Sanitation facilities, hygienic conditions, and prevalence of acute diarrhea among under-five

18 Pages·2017·2.12 MB·English

RESEARCHARTICLE
Sanitation facilities, hygienic conditions, and
prevalence of acute diarrhea among under-
five children in slums of Addis Ababa,
Ethiopia: Baseline survey of a longitudinal
study
MetadelAdane1*,BezatuMengistie2,HelmutKloos3,GirmayMedhin4,WorkuMulat5
a1111111111
a1111111111
1 EthiopianInstituteofWaterResources(EIWR),AddisAbabaUniversity,AddisAbaba,Ethiopia,2 College
a1111111111 ofHealthandMedicalSciences,HaramayaUniversity,Haramaya,Ethiopia,3 DepartmentofEpidemiology
a1111111111 andBiostatistics,UniversityofCalifornia,SanFrancisco,UnitedStatesofAmerica,4 AkliluLemmaInstitute
a1111111111 ofPathobiology,AddisAbabaUniversity,AddisAbaba,Ethiopia,5 DepartmentofCivilandEnvironmental
Engineering,UniversityofConnecticut,Storrs,UnitedStatesofAmerica
*[email protected]
OPENACCESS
Abstract
Citation:AdaneM,MengistieB,KloosH,Medhin
G,MulatW(2017)Sanitationfacilities,hygienic
conditions,andprevalenceofacutediarrhea
Background
amongunder-fivechildreninslumsofAddis
Ababa,Ethiopia:Baselinesurveyofalongitudinal Indevelopingcountries,childrenundertheageoffiveyearswholiveinslumsarehighlyvul-
study.PLoSONE12(8):e0182783.https://doi.org/
nerabletodiarrhea.However,thereisapaucityofinformationontherelationshipbetween
10.1371/journal.pone.0182783
sanitationfacilitiesandhygienicconditionstoacutediarrheaamongunder-fivechildrenin
Editor:PhilipCHill,UniversityofOtago,NEW
slumareasofAddisAbaba,Ethiopia.Therefore,thisstudyexaminesthesanitationfacilities
ZEALAND
andhygienicconditionsintheslumsofAddisAbabaandidentifiesthemainfactorssignifi-
Received:March6,2017
cantlyassociatedwithacutediarrheaamongchildrenaged0–50monthsinthoseslums.
Accepted:July23,2017
Methods
Published:August30,2017
Copyright:Thisisanopenaccessarticle,freeofall Acommunity-basedcross-sectionalhouseholdsurveywascarriedoutbetweenSeptember
copyright,andmaybefreelyreproduced, andNovember2014,thatthenservedasthebaselinesurveyofalongitudinalstudy.Forthis
distributed,transmitted,modified,builtupon,or
survey,697childrenaged0–50monthswererecruitedfromtwoslumdistrictsinAddis
otherwiseusedbyanyoneforanylawfulpurpose.
Ababa.Apre-testedstructuredquestionnaireandanobservationalchecklistwereusedfor
TheworkismadeavailableundertheCreative
CommonsCC0publicdomaindedication. datacollection.Multivariablelogisticregressionanalysiswasusedtoidentifysanitationfacil-
itiesandhygiene-relatedfactorsthatweresignificantlyassociatedwithacutediarrheaby
DataAvailabilityStatement:Allrelevantdataare
inthepaperanditsSupportingInformationfiles. controllingpotentialconfoundingeffectsofselectedsocio-demographicfactors.Adjusted
oddsratio(AOR)withcorresponding95%confidenceinterval(CI)wasusedtoquantifythe
Funding:EthiopianInstituteofWaterResourcesof
AddisAbabaUniversityfundedthisresearch strengthofassociation.
project.Thefundershadnoroleinstudydesign,
datacollectionandanalysis,decisionstopublish, Mainfindings
interpretationofthedataandpreparationofthe
manuscriptforpublication. Theprevalenceofacutediarrheaamongchildrenaged0–50monthsinthestudyareawas
11.9%and94.6%ofthesanitationfacilitieswereunimproved.Sharingofasanitationfacility
Competinginterests:Theauthorsdeclarethatthey
havenocompetinginterests. bysixormorehouseholds(AOR=4.7;95%CI:2.4–9.4),proximityofsanitationfacilities
PLOSONE|https://doi.org/10.1371/journal.pone.0182783 August30,2017 1/18
SanitationfacilitiesandhygienicconditionsinAddisAbabaslums
Abbreviations:AOR,Adjustedoddsratio;CI, within15metersofhomes(AOR=6.6;95%CI:2.5–17.0),presenceoffeces(AOR=3.9;
Confidenceinterval;JMP,JointMonitoring 95%CI:1.5–10.3)andflies(AOR=2.5;95%CI:1.3–5.0)onthefloorofand/oraroundsani-
Programme;OR,Crudeoddsratio;UNICEF,United
tationfacilities,andpresenceofuncollectedgarbageinsidehousecompounds(AOR=3.2;
NationsChildren’sFund;WHO,WorldHealth
Organization. 95%CI:1.2–8.4)weresignificantlyassociatedwithacutediarrhea.
Conclusion
Thisstudyrevealstheslumenvironmenttobehighriskfordiarrheaduetocloseproximityof
sanitationfacilitiestohomes,sharingofsanitationfacilities,andpoorhygieneofthesanita-
tionfacilitiesandhousingcompounds.Werecommendthedevelopmentofacomprehen-
sivediarrhealdiseasepreventionprogramthatfocusesonimprovingthecleanlinessofthe
sanitationfacilitiesandhousingcompounds.Increasingthenumberofimprovedsanitation
facilitiesatanappropriatedistancefromhousesisalsoessentialinordertoreducethenum-
berofhouseholdsthatshareonelatrine.
Background
TheUnitedNationsHumanSettlementsProgrammehasreportedmassiveurbangrowthin
low-andmiddle-incomecountriesresultinginsprawlingslumsthatarenowhometomore
thanhalfthepopulationofcitiessuchasMumbaiinIndia;KiberasluminNairobi,Kenya;
MexicoCityinMexico[1];andAddisAbabainEthiopia[2].Therapidityofurbanizationin
thesecountrieshascauseddynamicgrowthofurbanslumsandcontributedtoincreasing
numbersofinformalslumdwellers[3,4].Theresulthasbeenovercrowdedlivingconditions
[5];inadequatesanitationfacilities[6];andexposureofslumdwellers,especiallychildren
underfiveyearsofage,toahighriskofdisease[7].Worldwide,abouteightmillionchildren
diedin2010beforereachingtheageoffive,mainlyduetopoorsanitationfacilitiesandunhy-
gienicconditions[8].
Mostpeopleexpectthaturbanareashavebetterchildhealthandlowerchildmortalitythan
ruralareas[9,10].However,recentstudieshaveconsistentlyindicatedthatunder-fivechildren
incitiesofdevelopingcountrieshavebeenfrequentvictimsofdiarrhea,mainlyduetolackof
improvedsanitationfacilities,poorhygienicpractices[11],andthelowhygienicstatusof
sharedsanitationfacilities[12].Despitetheoverallfavorablehealthstatisticsinurbanareas,
severalstudieshavepointedoutlargevariationsamongcountriesandwithinurbanareasand
thepotentialinfluenceofslumsonthesevariations[9,13–15].Disparitiesinhealthdetermi-
nantsbetweenslumandnon-slumareashavevariedwithinthesocioeconomiccontextofeach
country[15].Forexample,researchershavefoundthaturbancaregiversinEthiopiadisposed
ofthefecesofunder-fivechildrenmoresafelythandidruralcaregiversandsafedisposalwas
associatedwithhavinganimprovedsanitationfacility[16].However,themerepresenceof
householdsanitationfacilitiesinurbanareasdidnotnecessarilyresultinfavorablehealthout-
comes[17].Thus,policiesbasedonthecurrentsystemofmonitoringsanitationfacilitiesfail
toconsidertherangesofchallengesandsolutionsinmeetingsanitationneeds[18].
SlumsareknowninEthiopiaas“yedekemubetoch/seferoch,”meaningdeteriorated/dilapi-
datedhousesorsettlements[19].Thisdefinitionofslumsfocusesontheirphysicalstructure
withoutconsideringtheirsocio-economicandhealthcharacteristics,bothofwhichmustalso
beaddressedforremedialandpreventiveactionstosucceed.AccordingtoSclaretal.[20],
nationalgovernmentsandglobalsocietyingeneralcouldaccumulateamassivehealthdebtif
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SanitationfacilitiesandhygienicconditionsinAddisAbabaslums
countriesneglectthehealthofchildreninurbanslums.In2011,theDemographicandHealth
Surveydatarevealedthatdiarrheaprevalenceforunder-fivechildreninAddisAbabawas9.4%
[21];thesurveydidnotinvestigatesanitationfacilitiesandhygiene-relatedfactorsassociated
withdiarrhea.Recentstudiesinvariousdevelopingcountrieshaverecommendedthatparticu-
larattentionbegiventoexamininghealthdeterminantsforslum-dwellingchildrenunderfive
[7,22].Furthermore,intheslumsofAddisAbaba,toourknowledge,nootherstudieshave
beenundertakenonsanitationfacilitiesandhygienicconditionsasfactorsassociatedwith
acutediarrhea.Lackofreliabledata,particularlyonsanitationfacilitiesandhygieniccondi-
tionsinslumareasofAddisAbaba,hindersplanningforandimplementationofdiarrheapre-
ventionprogramsamongunder-fivechildren.Effectivediarrheapreventionprogramsmay
facilitatetheachievementofUNSustainableDevelopmentGoalsby2030,specificallyGoal3
(ensurehealthandwell-beingforall,ateverystageoflife),particularlyTarget3.2(endpre-
ventabledeathsofchildrenunderfiveyearsofage,withallcountriesaimingtoreduceunder-
fivemortalitytoatleastaslowas25per1,000livebirths)andGoal6(ensureavailabilityand
sustainablemanagementofwaterandsanitationforall),particularlyTarget6.2(achieveaccess
toadequateandequitablesanitationandhygieneforall,andendopendefecation)[23].
Therefore,thisstudywasdesignedtoexaminethesanitationfacilitiesandhygienepractices
intheslumsofAddisAbabainrelationtoacutediarrheaamongunder-fivechildren.Results
mayhelpurbanhealthpolicymakersandprogrammanagersinthedevelopmentandimple-
mentationofimprovedsanitationfacilitiesandhygieneprogramsforpreventingacutediar-
rheaintheslumareasofAddisAbabaandotherslumsinEthiopiaandthroughoutsub-
SaharanAfrica.
Materialsandmethods
Studysetting
Thisstudywasconductedintwoslumdistricts(woredas)inAddisAbaba:GulleleSub-City’s
District01andLidetaSub-City’sDistrict05(Fig1).AddisAbaba’spopulationwasestimated
tobe3,273,000in2014–15,ofwhich1,551,000(47.4%)weremalesand1,722,000(52.6%)were
females[24].In2008,thecity-widedataonbasicindicatorsinAddisAbabashowedthat26%
ofthehousesandthemajorityofslumdwellershadnotoiletfacilities,33%ofhouseholds
sharedatoiletwithmorethansixhouseholds,35%ofthegeneratedgarbage/refusewasnever
collected,and71%ofthehouseholdsdidnothaveadequatesanitationfacilities[25].
Studydesignandoutcomevariable
Acommunity-basedcross-sectionalstudydesignwasusedtogatherdataregardingchildren
aged0–50monthsintheslumsofAddisAbababetweenSeptemberandNovember2014.Chil-
drenover50monthswerenotincludedbecausethestudywasabaselinesurveyinalongitudi-
nalstudyconsistingoffourroundsofsurveystobeconductedatthree-monthintervalsamong
thesamestudyparticipants.Duringrecruitmentofchildrenforthebaselinesurvey,oneofthe
criteriawasthatallstudyparticipantsshouldbeunderfiveyearsofageattheendofthelongi-
tudinalstudy,atthefourthround,inAugust2015.Therefore,theagerangesofparticipantsat
eachroundwereasfollows:Firstround,0–50months;secondround,3–53months;third
round,6–56months;andfourthround,9–59months.Thus,forthebaselinesurvey,weused
theagecategoryof0–50months.
Theoutcomevariableofthisstudywasacutediarrhea,denotedasyes(1)orno(0);where
yesindicatedthepresenceofacutediarrheaandnoindicatedtheabsenceofacutediarrhea
duringthetwoweekspriortothebaselinesurvey.Usingtheoutcomevariableofpresenceof
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SanitationfacilitiesandhygienicconditionsinAddisAbabaslums
Fig1.Mapofthestudyarea.
https://doi.org/10.1371/journal.pone.0182783.g001
acutediarrhea,weestimatedtheprevalenceofacutediarrheaamongtheparticipating
children.
Samplesize
Thesamplesizeestimationforthisstudywasbasedonthefactthatthestudywasthebaseline
surveyofalongitudinalstudy;samplesizewascalculatedwiththeprimaryobjectiveofstudy-
ingtheseasonalprevalenceofacutediarrheaamongunder-fivechildren.However,sincethe
longitudinalstudyutilizedarepeatedcross-sectionalsurveythroughfollow-upofthesame
studyparticipants,thesamplesizeestimationmethodsandassumptionsforcalculatingthe
samesamplesizewerethesame.Hence,samplesizewasestimatedusingthesingle-propor-
tionformula[26]:n=(Z - )2(cid:3)P(1-P)/W2withtheassumptionsthatZ - is95%CI,Whas
1 a/2 1 a/2
amarginoferrorof3%,andPis11%estimatedprevalenceofacutediarrheaamongunder-
fivechildrenintheslumsofAddisAbaba.Thecalculatedsamplesizewas418.Consideringa
designeffectof1.5anda10%non-responserate,afinalsamplesizeof697childrenwas
determined.
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SanitationfacilitiesandhygienicconditionsinAddisAbabaslums
Studypopulationandsamplingprocedures
Amulti-stagesamplingmethodwithtwostageswasemployedtoselectthestudypopula-
tion.Inthefirststage,twoslumdistrictswererandomlyselectedfromtheidentifiedslum
districtsinAddisAbaba.Duringthisstage,slumdistrictsincludedinthecity-wideslum
upgradingplan(beingimplementeduntil2025bytheAddisAbabaCityAdministration
HousingAgency)wereexcludedfromthestudy.Todeterminethesamplingpopulationin
thestudydistricts,apreliminarysurveywasconductedinthetwoselectedslumdistricts
throughtransectwalksinahouse-to-houseenumerationofchildrenwhosemaximumage
wouldbe50monthsattheendofthebaselinesurveyperiod.Then,samplesizeswerepro-
portionallyallocatedforthetwodistricts.Bythesecondstage,systematicsamplingtech-
niqueswereusedineverythirdhouseholdtoselectstudyparticipants.Householdswhere
studyparticipantswerenotavailableduringthesurveywererevisitedonceonthesame
dayorthenextday.Ifnotavailableagain,thestudyparticipantwasconsideredanon-
respondent.
Inclusionandexclusioncriteria
Childrenaged0–50monthswereincludedduringselectionofthestudyparticipants.Inhouse-
holdswithmorethanoneeligiblechild,onechildwasrandomlyselectedandrecruitedinto
thestudy.Eligiblechildrenwithbloodydiarrheaand/orpersistentdiarrheatwoweekspriorto
thesurveywereexcluded.Bloodydiarrheawasexcludedbecauseitisfrequentlycausedbydys-
entery,andpersistentdiarrheawasexcludedbecauseofitsdurationof14daysorlonger[27].
Bothoftheseconditionswerebeyondthescopeofthisstudy.
Operationaldefinitions
Acutediarrhea. DiarrheawasidentifiedusingWorldHealthOrganization(WHO)[28]
signsandsymptomsfordiarrheabyquestioningtheparticipants’caregiversaboutsignsand
symptomsofdiarrheatwoweekspriortodataenumeration,suchasconsistencyofbowel
movements,fever,vomiting,bloodinstool,mucusinstool,waterystool,andfrequencyof
abnormalstool.TheWHOprotocol[28]definesdiarrheaasthepassageofthreeormore
abnormallyloose,watery,orliquidstoolsovera24-hourperiod.However,theWHOprotocol
didnotspecifytherecallperiodandthetypesofdiarrhea(acute/waterydiarrhea,bloodydiar-
rhea,orpersistentdiarrhea).Becauseourstudyfocusedonacutediarrhea,weadoptedatwo-
weekrecallperiod,asspecifiedintheWorldGastroenterologyOrganizationglobalguidelines
foracutediarrheasurveys[29].
Sanitation. WHOdefinessanitationastheprovisionoffacilitiesandservicesforthesafe
disposalofhumanfecesandurine.Sanitationalsoreferstothemaintenanceofcleanliness
(hygienicconditions)throughservicessuchaspropergarbagecollectionandwastewater
disposal.
Sanitationfacilities. Referstolatrinesofvarioustypes.
Sharedsanitation. Referstounimprovedsanitationfacilitiesthataresharedbytwoor
morehouseholds,includingpubliclatrines.
Improvedsanitation. TheJointMonitoringProgramme(JMP)forwatersupplyandsani-
tationofWHOandUNICEFdefinesimprovedsanitationasflushtoiletsandpitlatrinesusing
theflush/pour-flushmethodthatareconnectedtoeitherasewerorasepticsystem,ventilated
improvedpitlatrines,andpitlatrineswithslabandcompostingtoilet[30]
Unimprovedsanitation. TheJMPforwatersupplyandsanitationofWHOandUNICEF
definesunimprovedsanitationaspitlatrineswithoutaslab,opendefecation,andpublic
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SanitationfacilitiesandhygienicconditionsinAddisAbabaslums
latrines.Improvedsanitationfacilitiesthataresharedbytwoormorehouseholdsareclassified
asunimprovedbecausesharedsanitationfacilitiestendtobelesshygienicandlessaccessible
thanprivatesanitationfacilitiesusedbyasinglehousehold[30].
Opendefecation. Inthisstudy,opendefecationisaself-reportedbehavior,includingdef-
ecatinginfields,bushes,forests,openbodiesofwater,orotheropenspaces.
Housesrentedfromgovernmentandprivateowners. Housesrentedfromthegovern-
mentareaffordableforlow-incomecitizens,whereashousesrentedfromprivateownersare
expensive.However,rentingprivatehousesdidnotreflectahigherhouseholdincomeor
socio-economicvariation;itmerelyindicatedarelativelylargerexpense.
Ethicalconsiderations
EthicalclearanceforthisstudywasobtainedfromtheInstitutionalEthicalReviewCommittee
ofWolloUniversity,CollegeofMedicineandHealthSciences.Thecommitteeprovided
approvalafterreviewingboththeprotocolandtheconsentforms.Permissiontoconductthe
studywasobtainedfromAddisAbabaCityHealthAdministrationBureau,GulleleandLideta
Sub-Cityhealthoffices,andtherespectivestudyareaslumdistricthealthoffices.Written
informedassentandconsentwereobtainedfromthecaregiversofparticipatingchildren,
assentonbehalfoftheparticipatingchildrenandconsentforthecaregiversthemselves.Confi-
dentialitywasassuredbycollectingthedataanonymouslyandcodingthenamesofthe
respondents.
Datacollectionanddataqualityassurance
Householdsurveydatawerecollectedusingapre-testedstructuredquestionnaireandan
observationalchecklist.Thequestionnaireandtheobservationalchecklistwerefirstprepared
inEnglishandthentranslatedintoAmharicforparticipatinghouseholduse.Thequestion-
nairewaspre-testedon10%ofthestudyhouseholdsinonerandomlyselectednearbyslum
districttoevaluatefacevalidityandtoensurethatthecaregiversunderstoodthequestions.
Anyamendmentmadeinthequestionnairewasbasedonthepre-test.Seventrainedfemale
nursesandenvironmentalhealthprofessionalsadministeredthesurveybyinterviewingpri-
marycaregivers(mothers)usingapre-testedstructuredquestionnaire.Toreducebias,the
dataenumeratorswereblindedanddidnotknowiftheyweresurveyingstudyareasinslums
ornon-slums.
Dataenumeratorsandstudyrespondentswerealsoblindedaboutthehypothesisofthe
studytoreducebias.Dailysupervisionwasprovidedbytwopublichealthprofessionalsand
theprincipalinvestigatorcheckingthecompletenessofthequestionnairesandtheconsistency
ofthedata.DatawereenteredusingEpiDataVersion3.1(EpiDataAssociation,Odense,Den-
mark)statisticalsoftwareandthenexportedtotheStatisticalPackagefortheSocialSciences
(SPSS)Version24.0(IBMCorp.,Armonk,N.Y.,USA)fordatacleaning.Inordertoverifythe
accuracyofdataentries,twogenericdataverificationstrategieswereemployedasdescribed
elsewhere[31].
Independentvariables
Ninesocio-demographicandchild-relatedvariableswereconsideredinthisanalysisas
potentialconfounders(Table1).Tenselectedsanitationfacilitiesandhygienevariableswere
alsoincludedinthisstudy.Onesanitationvariablewasself-reported(numberofhouseholds
sharingalatrine),onesanitationvariablewasmeasuredbydataenumerators(proximityof
latrinestohome),andsanitationstatus(improvedorunimproved)wasclassifiedbythe
researcherbasedonthetypesofsanitationfacilitiesreportedandthenumberofhouseholds
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SanitationfacilitiesandhygienicconditionsinAddisAbabaslums
Table1. Descriptionofsocio-demographic,sanitationfacility,andhygienevariablesincludedinthisanalysis.
Variabledescription Formatforanalysis
Socio-demographiccharacteristic
Slumdistrict Binary,referencecategorywasGulleleSub-City’sDistrict01
Ageofcaregivers(years) Categoricalvariable,referencecategorywascaregivers’ageabove34years
Caregivers’educationalattainment Binary,referencecategorywasliteratecaregivers.Literacydenotedas
caregiversabletoreadandwritebyhavingattendedeitherformalorinformal
education;illiteracyreferstocaregiversbeingunabletoreadorwrite.
Educationalattainmentwasmeasuredbyself-reportingwithoutliteracytest.
Maritalstatusofcaregivers Categorical,referencecategorywascaregiverswhoweremarried.
Householdmonthlyincome Binary,referencecategorywasmonthlyhouseholdincome$50US+orabove
Houseownership Categoricalvariable,referencecategorywasownedorotherhouses.Other
housesarehousesthatwereillegallyconstructedandhadnoownerorhouses
temporarilyprovidedbyfamiliestorelativesorotherpersons.
Householdsize Binary,referencecategorywashouseholdswithsixpersonsormore.
Child’sage Categoricalvariable,referencecategorywaschild’sagebetween36and50
months.
Child’ssex Binary,referencecategorywasfemalesex.
Sanitationfacilityvariables
Sanitationstatus Binary,referencecategorywasimprovedsanitation.
Numberofhouseholdssharingonesanitationfacility Binary,referencecategorywas1–5households.Sharingsanitationfacilitiesdid
notincludehouseholdsthatpracticedopendefecation.
Typesofsanitationfacilityused Categoricalvariable,referencecategorywaspitlatrinewithslab.
Proximityofsanitationfacilitytohome Binary,referencecategorywasdistanceofsanitationfacilities15metersormore
fromhomes.Proximitywasnotmeasuredforhouseholdsthatpracticedopen
defecation.
Hygienevariables
Fecesobservedonthefloorand/oraroundthesanitationfacilities Binary,referencecategorywasnofecesobservedonthefloorand/oraroundthe
sanitationfacilitiesduringthetwoweekspriortothesurvey.
Fliesobservedonthefloorand/oraroundthesanitationfacilities Binary,referencecategorywasnofliesobservedonthefloorand/oraroundthe
sanitationfacilitiesduringthetwoweekspriortothesurvey.
Uncollectedgarbage/refuseobservedinsidethehousecompound Binary,referencecategorywasuncollectedgarbage/refuseobservedinsidethe
housecompoundduringthetwoweekspriortothesurvey.
Domesticsewageobservedinsidethehousecompound Binary,referencecategorywasdomesticsewageobservedinsidethehouse
compoundduringthetwoweekspriortothesurvey.
Wastedisposalmethod
Garbage/refusedisposalmethods Categoricalvariable,referencecategorywasgarbage/refusedisposedofthrough
house-to-housegarbage/refusecollectorsorputintomunicipalgarbage/refuse
container.
Domesticsewagedischargemethods Categoricalvariable,referencecategorywasdomesticsewagedischarged
throughwastewaterdisposalthroughmeshwire.
+Theaverageexchangerate$1US(UnitedStatesDollars)=20.0ETB(Ethiopiabirr)fromSeptembertoNovember,2014.
https://doi.org/10.1371/journal.pone.0182783.t001
sharingalatrine.Typesofsanitationfacilitiesweremeasuredbydataenumeratorsusingboth
self-report(opendefecation)anddirectobservation(publiclatrine,pitlatrinewithslab,and
pitlatrinewithoutslab).Fourhygienevariablesweredirectlyobservedbydataenumerators
(fecesandfliesonthefloorand/oraroundthesanitationfacilities,garbage/refuseanddomes-
ticsewageinsidethehousingcompound),andtwowastemanagementvariableswereself-
reported(garbage/refusedisposalmethodsanddomesticsewagedischargemethods)
(Table1).
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Dataanalysis
DatawereanalyzedusingSTATAVersion14.0(StataCorpLP,CollegeStation,TX).Descrip-
tivestatisticswerecalculatedincludingmeansand±SD(standarddeviations)forcontinuous
variables.Dataanalysiswasperformedusingabinarylogisticregressionmodelat95%CI.The
modelingstrategyinvolvedestimatingthecrudeoddsratio(OR)usingbivariateanalysisand
adjustedoddsratio(AOR)usingmultivariableanalysis.
Bivariateanalysiswasemployedtoidentifyfactorsassociatedwithacutediarrheaat
p<0.05withoutcontrollingconfounders,whereasinthemultivariableanalysis,theassocia-
tionbetweensanitationandhygienefactorswithacutediarrheawasexaminedbycontrolling
forpotentialconfounders[32,33]ofsocio-demographicfactors.Multi-collinearityofvariables
wasassessedbycalculatingthevarianceinflationfactor.Hosmer-Lemeshowstatisticwasused
totestthegoodness-of-fitofthemodel[34].Theadjustedmodelestimatedtheoveralleffectof
allvariablestoselectthesignificantdeterminantsafteradjustmentforconfoundingfactors.
Fromtheadjustedanalysis,variableswithp<0.05weretakenasstatisticallysignificantand
independentlyassociatedwithacutediarrhea.
Results
Socio-demographiccharacteristics
Ofthe697studyparticipants,sevencaregiverswerenon-respondents(1%).Theprevalenceof
acutediarrheawas11.9%.Themajority(79.4%)ofthecaregiverswereliterate;64.2%ofslum
residentslivedinhousesrentedfromtheirdistrictadministrationand17%rentedfromprivate
owners.Almostone-third(31%)ofthehouseholdshadsixormorepersons.Characteristicsof
othersocio-demographicfactorsandtheresultsofthebivariateanalysisofacutediarrheaare
summarizedinTable2.
Characteristicsofsanitationfacilitiesandhygienicconditions
Themajority(94.6%)ofthesanitationfacilitieswereunimproved.Oftheseunimprovedfacili-
ties,11.6%wereanimprovedtypebutbecausetheimprovedfacilitiesweresharedbytwoor
morehouseholds,theywerecategorizedasunimproved.Only5.4%ofsanitationfacilitieswere
improvedandusedbyonehousehold.Byexcludingopendefecationusers,353(54%)house-
holdssharedonesanitaryfacilitywithonetofiveotherhouseholdsand301(46%)households
sharedasanitaryfacilitywithsixormorehouseholds.Fecesandflieswereobservedonthe
floorand/oraround63.4%and39.4%,respectively,ofthesanitationfacilities.Uncollectedgar-
bage/refuseanddomesticsewagewereobservedinside55.4%and50.7%ofhousecompounds,
respectively(Table2).
Factorsassociatedwithacutediarrheainmultivariableanalysis
Themultivariableanalysisshowsthatshareduseofsanitationfacilitiesbysixormorehouse-
holds,proximityofsanitationfacilitieswithin15metersofhomes,presenceoffecesandflies
onthefloorand/oraroundthesanitationfacilities,and/orpresenceofuncollectedgarbage/
refuseinsidethehousecompoundsweresignificantlyassociatedwithacutediarrhea.
Theoddsofdevelopingacutediarrheainhouseholdsthatsharedonelatrineamongsix
ormorehouseholdswere4.7times(AOR=4.7;95%CI:2.4–9.4)higherthanforthoseshar-
ingonelatrineamongonetofivehouseholds.Theoddsofdevelopingacutediarrheain
householdswithproximityoflatrineswithin15meterswere6.6times(AOR=6.6;95%CI:
2.5–17.0)higherthaninhouseholdshavinglatrinesfartheraway.Thelikelihoodofchildren
developingacutediarrheawherefeceswereobservedonthefloorand/oraroundthe
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Table2. Bivariateanalysisofsocio-demographic,sanitationfacility,andhygienefactorswithacutediarrheaamongchildrenaged0–50monthsin
slumsofAddisAbaba,Ethiopia,SeptembertoNovember,2014.
Variable Number(n) Percentage(%) Acutediarrhea OR(95%CI)a
(yes)
Socio-demographicfactor
Slumdistrict
District05 319 46.2 45 1.5(0.9–2.4)
District01 371 53.8 37 1
Ageofcaregivers(years)
<25 106 15.4 17 1.6(0.8–3.2)
25–34 405 58.7 46 1.1(0.6–1.9)
>34 179 25.9 19 1
Caregivers’educationalattainment
Illiterate 142 20.6 21 1.4(0.8–2.4)
Literate 548 79.4 61 1
Monthlyhouseholdincome
Lessthan$50US 250 36.2 48 2.8(1.8–4.5)
$50USorabove 440 63.8 34 1
Houseownership
Rentedfromkebele 443 64.2 53 1.1(0.6–2.1)
Rentedfromprivateowner 117 17.0 15 1.2(0.6–2.6)
Ownedorother 130 18.8 14 1
Householdsize
6ormorepersons 214 31.0 41 2.5(1.6–4.0)
2–5persons 476 69.0 41 1
Maritalstatusofcaregivers
Single 46 6.7 10 2.3(1.1–4.8)
Widowedordivorced 69 10.0 10 1.4(0.7–2.9)
Married 575 83.3 62 1
Child’sage(months)
0–5 41 6.0 7 2.9(1.1–7.8)
6–11 103 14.9 17 2.7(1.2–6.0)
12–23 198 28.7 30 2.5(1.2–5.0)
24–35 169 24.5 16 1.4(0.7–3.2)
36–50 179 25.9 12 1
Child’ssex
Male 378 54.8 53 1.6(0.9–2.6)
Female 312 45.2 29 1
Sanitationfacilityfactors
Sanitationfacilitystatus
Unimproved¥ 653 94.6 82 ǂ
Improved 37 5.4 0 1
Typeofsanitationfacility
Pitlatrinewithoutslab 185 26.8 17 0.9(0.4–1.9)
Publiclatrine 352 51.0 40 1.1(0.6–2.2)
Opendefecation 36 5.2 13 4.9(2.0–12.2)
Pitlatrinewithslab 117 17.0 12 1
Numberofhouseholdssharingonesanitationfacility*
6ormorehouseholds 301 46.0 52 4.1(2.3–7.3)
1–5households 353 54.0 17 1
(Continued)
PLOSONE|https://doi.org/10.1371/journal.pone.0182783 August30,2017 9/18
SanitationfacilitiesandhygienicconditionsinAddisAbabaslums
Table2. (Continued)
Variable Number(n) Percentage(%) Acutediarrhea OR(95%CI)a
(yes)
Proximityofsanitationfacilityfromhome(meters)*
<15m 430 65.7 63 6.2(2.7–14.7)
15mormore 224 34.3 6 1
Hygienefactors
Fecesobservedonthefloorand/oraroundthesanitationfacilities*
Yes 414 63.3 63 7.2(3.1–16.9)
No 240 36.7 6 1
Fliesobservedonthefloorand/oraroundthesanitationfacilities*
Yes 258 39.4 48 4.1(2.4–7.0)
No 396 60.6 21 1
Uncollectedgarbageseeninsidethehousecompound
Yes 382 55.4 70 5.5(2.9–10.4)
No 308 45.6 12 1
Domesticsewageseeninsidethehousecompound
Yes 350 50.7 66 5.0(2.8–8.9)
No 340 49.3 16 1
Wastedisposalmethod
Garbage/refusedisposalmethod
Disposedintoopenpit 43 6.2 10 3.0(1.4–6.4)
Discardedinopenareaoutsidethecompound 87 12.6 14 1.9(0.9–3.6)
Thrownawayinsidecompound 39 5.7 10 3.4(1.6–7.4)
Takenbyhouse-to-housegarbagecollectorsorputintomunicipalgarbage 521 75.5 48 1
container
Domesticsewagedischargemethod
Openditchoutsidethecompound 462 66.9 53 1.2(0.6–2.7)
Dischargedinsidecompound 60 8.7 12 2.4(0.9–6.2)
Dischargedoutsidecompound 84 12.2 9 1.2(0.4–3.2)
Dischargedwithwastewaterdisposalthroughmeshwire 84 12.2 8 1
OR,Crudeoddsratio;CI,Confidenceinterval;$US,UnitedStatesDollars.
aDenotescrudeoddsratiousing95%confidenceintervalinbivariatelogisticregressionanalysis.
1Referencecategory.
*Notincludingopen-defecation-userhouseholds.
¥Includingimprovedsanitationfacilitiessharedbytwoormorehouseholds.
ǂOddsrationotcalculatedsincesanitationfacilitystatus(improvedvsunimproved)wasnotconsideredforbivariateandmultivariableanalysisbecauseno
acutediarrheacasesoccurredinhouseholdsthatusedimprovedsanitationfacilities.
https://doi.org/10.1371/journal.pone.0182783.t002
sanitationfacilitieswas3.9times(AOR=3.9;95%CI:1.5–10.3)higherthanforchildren
havingcleanlatrines.Furthermore,thelikelihoodofchildrendevelopingacutediarrhea
whereflieswereobservedonthefloorand/oraroundthesanitationfacilitieswas2.5times
(AOR=2.5;95%CI:1.3–5.0)higherthanforchildrenhavingsanitationfacilitieswhereno
flieswereobserved.Thelikelihoodofchildrendevelopingacutediarrheainhouseholds
havinguncollectedgarbage/refuseobservedinsidethehousecompoundwas3.2times
(AOR=3.2;95%CI:1.2–8.4)higherthanforthoseinhouseholdswhererefusewasregularly
collected(Table3).
PLOSONE|https://doi.org/10.1371/journal.pone.0182783 August30,2017 10/18