Household latrine utilization and associated factors in semi-urban areas of northeastern Ethiopia.

BACKGROUND: Latrine utilization is the actual behavior in a practice of regularly using existing latrines for safe disposal of excreta. Latrine utilization is a common problem in semi-urban areas of developing countries, including Ethiopia. Since the status of latrine utilization and associated factors among semi-urban areas of northeastern Ethiopia, including Alansha in South Wollo Zone is unknown, local data is needed in order to assess the need for planning of intervention programs for the improvement of latrine utilization to support consistent and sustained latrine utilization. This study is designed to address this knowledge gap.
METHODS: A cross-sectional study was conducted from February to March, 2019 among 401 systematically selected households. Data were collected by trained workers using a pre-tested, structured questionnaire via face-to-face interviews and on-the-spot observations of the latrines. A systematic random sampling method was used to select participant households. Data were entered using EpiData version 3.1 and exported to Statistical Package for the Social Sciences (SPSS) version 25.0 for data cleaning and analysis. The wealth index status of participants was estimated using principal component analysis. Data were analyzed using a binary logistic regression model at 95% confidence interval (CI). From the multivariable logistic regression analysis, variables with p-value < 0.05 were taken as statistically significant and independently associated with latrine utilization. Model fitness was checked using Hosmer-Lemeshow test. RESULT: We found that the prevalence of latrine utilization among households was 71.8% (95% CI [67.5-76.1%]) while 28.2% (95% CI [23.9-32.5%]) did not utilize latrines. About one-fifth (21.7%) of participant households were found to have a pit latrine with slab and 78.3% (311) used pit latrines without slab. The hygienic condition of the majority (82.9%) of the latrines was dirty and only 17.1% clean. Household family size from one to three persons (AOR: 3.99, 95% CI [1.20-6.24]), presence of primary or secondary school student in a house (AOR: 2.33, 95% CI [1.42-3.83]), number of years since latrine was constructed (≥ 2 years) (AOR: 1.82, 95% CI [1.12-2.95]) and a frequency of daily cleaning of the latrine (AOR: 2.19, 95% CI [1.12-4.28]) were factors significantly associated with latrine utilization.
CONCLUSION: Seven out of ten households utilized a latrine. Factors significantly associated with latrine utilization were household family size from one to three persons, presence of primary or secondary school student in the house, time since household latrine had been constructed of two or more years and daily frequency of latrine cleaning. Therefore, it is recommended that measures to promote behavioral change towards further improvement in sustainable and consistent latrine utilization should be carried out based on the evidence of the determinant factors found in this study.

Background

A lack of sanitation facilities compels people to practice open defecation. In 2010, 15% of the world’s population still practiced open defecation [1]. Open defecation contributed to poor household sanitation, which increases the risk of transmission of diseases such as diarrhea [2]. Globally, 2.3 billion human beings still do not have access to basic sanitation facilities, of whom the highest proportions are found in South Asia and Sub-Saharan Africa [3]. In Africa, the presence of open defecation has been attributed to a likely cultural-habitual preference for open defecation practice and inadequate water availability [4]. Pit latrines are in use by more than half the urban population in Sub-Saharan Africa (SSA); however, the performance of many of these types of latrines have been found to be unsatisfactory [5]. A worldwide systematic review and meta-analysis study found that latrine use was associated with better maintenance, accessibility, privacy, facility type, cleanliness, and better hygiene access [6].

The 2016 Ethiopia Demographic and Health Survey (EDHS) showed that the extent of national open defecation was 32.9% and more than half (56%) of rural households used unimproved toilet facilities [7]. In Ethiopia, latrine facility coverage has been increasing since the health extension [8, 9] and water, sanitation and hygiene (WASH) program started [10]. As a result, the rate of reduction of open defecation has been remarkable; a 25% reduction per decade for the years 1990–2015 (from 92% in 1990 to 29% in 2015) [3]. However, there has been comparably less attention to utilization of latrine facilities in rural areas versus urban areas of Ethiopia [11].

Problems related to latrine utilization include lack of a functional latrine, latrines located a long distance away from areas where farmers work, and latrines lacking a superstructure [12]. Another study in rural Ethiopia showed that latrine use was due to ownership of a latrine that had a superstructure, having a clean latrine, and having a latrine with a protected door [13]. A study conducted in the Amhara region in Ethiopia found that latrine utilization was associated with education, relative wealth, urban residence and history of travel [14]. Furthermore, a study in Denbia District, found that integration of strategies to promote hygiene behavioral change with construction of sanitation facilities is crucial; and that a long-established habit and comfort with open defecation was the main reason of 60.4% of adults for not using a latrine [11].

These gaps point out the need for this study in order to establish evidence-based information on latrine utilization status and to identify factors associated with the utilization of latrine in the previously-unstudied areas of semi-urban Alansha, Ethiopia. An understanding of latrine utilization in this area will guide the planning of targeted intervention programs for improvement of household latrine utilization, which is included in the United Nations Sustainable Development Goals (SDGs), particularly in Goal 6, which includes the target of achieving access to basic sanitation for all [15]. The findings of this study may help to improve latrine utilization in the development of improved sanitation facilities in the semi-urban areas in Alansha in northeastern Ethiopia and throughout semi-urban areas in Ethiopia.

Methods

Study design and study area

A cross-sectional study was conducted from February to March, 2019 in the semi-urban areas of Alansha, located in Kutaber District of South Wollo Zone in northeastern Ethiopia. Alansha had one semi-urban kebele. Kebele is the smallest administrative unit in Ethiopia, with an average population of 5,000. Agriculture is the area’s main economic activity. It has a total population of 8,907 including 4,426 (49.7%) men and 4,481 (50.3%) women, and a total of 1,845 households. Two elementary schools and one health post are found in the area. Alansha is situated on a plateau and some sloping areas in a mountainous region that runs north to south. Latrine coverage in the areas is 99% (Semi-urban Alansha kebele Administration, unpublished document data, 2018).

Sample size determination and sampling procedures

The sample size was determined using the single population proportion formula [16] considering the assumptions of: Z at 95% confidence interval (CI) is 1.96, p is an estimate of the proportion of latrine utilization (57.3%), which is taken from a similar study conducted in Tigray Region, Gulomekada District, Ethiopia [17] and d margin of error (5%). A sample size correction formula was also employed since the source population (8,907) was less than 10,000. After adjusting for an anticipated 10% non-response rate, the final sample size was determined to be 401.

The semi-urban area of Alansha had one kebele with 1,845 total households, including a total population 8,907 from which a final sample size of 401 was included. The source population of this study was all people in the semi-urban area of Alansha and the study population was those households selected from residents of semi-urban Alansha. Systematic random sampling was used to find households; total households divided by final sample size gave a sampling interval of 5. Then, data were collected at an interval of every fifth house.

Inclusion and exclusion criteria

All households with a functional latrine during the study period were included. Members of each household who were less than 18 years old during the data collection period were excluded as study participants.

Operational definitions

Semi-urban

A partially urban, partially rural area that was not within a municipality; where the population of city residents was 2,000 or more; where it was estimated that there was potential to earn income, on average, other than land lease sale, of $896.50 USD (1 USD [United States Dollars] = 27.8862 Ethiopia birr during the study period) or more per year; where 20% of city residents engaged in an occupation other than agriculture; that may serve as a development center; that had good transportation [18].

Latrine utilization

Determined using “signs of use” such as a household having a functional latrine, children’s faeces being safely disposed of, no observable faeces in the compound and at least one observable sign of use (e.g., foot path to the latrine not covered by grass, latrine odor, lack of spider web in squatting hole, presence of anal cleansing material, fresh faeces in the squatting hole, or a wet slab) [19].

Safe disposal of child faeces

Children's faeces disposed of in a toilet, not in the open.

Poor latrine

A latrine without superstructure and lacking walls.

Fair latrine

A latrine having superstructure, without a door (any cover) but with a leaking roof at time of data collection.

Good latrine

A latrine having superstructure, with a door (any cover) and possibility of maintaining privacy during defecation.

Dirty latrine

Visible faeces and/or urine on the floor around the latrine and latrine not swept at the time of data collection.

Clean latrine

Pit not full, no faecal matter seen around the pit latrine, area properly swept and absence of bad smell at time of data collection.

Open defecation

Self-reported behavior, including defecating in fields, bushes, forests, open bodies of water, or other open spaces [20].

Sanitation

The provision of facilities for the safe disposal of human faeces and urine [21].

Variables measured

The outcome variable of this study was latrine utilization, which is a binary outcome denoted as yes (1) for latrine utilized or no (0) for latrine not utilized. The independent variables included socio-demographic and economic, environmental and behavioral factors. Socio-demographic variables that were considered in this study as potential confounders and measured by face-to-face interviewers included head of household marital status, occupation, educational status, sex, age, religion; presence of primary or secondary school student in the household; presence of children under five; and household size (number of persons). The wealth index of a household was also computed using principal component analysis. A wealth index score was classified using the EDHS 2016 five categories as lowest, second, middle, fourth and highest income [7].

Latrine-related variables that were measured by on-the-spot observation were type of latrine, condition of latrine (poor, fair, good), faeces seen around pit hole/floor of latrine, latrine location, presence of squat hole cover, latrine slab sealed with mud/cement and presence of latrine walls, roof and door. Latrine variables that were measured in self-reported of study participants included the means of disposal of under-five children’s faeces, number of years since the latrine had been constructed and number of times a latrine had been constructed. Distance of latrine from the house was measured in meters.

Behavioral variables that were measured by self-report of the study participants included frequency of latrine cleaning, latrine hygienic condition, whether information had been received about constructing a latrine, reasons for constructing a latrine, what person was responsible for constructing latrine, whether a lack of latrine was considered as culturally taboo and types of taboos. Presence of handwashing facility in/near latrines was measured by on-the-spot observation.

Data collection and data quality assurance

Data were collected by face-to-face interviews and on-the-spot- observation. The questionnaires were first prepared in English and translated to Amharic, and then re-translated back to English to ensure consistency. A pretest of the questionnaire was conducted with 5% from the total sample size (20 of 401 questionnaires) to check the consistency and clarity of the questions. It was undertaken on 20 households that were not included in the study before the actual data collection period. The aim was to determine if there were any difficulties filling out the questionnaire, challenges in interviewing, or misunderstanding of the questions by enumerators. During data collection, one supervisor collected the questionnaires from each enumerator on a daily basis, checking the consistency and the completeness of the completed questionnaire on the spot.

The four data collectors were environmental health professionals with a BSc degree. The principal investigator provided one day of training for the four data collectors and one supervisor before actual data collection took place. The training was focused on how to fill out the questionnaire through interview and on-the-spot observation of the latrines, how to approach the study participants and about ethical issues during the data collection. Field supervision and daily meetings were conducted to solve any problems that came up to ensure the quality of data collection. To check the quality of the entered data, 10% of the entered questionnaires were randomly selected and re-entered to control data entry errors.

Data management and analysis

All field questionnaires were first checked, coded and entered in to EpiData version 3.1 (EpiData Association, Odense, Denmark) statistical software and then exported into Statistical Package for the Social Sciences (SPSS) version 25.0 (IBM Corp., Armonk, N.Y., USA) for data cleaning and analysis. Principal component analysis was used to construct the household wealth index with the considerations of the assumptions: communality value > 0.5, Kaiser-Meyer-Olkin (KMO) value > 0.5, and eigenvalues greater than one [22]. Wealth index was calculated by national wealth quintiles compiled by assigning the household score to each usual (de jure) household member, ranking each person in the household population by her or his score, and then dividing the distribution into five equal categories, namely lowest, second, middle, fourth and highest. The prevalence of latrine utilization was estimated from the proportion of individuals who practiced proper latrine utilization within the total number of study households (total sample size) with functional latrine was multiplied by 100.

The presence of multi-collinearity among independent variables was checked using standard error at the cutoff value of 2 [23], which was not observed. Binary logistic regression model was fitted to assess factors associated with latrine utilization. Bivariate analysis (crude odds ratio [COR]) with 95% CI was used to assess the crude association and to select important variables to be included in the final model. From the bivariate analysis, p<0.25 was retained into multivariable logistic regression model analysis. Finally, multivariable-logistic regressions (adjusted odds ratio [AOR]) with 95% CI was used to control potential confounders and to identify independent predictors of latrine utilization. From the adjusted analysis, a significance level of p < 0.05 was declared as a factor significantly associated with latrine utilization. Model fitness was checked using Hosmer-Lemeshow test [23] and the model was fit at p-value = 0.957.

Ethical approval and consent to participate

An ethical clearance letter was obtained from the Ethical Review Committee of Wollo University College of Medicine and Health Sciences (protocol number: WU/ERC/501/02/19). All study participants were informed about the purpose of the study, and their verbal consent was obtained and recorded by data collectors. The ethics committee approved the verbal consent procedure because the study interviews about latrine utilization and spot-check observation of latrines were not considered to have major ethical issues, and no blood or other ethically sensitive samples were taken. In the study area, latrine observation and interviews by local health experts are common and routine activities for the study participants. The respondents’ right to refuse or withdraw from participating the interview was fully maintained and the information provided by each respondent was kept strictly confidential.

Results

Socio-demographic and economic characteristics of the study participants

In this study, of the total 401 participants, 397 responded, for a response rate of 99.0%. More than two-third 69.3% (275) of participants were female and the rest were male 30.7% (122). The number of people who were illiterate accounted for half 51.6% (205) of study participants. The occupation of more than one-third 41.8% (166) of the study participants was housewife, whereas 36.5% (145) were farmers. The household size of a majority of the households was one to three persons 91.9% (365) and three-fourths 75.1% (298) of the households had a primary or secondary school student in the house. One-fourth 26.2% (104) of households were in the lowest wealth index category, whereas one-fifth 20.2% (80) were in the middle income category and about one-tenth 10.8% (43) were in the highest income category (Table 1).

Table 1

Socio-demographic characteristics and bivariate analysis with latrine utilization in semi-urban areas in northeastern Ethiopia, February to March, 2019.

Variables		Latrine utilization (N = 397)		COR (95%CI)	p-value
	Frequency	Utilized (n = 285)	Not utilized (n = 112)
	%(n)	%(n)	%(n)
Head of household
Mother	78.3(311)	21.8(62)	21.4(24)	1.02(0.59–1.73)	0.943
Father	21.7(86)	78.2(223)	78.6(88)	Ref
Sex
Male	30.7(122)	31.9(91)	27.7(31)	1.23(0.76–1.99)	0.409
Female	69.3(275)	68.1(194)	72.3(81)	Ref
Age (years)
18–40	25.2(100)	23.5(67)	29.5(33)	Ref
41–60	41.1(163)	43.2(123)	35.7(40)	1.51(0.87–2.62)	0.138*
61–80	19.1(76)	18.2(52)	21.4(24)	1.06(0.56–2.02)	0.842
>81	14.6(58)	15.1(43)	13.4(15)	1.4(0.68–2.9)	0.348
Religion
Muslim	95.5(379)	95.8(273)	94.6(106)	1.29(0.47–3.52)	0.622
Christian	18(4.5)	4.2(12)	5.4(6)	Ref
Occupation
Housewife	41.8(166)	44.2(126)	35.7(40)	1.32(0.80–2.20)	0.270
Day laborer	8.1(32)	6.3(18)	12.5(14)	0.54(0.25–1.19)	0.126*
Government employee	6.3(25)	5.6(16)	8.0(9)	0.75(0.31–1.83)	0.526
Merchant	7.3(29)	8.1(23)	5.4(6)	1.62(0.62–4.25)	0.330
Farmer	36.5(145)	35.8(102)	38.4(43)	Ref
Educational status
Illiterate	51.6(205)	52.3(149)	50.0(56)	Ref
Able to read and write	17.6(70)	17.2(49)	18.7(21)	0.89(0.48–1.59)	0.666
Primary education	14.9(59)	14.4(41)	16.1(18)	0.86(0.45–1.63)	0.631
Secondary education	9.8(39)	9.5(27)	10.7(12)	0.85(0.40–1.78)	0.660
Post-secondary education	6.0(24)	6.6(19)	4.5(5)	1.42(0.51–4.01)	0.498
Household size (persons)
1–3	91.9(365)	93.7(267)	87.4(98)	3.81(1.18–7.30)	0.025*
4–6	5.0(20)	4.6(13)	6.3(7)	2.60(0.60–6.31)	0.203*
>6	3.0(12)	1.7(5)	6.3(7)	Ref
Presence of primary or secondary school student in household
Yes	75.1(298)	80.0(228)	62.5(70)	2.40(1.49–3.88)	<0.001*
No	24.9(99)	20.0(57)	37.5(42)	Ref
Presence of children under five in household
No	50.9(202)	62.1(177)	766.1(74)	1.05(0.68–1.63)	0.826
Yes	49.1(195)	37.9(108)	33.9(38)	Ref
Wealth index
Lowest	26.2(104)	24.2(69)	31.2(35)	Ref
Second	29.0(115)	29.8(85)	26.8(30)	1.44(0.80–2.57)	0.222*
Middle	20.2(80)	20.7(59)	18.8(21)	1.43(0.74–2.71)	0.280
Fourth	13.9(55)	14.4(41)	12.5(14)	1.49(0.71–3.08)	0.288
Highest	10.8(43)	10.9(31)	10.7(12)	1.31(0.60–2.86)	0.497

Ref, Reference category

*variables from bivariate analysis of p-value < 0.25 considered for multivariable analysis

From the bi-variable analysis of socio-demographic factors, households having a wealth index in the second category had 1.44 times (COR: 1.44, 95% CI [0.80–2.57]) higher latrine utilization than those households in the lowest wealth index category. The odds of latrine utilization among households that had a family size of one to three persons were 3.8 times (COR: 3.81, 95% CI [1.18–7.30]) higher than among households that had a family size of greater than six persons. Households that included a primary or secondary school student were 2.4 times (COR: 2.40, 95% CI [1.49–3.88]) more likely to utilize a latrine than households that did not (Table 1).

Latrine characteristics

Among households included in the study, 21.7% (86) were found to use a pit latrine with slab and 78.3% (311) used pit latrines without slab. The time since the latrine had been constructed was two years or more for 43.8% (174) of households. About 31.2% (124) of latrines were located inside the house compound and 48.6% (193) outside the house compound. Nearly half 47.1% (187) of households had constructed latrines for the second time and about one-fourth 23.4% (93) households had constructed latrines for the first time. About three-fourth 74.1% (294) of latrines had a door and 25.9% (103) did not have a door. The condition of half 49.6% (197) of the latrines was poor and almost one-tenth 12.1% (48) of latrines were in good condition. A majority 78.3% (311) of the latrines slab were not sealed with mud/cement (Table 2).

Table 2

Latrine characteristics and bivariate analysis with latrine utilization in semi-urban areas in northeastern Ethiopia, February to March, 2019.

Variables		Latrine utilization (N = 397)		COR (95% CI)	p-value
	Frequency	Utilized (n = 285)	Not utilized (n = 112)
	%(n)	%(n)	%(n)
Type of latrine
Pit latrine with slab	21.7(86)	23.2(66)	17.9(20)	1.39(0.80–2.42)	0.250*
Pit latrine without slab	78.3(311)	76.8(219)	82.1(92)	Ref
Means of disposal of faeces of children under five
Pit latrine disposal	145.3(180)	45.6(130)	44.6(50)	0.92(0.57–1.50)	0.714
Disposal in the compound	38.3(152)	37.5(107)	40.2(45)	1.09(0.57–2.06)	0.801
Disposal outside the compound	16.4(65)	16.9(48)	15.2(17)	Ref
Condition of latrine
Poor	49.6(197)	48.8(139)	51.8(58)	Ref
Fair	38.3(152)	37.9(108)	39.3(44)	1.02(0.64–1.63)	0.920
Good	12.1(48)	13.3(38)	8.9(10)	1.59(0.74–3.40)	0.235*
Faeces seen around pit hole/floor of latrine
No	55.7(221)	56.8(162)	52.7(59)	1.18 (0.76–1.18)	0.453
Yes	44.3(176)	43.2(123)	47.3(53)	Ref
Distance of latrine from the house (meters)
< 6	3.5(14)	3.1(9)	4.5(5)	0.57(0.17–1.98)	0.380
6–50	80.9(321)	80.4(229)	82.1(92)	0.79(0.42–1.49)	0.474
> 50	15.6(62)	16.5(47)	13.4(15)	Ref
Latrine location
Inside compound	31.2(124)	29.5(84)	35.7(40)	0.96(0.52–1.75)	0.880
Outside compound	48.6(193)	51.2(146)	42.0(47)	1.41(0.79–2.51)	0.240*
No compound/latrine distant from home	20.2(80)	19.3(55)	22.3(25)	Ref
Number of years since latrine was constructed
≥ 2	43.8(174)	47.7(136)	33.9(38)	1.78(1.23–2.80)	0.013*
< 2	56.2(223)	52.3(149)	66.1(74)	Ref
Number of times latrine has been constructed
First time	23.4(93)	22.4(64)	25.9(29)	Ref
Second time	47.1(187)	46.7(133)	48.2(54)	1.12(0.65–1.92)	0.691
Third time	16.9(67)	18.6(53)	12.5(14)	1.72(0.82–3.56)	0.150*
Fourth or more time	12.6(50)	12.3(35)	13.4(15)	1.06(0.50–2.23)	0.884
Latrine squat hole covered
Yes	37.0(147)	37.5(107)	35.7(40)	1.08(0.69–1.70)	0.734
No	63.0(250)	62.5(178)	25.3(72)	Ref
Latrine slab sealed with mud/cement
Yes	21.7(86)	25.8(62)	21.4(24)	1.02(0.56–1.72)	0.943
No	78.3(311)	78.2(223)	78.6(88)	Ref
Latrine has walls
Yes	75.1(298)	80.0(228)	62.5(70)	2.4(1.49–3.88)	0.001*
No	24.9(99)	20.0(57)	37.5(42)	Ref
Latrine has a roof
Yes	39.5(157)	40.3(115)	37.5(42)	1.12 (0.72–1.77)	0.601
No	60.5(240)	59.6(170)	62.5(70)	Ref
Latrine has a door
Yes	74.1(294)	78.2(223)	63.4(71)	2.08(1.29–3.35)	0.003*
No	25.9(103)	21.8(62)	36.6(41)	Ref

Ref, Reference category

*variables from bivariate analysis of p-value < 0.25 considered for multivariable analysis

From the bivariate analysis, we found that the odds of a pit latrine with slab being utilized was 1.39 times (COR: 1.39, 95% CI [0.80–2.42]) higher than a pit latrine without slab. The odds of a latrine being utilized by households whose latrine had been constructed two or more years previously were 1.78 times (COR: 1.78, 95% CI [1.23–2.80]) greater than those households whose latrines had been constructed less than two years previously. Study participants who had constructed a latrine for the third time were 1.72 times (COR: 1.72, 95% CI [0.82–3.56]) more likely to utilize their latrine than those who had constructed a latrine for the first time (Table 2).

Behavioral characteristics

Of the total study participants, 30.2% (120) of households reported cleaning the latrine rarely, whereas one-fourth (24.2%) of the households cleaned the latrine daily. The hygienic condition of a majority 82.9% (329) of the latrines was dirty and 17.1% (68) clean. Three-fourth (74.3%) of the study participants had received information about constructing latrines. The majority 62.5% (248) of households constructed latrines because of the advice of health extension workers and about one-fourth 23.4% (93) constructed latrines on their own initiative. About 45.8% (182) of the study participants considered that lacking a latrine was a cultural taboo; the types of the taboo were shem (46.7%), presence of bad smell (31.3%), fly problem (11.5%) and disease problem (10.4%) (Table 3).

Table 3

Behavioral characteristics and bivariate analysis with latrine utilization in semi-urban areas in northeastern Ethiopia, February to March, 2019.

Variables		Latrine utilization (N = 397)		COR (95% CI)	p-value
	Frequency	Utilized (n = 285)	Not utilized (n = 112)
	%(n)	%(n)	%(n)
Frequency of latrine cleaning
Weekly	24.7(98)	22.4(64)	30.4(34)	0.83(0.47–1.48)	0.545
Daily	24.2(96)	27.4(78)	16.1(18)	1.93(1.02–3.67)	0.045*
When dirty	20.9(83)	21.1(60)	20.5(23)	1.16(0.62–2.15)	0.632
Rarely	30.2(120)	29.1(83)	33.0(37)	Ref
Latrine hygienic condition
Clean	17.1(68)	48(16.8)	17.9(20)	0.93(0.52–1.67)	0.809
Dirty	82.9(329)	83.2(237)	82.1(92)	Ref
Information received about constructing latrine
Yes	74.3(295)	78.2(223)	64.3(72)	2.0(1.24–3.22)	0.005*
No	25.7(102)	21.8(62)	35.7(40)	Ref
Reasons to construct latrine
Advice by health extension worker	62.5(248)	62.1(177)	63.4(71)	1.13(0.38–3.39)	0.823
From seeing others build	10.1(40)	9.1(26)	12.5(14)	0.84(0.24–2.92)	0.789
Self-initiated	23.4(93)	24.9(71)	19.6(22)	1.47(0.46–4.68)	0.517
Imposition from kebele	4.0(16)	3.9(11)	4.5(5)	Ref
Person responsible for constructing latrine
Men	33.5(133)	33.7(96)	33.0(37)	1.04(0.63–1.7)	0.884
Women	20.7(82)	20.0(59)	20.5(23)	1.02(0.57–1.83)	0.931
Both	45.8(182)	45.6(130)	46.5(52)	Ref
Lack of latrine considered culturally taboo
No	54.2(215)	54.4(155)	53.6(60)	1.03(0.67–1.60)	0.883
Yes	45.8(182)	45.6(130)	46.4(52)	Ref
Type of taboo
Shem	46.7(85)	50.8(66)	36.5(19)	1.63(0.55–4.86)	0.383
Presence of bad smell	31.3(57)	28.5(37)	38.5(20)	0.85(0.28–2.59)	0.780
Fly problem	11.5(21)	10.8(14)	13.5(7)	0.92(0.25–3.48)	0.906
Disease problem	10.4(19)	10.0(13)	11.5(6)	Ref
Presence of handwashing facility near latrines
No	138.8(154)	38.9(111)	38.4(43)	1.02(0.65–1.60)	0.919
Yes	61.2(243)	61.1(174)	61.6(69)	Ref

Ref, Reference category

*variables from bivariate analysis of p-value < 0.25 considered for multivariable analysis

From the bivariate analysis, households that cleaned their latrine daily were 1.93 times (COR: 1.93, 95% CI [1.02–3.67]) more likely to use it compared with those that cleaned their latrine rarely. The odds of latrine utilization among study participants who had received information about latrine construction were 2 times (COR: 2.0, 95% CI [1.24–3.22]) higher than among those who had not received information about latrine construction (Table 3).

Prevalence of latrine utilization

The prevalence of latrine utilization was 71.8% (95% CI [67.5–76.1%]), whereas 28.2% (95% CI [23.9–32.5%]) of participants did not utilize latrines (Fig 1).

Fig 1

Latrine utilization status in semi-urban areas of Alansha, South Wollo Zone, northeastern Ethiopia, February to March, 2019.

Factors associated with latrine utilization

The multivariable analysis revealed that household family size of one to three persons, presence of primary or secondary school student in the house, number of years since construction of the latrine equal or greater than two and daily cleaning of latrine were significantly associated with latrine utilization. The odds of latrine utilization of households that had one to three family members were 3.99 times (AOR: 3.99, 95% CI [1.20–6.24]) higher than of households of greater than six members. The study also revealed that the odds of latrine utilization for households that included a primary or secondary school student were 2.33 times (AOR: 2.33, 95% CI [1.42–3.83]) higher than for those that did not include a primary or secondary school student.

Furthermore, the odds of latrine utilization in households in which it had been two or more years since the latrine had been constructed were 1.82 times (AOR: 1.82, 95% CI [1.12–2.95]) higher than for households in which it had been constructed more recently. The odds of latrine utilization for households that cleaned the latrine daily were 2.19 times (AOR: 2.19, 95% CI [1.12–4.28]) higher than for households that cleaned their latrine rarely (Table 4).

Table 4

Factors significantly associated with latrine utilization from multivariable logistic regression analysis in semi-urban areas in Northeastern Ethiopia, February to March, 2019.

Variables*	AOR (95% CI)
Household size (persons)
1–3	3.99(1.20–6.24)
4–6	3.05(0.67–5.90)
>6	Ref
Presence of primary or secondary school student in a household
Yes	2.33(1.42–3.83)
No	Ref
Number of years since latrine constructed
≥ 2	1.82(1.12–2.95)
< 2	Ref
Cleaning frequency of latrine
Weekly	1.03(0.57–1.89)
Daily	2.19(1.12–4.28)
When dirty	1.33(0.69–2.54)
Other (rarely)	Ref

Ref, Reference category; AOR, Adjusted odds ratio; CI, Confidence interval.

*Variables adjusted for multivariable analysis were study participant age, occupation, household size, presence of primary or secondary school student in the household, wealth index, type of latrine, condition of latrine, latrine location, years since latrine constructed, number of times

Latrine had been constructed, latrine having wall, door, frequency of latrine cleaning, information received about constructing latrine and presence of water in handwashing facility.

Discussion

This community-based cross-sectional study found that nearly three-fourths of participants utilized latrines, and that latrine usage was significantly associated with a household family size of one to three persons, presence of primary or secondary school student in the household, time since the construction of the latrine of two or more years and daily cleaning of the latrine.

In this study, the rate of latrine utilization was lower than found in a study done in Wondo Genet in SNNPs (South Nation Nationalities and Peoples), Ethiopia [24] and Hotesa Arisi District, Oromia Region in Ethiopia [25], but higher than found in various other rural areas of Ethiopia such as Anded [26], Denbia [11], Chencha [12], Enderta [27], Laelai Maichew District [28] and by national systematic review and meta-analysis survey of latrine utilization [29]. The relatively higher prevalence of latrine utilization in our study compared with the rural areas mentioned might be due to residents of this semi-urban area having a better awareness of latrine utilization, sanitation and hygiene practices, education opportunities and the presence of government employees in Alansha having a positive influence on latrine utilization.

Our study indicated that a household family size of one to three persons was one of the determinant factor for latrine utilization, a finding consistent with similar studies in other areas of Ethiopia such as in Southeast Zone of Tigray [30] and in Hawassa [31]. Sharing one latrine among fewer family members results in the latrine being used less frequently overall, making the latrine more likely to be cleaner, which in turn may increase latrine utilization. However, sharing of a latrine by a large family increases the number of times the latrine is used on a daily basis, thereby making the latrine more likely to be dirty, which in turn may decrease utilization of the latrine. A study in slums of Addis Ababa showed that a large family size of six or more persons led to poor hygiene of the latrines, which was in turn associated with diarrhea among under-five children [20] and that the presence of continuously available latrines helped to control the diarrheal disease [32]. The presence of a larger family size may compromise an individual’s feeling of responsibility to use the latrine properly, another possible reason for latrines to be dirty, as this study revealed.

Our study also revealed that the presence of a primary or secondary school student in a household increased the odds of latrine utilization, which is consistent with similar studies in other areas of Ethiopia such as in Hullet Eju Enessie in Gojjam [19], Laelai Maichew District in Tigray [30] and Denbia district in Gondar [11]. This might be due to the fact that primary or secondary school students were more exposed to hygiene information in the school environment and therefore their presence positively favored latrine utilization at home. A study in Uganda also found that the presence of a primary or secondary school student positively favored latrine utilization in the home environment [33]. The study area district administrator reported (via personal communication) that the health extension program was closely linked to the promotion of health at school, which was an additional opportunity for students to learn healthy lifestyles. Another study revealed that the active involvement of health professionals in latrine hygiene and sanitation is crucial to accelerating and consolidating progress towards the desired goals [34].

Our study showed that households in which it had been two and more years since the latrine was constructed were more likely to utilize their latrine than those in which the latrine had been constructed more recently. Findings consistent with ours are mentioned in studies of Ethiopian areas including Aneded district [26], Dilla town [35], Chencha [12] and in Wondo Genet [24]. The number of years since the construction of a latrine being a factor for latrine utilization might be due to the fact that attainment of behavioral change among household members may take some period of time. Therefore, to improve latrine utilization, a continuous effort in education, support and monitoring of latrines needs to be regularly maintained until community behavioral change is observed in a sustained manner. Similar with our study findings, a study conducted in India also showed that more years since latrine construction increased the utilization of the latrine [36].

This study also revealed that daily cleaning of the latrine was significantly associated with latrine utilization, a finding similar to several Ethiopian studies in Wondo Genet [24], Hetosa district [25], Laelai Maichew [30] and Aneded district [26]. In addition, our finding was consistent with a study in Kenya [37]. When latrines are cleaned frequently, faeces, flies and bad odors are eliminated, all of which may increase latrine utilization.

Limitations of the study

One of the limitations of this study was that data was obtained from a cross-sectional survey study, which may be exposed to bias due to self-reporting. During self-reporting, there may be an occurrence of social desirability bias [38]. In the absence of follow-up observational data, this work may greatly underestimate or overestimate the magnitude of latrine utilization and other independent variables. Although the latrine utilization during the study period was determined by using on-the-spot- observation, it was difficult to determine whether there was consistent use of the latrine using a cross-sectional study.

Another limitation of this cross-sectional study was the difficulty of establishing causal relationships between the latrine utilization status and independent factors. Also, our study was conducted during February and March, a period that is in a relatively dry season in the study area, and further studies that considered latrine utilization during seasonal variation is recommended. Furthermore, the results of this study may not be representative of the occurrence and underlying factors of latrine utilization across all semi-urban areas in northeastern Ethiopia due to the study being conducted only in small semi-urban areas.

Conclusion

Based on the findings, we concluded that a majority of households utilized a latrine. From this study, we concluded that factors significantly associated with latrine utilization were a household family size from one to three persons, presence of primary or secondary school student in the household, number of years since latrine construction (two years or more) and daily cleaning of the latrine. It is recommended that promotion of behavioral change toward sustainable and consistent latrine use should be carried out as an essential step for further improvement of latrine utilization status. Further observational research triangulated with qualitative study should be conducted to provide more strong evidence for further improvement of household latrine utilization status.

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6 May 2020

PONE-D-20-01859

Household Latrine Utilization and Its Association with Household Family Size in Semi-Urban Areas of Alansha, South Wollo, Northeastern, Ethiopia

PLOS ONE

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https://www.ajol.info/index.php/ejhd/article/view/62959

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https://www.dx.doi.org/10.11604/pamj.26/08/2014.18.334.4206

https://doi.org/10.4172/2167-1095.1000174

https://doi.org/10.5897/AJEST2016.2223

https://dhsprogram.com/pubs/pdf/FR328/FR328.pdf

https://doi.org/10.1186/s13104-019-4684-3

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Reviewer #1: This manuscript accepted with major comments.

Overall this is a good study but needs to be reviewed and toned down by the authors. The author need to focus and re-write the result section and should present the results more clearly and in a standard way.

Reviewer #2: Review report (Reviewer # 1 Habtamu Tolera)

The manuscript reports the findings regarding Household Latrine utilization and its association with household family size in semi-urban areas of Alansha, south Wollo, northeastern, Ethiopia. This kind of study is much relevant in context of developing countries like Ethiopia. The study has large sample and tried to represent each unit from the study setting Analysis has been made well and the authors have made relevant conclusions/recommendations based on the findings. However, I have some concerns which should be addressed and revised accordingly to get published in PLoS ONE. You can also refer to the attached PDF file.

Abstract

Page # 2 line 30, under the methods section it was said that “a cross-sectional study was conducted … among 397 households”. Likewise, on page # 2 line 40 under the same section author (s) also mentioned a total of 401 households … were assessed ...” Why different figures? This needed to be corrected. On page # 2 line 38 you should delete the unnecessary phrase used in the bracket which is called “significant at” because Р-value is enough to describe the significance of the model high level scholars or readers.

Background

On page # 2 lines 64 and 65 needs you citing source (s). This concern works for all if such cases were there elsewhere across the text.

On page 4 line 66 and 67 you described that “In 2010, 67 15% of the population still practiced open defecation” Why did not refer recent global report or figure?

PLoS ONE follows Vancouver style for in text-citation, should be indicated by the reference number in rectangular brackets but authors used APA style across the entire manuscript. Suiting journal’s instructions is vital.

On page # 4 line 69 you should have to discuss Ethiopian (local) context regarding the prevalence of open defection. Use at least 2016 EDHS report, the proportion of overall population in the country who use open defecation or open field than modern latrine facilities. On page 4 lines 74 and 75 you described that “Lack of latrine utilization has been due mainly to, …” You need to acknowledge or cite original source(s).

On page # 4 lines 80-82 seems concluding point. Put it under “conclusion section” in the last page of the manuscript.

Page # 5 Line 95 delete the phrase “recent data from the”.

On page # 5 Line 100 you need to mention EDHS 2016 as it was the most recent survey than the Mini DHS of 2014. so better to describe like this, “The recent data from the Ethiopia Demographic and Health Survey (EDHS) (2016) indicated that 6% of Ethiopian households…”

Materials and methods

On page # 5 line 116, under a section called study setting “which is located….” is appropriate.

Delete the outcome variable from the sub-section “Study design and outcome variable”. Move your whole discussion about outcome variable and insert before a sub-section “Independent variable”, separately or you can merge both outcome and independent variables into one under a sub-tittle “Variables measured”. Hence, move the whole texts from lines 126 through 134 there.

Page # 6 lines 129 and 130 you mentioned, “…World Health Organization (WHO) and Joint Monitoring Program (JMP) “signs of use …” . It needs you citing the original source

Consistency should be kept across the manuscript, e.g. on page 6 line 116 you used woreda but on page # 4 line 85 I have seen “In Denbia District” and elsewhere you also used the word “district”, I advise you use either of the two, “Woreda “(should be italicized) or “District” .

Page # 9 line 178, you mentioned that,” …Environmental Health” use lower case. Page #9, line 180, rewrite the sentence like this “The principal investigator provided a training that took the whole one day…”

Page # 9 lines 191 through 193 does not convey a clear message for readers. Please rewrite this sentence

On page # 10 under a section Independent variable you missed to list the Households wealth status distributions across five categories: poorest, second, middle, fourth and highest should be described as an exposure variable. you need to discuss the issue here as well

On page # 10 line 208, a kind of ambiguity happens there, so delete “other” and use instead “Ash” or use “other” and define what it features in bracket

Ethical consideration needs citing of ECR’s protocol number of the approval letter.

Move the sentence on page # 11 from lines 216 through 218 to the last section of this paragraph.

Results

Rewrite line 239 like this, “In this study, of the total 401 participants,”, Line 240 like this, “Out of this, the majority (71.8%),...”. Line 241 like this, “Across gender, of the total 397 respondents,”. Line 243 lie this, “who were Muslims were…”, “other religion followers were…”

Table caption for Table 1 should be placed in the text immediately after you referenced the table in the in-text citation, in the last paragraph of your respective discussion about the table. This comment works for the remaining tables in the entire manuscript or elsewhere in the text.

On page # 12, rewrite the sentence from lines 247 through 250. Correct line 252 like this, “Of the total respondents,30.2% of households reportedly showed that they had a cleaning frequency (of latrines) rarely while 24.7% reported that they made every day”. Please line 253 is not clear for me rewrite.

Discussion

On page 14 line 282, rewrite like this, “ in this study, the rate of latrine facility utilization…”. Line 283 and 284 like this, “elsewhere in other parts of Ethiopia such as...”. Line 285 through 290 is too long sentence. Please keep it succinct and to the point.

Try to rewrite a sentence from line 292 through 295 like this, After adjusting for all variables, a socio-demographic factors in a form of households with small family size of 1-3 members were significantly associated with latrine facility utilization as opposed to households with larger family members (4 person or more), which is consistent with studies in southeastern zone of Tigray(), and in Hawassa ( )

Lines 297 through 299 is not clear, rewrite this paragraph.

Conclusion

In conclusion, there is no need to make discussion, just write the major conclusions and what recommendations they could made for policy makers. Your conclusion under abstract section is better stated than the one that was found at the last page of the manuscript. Move the concluding points under Abstract section to your Major “Conclusion” section in the last page of the manuscript.

Acknowledgement

In PLoS ONE, you acknowledge funders not under Acknowledgment section but under funding section during online submission.

Reference list

Change reference lists into Vancouver style please. Avoid capitalization problems as well. Do according to the Journal’s guideline

Overall, some editorial works are here in the manuscript. It should be made more concise and clearer in each section. They should check and revised thoroughly.

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Reviewer #1: Yes: Mahfuza Islam

Reviewer #2: Yes: Habtamu Tolera

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30 Jul 2020

Date: 31 July, 2020

Manuscript ID: PONE-D-20-01859R1

Household latrine utilization and associated factors in Semi-Urban areas in Northeastern Ethiopia

Corresponding authors: Metadel Adane (PhD)

Dear Emily Chenette, staff editor, PLoS ONE

Thank you for your letter dated May 06, 2020 with a decision of revision needed. We were pleased to know that our manuscript was considered potentially acceptable for publication in PLoS ONE, subject to adequate revision as requested by the reviewers. Based on the instructions provided in your letter, we uploaded the file of the rebuttal letter; the marked up copy of the revised manuscript highlighting the changes made in the original submitted version and the clean copy of the revised manuscript.

We have revised the manuscript by modifying the abstract, introduction, methods, results, discussion and other sections, based on the comments made by the reviewers and using the journal guidelines. Accordingly, we have marked in red color all the changes made during the revision process. Appended to this letter is our point-by-point response (rebuttal letter) to the comments made by the reviewers.

We agree with almost all the comments/questions raised by the reviewers and provided justification for disagreeing with some of them. We would like to take this opportunity to express our thanks to the reviewers for their valuable comments and to thank you for allowing us to resubmit a revision of the manuscript.

Funding

Amhara Region Health Bureau funded this study. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

I hope that the revised manuscript is accepted for publication in PLoS ONE.

Rebuttal letter

Response to the Journal Requirements

Question #1: Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming

Response: Thank you for this remark. We re-formatted the revised manuscript using the PLoS ONE format guidelines. The whole content of the manuscript, including the abstract, introduction, methods, discussion and reference are formatted using the guidelines (please see the revised version for each section).

Comment #2. We noticed you have some minor occurrence (s) of overlapping text with the following previous publication (s), which needs to be addressed: In your revision ensure you cite all your sources (including your own works), and quote or rephrase any duplicated text outside the Methods section. Further consideration is dependent on these concerns being addressed.

Response: We addressed this issue seriously and please check the revised version.

Comment #3. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information.

Response: We provided the questionnaire in original language and English version as supporting information S1 and S2 (please see the revised version attachment).

Comment #4. Thank you for stating the following in the Acknowledgments Section of your manuscript: We appreciate the support of Amhara Regional Government Health Bureau by providing for funds for this study.' We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: 'The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.'

Response: Thank you for these pertinent comments. We made the necessary changes and we noted the funding statement in the cover letter.

Comment #5. - Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified how verbal consent was documented and witnessed.

Response: We provided all the ethical consideration issues of the oral/verbal consent statement and please see the revised version (see the revised version).

Line by line response to reviewers

Reviewer # 1

Comments on Manuscript:

Overall this is a good study but needs to be reviewed and toned down by the authors for the following checks:

Response: Thank you for the positive remark on our manuscript and we made all the corrections throughout the manuscript as follow.

Title:

The authors may revise the language of the title/s to improve readability. Author may consider writing the title as “Household Latrine Utilization and Its Association with Household Family Size in Semi-Urban Areas in Ethiopia”.

Response: We revised the title almost similar with the reviewer comment. The modified title is “Household latrine utilization and associated factors in Semi-Urban areas in Northeastern Ethiopia”. This title is directly fits the content of the paper.

Abstract:

1) Author reported a different number of households in method and result of the abstract. In line 30, number of households mentioned 397 but in line 40, it was mentioned 401. Later on, in line 151 final sample sizes mentioned as 401. I would suggest checking the number and making it clear.

Response: Thank you for the comment and the error is corrected (please see the revised version).

2. In line 43, need a space between 285 and (71.8%).

Response: We add space as suggested.

3. In line 42 put a coma (,) instead of full stop (.) after the value 3.99

Response: We put comma and sorry for this error.

4. In line 43, need a space between constructed and ≥2 years. Author made the same error in line 240-242 as well as in many lines of the manuscript and in the table of result. I would suggest checking for the same error throughout the manuscript.

Response: Thank you and we updated and checked similar errors throughout the paper.

Materials and Methods

5. In line 176, author may consider to write “spot check observation” instead of “observation”.

Response: Thank you for this pertinent comment. We revised as suggested (See the revised version throughout the paper in lines 185).

6. In line 207, what do author mean by “kebele”? Make it clear.

Response: We defined kebele in the study area sub-heading to make it clear for readers. kebele is the smallest administrative unit in Ethiopia consisted of an average 5,000 populations (See the revised version in lines 109 to 111).

Results

I would recommend the author to re-write the result section including the results Tables (Table1 to table 4). Author need to work on the following points:

Response: We updated Tables 1 to 4 (See all the revised tables).

7. Report the prevalence and keep the number within bracket, eg 71.8% (285). Make the changes throughout the result section. In addition, remove the decimal if the prevalence more than 10%. Author should report the bivariate result in the result section.

Response: We thank for this pertinent comment and we revised as suggested. However we reported the decimal as it is without approximation since to be consistent with throughout the paper.

8. In line 247, re-write the result to improve readability.

Response: The sentence is revised to make it clear.

9. In line 261, check the value of 95% CI. A proof reading is must for the author, especially in the result section.

Response: Thank you. We corrected the errors.

10. The title of the tables is too long. I would recommend the author to make it short. Better to remove the location and duration from the title, eg. “Table 1: Socio-demographic characteristics and bivariate analyses with latrine utilization in semi-urban area in Ethiopia”.

Response: The title of Table 1 to Table 4 is revised to make it short and precise (See the titles of Table 1 to Table 4).

11. Author may consider bold the significant results in the tables.

Response: For Table 4, we make it bold for the significant results (See Table 4). However, for other Tables, being significant from the bivariate analysis is not important due to the confounders not controlled (See Table 4).

12. In line 423-424 (Table 1), I would recommend the author to report prevalence for the column utilized and not utilized. Same recommendation for the rest of the tables. Without prevalence it’s difficult to check the bivariate results.

Response: We agree with the given comments and we reported the prevalence for column as suggested (See Table 1).

13. In line 454-455 (Table 3), author mentioned “n (%)” in 3rd and 4th column but only report the frequency. I would recommend to report both frequency and %.

Response: Thank you for this key comment. We revised all tables and the frequency and percentage was estimated (See Table 3).

Discussion

14. In line 278, Author should remove number (prevalence or 95% CI) form the discussion section. It’s not a good practice to report the result in the discussion.

Response: Thank you, we updated as suggested.

15. Author should work on the discussion depending on the changes of result section.

Response: We revised the discussion as suggested (please see the revised version of the discussion in pages 321 to 397).

Reviewer #2

Review report (Reviewer # 2 Habtamu Tolera)

The manuscript reports the findings regarding Household Latrine utilization and its association with household family size in semi-urban areas of Alansha, south Wollo, northeastern, Ethiopia. This kind of study is much relevant in context of developing countries like Ethiopia. The study has large sample and tried to represent each unit from the study setting Analysis has been made well and the authors have made relevant conclusions/recommendations based on the findings. However, I have some concerns which should be addressed and revised accordingly to get published in PLoS ONE.

Abstract

Page # 2 line 30, under the methods section it was said that “a cross-sectional study was conducted … among 397 households”. Likewise, on page # 2 line 40 under the same section author (s) also mentioned a total of 401 households … were assessed ...” Why different figures? This needed to be corrected. On page # 2 line 38 you should delete the unnecessary phrase used in the bracket which is called “significant at” because Р-value is enough to describe the significance of the model high level scholars or readers.

Response: This error is corrected (See abstract).

Background

On page # 2 lines 64 and 65 needs you citing source (s). This concern works for all if such cases were there elsewhere across the text.

Response: Thank you and we cited.

On page 4 line 66 and 67 you described that “In 2010, 67 15% of the population still practiced open defecation” Why did not refer recent global report or figure?

Response: It is deleted.

PLoS ONE follows Vancouver style for in text-citation, should be indicated by the reference number in rectangular brackets but authors used APA style across the entire manuscript. Suiting journal’s instructions is vital.

Response:

On page # 4 line 69 you should have to discuss Ethiopian (local) context regarding the prevalence of open defection. Use at least 2016 EDHS report, the proportion of overall population in the country who use open defecation or open field than modern latrine facilities.

Response: It is revised as recommended focusing to Ethiopian Open defecation status (see lines 73 to 75).

On page 4 lines 74 and 75 you described that “Lack of latrine utilization has been due mainly to, …” You need to acknowledge or cite original source(s).

Response:

On page # 4 lines 80-82 seems concluding point. Put it under “conclusion section” in the last page of the manuscript.

Response: It is moved to the conclusion section (see the conclusion).

Page # 5 Line 95 delete the phrase “recent data from the”.

Response: Deleted

On page # 5 Line 100 you need to mention EDHS 2016 as it was the most recent survey than the Mini DHS of 2014. so better to describe like this, “The recent data from the Ethiopia Demographic and Health Survey (EDHS) (2016) indicated that 6% of Ethiopian households…”

Response: Thank you, it is updated.

Materials and methods

On page # 5 line 116, under a section called study setting “which is located….” is appropriate.

Response: Thank you, it is changed.

Delete the outcome variable from the sub-section “Study design and outcome variable”. Response: Yes, it is deleted

Move your whole discussion about outcome variable and insert before a sub-section “Independent variable”, separately or you can merge both outcome and independent variables into one under a sub-tittle “Variables measured”. Hence, move the whole texts from lines 126 through 134 there.

Response: It sub-titled as variables measured (see line 158).

Page # 6 lines 129 and 130 you mentioned, “…World Health Organization (WHO) and Joint Monitoring Program (JMP) “signs of use …” . It needs you citing the original source

Response: It is deleted since it is not the correct source.

Consistency should be kept across the manuscript, e.g. on page 6 line 116 you used woreda but on page # 4 line 85 I have seen “In Denbia District” and elsewhere you also used the word “district”, I advise you use either of the two, “Woreda “(should be italicized) or “District”.

Response: It changed to district throughout the paper (see the revised version).

Page # 9 line 178, you mentioned that,” …Environmental Health” use lower case. Page #9, line 180, rewrite the sentence like this “The principal investigator provided a training that took the whole one day…”

Response: Yes, Environmental Health changed to lower case letters as environmental health (See line 194).

Page # 9 lines 191 through 193 does not convey a clear message for readers. Please rewrite this sentence.

Response: It is re-written, please see the revised version

On page # 10 under a section Independent variable you missed to list the Households wealth status distributions across five categories: poorest, second, middle, fourth and highest should be described as an exposure variable. You need to discuss the issue here as well.

Response: We put the wealth categories of lowest, second, middle, fourth and highest (see the revised version in lines 176 to 177).

On page # 10 line 208, a kind of ambiguity happens there, so delete “other” and use instead “Ash” or use “other” and define what it features in bracket.

Response: we deleted all to avoid confusions.

Ethical consideration needs citing of ECR’s protocol number of the approval letter.

Response: We cited the protocol number (See line 231).

Move the sentence on page # 11 from lines 216 through 218 to the last section of this paragraph.

Response: We provided the details for verbal/oral consent. Please see the revised version at the ethical consideration section (See lines 230 to 240).

Results

Rewrite line 239 like this, “In this study, of the total 401 participants,”, Line 240 like this, “Out of this, the majority (71.8%),...”. Line 241 like this, “Across gender, of the total 397 respondents,”. Line 243 lie this, “who were Muslims were…”, “other religion followers were…”

Response: We revised the sentence to make it more clear (See lines 244 to 247).

Table caption for Table 1 should be placed in the text immediately after you referenced the table in the in-text citation, in the last paragraph of your respective discussion about the table. This comment works for the remaining tables in the entire manuscript or elsewhere in the text.

Response: As per the format for PLoS ONE, caption inside the text is needed for figures but for Tables captions is needed in the title of the table. We did as per the guidelines.

On page # 12, rewrite the sentence from lines 247 through 250. Correct line 252 like this, “Of the total respondents,30.2% of households reportedly showed that they had a cleaning frequency (of latrines) rarely while 24.7% reported that they made every day”. Please line 253 is not clear for me rewrite.

Response: We did the amendment as suggested. Thank you.

Discussion

On page 14 line 282, rewrite like this, “in this study, the rate of latrine facility utilization…”. Line 283 and 284 like this, “elsewhere in other parts of Ethiopia such as...”. Line 285 through 290 is too long sentence. Please keep it succinct and to the point.

Response: Thank you and we did as suggested (please check the revised version in lines 323 to 337).

Try to rewrite a sentence from line 292 through 295 like this, After adjusting for all variables, a socio-demographic factors in a form of households with small family size of 1-3 members were significantly associated with latrine facility utilization as opposed to households with larger family members (4 person or more), which is consistent with studies in southeastern zone of Tigray(), and in Hawassa ( ).

Response: We rewrite as suggested and please check in lines 339 to 344.

Lines 297 through 299 is not clear, rewrite this paragraph.

Response: We re-write lines 297 to 299.

Conclusion

In conclusion, there is no need to make discussion, just write the major conclusions and what recommendations they could made for policy makers. Your conclusion under abstract section is better stated than the one that was found at the last page of the manuscript. Move the concluding points under Abstract section to your Major “Conclusion” section in the last page of the manuscript.

Response: We thank you for this key comment. We revised the conclusion as suggested (See the revised version of the conclusion).

Acknowledgement

In PLoS ONE, you acknowledge funders not under Acknowledgment section but under funding section during online submission.

Response: We deleted the funder in the acknowledgment section (See the revised version acknowledgment).

Reference list

Change reference lists into Vancouver style please. Avoid capitalization problems as well. Do according to the Journal’s guideline.

Response: Yes, it is formatted as per the PLoS ONE guidelines for references.

Overall, some editorial works are here in the manuscript. It should be made more concise and clearer in each section. They should check and revised thoroughly.

Response: Thank you for the remark and we revised the paper throughout.

We would like to thank the reviewers and editors for evaluating our manuscript. We have tried to address all the concerns in a proper way and believe that our paper has been improved considerably. We would be happy to make further corrections if necessary and look forward to hearing from you all soon.

I hope that the revised manuscript is accepted for publication in PLoS ONE.

Sincerely yours,

Metadel Adane (PhD)

13 Oct 2020

Household latrine utilization and associated factors in Semi-Urban areas of Northeastern Ethiopia

PONE-D-20-01859R1

Dear Dr. Adane (PhD),

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Miguel A. Fernández, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: It was nice to see the progress of the manuscript. The author has addressed all of the comments. It is now very well developed.

Reviewer #2: Reviewer # 1: Habtamu Tolera (PH.D)

The authors have revised the manuscript titled “Household Latrine utilization and its association with household family size in semi-urban areas of Alansha, south Wollo, northeastern, Ethiopia” as per the comments. The authors did the best job in the revision. I do not have more concerns and attachments in this review. Thus I recommend you to accept the paper without modification.

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Reviewer #1: Yes: Mahfuza Islam

Reviewer #2: Yes: Habtamu Tolera

Submitted filename: Reviewer comments on PONE-D-20-01859.docx

Click here for additional data file.

4 Nov 2020

PONE-D-20-01859R1

Household latrine utilization and associated factors in Semi-Urban areas of northeastern Ethiopia

Dear Dr. Adane (PhD):

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr Miguel A. Fernández

Academic Editor

PLOS ONE