Child Feces Disposal in 96441 SIERRA LEONE Key messages: • In 2013, 28 percent of households in Sierra Leone surveyed reported unsafe disposal of the feces of their youngest child under age three. • Even among households with improved toilets or latrines, 19 percent reported unsafe child feces disposal behavior. • Safe child feces disposal steadily increases with the wealth of the household: only 57 percent of the least wealthy quintile reports safe disposal compared to 83 percent of the wealthiest quintile.1 OVERVIEW children whose feces are safely disposed of, out of 31 countries in Sub-Saharan Africa with available comparable Multiple Indicator Safe disposal of children’s feces is as essential as the safe disposal of Cluster Survey (MICS) or Demographic and Health Survey (DHS) adults’ feces. This brief provides an overview of the available data data available from 2006 to 2013. on child feces disposal in Sierra Leone and concludes with ideas to strengthen safe disposal practices, based on emerging good practice. In Sierra Leone, households lacking improved sanitation, those in rural areas, and the least wealthy households—as well as households The Joint Monitoring Programme for Water Supply and Sanitation with younger children—have a higher prevalence of unsafe disposal (JMP) tracks progress toward Millennium Development Goal 7 target of child feces. Between 2003 and 2013, reported safe disposal of to halve, by 2015, the proportion of people without sustainable access children’s feces decreased in urban areas and increased in rural areas to safe drinking water and basic sanitation. The JMP standardized (see Figure 2). Households in urban areas remained substantially definition for an improved sanitation facility is one that hygienically more likely to use safe feces disposal than rural households. separates human excreta from human contact.2 Households practicing open defecation reported the highest level of In the latest JMP report, only 13 percent of Sierra Leone’s population unsafe child feces disposal, at 59 percent (Figure 3). had access to improved sanitation in 2012.3 This means that 5.2 million individuals in Sierra Leone lacked improved sanitation in A shift in safe disposal practices is also seen as children grow: children 2012; of these, 1.6 million practice open defecation. However, these are increasingly likely to use a toilet/latrine themselves, or have their estimates are based on the household’s primary sanitation facility, feces put or rinsed into one. Although safe disposal increases with the and may overlook the sanitation practices of young children. In age of the child, use of a toilet/latrine remains low at 2–11 percent many cases, children may not be able to use an improved toilet or regardless of age (see Figure 4). At these young ages, the behavior of latrine—because of their age and stage of physical development or the child’s caregiver is critical to dispose of their feces safely and shape the safety concerns of their caregivers—even if their household has the child’s toilet training. access to one. SUMMARY OF CHILD What Is “Safe Disposal” of a Child’s Feces? FECES DISPOSAL DATA The safest way to dispose of a child’s feces is to help the In 2013, 72 percent of households surveyed in Sierra Leone reported child use a toilet or latrine or, for very young children, to put that the feces of their youngest children under age three were safely or rinse their feces into a toilet or latrine. For the purposes disposed of. However, only 6 percent of households reported that of this brief, these disposal methods are referred to as their youngest children’s feces were deposited into an improved “safe,” whereas other methods are considered “unsafe.” By sanitation facility, according to DHS 2013 (see Figure 1). This low definition, “safe disposal” is only possible where there percentage of households reporting improved child feces disposal is access to a toilet or latrine. When a child’s feces is put suggests that children under age three have worse sanitation than or rinsed into an “improved” toilet or latrine, this is termed the country’s broader population, where 13 percent use improved “improved child feces disposal.” sanitation. Sierra Leone ranked 12th best for the proportion of February 2015 1 FIGURE 1 Even though safe disposal is relatively high, the prevalence of improved disposal is much lower, at only 6 percent. Percentage of households reporting each feces disposal practice for their youngest child under age three, 2013. Unsafe Disposal Safe Disposal Missing, 1% Child used toilet/latrine Other, 3% & household (HH) Left in the open, 7% used improved sanitation, 0% Buried, 1% Improved disposal = 6% Put/rinsed Child feces put/rinsed into drain or into toilet/latrine & ditch, 8% HH used improved sanitation, 6% Safe Thrown into disposal = 72% garbage, 9% Child used toilet/latrine, but HH used unimproved sanitation, 2% Child feces put/rinsed into toilet/latrine, but HH used unimproved sanitation, 64% FIGURE 2 Households in urban areas remained FIGURE 3 The majority (77–84 percent) of substantially more likely to use safe feces disposal households with access to any sanitation facility than rural households. Percent of households reporting (shared, unimproved, or improved) reported safe safe feces disposal for their youngest child under age three, child feces disposal. Reported feces disposal practice for by urban and rural residence, Sierra Leone, 2000 and households’ youngest child under age three, by household 2013.4 sanitation facility type, Sierra Leone, 2013. 100 93% 100 4% 5% 3% 6% 2% 7% 10% 1% 81% 5% 6% 80 80 24% 8% 69% % of children % of children 62% 12% 60 60 2% 16% 75% 82% 76% 40 40 20 20 39% 0 2% 2% 3% 5% 0 Urban Rural Urban Rural Open Unimproved Shared Improved 2000 2013 defecation (32% of (38% of (8% of (22% of households) households) households) Years households) Type of sanitation facility used by household Other Thrown into garbage Left in the open Put/rinsed into toilet/latrine Safe disposal differs widely across the wealth asset quintiles (see Put/rinsed into drain or ditch Child used toilet/latrine Figure 5).5 The least wealthy 20 percent of households is substantially Buried less likely than the wealthier households to report safe child feces disposal; only 57 percent of the least wealthy quintile reports safe disposal. Looking at overall sanitation facility coverage for households with children under age three in Sierra Leone, only 52 percent of the among households without access to improved sanitation, in rural least wealthy households reported use of a toilet/latrine compared to areas, and those that are least wealthy. For example, unsafe disposal 97 percent of the wealthiest quintile. This is an important factor in in rural areas and among the least wealthy households is worse than child feces disposal: by definition, safe disposal is only possible when among children overall. Although this brief only focuses on one there is access to a toilet/latrine. socioeconomic indicator at a time, applying multiple lenses would show even greater extremes of disparity—with the least wealthy rural Behind this national-level data, there is wide variation in child feces households with the youngest children and no sanitation facility disposal practices, with a greater prevalence of unsafe practices likely reporting the greatest prevalence of unsafe disposal. 2 FIGURE 4 Although safe disposal increases with the age of the child, use of a toilet/latrine remains low at What Is the Impact of Unsafe Disposal 2–11 percent regardless of age. Reported feces disposal of Child Feces? practice for children of different ages, Sierra Leone, 2013. There is widespread belief that the feces of infants and young children are not harmful, but this is untrue. In fact, 1% 100 5% 6% 3% there is evidence that children’s feces could be more risky 7% 7% 2% 8% 1% 8% 1% 6% 3% 6% 1% 7% 1% 4% 3% than adults’ feces, due to a higher prevalence of diarrhea 80 12% 7% 1% and pathogens—such as hepatitis A, rotavirus, and E. coli—in % of children 12% 60 children than in adults.6 Therefore, children’s feces should 71% be treated with the same concern as adult feces, using safe 75% 75% 76% 40 disposal methods that ensure separation from human contact 62% and household contamination. 20 In particular, the unsafe disposal of children’s feces may be 2% 2% 3% 5% 11% 0 an important contaminant in household environments, posing 0 1 2 3 4 a high risk of exposure to young infants.7 Poor sanitation can Child age (years) result in substantial health impacts in children, including a higher prevalence of diarrheal disease, intestinal worms, Other Thrown into garbage Left in the open Put/rinsed into toilet/latrine enteropathy, malnutrition, and death. According to the World Put/rinsed into drain or ditch Child used toilet/latrine Health Organization (WHO), most diarrheal deaths in the Buried world (88 percent) are caused by unsafe water, sanitation, or hygiene. More than 99 percent of these deaths are in FIGURE 5 Safe child feces disposal steadily developing countries, and about eight in every 10 deaths are increases with increasing wealth. Reported feces children.8 Diarrhea obliges households to spend significant disposal practice for children aged under three years by sums on medicine, transportation, health facility fees, and household wealth quintile, Sierra Leone, 2013. more, and can mean lost work, wages, and productivity among working household members.9 Stunting and worm 2% 2% infestation can reduce children’s intellectual capacity, which 100 4% 7% 2% 6% 4% 7% 3% 11% 1% affects productivity later in life. The WHO estimates that the 15% 6% 1% 7% 1% 4% 1% 2% average IQ loss per worm infection is around 3.75 points.”10 80 9% 11% 9% % of children 1% 60 13% 80% 79% 40 69% 70% 56% 20 1% 2% 2% 3% 4% FIGURE 6 Percentage of households reporting safe 0 feces disposal for their youngest child under age Poorest Poorer Middle Richer Richest Wealth quintile of child’s household three, Africa.11 Other Thrown into garbage Left in the open Put/rinsed into toilet/latrine Put/rinsed into drain or ditch Child used toilet/latrine Buried IDEAS FOR CONSIDERATION In Sierra Leone, there are few interventions aimed at the safe disposal of children’s feces during the first years of life. In general, sanitation for children under age three has been a neglected area of policy and program intervention. Given the relatively few programs focusing on children’s sanitation in Sierra Leone and globally, there is 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 governments interested in improving the management of children’s feces could consider: • Conducting formative research to understand the behavioral drivers and barriers to safe child feces disposal 3 • Strengthening efforts to change the behavior of caregivers through Sierra Leone: Government of Sierra Leone. Statistics Sierra Leone (SSL) programs that encourage cleaning children after defecation, potty and ICF International. Sierra Leone Demographic and Health Survey training children, and using appropriate methods to transport 2013. 2014. Freetown, Sierra Leone: SSL, and Rockville, Maryland: ICF feces to a toilet/latrine as well as handwashing with soap after fecal International. 5 These asset indices used to classify households into wealth quintiles have contact and before preparing food or feeding a child not been adjusted to remove drinking water or sanitation variables. • Exploring opportunities to integrate child sanitation into existing 6 Feachem, R., D. Bradley, H Garelick, et al. 1983. Sanitation and Disease: interventions that target caregivers of young children, such as Health Aspects of Excreta and Wastewater Management. World Bank including key messages in antenatal/newborn care materials and Studies in Water Supply and Sanitation 3. Chichester, UK: John Wiley & infant and young child feeding guidance provided to parents, Sons. and ensuring that midwives’ training, as well as early childhood 7 Gil, A., C. Lanata, E. Kleinau, and M. Penny. 2004. Children’s Feces Disposal development materials and preschool programs, include Practices in Developing Countries and Interventions to Prevent Diarrheal information on safe child feces disposal Diseases: A Literature Review. Strategic Report 11. Peru: Environmental • Partnering with the private sector to improve feces management Health Project (EHP). 8 WHO. 2009. Global Health Risks: Mortality and Burden of Disease tools, such as potties, diapers, tools for retrofitting latrines for child use, and scoopers Attributable to Selected Major Risks. Geneva: World Health Organization, 23. • Improving the enabling environment for management of 9 Favin, M., G. Naimoli, and L. Sherburne. 2004. Improving Health children’s feces by including specific child feces related criteria in Through Behavior Change: A Process Guide on Hygiene Promotion. Joint open defecation free (ODF) verification protocols and in national Publication 7. Washington, DC: Environmental Health Project (EHP). sanitation policies, strategies, or monitoring mechanisms. 10 WHO. 2005. Report of the Third Global Meeting of the Partners for Parasite Control: Deworming for Health and Development. Geneva: World Health Organization, 15. DATA SOURCES 11 The latest available MICS/DHS survey with data for each country, as of March 2014. Please see the Data Sources section for more information. Unless otherwise specified, all analysis in this brief is based on child feces 12 Stanton, B., J. Clemens, K. Azis, and M. Rahamanr. 1987. “Twenty-Four- disposal behavior self-reported by the child’s mother or caregiver in the 2013 Hour Recall, Knowledge-Attitude-Practice Questionnaires and Direct Sierra Leone DHS which is the latest MICS or DHS available for Sierra Leone Observations of Sanitary Practices: A Comparative Study.” Bulletin of the that records child feces disposal behaviors. World Health Organization. Geneva: World Health Organization. 13 Akhtaruzzaman, M. N., and S. N. Islam. 2011. Nutrition, Health and The MICS and DHS collect data in a generally harmonized manner and Demographic Survey of Bangladesh—2011: A Preliminary Report. Bangladesh: hence are the basis for this country profile series. However, whereas the DHS University of Dhaka, 19. collects data on the youngest child under age five living with the mother for each 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 NOTES Figure 4. As a result of limiting the analysis to children under three only, the figures reported here differ than what is reported in the DHS. We’re interested in your thoughts. Have you found different evidence of what works through your own programming? If you have thoughts to It is likely that self-reports overestimate safe disposal.12 In Bangladesh, for share, or know of a program that is encouraging the safe disposal of child example, although 22 percent of children reportedly either used a toilet/ feces, please contact WSP at worldbankwater@worldbank.org or UNICEF latrine or their feces were put or rinsed into the toilet/latrine (according to at WASH@unicef.org so that we can integrate your information into future MICS 2006), a structured observation of behavior conducted under UNICEF’s program guidance. Sanitation, Hygiene Education and Water Supply in Bangladesh (SHEWA-B) program in 2007 found only 9 percent of subjects disposed of child feces into a toilet/specific pit.13 Regardless of this issue, self-reports are currently regarded as the most efficient method for gauging safe disposal of children’s feces. ACKNOWLEDGEMENTS This brief was developed jointly by WSP and the United Nations Children’s Fund (UNICEF) as part of a series of country profiles about sanitation for REFERENCES children under age three. 1 Statistics Sierra Leone (SSL) and ICF International. Sierra Leone The findings, interpretations, and conclusions expressed herein are those of Demographic and Health Survey 2013 (Sierra Leone and USA: SSL and the author(s), and do not necessarily reflect the views of the International ICF International, 2014) Please see the Data Sources section above. Bank for Reconstruction and Development / The World Bank and its affiliated 2 The JMP has established a set of standardized definitions to categorize organizations, or those of the Executive Directors of The World Bank or the improved sanitation, which are used to track progress toward Millennium governments they represent, or of UNICEF. Development Goal 7. However, these definitions are not always the same as those used by national governments. See Progress on Drinking Water © 2015 by International Bank for Reconstruction and Development / The and Sanitation: Update 2014. World Bank and UNICEF. 3 WHO/UNICEF Joint Monitoring Programme. 2014. Progress on Drinking Water and Sanitation: Update 2014. Geneva: World Health Organization. Photo Credit: © UNICEF/SRLA2009-0043/Asselin (page 1) 4 Government of Sierra Leone and UNICEF. 2000. The Status Of Women And Children In Sierra Leone: A Household Survey Report (MICS-2) 2000. 4