Child Feces Disposal in 96433 MALAWI Key messages: • In 2010, 21 percent of households surveyed in Malawi reported unsafe disposal of the feces of their youngest child under age three. • Among households with improved toilets or latrines, 14 percent reported unsafe child feces disposal behavior. • Safe child feces disposal steadily increases with the wealth of the household: 69 percent of the poorest quintile reports safe disposal compared to 89 percent of the richest quintile.1 OVERVIEW In Malawi, households lacking improved sanitation, those in rural areas, and poorer households—as well as households with Safe disposal of children’s feces is as essential as the safe disposal of younger children—have a higher prevalence of unsafe child feces adults’ feces. This brief provides an overview of the available data on disposal. Households practicing open defecation reported the child feces disposal in Malawi and concludes with ideas to strengthen highest prevalence of unsafe child feces disposal at 64 percent (see safe disposal practices, based on emerging good practice. Figure  3). For the remaining 36 percent of households practicing The Joint Monitoring Programme for Water Supply and Sanitation open defecation (i.e., they do not use a latrine), it is possible, but not (JMP) tracks progress toward the Millennium Development Goal 7 probable, that they deposit their children’s feces into a latrine (see target to halve, by 2015, the proportion of people without sustainable notes on self-reported data in the “Data Sources” section). access to safe drinking water and basic sanitation. The JMP A shift in safe disposal practices is also seen as children grow: children standardized definition for an improved sanitation facility is one that are increasingly likely to use a toilet/latrine themselves, or have their hygienically separates human excreta from human contact.2 feces put or rinsed into one. At these young ages, the behavior of the According to the latest JMP report, only 10 percent of Malawi’s child’s caregiver is critical to dispose of the feces safely and shape the population had access to improved sanitation in 2012.3 This means child’s toilet training (see Figure 4). that 14.3 million individuals in Malawi lacked improved sanitation in Safe disposal is fairly high across all wealth asset quintiles.4 The 2012; of these, 1.1 million practice open defecation. However, these poorest quintile of households is slightly less likely than the richer estimates are based on the household’s primary sanitation facility, and richest households to report safe child feces disposal: 70 percent and may overlook the sanitation practices of young children. In many of the poorest quintile reports safe disposal (see Figure 5). Looking cases, children may not be able to use an improved toilet or latrine— at overall sanitation facility coverage for households with children because of their age and stage of physical development or the safety under age three in Malawi, only 74 percent of the poorest households concerns of their caregivers—even if their household has access to one. reported use of any toilet/latrine, improved or unimproved, compared SUMMARY OF CHILD FECES DISPOSAL DATA What Is “Safe Disposal” of a Child’s Feces? In 2009, over three-quarters of households (79 percent) surveyed The safest way to dispose of a child’s feces is to help in Malawi reported that the feces of their youngest child under the child use a toilet or latrine or, for very young children, age three were safely disposed of. Only 7 percent of households in to put or rinse their feces into a toilet or latrine. For the Malawi reported that their youngest child’s feces were deposited into purposes of this brief, these disposal methods are referred an improved sanitation facility, according to the 2010 Malawi DHS to as “safe,” whereas other methods are considered “unsafe.” (see Figure 1). This low percentage of households reporting improved By definition, “safe disposal” is only possible where there child feces disposal is slightly lower than the overall percentage of is access to a toilet or latrine. When a child’s feces is put households using improved sanitation (10 percent). This provides or rinsed into an “improved” toilet or latrine, this is termed evidence that although good disposal behavior is relatively common, “improved child feces disposal.” a main block is access to improved sanitation facilities. December 2014 1 FIGURE 1  Safe disposal prevalence is relatively high, but the prevalence of improved disposal is negligible. Percentage of households reporting each feces disposal practice for their youngest child under age three, Malawi, 2010. Unsafe Disposal Safe Disposal Missing, 1% Other, 3% Child used toilet/latrine Left in the open, 2% and household (HH) used improved Buried, 4% sanitation, 1% Improved Thrown into disposal = 7% Child feces put/rinsed garbage, 3% in toilet/latrine and Put/rinsed into HH used improved drain or ditch, 8% Safe sanitation, 6% disposal = 79% Child used toilet/latrine, but HH used unimproved sanitation, 8% Child feces put/rinsed in toilet/latrine but HH used unimproved sanitation, 64% FIGURE 2  Malawi ranked second best for the FIGURE 3  Over 80 percent of households with percentage of children whose feces are safely access to any sanitation facility (shared, unimproved, disposed of, out of 31 countries in Sub-Saharan or improved) reported safe child feces disposal. Africa with available MICS or DHS data. Percentage of Reported feces disposal practice for household’s youngest households reporting safe feces disposal for their youngest child under age three, by household sanitation facility type, child under age three, sub-Saharan Africa.5 Malawi, 2010. 100 13% 20% 14% 80 % of children 64% 60 80% 87% 86% 40 20 36% 0 Open Unimproved Shared Improved defecation (68% of (8% of (11% of (13% of households) households) households) households) Type of sanitation facility used by household Unsafe child feces disposal Safe child feces disposal areas, and those that are poorer. Although this brief only focuses on one socioeconomic indicator at a time, applying multiple lenses would show even greater extremes of disparity—with the poorest rural households reporting the greatest prevalence of unsafe disposal. to 99 percent of the richest quintile. This is an important factor in IDEAS FOR CONSIDERATION child feces disposal: by definition, safe disposal is only possible when there is access to a toilet/latrine. In Malawi, few interventions have focused on improving the safe disposal of children’s feces during the first years of life. In general, Behind this national-level data, there is wide variation in child feces sanitation for children under age three has been a neglected area of disposal practices, with a greater prevalence of unsafe practices policy and program intervention. Given the relatively few programs among households without access to improved sanitation, in rural focusing on children’s sanitation in Malawi and globally, there is 2 FIGURE 4  Safe child feces disposal steadily increases with children’s age. Reported feces disposal What Is the Impact of Unsafe Disposal practice for children of different ages, Malawi, 2010. of Child Feces? 100 6% 1% 2% 2% 3% 1% There is widespread belief that the feces of infants and 5% 3% 5% 3% 2% 3% 6% 4% young children are not harmful, but this is untrue. In fact, 80 18% there is evidence that children’s feces could be more risky % of children 60 than adults’ feces, due to a higher prevalence of diarrhea 71% and pathogens—such as hepatitis A, rotavirus, and E. coli—in 80% children than in adults.6 Therefore, children’s feces should 40 64% be treated with the same concern as adults’ feces, using 20 safe disposal methods that ensure separation from human 1% 3% 13% contact and household contamination. 0 0 1 2 In particular, the unsafe disposal of children’s feces may be Child age (years) an important contaminant in household environments, posing Missing Thrown into garbage a high risk of exposure to young infants.7 Poor sanitation can Other Put/rinsed into drain or ditch result in substantial health impacts in children, including a Left in the open Put/rinsed into toilet/latrine higher prevalence of diarrheal disease, intestinal worms, Buried Child used toilet/latrine enteropathy, malnutrition, and death. According to the World Health Organization (WHO), most diarrheal deaths in the world (88 percent) are caused by unsafe water, sanitation, FIGURE 5  Safe child feces disposal increases or hygiene. More than 99 percent of these deaths are in steadily with increasing wealth. Reported feces disposal developing countries, and about eight in every 10 deaths are practice for household’s youngest child under age three, by children.8 Diarrhea obliges households to spend significant household wealth quintile, Malawi, 2010. sums on medicine, transportation, health facility fees, and more, and can mean lost work, wages, and productivity 100 2% among working household members.9 Stunting and worm 4% 3% 3% 1% 4% 2% 3% 1% 2% 1% 5% 4% 3% 4% 2% 7% 2% 7% 1% 1% infestation can reduce children’s intellectual capacity, which 7% 4% 7% 80 8% affects productivity later in life. The WHO estimates that the 11% average IQ loss per worm infection is around 3.75 points.10 % of children 60 40 74% 76% 80% 63% 71% • Exploring opportunities to integrate child sanitation into existing interventions that target caregivers of young children, such as 20 including key messages in antenatal/newborn care materials and 0 7% 6% 7% 7% 8% infant and young child feeding guidance provided to parents, Poorest Poorer Middle Richer Richest ensuring that midwives’ training, as well as early childhood Wealth quintile of child’s household development materials and preschool programs, include information on safe child feces disposal Missing Thrown into garbage • Partnering with the private sector to improve feces management Other Put/rinsed into drain or ditch Left in the open Put/rinsed into toilet/latrine tools, such as potties, diapers, tools for retrofitting latrines for Buried Child used toilet/latrine child use, and scoopers • Improving the enabling environment for management of children’s feces, by including specific child feces related criteria in not a strong evidence base of effective strategies for increasing the open defecation free (ODF) verification protocols and in national safe disposal of children’s feces. Significant knowledge gaps must be sanitation policies, strategies, or monitoring mechanisms. filled before comprehensive, practical, evidence-based policy and program guidance will be available. Nevertheless, organizations and governments interested in improving the management of children’s DATA SOURCES feces could consider: Unless otherwise specified, all analysis in this brief is based on households’ • Conducting formative research to understand the behavioral self-reported behavior for disposing of children’s feces, as collected in the drivers and barriers to safe child feces disposal 2010 Malawi Demographic Health Survey (DHS), which is the latest DHS or Multiple Indicator Cluster Survey (MICS) available for Malawi that records • Strengthening inclusion of safe child feces disposal into child feces disposal behavior. Community Led Total Sanitation (CLTS) programs and other hygiene promotion activities to encourage cleaning children after The MICS and DHS collect data in a generally harmonized manner and hence defecation, potty training children, and using appropriate methods are the basis for this country profile series. However, whereas the DHS collects to transport feces to a toilet/latrine as well as handwashing with data on the youngest child under age five living with the mother for each soap after fecal contact and before preparing food or feeding a child household, the MICS collects data on all children under age three who lives with the respondent (mother or caretaker). 3 3 WHO/UNICEF Joint Monitoring Programme, 2014. Progress on Drinking Water and Sanitation: Update 2014. Geneva: World Health Organization. 4 The wealth indices used to classify households into wealth quintiles include drinking water and sanitation variables. 5 The latest available MICS/DHS survey with data for each country, as of March 2014. Survey years range from 2006–2012. Please see the data notes at the end of the brief. 6 Feachem, R., D. Bradley, H. Garelick, et al. 1983.  Sanitation and Disease: Health Aspects of Excreta and Wastewater Management. World Bank Studies in Water Supply and Sanitation 3. Chichester, UK: John Wiley & Sons. 7 Gil, A., C. Lanata, E. Kleinau, and M. Penny. 2004. Children’s Feces Disposal Practices in Developing Countries and Interventions to Prevent Diarrheal Diseases: A Literature Review. Strategic Report 11. Peru: Environmental Health Project (EHP). 8 WHO. 2009. Global Health Risks: Mortality and Burden of Disease Attributable to Selected Major Risks. Geneva: World Health Organization, 23. 9 Favin, M., G. Naimoli, and L. Sherburne. 2004. Improving Health Through Behavior Change: A Process Guide on Hygiene Promotion. Joint Publication 7. Washington, DC: Environmental Health Project (EHP). 10 WHO. 2005. Report of the Third Global Meeting of the Partners for Parasite Control: Deworming for Health and Development. Geneva: World Health Organization, 15. 11 Stanton, B., J. Clemens, K. Azis, and M. Rahamanr. 1987. “Twenty-Four- Hour Recall, Knowledge-Attitude-Practice Questionnaires and Direct Observations of Sanitary Practices: A Comparative Study.” Bulletin of the World Health Organization. Geneva: World Health Organization. However, the fact that the MICS data are for all children in the age group 12 Akhtaruzzaman, M. N., and S. N. Islam. 2011. Nutrition, Health and and the DHS data are only for the youngest per household means that some Demographic Survey of Bangladesh—2011: A Preliminary Report. limitations to the comparability of the MICS and DHS data presented in Bangladesh: University of Dhaka, 19. Figure  2 remain. Figure 2 presents MICS data for the following countries: Central African Republic, Chad, the Democratic Republic of Congo (DRC), Gambia, Ghana, Malawi, Mauritania, Nigeria, Sierra Leone, Somalia, South Sudan, Swaziland, Togo, and Tunisia. Figure 2 presents DHS data for NOTES the following countries: Benin, Burkina Faso, Burundi, Cameroon, Cote We’re interested in your thoughts. Have you found different evidence D’Ivoire, Egypt, Ethiopia, Guinea, Kenya, Lesotho, Liberia, Madagascar, Mali, of what works through your own programming? If you have thoughts to Mauritania, Morocco, Mozambique, Namibia, Niger, Rwanda, Sao tome and share, or know of a program that is encouraging the safe disposal of child Principe, Senegal, Tanzania, Uganda, Zambia, and Zimbabwe. feces, please contact WSP at worldbankwater@worldbank.org or UNICEF at WASH@unicef.org so that we can integrate your information into future It is likely that self-reports overestimate safe disposal.11 In Bangladesh, for program guidance. example, although 22 percent of children reportedly either used a toilet/ latrine or their feces were put or rinsed into the toilet/latrine (according to MICS 2006), a structured observation of behavior conducted under UNICEF’s Sanitation, Hygiene Education and Water Supply in Bangladesh (SHEWA-B) ACKNOWLEDGEMENTS program in 2007 found only 9 percent of subjects disposed of child feces into a toilet/specific pit.12 Regardless of this issue, self-reports are currently regarded This brief was developed jointly by WSP and the United Nations Children’s as the most efficient method for gauging safe disposal of children’s feces. Fund (UNICEF) as part of a series of country profiles about sanitation for children under age three. The findings, interpretations, and conclusions expressed herein are those of REFERENCES the author(s), and do not necessarily reflect the views of the International Bank for Reconstruction and Development / The World Bank and its affiliated 1 National Statistical Office and ICF Macro. 2011. Malawi Demographic and organizations, or those of the Executive Directors of The World Bank or the Health Survey 2010. Zomba, Malawi and Calverton, MD. Please see the governments they represent, or of UNICEF. “Data Sources” section. 2 The JMP has established a set of standardized definitions to categorize © 2015 by International Bank for Reconstruction and Development / The improved sanitation, which are used to track progress toward Millennium World Bank and UNICEF. Development Goal 7. However, these definitions are not always the same as those used by national governments. See Progress on Drinking Water Photo Credits: © UNICEF/MLWB2012-01537/Nesbitt (page 1); © UNICEF/ and Sanitation: Update 2014. MLWB2011-00279/Noorani (page 4) 4