How clearing up kids’ poop could save lives

“[We have] no proper place to dispose of the poo and the distance from the house to the shared toilet is far.” This is one of the reasons a mother gave to a team of WASH researchers in Bubumala village, Solomon Islands, to explain why she does not dispose of her children’s feces in a “safe” way.

The World Bank’s Water and Sanitation Program considers safe disposal for a child’s stools to be in a toilet or latrine. But in the Solomon Islands, parents might leave their child’s poop on the ground where it landed, throw it in the sea, a mangrove, or perhaps in the trash. Later, a child might play in that contaminated area and become seriously sick.

Around the world, child feces management, or CFM, is a complex, neglected issue causing childhood illness and death. While water, sanitation, and hygiene programs seek to tackle open defecation in communities, they have historically addressed children’s toileting habits inadequately. Communities misunderstand the serious outcomes of CFM and societal factors, including gender roles in childcare, affect the problem.

Childhood illness and death

Tackling CFM in the Solomon Islands is important because diarrhea causes about 25% of its total childhood deaths. Children can easily ingest dangerous pathogens from contaminated dirt. “There's a belief that young children's feces are safe or safer than adults,” said Regina Souter, senior research fellow at the International WaterCentre in Griffith University, Australia. “In fact, it might actually be the opposite.”

Evidence suggests children’s feces could be less safe due to a higher prevalence of diarrhea and pathogens. A 2014 study in rural Bangladesh found households with unsafe child feces disposal practices had “a more than 5 times greater odds of having diarrheagenic E coli in the soil in areas where study children were observed playing.”

Souter is managing a three-year research project in the Solomon Islands, which runs until 2022 and is working to improve CFM practices in line with a national sanitation policy. Her organization is working alongside two partners: the Solomon Islands National University and the London School of Hygiene and Tropical Medicine, with support from the Australian Government’s Water for Women Fund.

In the Solomon Islands, 80% of the population lives in rural areas where there is 80% open-defecation. Although unsafe water and poor sanitation also contribute to high levels of diarrhea, better CFM could reduce cases. Child malnutrition and stunting, which poor CFM can also cause, affect 33% of the children. But Souter says the issue is “low down on the list” for locals.

“When you have that cultural norm where open defecation is quite accepted … no one is going to build a latrine just to put their children's feces in there for a few years,” Souter says.

What about children?

This situation in the Solomon Islands is not uncommon, but WASH programs can fail to address CFM. In 2015, a WSP study of 26 locations, including Afghanistan, Chad, and Indonesia, found more than 50% of households with children under 3 in 15 of the locations reported unsafely disposing of children's feces. The same research found that in India, over 54% of households with improved sanitation still unsafely dispose of their children’s feces, with 23% of those with improved sanitation simply leaving the feces in the open and not disposing of them.

“In general, sanitation for children has been a neglected area of research, policy, and program intervention,” the report states.

Souter said WASH programs can overlook children’s needs by building unsuitable toilets, for example pits that children fear falling into. “It's a significant oversight in the definition of success to not think about children,” she said.

Societal expectations

IWC’s project approach builds on an existing Solomon Islands Government commitment to improve sanitation across the country through a Community-Led Total Sanitation approach. This method sees civil society organizations trying to mobilize communities to eliminate open defecation themselves by taking ownership of efforts to improve practices. For example, by letting the community decide where to locate latrines and building them.

UNICEF WASH specialist Emily Rand has seen a similar motivational approach work successfully in WASH programs in Vanuatu.

“It’s more sustainable in the long term if communities themselves are finding solutions,” she said. “After cyclones happen [in Vanuatu] people just rebuild their toilets … without any assistance from [the] government.”

But tackling the causes of CFM and changing habits in a socially sensitive way is not as straightforward as simply educating people about the dangers of pathogen transmission. In the Solomon Islands, IWC had to consider gender norms. Some men refuse to handle their children’s excrement. “I’d never try it,” one father told researchers. “If I do that it will be a disgrace for me.”

In addition, women are more likely to have primary responsibility for childcare activities and a high domestic workload. Asking them to take action to improve CFM is likely to increase their burden — such as having to stop their chores to walk a long way to a latrine.

The team was also aware of high incidents of gender-based violence in the Solomon Islands – 64% of women aged 15-49 are victims of physical and sexual violence by their intimate partners. “Perceived failure to carry out additional tasks could carry the risk of GBV, as could attempts by women themselves to actively involve their husbands in these tasks,” warned a IWC literature review seen by Devex.

However, the team found GBV and men’s willingness to dispose of their children’s feces were less of a problem than they anticipated. “But most of [the men] said they only did that when the women weren't there,” says Souter. “There is still a shift required — it is still the burden definitely falling on women.”

Souter and her team are approaching communities by trying to motivate them to change their behavior, rather than providing education about CFM. She says so far her team has observed “the feeling of nurture” and “wanting to be good parents” as convincing motivators toward practicing safer CFM.

How else can we tackle CFM?

LSHTM’s Adam Biran says other approaches to CFM are also effective, such as introducing new products or technologies to help children use latrines at an earlier age. For example, plastic surrounds that reduce the size of the hole on a latrine, making it harder for children to fall in. “Encouraging people to build poor quality toilets, and then lecturing them to throw their children's feces in them, isn’t likely to be terribly effective,” he says.

When considering whether to include CFM in a WASH program, he recommends professionals consider the health risk of poor CFM in locations, for example, throwing feces in the sea is less of an immediate health risk than children defecating in urban slum areas outside their homes. Biran says CFM messaging can be included in general sanitation-improving projects.

“People may not have seen the toilet as an important place for disposing of children's feces,” he said, adding that CFM is “something we should be careful not to forget.”

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