To explore child defecation and faeces management practices in rural Bangladesh with the aim to redesign and pilot a tool to facilitate removal and disposal of faeces.
To explore child defecation and faeces management practices in rural Bangladesh with the aim to redesign and pilot a tool to facilitate removal and disposal of faeces.
We conducted six group discussions, six short interviews and three observations of practices and designed the new tool. We piloted the new tool and elicited feedback through two in-depth interviews and two observations.
Until three years of age, a child commonly defecates in the courtyard and occasionally inside the house. A heavy digging hoe was commonly used to remove child faeces. Mothers preferred a redesigned ‘mini-hoe’ and found it easier to use for removal and disposal of liquid faeces.
Promoting modified local tools may contribute to improving environmental sanitation and health.
Explorer les pratiques de défécation des enfants et les efforts pour l'enlèvement et l’élimination des excréments, en zone rurale au Bangladesh, dans le but de développer et appliquer un outil pour faciliter ce processus.
Nous avons mené 6 discussions de groupe, 6 courtes interviews, 3 observations de pratiques et avons conçu le nouvel outil. Nous avons appliqué ce nouvel outil et suscité des commentaires à travers 2 interviews en profondeur et 2 observations.
Jusqu’à trois ans, un enfant défèque souvent dans la cour et parfois à l'intérieur de la maison. Une houe à creuser était couramment utilisée pour enlever les selles de l'enfant. Les mères ont préféré une version remaniée «mini-houe» et l'ont trouvée plus facile à utiliser pour l'enlèvement et l’élimination des selles liquides.
Promouvoir des outils locaux modifiés peut contribuer à l'amélioration de l'assainissement de l'environnement et de la santé.
Explorar las prácticas de defecación de los niños, así como los esfuerzos para retirarlas y desecharlos en zonas rurales de Bangladesh, con el objetivo de desarrollar y adaptar una herramienta que facilitase el proceso.
Hemos realizado 6 discusiones en grupo, 6 entrevistas cortas, 3 observaciones de prácticas y el diseño de una nueva herramienta. Hemos probado la nueva herramienta y obtenido información de los usuarios mediante 2 entrevistas en profundidad y 2 observaciones.
Hasta los tres años de edad por lo general un niño defeca en el jardín, y ocasionalmente dentro de la casa. Comúnmente se utilizaba una azada grande y pesada para remover las heces del niño. Las madres preferían utilizar una “pequeña azada” rediseñada, la cual encontraron que era más fácil de utilizar para remover y deshacerse de las heces líquidas.
Promover herramientas locales modificadas puede contribuir a mejorar la sanidad ambiental y la salud.
Diarrhoeal disease is the second leading cause of child mortality worldwide (Boschi-Pinto et al. 2009). The presence of child faeces in the household premises and not disposing child faeces in a latrine are related to an increased incidence of diarrhoea of young children, especially those under 2 years of age (Baltazar & Solon 1989; Alam & Wai 1991; Mertens et al. 1992; Traore et al. 1994; Wilunda & Panza 2009). A recent Cochrane review concluded that interventions to improve faeces disposal are potentially effective in preventing diarrhoeal diseases, but noted that the quality of existing evidence is poor (Clasen et al. 2010).
The practice of child defecation on the ground is common in urban and rural settings of many countries (Baltazar & Solon 1989; Mertens et al. 1992; Aulia et al. 1994; Traore et al. 1994; Yeager et al. 1999) including Bangladesh (Alam et al. 1989; Alam & Wai 1991). A study in Bangladesh from over 20 years ago reported that 35% of children aged <5 years defecated in the household premises or the surrounding outdoor area (Alam et al. 1989). A recent study conducted in 2011 also reported that open defecation in the courtyard for children aged <5 years is still common in rural Bangladesh (Ashraf et al. 2011). According to the country report from the Ministry of Local Government Rural Development of Bangladesh, usually child faeces are disposed in an open place, and only 22% of child faeces are disposed hygienically (LGRD 2008). Rural residents of Bangladesh live in a faeces-laden domestic environment as both humans and animal share the same living space (Yusuf & Zakir Hussain 1990). Children commonly touch or ingest faeces from the household play area in rural Bangladesh (Ahmed et al. 1991). Faecal contamination and rubbish disposal in infants' outdoor play areas and hand and mouth contact with contaminated materials were associated with diarrhoea in children under 2 years in rural Bangladesh (Zeitlin et al. 1995).
Although both human and animal faeces contain gastrointestinal pathogens which can be transmitted through a contaminated environment (Curtis et al. 2000), most sanitation intervention efforts by the government of Bangladesh have ignored child and animal faeces management and instead targeted latrine building (BBS-UNICEF 2010). Safer disposal of both child and animal faeces from household environments is important because the household is the principal habitat of young children (Cairncross et al. 1996). We explored child defecation practices and faeces removing and disposing efforts of rural residents to develop and pilot a tool to facilitate faeces removal and disposal and use of this tool in rural households.
In February 2010, a team of three qualitative researchers conducted this study in three villages of Faridpur district. We selected these villages because they were sites of ongoing studies of the icddr, b, Bangladesh, and we had built rapport with the communities.
We collected data in two phases. First, we explored child defecation practices, the faeces disposal methods used by households, including the tools used for removing and disposing faeces from the household or from the surrounding outdoor area, and advantages and limitations of the existing tools. We asked participants to suggest new tools. Second, we redesigned the existing tools based on the collected information and suggestions of the informants and tested the tools in the community for acceptability.
Initially, we conducted group discussions with the mothers of children aged <5 years in two villages, and later, we conducted four group discussions in all three villages with the women members of those households with children aged <5 years (Table 1). During these discussions, respondents reported that children ≤3 years primarily defecated in the open, so we subsequently conducted six short interviews with the mothers of children ≤3 years (Table 1). The group discussions ranged from 20 to 40 min, and the short interviews ranged from 15 to 40 min. We also observed child defecation practices and method of scooping and disposing faeces for 2–5 h in three households. We recorded the group discussions and interviews using an audio recorder, and we also took field notes.
|Phase 1||Group discussion||Mother of <5 children||2|
|Group discussion||Women of the household of <5 children||4|
|Short interview||Mother of ≤ 3 children||6|
|Observation||Household of ≤ 3 children||3|
|Phase 2||Deployed new tools||Household of ≤ 3 children||2|
|In-depth interview||Mother of ≤ 3 children||2|
|Observation||Household of ≤ 3 children||2|
Based on the recommendations and suggestions of the informants from the three villages, we redesigned two tools and contracted local craftsmen to construct our redesigned versions with locally available materials. Later, we distributed both tools to two families who had a child ≤3 years old who volunteered to test the tools. After 1 week, we conducted in-depth interviews, ranging from 30 to 40 min, with the two mothers who had used the redesigned tools. We also asked the mothers to demonstrate faeces removal and disposal using the tool (Table 1). The mothers used poultry faeces for the demonstration because at the time of demonstration, their children had not recently defecated.
We transcribed the recorded data from interviews and group discussions and expanded the field notes. Three researchers reviewed the transcripts and field notes to identify emerging themes and subthemes through an iterative process. We summarised the data of the emerging themes according to the study objectives.
We explained the study objective to the participants and informed consent before the group discussions, interviews and observations. The study was part of a larger protocol on water, sanitation and hygiene research that was approved by the Ethical Review Committee of the icddr,b, Bangladesh.
Twenty mothers with children aged between 4 and 60 months and 24 women members of those households who had children aged <5 years participated in the study. All the women were aged between 20 and 35 years and were housewives.
Informants stated that until 6 months of age, children defecated in their cloth wrapper (katha) or on the clothes of the mother. Mothers reported that they washed the katha in the nearest water source. They said that from the time children started crawling until they reached approximately 3 years of age, they defecated on the ground in the common courtyard and occasionally inside the house. We observed that usually this courtyard was shared by several households and that children of different age groups from those households, and from neighbouring households, played, urinated and defecated in that shared yard. Adults also shared the same yard for different purposes, such as preparing food, sewing clothes and sitting together for conversation. Informants also reported that from the age of 3 years, children started learning to defecate in the household latrines. Only two of the 20 mothers reported that a few families used plastic potties specifically designed for child defecation.
Dry leaves and/or straw (Laba-jhaba): Informants stated that they used bits of ‘dry leaves and straw’ (laba-jhaba) to scoop up the faeces and dump them either in ditches or bushes beside or near the household. When the child was 6–10 months old, mothers removed the faeces from the ground using ‘laba-jhaba’. When the faeces were soft or liquid, they put ash on them first, then remove them with ‘laba-jhaba’, and finally, they had to smear mud or cow dung over the place of defecation. They explained that ‘laba-jhaba’ could not be used for children older than 10 months, and sometimes, the mother's hands became smeared with faeces while cleaning with ‘laba-jhaba’: ‘When children become older, their faeces cannot be cleaned by laba-jhaba, as they start eating rice and other food, and their faeces become stinky and repulsive’.
Heavy agricultural hoe (kodal): The mothers commonly used a heavy agricultural hoe, formally classified by the experts as a ‘Chillington-type heavy-duty-digging hoe’ (Figure 1), to scoop the faeces of children >10 months of age and occasionally used it for faeces of children <10 months. The mothers scooped the faeces with the scraping part of the hoe and then disposed the faeces either in the nearest bush or ditch or inside the toilet. One mother reported that when she used ‘labajhaba’, she threw the faeces in the bush beside the house, and when she used the hoe, she threw the faeces in the toilet. She explained that she did not dump faeces with ‘laba-jhaba’ in the toilet because it would block the toilet pipe.
Mothers reported that after removing and disposing of the faeces, they rinsed the hoe with water and scrubbed it with their bare feet. When children grew older and their faeces became smelly, using a hoe for removing and disposing faeces was preferable because they could avoid touching faeces with their hands and keep the smelly faeces away from their faces.
Informants reported that this agricultural hoe was a very useful tool for a rural household. Aside from removing and disposing child faeces, they also used it for various purposes: gardening, building and repairing their houses, and scooping animal and poultry faeces. This hoe could also clean liquid or watery faeces completely from the ground by collecting a layer of soil beneath the faeces. On the other hand, some informants mentioned that it was difficult to use their usual hoe to scoop up liquid faeces as the liquid spilled over the scraping part of the hoe (Figure 1). For this reason, they used this hoe only for solid faeces. Some also mentioned that this hoe was heavy, and it was difficult for them to use it for scraping soil. The usual weight of this hoe was 2.7 kg, with a wooden handle 81 cm in length.
Although not every household had such a hoe, it was available in most households, and if they did not have one, informants could borrow one from their neighbours. Mothers reported that the hoe was not always available at home or around as it was mainly used for agricultural purposes. They considered it unreasonable to buy one only for removing and disposing faeces as it was expensive (US$ 3–4). They also mentioned that if this hoe was not available at home, they scooped the faeces using laba-jhaba.
Some informants mentioned that elderly people forbade them from using this type of hoe saying that when a woman had a small child (aged around up to 6–10 months), she should not touch the faeces with a hoe as it might cause stomach ache or cause other harm to the child. Others reported that they did not have any such inhibition.
Only two mothers of 20 reported that two neighbouring families were using a potty. They mentioned that it helped build a good practice for children as they had a fixed place to defecate every day. Using a potty did not make other places dirty, and it could be cleaned easily. They cleaned the potty by washing it with ‘laba-jhaba’ and water by hand. They mentioned that those who could afford it, used a potty for their children. Others mentioned that a potty was unaffordable, and they were not willing to buy such an expensive item (1–6 US$) which can be used only for about two and half years and cannot serve any other purpose. Nevertheless, they expressed their desire to buy one if they could afford it.
Informants suggested two different designs for the improved tool; one was similar to a ‘mini-hoe’ (Figure 2); the other one was similar to a ‘mini-shovel’ (Figure 3). The mini-hoe has the handle at an acute angle to the plane of the hoe, and the user pulls the hoe towards herself. For the mini-shovel, the handle is at an obtuse angle to the plane of the hoe, and the user pushes contents away from her body.
Informants suggested making the scraping part of the hoe sharper (Figure 4), sturdier and thinner to be able to cut through hard soil. They also suggested that the scraping part should be about six inches wide, and the three sides should be curved (Figure 4), so that liquid faeces do not spill during disposal. Informants mentioned that the tool should be made of iron because plastic or tin would bend. The handle should be at least two feet long, because they did not want to be near the faeces as they smell bad and they suggested making the handle of either bamboo or wood so that it be light. They said they would consider buying such a tool if it was inexpensive. They suggested that they might buy it for approximately 0.50–0.75. US$ (30–50 Taka) and the government should subsidise the price.
We shared the designs with a local blacksmith who made the new tools with materials available in the local market. His estimated cost for each tool would be approximately 1–1.5 US$. The weight of the mini-hoe was ~1 kilogram with a 59-centimetre long wooden handle, and the mini-shovel weighed 1.2 kg with a 62-centimetre long wooden handle.
The two households who participated in testing the redesigned tools reported that the mini-hoe was more useful for removing and disposing child faeces than their existing heavy-duty-digging hoe, as it was lighter and easy to handle. The sharp edge of the scraping part of the mini-hoe we developed was useful for scraping faeces from the soil as it required less pressure. They also noted that as the mini-hoe was not suitable for heavy agricultural work, people would not use it in the field, and it would be available at home all the time for removing and disposing faeces. They said that the mini-hoe could also be used for removing and disposing poultry faeces, cow dung and faeces of other animal as well as that of the elderly and sick people. They found the mini-hoe useful for discarding liquid faeces and easy to clean. ‘The new hoe is good because its edges are bent. Liquid faeces do not spill from it, and it can contain water while cleaning’. Women were willing to use the new mini-hoe and said that the mini-shovel was not as user-friendly, because it could not remove faeces completely from the ground and required a lot of energy to scoop the faeces.
Defecation of children in the open is customary among the rural residents of Bangladesh, and mothers use different methods to remove faeces from the courtyard and from inside the household. We identified and modified the Chillington-type heavy-duty-digging hoe commonly used for farming in rural Bangladesh to make it lighter and easier to use for faeces removal and disposal in the courtyards of rural compounds to facilitate improved faeces disposal practices and thereby reduce faeces in the household environment.
The pattern of child defecation and the place of defecation in these communities varied with age of the child. Until the age of three, defecation in an open space within the household area was a common practice as has been reported in other communities (Traore et al. 1994; Curtis et al. 1995; Huttly et al. 1998). The age of the child determined the different faeces removal methods and/or tools to dispose child faeces from the household premises. The mothers explained their preferences for different ways to dispose of faeces based on convenience, the concept of disgust, availability and affordability. Availability and affordability were important considerations for mothers in a faeces disposal study in a peri-urban community Peruvian shanty town (Yeager et al. 1999).
Leaves and/or straw (laba-jhaba) was the most available, convenient and easily disposable option for these communities; however, this encourages inappropriate faeces disposal in the nearby bushes. Therefore, mothers frequently used it for cleaning child faeces, unless it conflicted with their concept of disgust related to the transition in a child's diet and associated appearance of his/her stools. A community-based trial improving hygiene practices in 10 villages of rural Bangladesh by Ahmed (Ahmed et al. 1991) over 25 years ago found that straw and leaves were usually used to wipe faeces from the household soil which left the soil, and the hand of the mother contaminated. In our study communities, a heavy agricultural hoe was the second most available choice that allowed the mother to remove faeces completely from the ground and keep her hands clean. The community-based trial by Ahmed also found that about one-third of the mothers used a short-handled hoe for removing child faeces from the courtyard.
The improved new tool, a mini-hoe, which was a modification of the heavy agricultural hoe, was more acceptable to the mothers compared to the mini-shovel. The mothers were already used to using a hoe, so this design did not require any change in a child's usual defecation behaviour and mothers' practices. Moreover, the materials used for the new tool were locally available. A recent trial of improved practices in rural Bangladesh showed that the mothers were able to use the mini-hoe for environmental faecal management, including removal of child faeces, poultry faeces and animal faeces from the household premises (Hussain et al. 2011). The mothers also reported that use of mini-hoe increased their personal hygiene, improved environment, reduced workload and saved time (Hussain et al. 2011).
A variety of factors will affect whether the new mini-hoe is adopted on a large scale in communities. Factors affecting acceptance of water and sanitation technologies are summarised in the technology dimension (column) in the Integrated Behavioral Model for Water, Sanitation and Hygiene (IBM-WASH) (R. Dreibelbis, P.J. Winch, K.R.S. Hulland, E. Leontsini, P.K. Ram, L. Unicomb, S.P. Luby., Under review). At the behavioural level of the model, these include ease of use and whether the presence of the hoe itself acts as a cue to perform the behaviour of removal and disposal of child faeces. At the individual level are the perceived value, convenience and other advantages and disadvantages of the hoe from the perspective of users. At the household level, household members need to share access to the hoe and decide among themselves who is responsible for faeces disposal.
The expressed willingness to use a potty if it were affordable suggests a positive attitude towards potties in the community. Promoting potties are another option for disposing child faeces. As part the observation of a cohort study in a Peruvian Shanty Town of Lima, Huttly (Huttly et al. 1994) found that when the child defecated in a potty, most of the times the faeces were safely disposed in the latrine. However, a qualitative study conducted in the same place reported that use of potties requires training the child and needs effort to clean the potty which can be inconvenient for mothers (Yeager et al. 1999).
This study was conducted using a small sample size, and the child defecation and faeces disposal methods of other parts of the country may be different. However, our findings were consistent with the study findings of a community hygiene intervention trial conducted in rural Bangladesh 25 years ago (Ahmed et al. 1991). Another probable limitation might be courtesy bias regarding the improved tools as we distributed them free of cost. A broader evaluation will be useful to fully assess the acceptability of this tool.
Health intervention strategies that prioritise a community's preferences and practices can significantly increased the uptake of the intervention in the communities (Ka'opua et al. 2011; Ahmed et al. 1991; Panter-Brick et al. 2006) over the intervention strategies that are culturally incompatible and often developed without understanding the preferences and practices of the target community (Rheinlander et al. 2010). The mini-hoe addressed most of the inconvenience that the mother experienced regarding heavy agricultural hoe and was compatible with the mother's desire, that is, lighter, easier to use and useful for removing and disposing liquid faeces. Hence, promoting an improved version of a familiar tool for use in household faeces management, such as that described in our study may be acceptable within the community.
The new improved mini-hoe can scoop faeces off the ground and move them from one place to another but alone it does not provide the solution for removing and disposing faeces from the household environment. However, this tool can function as part of an integrated approach to reduce environmental contamination, which comprises scooping, transporting and safely removing the faeces from environment. Further study is needed to test this improved mini-hoe along with exploring the issues related to safe and hygienic disposal of faeces that might include immediate disposal of child, animal and poultry faeces either in the toilet or in a fixed pit to reduce faecal contamination of the environment.
We are indebted to our study participants for their time and invaluable information. We thank Md. Shamim Azad for his contribution in data collection. We are thankful to Syed Latif Hossain, CEO of Aura Communications for his contribution in the photography. We also thank Dorothy Southern for her guidance in writing the manuscript and Andrea Mikolon for reviewing the manuscript. This study was funded by the Bill and Melinda Gates Foundation. icddr,b acknowledges with gratitude the commitment of the Bill and Melinda Gates Foundation to its research efforts.