Defecation practices of young children in a Peruvian shanty town

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Abstract

Little is known about feces disposal practices, their determinants and feasibility for change, despite their importance in the control of diarrheal diseases. We report here the results of formative research for the development of an intervention to promote sanitary disposal of feces of young children. The study was conducted in a densely populated shanty town area of Lima, where water and sanitation systems are scarce. In-depth interviews were undertaken with mothers, husbands and community leaders. Group discussions were held with mothers in order to validate findings from the interviews, investigate particular topics further and explore reactions to possible intervention strategies. The principal defecation sites for young children were diapers, potties, the ground in or near the home, the hill, latrines and flush toilets. The main determinants found were the age of the child, the effort required by the method, perceptions of dirtiness and the availability of resources. Almost all children under one year of age use diapers but the high resource cost of diaper washing is a strong motivation for mothers to move their children on as early as possible. Potties were considered the most socially acceptable and `hygienic' defecation method for children between one and three years of age. Nevertheless, defecation directly onto the ground is common at this age. Potty training is deemed to be quite difficult and the long term achievements are determined by the initial training success. In most cases, the training process is authoritative and inconsistent. The use of latrines and flush toilets is not considered appropriate for children until they are three to four years old.

Based on these initial findings, a micro-trial was conducted to assess the feasibility and acceptability of promoting greater use of potties and associated practices. The results of the trial were very encouraging and provided valuable information for the design of a community-wide intervention.

Our findings help explain why the emphasis given in most sanitation projects, where efforts have been concentrated on the promotion of latrines, has failed to induce their utilization by small children. Sanitation projects should incorporate interventions that will promote hygienic defecation and stool clearance practices for infants and small children.

Introduction

Diarrheal diseases remain one of the leading causes of morbidity and mortality among young children in developing countries Bern et al., 1992, The World Bank, 1993. Significant advances have been made in the case management of children experiencing diarrhea but if the morbidity burden is to be reduced then preventive strategies must be considered. Among the principal strategies identified is the promotion of improved domestic and personal hygiene Feachem, 1986, Huttly et al., 1997. While this is often considered in conjunction with improved sanitary hardware such as water supplies and latrines, there is increased recognition of its independent value. That is, even where sanitary hardware is poor or lacking, appropriate behavioural modification interventions can have a health impact. A review of ten such interventions found a median reduction in diarrheal morbidity among young children of 33% (range 14–89%) (Huttly et al., 1997).

Although the sanitary disposal of feces has been identified by the World Health Organization as one of the three key water-related behaviors for promotion, surprisingly little is known about disposal practices, their determinants, feasibility for change and health impact of related interventions. This is in stark contrast to handwashing which was the sole behavior promoted in half of the studies reviewed by Huttly et al., 1997. Yet with 1.7 billion of the world's population lacking access to adequate sanitation (The World Bank, 1992) and the low rate of use of latrines by young children Huttly et al., 1994, Curits et al., 1995 there is a need for development of appropriate interventions in this area.

We report here the results of formative research for the development of a behavioral intervention to promote sanitary disposal of feces. The study took place in a shanty town of Lima, Peru, a low income area with only basic infrastructure typical of many rapidly-growing cities. Previous studies in the area had provided us with insight into the prevailing feces disposal practices Huttly et al., 1994, Huttly et al., 1998. The aims of the study presented here were to update this information, to explore the practices in more detail, to understand their determinants and to formulate an appropriate intervention strategy for implementation in the community.

Section snippets

Study setting

The study was carried out in two communities of Canto Rey, a densely populated shanty-town located in the San Juan de Lurigancho district of Lima. The shanty town is situated on rocky terrain, surrounded by dry hills without vegetation Lopez de Romaña et al., 1987, Yeager et al., 1991. There is no rainfall in Lima and water is purchased from tankers or, occasionally, obtained from infrequent piped supplies. One study community, Santa Maria, was chosen as it provided a sample of the distinct

Results

The principal defecation practices for children are diapers, use of potties, defecation directly onto the ground in or near the home, use of the hill, latrines and flush toilets. Each practice and the behaviors reported by mothers to be associated with it, will be described in the order in which they are most frequently performed as children grow.

Discussion

The study presented here has shown the range of feces disposal practices prevalent in this dry peri-urban area and attempted to understand their determinants in order to develop appropriate intervention strategies. From a public health viewpoint this is an important area, with the potential for a significant health impact if the fecal-oral transmission route can be interrupted. Yet this study is one of the first to investigate such practices in depth. By selecting informants purposively in the

Acknowledgements

Financial support for this study was provided by the Overseas Development Administration (now the Department for International Development) of the United Kingdom. We are indebted to the study community for their generous cooperation. The authors are grateful to Dr. Elena Hurtado and Gina Gogin for their contributions to this study and to Dr. Mary Penny for her helpful comments on earlier drafts of this publication.

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