Sanitation Practice of Slum Communities in Addis Ababa, Ethiopia

Globally, an estimated 2.5 billion people lack access to improved sanitation which is more than 35% of the world’s population and about 1billion people, 15% of the world population do not have access to any kind of sanitation facility and exercise open defecation. A total of 16% of population living in urban Ethiopia do not have access to any kind of sanitation facility and exercise open defecation, of which the huge proportion lives in the slum areas. Objectives: To assess the level of practice and associated factors towards sanitation in the urban slum communities of Addis Ababa, Ethiopia. Methods: A community based cross-sectional study design was conducted on January 2015 in Addis Ketema, Lideta, Kirkos, and Gulelle sub cities of Addis Ababa. Using stratified sampling 636 sample households was selected and data was collected from 624 household, which is 98.1% of estimated sample size. Results: Practice of sanitation was 43.89% and it gets higher in households found in Lideta [AOR=3.37, 95% CI=1.12-10.15, p<0.031], Kirkos [AOR= 4.97, 95% CI=1.76-14.04, p<0.002], and Gullele [AOR= 10.16, 95% CI=3.61-28.58, p<0.000] sub cities; and who own previous latrines [AOR= 6.26, 95% CI=3.01-13.01, p<0.000]. It gets lower in households who share latrine with other neighboring households [AOR= 0.08, 95% CI=0.03-0.17, p<0.000], those who own simple pit latrines [AOR= 0.02, 95% CI=0.05-0.74, p<0.016], those who didn’t receive support during the construction of their latrine, [AOR=0.004, 95% CI=0.001– 0.014, p<0.000], and those whose annual income is between 55,001 ETB and 65,000 ETB [AOR=0.15, 95% CI= 0.02– 0.88, p<0.036]. The level of practice of sanitation in the study population is low. Latrine sharing habit, not hiring sanitation facility builder/ skilled mason, and need for subsidy and support during latrine construction were found to be the main factors contributing for this low practice. Establishing well organized and responsible body at each level of administration that will incept and execute awareness and promotion activities to improve the practice of sanitation should be done using different promotion approaches.


Introduction
Sanitation is the application of different techniques and methods for the safe and sustainable management of human excreta, including the collection, storage, treatment, and disposal of feces and urine [1]. Globally, an estimated 2.5 billion people lack access to improved sanitation which is more than 35% of the world's population and about 1billion people, 15% of the world population do not have access to any kind of sanitation facility and exercise open defecation. This low coverage coupled with unsafe water causes around 1.6 million deaths of children with age less than five years [2].
Increasing the number of people with access to safe water supply, sanitation and hygiene has proven to be most effective but challenging throughout the developing world. Improving water, sanitation and hygiene has the potential to prevent at least 9.1% of the global disease burden and 6.3% of all deaths [3].
Access to safe sanitation services in Ethiopia is among the lowest in Sub-Saharan Africa with 56% nationally, and 84% in the urban. Overall, 38% of households have no toilet facility, 16% in urban areas and 45% in rural areas [4]. Poor practice of sanitation by the community together with issues like poor financing towards sanitation infrastructures, low promotion activities, and gaps in monitoring and evaluation by the government are still the major causes for this low coverage and suffering of urban households, especially in slum areas.
Although sanitation has been a problem in different developing countries including Ethiopia, there is still a gap in measuring its practice at community level; and also identification of factors that affect sanitation practice and strategies to control them is yet to be established. Some studies in India and other developing countries have been conducted but they mainly focus on hygiene than sanitation [5 -7].
This study focused on practice of sanitation in urban slum areas because the coverage of improved sanitation is very low and current way of sanitation improvement system should be changed. In addition, there is no other research conducted in the Ethiopian urban context to assess the sanitation practice of the community and set recommendations to solve the factors that hinder it. Thus, this study would be helpful for policy and decision makers in planning and implementation of sanitation strategies. It can also serve as a baseline research for sanitation programs and strategies that could be adopted or scaled-up in the near or far future by providing information on current community sanitation practices, opportunities, and challenges.

General Objective
To assess the level of practice and associated factors towards sanitation among the slum communities of Addis Ababa.

Specific Objectives
To describe the practice of sanitation by urban slum communities living in Addis Ababa. To identify factors associated with practice regarding sanitation in urban slum communities of Addis Ababa.

Methods
Study Area: The study was conducted in Addis Ketema, Lideta, Kirkos, and Gullele sub cities of Addis Ababa from October 2014 up to March 2015. The total study area encompasses about 64.48 square kilometers with total population over 1.2 million residents in 41 woredas of Addis Ababa.
Study Design: Community based cross-sectional study design was employed. Household owners in the study area, Addis Ketema, Lideta, Kirkos, and Gullele sub cities, were considered to be the specific study units for this research. All households in the study area were eligible to be included in the study with the exclusion of public and private organizations or institutions; and commercial organizations.
Sample Size: The sample size was calculated by using the formula for estimation of single proportion for specific objective one due to the nature of the study design; Where Z value is 1.95 at 95%CI; P is the prevalence; and d is the margin error of estimation, which provides a sample of 384; and 423 households after taking an estimate of 10% non respondent rate.
For specific objective two, associated factors, sample size was computed by using the formula for two population proportions, n = (Z α/2 +Z β ) 2 * (p 1 (1-p 1 )+p 2 (1-p 2 )) / (p 1 -p 2 ) 2 (2) And since there is no study done on this regard, the author was obligated to take the standard estimation of prevalence 50% and odds ratio of 2 to acquire the maximum sample size possible, which gives 296 samples and 326 after considering 10% non respondent rate.
The study used the maximum calculated sample size to address all its objectives, which is 423. But considering minor demographic difference in the study areas and to correct errors that could happen due to a stratified sampling technique the study used a design effect of 1.5 and the acquired final sample size was 636.
Sampling Procedures: The study used a stratified sampling technique to identify and acquire the required sample size, 636households, to address all its objectives; which was proportionally allocated for the four sub cities, that is 159 households per sub city. Because of the population difference between the sub cities ranges from 0.6% to 11.7% at most, the author believes the proportional allocation of study subjects will not cause any bias.
Then, after creating a stratum of high, middle, and low income woredas of each sub city based on their socioeconomic indicators, one sample woreda from each stratum of each sub city was selected by using a lottery method providing a total of 12 woredas with a sample of 53 households each. Finally the study participants were selected by using simple random sampling technique from a sampling registry obtained from the selected woreda health offices, i.e., Urban Health Extension Professionals' registry book/list. Procedure for Data Collection: Questionnaires used by WSP, UNICEF, and WHO in different developing countries for sanitation projects/scale-up programs were adopted, reviewed, and modified by the author and the advisor to include different indicators that will help address the study objectives in the urban slum context. The questionnaires were re-tested after the provision of one day training for both data collectors and supervisors (with experience of participating in data collection before; with no sex exception) before they were finally put to use.
Study Variables Dependant / Outcome / Variables: Practice of sanitation Independent / Explanatory / Variables: Socio-demographic variables (Age, Sex, Level of education, Income) Type of sanitation Product available Price of available sanitation products Place where sanitation products are available Promotion of sanitation products Operational Definitions Improved Sanitation: is sanitation facility that hygienically separates human excreta from human contact [2].
Unimproved Sanitation: is sanitation facility that does not ensure hygienic separation of human excreta from human contact [2].
Shared Sanitation Facilities: Sanitation facilities of an otherwise acceptable type shared between two or more households [2].
Adequate Practice: when the response of study participants is above the median of all the Practice questions.
Inadequate Practice: when the response of study participants is below or equal to the median of all the Practice questions.
Data Quality Control All the collected questionnaires were properly organized and categorized according to their sub cities. They were reviewed, and ambiguous recordings due to hand writing or else were edited and cleared by the author and data collectors before entry. Care was taken not to discard any questionnaire that are incomplete or of non-respondent. After organizing and coding the entire necessary template the data entry was made by the author and trained data encoder (a trained professional with experience of data entry and template development for different research work) by using Epi info Version 3.5.4. The encoded data was exported to SPSS Version 20 for further analysis.

Ethical consideration
The ethical clearance was obtained from the institutional review board of University of Gondar before data collection is started. All study participants were adequately informed about the purpose, method and anticipated benefit of the study by the data collectors before collecting any data that was used for this study. They were clearly informed about options regarding voluntary participation in the study, and verbal consent was obtained from each participant willing to be part of the study. Also confidentiality of the study subjects was maintained and each and every data collected was only used for the sole purpose of this study.

Socio-demographic Status
From a total sample of 636 randomly selected households 624 (98.11%) respondents participated in the household survey, of which 421 (67.5%) are female. About 39.6% of respondents can't read and write followed by those who can only read and write (21%), and a collective of 31.2% of participants have attended primary and secondary education, but those who have tertiary level education (over high school) is only 8.2%. Regarding the main source of income, 47.4% of households depend on salary from their employment in governmental and private organizations, and 29% depend on their business trading, while the rest 23.6% of the households depend on other sources of income and monetary gifts from others. Over half of the study participants, 56.1%, fail to disclose their total income during the past year whereas 27.1% and 7.4% of respondents claimed that they have earned less than 25,000 ETB and over 65,000 ETB respectively.

Latrine Status
A total of 93.1% of study households have latrine, of which, six out of ten (65.4%), have unimproved pit latrine. The number of households that own improved hygiene and sanitation facility is only 26.2% (7.1% flush/pour flush latrine and 19.1% VIP pit latrine); and 43 (6.9%) of surveyed households does not own any kind of latrine. Of the surveyed households about 45.43% of latrines are shared ones.
About six out of every ten latrines have a lined pit septic tank and 29.1% have an unlined septic tank pit. Without considering minor material modifications and taking in to account of the use of local inputs, 70.7% and 21.7% of the observed latrines have concrete/ cement and wood/ mud latrine floors respectively. During the survey, the walls of the existing latrines was found out to be 55.2 brick/ concrete, 22.2% mud/ wood, 18.9% iron sheet. Regarding to the roofs of available sanitation facility, majority of them, 91.6%, have iron sheet, while 2.9% have roof made of local salvage materials.

Defecation site
Adult defecation site in the study participant household is dominated by shared latrine which is 61.50% followed by private latrine 31.40%. This is also true for children; 25.50% communal latrine and 10.9% private latrine. The results for babies' fecal matter disposal shows that, out of the households who have babies, 70.49% households put it in to latrines, 23.50% dispose it in to garbage or ditch while the other 6.01% of the households leave it in the open.
Latrine Functionality Out of the 581 latrines observed in the survey, 7 VIP pit latrines, 6 simple pit latrines, and 1 flush latrine, a total of 14 (2.4%) latrines were found out to be non functional. The main reason for this non functionality of latrines was observed to be due to dirty and smelly latrines because of full pit/ septic tank of the latrines (57.14%), broken slab (50%), and missing superstructure (28.57%).

Improvements from Previous Latrine
A total of 186 (32.01%) households claimed to have a previous latrine before the one that they are currently using. These households have made some improvements on their current latrines compared to the one they used to own before. Thus, 43.31% has lined the pit with tight masonry coarse, 55.37%has improved wall, 53.76% has improved roof, and 54.83% has improved slab.
Latrine Construction Though 24.8% of participants have other undisclosed reasons to build their latrine, 21.6% and 21.5% of the study participant households has constructed their latrine due to the construction of new house and subsidy offering from a program respectively. A total of 194 (31.1%) households have received support during the construction of latrine of which 96.39% and 73.71% has received material and labor support from an organization, their relatives and/or neighbors respectively. About 101 (17.83%) households have hired a mason/other professional to build their latrine with cost, 48.51%, being the main criteria of selection.
Since practice of sanitation is mainly dependent on the availability of sanitation and/or latrine components at household level, it is only computed for latrine owners. And based on that, computing all the necessary variables and taking the median as a cutoff point to determine practice, about 43.9% of the surveyed households are practicing sanitation. Hire Latrine Builder: compared to those households who hired skilled mason or latrine builder to construct their latrine, households who did not hire skilled mason have low level of practice of sanitation with [AOR=0.03, 95% CI= 0.008-0.13, p<0.000].

Factors Affecting Practice of Sanitation in Slum Communities in Addis Ababa
Income: compared to those whose annual income is 25,000 ETB and less, those who earn 55,001 ETB -65,000 ETB have low level of practice; [AOR=0.15, 95% CI= 0.02-0.88, p<0.036].

Discussion
From the study findings, it can be said that the level of practice of sanitation in the community is not very high and as of the expected level. This can be explained from many different angles starting from type of available products, promotion channels used for awareness creation, socioeconomic and other determinant factors of the community, and policy issues.
Even though, based on the study finding, 93.1% of the households have access to sanitation facility, about 65.4% were unimproved pit latrines, and they were dominant in households with low economic income. The latrine preference shows that nearly all households prefer flush latrines for their households, but considering the expensiveness of this type of latrine, it is impossible to take these slum households to the top of the sanitation scale over night, or even in a short period of time. The next best desirable and economically acceptable preferred latrine was found out to be improved VIP latrines. Considering cost implications and easiness in operation and other aspects, targeting these slums to settle on this type of latrines is reasonable to the community. But still, creating demand on this type of products and influencing the community to make sanitation as one of the most important basic needs is the main pin point besides offering the community with many option of improved sanitation products. Similar results were found in other studies [8].
The study shows that, just over six out of ten households does not own their own latrine and share a latrine with other community members. This is found out to be one of the main factors contributing to the low practice of sanitation in the study population. This latrine sharing is also found in other developing countries including Bangladesh, Nepal, and Nigeria. According to a study conducted in these countries, households who don't have their own latrine, among poor families, just over half reported that they already had access to a toilet elsewhere [9].
Scaling up from current unimproved sanitation facility to the next close improved one is common in many countries and it was also observed in this study. For instance, households that have previous experience of owning unimproved latrine were now upgrading to a better and more likely to be called improved hygiene and sanitation facility by lining the pit, adding a quality slab, making the superstructure to a more privacy maintaining one, and the likes. The more improved sanitation facility they own from their previous one, households tend to have more future plan to upgrade their sanitation facility and highly engage in practicing sanitation.
Any financing for sanitation which does not flow directly from the immediately benefiting for the provision of sanitation goods and services can be defined as a subsidy [10]. The study findings show that those who received support during the construction of latrine were bound to have a good practice of sanitation and more likely to have improved sanitation status than others. These points towards the issue of subsidy and support of the urban poor related to hygiene and sanitation should not be ignored. This was also found to be true according to other studies [11,12].
Though 7 out of 10 study participants are off to sanitation related subsidies in this study, it doesn't necessarily mean that each and every sanitation related activities should be subsidized for urban slums; rather segmenting those in critical need and addressing their issue should be taken as the best alternative. Because, the type of subsidy, according to this study, does not matter as long as it addresses the right fall backs of the community. Subsidy doesn't necessary mean money.

Conclusion
The level of practice of sanitation in the study population was found to be low. Low income households in these slum areas were most dominantly using unimproved pit latrines. Latrine sharing habit, hiring sanitation facility builder/ skilled mason, and need for subsidy and support during latrine construction was found out to be the main factors contributing for the low level of sanitation practice in the study population. The main reason for non functionality of household latrines was full pits, and the issue of delays and long waiting time to disluge/ empty the pits is found to be contributing to that.

Recommendations
Implementing the developed urban sanitation implementation strategic plan in a well organized and integrated manner by providing special attention to the poor segment of the community, especially in the slums is the first step.
Organizing and strengthening a responsible body that leads sanitation improvement activities at each level of administration, i.e., city, sub city, and woreda, should be done.
To improve the practice of sanitation, awareness creation and promotion activities should be incepted and executed.
Sanitation subsidy programs in slum areas should be designed and implemented in an integrated manner to improve the sanitation status of the slum community addressing the underlying causes of the problem.
Conducting other studies related to the sanitation service delivery system, effectiveness of hygiene and sanitation interventions could be helpful to understand the main issues related to factors beyond the community level and establish ways to overcome them.