. The studies were screened by two independent review
authors (NES and DBG). Articles found through database searches were evaluated for inclusion at three levels, i.e., by
title, then by abstract, and finally by full text. The full texts of selected studies were retrieved and assessed in detail against
the inclusion criteria. Discrepancies were discussed between the reviewers, and the inclusion criteria were refined. In the
case of uncertainty in the decision to include or exclude an item, the reviewer included that item for the next level of screen-
ing. The documents without abstracts were viewed at the full-text level.
Data extraction
The JBI Adapted Data Extraction Form was used to extract the study characteristics and status of children’s fecal disposal
practices and the odds ratios showing the association between unsafe disposal of children’s feces and reported diarrhea. A
structured extraction excel sheet was created, and information from each record was collected using this excel sheet for
the systematic review. For each study, the author’s name and year of publication, country of origin and group of included
studies, type of included study, sample size, description of child fecal disposal practices, and results of included studies
were extracted by two reviewers. Any disagreements between the reviewers were resolved through discussion or with a
third reviewer.
Outcome of interest
The primary outcome of this review was the pooled prevalence of unsafe disposal of children’s feces, and the secondary out-
come of this study was the estimate of the association between unsafe disposal of children’s feces and reported diarrhea.
Disposal of children’s feces was defined based on the WHO/UNICEF-JMP on water supply and sanitation (WHO/
UNICEF 2006) as safe disposal when households responded that they were collected and disposed of in a latrine or
buried, and unsafe disposal when they said they were put down a drain or ditch, thrown in the trash, or left open. Whereas
diarrhea is defined as three or more loose or watery stools in a 24-hour period, or any loose stool that contains blood or
mucus.
Evaluation of study quality
The methodological quality of all studies that met the selection criteria was independently assessed by two authors (NES and
DBG) using the Critical Appraisal Tools of the Joanna Briggs Institute (JBI) (Aromataris & Munn 2020). Each study was indi-
vidually and independently assessed by the two reviewers, both at the outcome and study level, to generate an overall risk of
bias score. The two authors’scores for each bias criterion were then compared. Disagreements between the two authors
regarding individual bias criteria were identified and discussed to reach consensus. Studies with a score of 7 were con-
sidered high quality, studies with a score of 4–6 were considered moderate quality, and studies with a score of 3were
considered low quality.
Data synthesis and statistical analysis
The individual studies were concisely described using an overview table. The summary table describes in particular the
characteristics of the included studies and the most important results. Based on the summary table, we first performed a nar-
rative synthesis to describe the characteristics of the included studies and the main findings. Then, using Stata Version 16
(College Station, TX 77845, USA), a random effects model was used to perform a meta-analysis. If the included study did
not provide a 95% confidence interval (CI) for the prevalence of child feces disposal practices, the 95% CI was derived
using the standard error (SE) and prevalence of child feces disposal practices from each included study. SE was calculated
using the formula SE ¼ffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
(p(1 p)=n)
pfor studies that did not present it. The calculated SE and prevalence of each study were
then entered into Stata software to calculate the overall pooled prevalence of unsafe child feces disposal practices and its 95%
CI. Similarly, the association between unsafe child feces disposal practices and reported diarrhea was summarized using stat-
istical estimates of effect size, odds ratio (OR), and 95% CI of the study factors. Subgroup analyses were conducted depending
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 744
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
on the study region/continent and data source (demographic and health surveys (DHS) or not). After excluding one study
(leave-one-out), a sensitivity analysis was performed to determine the impact of each study on the pooled estimate.
Heterogeneity was assessed statistically using a chi-square test (Q-test) for statistics and an inverse variance index (I
2
)
(Higgins & Thompson 2002). The I
2
values were classified as follows: no relevant heterogeneity (0–25%), moderate hetero-
geneity (25–50%), and significant heterogeneity (50–100%). The data were considered homogeneous when I
2
was 50%.
Fixed effects models were used to construct summary ORs and 95% CIs where there was no heterogeneity. Where there
was statistical heterogeneity, random effects models were applied. Forest plots were created to show the pooled estimates
with a 95% CI. In a forest plot, the box in the middle of each horizontal line (confidence interval, CI) represents the point
estimate of the effect for a single study. The box’s size reflects how much the study weighs in comparison to the combined
estimate. The diamond represents the overall effect estimate of the meta-analysis. The pooled effect point estimate is rep-
resented by the diamond’s center on the x-axis, and the 95% CI around that point estimate is shown by the diamond’s
width (Chang et al. 2022). A funnel plot and the Eggers test for publication bias were used to assess publication bias. The
symmetrical funnel plot and the insignificant Eggers test were used to argue no serious publication.
RESULTS
Study selection process
A total of 865 published and unpublished records were discovered in our initial literature search through electronic databases
and additional hand searches. Two hundred and twenty-three records were removed due to overlap. After removing dupli-
cates, 642 studies were searched for titles and abstracts. After excluding 603 irrelevant articles, the full texts of 39 articles
were examined. Since the records were irrelevant to this review, 19 of the 39 articles examined for full text were excluded.
Finally, this systematic review and meta-analysis included 20 (19 published and 1 unpublished) records (Figure 1).
Figure 1 |Flowchart of study selection for systematic review and meta-analysis of unsafe child feces disposal practices and its association
with childhood diarrhea.
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 745
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
Characteristics of the included studies
In a total of 865 published and unpublished records, 20 cross-sectional studies that met the inclusion criteria and focused
on the prevalence of unsafe fecal disposal practices in children and their association with childhood diarrhea were
included in the analysis. The current meta-analysis included eight studies from Ethiopia (Mihrete et al. 2014;Azage
& Haile 2015;Sahiledengle 2019,2020;Alemayehu et al. 2021;Getahun & Adane 2021;Soboksa 2021;Soboksa
et al. 2021), two studies from Nigeria (Aluko et al. 2017;Aliyu & Dahiru 2019), two studies from Indonesia (Cronin
et al. 2016;Sidabalok et al. 2019), one each from India (Bawankule et al. 2017), Papua New Guinea (Seidu et al.
2020), Eswatini (Simelane et al. 2020), Cambodia (Vong et al. 2021), Thailand (Wilunda & Alessio 2009), Bangladesh
(Islam et al. 2020), Kenya (Siruri 2013), and a study that compiled DHS from 15 sub-Saharan African countries
(Seidu et al. 2021) were represented. The sample size of the study ranged from 221 to 128,096 participants. The preva-
lence of unsafe disposal of child feces ranged from 9.20 to 80.33%. The lowest prevalence of unsafe disposal of children’s
feces was reported in a study conducted by Alemayehu et al. (2021) in Ethiopia (Alemayehu et al. 2021), whereas the
highest prevalence of unsafe disposal of child feces was reported in a study conducted in Nigeria by Aluko et al.
(2017)(Table 1).
Risk of bias
The quality of the included studies was assessed using the JBI checklist for analytical cross-sectional studies (Moola et al.
2020). Among the 20 included studies, 14 of the included studies were high-quality studies (Azage & Haile 2015;Cronin
et al. 2016;Bawankule et al. 2017;Islam et al. 2018;Aliyu & Dahiru 2019;Sahiledengle 2019,2020;Seidu et al. 2020,
2021;Simelane et al. 2020;Getahun & Adane 2021;Soboksa 2021;Soboksa et al. 2021;Vong et al. 2021), while 6 studies
were of moderate (Wilunda & Alessio 2009;Siruri 2013;Mihrete et al. 2014;Aluko et al. 2017;Sidabalok et al. 2019;
Alemayehu et al. 2021) according to our assessment (Supplementary Material, Table S2).
Table 1 |Descriptive summary of 20 studies included in the systematic review and meta-analysis
S.No Author, publication year Study site Study design Sample size
Age group
included
Prevalence of unsafe
disposal (%) with 95% CI
1. Aliyu & Dahiru (2019) Nigeria Cross-sectional 19,288 ,5 40.60 (39.91–41.30)
2. Azage & Haile (2015) Ethiopia Cross-sectional 11,126 ,5 66.32 (65.44–67.20)
3. Bawankule et al. (2017) India Cross-sectional 35,273 ,5 79.00 (78.57–79.42)
4. Cronin et al. (2016) Indonesia Cross-sectional 4,909 ,2 52.80 (51.39–54.21)
5. Sahiledengle (2020) Ethiopia Cross-sectional 20,629 ,5 77.70 (76.30–79.00)
6. Sahiledengle (2019) Ethiopia Cross-sectional 4,145 ,5 63.10 (59.50–66.60)
7. Seidu et al. (2020) Papua New Guinea Cross-sectional 2,095 ,5 56.00 (54.50–58.00)
8. Seidu et al. (2021) 15 Sub-Sahara Africa countries Cross-sectional 128,096 ,5 41.27 (41.00–41.54)
9. Simelane et al. (2020) Eswatini Cross-sectional 2,765 ,3 41.80 (39.30–44.40)
10. Vong et al. (2021) Cambodia Cross-sectional 5,745 ,5 29.27 (27.51–31.09)
11. Mihrete et al. (2014) Ethiopia Cross-sectional 925 ,5 55.40 (51.86–58.37)
12. Sidabalok et al. (2019) Indonesia Cross-sectional 1,007 ,5 42.70 (39.62–45.82)
13. Alemayehu et al. (2021) Ethiopia Cross-sectional 620 ,5 9.20 (7.04–11.75)
14. Wilunda & Alessio (2009) Thailand Cross-sectional 5,658 ,5 35.35 (34.10–36.61)
15. Soboksa (2021) Ethiopia Cross-sectional 9,754 ,5 75.20 (74.30–76.02)
16. Islam et al. (2018) Bangladesh Cross-sectional 803 ,5 80.00 (76.75–82.43)
17. Getahun & Adane (2021) Ethiopia Cross-sectional 485 ,5 43.20 (38.84–47.84)
18. Aluko et al. (2017) Nigeria Cross-sectional 300 ,5 80.33 (75.38–84.68)
19. Soboksa et al. (2021) Ethiopia Cross-sectional 756 ,5 69.58 (66.16–72.89)
20. Siruri (2013) Kenya Cross-sectional 221 ,5 13.57 (9.35–18,81)
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 746
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
Prevalence of unsafe child feces disposal
As shown in Figure 2, based on 20 studies with 240,706 participants, the pooled prevalence of unsafe children’s feces disposal
practice among mothers/guardians was 52.63% (95% CI: 0.43–0.62) (Wilunda & Alessio 2009;Siruri 2013;Mihrete et al.
2014;Azage & Haile 2015;Cronin et al. 2016;Aluko et al. 2017;Bawankule et al. 2017;Aliyu & Dahiru 2019;Sahiledengle
2019,2020;Islam et al. 2020;Seidu et al. 2020,2021;Simelane et al. 2020;Alemayehu et al. 2021;Getahun & Adane 2021;
Soboksa 2021;Soboksa et al. 2021;Vong et al. 2021). The studies included in this systematic review and meta-analysis were
highly heterogeneous (I
2
¼99.94, p¼0.001). Therefore, a random effects model was used to estimate the pooled prevalence
of unsafe disposal practices for child feces among mothers/guardians. In this analysis, the lowest prevalence of unsafe dispo-
sal of infant feces was reported from Ethiopia (9.20%) (Alemayehu et al. 2021), while the highest was reported from a study
conducted in Nigeria (80.33%) (Aluko et al. 2017;Figure 2).
Association between unsafe disposal practice child feces and diarrhea
The association between unsafe disposal of children’s feces and diarrhea has been assessed in 20 studies (Wilunda & Alessio
2009;Siruri 2013;Mihrete et al. 2014;Azage & Haile 2015;Cronin et al. 2016;Aluko et al. 2017;Bawankule et al. 2017;
Aliyu & Dahiru 2019;Sahiledengle 2019,2020;Islam et al. 2020;Seidu et al. 2020,2021;Simelane et al. 2020;Alemayehu
et al. 2021;Getahun & Adane 2021;Soboksa 2021;Soboksa et al. 2021;Vong et al. 2021). Individual studies in Ethiopia
(OR: 0.38, 95% CI: 0.25–0.51) and Nigeria (OR: 0.24, 95% CI: 0.06–0.42) showed a lower risk of diarrhea, while studies
Figure 2 |Forest plot of the pooled prevalence of unsafe child feces disposal practices of 20 studies included in the systematic review and
meta-analysis.
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 747
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
in Ethiopia of Alemayehu et al. (OR: 3.82, 95% CI: 1.58–6.06) and Getahun and Adane (OR: 3.31, 95% CI: 1.60–5.01) showed
a higher likelihood of diarrhea in children. The overall meta-analysis showed that children whose mothers/guardians engaged
in improper disposal of children’s feces were 1.04 times more likely to have diarrhea (OR: 1.04, 95% CI: 0.84–1.24). However,
the results showed that there was no significant association and that there was a high degree of heterogeneity (97.38%)
between the included studies (Figure 3).
Subgroup analysis
Subgroup analyses were performed in this study based on study region/continent and data source (DHS or not). Accordingly,
studies conducted in Africa, despite high heterogeneity (I
2
¼96.28%, p¼0.001), found no significant association between
unsafe methods of disposal of children’s feces and diarrhea in children (OR ¼0.84, 95% CI ¼0.64–1.05). However, as a col-
lective of studies conducted in Asia, unsafe disposal of child feces was significantly associated with diarrhea risk (OR ¼1.33,
95% CI ¼1.25–1.41), with no significant heterogeneity between included studies (I
2
¼0%, p¼0.46) (Figure 4).
Looking at the subgroup analysis by data source (DHS or not), according to DHS data, maternal/guardian unsafe disposal
practices for child feces increase the likelihood of child diarrhea slightly but not significantly (OR ¼1.01, 95% CI ¼0.85–
1.17), and there was significant heterogeneity between the included studies (I
2
¼95.58%, p¼0.001). In studies using primary
data (non-DHS), also there was also no association between unsafe disposal of children’s feces and diarrhea (OR ¼1.27, 95%
CI ¼0.63–1.91). However, in the non-DHS subgroup analysis, there was an increase in childhood diarrhea and significant
heterogeneity between included studies (I
2
¼94.77%, p¼0.001) (Figure 5).
Sensitivity analysis
The sensitivity analysis of the relationship between unsafe methods of disposing of children’s feces and diarrhea in children is
presented in Table 2. To identify the potential source of heterogeneity in the analysis, a leave-one-out sensitivity analysis
Figure 3 |Forest plot of the pooled odds ratio of unsafe child feces disposal practices and childhood diarrhea.
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 748
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
related to unsafe methods of disposing of childhood feces and childhood diarrhea was performed. According to the results,
not a single study had an effect on overall childhood diarrhea.
Publication bias
A visual inspection of the funnel plot is revealed that the distribution of studies was asymmetric, indicating that there was a
publication bias (Figure 6). In addition, we used Eggers’tests to detect the presence of publication bias due to small study
effect, and the results showed that there is statistically significant publication bias in assessing the association between
unsafe child feces disposal practices and diarrhea due to small study effect ( p-values of 0.001).
DISCUSSION
The aim of this study was to pool the available evidence on the extent of unsafe child feces disposal practices and its associ-
ation with reported diarrhea in children in low- and middle-income countries. According to this systematic review and meta-
analysis, the pooled prevalence of unsafe child feces disposal practices in low- and middle-income countries was 52.63% (95%
CI: 0.43–0.62). Our study finding is almost similar to a Water Safety Plans (WSP) and UNICEF investigation of 24 countries,
which found that over 50% of households in 14 of the 24 countries did not dispose of their children’s feces in any type of toilet
or latrine; that is, the feces were disposed of unsafely (World Bank Group and UNICEF 2014). Despite the fact that we found
a high prevalence of unsafe disposal in our analysis, the sustainable development goal (SDG) number 6, which aims to end
open defecation by 2030, is important for reducing unsafe disposal of child feces (Le Blanc 2015;Bárcena et al. 2018).
Figure 4 |Forest plot of the subgroup analysis by region pooled odds ratio of unsafe child feces disposal practices and childhood diarrhea.
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 749
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
Generally, children are at a higher risk than adults of getting infected by enteric pathogens when their feces are left in the
open. Studies have shown improper disposal of children’s feces leads to a greater risk of diarrhea in children under 5 years of
age (Gil et al. 2004;Majorin et al. 2014;Bawankule et al. 2017). In the current systematic review and meta-analysis, the risk of
diarrhea increased by 4% due to unsafe child feces disposal practices by mothers/guardians even though statistically not sig-
nificant. Our study finding was supported by a meta-analysis done on children’s feces disposal practices, which showed that
unsafe child feces disposal practices increased the risk of diarrheal diseases by 23% (Gil et al. 2004). Additionally, our study
finding was supported by an intervention study conducted in the city of Bangladesh, which showed a 26% reduction in pedi-
atric diarrhea from improved safe disposal of infant feces, although the amount of risk reduction varied widely (Stanton &
Clemens 1987). The possible explanation for the above-observed discrepancy between the current meta-analysis and compar-
able findings might be due to the difference in the socio-demographic characteristics of the study participants, sample size or
study design.
A review of studies found that a considerable number of children’s feces were not removed from their original defecation
sites, which are responsible for contamination, could be a major cause of diarrhea (Gil et al. 2004). However, in our subgroup
analysis of the study, there was no significant association between the presence of diarrhea and unsafe maternal/guardian
disposal practices when disposing of children feces in the sub-analysis of studies conducted in African countries. A similar
finding was reported by a longitudinal study conducted as part of a randomized controlled trial in rural Bangladesh
(Islam et al. 2020). In areas where child feces are not removed from their original defecation sites, the presence of diarrhea
Figure 5 |Forest plot of the subgroup analysis by data source pooled odds ratio of unsafe child feces disposal practices and childhood
diarrhea.
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 750
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
may be influenced not only by unsafe stool disposal but also by feeding practices, maternal personal hygiene, and environ-
mental sanitation. This implies that, in addition to sanitation facility improvements, behavior change strategies on feeding
practices, maternal/guardian personal hygiene practices, drinking water handling, and proper utilization and increasing
latrine access are required.
Table 2 |Sensitivity analysis of 20 studies included in the systematic review and meta-analysis of unsafe child feces disposal practices and
its association with childhood diarrhea
No. Omitted study Pooled odds ratio (95% CI) I
2
P-value
1Aliyu & Dahiru (2019) 1.05 0.84–1.26 97.67 0.001
2Azage & Haile (2015) 1.05 0.84–1.27 97.49 0.001
3Bawankule et al. (2017) 1.02 0.81–1.24 97.27 0.001
4Cronin et al. (2016) 1.02 0.81–1.22 97.43 0.001
5Sahiledengle (2020) 1.06 0.84–1.29 97.68 0.001
6Sahiledengle (2019) 1.07 0.86–1.29 97.57 0.001
7Seidu et al. (2020) 1.06 0.85–1.28 97.75 0.001
8Seidu et al. (2021) 1.07 0.84–1.29 97.22 0.001
9Simelane et al. (2020) 1.07 0.84–1.29 97.84 0.001
10 Vong et al. (2021) 1.02 0.80–1.23 97.58 0.001
11 Mihrete et al. (2014) 1.08 0.88–1.28 97.23 0.001
12 Sidabalok et al. (2019) 1.00 0.81–1.20 97.23 0.001
13 Alemayehu et al. (2021) 1.01 0.82–1.21 97.35 0.001
14 Wilunda & Alessio (2009) 1.02 0.81–1.23 97.48 0.001
15 Soboksa (2021) 1.07 0.85–1.29 97.66 0.001
16 Islam et al. (2018) 1.04 0.83–1.25 97.63 0.001
17 Getahun & Adane (2021) 1.01 0.81–1.20 97.25 0.001
18 Aluko et al. (2017) 1.07 0.89–1.29 96.69 0.001
19 Soboksa et al. (2021) 1.00 0.80–1.20 97.41 0.001
20 Siruri (2013) 1.03 0.83–1.23 97.52 0.001
Figure 6 |Funnel plot with 95% confidence limits of the association between unsafe child feces disposal practices and childhood diarrhea.
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 751
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
On the other hand, aggregate studies conducted in Asia showed that the likelihood of diarrhea increased significantly when
mothers/guardians engaged in unsafe disposal of infant feces. The results of this subgroup analysis confirm a previous sys-
tematic review and meta-analysis which found that unsafe practices for disposing of infant feces increase the risk of
diarrheal disease (Gil et al. 2004). This could be because open feces in the compound, as well as wash-off or run-off from
precipitation into other compounds and nearby watercourses (unsafe disposal of child feces), can increase the risk of fecal
exposure for compound members, particularly young children who spend time in the courtyard area and have hand contact
with feces or soil contaminated by feces (fecal pathogens) that cause diarrhea diseases in children (Gil et al. 2004;Kwong
et al. 2016). These results indicate the need for further systematic review and meta-analysis of intervention studies on the
effects of unsafe child fecal disposal practices on diarrhea in children to examine the relationships between child fecal dis-
posal practices and diarrhea.
We recognized some limitations in this systematic review and meta-analysis. The first concern was the use of English-only
articles. Another limitation is that because all studies in this review were cross-sectional, the outcome variable may be
affected by other confounding variables. In addition, because the articles included were from a limited number of countries,
the pooled prevalence and likelihood OR may not represent the entire population in low- and middle-income countries.
CONCLUSIONS
The pooled prevalence of unsafe child feces disposal practices among mothers/guardians was high in low- and middle-income
countries according to this study. This meta-analysis also showed that there was no significant association between unsafe
child feces disposal practices and childhood diarrhea. According to the subgroup study, there is no significant link between
unsafe child feces disposal practices and child diarrhea in Africa. However, when studies from Asia were pooled, unsafe dis-
posal of child feces was found to be significantly associated with the odds of diarrhea. Non-governmental organizations and
government organizations should increase their efforts to reduce unsafe child feces disposal in light of the findings. It is also
critical to promote the advantages of proper child feces disposal. Strengthening safe child feces disposal is recommended in
Asia to reduce childhood diarrhea, whereas in Africa, it is better to focus on sanitation facility improvements, hygiene, and
sanitation behavior change strategies rather than safe child feces disposal. Furthermore, additional systematic reviews and
meta-analysis are recommended to assess the link between unsafe fecal disposal practices in children and childhood diarrhea.
ACKNOWLEDGEMENTS
We thank the authors of the studies included in this analysis.
FUNDING
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
AUTHORS’CONTRIBUTIONS
N.E.S. conceptualize the review. N.E.S. and D.B.G. extracted data and, with the support of B.N., conducted a meta-analysis.
The manuscript was written by N.E.S., B.N., A.E.H., and B.K.O. contributed to the critical review of the manuscript. All
authors read and approved the final manuscript.
DATA AVAILABILITY STATEMENT
All relevant data are included in the paper or its Supplementary Information.
CONFLICT OF INTEREST
The authors declare there is no conflict.
REFERENCES
Alemayehu, K., Oljira, L., Demena, M., Birhanu, A. & Workineh, D. 2021 Prevalence and determinants of diarrheal diseases among under-
five children in Horo Guduru Wollega Zone, Oromia Region, Western Ethiopia: a community-based cross-sectional study.Can. J. Infect.
Dis. Med. Microbiol. 2021. https://doi.org/10.1155/2021/5547742.
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 752
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
Aliyu, A. & Dahiru, T. 2019 Factors associated with safe disposal practices of child’s faeces in Nigeria: evidence from 2013 Nigeria
Demographic and Health Survey.Niger. Med. J. 60, 198. https://doi.org/10.4103/nmj.nmj_3_19.
Aluko, O. O., Afolabi, O. T., Olaoye, E. A., Adebayo, A. D., Oyetola, S. O. & Abegunde, O. O. 2017 The management of the faeces passed by
under five children: an exploratory, cross-sectional research in an urban community in Southwest Nigeria.BMC Public Health 17,1–15.
https://doi.org/10.1186/s12889-017-4078-1.
Aromataris, E. & Munn, Z. 2020 JBI Reviewer’s Manual. The Joanna Briggs Institute.
Azage, M. & Haile, D. 2015 Factors associated with safe child feces disposal practices in Ethiopia: evidence from demographic and health
survey.Arch. Public Health 73,1–9. https://doi.org/10.1186/s13690-015-0090-z.
Bárcena, A., Cimoli, M., García-Buchaca, R., Yáñez, L. F. & Pérez, R. 2018 The 2030 Agenda and the Sustainable Development Goals: An
Opportunity for Latin America and the Caribbean Thank You for Your Interest in This ECLAC Publication.
Bauza, V., Ocharo, R. M., Nguyen, T. H. & Guest, J. S. 2017 Soil ingestion is associated with child diarrhea in an urban slum of Nairobi,
Kenya.Am. J. Trop. Med. Hyg. 96, 569–575. https://doi.org/10.4269/ajtmh.16-0543.
Bauza, V., Majorin, F., Routray, P., Sclar, G. D., Caruso, B. A. & Clasen, T. 2020 Child feces management practices and fecal contamination: a
cross-sectional study in rural Odisha, India.Sci. Total Environ. 709, 136169. https://doi.org/10.1016/j.scitotenv.2019.136169.
Bawankule, R., Singh, A., Kumar, K. & Pedgaonkar, S. 2017 Disposal of children’s stools and its association with childhood diarrhea in India.
BMC Public Health 17,1–9. https://doi.org/10.1186/s12889-016-3948-2.
Chang, Y., Phillips, M. R., Guymer, R. H., Thabane, L., Bhandari, M., Chaudhary, V., Wykoff, C. C., Sivaprasad, S., Kaiser, P., Sarraf, D.,
Bakri, S., Garg, S. J., Singh, R. P., Holz, F. G. & Wong, T. Y. 2022 The 5 min meta-analysis: understanding how to read and interpret a
forest plot.Eye 36, 673–675. https://doi.org/10.1038/s41433-021-01867-6.
Cronin, A. A., Sebayang, S. K., Torlesse, H. & Nandy, R. 2016 Association of safe disposal of child feces and reported diarrhea in Indonesia:
need for stronger focus on a neglected risk.Int. J. Environ. Res. Public Health 13,1–13. https://doi.org/10.3390/ijerph13030310.
Getahun, W. & Adane, M. 2021 Prevalence of acute diarrhea and associated factors among children under five in semi-urban areas of
northeastern Ethiopia.BMC Pediatr. 21,1–15. https://doi.org/10.1186/s12887-021-02762-5.
Gil, A., Lanata, C., Kleinau, E. & Penny, M. 2004 Strategic Report 11 Children’s Feces Disposal Practices in Developing Countries and
Interventions to Prevent Diarrheal Diseases, for International Development.
Hannah, R. & Roser, M. 2021 Clean water and sanitation. In: Our World in Data. https://doi.org/10.1007/978-3-030-38815-7_6.
Higgins, J. P. T. & Thompson, S. G. 2002 Quantifying heterogeneity in a meta-analysis.Stat. Med. 21, 1539–1558. https://doi.org/10.1002/
sim.1186.
Islam, M., Ercumen, A., Ashraf, S., Rahman, M., Shoab, A. K., Luby, S. P. & Unicomb, L. 2018 Unsafe disposal of feces of children ,3 years
among households with latrine access in rural Bangladesh: association with household characteristics, fly presence and child diarrhea.
PLoS ONE 13,1–13. https://doi.org/10.1371/journal.pone.0195218.
Islam, M., Rahman, M., Unicomb, L., Kafi, M. A. H., Rahman, M., Alam, M., Sen, D., Islam, S., Pickering, A. J., Hubbard, A. E., Luby, S. P.,
Arnold, B. F., Colford, J. M. & Ercumen, A. 2020 Child defecation and feces management practices in rural Bangladesh: associations
with fecal contamination, observed hand cleanliness and child diarrhea.PLoS ONE 15,1–16. https://doi.org/10.1371/journal.pone.
0236163.
Kwong, L. H., Ercumen, A., Pickering, A. J., Unicomb, L., Davis, J. & Luby, S. P. 2016 Hand- and object-mouthing of rural Bangladeshi
children 3–18 months old.Int. J. Environ. Res. Public Health 13. https://doi.org/10.3390/ijerph13060563.
Lamichhane, P., Sharma, A. & Mahal, A. 2018 Does safe disposal of child faeces matter? An assessment of access to improved sanitation and
child faeces disposal behaviour and diarrhoea in rural Nepal.Int. Health 10, 277–284. https://doi.org/10.1093/inthealth/ihy030.
Le Blanc, D. 2015 Towards integration at last? The Sustainable Development Goals as a network of targets.Sustainable Dev. 23, 176–187.
https://doi.org/10.1002/sd.1582.
Majorin, F., Freeman, M. C., Barnard, S., Routray, P., Boisson, S. & Clasen, T. 2014 Child feces disposal practices in rural Orissa: a cross
sectional study.PLoS ONE 9,1–7. https://doi.org/10.1371/journal.pone.0089551.
Majorin, F., Torondel, B., Chan, G. K. S. & Clasen, T. 2019 Interventions to improve disposal of child faeces for preventing diarrhoea and soil-
transmitted helminth infection.Cochrane Database Syst. Rev. 2019. https://doi.org/10.1002/14651858.CD011055.pub2.
Mihrete, T. S., Alemie, G. A. & Teferra, A. S. 2014 Determinants of childhood diarrhea among underfive children in Benishangul Gumuz
Regional State, North West Ethiopia.BMC Pediatr. 14,1–9.
Moher, D., Liberati, A., Tetzlaff, J., Altman, D. G., Altman, D., Antes, G., Atkins, D., Barbour, V., Barrowman, N., Berlin, J. A., Clark, J.,
Clarke, M., Cook, D., D’Amico, R., Deeks, J. J., Devereaux, P. J., Dickersin, K., Egger, M., Ernst, E., Gøtzsche, P. C., Grimshaw, J., Guyatt,
G., Higgins, J., Ioannidis, J. P. A., Kleijnen, J., Lang, T., Magrini, N., McNamee, D., Moja, L., Mulrow, C., Napoli, M., Oxman, A., Pham,
B., Rennie, D., Sampson, M., Schulz, K. F., Shekelle, P. G., Tovey, D. & Tugwell, P. 2009 Preferred reporting items for systematic reviews
and meta-analyses: the PRISMA statement.PLoS Med. 7, 889–896. https://doi.org/10.3736/jcim20090918.
Moola, S., Munn, Z., Tufanaru, C., Aromataris, E., Sears, K., Sfetc, R., Currie, M., Lisy, K., Qureshi, R., Mattis, P. & Mu, P.-F. 2020 Chapter 7:
systematic reviews of etiology and risk. In: JBI Manual for Evidence Synthesis. https://doi.org/10.46658/jbimes-20-08.
Sahiledengle, B. 2019 Prevalence and associated factors of safe and improved infant and young children stool disposal in Ethiopia: evidence
from demographic and health survey.BMC Public Health 19,1–13. https://doi.org/10.1186/s12889-019-7325-9.
Sahiledengle, B. 2020 Unsafe child feces disposal status in Ethiopia: what factors matter? Analysis of pooled data from four demographic and
health surveys.BMC Public Health 20,1–12. https://doi.org/10.1186/s12889-020-08945-6.
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 753
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
Sara, S. & Graham, J. 2014 Ending open defecation in rural Tanzania: which factors facilitate latrine adoption? Int. J. Environ. Res. Public
Health 11, 9854–9870. https://doi.org/10.3390/ijerph110909854.
Seidu, A. A., Agbaglo, E., Ahinkorah, B. O., Dadzie, L. K., Bukari, I., Ameyaw, E. K. & Yaya, S. 2020 Individual and contextual factors
associated with disposal of children’s stools in Papua New Guinea: evidence from the 2016–2018 demographic and health survey.BMC
Public Health 20,1–11. https://doi.org/10.1186/s12889-020-09852-6.
Seidu, A. A., Ahinkorah, B. O., Kissah-Korsah, K., Agbaglo, E., Dadzie, L. K., Ameyaw, E. K., Budu, E. & Hagan, J. E. 2021 A multilevel
analysis of individual and contextual factors associated with the practice of safe disposal of children’s faeces in sub-Saharan Africa.PLoS
ONE 16,1–17. https://doi.org/10.1371/journal.pone.0254774.
Sidabalok, D. L., Samsudin, S. & Djaja, I. M. 2019 Relationship Between Environmental Factors and Personal Hygiene with Diarrhea among
Children Under Five in West Kotawaringin, Central Kalimantan. https://doi.org/10.26911/the6thicph.01.17.
Simelane, M. S., Chemhaka, G. B., Maphosa, T. & Zwane, E. 2020 Unsafe disposal of faeces and its correlates among children under three
years in Eswatini.S. Afr. J. Child Heal. 14, 217–223. https://doi.org/10.7196/SAJCH.2020.v14i4.1726.
Siruri, B. M. 2013 Environmental and Behavioral Factors on Diarrhea Occurrence in Children Under Five Years Old in Mabera Sub-county,
Migori County Kenya. Maseno University.
Soboksa, N. E. 2021 Associations between improved water supply and sanitation usage and childhood diarrhea in Ethiopia: an analysis of the
2016 demographic and health survey.Environ. Health Insights 15,1–10. https://doi.org/10.1177/11786302211002552.
Soboksa, N. E., Gar, S. R., Hailu, A. B. & Alemu, B. M. 2021 Child defecation, feces disposal practices and associated factors in community-
led total sanitation adopted districts in Jimma Zone, Ethiopia.Environ. Challenges 3, 100059. https://doi.org/10.1016/j.envc.2021.
100059.
Stanton, B. F. & Clemens, J. D. 1987 An educational intervention for altering water-sanitation behaviors to reduce childhood diarrhea in
urban Bangladesh: II. A randomized trial to assess the impact of the intervention on hygienic behaviors and rates of diarrhea.Am. J.
Epidemiol. 125, 292–301. https://doi.org/10.1093/oxfordjournals.aje.a114529.
Sultana, R., Mondal, U. K., Rimi, N. A., Unicomb, L., Winch, P. J., Nahar, N. & Luby, S. P. 2013 An improved tool for household faeces
management in rural Bangladeshi communities.Trop. Med. Int. Health 18, 854–860. https://doi.org/10.1111/tmi.12103.
Vong, P., Banchonhattakit, P., Sim, S., Pall, C. & Dewey, R. S. 2021 Unhygienic stool-disposal practices among mothers of children under five
in Cambodia: evidence from a demographic and health survey.PLoS ONE. https://doi.org/10.1371/journal.pone.0249006.
WHO 2019 Sanitation [WWW Document]. WHO Press. Available from: https://www.who.int/news-room/fact-sheets/detail/sanitation
(accessed 23 Feburary 20).
WHO 2022 Sanitation [WWW Document]. Available from: https://www.who.int/news-room/fact-sheets/detail/sanitation (accessed 28
September 2022).
WHO/UNICEF 2006 Core Questions on Drinking Water and Sanitation for Household Surveys.
Wilunda, C. & Alessio, P. 2009 Factors associated with diarrhea and acute respiratory infections among children less than 5 years old in
Thailand: a secondary analysis of Thailand multiple indicator. J. Health Res. 23,17–22.
World Bank Group and UNICEF 2014 Child Feces Disposal in Lao PDR. Washington, DC.
World Bank/UNICEF 2015 Child Feces Disposal in Kenya. Available from: http://www.wsp.org/sites/wsp.org/files/publications/WSP-
Kenya-CFDProfile.pdf.
First received 4 March 2022; accepted in revised form 13 October 2022. Available online 25 October 2022
Journal of Water, Sanitation and Hygiene for Development Vol 12 No 11, 754
Downloaded from http://iwaponline.com/washdev/article-pdf/12/11/742/1139619/washdev0120742.pdf
by guest
on 30 November 2022
