Spatiotemporal distribution and determinants of open defecation among households in Ethiopia: A Mixed effect and spatial analysis
Authors: Belay Daniel Gashaneh , Chilot Dagmawi , Asratie Melaku Hunie 
Published: May 2022

Background
Open defecation is the disposal of human faeces in the fields, forests, bushes, and open bodies of water. It is practiced more in sub-Saharan African countries and is considered a sign of underdevelopment. Open defecation facilitates the transmission of pathogens that cause diarrheal diseases which is the second leading contributor to the global burden of disease. In Ethiopia, it kills half a million under-five children annually. Even though open defecation practice is a major cause of childhood mortality and morbidity in Ethiopia, there is minimal evidence on the trend, spatiotemporal distribution, wealth-related inequalities, and other determinates of open defecation practice.

Objectives
Therefore, this study aimed to investigate the trend, spatiotemporal distribution, and determinants of open defecation among households in Ethiopia.

Methods
Cross-sectionally collected secondary data analysis was conducted based on 2016 Ethiopian Demographic and Health Survey (EDHS). A total weighted sample of 16,554 households was included. We assessed the 16 years (2000–2016) trend of open defecation with 95% confidence intervals. Data were weighted, recoded, cleaned, and analyzed using STATA version 14.2 software. A mixed-effect analysis was employed to identify factors contributing to open defecation practice in Ethiopia. In the final multivariable analysis, the associations between dependent and independent variables were presented using adjusted odds ratios and 95% confidence intervals with a p-value of <0.05. The concentration index was used to assess wealth-related inequalities, while spatial analysis was used to explore the spatial distribution and significant windows of open defecation practice.

Results
The trend of open defecation practice in Ethiopia was significantly decreased from 81.96% (95% CI: 81.08, 82.8) in 2000 EDHS, to 32.23% (95% CI: 31.16, 33.31) in 2016 EDHS. Individual-level factors such as; age, educational attainment, marital status, media exposure, wealth status, and source of drinking water, as well as community-level factors such as residence, region, community-level poverty, and community level media usage, had a significant association. Open defecation practice was significantly and disproportionately concentrated on the poor households [C = -0.669; 95% CI: -0.716, -0.622]. A non-random open defecation practice was observed in Ethiopia. Among the 11 regions, primary clusters were identified in only 3 regions (Afar, Somali, and Eastern Amhara)

Conclusion
Open defecation practice remains a public health problem irrespective of the significant decrease seen in Ethiopia for the past 16 years. Individual and community-level factors had a significant association with this problem. Since it is a leading cause of under-five children mortality and morbidity, the Ethiopian ministry of health should plan and work on basic sanitation programs that focus on the poorest communities, rural societies, and small peripheral regions. These programs should include regional planning for sanitation, and translation of materials into local languages to prevent under-five mortality and morbidity due to diarrheal diseases caused by open defecation.