Geographical variation and factors associated with unsafe child stool disposal in Ethiopia: A spatial and multilevel analysis

Background: Unsafe disposal of childrens stool makes children susceptible to fecaloral diseases and children remain vulnerable till the stools of all children are disposed of safely. There is a paucity of data on spatial distribution and factors associated with unsafe child stool disposal in Ethiopia. Previous estimates, however, do not include information regarding individual and community level factors associated with unsafe child stool disposal. Hence, the current study aimed to explore the spatial distribution and to identify factors associated with unsafe child stool disposal in Ethiopia. Methods: A secondary data analysis was conducted using the recent 2016 Ethiopian demographic and health survey data. A total of 4145 children aged 0 to 23 months with their mother were included in this analysis. The Getis Ord spatial statistical tool was used to identify high and low hotspots areas of unsafe child stool disposal. The Bernoulli model was applied using Kilduff SaTScan version 9.6 software to identify significant spatial clusters. A multilevel binary logistic regression model was fitted to identify factors associated with unsafe child stool disposal. Results: Unsafe child stool disposal was spatially clustered in Ethiopia (Morans Index 0.211, p value< 0.0001), and significant spatial SaTScan clusters of areas with a high rate of unsafe child stool disposal were detected. The most likely primary SaTScan cluster was detected in Tigray, Amhara, Afar (north), and Benishangul Gumuz (north) regions (LLR: 41.62, p<0.0001). Unsafe child stool disposal is more prevalent among households that had unimproved toilet facility (AOR=1.54, 95%CI: 1.17-2.02), and those with high community poorer level (AOR: 1.74, 95%CI: 1.23-2.46). Higher prevalence of unsafe child stool disposal was also found in households with poor wealth quintiles. Children belong to agrarian regions (AOR: 0.62, 95%CI 0.42-0.91), children 6/11 months of age (AOR: 0.66, 95%CI: 0.52-0.83), 12-17 months of age (AOR: 0.68, 95%CI: 0.54-0.86), and 18/23 months of age (AOR: 0.58, 95%CI: 0.45-0.74) had lower odds of unsafe child stool disposal. Conclusions: Unsafe child stool disposal was spatially clustered. Higher odds of unsafe child stool disposal were found in households with high community poverty level, poor, unimproved toilet facility, and with the youngest children. Hence, the health authorities could tailor effective child stool management programs to mitigate the inequalities identified in this study. It is also better to consider child stool management intervention in existing sanitation activities considering the identified factors.