Latrine utilization and associated factors among kebeles implementing and non implementing Urban Community Led Total Sanitation and Hygiene in Hawassa town , Ethiopia

A major public health problem in developing countries including Ethiopia is related with poor sanitation and hygiene. Globally, over 2.5 billion people are still without access to improved sanitation. In 2010, 15% of the population still practice open defecation. The main objective of this study was to compare the latrine utilization rate and identify determinant factors among kebeles implementing and not implementing Urban Community Led Total Sanitation and Hygiene (UCLTSH) in Hawassa town. Comparative cross sectional study design was carried out in Hawassa town in 704 households in 3 kebeles undertaken UCLTSH and in randomly selected comparison 3 kebeles where UCLTSH was not implemented. Data entry and cleaning was undertaken by using EPI-info version 3.5.3 and analyzed using SPSS version 20. Multivariate logistic regression was used for independent variables with statistical significant association in bi-variate analysis. In this study, majority of the households 318 (90.3%) of UCLTSH implementers and 299 (85.4%) of non-implementers utilized latrines. The odds of latrine utilization were 1.59 times among households implementing UCLTSH compared with that among non UCLTSH [OR 1.59, 95% CI (1.00, 2.53)]. In relation to functional latrine, it was one of the factors affecting latrine utilization [AOR 28.26, 95% CI (13.03, 61.27)]. This study shows communities implementing urban community led total sanitation and hygiene was better in latrine utilization and having latrine facility than non-implementers. It is recommended that the town health office and municipality should expand the UCLTSH to other kebeles of the town.


INTRODUCTION
Globally, lack of sanitation is a serious health problem, affecting billions of people around the world, predominantly the third world country [1,2].Sanitation is essential for life health and human dignity.When human beings do not have access to sanitation facilities, they suffer a lot in the overall socio-economic and environmental existence.The main health problems, especially in developing countries like Ethiopia, are results of poor access of potable water, poor hygiene and sanitation practices.In these cases, sanitation is a basic necessity that affects everyone's life.Proper disposal of household waste is of critical important to prevent feco-oral and vector borne diseases (Cairncross, 2003).
Globally, over 2.5 billion people are still without access to improved sanitation.In 2010, 15% of the population still practice open defecation (Ammar, 2010).Bangladesh is one of the poorest countries in the world with a large number of people still living without improved sanitation (Kar and Pasteur, 2005).
The Ethiopian Hygiene and Sanitation Strategy aggressively calls for all households to have access to and use a sanitary latrine; as the country yet swing at lowest status where 84.5% of the population still uses substandard sanitation and hygiene facilities; even where toilets exist, many are not used and open defecation is common.Most of toilets of urban households are fixed point open defecation places (Plan international Ethiopia, 2014).
Community-Led Total Sanitation (CLTS) is an integrated approach to achieving and sustaining open defecation free (ODF) status.CLTS processes can precede and lead on to, or occur simultaneously with, improvement of latrine design, the adoption and improvement of hygienic practices, solid waste management, waste water disposal, care, protection and maintenance of drinking water sources, and other environmental measures.In many cases, CLTS initiates a series of new collective local development actions by the ODF communities (Kar and Chambers, 2008).
For plan international undertaking CLTS activities in Africa (Singeling, 2012;Ammar, 2010), the approach was first introduced in Ethiopia in October 2004 when DrkamalKar visited Arba Minch, in Ethiopia, to conduct training activities for the staff of an Irish NGO, engaged in integrated rural development (Kar and Milward, 2011).Community led total sanitation and hygiene is effective in many countries, the plan project in Ethiopia is really getting successful.In 2010, only 10 kebeles (smallest administrative unit) were triggered.By the end of 2011, 46 kebeles with 47,846 households have gained access to safe sanitation and hygiene services by reaching ODF (Singeling, 2012).
Currently, CLTSH implementation is one of the approaches used to improve hygiene and sanitation status of the people, and its implementation in rural set up in many parts of Ethiopia.The focus of rural CLTSH is to trigger the community and announcing of free open defecation.Its main objective is to focus on open defecation, open urination, open waste disposal and poor waste handling and sanitation practice.However, in urban set up, its effectiveness is not well studied so far, CLTSH practice in urban context is not familiar.Hawassa town is the pioneer town that started to implement urban community led total sanitation and hygiene.So, this study was to help compare the latrine utilization among communities implementing and non-implementing Urban Community led Sanitation and Hygiene (UCLTSH) in Hawassa town.
This study contributes in identifying current status of hygiene and sanitation in UCLTSH and non CLTSH communities of Hawassa town and compare about latrine utilization among UCLTSH implementing and in non UCLTSH implementing and also identify other contributing factors for latrine utilization.The study is important for policy makers, implementing partners and community to resolve the problems related to sanitation, in planning and to take remedial action and modification on implementation of urban community led total sanitation and hygiene.It will also offer base line information for further similar studies.

Study setting
The study was conducted in Hawassa town Southern Nations and Nationality People Region (SNNPR) from December 30, 2014 to January 5, 2015.The town is situated 275 km to south of Addis Ababa.Hawassa town is divided into 7 urban sub cities containing 32 kebeles and one rural sub city having 12 kebeles.The total population of Hawassa town is 356,288 from this 51.7% were male the remaining 48.3 were female and the total households of the town were estimated to be 79,175 (Hawassa Town Health office, 2013).Plan International Ethiopia piloted well designed Urban CLTSH in three kebeles in the urban slum villages/units in Hawassa town as of August, 2013.

Study design
Comparative cross sectional study design was conducted in six kebeles of which three kebeles were from UCLTSH implemented and three kebeles from non UCLTSH.

Study population
The study populations were all randomly selected households from each selected kebeles of Hawassa town (Piyasa, Harari, Nigatkokobe, Wukero, Hoganewacho and Gebeyadarkebeles).
*Corresponding author.E-mail: mesfintafa2011@gmail.com Author(s) agree that this article remain permanently open access under the terms of the Creative Commons Attribution License 4.0 International License

Inclusion criteria
All selected households head or member of household >18 years and stay in the area for at least 6 months before data collection date.

Exclusion criteria
Households those who were unable to respond due to mental disorder or other health problem were excluded from the study.

Sample size determination
The sample size was calculated using a two proportion sample size calculation equation in Epi Info Version 3.5.1.With the following assumptions; Zα/2=1.96 at 95%CI, Zβ= power of detection (80%), P1:P2=1:1.Assuming the proportion of latrine utilization among the general urban population is 62% (P1) among those who have accessed latrine (Awoke and Muche, 2013), and assuming to detect a difference of 10% between latrine utilization among the two population (Exposed to CLTSH and not exposed to CLTSH), the sample size was 320 (n1=160+ n2= 160).The total with 2.0 design effect and 10% contingency is 704 (352 each).

Sampling procedures
Multi stage sampling technique was used.Hawassa town was selected purposively.From the 7 urban sub cities, three kebeles in 3 sub city which has already undertaken UCLTSH starting from August 2013 were considered purposively.Concerning non UCLTSH from the remaining four (Ammar, 2010) urban sub cities, 3 sub cities were selected randomly and one kebeles from each selected sub city not implementing UCLTSH was selected in the same way as sub city.Finally, households were selected using systematic random sampling from each 6 kebeles (Figure 1).

Data collection procedures
The questionnaire was adapted from previous literature on sanitation based study.This questionnaire was translated from English language to Amharic for easy understanding of data collectors and respondents.Data was collected through interview by using structured questionnaire and observation of latrine followed after interview.Ten college graduated students that have previous experience on data collection were recruited as data collector and 2 supervisors with environmental health back ground were participated during data collection.

Data quality assurance
Training was provided for data collectors and supervisors before actual data collection took place.The training was focused on how to fill the questionnaire and how to approach the respondents.A pretest was undertaken on 32 households which were not included in the study a week before actual data collection period.The aim was to figure out any difficulty in filling the questionnaire, challenges in interviewing and to check if there is miss understanding of the questions by enumerators.The pre-test also helped to check consistency and the same understanding.The supervisors were collecting completed questionnaires from each enumerator in daily bases and checking the consistency and the completeness at the spot.

Data analysis procedures
The collected data was coded, cleaned and entered to computer by using EPI-info version 3.5.3and data were entered double by principal investigator and other experienced personnel to cross check and ensure the consistency of data and transformed to SPSS version 20 for detail analysis.
Descriptive statistics, such as proportion describing the study population in relation to variables and latrine utilization was used to address objective one (latrine utilization).Odds ratio with 95% confidence interval was calculated for objective two.Bi-variate analysis was conducted and these variables significant in a bivariate analysis were further analyzed in multi-variate analysis in order to control confounders that may affect the association of outcome and exposure variables.Some selected variables that are significantly associated with dependent variable at bi-variate analysis were further analyzed in the multi-variate to identify their related effects among communities implement UCLTSH and nonimplementers.
Finally, multivariate logistic regression was used for independent variables with statistical significant association in bi-variate analysis at P-value <0.05 to control confounders.P-value less than 0.05 were taken as significant.The result of the study was also displayed by percentage and tables on findings of the study.

Community-Led Total Sanitation and Hygiene (CLTSH):
Emphasizes changing sanitation and hygiene behavior of communities towards open defecation free environment, hand washing practice and keeping drinking water safe (Kar and Chambers, 2008).
Functional latrine: It is a latrine usable at the time of data collection.
Proper latrine utilization: Is an household having functional latrines, safe disposal of child faeces, no observable faeces in the compound and show at least one sign of use (foot path to the latrine not covered by grass, the latrine is smelly, presence of anal cleansing material, fresh faeces in the squatting hole, and the slab is wet).

Utilization of latrine:
When all members of family are using the latrine.

Safe disposal of child faeces: Use toilets and do not dispose children's faeces in the open.
Open defecation: Is defecating in the open and leaving the stuff exposed (FMOH, 2012;HawassaTown Health office, 2013).
Open defecation free: It describes a state in which all community members practice use of latrine at all times and a situation wherein no open defecation is practiced at all (Kar and Chambers, 2008).
Knowledge: Is a result of meaningful learning, information or understanding acquired.Good knowledge if75%, the overall knowledge questions (Q301-306) answered.
Attitude: Refers to evaluation of concept and there is a mediating evaluation response to every stimulus, towards all objects, which may be positive or negative or neutral.Good (positive attitude toward over all scores of  70% to attitude questions) (Q401-406).

Ethical consideration
Ethical clearance was obtained from Addis Continental Institute of Public Health and official letter was written from Adama Science and Technology University to SNNP regional health bureau and to respective offices to get permission to proceed the study.Verbal consent was obtained after explaining the purpose of the study.The confidentiality of the data was also informed before interview was started, any information forwarded was kept private and his/her name was not specified.Each household was asked at least for oral consent and those households that did not volunteer for the consent was not obligated.Only household's willing to take part in the study was interviewed.The question was asked by simple and local language.

Socio demographic characteristics of respondents
In this study, a total of 702 households participated, among these 339 (48.3%) were male and 363 (51.7%) were female respondents.Two hundred eight (64.5%) and 238 (79.6) of the head of the household were husband among UCLTSH implementers and nonimplementers, respectively.One hundred thirty one (41.2%) of the respondents among UCLTSH implementer were of age between 30 and 44 and 163 (54.5%) of non CLTSH implementer were above the age of 45.The mean age of the respondents was 44.9 SD, that is, 44.9 (15.2).The educational status of the UCLTSH implementer were 280 (88.1%) and 238 (79.6%) were literate, respectively.In respect to family size, unfortunately the majority range between 4 and 6 family members for both groups, that is, 164 (51.6%) and 140 (46.8%) for UCLTSH implementers and nonimplementers, respectively.The mean family size was 5.7 SD, that is, 5.7 (2.9).
Concerning the occupation of the head of house hold, 91 (28.6%) of them engaged in private, government and NGOs as employee among UCLTSH implementers and 101 (33.8) were engaged in merchant among non UCLTSH implementers.Majority of the income of the households were below 1000 Ethiopian birr in both groups.There was no statistical difference in some variables like number family size P-value (0.25), age of the respondents P-value (0.66), occupation of the head of the house hold P-value (0.74) and average monthly income P-value (0.16).On other hand, there were statistical difference observed between implementers and non-implementers of UCLTSH in educational status of the head of the house hold P-value (0.05) (Table 1).
One hundred and thirteen (35.5%) of UCLTSH implementers and ninety-four (31.4%) of nonimplementers covered their latrine holes.Reason for not having any type of latrine facility 15 (57.7%) were due to shortage of money and 11 (42.3%)due to lack of space.Concerning the distance of latrine from home, the highest 112 (35.2%) among UCLTSH implementers ranged from 6 to 11 m, while 143 (47.8%) among non-implementers is above 11 m.
There was no statistical difference in relation to distance of latrine from house, functional latrine and latrine with covered hole with a P-value of 0.24, 0.46 and 0.28, respectively between the two comparisons groups.On the other hand, there were statistical difference observed between implementers and non-implementers of UCLTSH in availability of latrine, type of latrine owned and year since latrine constructed (Table 2).

Behavioral factors
Two hundred thirty three (73.3%)among UCLTSH implementers and one hundred fifty six (52.2%) of non CLTSH implementers were self-initiated to construct latrine.Result indicates that in both groups, majority of the decision to construct latrine was made by family member's initiation, which is 275 (86.5%) among UCLTSH implementers and 187 (62.5%) among nonimplementers.
Concerning utilization of latrine, majority of the respondents, that is, 318 (90.3%) of UCLTSH implementers and 299 (85.4%) of non-implementers utilized their latrine facility.Two hundred and sixty-two (82.4%) of UCLTSH implementers and one hundred eighty (60.2%) of non-UCLTSH implementers reason for construction of latrine was health purpose.The perceived de-motivating factors towards the adoption of safe hygienic practices 155 (48.7%) among UCLTSH implementers were due to poor living condition, while 136 (45.5%) among non-UCLTSH implementers were due to low literacy (education) level.
There were no statistical differences in some variables like source of information or who initiate you to construct latrine P-value (0.21), what will you do when passersby practice open defecation P-value (0.65), what would you do when you are out of the house and in urgency P-value (0.6), what you feel if defecating openly P-value (0.24), benefits of latrine P-value (0.65), who open defecate pvalue (0.06) and what are the perceived de-motivating factors towards the adoption of safe hygienic practices Pvalue (0.43).On the other hand, there were statistical difference observed between implementers and nonimplementers of UCLTSH in latrine utilization, who decided to construct latrine and belief/taboos with location/sharing use of latrines (Table 3).

Institution/Infrastructure related factors
In this study, among 352 households implementing UCLTSH, only 168 (47.7%) were declared open defecation free.One hundred fifty (47.2%) of the respondents among UCLTSH implementers and 232    ODF,42.9,21.4,19.6,13.6 and 2.6% were led by communities, government, health expert (health extension professionals), NGOs and others like community based and faith based organizations, respectively (Table 4).

DISCUSSION
This study showed that majority of the respondents, 90.3% of UCLTSH implementers and 85.4% non-UCLTSH implementers utilize their latrine facility.Similarly, a study done at Denbia district, Northwest Ethiopia, 86.8% of the respondents were using latrines (Yimam et al., 2014), this is almost the same with non-CLTSH communities of this study.However, the UCLTSH implementers are still better in latrine utilization compared to Denbia district.

Table 3 .
Knowledge and behavioral factors of study population in Hawassa town January, 2015 (n=702).