research proposal on latrine utilization

• Research article
• Open access
• Published: 20 July 2018

Household latrine utilization and its association with educational status of household heads in Ethiopia: a systematic review and meta-analysis

• Cheru Tesema Leshargie 1 ,
• Animut Alebel 2 ,
• Ayenew Negesse 3 ,
• Getachew Mengistu 4 ,
• Amsalu Taye Wondemagegn 5 ,
• Henok Mulugeta 2 ,
• Bekele Tesfaye 2 ,
• Nakachew Mekonnen Alamirew 1 ,
• Fasil Wagnew 2 ,
• Yihalem Abebe Belay 1 ,
• Aster Ferede 1 ,
• Mezinew Sintayehu 2 ,
• Getnet Dessie 2 ,
• Dube Jara Boneya 1 ,
• Molla Yigzaw Birhanu 1 &
• Getiye Dejenu Kibret 1  

BMC Public Health volume  18 , Article number:  901 ( 2018 ) Cite this article

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Ethiopia has been experiencing a high prevalence of communicable diseases, which resulted in high morbidity, mortality, and hospital admission rates. One of the highest contributing factors for this is lower level of latrine utilization. There had been significantly varying finding reports with regard to the level of latrine utilization and its association with education level from different pocket studies in the country. Therefore, this systematic review and meta-analysis was aimed to estimate the pooled prevalence of household latrine utilization and its association with education status of household heads, in Ethiopia using available studies.

This systematic review and meta-analysis was conducted using available data from the international databases, including PubMed, Google Scholar, Science direct, Cochrane library and unpublished reports. All observational studies reporting the prevalence of latrine utilization in Ethiopia were included. Four authors independently extracted all necessary data using a standardized data extraction format. STATA 13 statistical software was used to analyze the data. The Cochrane Q test statistics and I 2 test were used to assess the heterogeneity between the studies. A random effect model was computed to estimate the pooled level of latrine utilization in Ethiopia. In addition, the association between latrine utilization and the educational level of the users was analyzed.

After reviewing of 1608 studies, 17 studies were finally included in our meta-analysis. The result of 16 studies revealed that the pooled prevalence of latrine utilization level in Ethiopia was 50.02% (95%CI: 40.23, 59.81%). The highest level (67.4%) of latrine utilization was reported from Southern Nations Nationality and People regional state, followed by Amhara regional state (50.1%). Participants who completed their high school and above education were more likely (OR: 1.79, 95%CI: 1.05, 3.05) to utilize latrine compared to those who did not attend formal education.

In Ethiopia, only half of the households utilize latrine and the level of utilization has significant association with educational status.

Peer Review reports

Communicable diseases are serious public health problems, affecting billions of people around the world, mainly the third world countries [ 1 , 2 ]. Latrine utilization, the main determinant for communicable diseases control, is still at its lower level in developing countries including Ethiopia [ 3 ]. Access to safe drinking water and sanitation is a basic necessity that is vital for human health and among the basic human rights declared by the United Nations. Ensuring sanitation demands the availability of facilities and services for the safe disposal of human excreta. It is one of the components of the sustainable development goals that are set to be achieved by 2030 [ 4 , 5 , 6 , 7 ].

Worldwide, a tremendous progress has been made in increasing access to facilities that ensure hygienic separation of human excreta from human contact. More than half of the global population used basic sanitation services and nearly two out of five people (39%) utilized safely managed sanitation services. Nevertheless, billions of people still remained without even the basic sanitation services and around 800 million people used unimproved facilities. Most countries are moving off the track to attain the desired coverage for sanitation set in the sustainable development goals [ 8 , 9 , 10 ].

In communities where access to improved sanitation facilities is low, people are forced to engage in unsafe practice of open defecation. This practice continues to be a major challenge and about 2.3 billion people who still lack basic sanitation service either practice open defecation (892 million) or use unimproved facilities such as pit latrines without a slab or platform, hanging latrines or bucket latrines (856 million) [ 11 ]. In sub-Saharan Africa, the number of people who defecate in the open field rose from 204 to 220 million by 2015 [ 8 , 9 , 12 , 13 ]. Diarrheal and other communicable diseases are often linked with poor sanitation and open defecation. Moreover, higher rates of open defecation are also associated with significant socioeconomic, environmental and major public health consequences affecting the overall health and dignity of mankind, the most vulnerable groups being women and children [ 1 , 14 , 15 , 16 , 17 , 18 , 19 ].

Increasing availability and proper utilization of latrines is essential and a cost-effective strategy to overcome disease burden associated with improper excreta management [ 20 , 21 , 22 ]. The use of latrines can be affected by a range of behavioral, cultural, social, geographic and economic factors differing across communities [ 23 , 24 , 25 , 26 , 27 , 28 , 29 ].

According to the 2016 Ethiopian Demographic and Health Surveys report, 56% of the rural households use unimproved toilet facilities. One in every three households in the country has no toilet facility [ 30 ]. The inauguration of the health extension program in 2003 and the national water supply, sanitation and hygiene [ 31 ] program contributed much to the improved coverage of latrines across the country. However, achieving real gains in increasing latrine use and quality remained as a challenge [ 32 , 33 , 34 , 35 ].

In Ethiopia, different fragmented and small studies have been conducted to assess the level of latrine utilization. Nevertheless, the findings of these studies reported highly varying figures. Some of the findings showed as the level of latrine utilization is at a good progress, while some others revealed the awkward aspect. The previous studies also indicated the presence of significant variability in latrine utilization from region to region [ 36 , 37 ].

Determining the pooled prevalence of latrine utilization at a country level will provide an overall figure with better estimation accuracy. Therefore, this systematic review and meta-analysis was aimed at estimating the pooled prevalence of latrine utilization and its association with education level. The findings from this study will have a paramount importance for decision makers revealing at what level the country is with regard to latrine utilization.

Searching strategies

This systematic review and meta-analysis was conducted to estimate the pooled prevalence of latrine utilization and its association with educational level of the user in Ethiopia. To conduct this study, all potentially relevant articles, grey literatures, and government reports were meticulously searched. The Preferred Reporting Items of Systematic Reviews and Meta-Analysis (PRISMA) checklist guideline was used to ensure the scientific rigor [ 38 ]. We searched articles from international databases including Cochrane library, PubMed, Google Scholar, and Science direct. The reviewers used the following keywords “prevalence”, “(“toilet facilities“[MeSH Terms] OR (“toilet“[All Fields] AND “facilities“[All Fields]) OR “toilet facilities“[All Fields] OR “latrine“[All Fields]) AND (“utilization“[Subheading] OR “utilization”[All Fields]) AND (“ethiopia“[MeSH Terms] OR “ethiopia”[All Fields]) to get published articles from above mentioned databases.

“The search was carried out from September to October, 2017. All articles published until October, 2017 were included in the review.

Inclusion and exclusion criteria

The current meta-analysis and systematic review included studies conducted only in Ethiopia and that reported the level of latrine utilization, articles published in the scientific journals and grey literatures. Studies written in English language and full-text articles only were considered. In addition, the review considered all observational study designs (Cross-sectional, case-control, and cohort) reported the level of latrine utilization in Ethiopia. We excluded articles which were not able to be accessed for full article text after communicating the principal investigator of the primary studies by email at least three times.

Outcome of interest

The primary outcome of interest was the pooled prevalence of latrine utilization. The prevalence was computed from the proportion in which the number of individuals who had proper latrine utilization to the total number of households with functional latrine multiplied by 100. Estimate of the association between educational status and level of latrine utilization was also a second outcome.

Study setting

This systematic review and meta-analysis was conducted in Ethiopia. The country is located in the Horn of Africa with projected population of 107,421,970 by 2018 year. The country is divided into nine regions and two administrative cities. The regions are Afar, Amhara, Benishangul-Gumuz, Gambella, Harari, Oromia, Southern Nations, Nationalities, and Peoples of Ethiopia, and two city administrates are Addis Ababa and Dire Dawa [ 39 ].

Operational definitions

Improved sanitation facilities ( Latrine) are those designed to hygienically separate excreta from human contact. These include wet sanitation technologies (flush and pour flush toilets connecting to sewers, septic tanks or pit latrines) and dry sanitation technologies (ventilated improved pit latrines; pit latrines with slabs; or composting toilets) [ 11 ].

Latrine utilization – households with either shared or private functional latrines functional latrines and the family disposed the faeces of under-five children in a latrine, no observable faeces in the compound, no observable fresh faeces on the inner side of the squatting hole and the presence of clear foot-path to the latrine is uncovered with grasses or other barriers of walking [ 1 ].

Education categories : The primary studies classified education for the head of the households as 1) not attended formal education, 2) attended primary education (1–8), 3) attended secondary Educations and 4) college and above.

Data abstraction

Four authors (CTL, AA, AF and HM) independently searched the studies, articles, and reports, and extracted all necessary data using a standardized data extraction format using Microsoft Excel. The extracted parameters were: primary author, publication year, region where the study was conducted, the study design used, sample size, level of latrine utilization, and quality of each study. Then, three authors (AT, GDK and NM) checked the data extraction process. Finally, nine authors (AN, BT, FW, DJB, GM, YA, GDK, MYB and MS) participated in resolving the disagreement.

Quality assessment of the studies

We used Newcastle-Ottawa Scale adapted for cross-sectional studies quality assessment to assess the quality of each study [ 40 ]. The tool has mainly three sections; the first section grades from five stars and mainly focuses on the methodological quality of each study (sample size, response rate and sampling technique). The second section deals with the comparability of the studies, with a possibility of two stars to be gained. The last section deals with the outcomes and statistical analysis of the original study with a possibility of three stars to be gained (Additional file 1 ). Two authors independently assessed the quality of each original study. Disagreements between two authors were resolved by taking the mean score of the two authors. Finally, researches with a scale of ≥6 out of 10 were considered as achieving high quality. This cut-off point was declared after reviewing relevant literatures.

Data analysis

The extracted data were compiled in Microsoft Excel format and analyzed using STATA version 13 statistical software. The binomial distribution formula was used to calculate standard error for each eligible original article. Heterogeneity between studies was assessed using Cochran’s Q- statistics and Higgins’ and Thompson’s I 2 test [ 41 ]. As the preliminary output of the test statistics revealed a significant heterogeneity among studies ( I 2  = 99.5%, p  = 0.00), random Effects meta-analysis model was used for approximation of the Der Simonian and Laird’s pooled effect. Subgroup analysis was also performed among regions, study setting and education in relation to the latrine utilization as well as trends of latrine utilization was made. To reduce the random variations between the individual point estimates of the primary study, a subgroup analysis was carried out based on study settings (regions). Possible source of heterogeneity was also identified by Univariate Meta-regression by taking the sample size and year of publication as covariates. Furthermore, Egger and Begg tests at 5% significant level were employed to assess publication bias [ 42 ]. The point prevalence with its corresponding 95% confidence interval was presented using forest plot. In this forest plot, the size of each individual box revealed the weight of the study, while each crossed line refers to 95% confidence interval. We conducted log-odd ratio for the second outcome (the relationship between latrine utilization and educational status of the households.

One thousand six hundred eight (1608) primary studies that addressed latrine utilization and associated factors were searched using both through PubMed, Google Scholar, science direct and grey as well as the government reports. Seven hundred twelve (42.3%) of these identified articles were excluded because of similarity and duplicated articles. Among the remaining 896articles, 543 articles were excluded after reviewing their titles for a reason of relevance for our objective. The rest 353 articles were screened for abstracts and 286 were excluded after reading their abstract sections. Therefore, 71 full-text articles were accessed and assessed for eligibility based on the pre-set criteria, and from these 52 were excluded for not fitting the inclusion criteria. Finally, 19 studies fulfilled the eligibility criteria and included in the final meta-analysis (Fig. 1 ).

Flow chart to describe the selection of studies for a systematic review and meta-analysis of the level of latrine utilization and is association with educational status at Ethiopia

Overview of included studies

These 19 (of which 2 were unpublished) studies were published from 1999 to 2017. In the current meta-analysis, 966,362 study participants were involved to estimate the pooled prevalence of latrine utilization in Ethiopia in which the lowest (30.99%) latrine utilization was observed from a study conducted at Akaki, Oromia region [ 43 ] while the highest prevalence (99.4%) was reported from a study conducted in Dembia district of Amhara region [ 44 ]. Regarding the study design, all (100%) of the studies were cross-sectional study designs. The sample sizes of the studies ranged from 355 to 955,985. This meta-analysis and systematic review used data taken from primary studies of five (5) (Amhara, south nation and nationality people of Ethiopia, Oromia, Tigray and Harari) regions of Ethiopia that shares eight (42%), 4 (21%), 4 (21%), 2 (1%) and 1 (0.5%) respectively (see the Additional file 2 ).

• Meta-analysis

As indicated above in the Additional file 2 , 19 studies were found to be eligible for the analysis. Of these, two studies [ 44 , 45 ] were excluded from forest plot of the pooled level of latrine utilization after we did sensitiy analysis. The sensitivity analysis for Amhara, Tigray, SNNP and others (Oromia and Harar) regions were revealed as (I 2  = 98.3, p value = 0.001), (I 2  = 98.9, p value = 0.001), (I 2  = 62.7, p value = 0.001) respectively. Seventeen articles were considered to determine the pooled prevalence of latrine utilization in Ethiopia that found to be 50.2% (95% CI: 40.23, 59.81%). High heterogeneity, (I 2  = 99.5, p value < 0.001), was observed between 17 primary studies included in this review. As a result, to reduce it, we performed a subgroup analysis (I 2  = 99.5, p value = 0.001) and come up a slight improvement. The regional subgroup analysis revealed that significant regional variation regarding latrine utilization was observed across the country. Southern nation nationalities and people of Ethiopian have better latrine utilization while Oromia utilizes least. As a result, a random effect model was employed to estimate the pooled prevalence of latrine utilization in Ethiopia.

To identify the possible source of heterogeneity, different factors associated with the heterogeneity such as publication year and sample size of the study were investigated by using Univariate meta-regression models, but none of these variables were found to be statistically significant. Even though it is not statistically significant for the increments of both sample size and publication year, as sample size, increase the level of latrine utilization was showed slightly decreased, whereas the proportion showed level of latrine utilization increments as publication years does also (Table 1 ). Moreover, Publication bias was also assessed using Begg and Egger tests. The result of Begg and Egger tests were not statistically significant for estimating the level of latrine utilization ( p  = 0.15) and ( p  = 0.3) respectively (Figs. 2 , 3 , 4 ).

Forest plot of the pooled prevalence of latrine utilization in Ethiopia

The Univariate Meta regression to identify possible source of heterogeneity by publication year

The Univariate Meta regression to identify possible source of heterogeneity by sample size

Subgroup analysis

In order to appreciate the heterogeneity of individual studies, subgroup analysis was conducted based on the region where the studies were conducted. The output of subgroup analysis revealed that, the highest latrine utilization was observed in south nation and nationalities and peoples of Ethiopia with a prevalence of 67.4% (95% CI: 50.3, 84.5) followed by Amhara with pooled latrine utilization of 50.1% (95% CI: 39.7, 62.2). Besides, subgroup analysis based on the sample size (≥500 and<500) of studies revealed that subgroup of sample size ≥500, 55.9% (95% CI: 40.0, 71.8%) revealed a higher latrine utilization than the subgroup of sample size < 500, 43.4% (95% CI: 34.9, 59.8%) (Table 2 ).

Similarly, subgroup analysis was also performed between study settings (urban, rural and both). The pooled latrine utilization for study settings that means rural, both and urban were found to be 49.25(38.48, 60.01), 40.84(33.95, 47.74) and 61.85(43.88, 79.81) respectively (Fig. 5 ).

The subgroup analysis of latrine utilization status by study settings (rural, both urban and rural, and urban) in Ethiopia

The association between latrine utilization and educational status

A total of 7(41.2%) studies that fulfilled the inclusion criteria and which were considered for determining the pooled level of latrine utilization assessed the association between education and latrine utilization practice. Only one (14.3%) of the studies estimated that education has a negative association with latrine utilization. That is, respondents who are literate are less likely to utilize latrine compared with the illiterate respondents [ 46 ].

The remaining 6(85.7%) of the studies reported that [ 44 , 47 , 48 , 49 , 50 , 51 ] as people get education they use a latrine (Positive association). The heterogeneity (I 2  = 90.4% and P -value < 0.001) became lower during this subgroup analysis when compared with the pooled latrine use analysis result. However, lower heterogeneity (compared with the pooled results of all 17 studies) was observed during subgroup analysis, a random effect meta-analysis model was employed to determine the association between latrine utilization and educational status of the respondents. The overall effect of educational status (as indicated in this subgroup analysis) showed that individual educational status was significantly associated with latrine utilization (OR: 1.79, 95%CI: 1.05, 3.05) (Fig. 6 ).

The pooled odds ratio of the association between latrine utilization and educational status in Ethiopia

This systematic review and meta-analysis disclosed that the pooled level of latrine utilization in Ethiopia was 50.0% (95% CI: 40.23, 59.81%). This finding is lower than a study conducted in Ghana which revealed that 66.5% of the community had proper latrine utilization [ 52 ]. Similarly, the finding of this meta-analysis is slightly lower that a study conducted in Sub-Saharan African countries revealed that proper latrine utilization was estimated to be 63%). Likewise, the finding is much lower than a community-based study conducted in Nepal (94.3%) [ 53 ]. The possible explanation for the above-observed discrepancy between the current meta-analysis and comparable findings might be due to the difference in the Sociodemographic characteristics of the study participants. A report from other sub-Saharan African countries contained a data mostly collected from the urban population while in this study; both urban and rural settings were considered. The other possible explanation for the above variation could be due to the difference in study design.

However, the current pooled analysis of latrine utilization is higher than a the world health organization report (39%) [ 10 ]. Similarly, the current pooled latrine utilization result is slightly higher than from southern Asia countries reported by the world health organization [ 54 ] and Indian where only 47% of the respondents use latrine always [ 55 ]. The observed discrepancy could be resulted from time, study setting, sample size and socioeconomic difference among the different settings. The additional possible justification for the discrepancy might be because of half the population of in developing world lacks basic sanitation [ 56 ]. In addition, in Ethiopia, the government has been implementing different interventions to improve the level of latrine utilization (basic sanitation) for example, the implementation of health extension package since 2003. The health policy (focused on prevention of diseases and promotion of health using the provision of basic sanitation in all level of the country) of Ethiopia could be also another determinant factor for the slight improvement of the latrine utilization level in the country [ 57 ].

The pooled prevalence of latrine utilization level in Southern Nation and nationalities and People region of Ethiopia (SNNRPE) was 67.4% which is higher than the pooled prevalence of latrine utilization level than other regions of the country Ethiopia; in Amhara 50.1%, in Tigray 41.5% and others 36.3%. The possible explanations for this variation might be due to the difference in socioeconomic and sociocultural difference between the regions. The other possible explanation for this variation might be due to differences in the study period in which data collection period for all studies taken from the SNNRPE is recent than the others. On top of the above possible justification, almost half of the studies conducted at south nation nationality and people of Ethiopia were conducted in urban set-up including the capital city of the region. In addition, from this subgroup analysis, it was observed that the estimated latrine utilization level in the SNNRPE was 64.7%, which is higher than the estimated report on latrine utilization by the Min Ethiopian demographic health survey 2014 which was 54% [ 58 ] of the community use latrine. The subgroup analysis also revealed that latrine utilization was better in Amhara region next to the SNNRPE followed by Tigray. This finding was directly related with the educational development of the regions. Currently, the quality of education reported better at Tigray, Amhara region, Oromia and SNNPE, while bringing quality education on the rest regions are still challenging due to their living style. People living other than these detailed above lives a nomadic and pastoral life.

In this systematic review and meta-analysis, we performed a subgroup analysis by study settings (urban, both setting and rural). However, the finding was not statistically significant despite a slight discrepancy. Latrine utilization was found to be better in the urban setting (61.85%) as compared to rural (49.25%) and both (40.84%). Better latrine utilizations in urban setting might be due to high literate populations reside urban than the counterpart settings.

Educational level of the respondents has a significant association with latrine utilization. The finding of this study is supported by other similar study conducted on the impact of sanitation intervention on latrine coverage and uses a worldwide report that means education level has an effect on the community latrine utilization [ 59 ]. This might be due to that education has a significant influence on human behavior towards behaving health activities. Similarly as peoples’ educational status increases, their knowledge on the diseases causation, transmission and the role of human waste to the occurrence of communicable diseases increases. Therefore, to keep their health well they manage and dispose of every type of wastes (including human excreta) safely wherein properly constructed latrine. On the contrary to this study, educational status of the respondents (head of the household) has no any significant association with latrine utilization in one study conducted in Nepal [ 60 ]. This might be due to the fact that even though slightly more than half of the participates were illiterate (51.7%), the government of Nepal is committed to improving sanitation throughout the country, one priority campaign is improving latrine coverage towards attaining open defecation free areas all over the country by 2017 [ 17 ]. Despite the fact that a lot activities and strategies(like training manpower, ONE WASH, Health Extension Package and Community Lead Total Sanitation and Hygiene Behavioral Change) have been conducted in the country Ethiopia, latrine utilization was remain on half of the country vision which was 100% basic sanitation (including proper latrine utilization) [ 61 ].

Education and creating awareness is one among the 16 packages included in the health extension packages. Health extension workers employed to implement this packages provide a routine health education to improve the community awareness to increase latrine utilizations [ 62 ]. This implies that as the educational level of individual increased latrine utilization will increase.

Limitations of the study

In this systematic review and meta-analysis, we recognized some limitations. The first concern was the use of only English language articles as inclusion criteria. The other constraint is the cross sectional nature of the included articles, which can affect the second objective due to the presence of confounders. In addition, the pooled prevalence might not represent the whole country as the included articles were only from six administrative regions.

Only half of the community has had latrine utilization practice and which is lower compared with the country target 100% set to be met by 2015. This meta-analysis also showed that educational status of the community has a significant association with latrine utilization; that is, attending formal education is a positive predictor for community latrine utilization.

Abbreviations

Ethiopian Demographic and Health Survey

Millennium Development Goals

Preferred Reporting of Systematic Reviews and Meta-Analysis

Southern Nation and Nationalities People region of Ethiopia

Water Sanitation and hygiene

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Acknowledgements

The authors of this work would like to forward great and deepest gratitude for Debremarkos University for creating convenient environment and internet service. Last but not least, we would like to forward our acknowledgement for Dr. Belete Tafesse, who is a fluent in English and experienced academics in editing a manuscript for his time spent and willingness to edit this manuscript and made the necessary revision.

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CTL: Conception of research protocol, study design, literature review, data extraction, data analysis, interpretation and drafting the manuscript. AA, AN, GM, AT, HM, BT, NM, FW, YAB, AF, MS, GDA, DJB, MYB and GDK: data extraction and quality assessment, data analysis and reviewing manuscript. MYB: revised the entire section of the final manuscript critically. And also he gave final approval of the version to be published. All authors have read and approved the manuscript.

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Quality assessment of 19 included studies. (DOCX 17 kb)

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Descriptive summary of 19 studies included in the meta-analysis of the level of latrine utilizations and its association with educational status in Ethiopia. (DOCX 22 kb)

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Leshargie, C.T., Alebel, A., Negesse, A. et al. Household latrine utilization and its association with educational status of household heads in Ethiopia: a systematic review and meta-analysis. BMC Public Health 18 , 901 (2018). https://doi.org/10.1186/s12889-018-5798-6

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A Community-Based Cross-Sectional Study on Latrine Utilization and Associated Factors Among Rural Community of East Meskan District, Gurage Zone, Southern Ethiopia

Elsabet negussie zewede.

1 Department of Public Health, Adama Hospital Medical College, Adama, Ethiopia

Nardos Tilahun Bekele

Yohannes mekuria negussie.

2 Department of Medicine, Adama General Hospital and Medical College, Adama, Ethiopia

Mihiret Shawel Getahun

3 Department of Nursing, Adama General Hospital and Medical College, Adama, Ethiopia

Abenet Menene Gurara

4 Department of Nursing, Arsi University, Asella, Ethiopia

Using sanitary facilities is proven to enhance health and halt the spread of fecal-to-oral disease. Despite efforts to improve the availability of latrine facilities in developing countries like Ethiopia, finding a village that is entirely free of open defecation remains difficult. To determine the need for intervention programs and promote regular latrine usage, local data is essential.

This study aimed to assess latrine utilization and associated factors among households in East Meskan District, Southern Ethiopia.

A community-based cross-sectional study was conducted among 630 households from April 15 to May 30, 2022. A simple random sampling technique was used to select the study households. Data were collected using an interviewer-administered structured questionnaire and an observational checklist. The collected data were then entered into Epi-Info version 7.1 and analyzed using SPSS version 21. In binary logistic regression analysis, independent variables with a P -value < .25 were considered candidates for multiple logistic regression analysis. The association was expressed in odds ratio with a 95% confidence interval (CI), and significance was declared at P -value < .05 in the final model.

The magnitude of latrine utilization was 73.3% (95% CI: 69.7, 76.8) in the study district. Husband being family head (adjusted odds ratio [AOR] = 12.9; 95% CI: 5.78 ,28.90), being female (AOR = 16.4; 95% CI: 6.52, 41.27), family size less than 5 (AOR = 24.2; 95% CI: 11.49, 51.09), absence of school children (AOR = 0.3; 95% CI: 0.13, 0.51), and greater than 2 years since latrine was constructed (AOR = 14; 95% CI: 7.18, 27.41) had a significant association with latrine utilization.

In this study, utilization of latrines was low compared to the national target plan. Family head, sex, family size, presence of school children, and length of years in which the latrine was constructed were factors associated with latrine utilization. Thus, regular supervision of early latrine construction and utilization in communities is essential.

Latrines are excreta disposal facilities that can safely separate human excreta from human and insect contact. The use of sanitation facilities is known to halt the spread of fecal-to-oral disease. In addition to their physical presence, effective sanitation facility utilization enhances health ( Tamene & Afework, 2021 ).

More than 2.5 billion people worldwide lack access to sanitation and hygienic facilities, particularly in South Asia and Sub-Saharan Africa (SSA) have the highest percentages of these people. Diseases attributed to inadequate water, sanitation, and hygiene account for more than 4% of all disease burdens and deaths ( Abebe et al., 2020 ; Garn et al., 2017 ). In SSA countries like Ethiopia, 76% of the rural population did not have access to proper sanitary facilities, and a high burden of diarrheal infections existed ( Nunbogu et al., 2019 ). The percentage of households with latrine facilities increased nationwide from 55% in 2011 to 61% in 2016, according to the Ethiopian Demographic and Health Surveys (EDHS) report. In rural areas, 59% of families utilize unimproved toilet facilities ( Girma et al., 2018 ; Tamene & Afework, 2021 ). The progress, however, fell far short of the national target, which was set at 100% ( Gebremariam & Tsehaye, 2019 ).

According to the World Health Organization (WHO), 1.5 million children die each year from diarrhea, which is caused by a combination of poor sanitation and poor personal hygiene ( Farah et al., 2015 ). In developing nations, 88% of all deaths from diarrheal diseases are caused by inadequate access to sanitation, the use of contaminated drinking water, and poor hygiene combined. Improvements in sanitation alone, according to sanitation and health experts, have the potential to reduce parasite infections that harm children’s development and the global prevalence of diarrheal disease, which is a primary cause of death for children, by one-third ( Beyene et al., 2015 ; Islam et al., 2018 ). Because of inadequate sanitation, 15% of all fatalities result from diarrhea, primarily among a large number of children under the age of five. In addition to diarrheal illnesses, worm infestations are very common and significantly increase malnutrition levels ( Godana & Mengistie, 2017 ; Ssekamatte et al., 2019 ).

Review of Literature

The combined global economic loss in 2015 attributed to early deaths connected to sanitation, medical costs for diseases related to sanitation, output lost due to illness, and time lost to use sanitation facilities was projected to be 222.9 billion dollars ( Godana & Mengistie, 2017 ; Nyanza et al., 2018 ; Tamene & Afework, 2021 ).

Studies conducted in several regions of Ethiopia to evaluate latrine utilization and associated factors indicated that the prevalence of latrine utilization is unsatisfactory and ranges from 60% to 71% in various settings ( Asnake & Adane, 2020 ; Koyra et al., 2017 ). The use of latrines can be affected by a range of behavioral, cultural, social, geographic, and economic factors differing across communities ( Leshargie et al., 2018 ).

Despite years of effort to increase the availability of latrine facilities, it is still difficult to find a village that is completely free from open defecation. The country's report points out a large discrepancy between the availability and utilization of latrine facilities in rural communities ( Beyene et al., 2015 ). It is necessary to conduct such studies because the government's regular report on both latrine coverage and utilization has indicated a gap between what is real and what is desired. Open defecation and unsafe excreta disposal continue to be widespread in the study area, with major public health and economic consequences. Data on the utilization of latrines is still inadequate. Therefore, this study aimed to assess the utilization of latrine facilities and identify the associated factors that are helpful strategies to fill the identified gaps. Moreover, the findings of this study will help the health sectors at different levels, communities, and local decision-makers for health intervention programs with a view of adding to the existing body of knowledge to improve sanitation facilities in the study area in particular and reduce open defecation through different strategies.

A community-based cross-sectional study was conducted from April 15 to May 30, 2022. East Meskan district is located 155 kilometers southeast of Addis Ababa, 90 kilometers east of Wolkite town, the administrative center of the Gurage zone, and 20 kilometers east of Butajira town. In 2021, the district administration office reports a total population of approximately 67,891 people, 34,624 females, and 33,267 males. The district has 15 kebeles (a small administrative unit in Ethiopia) , (one urban and 14 rural), and the total number of households is 13,855. There are three health centers and 14 health posts in the district. The current study was conducted on seven rural kebeles namely Elle, Bati Legano, Waja Bati, Bati futo, Ensenousme, Bamo, and Yemrwach.

Research Questions

• What is the magnitude of latrine utilization and associated factors among the rural community of East Meskan District, Gurage Zone, Southern Ethiopia?
• What are the factors that are associated with latrine utilization and associated factors among the rural community of East Meskan District, Gurage Zone, Southern Ethiopia?

An independent sample size was calculated for the two specific objectives of the current study and the largest sample was taken. The largest sample size was the one calculated using the single population proportion formula with the following assumptions: Based on a similar study done in Chencha District, SNNPR state where 60% of rural communities utilized latrines ( Koyra et al., 2017 ), with margin of error of 4% at the 95% confidence level, and with a 10% non-response rate, thus the total sample size required is 640 households.

Using a simple random sampling technique, seven kebeles were chosen at random from a total of 14 kebeles . Each of the selected kebeles received a consecutive sample size based on a proportional allocation to household number. Following that, study households were chosen from each selected kebele using simple random sampling from lists of households obtained from each kebele office executed via the lottery method. The household heads were then interviewed in the selected households, and observations were made ( Figure 1 ).

Schematic presentation of sampling procedure to assess latrine utilization and associated factors in East Meskan district Gurage zone, Southern, Ethiopia, 2022.

Inclusion/Exclusion Criteria

The study populations were all households that have latrines in the selected kebeles of East Meskan District. Household heads that had lived for more than 6 months were included in the study. Members of each household who were less than 18 years old during the data collection period were excluded as study participants.

Data Collection

The data were collected by using an interviewer-administered structured questionnaire and observational checklist, which were developed after reviewing previous studies and different literature ( Asnake & Adane, 2020 ; Beyene et al., 2015 ). The questionnaire was initially prepared in English then translated into Amharic and then translated back into English by different experienced persons to check the consistency of meaning. Data were collected by seven diploma nurses and supervised by two BSc Environmental Health professionals. The questionnaires were pre-tested on 5% of the total sample size of the study households in non-selected Beche bulchano kebele to ensure consistency in terms of easy understandability, coherence, and completeness to households. Data collectors and supervisors received one-day training on the data collection process. Supervisors reviewed and checked the collected data every day for completeness and consistency.

Study Variables

In the present study, the dependent variable is latrine utilization, and the independent variables are age, sex, religion, ethnicity, occupational status, educational status, marital status, average, monthly income, family size, presence of under-five children, and presence of schoolchildren.

Operational Definitions

Latrine utilization: Households with functioning latrines of any design must exhibit at least these indicators of use: a functional footpath to the toilet or pavement covered in grass, the presence of fresh feces near the squat hole, the absence of a spider web in the gate, wetness of the slab, visible anal cleansing materials, and the presence of flies ( Asnake & Adane, 2020 ; Omer et al., 2022 ).

School children: Refers to whether there are any children in the household who are enrolled in formal education at the elementary school level or higher ( Woyessa et al., 2022 ).

Latrine maintenance: Maintaining the existing functional latrine in case of broken sub or superstructures without digging a new hole ( Koyra et al., 2017 ).

Shared latrines: Sanitation facilities shared between two or more households. Shared facilities include public toilets.

Statistical Analysis

The collected data were entered into Epi-Info version 7 and then exported to SPSS version 21 for analysis. Before analysis, data processing activities such as cleaning and coding were performed. Normality for continuous variables was checked using the Shapiro–Wilk test. Descriptive statistics were used to determine the magnitude of latrine utilization. Binary logistic regression was used to model the relationship between the dependent variable and the independent variable. The statistical assumptions for binary logistic regression (adequacy of sample in each cross-tabulated result, expected count in each cell) were assessed, and multi-collinearity was checked using variation inflation factor (VIF) at VIF > 10 indicating the presence of multi-collinearity. Simple logistic regression analysis was used to identify independent variables with a P -value < .25 considered a candidate for the multiple logistic regression analysis. Multiple logistic regression was applied to estimate the effects of independent variables on latrine utilization after adjusting for the effects of possible confounding effects. The regression model was fitted using the standard model-building approach. In the process of fitting the model, variables that didn’t have a significant association with latrine utilization at P -value < .05 were excluded from the model. The odds of latrine utilization were estimated using an adjusted odds ratio (AOR) with 95% confidence intervals (CIs). At this level, the significance of associations was declared at a P -value of .05. The model fitness test was checked by the Hosmer and Lemeshow goodness of fit test at P -value ≥ .05.

Socio-Demographic Characteristics

In this study, a total of 630 households participated, giving a 98.4% response rate. Of these 504 (80%) respondents were female, 546 (86%) respondents were Gurage by ethnicity, and 567 (89.4%) respondents were Muslim. Regarding marital status, 589 (89%) of respondents were married. The study showed that a family size less than 5 was 357 (56.7%) and 420 (66%) of households have under-five children. About 301 (47.6%) of heads of household were farmers and 357 (56.7%) of them were unable to read and write ( Table 1 ).

Table 1.

Socio-Demographic Characteristics of Respondents in a Rural Community of East Meskan District, 2022 ( n  = 630).

Note. HHs = households; ETB = Ethiopian birr.

Behavioral Factors

Five hundred and forty-six (86.7%) of the respondents who had latrines explained that they were advised by health extension workers to construct latrines. All 100% of respondents explained that the importance of having a latrine is to prevent disease and to keep a clean village. In this study, 323 (70%) respondents washed their hands after using the latrine and 267 (82.8%) of them washed their hands after using the latrine with only water ( Table 2 ) .

Table 2.

Behavioral Factors of the Rural Households in East Meskan District 2022 ( n  = 630).

Characteristics of Latrine Facilities

Among the household latrines, 441 (70%) of them needed maintenance. Latrine superstructures made of wood and plastic accounted for 231 (36.7%), while wood and cloth accounted for 169 (26.8%). A total of 567 latrines (90%) were privately owned, 441 (70%) of latrines had a door and in 147 (23.3%) of latrines, feces were observed on the floor. 525 (83.3%) had been more than two years since the construction of the latrine ( Table 3 ).

Table 3.

Characteristics of Latrine Facilities in Rural Households of East Meskan District, 2022 ( n  = 630).

Research Question Results

Latrine utilization.

The result of this study showed that the magnitude of latrine utilization among the East Meskan district rural community was 73.3% (95% CI: 69.7, 76) ( Figure 2 ). Of those who did not practice latrine utilization 105 (62.5%) participants claimed that the unreasonable unpleasant odor was their reason ( Figure 3 ).

Latrine utilization in a rural community of East Meskan district, Gurage zone, Southern, Ethiopia, 2022.

Study participant's reasons for not practicing latrine utilization in a rural community of East Meskan district, Gurage zone, Southern, Ethiopia, 2022 ( n  = 168).

Factors Associated with Latrine Utilization

Family head, sex, occupation, educational status, family size, under-five children, presence of school children, privately owned latrine, the component of latrine, years since latrine was constructed, and status of latrine were the variables that fulfilled the criteria P  < .25 and transferred to multivariable analysis. After adjusting for confounder variables in the multivariable analysis, family head, sex of respondent, family size, presence of school children, and years since the latrine was constructed were significantly associated with latrine utilization.

Accordingly, in the multivariable analysis respondents with a family head being a husband were 12.9 (AOR = 12.9, 95% CI: 5.78, 28.90) times more likely to utilize a latrine than a family head being a wife. Regarding the sex of respondents, females were 16.4 (AOR = 16.4, 95% CI: 6.52, 41.27) times more likely to utilize latrines than males. Regarding family size, those households who had a family size of less than five were 24 (AOR = 24.2, 95% CI: 11.49, 51.09) times more likely to utilize a latrine than a family size more than and equal to five. Households who do not have school children were 70% (AOR = 0.3, 95% CI: 0.13, 0.51) less likely to utilize a latrine than Households who have school children. Households with more than two years since the construction of the latrine were 14 (AOR = 14, 95% CI: 7.18, 27.41) times more likely to utilize a latrine than those who constructed their latrine less than or equal to two years ( Table 4 ).

Table 4.

Factors Associated with Latrine Utilization in a Rural Community of East Meskan District, 2022.

Abbreviations: COR = crude odds ratio; CI = confidence interval; AOR = adjusted odds ratio.

Note. *Significant at P -value < .25 in unadjusted logistic regression analysis, **significant at P  < .05 in adjusted logistic regression analysis, 1 = Reference.

The main objective of this study was to assess the level of latrine utilization and its associated factors in the East Meskan District. Accordingly, the present study revealed that the level of latrine utilization in the community of the study area was 73.3% [(95% CI: 69.6–76.97)]. This study's findings were higher than those of Chencha District (60%) ( Koyra et al., 2017 ), Dembia District (61.2%) ( Yimam et al., 2014 ), and Aneded District (63%) in North West Ethiopia ( Chanie et al., 2016 ). However, it was lower than the finding in Derashe District (88.7%) ( Godana & Mengistie, 2017 ), Mahal Meda (91.2%) ( Abebe et al., 2020 ), and a report from the rural village of Vietnam (79.2%) ( Le & Makarchev, 2020 ).

This variation could be explained by the fact that the study population of these areas could have socioeconomic and cultural differences and may also be due to sample size and study period differences. The relatively higher prevalence of latrine utilization could be attributed to the fact that the majority of residents in this area are Muslim; Muslims in general have extremely high personal hygiene standards, as Islam places a high value on both physical and spiritual cleanliness and purification. While humankind in general usually considers cleanliness to be a pleasing attribute, Islam insists on it.

The study revealed that respondents with the head of the family being the husband were 12.9 times more likely to utilize a latrine compared to the head of the family the wife. The result was supported by a similar study conducted in a rural village in Vietnam ( Le & Makarchev, 2020 ). The reason could be that in many female-headed households, low income combined with a lack of technical expertise or physical ability to dig soil and erect latrines severely limits the sanitation options available to them.

According to this study, females were 16.4 times more likely to utilize a latrine than males. This could be because many of the men and a few of the women work in their farm fields from dawn to dusk. For many, the lack of community-level public latrines near their farms encouraged open defecation. They do not return to their residence to use the latrine when they are on the farm because it is too far away.

Households with a family size of less than five were 24 times more likely to utilize a latrine than households with a family size greater and equal to five. This result was supported by a similar study conducted in semi-urban areas of northeastern Ethiopia ( Asnake & Adane, 2020 ). This could be because the family size is too large, and if there aren't enough squat holes, the chances of finding a latrine that isn't already occupied by another member decrease. Sharing a latrine among a small number of family size results in less frequent latrine usage, which increases the chance of the latrine being cleaner, this in turn increases latrine utilization. Sharing a latrine with a large family, on the other hand, increases the number of times the latrine is used daily and puts a person's sense of responsibility to use the latrine properly in danger, resulting in the latrine being dirty, which may decrease latrine utilization. Furthermore, because latrines in rural areas are built at a shallow depth, they will be out of service sooner ( Asnake & Adane, 2020 ).

Households who do not have school children were 70% less likely to utilize latrines than households who have school children. This study was supported by other studies Achefer District Amhara Region ( Kishiru et al., 2019 ) and Hulet Ejju Enessie Woreda ( Anteneh & Kumie, 2010 ). The justification could be school children may have gotten information from the school about sanitation and implemented it with their parents and developed awareness in the community ( Koyra et al., 2017 ).

Households with more than two years since the construction of the latrine were 14 times more likely to utilize a latrine than their counterpart. This result was supported by other studies done Mahal Meda ( Abebe et al., 2020 ) and Hulet Ejju Enessie Woreda ( Anteneh & Kumie, 2010 ). This could be because behavioral changes in the community require a lot of time. The longer they use the latrine, the more comfortable they become with it and the more they notice the positive effects of using it ( Asnake & Adane, 2020 ).

Strengths and Limitations of the Study

The main strength of this study was its attempt to address a neglected health concern in the study area by obtaining data from primary sources. As a limitation, the study was cross-sectional; therefore, it is difficult to establish a temporal relationship between the dependent and independent variables. In the absence of follow-up, the magnitude of latrine utilization and other independent variables may be greatly underestimated or overestimated in this study. Although on-the-spot observation was used to determine latrine utilization during the study period, it was difficult to determine whether there was the consistent use of the latrine using.

This study concluded that latrine utilization was found to be low. Family head, sex, family size, presence of school children, and the length of years in which the latrine was constructed were the major predictors affecting the utilization of latrines. East Meskan District Health Office should conduct regular supervision of early latrine construction and use in the communities.

Implications for Practice and Research

Open defecation and inadequate sanitation are frequently connected to diarrhea and other communicable diseases. Increased open defecation rates are also linked to serious economic, environmental, and substantial public health effects that have an impact on the general well-being and dignity of mankind. Regular supervision of early latrine construction and utilization in communities should be conducted. Households with latrines should have enough latrines to accommodate the number of people living in the same household and adapt to latrine usage.

To enhance knowledge regarding the causes, modes of transmission, and contribution of human waste to the incidence of infectious illnesses, a variety of diverse actions, strategies, and programs must be implemented. Having said that, nurses design initiatives to promote community health and educate people about the risks associated with not using latrines. Changing habits that can significantly affect someone's health is the ultimate goal. Researchers should further investigate with qualitative research to understand the behavioral aspects of the community and the effective utilization of latrines and associated factors.

Acknowledgments

The authors would like to express their gratitude to the East Meskan District Health Office and the kebele administrative for their invaluable assistance in providing necessary information and facilitating data collection. We are extremely grateful to the participants and data collectors.

Authors’ Contributions: ENZ worked on the conception and design of the study, training and supervising the data collectors, data analysis, and interpretation of the data. NTB redid the statistical analysis and drafted the manuscript. NTB and YMN critically reviewed the draft manuscript and wrote the final version. MSG and AMG advised the study. All authors read and approved the final manuscript.

Data Availability: The data that support the findings of this study are available upon reasonable request.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethics Approval and Consent to Participate: Ethical approval and clearance were obtained from the Institutional Review Board (IRB) of Adama Hospital Medical College, and a letter was submitted to the Gurage Zone health department and East Meskan District Health office, and respective Kebele administrators. Respondents were informed about the purpose of the study, the importance, and the duration of the study to get their free time. The information sheet and consent were provided for respondents for those who can read and the interviewer read for those who can’t read. Verbal consent from all study subjects was obtained before data collection. Participants were informed that they have the full right to discontinue or refuse to participate in the study or to be interviewed. To ensure confidentiality, the name of the interviewee was not written on the questionnaire.

ORCID iDs: Nardos Tilahun Bekele https://orcid.org/0000-0001-6303-1347

Yohannes Mekuria Negussie https://orcid.org/0000-0002-1332-670X

Mihiret Shawel Getahun https://orcid.org/0000-0003-2758-2760

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Methodology, results and discussion, data availability statement, conflict of interest, a historical and critical review of latrine-siting guidelines.

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Christopher Nenninger , Jeffrey Cunningham , James R. Mihelcic; A historical and critical review of latrine-siting guidelines. Journal of Water, Sanitation and Hygiene for Development 1 October 2023; 13 (10): 833–846. doi: https://doi.org/10.2166/washdev.2023.140

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Latrines are an effective way for people in low- and middle-income countries to move away from open defecation. Guidelines are used to provide a recommended horizontal setback distance from a latrine to a downgradient well to ensure the safety of the well from subsurface contaminants. We collected 107 journal papers, books, and reports to critically review the recommended setback distances and how these recommendations are derived. It was discovered that the four most common guidelines/reviews are all based principally on just four field studies, all of which were conducted over 40 years ago, which casts doubt on a frequently used one-size-fits-all approach. More recent methods for latrine siting use both field data and some sort of modeling component to account for the different site conditions, but these models have not been verified for use outside their respective studies. They are also limited in how they consider the hydraulic connection between the latrine and the well. We recommend that future siting guidelines should focus more on vertical separation, include chemical contamination, and be based on models describing how latrines and wells are hydraulically connected, along with the fate and transport of potentially harmful contaminants.

Most common guidelines are based on four field studies, conducted over 40 years ago.

Latrine-siting guidelines must account for the vertical transport of pollutants.

Siting guidelines should account for the distinct features of loadings and transport of bacteria and viruses.

In situ treatment technologies and resource recovery strategies may influence pollutant loadings.

Models can assist with site-specific siting.

Worldwide, about 1.6 billion people use latrines, with about 40 million new users each year ( WHO/UNICEF 2021 ). The steady increase in latrine usage is in response not only to progress towards meeting Sustainable Development Goal #6 but also to the growing population in low- and middle-income countries (LMICs). Although increased latrine coverage is positive for the world's efforts to achieve adequate and equitable sanitation for all, latrine pits are not primarily constructed to prevent fecal contamination from entering subsurface soil or groundwater, only to physically separate humans from their waste ( Orner et al. 2018 ). This means a pit latrine can act as a point source of chemical and/or microbial pollution to the subsurface, especially if soil properties do not provide sufficient assimilation of pollutants, and/or if the groundwater table is shallow. This may be particularly important where community members access shallow groundwater via hand-dug wells or handpumps ( Smits & Sutton 2012 ; Butterworth et al. 2013 ).

To address the challenge of providing improved sanitation while also protecting easily accessible water supplies, governments, international agencies, and non-governmental organizations have published siting guidelines that provide recommended vertical distances between the bottom of a latrine and the water table, as well as horizontal distances between an individual latrine and nearby sources of water (known as the ‘setback’ distance). However, the recommended distances of these guidelines, specifically horizontal, are often based on a ‘one-size-fits-all’ approach that does not consider local conditions that influence the transport of microbial and chemical constituents from a latrine pit ( Wilcox et al. 2010 ; Graham & Polizzotto 2013 ; Ngasala et al. 2021 ). Another limitation with many of the previously published recommended distances is that several of the guidelines have been passed down over the span of decades without critical re-evaluation of their validity or use of new knowledge.

Several previous papers have reviewed important aspects of latrine installation, usage, and/or maintenance. These include best emptying practices ( Thye et al. 2011 ), latrine coverage and use ( Garn et al. 2016 ; Igaki et al. 2021 ), usage and performance in urban areas ( Nakagiri et al. 2016 ), attitudes towards latrines and culturally appropriate technologies in indigenous communities ( Libby et al. 2020 ), groundwater pollution from latrines ( Banks et al. 2002 ; Dzwairo et al. 2006 ; Templeton et al. 2015 ; Dzwairo 2018 ), technologies for in-situ treatment ( Saxena & Den 2022 ), and potential of the technology for resource recovery ( Orner & Mihelcic 2018 ). Although some of these studies briefly or tangentially discuss siting guidelines or safe setback distances, none of them critically evaluate the recommended horizontal distances that are commonly used or cited.

Graham & Polizzotto (2013) have provided what is, up until now, probably the most comprehensive review of latrine-siting guidelines. Important information provided by these authors includes an estimation of the number of people using latrines globally, the impact pit latrines have on groundwater, and gaps in our knowledge about the potential pollution pit latrines can have on groundwater. Notably, they also cite four prior latrine-siting studies ( Lewis et al. 1982 ; Franceys et al. 1992 ; Sphere Project 2011 ; Water Aid 2011 ) that recommend distances of 15–50 m between a latrine and a nearby water source. However, despite the contributions of Graham & Polizzotto (2013) , they do not look into the history of the recommended siting distances, nor do they evaluate how those guidelines have evolved over time. Therefore, appropriate siting for latrines cannot yet be considered a settled issue.

Furthermore, although providing sanitation for all is one end aim of Sustainable Development Goal #6, accomplishing this goal via increased latrine coverage and usage may have an unintended consequence of impeding the world's ability to provide universal and equitable access to safe and affordable drinking water for all. This may especially be true in contexts or communities where households employing on-site sanitation are also applying principles of self-supply to access shallow groundwater ( Smits & Sutton 2012 ). In rural areas especially, there is a push not only to provide better quality of water, but also to improve accessibility of that water, because safely managed water is defined as an improved source that is ‘accessible on [the] premise’ and ‘available when needed’ ( WHO/UNICEF 2021 ). Efforts to improve accessibility may therefore have the unintended consequence of bringing water sources closer to latrines that threaten the quality of the water. Thus, it is important to acknowledge the balance between providing equitable sanitation with providing safe and affordable drinking water for all. The provision of safe drinking water cannot be assured without careful consideration of where people dispose of their excrement.

Accordingly, in order to better inform more integrated decisions regarding the simultaneous provision of sanitation and safe water, the objectives of this critical and comprehensive review are to: (1) compile and summarize past papers recommending horizontal distances between a latrine and water source, (2) assess the most commonly used guidelines to determine the origin of each recommended horizontal distance, (3) critically assess the limitations or range of applicability of the most common guidelines, (4) discuss recent trends and advancements in properly locating latrines away from water sources, and (5) recommend actions that can be integrated into future latrine-siting guidelines. Our overall goal is to provide new insights that will assist the world in achieving multiple targets of Sustainable Development Goal #6, specifically the three targets of achieving universal and equitable access to safe and affordable drinking water for all, achieving access to adequate and equitable sanitation and hygiene for all, and improving water quality by reducing pollution.

Stage 1: Database search

To obtain previously published books, journal papers, reports, or other documents recommending a horizontal setback distance, the search engines of Web of Science and Google Scholar were used. The different phrases and key words used in the search engines to gather literature were: ‘latrine distances,’ ‘latrine siting guidelines,’ ‘latrine setback distances,’ ‘pit latrine safe distances,’ ‘on-site sanitation distances,’ and ‘latrine separation distance.’ Manual searches were also performed using academic books the authors already had in their possession. For the search, we took any paper studying or discussing latrines, and considered a pit latrine and its various modifications to include a pit that collects and stores excreta as described by Feachem et al. (1981) , Tilley et al. (2014) , and Orner et al. (2018) . All documents recommending or discussing a setback distance – whether those documents were review articles, research articles, reports, or ‘gray’ literature (pamphlets, documents issued by unknown organizations, etc.) – were included in the following analysis. We included gray literature as some investigators might use Internet search engines (like Google) instead of scholastic databases (e.g., Web of Science), and we wanted our review to include all potential possibilities.

Stage 2: Ancestry search

From each document obtained from Stage 1, we determined if that document contained a recommended latrine setback distance. If so, we recorded the distance recommended and the source (citation) on which that recommended distance was based, i.e., the ‘ancestor’ of the paper identified in Stage 1. Then, the process was repeated iteratively with each identified ancestor. A paper was only included as part of the citation history (ancestry) if it was explicitly cited when it discussed setback distances between a well (or another type of water source) and a latrine. The iterative ancestry search process continued until either an original reference (a paper doing its own field research without mentioning any other relevant papers) was reached, two consecutive sources were in a language other than English, a reference was reached that had already been identified in the ancestry of another paper, or a source listed no references and attempts to contact the authors to obtain the references they used in the document failed. Siting guidelines in relation to septic tanks (as opposed to latrines) were not reviewed; if the search led to a paper considering septic tanks explicitly, it was included in the literature gathered, but then there was no iteration after the septic tank paper was counted. The literature search ended on November 14, 2022.

Stage 3: Document classification and citation counts

Each of the documents identified in Stages 1 and 2 was assigned one of three classifications. Field studies are documents that conduct their own data collection and make a latrine-siting recommendation based wholly or in part on those data. Reviews are documents that do not conduct original research but synthesize previous work done by others. Any document not falling into one of these two categories was designated a guideline document . These are generally documents that focus on some aspect of latrine management and, as part of their analysis, refer to a recommended setback distance that had previously appeared in a separate document.

The final step was a citation count. We counted how many times each document in our overall set (from Stages 1 and 2) was cited by any other document within the set. Of particular interest is which field studies and/or guideline documents are cited most often, as this is likely to give an indication of the setback distances that are most commonly used in practice.

Objective 1: Compile past documents

From the original database search (Stage 1), 51 documents were identified (see Supplementary material, Figure S2). From these 51 original documents, 56 additional ‘ancestor’ documents were found searching the reference history in Stage 2, for a total of 107 documents gathered. Any document that was identified in both the database search (Stage 1) and the ancestry search (Stage 2) was counted as part of the original database search. A complete list of the documents found from the search (and the phrase used to find each one) and reference history can be found in Supplementary material, Table S1. Breaking it down by category, there are 52 field studies, nine reviews, and 46 guideline documents.

Objective 2: Determine origin of common siting guidelines

Citation family tree for siting a latrine near a water source. Black lines represent direct citations while dashed orange lines mean there is one degree of separation in the citation history, with the intermediate reference not included in the figure. References placed in trapezoids are reviews, references in rectangles are guideline documents, and references in ovals are field studies. * denote field studies done on bacteria; @ denote field studies done on viruses; & denote field studies done on physical parameters; $ denote field studies done on both bacteria and chemicals; and # denote field studies done on chemicals only.

From Figure 1 it can be seen that 20 of the 26 most commonly cited documents are connected in some way. The four most commonly used guideline documents and reviews are those of Franceys et al. (1992 , cited nine times), ARGOSS (2001 , cited nine times), Lewis et al. (1982 , cited eight times), and Wagner & Lanoix (1958 , cited four times). These total citation numbers were obtained from the larger set of 107 papers provided in Supplementary material. Three of these four documents ( Wagner & Lanoix 1958 ; Lewis et al. 1982 ; Franceys et al. 1992 ) recommend a horizontal setback distance of 15 m for placement of a latrine near a water source. The fourth of these ( ARGOSS 2001 ) recommends that the latrine be placed at a distance equal to that which viruses can travel in the subsurface in 25 days (based on local soil type and decay rate).

Of the 46 identified guideline documents, 34 were found to be connected to the four most cited documents in their ancestry (this includes the four most cited documents themselves). From Figure 1 , it can be seen some of the four most cited papers even cite each other (e.g., Franceys et al. (1992) citing Lewis et al. (1982) , and ARGOSS (2001) citing Franceys et al. (1992) ). The field papers most commonly cited are those of Lewis et al. (1980 , cited eight times), Dzwairo et al. (2006 , cited six times), Caldwell & Parr (1937 , cited six times), Caldwell (1938 , cited four times), and Still & Nash (2002 , cited three times).

Objective 3: Critically assess common guidelines

Field papers directly cited by the four most cited latrine-siting documents

The second limitation of the four most commonly cited guideline documents is that three of them ( Wagner & Lanoix 1958 ; Lewis et al. 1982 ; Franceys et al. 1992 ) provide a recommended setback distance of 15 m, but the distances traveled by the pollution in the field studies listed in Table 1 are greater than this, in the range of 25–50 m. To be protective of health, we would expect the recommended setback distance to be greater than – not lower than – the distance traveled by pollutants of concern. To explain this surprising observation, we note that the four commonly cited guidelines are often based on just one particular pollutant from a field study, and did not consider all of the pollutants measured (like chemical) in the study, even if it is found those pollutants travel further than the pollutant they considered in their respective document.

Parameters to consider when siting a pit latrine to protect local groundwater resource (reprinted with permission of WEDC, Loughborough University ( 2023 ), based on Sugden (2006) ).

To elaborate on just two such locally varying factors in Figure 2 , we consider the importance of soil type (factors 2 and 4 in Figure 2 ) and depth of the vadose zone (factor 3 in Figure 2 ). It is known that soil type affects how microbial contaminants travel ( Yates et al. 1988 ). Fewer studies have investigated the removal of microorganisms in vadose zones compared with removal in groundwater and soils ( Schijven et al. 2017 ). However, it appears that in soil media, pumice sand and uniform sand are reported to have better rates of microbial removal ( Pang 2009 ). Estimates on the removal rate of various microorganisms for distance traveled (log 10 /m) are also reported for different subsurface media ( Pang 2009 ). Chemical contaminants such as nitrate that can adversely affect human health are often considered to travel at the same rate as water ( Templeton et al. 2015 ). Considering the four most cited papers for latrine siting, Franceys et al. (1992) and Lewis et al. (1982) both suggest that in finer soils, latrines can be placed closer to wells as finer soils do a better job of limiting pathogen movement. ARGOSS (2001) does not provide a recommended distance but instead provides a risk level and states the distance should be based on how far viruses are expected to travel in 25 days. Wagner & Lanoix (1958) give 15 m as a general distance to avoid bacterial contamination.

Except for Lewis et al. (1982) , none of the other most cited guideline documents considers the depth of the water table in their siting guideline. If the water table is deep enough, it may take too long for pathogens to reach there before they either die off or reduce in concentration. This could play a large role in latrine siting in situations where a household or community hand pump (or shallow well) that accesses shallow groundwater is placed close to house(s) and latrines. Assuming a flat ground surface, the flow of liquids and contaminants from a latrine is primarily vertical and not horizontal. This is especially important when the water table is high. Templeton et al. (2015) had previously made the important point that depth to the vadose zone (and not the horizontal distance between a latrine and a well) is actually the most important parameter when it comes to latrine placement and siting. Much of the data provided by other studies supports this contention of Templeton et al. (2015) ; for example, Islam et al. (2016) found that pollution traveled only a short horizontal distance of 4.5 m when the vertical distance between the latrine and water table was large (7.5–20 m). Also important is the knowledge that hand pumps are only effective in lifting water down to 10 m ( Marshall 2017 ).

Objective 4: Review recent trends and advancements

The four most commonly cited documents – those of Franceys et al. (1992) , Lewis et al. (1982) , ARGOSS (2001) , and Wagner & Lanoix (1958) – are all at least 20 years old. In the past two decades, there has been a lot of additional work on developing latrine-siting guidelines. Based on our literature review, we identified three trends and advancements that are prevalent in much of the recent literature.

Firstly, within the past 20 years, there has been a shift regarding how the recommended setback distance is found. This is because studies originated in the new millennium that included a modeling component to determine a safe distance between a latrine and a water source. These water sources range from drilled wells, to canals and lakes. Modeling enables a user or researcher to account for physical, chemical, and biological processes while making estimates for a setback distance. These modeling papers also move away from the one-size-fits-all latrine-siting approach used by older papers and discussed above to a site-specific approach. However, it should be noted that Lewis et al. (1982) is the earliest identified paper that considered the hydrogeological environment while developing a five-step decision tree (something that could be considered a ‘model’ in Figure 6.2 in their paper) for proper latrine distancing. Specifically, they looked at the hydraulic loading rate of the latrine, groundwater depth below the latrine, and soil type. Their paper looked at the relationship between a single latrine and a shallow borehole .

Papers using modeling to determine a safe, horizontal setback distance, and the type of model they used

Distances are all site-specific for each paper.

Compared to the distances provided in Table 1 , all the distances in Table 2 except one are greater than the Table 1 distances. Table 1 distances range from 25 to 30 m and Table 2 distances range from 22 to 75 m, some of which are more than two times greater than in Table 1 . Specifically, distances from the latrine to the water source were found to be 22, 75, 34, and 48 m from the four references covered in Table 2 (in order they appear). Although the references in Table 2 all performed extensive modeling work at their respective sites, these models have not been tested in other locations or with other contaminants (besides the ones in the original study). Something else the authors do not consider is how in situ treatment technologies (e.g., permeable reactive barriers ( Rao & Malini 2015 ; Naser et al. 2019 ; Suhogusoff et al. 2019 )) or adding additional resource recovery infrastructure (e.g., a urine diverting component ( Tilley et al. 2014 ; Mkhize et al. 2017 ; Naughton et al. 2018 )) to the latrine could help reduce the recommended distance. Even though recent papers have made advancements with the methods used to get a setback distance, there is no clear consensus on what mechanisms of contaminant growth and removal to consider.

The large range of distances in Table 2 may result from the second recent advancement identified: improved estimation of microbiological behavior in the subsurface. This leads to a better understanding of the mechanisms of microbial contaminant growth and removal a specific model considers, building more robust models. However, the biggest factor affecting these distances is likely inactivation of the respective microbial contaminant. The modeling paper with the largest distance ( Molin et al. 2008 ) modelled two viruses and one bacterium and determined the inactivation rate is likely the cause of why one virus (Hepatitis A) had such a higher travel distance than the other two pathogens (Rotavirus and E. coli ).

The type of contaminant modelled also may play a part in the large differences between the distances in Tables 1 and 2 . The papers in Table 1 either considered bacteria or chemicals while the paper in Table 2 with the longest distance ( Molin et al. 2008 ) also considered viruses (while also considering chemicals and bacteria). When considering both bacteria and virus fate in the subsurface and the risk they pose to infectious disease, the following features are important in influencing environmental transmission: (1) the pathogen needs to be excreted in high numbers, (2) it must persist in the environment, and (3) it must also be highly infectious ( Aw 2018 ). Concentrations of viruses and bacteria measured in human feces are typically 10 6 –10 9 per gram of feces. Concentrations of protists (and helminths) though are much, much lower. Latrines located in developing regions of the world, where diarrheal diseases and intestinal parasites are more prevalent, are expected to experience a higher loading of pathogens versus developed regions ( Fletcher et al. 2013 ). In general, it is reported that for the same media, virus and bacteria removal rates are in the same order of magnitude, though they can be lower or higher ( Schijven et al. 2017 ), and while helminths are known to persist in the environment, their excretion in feces is relatively low and because of their size are thought to pose a low risk from transport out of the latrine pit (except during improper management of fecal sludge). The risk to a water supply associated with the excretion of viruses and bacteria is thus higher than for other classes of pathogens.

Furthermore, there are multiple parameters affecting both bacteria and viruses such as temperature, microbial activity, moisture content, pH, and organic matter ( Yates et al. 1988 ). Yates et al. (1988) and Matthes & Pekdeger (1981) determined the one factor most affecting the survival of viruses was temperature, where the length of time (in days) for virus survival ranging from a short time period of days (higher temperatures) to months (colder temperatures). The temperature in the subsurface is known to vary throughout the day ( Saito et al. 2006 ) from 7 to 25 °C in the upper 12 cm of soil. However, Holden & Fierer (2005) point out that the temperature range of the vadose (unsaturated) zone decreases considerably as depth increases as it becomes more insulated. With many pit latrines already being dug ∼2 m deep, there might not need to be a need to consider this temperature variation.

There are many similar ways bacteria and viruses travel within the subsurface. They both move better in more saturated soils, and with higher hydraulic loading rates (i.e., rainfall recharge). In the case of latrines, much of the hydraulic loading would come from urine, unless there was a pour-flushing mechanism involved as well (or the latrine also accepts effluent from water-based hygiene). An average human excretes anywhere between 0.6 and 1.1 L of urine a day (up to 0.45 m 3 /year) ( Franceys et al. 1992 ). Assuming the average person adds 0.060 m 3 /year of fecal matter ( Franceys et al. 1992 ) with water content 75% ( UMass n.d. ), an additional 0.045 m 3 of water is annually added into the pit from fecal matter. Thus, the presence of a urine collection system (e.g., Tilley et al. 2014 ; Trimmer et al. 2016 ; Mkhize et al. 2017 ) to collect valuable nutrients ( Mihelcic et al. 2011 ) will significantly reduce the hydraulic loading of the latrine pit into the subsurface. Another important factor in hydraulic loading associated with latrine usage is the number of household members using the latrine or whether the latrine is shared amongst several households. Besides Molin et al. (2008) , these modeling papers do not consider the varying degree of hydraulic loading. There also does not seem to be much conversation relating to the hydraulic connection between the latrine and the water source. If someone has an understanding of the hydraulic connectivity (or the lack thereof which would be best) between the latrine and the water source, they can make better siting decisions.

Because viruses are smaller compared to bacteria (about 0.02 μm for viruses to 0.4 μm for the smallest bacteria), some mechanisms affecting transport from a latrine pit to groundwater will be different. For example, the mechanism of filtration is expected to be more effective with bacteria than viruses with bacteria being more easily filtered out due to their larger size. Matthess et al. (1988) states another reason for bacteria filtering better could be due to their motility adding to diffusion and their tendency to aggregate more, increasing the diameter and thus allowing better filtration.

The third trend revised recommended setback distances, is a result of modeling, improved estimation of microbial behavior, and accounting for site-specific factors like soil type. Whereas the four old field papers said 15 m, now there are new field papers suggesting greater than 15 m, so the recommendations have changed in the past 20 years. This trend also comes from comparing the papers in Tables 1 and 2 . There are three overarching differences identified: (1) The timeline of the studies varies. For example, the field papers in Table 1 range from a few months to 1.5 years, while no timeline is specified in modeling papers in Table 2 . (2) Although the methods used in Table 1 appear adequate, the newer methods used in Table 2 tend to result in more conservative approaches and larger setback distances. (3) The field papers in Table 1 did not consider multiple locations, unlike the modeling papers reviewed in Table 2 . Specifically, the field papers ( Caldwell (1937) and Caldwell & Parr (1937) ) only visited one site and looked at soil log profiles while the modeling papers ( Megha et al. (2017) and Ngasala et al. (2021) ) looked at a range of soil types and included those soil types when they calculated the recommended horizontal distance in their models.

Objective 5: Recommend future actions for latrine siting

More authors are now incorporating modeling in their analysis to recommend a setback distance, oftentimes combining different software and techniques to the data obtained in the field. This methodology appears to be the best way to identify a safe distance between a latrine and a water source. However, not all models are constructed the same and have limitations as shown in Table 2 with the mechanisms of microbial growth and removal they consider. So, an important question is, what is the most optimal method to estimate site-specific distances between a latrine and a water source? The different mechanisms of microbial growth and removal will be affected by the local site conditions, so it is important to first understand those. Figure 2 previously showed several local conditions to consider when looking to properly site a latrine that will protect a local water source (in this case a water point or shallow well accessing groundwater). Therefore, it is imperative to understand what mechanisms of growth and removal to include in a model and just as importantly exclude different pollutants at different field locations.

Additionally, there needs to be a greater effort to understand the fate and transport of chemical pollution from latrines. Many of the latrine studies focus on microbial contaminants which can be chemically disinfected at the household level. However, treatment of chemical contaminants at the household or small utility level is much more complex for species such as nitrate, antibiotic residues, and other chemicals such as pharmaceuticals previously mentioned by Graham & Polizzotto (2013) . Accordingly, future research needs to look more deeply not only into the fate and transport of chemical contaminants from a latrine to the subsurface, but also at what levels pose an unacceptable risk to users of an impacted water supply.

Something else to consider in the development of a model is the issue of when certain field parameters are not determined in the field but are instead obtained from established values in the literature. This is likely to happen in parts of the world that lack established subsurface data or the resources to make site-specific subsurface measurements. Yates et al. (1986) have addressed this issue for the siting of septic tanks by using a kriging method, but only for a localized location. What is needed is the establishment of a global database for soils anyone can access to look at the ranges for different physical characteristics of soils for a particular area or region. The Food and Agriculture Organization of the United Nations has a soil portal leading to some physical data for soils worldwide, but it still lacks important data (such as hydraulic conductivity) to use for modeling. There will also be additional uncertainty in the use of any model because of changes in local weather and influences of climate change on local weather which can change groundwater table depth, vadose zone moisture content, and regional flow; however, models have the ability to account for these changes.

The parameters given the most attention when considering proper latrine siting should be reevaluated. As previously discussed, there is a compelling argument that the vertical distance from the bottom of the latrine to the top of the water table is the most important parameter to consider when siting a latrine near a downgradient well. However, previous studies and guidelines mostly focus on the horizontal distance between the latrine and the well and do not give enough attention to siting guidelines based on the vertical distance. Therefore, future research should look more closely at how the depth of the vadose zone affects the minimum acceptable horizontal setback distance.

Future research should also consider the context of where a latrine is being sited, that is, in a rural, peri-urban, or urban area. Latrine siting in areas that do not have piped water may already pose a greater risk to groundwater due to latrine density and physical space constraints. This must also consider informal settlements and slums. The presence of a piped water source may alleviate this risk; however, piped water systems that are not maintained at sufficient pressures can be contaminated from the surrounding subsurface due to transient intrusion and backflow ( WSDOH 2006 ; Kumpel & Nelson 2014 ). The impact of latrine technologies design to capture nutrients or decrease pathogen or chemical concentrations exiting a pit need to also be considered as was addressed previously. Such technologies could be especially useful in peri-urban and urban areas.

The overall goal of our critical and historical review is to move towards global achievement of access to adequate and equitable sanitation and hygiene for all, while also ensuring that local water resources are not impacted by the placement of onsite sanitation via the construction of latrines. A citation tree showed that the four most common latrine-siting documents directly related to four field studies that investigated groundwater pollution from latrines with 20 of the 26 most commonly used papers are connected in some way. These four field papers recommend a distance ranging from 15 to 30 m, with three of these papers having a greater distance than any of what the four most cited guidelines and reviews recommend (i.e., 15 m). More recent field papers looking into proper latrine siting often incorporate a modeling component to provide a more sophisticated setback distance. Several modeling papers suggest the safe distances from a latrine to a water source should be 22–75 m, depending on chemical pollutants and if the pathogen of concern is a bacteria or virus.

We therefore conclude that new ways to estimate a low-risk setback distance of latrines from a water source are needed in order to better understand the impact the vadose zone has on pathogen fate and transport. There also needs to be a better understanding of the impact of technological advances on latrines that aid pathogen destruction or resource recovery influence pathogen and chemical loading into the subsurface. Other factors that influence this process of finding appropriate setback distances are locations where self-supply is used to access shallow groundwater or piped water systems that are not maintained at sufficient pressure. The endgame of proper latrine siting is likely some sort of model accounting for site-specific conditions and the hydraulic connection between the well and latrine. As previously stated, there will always be some uncertainty with modeling as it is difficult to account for seasonal variation due to climate change as well as space constraints depending on whether the area is urban, peri-urban, or rural, but modeling appears to have the highest ceiling to solve this problem.

Although much literature was gathered during this review, it is not all-encompassing. Future research should look at other on-site technologies other than latrines. One example is critically reviewing similar papers that evaluate the safe distance of a water supply to a sited septic tank, a more advanced technology to a latrine more commonly associated with water-flushed toilets. Though we were careful in searching for literature that covered our definition of what a latrine was in regard to the objectives of this review, we are also aware that some investigators use wording such as toilet, septic tank and latrine interchangeably, potentially leading to some missed literature by the authors. We believe our search methods have accounted for a sizeable majority of key papers. However, future efforts may consider not only latrines, but also septic tank siting guidelines to see what the distances are for each.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.

Supplementary data

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Household latrine utilization and associated factors in semi-urban areas of northeastern Ethiopia

Affiliations.

• 1 Quality Improvement Unit, Woldia Comprehensive Specialized Hospital, Woldia, Ethiopia.
• 2 Department of Environmental Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia.
• PMID: 33180832
• PMCID: PMC7660512
• DOI: 10.1371/journal.pone.0241270

Background: Latrine utilization is the actual behavior in a practice of regularly using existing latrines for safe disposal of excreta. Latrine utilization is a common problem in semi-urban areas of developing countries, including Ethiopia. Since the status of latrine utilization and associated factors among semi-urban areas of northeastern Ethiopia, including Alansha in South Wollo Zone is unknown, local data is needed in order to assess the need for planning of intervention programs for the improvement of latrine utilization to support consistent and sustained latrine utilization. This study is designed to address this knowledge gap.

Methods: A cross-sectional study was conducted from February to March, 2019 among 401 systematically selected households. Data were collected by trained workers using a pre-tested, structured questionnaire via face-to-face interviews and on-the-spot observations of the latrines. A systematic random sampling method was used to select participant households. Data were entered using EpiData version 3.1 and exported to Statistical Package for the Social Sciences (SPSS) version 25.0 for data cleaning and analysis. The wealth index status of participants was estimated using principal component analysis. Data were analyzed using a binary logistic regression model at 95% confidence interval (CI). From the multivariable logistic regression analysis, variables with p-value < 0.05 were taken as statistically significant and independently associated with latrine utilization. Model fitness was checked using Hosmer-Lemeshow test.

Result: We found that the prevalence of latrine utilization among households was 71.8% (95% CI [67.5-76.1%]) while 28.2% (95% CI [23.9-32.5%]) did not utilize latrines. About one-fifth (21.7%) of participant households were found to have a pit latrine with slab and 78.3% (311) used pit latrines without slab. The hygienic condition of the majority (82.9%) of the latrines was dirty and only 17.1% clean. Household family size from one to three persons (AOR: 3.99, 95% CI [1.20-6.24]), presence of primary or secondary school student in a house (AOR: 2.33, 95% CI [1.42-3.83]), number of years since latrine was constructed (≥ 2 years) (AOR: 1.82, 95% CI [1.12-2.95]) and a frequency of daily cleaning of the latrine (AOR: 2.19, 95% CI [1.12-4.28]) were factors significantly associated with latrine utilization.

Conclusion: Seven out of ten households utilized a latrine. Factors significantly associated with latrine utilization were household family size from one to three persons, presence of primary or secondary school student in the house, time since household latrine had been constructed of two or more years and daily frequency of latrine cleaning. Therefore, it is recommended that measures to promote behavioral change towards further improvement in sustainable and consistent latrine utilization should be carried out based on the evidence of the determinant factors found in this study.

Publication types

• Research Support, Non-U.S. Gov't
• Aged, 80 and over
• Cross-Sectional Studies
• Ethiopia / epidemiology
• Family Characteristics*
• Logistic Models
• Middle Aged
• Multivariate Analysis
• Socioeconomic Factors
• Toilet Facilities*
• Urban Population*
• Young Adult

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