Child Feces Disposal in 96422 BURKINA FASO Key messages: • In 2010, 79 percent of households surveyed in Burkina Faso reported unsafe disposal of the feces of their youngest child under age three. • Even among households with improved toilets or latrines, 32 percent reported unsafe child feces disposal behavior. • Urban households were 7 times more likely to safely dispose of their children’s feces than rural households (73 percent versus 10 percent).1 OVERVIEW households (62  percent) reported throwing children’s feces into the garbage. Because of variable solid waste management systems and Safe disposal of children’s feces is as essential as the safe disposal of environmental health concerns such as leeching, this is considered adults’ feces. This brief provides an overview of the available data an unsafe practice.4 on child feces disposal in Burkina Faso and concludes with ideas to strengthen safe disposal practices, based on emerging good practice. Households lacking improved sanitation, those in rural areas, and poorer households—as well as households with younger children— The Joint Monitoring Programme for Water Supply and Sanitation have a higher prevalence of unsafe disposal of child feces. Between (JMP) tracks progress toward the Millennium Development Goal 7 2003 and 2010, overall reported safe disposal of child feces remained target to halve, by 2015, the proportion of people without sustainable approximately the same, but was substantially higher in urban areas access to safe drinking water and basic sanitation. The JMP (see Figure 2). 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). For these In the latest JMP report, only 19 percent of Burkina Faso’s population households practicing open defecation (i.e., they do not use a latrine), had access to improved sanitation in 2012.3 This means that 2  percent reported safe child feces disposal. It is possible, but not 13.4 million individuals in Burkina Faso lacked improved sanitation probable, that households that do not use a latrine themselves deposit in 2012, of which 9.3 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 A slight shift in safe disposal practices is also seen as children grow cases, children may not be able to use an improved toilet or latrine— (see Figure 4): only 20 percent of households with children under one because of their age and stage of physical development or the safety year old report safe disposal, compared to 31 percent of households concerns of their caregivers—even if their household has access to one. SUMMARY OF CHILD FECES What Is “Safe Disposal” of a Child’s Feces? DISPOSAL DATA The safest way to dispose of a child’s feces is to help the In Burkina Faso in 2010, less than a quarter (22 percent) of households child use a toilet or latrine or, for very young children, to put reported that the feces of their youngest child under age three were or rinse their feces into a toilet or latrine. For the purposes safely disposed. Only 9 percent of households reported that their of this brief, these disposal methods are referred to as youngest child’s feces were disposed of into an improved sanitation “safe,” whereas other methods are considered “unsafe.” By facility, according to the 2010 Demographic and Health Survey definition, “safe disposal” is only possible where there (DHS) (see Figure 1). This low percentage of households reporting is access to a toilet or latrine. When a child’s feces is put improved child feces disposal suggests that children under age three or rinsed into an “improved” toilet or latrine, this is termed have worse sanitation than the country’s broader population, where “improved child feces disposal.” 19 percent use improved sanitation. Interestingly, a majority of February 2015 1 FIGURE 1 The prevalence of safe disposal is low and improved disposal even lower. In 2010, 11 percent of households left their child’s feces in the open. Percentage of households reporting each feces disposal practice for their youngest child under age three, Burkina Faso, 2010. Unsafe Disposal Safe Disposal Other, 2% Child used toilet/latrine and household (HH) Left in the open, 11% used improved Buried, 2% sanitation, <1% Improved Child feces put/rinsed disposal = 9% in toilet/latrine and HH used improved Safe sanitation, 8% disposal = 22% Thrown into Child used toilet/latrine, garbage, 62% but HH used unimproved sanitation, <1% Child feces put/rinsed in toilet/latrine but HH used unimproved sanitation, 12% Missing, <1% Put/rinsed into drain or ditch, <1% FIGURE 2 The prevalence of safe child feces FIGURE 3 Even among households with improved disposal has stagnated over time, but remains more sanitation, only two-thirds (68 percent) reported safe than seven times higher in urban than in rural areas. child feces disposal. Reported feces disposal practice Percentage of households reporting safe feces disposal for for households’ youngest child under age 3, by household their youngest child under age three, by urban and rural sanitation facility type, Burkina Faso, 2010. residence, Burkina Faso, 2003 and 2010.5 100 100 76% 38% 32% 80 73% 80 51% % of children % of children 60 60 98% 40 40 62% 68% 20 20 49% 8% 10% 0 0 2% Urban Rural Urban Rural Open Unimproved Shared Improved 2003 2010 defecation (7% of (13% of (12% of (68% of households) households) households) households) Type of sanitation facility used by household (HH) with children who are four years old. Although safe disposal increases slightly with the age of the child, use of a toilet/latrine is fairly Unsafe child feces disposal Safe child feces disposal limited and only reaches to 5 percent for children age four. The feces of the oldest children are also the most likely to be left in the open (27  percent), which is essentially open defecation. At these young for households with children under age three in Burkina Faso, less ages, the behavior of the child’s caregiver is critical to dispose of their than 1 percent of the poorest households reported use of any toilet/ feces safely and shape the child’s toilet training. latrine (improved, shared, or unimproved), compared to 94 percent of the richest quintile. This is an important factor in children’s feces Safe disposal differs widely across the wealth asset quintiles.6 The disposal: by definition, safe disposal is only possible when there is poorest three quintiles of households are substantially less likely than access to a toilet/latrine. the richer and richest households to report safe child feces disposal; only 2–9 percent of the poorest three quintiles report safe disposal Behind this national-level data, there is wide variation in child feces (see Figure 5). The feces of 14 percent of children in the poorest disposal practices, with a greater prevalence of unsafe practices three quintiles of households were left in the open—equivalent among households without access to improved sanitation, in rural to open defecation. Looking at overall sanitation facility coverage areas, and those that are poorer. For example, unsafe disposal in 2 FIGURE 4 Child feces disposal behaviors differ across age groups: the oldest have the highest What Is the Impact of Unsafe Disposal prevalence of safe disposal but also have the highest of Child Feces? prevalence of open defecation. Reported feces disposal There is widespread belief that the feces of infants and young practice for children of different ages, Burkina Faso, 2010. children are not harmful, but this is untrue. In fact, there is evidence that children’s feces could be more risky than adult 100 3% 1% 1% 3% 1% 4% 1% 6% 11% feces, due to a higher prevalence of diarrhea and pathogens— 3% 2% 19% 80 26% 27% such as hepatitis A, rotavirus, and E. coli—in children than in 2% adults.7 Therefore, children’s feces should be treated with the % of children 2% 1% 60 same concern as adult feces, using safe disposal methods 68% 63% 53% 35% that ensure separation from human contact and household 43% 40 contamination. <1% 20 1% <1% 23% 27% In particular, the unsafe disposal of children’s feces may be 20% 21% 23% 1% 2% an important contaminant in household environments, posing 0 5% a high risk of exposure to young infants.8 Poor sanitation can 0 1 2 3 4 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 Health Organization (WHO), most diarrheal deaths in the Left in the open Put/rinsed into toilet/latrine world (88 percent) are caused by unsafe water, sanitation, Buried Child used toilet/latrine or hygiene. More than 99 percent of these deaths are in FIGURE 5 Safe child feces disposal increases developing countries, and about eight in every 10 deaths are 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 households’ youngest child under age among working household members.10 Stunting and worm three, by household wealth quintile, Burkina Faso, infestation can reduce children’s intellectual capacity, which 2010. affects productivity later in life. The WHO estimates that the average IQ loss per worm infection is around 3.75 points.11 100 2% 2% 3% 1% 2% 2% 1% 14% 14% 14% 10% 14% 2% 2% 1% 80 3% 3% a neglected area of policy and program intervention in the country. % of children Given the relatively few programs focusing on children’s sanitation 60 58% in Burkina Faso and globally, there is not a strong evidence base of 80% 76% 70% 79% effective strategies for increasing the safe disposal of children’s feces. 40 Significant knowledge gaps must be filled before comprehensive, <1% 20 practical evidence-based policy and program guidance will be 26% available. Nevertheless, organizations and governments interested in 2% <1% 4% 9% 2% 0 improving the management of children’s feces could consider: Poorest Poorer Middle Richer Richest Wealth quintile of child’s household • Conducting formative research to understand the behavioral drivers and barriers to safe child feces disposal Missing Thrown into garbage Other Put/rinsed into drain or ditch • Strengthening efforts to change the behavior of caregivers through Left in the open Put/rinsed into toilet/latrine programs that encourage cleaning children after defecation, potty Buried Child used toilet/latrine training children, and using appropriate methods to transport feces to a toilet/latrine, as well as handwashing with soap after fecal rural areas and among the poorest 60 percent of households is worse contact and before preparing food or feeding a child than among children overall. Although this brief only focuses on one • Exploring opportunities to integrate child sanitation into existing socioeconomic indicator at a time, applying multiple lenses would interventions that target caregivers of young children, such as show even greater extremes of disparity—with the poorest rural including key messages in antenatal/newborn care materials and households with the youngest children and no sanitation facility infant and young child feeding guidance provided to parents, likely reporting the greatest prevalence of unsafe disposal. ensuring that midwives’ training includes information on safe child feces disposal, and integrating child sanitation information into early childhood development materials and preschool programs IDEAS FOR CONSIDERATION • Partnering with the private sector to improve feces management tools, such as potties, diapers, tools for retrofitting latrines for In the past, some hygiene promotion programs in Burkina Faso child use, and scoopers have included messaging on safe disposal of children’s feces, and • Improving the enabling environment for management of some interesting research was done that showed: “it is not where the children’s feces, by including specific child feces related criteria in child defecates that matters but how the mother then deals with it.”12 open defecation free (ODF) verification protocols and in national However, in general, sanitation for children under age three has been sanitation policies, strategies, or monitoring mechanisms. 3 Multiples du Burkina Faso 2010. Ouagadougou, Burkina Faso: INSD, and Calverton, Maryland: ICF International; and INSD and ICF International. 2004. Enquête Démographique et de Santé et à Indicateurs Multiples du Burkina Faso 2003. Ouagadougou, Burkina Faso: INSD, and Calverton, Maryland: ICF International. 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. Opportunities to integrate child sanitation into existing interventions that 10 Favin, M., Naimoli, G., and Sherburne, L. 2004. Improving Health Through target caregivers of young children could be explored when appropriate. 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 DATA SOURCES Control: Deworming for Health and Development. Geneva: World Health Organization, 15. Unless otherwise specified, all analysis in this brief is based on child feces 12 Traoré, E., S. Cousens, V. Curtis, T. Mertens, F. Tall, A. Traoré, B. Kanki, disposal behavior self-reported by the child’s mother or caregiver in the 2010 I. Diallo, A. Rochereau, J. P. Chiron. “Child Defecation Behaviour, Stool Burkina Faso Demographic and Health Survey (DHS), which is the latest Disposal Practices, and Childhood Diarrhoea in Burkina Faso: Results Multiple Indicator Cluster Survey (MICS) or DHS available for Burkina Faso from a Case-Control Study.” Journal of Epidemiology & Community that records child feces disposal behaviors. Health 1994 (84): 270–275. http://jech.bmj.com/content/48/3/270.short .doi:10.1136/jech.48.3.270 The MICS and DHS collect data in a generally harmonized manner and hence 13 Stanton, B., J. Clemens, K. Azis, and M. Rahamanr. 1987. “Twenty-Four- are the basis for this country profile series. However, whereas the DHS collects Hour Recall, Knowledge-Attitude-Practice Questionnaires and Direct data on the youngest child under age five living with the mother for each Observations of Sanitary Practices: A Comparative Study.” Bulletin of the household, the MICS collects data on all children under age three who live World Health Organization. Geneva: World Health Organization. with the respondent (mother or caretaker). To maximize comparability, we 14 S. Cousens, B. Kanki, S. Toure, I. Diallo, and V. Curtis. 1996. “Reactivity restricted all analysis to children under age three in all figures, except Figure 4. and Repeatability of Hygiene Behaviour: Structured Observations from Burkina Faso.” Social Science & Medicine 43 (9): 1299–1308. It is likely that self-reports overestimate safe disposal.13 A study conducted in Burkina Faso14 comparing self-reported behavior with structured observations found there was a tendency to over-report practices perceived as “good,” e.g., the child used a potty (75 percent reported vs. 66 percent observed) or feces NOTES from used potties were disposed in a latrine (67 percent reported vs. 56 percent observed). Regardless of this issue, self-reports are currently regarded as the We’re interested in your thoughts. Have you found different evidence most efficient method for gauging safe disposal of children’s feces. of what works through your own programming? If you have thoughts to share, or know of a program that is encouraging the safe disposal of child feces, please contact WSP at worldbankwater@worldbank.org or UNICEF at WASH@unicef.org so that we can integrate your information into future REFERENCES program guidance. 1 Institut National de la Statistique et de la Démographie (INSD) and ICF International. 2012. Enquête Démographique et de Santé et à Indicateurs Multiples du Burkina Faso 2010. Ouagadougou, Burkina Faso: INSD, and ACKNOWLEDGEMENTS Calverton, Maryland: ICF International. Please see the “Data Sources” section. This brief was developed jointly by WSP and the United Nations Children’s 2 The JMP has established a set of standardized definitions to categorize Fund (UNICEF) as part of a series of country profiles about sanitation for improved sanitation, which are used to track progress toward Millennium children under age three. Development Goal 7. However, these definitions are not always the same as those used by national governments. See Progress on Drinking Water The findings, interpretations, and conclusions expressed herein are those of and Sanitation: Update 2014. the author(s), and do not necessarily reflect the views of the International 3 WHO/UNICEF Joint Monitoring Programme, 2014. Progress on Drinking Bank for Reconstruction and Development / The World Bank and its affiliated Water and Sanitation: Update 2014. Geneva: World Health Organization. organizations, or those of the Executive Directors of The World Bank or the 4 Feachem, R., D. Bradley, H. Garelick, et al. 1983. Sanitation and Disease: governments they represent, or of UNICEF. Health Aspects of Excreta and Wastewater Management. World Bank Studies in Water Supply and Sanitation 3. Chichester, UK: John Wiley & © 2015 by International Bank for Reconstruction and Development / The Sons. World Bank and UNICEF. 5 Institut National de la Statistique et de la Démographie (INSD) and ICF Photo Credits: © UNICEF/NYHQ2012-0256/Asselin (page 1); © UNICEF/ International. 2012. Enquête Démographique et de Santé et à Indicateurs NYHQ2012-0243/Asselin (page 4) 4