Predictors of the resurgence and sustainability of open defecation-free status among adult residents in Kibwezi East Sub County, Makueni County, Kenya

INTRODUCTION

Reduced soil worms, cholera, diarrhea, trachoma, and malnutrition are some public health advantages associated with increased sanitation access.¹ Despite its well-known advantages, effective excreta disposal remains a challenge, particularly in attaining universal coverage of the dispersed rural populations that characterize most people in middle- and low- income countries.² Worldwide, 2.4 billion inhabitants have limited access to better sanitation, thus posing a challenge to sustaining open defecation-free status in villages.³ Eliminating open defecation and providing safe, affordable, and accessible sanitation for everyone everywhere are central tenets of Sustainable Development goal 6 (SDG 6).⁴ Research shows that adding latrines is not sufficient to reduce fecal-oral disease. Paramount indicators of ODF, such as toilet privacy, aperture covers, availability of facilities for handwashing with soap and water, and the absence of defecation sites, are non-negotiable in the effort to lowering the burden of these diseases. In Kenya, the estimated open defecation rate is 14%. Some counties, such as Turkana, Wajir, and Samburu, have open defecation rates exceeding 70% (MoH, 2017). Out of the 3643 villages in Makueni County, 860, or 23.6%, are open-defecation-free. Most of the open-defecation-free villages (488) are located in Kibwezi East Sub-County. The sanitation data from a records review indicates that 48% of certified villages (235 out of 488) had reverted to an open defecation state.

Despite these concerning trends, it is noteworthy that no published study has documented them or attempted to describe the factors associated with this state in Makueni County. Therefore this study sought to determine the infrastructural factors influencing the resurgence and sustainability of open defecation free status among adult residents in Kibwezi East Sub County.

METHODS

The researcher used descriptive cross-sectional method for this investigation. This method works well for obtaining data to determine the relationship between independent and dependent variables. The participants in this study were adult residents of Kibwezi Eest Sub County, Makueni County, Kenya. The four wards that make up the Sub-County Mtito/Andei, Thange, Ivingoni/Nzambani and Masongaleni. Participants meeting the inclusion criteria were individuals aged 18 and above, residents in the area for over two years, and community health volunteers (CHVs) with a completed Form IV. Exclusion criteria comprised individuals under 18, non-residents, those residing in the area for less than two years, participants with mental illness, and household heads or participants who did not provide consent to the study.

There are 3643 villages in Makueni County and 18142 households in Kibwezi East Sub County. Due to the high number of ODF villages (57%, 488 out 860) in Makueni County and increased reversion rates to open defecation (48%, 235 out of 488), Kibwezi East Sub County was purposively sampled. Cluster sampling by considering each ward as a cluster was employed to get study villages, proportionate sampling was utilized to get study units (households), and a simple random by use of rafts was employed to select and gather information from 423 household heads from a population of 18,142 households.

Background characteristics (age, gender, marital status, religion and education level) and infrastructure factors were included as independent variables. The resurgence and sustainability of open defecation free status amongst Kibwezi East Sub County residents, Makueni County, Kenya, was the dependent variable. A questionnaire and observation checklists were utilized to collect information on background characteristics and factors linked with the resurgence and sustainability of open defecation free status amongst community members. A pre-test was conducted among the residents of Kibwezi West Sub County to confirm its reliability. Data collection occurred during August 2023, spanning one month. The Chi-square test was used to look into the links between categorical variables (background and infrastructural factors) and the resurgence and sustainability of open defecation free status.

RESULTS

Background characteristics of the respondents

A total of 423 household heads were surveyed with a response rate of 100%. The socio-demographic profile of the participants is shown in the (Table 1).

Most respondents were Christians (98.8%), had completed primary education (52.9%), were female (68.6%), married (89.1%), and had an average age of 48.40 years. A Chi-square analysis was applied to examine the relationship of background features and the sustainability of open defecation free status among the residents. Further, the unadjusted odds of the outcome occurring given the dpendent variable were also computed. As shown in Table 2, individuals with education levels at or below primary education had higher odds of not sustaining ODF practices (uOR=1.567, 95% CI:1.061-2.315, p=0.024).

uOR=Unadjusted Odds Ratio, Dependent Variable (DV): “ODF Sustainability”. Reference Category: “NO”

Infrastructural factors influencing the resurgence and sustainability of open defecation free status

The (Table 3) summarizes key infrastructural factors related to facility accessibility, privacy, and management.

Most sanitary facilities (59.5%) were located within 10-50 meters, with a median walking time of 3.0 minutes. A majority of 91.7% (N=388) were accessible to people of all ages. Most respondents, 67.1% (N=275), reported no open defecation sites in their community.

uOR=Unadjusted Odds Ratio, Dependent Variable (DV):“ODF Sustainability. “Reference Category: “Yes”

Concerning lavatory wall materials, mud bricks were the predominant choice at 42.3%, while sand and cement screed dominated lavatory floors at 59.9%. A significant majority, 88.6% (N=373), had a roof in their lavatory, and 93.8% (N=390) were considered to have adequate privacy. However, 40.4% (N=169) encountered unpleasant odors from the toilet, and 42.4% (N=176) frequently encountered insects in the lavatory.

Association between infrastructural factors and the resurgence and sustainability of open defecation free status

In the (Table 4) below, ODF sustainability was less likely in households without user-friendly sanitary facilities (uOR=2.47, p<0.001) and roofless toilets (uOR=0.355, p<0.001). Longer walking times (>3 minutes) were associated with reduced ODF sustainability (uOR=0.341, p<0.001). Conversely, the absence of designated open defecation sites increased the odds of ODF sustainability by 1.669 times (uOR=1.669, p<0.001), and households with toilets emitting no unpleasant odors were more likely to sustain ODF (uOR=1.287, p=0.030).

DISCUSSION

Most of the respondents (98.8%, N=418) were Christians. This reveals the dominance of Christianity in the study area. In regards to education, most of the participants (52.9%, N=226) reported to have completed primary education. Studies have consistently shown that educational attainment has a strong effect on health behaviors and attitudes towards sanitation adoption and use. In the study, females (68.6%, N=269) dominated the sample. It is a clear indication that women and young girls may suffer a lot when a household lacks a decent sanitary facility for use by the members. This is in line with a study in Kenya by Njuguna, whose findings revealed that women and young girls in school are particularly at risk of violence and rape when searching open defecation sites, especially during late hours.⁶ The study further revealed that individuals with education levels at or below primary education had higher odds of not sustaining ODF practices.

The findings concur with the studies by Delaire et al where they reported a significant relationship between the mother's level of education, the presence of secondary school students, the frequency of latrine construction, latrine sanitation, and the use of latrines.⁷ The study further revealed that most of the sanitary facilities (59.5%) were located within 10–50 meters, with a median walking time of 3.0 minutes, and the longer walking times (>3 minutes) were associated with reduced ODF sustainability. The results are in line with WHO's recommendations that the pits be built at a reasonable distance from the house, ideally balancing easy access against smell.³ Additionally, the findings concur with those of Tessama et al who reported a significant relationship between the distance from the household to the toilet and ODF sustainability.⁸ In this study, ODF sustainability was less likely in households without user-friendly sanitary facilities. This result agrees with Delaire et al report that, in order to maintain the status of ODF, all sanitary facilities, including school toilets, should be suitable for the elderly and children of all ages and sizes.⁷

Further analysis from qualitative data revealed that, user-friendliness of sanitary facilities especially for the elderly population in the study area was a public health concern if we were to sustain ODF. Additionally, reports from qualitative analysis indicated that, common challenge was the lack of water in areas where SATO-PAN toilets were in use.

The reasons why households return to open defecation are likely to vary among contexts, according to Odagiri's report, which supports these conclusions.⁹ Many people who practice the open defecation method in some places may own toilets, but they may not use them because of poor construction, a lack of privacy, the availability of designated OD sites, or an offensive odour from the toilets.

Limitations

Challenges included long distances between sampled villages and households, compounded by limited resources. To address this, researcher used own savings. In quantitative data collection, biases were acknowledged and mitigated by employing an observation checklist. Monetary demands from study subjects were addressed by clarifying the study's educational nature, emphasizing voluntary participation.

CONCLUSION

This study achieved a high response rate. The findings indicate that socio-demographic factors, such as education levels and infrastructural factors such as time taken to access sanitary facility, absence of designated open defecation sites in the community and having a toilet that did not emit unpleasant odors are crucial for sustaining ODF status. Since education has been linked to better sustainability of ODF, the study recommends that the ministry of education continue with the efforts of 100% transition of pupils to secondary and higher education levels. Also, the community members should enhance infrastructural factors such as the provision of vent pipes, toilet roofing, construction of permanent toilets, latrine aperture covers, and hand washing facilities with running water and soap through subsidized government intervention. Further, the study recommends additional research to uncover more influencers to ODF sustainability.

ACKNOWLEDGEMENTS

The Kibwezi East Sub County residents who agreed to engage in this study are greatly appreciated by the authors. The county and sub-county administrations are also appreciated by the authors for allowing this study to be conducted in their respective regions.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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