Child Feces Disposal in 96423 CHAD Key messages: • In 2010, 82 percent of households surveyed in Chad reported unsafe disposal of the feces of their youngest child under age three. • Even among households with improved toilets or latrines, 33 percent reported unsafe child feces disposal behavior. • Safe child feces disposal dramatically increases with the wealth of the household: only 1 percent of the poorest quintile reports safe disposal compared to 65 percent of the richest quintile.1 OVERVIEW into the garbage. Due to variable solid waste management systems and environmetal health concerns such as leeching, this is considered Safe disposal of children’s feces is as essential as the safe disposal of an unsafe practice.4 adults’ feces. This brief provides an overview of the available data on child feces disposal in Chad and concludes with ideas to strengthen In Chad, households lacking improved sanitation, those in rural safe disposal practices, based on emerging good practice. areas, and poorer households—as well as households with younger children—have a higher prevalence of unsafe disposal of child The Joint Monitoring Programme for Water Supply and Sanitation feces. Between 2000 and 2010, reported safe disposal of child feces (JMP) tracks progress toward the Millennium Development Goal 7 decreased in both urban and rural areas (see Figure 2). Several factors target to halve, by 2015, the proportion of people without sustainable could have contributed to this decrease, but more research is needed access to safe drinking water and basic sanitation. The JMP to identify the key causes. standardized definition for an improved sanitation facility is one that hygienically separates human excreta from human contact.2 Households practicing open defecation reported the highest level of unsafe child feces disposal, at 98 percent (see Figure 3). However, According to the latest JMP report, only 12 percent of Chad’s 2 percent of households practicing open defecation (i.e., they do not population had access to improved sanitation in 2012.3 This means use a latrine) reported safe child feces disposal. It is possible, but not that around 10 million individuals in Chad lacked improved sanitation probable, that households that do not use a latrine themselves deposit in 2012, of which 7.4 million practice open defecation. However, these their children’s feces into a latrine.   estimates are based on the household’s primary sanitation facility, and may overlook the sanitation practices of young children. In many The prevalence of safe feces disposal is fairly similar across age groups: cases, children may not be able to use an improved toilet or latrine— 17–31 percent of households reported using safe feces disposal because of their age and stage of physical development or the safety regardless of the age of their youngest child under age three (see concerns of their caregivers—even if their household has access to one. Figure 4). At these young ages, the behavior of the child’s caregiver is critical to dispose of the feces safely and shape the child’s toilet training. SUMMARY OF CHILD FECES DISPOSAL DATA What Is “Safe Disposal” of a Child’s Feces? In Chad in 2010, less than a fifth of households (18 percent) reported The safest way to dispose of a child’s feces is to help that the feces of their youngest children under age three were safely the child use a toilet or latrine or, for very young children, disposed. Only 6 percent of households in Chad reported that their to put or rinse their feces into a toilet or latrine. For the youngest children’s feces were disposed of into an improved sanitation purposes of this brief, these disposal methods are referred facility, according to the 2010 Multiple Indicator Cluster Survey to as “safe,” whereas other methods are considered “unsafe.” (MICS) 4, as shown in Figure 1. This low percentage of households By definition, “safe disposal” is only possible where there reporting improved child feces disposal suggests that children is access to a toilet or latrine. When a child’s feces is put under age three have worse sanitation than the country’s broader or rinsed into an “improved” toilet or latrine, this is termed population, where 12 percent use improved sanitation. Interestingly, “improved child feces disposal.” a majority of households (51 percent) report throwing children’s feces December 2014 1 FIGURE 1  Safe disposal prevalence in Chad is very low, and the prevalence of improved disposal is negligible. In 2010, 15 percent of households left their child’s feces in the open. Percentage of children under age three with each feces disposal type, Chad, 2010. Unsafe Disposal Safe Disposal Missing, 3% Other, 2% Child used toilet/latrine and household (HH) Left in the open, 15% used improved sanitation, <1% Improved Buried, 7% Child feces put/rinsed disposal = 6% in toilet/latrine and HH used improved Safe sanitation, 6% disposal = 18% Thrown into Child used toilet/latrine, garbage, 51% but HH used unimproved sanitation, 1% Child feces put/rinsed in toilet/latrine but HH used unimproved sanitation, 11% Put/rinsed into drain or ditch, 5% FIGURE 2  The prevalence of safe child feces FIGURE 3  Even among households with improved disposal has decreased over time, but remains more sanitation, only two-thirds (67 percent) reported than 8 times higher in urban than in rural areas. safe child feces disposal behaviors. Reported feces Percentage of children under age three with safe feces disposal practice for children under age three, by household disposal, by urban and rural residence, Chad, 2000 and sanitation facility type, Chad, 2010. 2010.5 100 100 80 30% 33% 78% 61% % of children 80 60 60% 98% 60 % of children 40 40 70% 67% 20 39% 20 10% 7% 2% 0 0 Open Unimproved Shared Improved Urban Rural Urban Rural defecation (19% of (5% of (9% of (67% of households) households) households) 2000 2010 households) Type of sanitation facility used by household Unsafe child feces disposal Safe child feces disposal Safe disposal differs widely across the wealth asset quintiles.6 The poorest three quintiles of households were substantially less likely than the richer and richest households to report safe child feces Behind this national-level data, there is wide variation in child feces disposal (see Figure 5). Only 1–5 percent of the poorest three quintiles disposal practices, with a greater prevalence of unsafe practices reported safe disposal. Children’s feces from 16 percent of the poorest among households without access to improved sanitation, in rural households were left in the open, which is essentially open defecation. areas, and those that are poorer. For example, unsafe disposal in Looking at overall sanitation facility coverage for households with rural areas and among the poorest 60 percent of households is worse children under age three in Chad, less than 1 percent of the poorest than among children overall. Although this brief only focuses on one households reported use of a toilet/latrine compared to 92 percent of socioeconomic indicator at a time, applying multiple lenses would the richest quintile. This is an important factor in child feces disposal: show even greater extremes of disparity—with the poorest rural by definition, safe disposal is only possible when there is access to a households with the youngest children and no sanitation facility toilet/latrine. likely reporting the greatest prevalence of unsafe disposal. 2 FIGURE 4  Child feces disposal behaviors are fairly similar across child age groups; however, the oldest What Is the Impact of Unsafe Disposal have the highest prevalence of open defecation. of Child Feces? Reported feces disposal practice for children of different ages, Chad, 2010. There is widespread belief that the feces of infants and young children are not harmful, but this is untrue. In fact, 100 3% 2% there is evidence that children’s feces could be more risky 2% 1% 4% 1% 12% 15% than adults’ feces, due to a higher prevalence of diarrhea 19% 80 8% 6% and pathogens—such as hepatitis A, rotavirus, and E. coli—in 5% children than in adults.7 Therefore, children’s feces should % of children 60 51% be treated with the same concern as adults’ feces, using 51% 51% safe disposal methods that ensure separation from human 40 4% contact and household contamination. 20 8% 3% 19% In particular, the unsafe disposal of children’s feces may be 16% 15% an important contaminant in household environments, posing 0 1% 2% 2% 0 1 2 a high risk of exposure to young infants.8 Poor sanitation can Child age (years) result in substantial health impacts in children, including a higher prevalence of diarrheal disease, intestinal worms, Missing Thrown into garbage enteropathy, malnutrition, and death. According to the World Other Put/rinsed into drain or ditch Left in the open Put/rinsed into toilet/latrine Health Organization (WHO), most diarrheal deaths in the Buried Child used toilet/latrine world (88 percent) are caused by unsafe water, sanitation, or hygiene. More than 99 percent of these deaths are in developing countries, and about eight in every 10 deaths are FIGURE 5  Safe child feces disposal increases children.9 Diarrhea obliges households to spend significant substantially with increasing wealth, and is negligible sums on medicine, transportation, health facility fees, and in the poorest households. Reported feces disposal more, and can mean lost work, wages, and productivity practice for children under age 3, by household wealth among working household members.10 Stunting and worm quintile, Chad, 2010. infestation can reduce children’s intellectual capacity, which affects productivity later in life. The WHO estimates that the average IQ loss per worm infection is around 3.75 points.11 100 1% 2% 1% 1% 3% 16% 17% 14% 5% 22% 4% 80 10% 19% 6% 10% % of children 4% 60 • Conducting formative research to understand the behavioral 58% 50% drivers and barriers to safe child feces disposal 40 67% 59% 59% • Strengthening efforts to change the behavior of caregivers through 7% programs that encourage cleaning children after defecation, potty 20 training children, and using appropriate methods to transport 5% 5% 19% 0 3% 1% 3% 1% 4% 1% 2% 6% feces to a toilet/latrine as well as handwashing with soap after fecal Poorest Poorer Middle Richer Richest contact and before preparing food or feeding a child Wealth quintile of child’s household • Exploring opportunities to integrate child sanitation into existing interventions that target caregivers of young children, such as Missing Thrown into garbage including key messages in antenatal/newborn care materials and Other Put/rinsed into drain or ditch Left in the open Put/rinsed into toilet/latrine infant and young child feeding guidance provided to parents, Buried Child used toilet/latrine ensuring that midwives’ training, as well as early childhood development materials and preschool programs, include information on safe child feces disposal IDEAS FOR CONSIDERATION • Partnering with the private sector to improve feces management tools, such as potties, diapers, tools for retrofitting latrines for In Chad, there are few interventions aimed at the safe disposal of children’s use, and scoopers children’s feces during the first years of life. In general, sanitation • Improving the enabling environment for management of for children under age three has been a neglected area of policy children’s feces, by including specific child feces related criteria in and program intervention. Given the relatively few programs open defecation free (ODF) verification protocols and in national focusing on children’s sanitation in Chad and globally, there is sanitation policies, strategies, or monitoring mechanisms. not a strong evidence base of effective strategies for increasing the safe disposal of child feces. Significant knowledge gaps must be filled before comprehensive, practical evidence-based policy and program guidance will be available. Nevertheless, organizations and DATA SOURCES governments interested in improving the management of children’s Unless otherwise specified, all analysis in this brief is based on child feces feces could consider: disposal behavior self-reported by the child’s mother or caregiver in the 2010 3 5 Institut National de la Statistique, des Études Économiques et Démographiques (INSEED) and UNICEF. 2011. Enquête par Grappes à Indicateurs Multiples Tchad 2010. Chad: INSEED and UNICEF; and Institut National de la Statistique, des Études Économiques et Démographiques (INSEED) and UNICEF. 2001. Enquête par Grappes à Indicateurs Multiples Tchad 2000. Chad: INSEED and UNICEF. 6 The wealth indices used to classify households into wealth quintiles include drinking water and sanitation variables. 7 Feachem, R., D. Bradley, H. Garelick, et al. 1983.  Sanitation and Disease: Health Aspects of Excreta and Wastewater Management. World Bank Studies in Water Supply and Sanitation 3. Chichester, UK: John Wiley & Sons. 8 Gil, A., C. Lanata, E. Kleinau, and M. Penny. 2004. Children’s Feces Disposal Practices in Developing Countries and Interventions to Prevent Diarrheal Diseases: A Literature Review. Strategic Report 11. Peru: Environmental Health Project (EHP). 9 WHO. 2009. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva: World Health Organization, 23. 10 Favin, M., G. Naimoli, and L. Sherburne. 2004. Improving Health Through Behavior Change: A Process Guide on Hygiene Promotion. Joint Publication 7. Washington, DC: Environmental Health Project (EHP). 11 WHO. 2005. Report of the Third Global Meeting of the Partners for Parasite Control: Deworming for Health and Development. Geneva: World Health Organization, 15. Chad Multiple Indicator Cluster Survey (MICS) 4, which is the latest MICS or 12 Stanton, B., J. Clemens, K. Azis, and M. Rahamanr. 1987. “Twenty-Four- Demographic and Health Survey (DHS) available for Chad that records child Hour Recall, Knowledge-Attitude-Practice Questionnaires and Direct feces disposal behavior. Observations of Sanitary Practices: A Comparative Study.” Bulletin of the World Health Organization. Geneva: World Health Organization. The MICS and DHS collect data in a generally harmonized manner and hence 13 Akhtaruzzaman, M. N., and S. N. Islam. 2011. Nutrition, Health and are the basis for this country profile series. However, whereas the DHS collects Demographic Survey of Bangladesh—2011: A Preliminary Report. data on the youngest child under age five living with the mother for each Bangladesh: University of Dhaka, 19. household, the MICS collects data on all children under age three who live with the respondent (mother or caretaker). To maximize comparability, we restricted all analysis to children under age three in all figures, except Figure 4. It is likely that self-reports overestimate safe disposal.12 In Bangladesh, for NOTES example, although 22 percent of children reportedly either used a toilet/ We’re interested in your thoughts. Have you found different evidence latrine or their feces were put or rinsed into the toilet/latrine (according to of what works through your own programming? If you have thoughts to MICS 2006), a structured observation of behavior conducted under UNICEF’s share, or know of a program that is encouraging the safe disposal of child Sanitation, Hygiene Education and Water Supply in Bangladesh (SHEWA-B) feces, please contact WSP at worldbankwater@worldbank.org or UNICEF program in 2007 found that only 9 percent of subjects disposed of children’s at WASH@unicef.org so that we can integrate your information into future feces into a toilet/specific pit.13 Regardless of this issue, self-reports are program guidance. currently regarded as the most efficient method for gauging safe disposal of children’s feces. REFERENCES ACKNOWLEDGEMENTS This brief was developed jointly by WSP and the United Nations Children’s 1 Institut National de la Statistique, des Études Économiques et Fund (UNICEF) as part of a series of country profiles about sanitation for Démographiques (INSEED) and UNICEF, 2011. Enquéte par Grappes à children under age three. Indicateurs Multiples Tchad 2010. Chad: INSEED and UNICEF. Please see the “Data Sources” section. The findings, interpretations, and conclusions expressed herein are those of 2 The JMP has established a set of standardized definitions to categorize the author(s), and do not necessarily reflect the views of the International improved sanitation, which are used to track progress toward Millennium Bank for Reconstruction and Development / The World Bank and its affiliated Development Goal 7. However, these definitions are not always the same organizations, or those of the Executive Directors of The World Bank or the as those used by national governments. See Progress on Drinking Water governments they represent, or of UNICEF. and Sanitation: Update 2014. 3 WHO/UNICEF Joint Monitoring Programme, 2014. Progress on Drinking © 2015 by International Bank for Reconstruction and Development / The Water and Sanitation: Update 2014. Geneva: World Health Organization. World Bank and United Nations Children’s Fund UNICEF. 4 Feachem,  R.,  D Bradley,  H Garelick,  et al. 1983.  Sanitation and Disease: Health Aspects of Excreta and Wastewater Management. World Bank Studies Photo Credits: © UNICEF/UKLA2012-00043/Asselin (page 1); © World in Water Supply and Sanitation 3. Chichester, UK: John Wiley & Sons. Bank/NG026S06/2008 (page 4) 4