Child Feces Disposal in 96444 ZAMBIA Key messages: • In 2007, 33 percent of households surveyed in Zambia reported unsafe disposal of the feces of their youngest child under age three—i.e., they were not deposited into a latrine or toilet. • Even among households with improved toilets or latrines, 11 percent reported unsafe child feces disposal behavior. • Safe child feces disposal steadily increases with the wealth of the household: only 32 percent of the poorest quintile reports safe disposal compared to 93 percent of the richest quintile.1 OVERVIEW children—have a higher prevalence of unsafe disposal of child feces (see Figure 2). In 2007, 87 percent of urban households reported safe disposal Safe disposal of children’s feces is as essential as the safe disposal of compared to 52 percent of rural households. Households practicing open adults’ feces. This brief provides an overview of the available data on defecation reported the highest level of unsafe child feces disposal, at 71 child feces disposal in Zambia and concludes with ideas to strengthen percent. For these 22 percent of households practicing open defecation safe disposal practices, based on emerging good practice. (i.e., they do not use a latrine), it is possible, but not probable, that they The Joint Monitoring Programme for Water Supply and Sanitation deposit their children’s feces into a latrine (see Figure 3 and notes on self- (JMP) tracks progress toward the Millennium Development Goal 7 reported data in the “Data Sources” section). target to halve, by 2015, the proportion of people without sustainable The prevalence of safe feces disposal is fairly similar across age groups access to safe drinking water and basic sanitation. The JMP in Zambia. After age two, children are increasingly likely to use a toilet/ standardized definition for an improved sanitation facility is one that latrine themselves (see Figure 4). At these young ages, the behavior hygienically separates human excreta from human contact.2 of the child’s caregiver is critical to dispose of their feces safely and In the latest JMP report, only 43 percent of Zambia’s population had shape the child’s toilet training. The low prevalence of safe disposal in access to improved sanitation in 2012.3 This means that 8 million children age four is partly due to the large amount of missing data for individuals in Zambia lacked improved sanitation in 2012, of which this age category; this may reflect the fact that caregivers are no longer 2.25 million practice open defecation. However, this estimate is based as involved and thus not as aware of where their older children defecate. on the household’s primary sanitation facility, and may overlook Safe disposal differs widely across the wealth asset quintiles.4 The the sanitation practices of young children. In many cases, children poorest quintile of households is substantially less likely than richer may not be able to use an improved toilet or latrine—due to their households to report safe child feces disposal. Indeed, only 33 percent age and stage of physical development or the safety concerns of their of the poorest quintile reports safe disposal (see Figure 5). Looking at caregivers—even if their household has access to one. overall sanitation facility coverage for households with children under age three, only 37 percent of the poorest households reported use of SUMMARY OF CHILD FECES any toilet/latrine (improved, shared, or unimproved), compared to DISPOSAL DATA What Is “Safe Disposal” of a Child’s Feces? In 2007, two thirds (67 percent) of households in Zambia reported that the feces of their youngest child under age three were safely disposed of. Only The safest way to dispose of a child’s feces is to help the 18 percent of households in Zambia reported that their youngest child’s child use a toilet or latrine or, for very young children, to put feces were disposed of into an improved sanitation facility, according to or rinse their feces into a toilet or latrine. For the purposes the 2007 Demographic and Health Survey (DHS) (see Figure 1). This of this brief, these disposal methods are referred to as low percentage of households reporting improved child feces disposal “safe,” whereas other methods are considered “unsafe.” By suggests that children under age three have worse sanitation than the definition, “safe disposal” is only possible where there country’s broader population, where 43 percent use improved sanitation. is access to a toilet or latrine. When a child’s feces is put or rinsed into an “improved” toilet or latrine, this is termed In Zambia, households lacking improved sanitation, those in rural “improved child feces disposal.” areas, and poorer households—as well as households with younger December 2014 1 FIGURE 1  Safe disposal is relatively high, but prevalence of improved disposal is much lower. Percentage of households reporting each feces disposal practice for their youngest child under age three, Zambia, 2007. Unsafe Disposal Safe Disposal Child used toilet/latrine Other, 7% and household (HH) used improved Left in the open, 3% sanitation, 2% Improved Buried, 7% Child feces put/rinsed disposal = 18% in toilet/latrine and Thrown into HH used improved garbage, 8% Safe sanitation, 16% disposal = 67% Child used toilet/latrine, Put/rinsed into but HH used unimproved drain or ditch, 8% sanitation, 4% Child feces put/rinsed in toilet/latrine but HH used unimproved sanitation, 45% FIGURE 2  Households with access to an improved or shared facility were much more likely to use safe feces What Is the Impact of Unsafe Disposal disposal. Reported feces disposal practice for households’ of Child Feces? youngest child under age three, by household sanitation There is widespread belief that the feces of infants and young facility type, Zambia, 2007. children are not harmful, but this is untrue. In fact, there is evidence that children’s feces could be more risky than adult 100 11% feces, due to a higher prevalence of diarrhea and pathogens— 17% 80 33% such as hepatitis A, rotavirus, and E. coli—in children than in adults.5 Therefore, children’s feces should be treated with the % of children 60 71% same concern as adult feces, using safe disposal methods 89% that ensure separation from human contact and household 40 67% contamination. 83% 20 In particular, the unsafe disposal of children’s feces may be 29% an important contaminant in household environments, posing 0 Open Unimproved Shared Improved a high risk of exposure to young infants.6 Poor sanitation can defecation (39% of (20% of (20% of result in substantial health impacts in children, including a (22% of households) households) households) higher prevalence of diarrheal disease, intestinal worms, households) enteropathy, malnutrition, and death. According to the World Type of sanitation facility used by household (HH) Health Organization (WHO), most diarrheal deaths in the world (88 percent) are caused by unsafe water, sanitation, Unsafe child feces disposal Safe child feces disposal or hygiene. More than 99 percent of these deaths are in developing countries, and about eight in every 10 deaths are children.7 Diarrhea obliges households to spend significant sums on medicine, transportation, health facility fees, and 100 percent of households in the richest quintile. This is an important more, and can mean lost work, wages, and productivity factor in child feces disposal: by definition, safe disposal is only among working household members.8 Stunting and worm possible when there is access to a toilet/latrine. infestation can reduce children’s intellectual capacity, which Behind this national-level data, there is wide variation in child feces affects productivity later in life. The WHO estimates that the disposal practices, with a greater prevalence of unsafe practices average IQ loss per worm infection is around 3.75 points.9 among households without access to improved sanitation, in rural areas, and those that are poorer. For example, unsafe disposal in rural areas and among the poorest 20 percent of households is worse than among children overall. Although this brief only focuses on one IDEAS FOR CONSIDERATION socioeconomic indicator at a time, applying multiple lenses would show even greater extremes of disparity—with the poorest rural In Zambia, there are few interventions aimed specifically at the safe households with the youngest children and no sanitation facility disposal of children’s feces during the first years of life. In general, likely reporting the greatest prevalence of unsafe disposal. sanitation for children under age three has been a neglected area of 2 FIGURE 3  Percentage of households reporting safe feces disposal for their youngest child under age three, Africa.10 FIGURE 4  Children’s feces disposal behaviors are FIGURE 5  Safe child feces disposal steadily similar across different age groups. Toilet use begins increases with increasing wealth. Reported feces to increase at age two. Reported feces disposal practice disposal practice for households’ youngest child under age for children of different ages, Zambia, 2007. three, by household wealth quintile, Zambia, 2007. 100 6% 5% 100 1% 1% 8% 6% 6% 11% 7% 4% 1% 3% 2% 3% 27% 5% 2% 10% 7% 4% 9% 15% 4% 6% 4% 9% 80 8% 6% 7% 9% 7% 10% 5% 80 6% 10% 7% 9% 4% % of children 7% 16% 9% % of children 4% 22% 60 7% 60 5% 13% 84% 5% 16% 40 66% 56% 53% 76% 61% 40 56% 8% 36% 44% 20 20 31% 1% 3% 13% 14% 11% 0 2% 2% 10% 4% 9% 0 0 1 2 3 4 Poorest Poorer Middle Richer Richest Child age (years) Wealth quintile of child’s household Missing Buried Missing Buried Other Thrown into garbage Other Thrown into garbage Left in the open Put/rinsed into toilet/latrine Left in the open/not disposed of Put/rinsed into toilet/latrine Put/rinsed into drain or ditch Child used toilet/latrine Put/rinsed into drain or ditch Child used toilet/latrine policy and program intervention. Given the relatively few programs focusing on children’s sanitation in Zambia and globally, there is • Conducting formative research to understand the behavioral not a strong evidence base of effective strategies for increasing the drivers and barriers to safe child feces disposal safe disposal of children’s feces. Significant knowledge gaps must • Strengthening efforts to change the behavior of caregivers through be filled before comprehensive, practical evidence-based policy and programs that encourage cleaning children after defecation, potty program guidance will be available. Nevertheless, organizations and training children, and using appropriate methods to transport governments interested in improving the management of children’s feces into a toilet/latrine as well as handwashing with soap after feces could consider: fecal contact and before preparing food or feeding a child 3 REFERENCES 1 Central Statistical Office (CSO), Ministry of Health (MOH), Tropical Diseases Research Centre (TDRC), University of Zambia, and Macro International Inc. 2009. Zambia Demographic and Health Survey 2007. Lusaka, Zambia: CSO, and Calverton, Maryland: Macro International Inc. Please see the “Data Sources” section. 2 The JMP has established a set of standardized definitions to categorize improved sanitation, which are used to track progress toward Millennium Development Goal 7. However, these definitions are not always the same as those used by national governments. See Progress on Drinking Water and Sanitation: Update 2014. 3 WHO/UNICEF Joint Monitoring Programme. 2014. Progress on Drinking Water and Sanitation: Update 2014. Geneva: World Health Organization. 4 The wealth indices used to classify households into wealth quintiles include drinking water and sanitation variables. 5 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. • Exploring opportunities to integrate child sanitation into existing 6 Gil, A., C. Lanata, E. Kleinau, and M. Penny. 2004. Children’s Feces Disposal interventions that target caregivers of young children, such as Practices in Developing Countries and Interventions to Prevent Diarrheal including key messages in antenatal/newborn care materials and Diseases: A Literature Review. Strategic Report 11. Peru: Environmental infant and young child feeding guidance provided to parents, Health Project (EHP). ensuring midwives’ training includes information on safe child 7 WHO. 2009. Global Health Risks: Mortality and Burden of Disease feces disposal, and integrating child sanitation information into Attributable to Selected Major Risks. Geneva: World Health Organization, 23. 8 Favin, M., Naimoli, G., and Sherburne, L. 2004. Improving Health Through early childhood development materials and preschool programs Behavior Change: A Process Guide on Hygiene Promotion. Joint Publication 7. • Partnering with the private sector to improve feces management Washington, DC: Environmental Health Project (EHP). tools, such as potties, diapers, tools for retrofitting latrines for 9 WHO. 2005. Report of the Third Global Meeting of the Partners for Parasite child use, and scoopers Control: Deworming for Health and Development. Geneva: World Health • Improving the enabling environment for management of Organization, 15. children’s feces, by including specific child feces related criteria in 10 The latest available MICS/DHS survey with data for each country, as open defecation free (ODF) verification protocols and in national of May 2014. Survey years range from 2006–2012. Please see the “Data sanitation policies, strategies, or monitoring mechanisms. Sources” section at the end of the brief. 11 Stanton, B., J. Clemens, K. Azis, and M. Rahamanr. 1987. “Twenty-Four- Hour Recall, Knowledge-Attitude-Practice Questionnaires and Direct DATA SOURCES Observations of Sanitary Practices: A Comparative Study.” Bulletin of the World Health Organization. Geneva: World Health Organization. Unless otherwise specified, all analysis in this brief is based on child feces 12 Akhtaruzzaman, M. N., and S. N. Islam. 2011. Nutrition, Health and disposal behavior self-reported by the child’s mother or caregiver in the 2005 Demographic Survey of Bangladesh—2011: A Preliminary Report. Zambia DHS, which is the latest Multiple Indicator Cluster Survey (MICS) or Bangladesh: University of Dhaka, 19. DHS available for Zambia that records child feces disposal behaviors. The MICS and DHS collect data in a generally harmonized manner and hence NOTES are the basis for this country profile series. However, whereas the DHS collects data on the youngest child under age five living with the mother for each We’re interested in your thoughts. Have you found different evidence household, the MICS collects data on all children under age three who live with of what works through your own programming? If you have thoughts to the respondent (mother or caretaker). To maximize comparability, we restricted share, or know of a program that is encouraging the safe disposal of child all analysis to children under age three in all figures, except Figure 4. However, feces, please contact WSP at worldbankwater@worldbank.org or UNICEF at the fact that the MICS data are for all children in the age group and the DHS WASH@unicef.org so that we can integrate your information into future data are only for the youngest per household, means that some limitations to program guidance. the comparability of the MICS and DHS data presented in Figure 3 remain. The map in Figure 3 presents MICS data for the following countries: Central ACKNOWLEDGEMENTS African Republic, Chad, DRC, Gambia, Ghana, Malawi, Mauritania, Nigeria, Sierra Leone, Somalia, South Sudan, Swaziland, Togo, and Tunisia; DHS data is This brief was developed jointly by WSP and the United Nations Children’s presented for the following countries: Benin, Burkina Faso, Burundi, Cameroon, Fund (UNICEF) as part of a series of country profiles about sanitation for Cote D’Ivoire, Egypt, Ethiopia, Guinea, Kenya, Lesotho, Liberia, Madagascar, children under age three. Mali, Mauritania, Morocco, Mozambique, Namibia, Niger, Rwanda, Sao tome and Principe, Senegal, Tanzania, Uganda, Zambia, and Zimbabwe. The findings, interpretations, and conclusions expressed herein are those of the author(s), and do not necessarily reflect the views of the International It is likely that self-reports overestimate safe disposal.11 In Bangladesh, for Bank for Reconstruction and Development / The World Bank and its affiliated example, although 22 percent of children reportedly either used a toilet/latrine organizations, or those of the Executive Directors of The World Bank or the or their feces were put or rinsed into the toilet/latrine (according to MICS 2006), governments they represent, or of UNICEF. a structured observation of behavior conducted under UNICEF’s Sanitation, Hygiene Education and Water Supply in Bangladesh (SHEWA-B) program in © 2015 by International Bank for Reconstruction and Development / The 2007 found that only 9 percent of subjects disposed of child feces into a toilet/ World Bank and UNICEF. specific pit.12 Regardless of this issue, self-reports are currently regarded as the Photo Credits: © UNICEF/UKLA2013-04219/d’Elbee (page 1); © UNICEF/ most efficient method for gauging safe disposal of children’s feces. NYHQ2010-2928/Nesbitt (page 4) 4