Abstract
Background
Unsafe child feces disposal is a recognized public health concern linked to adverse child health outcomes. While previous studies have examined its impact, the spatial heterogeneity and determinants of unsafe child feces disposal in India remain underexplored. This study addresses this research gap by investigating the spatial distribution and key factors influencing unsafe disposal practices across Indian districts.
Method
This study utilized data from the National Family Health Survey-5 (2019–2021) to conduct a comprehensive spatial analysis. Univariate and Bivariate Local Indicators of Spatial Association (LISA) clustering were employed to identify spatial patterns of unsafe child feces disposal. To examine the determinants, a Spatial Error Model (SEM) was applied, while Fairlie decomposition was used to quantify the contribution of various factors to regional disparities.
Results
The Univariate LISA analysis identified 170 hotspot districts characterized by high levels of unsafe child feces disposal, primarily located in Odisha, Jharkhand, Bihar, Assam, and Tamil Nadu. The SEM analysis revealed that maternal education, household wealth, sanitation access, and religious affiliation are significant determinants. Hotspot districts demonstrated a 22% higher likelihood of unsafe disposal compared to cold spots. Decomposition results indicated that household wealth accounted for 65.3% of the observed disparity, followed by sanitation (17.1%), religion (7.4%), media exposure (4.5%), and education (3.2%).
Conclusion
This study underscores the pronounced spatial disparities in unsafe child feces disposal across Indian districts. Addressing these disparities requires targeted interventions focusing on improving sanitation, enhancing maternal education, and leveraging media outreach to promote safe disposal practices.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12889-026-26359-8.
Keywords: Spatial heterogeneity, Unsafe disposal, Child feces, India, Spatial regression
Introduction
The unsafe disposal of child feces, whether in open fields, waste containers, drainage systems, or through inadequate burial in soil, poses substantial public health risks, particularly for pediatric populations [1]. Such practices significantly heighten the transmission of infectious diseases, including diarrheal infections [2, 3], helminth infections [4], and other pathogen-driven diseases [5]. Notably, households practicing unsafe feces disposal face a 6%–23% higher risk of diarrheal infections compared to those with safe disposal practices. In addition to immediate public health consequences, unsafe child feces disposal is also associated with long-term health vulnerabilities [6, 7]. Consequently, promoting the safe child feces disposal practice is imperative to mitigating both short- and long-term public health risks [2, 8, 9]. A previous study estimated that improving water supply, promoting hygiene practices, and effectively managing child feces disposal could avert approximately 361,000 under-five deaths annually [9].
Despite the linkage between unsafe child feces disposal and health risks is well-established public health science, research and policy efforts predominantly focus on adult sanitation practices in India [10–12]. The implicit assumption that improvements in adult sanitation will naturally extend to child feces disposal remains largely unchallenged, although empirical evidence disputes this notion. While adult open defecation rates have declined to around 19%, the prevalence of unsafe child feces disposal practice remains disproportionately high (61%) in India [13]—indicating a significant and often overlooked public health concern. National sanitation initiatives, including the Total Sanitation Campaign, Nirmal Bharat Abhiyan, and the Swachh Bharat Mission, have markedly improved household sanitation coverage. However, the sanitation coverage advancements have not been translated into improvements in child feces disposal management. A limited number of recent studies have called attention to the importance of focusing on safe child feces disposal in India [14, 15]. However, existing studies lack an in-depth spatial perspective, which is crucial for formulating targeted interventions [14, 15].
Spatial analyses of unsafe child feces disposal have been extensively explored in sub-Saharan Africa and Cambodia [16–19], but remain notably underrepresented in the Indian context. India’s vast socio-demographic diversity across 707 districts likely leads to substantial district-level variation in child feces disposal practices [10–12]. Nevertheless, research predominantly focuses on spatial signatures of adult sanitation practices [10–12], overlooking spatial heterogeneity in child-specific sanitation practices. As India progresses toward a more decentralized public health system i.e., transitioning from state level to district level monitoring and management [15], policymakers require spatially nuanced research findings to develop district-specific policies and programs. Understanding decentralized policy relevance, the present study systematically examines district-level spatial patterns of unsafe child feces disposal using nationally representative data. This study will identify hotspots of unsafe child feces disposal practices and the factors driving spatial heterogeneity. These insights will help policymakers prioritize high-risk areas and implement targeted child sanitation hygiene strategies, fostering safer disposal practices and reducing related health risks.
Methods
Data
The current study utilized the fifth round of the National Family Health Survey (NFHS-5), conducted between 2019 and 2021 [13]. The NFHS 5 is an Indian adaptation of the Demographic and Health Survey (DHS), offers district level socio-demographic and public health estimations. The survey employed a multilevel stratified probability proportional to the sample size approach using the 2011 census data. The selection of households followed a systematic random sampling method from Primary Sampling Units (PSUs) in rural areas and Census Enumeration Blocks (CEBs) in urban areas. Households were selected through a systematic random sampling technique from PSUs in rural areas and CEBs in urban areas. The NFHS-5 dataset contains data from 636,699 sampled households. This study utilized the children’s file (KR file), comprising 232,920 children under five. After excluding children older than two years, non-de-jure children, deceased children, and non-youngest children, the final sample included 79,618 children aged two years and below [13].
Outcome variable
The outcome variable in this study is child feces disposal practices [14–19]. The variable is constructed as dichotomous, classified as safe (coded as 0) and unsafe (coded as 1). Safe disposal includes using toilets/latrines or appropriately burying. Unsafe disposal involves leaving feces in open areas, discarding them in garbage bins, or rinsing them into drains [13–15]. The classification is based on NFHS 5 and international standards [13, 16].
Explanatory variables
The present study used a range of explanatory variables, including the mother’s age (15–19 years), education level (illiterate), religion (Hindu), social group (Scheduled tribe), household wealth quintile (Poorest), absence of water facility in the household premises, unsafe sanitation facility at household, mother’s mass media exposure (no), and place of residence (rural) at district level. The selection criterion of explanatory variables was based on existing literature [15–18] and supplementary results from the multivariable logistic regression (Supplementary file 1). The descriptive statistics of the explanatory variables presented in the Supplementary file 1.
Statistical analyses
Univariate, bivariate, and spatial regression were utilized to present spatial insights into the unsafe disposal of children’s feces, employing the GeoDa software [20]. Univariate LISA examines spatial autocorrelation across districts based on any single indicator. The computation of Univariate Moran’s I index was conducted using the subsequent formula [20]:
 |
Where x is the selected study variable, and the mean of x is indicated by 
; Number of spatial divisions, represented by n. the standardized weight matrix between the observation i and j with zeroes on the diagonal denotes as 
; and 
is the aggregated spatial weights, that is, 
. Furthermore, the bivariate local Moran’s I analysis is defined by the following formula:
 |
Here, x and y are the outcome and explanatory variables, respectively, used in the analysis; 
refers mean of x; 
indicates the mean of y; n is the total number of spatial divisions. The standardized weight matrix was 
between the observation i and j with the diagonal zero; 
is the cumulative of all spatial weights, represents 
. Bivariate Moran’s I enables the spatial assessment of the correlation between two variables across a specified area based on the local Moran statistic’s significance. Moran’s I statistic typically ranges from − 1 to + 1: Positive values signify the spatial clustering of similar values, while negative values indicate the clustering of dissimilar ones [20]. A value of 0 indicates no discernible pattern or spatial autocorrelation. In LISA mapping, the clusters are categorized as follows: dark red for high-high clustering (hotspots), deep blue for low-low clustering, bright blue for low-high clustering, and light red for high-low clustering. High-high and low-low clusters are positively correlated, while high-low and low-high clusters are spatial outliers [20]. Additionally, a significance map color-codes sites based on their significance level, with values considered at p < 0.001, p < 0.010, and p < 0.050.
Further, a set of spatial regression models was employed to predict the significant factors linked with spatial heterogeneity in the unsafe disposal of child feces across districts in India [20]. First, the study performed an ordinary least square (OLS) model, followed by a spatial lag model (SLM) and spatial error model (SEM), successively [20]. The OLS model equation is as follows:
 |
Here, Y is the response variable, x is the vector of explanatory variables, the model intercept denotes α, and β denotes the corresponding coefficient vector [20]. Based on low Akaike Information Criterion (AIC) value, the present study considered SEM as best-fit-model to explain the spatial insights. The Spatial Error Model (SEM) was chosen as it accounts for the influence of exogenous factors that may significantly affect the outcomes but were not originally integrated into the model.
Finally, the current research study employed the Fairlie decomposition model to identify the factors explaining disparity between hot spots and cold spots of unsafe child feces disposal practices [14]. The study employed the Fairlie package, which can conduct non-linear decomposition specifically suited for binary dependent variables (e.g., child feces disposal). Description of the Fairlie decomposition method is presented in Supplementary file 1. An interpolation mapping employing ordinary kriging interpolation technique delineate micro-level spatial variation (within district level) in unsafe child feces disposal. The present study obtained shapefile of India from DHS website (https://dhsprogram.com/Data/).
Results
Univariate Moran’s I statistics of the study variables
A high significant local spatial autocorrelation observed on unsafe child feces disposal practice, mother’s age (15–19 years), education (illiterate), religion (Hindu), social group (Scheduled tribe), lack of mass media exposure, household wealth quintile (poorest), absence of household premise water facility and improved sanitation facility, and rural place of residence across districts (p ≤ 0.05) (Table 1). However, variation in degree of local spatial autocorrelation is observed, ranging from 0.764 (Hindu religion) to 0.535 (place of residence) (Table 1).
Table 1.
Univariate LISA statistics of selected outcome and explanatory variables, India 2019-21
| Explanatory variables | Univariate Moran I | p value |
|---|---|---|
| Unsafe child feces disposal practice | 0.669 | ≤ 0.05 |
| Mother’s age (15–19 Years) | 0.584 | ≤ 0.05 |
| Mother’s education (Illiterate) | 0.644 | ≤ 0.05 |
| Religion (Hindu) | 0.764 | ≤ 0.05 |
| Social group (Scheduled tribe) | 0.717 | ≤ 0.05 |
| Household wealth quintile (Poorest) | 0.730 | ≤ 0.05 |
| No water facility on premises | 0.673 | ≤ 0.05 |
| Household unimproved sanitation facility | 0.665 | ≤ 0.05 |
| Mother’s mass media exposure (No) | 0.695 | ≤ 0.05 |
| Place of residence (Rural) | 0.535 | ≤ 0.05 |
Hotspot clusters of unsafe child feces disposal practice
Univariate Moran LISA cluster mapping identified three hotspot zones of unsafe child feces disposal practice in India, comprising 170 districts. The largest hotspot zone extends across Odisha, Jharkhand, Bihar, Uttar Pradesh, Chhattisgarh, and adjacent districts. The second-largest hotspot zone is located in Assam, while while the third encompasses ten districts in Tamil Nadu (Fig. 1a). All clusters found to be statistically significant (p ≤ 0.05) (Fig. 1b). Further details on the hotspot districts are provided in Supplementary file.
Fig. 1.
Univariate Moran LISA mapping of unsafe child feces disposal, India 2019-21. Source: Authors
Spatial dispersion of unsafe disposal of children’s feces
The prevalence of unsafe child feces disposal practices was alarmingly high (exceeding 65%) in numerous districts across India, particularly in states such as Odisha, Jharkhand, Bihar, Uttar Pradesh, Assam, Madhya Pradesh, and Tamil Nadu (Fig. 2). Similarly, the prevalence was moderate (50.8%–65.4%) in districts of Maharashtra, Karnataka, and Andhra Pradesh. Contrary, such practices was significantly lower (below 34%) in most districts of Kerala, Punjab, Delhi, Haryana, Uttarakhand, Himachal Pradesh, and Jammu & Kashmir (Fig. 2). Additionally, a substantial spatial variation in unsafe feces disposal practices within district boundaries (PSU and CEB level) is observed in India (Fig. 3).
Fig. 2.
District level patterns of unsafe child feces disposal, India 2019-21. Source: Authors
Fig. 3.
Cluster (PSUs/CEBs) level mapping of unsafe child feces disposal practice, India 2019-21. Source: Authors
Results from bivariate Moran’s I
Unsafe child feces disposal practices demonstrated significant spatial autocorrelation with unimproved sanitation (Moran’s I: 0.717), followed by the poorest wealth quintile (Moran’s I: 0.711), maternal illiteracy (Moran’s I: 0.698), and the absence of a water facility within household premises (Moran’s I: 0.638) (Table 2). Maternal age, mass media exposure, and place of residence were also found to be positively autocorrelated with unsafe child feces disposal practices (Table 2).
Table 2.
Bivariate LISA statistics of unsafe disposal of children’s feces and selected explanatory variables, India, 2019-21
| Explanatory variables | Bivariate Moran I | p-value |
|---|---|---|
| Mother’s age (15–19 Years) | 0.542 | 0.05 |
| Mother’s education (Illiterate) | 0.698 | 0.05 |
| Religion (Hindu) | 0.595 | 0.05 |
| Social group (Scheduled tribe) | 0.553 | 0.05 |
| Household wealth quintile (Poorest) | 0.711 | 0.05 |
| No water facility on premises | 0.638 | 0.05 |
| Household unimproved sanitation facility | 0.717 | 0.05 |
| Mother’s mass media exposure (No) | 0.594 | 0.05 |
| Place of residence (Rural) | 0.510 | 0.05 |
A spatial positive autocorrelation between teen age mothers (15–19 years) and unsafe disposal observed across 94 districts. These districts were primarily located in Jharkhand, Bihar, Odisha, Assam, and Tamil Nadu (Fig. 4a). Excluding Tamil Nadu, almost same districts shown positive autocorrelation between maternal illiteracy and unsafe child feces disposal practices (Fig. 4b). A total of 138 districts in the east-central region and parts of Tamil Nadu and Assam exhibited high-high clusters of Hindu population and unsafe child feces disposal practices (Fig. 4c). Moreover, positive autocorrelation between tribal population and unsafe child feces disposal practices traced across 61 districts, particularly located in Jharkhand, Odisha, Chhattisgarh, and the northeastern hilly region (Fig. 4d). A total of 144 districts were identified as dual burden of household poverty and high prevalence of unsafe child feces disposal practices. These districts were predominantly located in Bihar, Uttar Pradesh, Jharkhand, Odisha, and Chhattisgarh (Fig. 4e). A positive spatial autocorrelation between no water facility at premises and unsafe disposal of child feces was found in 75 districts, primarily in Odisha, Jharkhand, and Chhattisgarh (Fig. 4f). Across 135 districts, a positive autocorrelation between household unimproved sanitation facility and unsafe child feces disposal practices was observed, particularly concentrated in Uttar Pradesh, Bihar, Jharkhand, Odisha, and Chhattisgarh (Fig. 4g). Almost similar districts also exhibited a positive spatial relationship between unsafe sanitation practices and rural areas (Fig. 4i). All bivariate clusters were found to statistically significant (p ≤ 0.05) (Supplementary file 2).
Fig. 4.
Bivariate LISA map showing spatial autocorrelation between prevalence of unsafe child feces disposal practices and proportion of (a) teen age mothers (15–19 years), (b) maternal illiteracy rate (c) Hindu, (d) Scheduled tribe, (e) poorest wealth quintile, (f) water outside house premises, (g) unimproved sanitation facility, (h) maternal no exposure to mass media (i) rural resident, India 2019-21. Source: Authors
Results from spatial regression models
The Spatial Error Model (SEM) was identified as the optimal model (AIC = 5356.9; λ = 0.690; p ≤ 0.001; and adjusted R-squared = 0.73) for examining predictors of spatial heterogeneity in unsafe child feces disposal practices in India (Table 3). The SEM model identified three key drivers of spatial heterogeneity in unsafe child feces disposal practices—namely, household unimproved sanitation facility, absence of a water facility on the household premises, and household poverty (Table 3). In particular, a rise of 1 point in the proportion of households with unimproved sanitation facilities is estimated to result in a three-fold positive change in the prevalence of unsafe child feces disposal practices (Coef. = 0.34; p ≤ 0.001). A 1-point positive change in the proportion of households without a water facility on the premises is associated with a 1.7-point positive change in the prevalence of unsafe child feces disposal practices (Coef. = 0.17; p ≤ 0.001). Similar results were also observed with the poorest household wealth quintiles (Coef. = 0.17; p ≤ 0.001). Furthermore, maternal illiteracy, religion, and rural residence are also positively associated with the coefficient of spatial clustering in unsafe child feces disposal practices.
Table 3.
Estimation of spatial coefficient of unsafe child feces disposal practices using ordinary least square (OLS), spatial lag model (SLM), and spatial error model (SEM), India 2019-21
| Predictors (District level) | OLS (p-value) |
SE | SLM (p-value) |
SE | SEM (p-value) |
SE |
|---|---|---|---|---|---|---|
| Maternal Age (15–19 years) (%) | 0.34 (0.009) | 0.13 | 0.07 (0.467) | 0.10 | 0.16 (0.236) | 0.14 |
| Maternal Illiteracy rate (%) | 0.03 (0.005) | 0.05 | 0.04 (0.038) | 0.04 | 0.11 (0.048) | 0.05 |
| Hindu (%) | 0.08 (≤ 0.001) | 0.02 | 0.02 (0.123) | 0.02 | 0.12 (≤ 0.001) | 0.03 |
| Scheduled Tribe (%) | 0.01 (0.650) | 0.02 | −0.01 (0.403) | 0.02 | −0.02 (0.277) | 0.03 |
| Poorest (%) | 0.34 (≤ 0.001) | 0.05 | 0.17 (≤ 0.001) | 0.04 | 0.17 (≤ 0.001) | 0.05 |
| No water facility on premises (%) | 0.13 (0.028) | 0.06 | 0.14(0.002) | 0.05 | 0.17 (≤ 0.001) | 0.05 |
| Unsafe Sanitation (%) | 0.47 (≤ 0.001) | 0.04 | 0.30 (≤ 0.001) | 0.04 | 0.34 (≤ 0.001) | 0.05 |
| No Mass media (%) | −0.14 (0.024) | 0.06 | −0.10 (0.040) | 0.05 | −0.01 (0.986) | 0.06 |
| Rural (%) | 0.08 (0.002) | 0.03 | 0.07 (≤ 0.001) | 0.02 | 0.08 (≤ 0.001) | 0.02 |
| N (Districts) | 707 | 707 | 707 | |||
| p (Rho) | 0.54 | |||||
| Lamda (i) | 0.69 (0.001) | |||||
| Akaike Info Criterion (AIC) | 5657.77 | 5410.3 | 5356.95 | |||
| R2 value | 0.56 | 0.71 | 0.73 |
OLS Ordinary Least Square, SLM Spatial Lag Model SEM Spatial Error Model, SE Standard Error
Spatial inequality in unsafe child feces disposal practice
The disparity in unsafe child feces disposal practices between high-high (hotspot) and low-low (cold spot) clusters was 22%, accounting for 50% of the total inequality. The probability of unsafe disposal practices in high-high clusters (hotspots) was significantly higher (0.70) compared to low-low clusters (0.48) (Table 4). Household wealth quintile emerged as the most critical factor, explaining 65% of the difference in unsafe disposal practices between high-high and low-low clusters, followed by unsafe sanitation facilities (17%), religion (7%), maternal exposure to mass media (4%), and educational background (3%) (Table 5).
Table 4.
Descriptive statistics of Fairlie decomposition model estimating spatial inequality in unsafe child feces disposal practices, India 2019–2021
| Total number of observations | 33,945 |
|---|---|
| Total number of observation (High-High cluster) | 26,287 |
| Total number of observation (Low-Low cluster) | 7,658 |
| Mean prediction of unsafe child feces disposal practices (High-High cluster) | 0.70 |
| Mean prediction of unsafe child feces disposal practices (Low-Low cluster) | 0.48 |
| Mean difference (Hotspot-Cold spot) | 0.22 |
| Total explained | 0.11 |
| Explained (%) | 50.03 |
| Unexplained (%) | 49.97 |
Table 5.
Estimation of coefficient of spatial inequality in unsafe child feces disposal practices, India 2019–2021
| Coefficient | Contribution (%) | SE | p value | 95% CI (LL) | 95% CI (UL) | |
|---|---|---|---|---|---|---|
| Maternal Age | 0.001 | 0.80 | 0.0002 | ≤ 0.001 | 0.000 | 0.001 |
| Maternal education | 0.004 | 3.25 | 0.0008 | ≤ 0.001 | 0.002 | 0.005 |
| Religion | 0.008 | 7.43 | 0.0008 | ≤ 0.001 | 0.007 | 0.010 |
| Social group | 0.001 | 0.58 | 0.001 | 0.506 | −0.001 | 0.002 |
| Household wealth quintile | 0.072 | 65.31 | 0.0026 | ≤ 0.001 | 0.067 | 0.077 |
| Mother’s mass media exposure | 0.005 | 4.46 | 0.001 | ≤ 0.001 | 0.003 | 0.007 |
| Household water facility on premises | 0.001 | 1.06 | 0.0004 | 0.004 | 0.000 | 0.002 |
| Household Sanitation facility | 0.019 | 17.1 | 0.0008 | ≤ 0.001 | 0.017 | 0.020 |
UL Upper Limit, LL Lower Limit, CI Confidence Interval, SE Standard Error
Discussion
District-level inequalities in socio-economic, cultural, and public health indicators are prevalent in India [13]. Due to these disparities, many districts within non-EAG states perform worse in public health outcomes compared to their respective state and national averages. Conversely, some districts within EAG states perform better in public health than their cumulative state averages and the national average [10–12]. However, such intra-state and inter-district variations in public health remained largely unexplored before NFHS-4 (2015–16) due to limited availability of user-friendly district level datasets. With the release of district-level data in NFHS-4, there has been a substantial advancement in understanding spatial heterogeneity at the district level [11]. Leveraging the NFHS data availability, the present study aims to map unsafe child feces disposal practices at both inter-district and intra-district levels in India, addressing a gap that has been overlooked in the existing literature. The study’s findings explored several critical spatial insights on unsafe child feces disposal practice in India, which are discussed in this section.
The primary finding of this study emphasizes that unsafe child feces disposal practices are widespread across India. Hotspots of these unsafe practices span nearly one-fourth of Indian districts, with a significant concentration in Odisha, Jharkhand, Bihar, Uttar Pradesh, and Chhattisgarh. These areas have also been identified in earlier studies as socio-economically disadvantaged zones characterized by high open defecation rates [12, 21–24]. The present study further links socio-economic poverty and the unmet need for improved sanitation and water facilities to the spatial clustering of unsafe child feces disposal practices in these regions. Therefore, to address the widespread prevalence of unsafe child feces disposal in these areas, a comprehensive, multi-sectoral strategy is essential. This strategy should include initiatives focused on economic empowerment, targeted female literacy programs, and the expansion of safe water and sanitation coverage. By integrating these measures into existing frameworks, such as the Swachh Bharat Mission, a sustainable and holistic improvement in child hygiene practices can be achieved, effectively breaking the cycle of unsafe disposal practices.
The second key finding of this study highlights that spatial disparities in unsafe child feces disposal practices are predominantly driven by household poverty. These results are consistent with both national and international literature [14–18], which asserts that impoverished households are not only economically disadvantaged but also face significant barriers in terms of educational attainment, sanitation, and access to water facilities. Collectively, these factors exacerbate the prevalence of unsafe disposal practices. Given these findings, it is imperative to prioritize interventions that promote household-level economic development, particularly through the strengthening of employment guarantee schemes. Additionally, targeted efforts to enhance access to sanitation and water facilities for socio-economically disadvantaged households are critical. A community focused approach, addressing both economic empowerment and infrastructural deficiencies, is essential for mitigating unsafe child feces disposal practices and fostering sustainable improvements in public health outcomes [21].
Thirdly, the absence of household water facilities found to be another significant factor driving the spatial clustering of unsafe child feces disposal practices in India. A recent government report (2025) states that over 79.9% of rural households now have access to tap water connections [25]. The Jal Jeevan Mission (JJM) has expanded access to tap water for more than 155 million households. While this has greatly improved water coverage, the remaining one-fifth of households without water facilities may still engage in unsafe disposal practices [11]. As water access continues to improve, the present study expects that the absence of water facilities will have a reduced impact on unsafe child feces disposal practices in the upcoming years. Finally, the present study found the significant role of maternal illiteracy in driving unsafe child feces disposal practices. Previous studies have shown that educated mothers are more likely to adopt safe sanitation practices, as they are better informed about hygiene and health risks [14, 22]. Contrary, illiterate mothers, particularly those from economically marginalized backgrounds, face multiple challenges. Limited access to education often means that they are unaware of the harmful effects of improper feces disposal [16, 26]. Additionally, these mothers are more likely to live in households with inadequate sanitation facilities, further compounding the problem. The lack of awareness, combined with the absence of proper sanitation infrastructure, leaves them with limted options for safely managing child feces [21]. The findings emphasize the need to address the interlinked issues of maternal illiteracy, poverty, and sanitation hygiene. Improving maternal education and expanding access to basic sanitation are critical strategies for reducing unsafe child feces disposal practice [27]. Targeted literacy programs and enhanced sanitation coverage should be prioritized to empower mothers and improve child health outcomes across disadvantaged communities.
While the prevalence of unsafe child feces disposal practices in India is threefold higher than adult open defecation rates, the policy focus on this hidden public health issue remains limited within both national and international academic discourse. The literature predominantly highlights the success and loopholes of national sanitation initiatives, including the Total Sanitation Campaign, Nirmal Bharat Abhiyan, and the Swachh Bharat Mission. However, there is a notable gap in evaluating whether these programmes have effectively translated into improvements in child feces disposal management. Although the present study identifies several spatial patterns associated with unsafe disposal practices, there remains a pressing need for further research. Specifically, future studies should undertake age-segregated analyses to better understand variations in unsafe disposal practices and their impacts on child health. Addressing this gap will provide critical insights for designing targeted interventions to improve sanitation outcomes among children.
Limitations and strengths the study
The study reveals several limitations that can impact the findings of the study. First, as a cross-sectional study, the study’s findings are confined to correlation rather than causal links, limiting the extent to which firm conclusions about causality can be drawn. Second, the computation of prevalence of unsafe child feces disposal practice reliance on self-reported data subjected to reporting biases. This dependence compromises the absolute accuracy of the findings as participants may provide answers influenced by what they believe is socially acceptable or struggle to recall past behaviors accurately [13]. Fourth, the study’s depiction of prevalence and predictors reflects only study period situation, failed to capture deep rooted practice. Finally, the inherent nature of quantitative analytical approach impedes the exploration of qualitative nuances such as cultural norms and habits that might influence disposal practices.
Despite several limitations in the study, it also boasts numerous strengths that deserve recognition.
First, this study represents a pioneering effort by contextualizing the spatial heterogeneity in unsafe child stool disposal practices in India. Second, the study maximizes the extensive reach of the NFHS data structure, extended analyses districts and cluster levels. Finally, applying sample weighting to counterbalance non-proportional sample allocation presents a nationally representative finding.
Conclusion
Significant spatial disparities in unsafe child feces disposal practices exist in India. Three major hotspot clusters were identified, primarily located in central India and adjacent states. Household poverty, limited sanitation and water facilities, and low maternal education emerged as significant drivers of these unsafe practices. Therefore, the present study underscores the importance of integrating behavioral change strategies with socioeconomic improvements to effectively mitigate unsafe disposal practices. Tailored interventions that address regional disparities while fostering community awareness and infrastructure development are essential. By prioritizing these targeted measures, policy initiatives can significantly enhance child hygiene and well-being in vulnerable regions.
Supplementary Information
Acknowledgements
None.
Authors’ contributions
MR: conceptualization, supervision, methodology, writing-review and editing. UV: Supervision, writing-review and editing. GK: investigation, formal analysis. SP: writing-review. KK: writing. ML: writing. Each author has participated adequately in work to take public responsibility for relevant portions of the content. The authors read and approved the final manuscript.
Funding
The present research did not receive any grant from any funding agency, commercial entity, or not-for-proft organization.
Data availability
This study used secondary data, which conducted by the DHS. The survey followed research ethical standards, including informed consent being obtained by all participants. The data is available in DHS website (https://dhsprogram.com/data/) based valid research proposal and user account.
Declarations
Ethics approval and consent to participate
The present study used secondary data, there for ethical approval not applicable.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Sclar GD, Bauza V, Bisoyi A, Clasen TF, Mosler HJ. Contextual and psychosocial factors influencing caregiver safe disposal of child feces and child latrine training in rural Odisha, India. PLoS One. 2022;17(9):e0274069. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Saha J, Mondal S, Chouhan P, Hussain M, Yang J, Bibi A. Occurrence of diarrheal disease among under-five children and associated sociodemographic and household environmental factors: an investigation based on national family health survey-4 in rural India. Children. 2022;9(5):658. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Talbert A, Thuo N, Karisa J, Chesaro C, Ohuma E, Ignas J, et al. Diarrhoea complicating severe acute malnutrition in Kenyan children: a prospective descriptive study of risk factors and outcome. PLoS One. 2012;7(6):e38321. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Roy E, Hasan KZ, Haque R, Haque AF, Siddique AK, Sack RB. Patterns and risk factors for helminthiasis in rural children aged under 2 in Bangladesh. S Afr J Child Health. 2011;5(3):78–84. [Google Scholar]
- 5.Chan EY, Tong KH, Dubois C, Mc Donnell K, Kim JH, Hung KK, Kwok KO. Narrative review of primary preventive interventions against water-borne diseases: scientific evidence of health-EDRM in contexts with inadequate safe drinking water. Int J Environ Res Public Health. 2021;18(23):12268. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Kim R, Rajpal S, Joe W, Corsi DJ, Sankar R, Kumar A, et al. Assessing associational strength of 23 correlates of child anthropometric failure: an econometric analysis of the 2015–2016 National Family Health Survey, India. Soc Sci Med. 2019;238:112374. [DOI] [PubMed] [Google Scholar]
- 7.Ajjampur SS, Koshy B, Venkataramani M, Sarkar R, Joseph AA, Jacob KS, Ward H, Kang G. Effect of cryptosporidial and giardial diarrhoea on social maturity, intelligence and physical growth in children in a semi-urban slum in South India. Ann Trop Paediatr. 2011;31(3):205–12. [DOI] [PubMed] [Google Scholar]
- 8.Ngure FM, Humphrey JH, Mbuya MN, Majo F, Mutasa K, Govha M, Mazarura E, Chasekwa B, Prendergast AJ, Curtis V, Boor KJ. Formative research on hygiene behaviors and geophagy among infants and young children and implications of exposure to fecal bacteria. Am J Trop Med Hyg. 2013;89(4):709. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Azage M, Haile D. Factors associated with safe child feces disposal practices in Ethiopia: evidence from demographic and health survey. Arch Public Health. 2015;73(1):1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Ghosh P, Hossain M, Sarkar S. Inequality among social groups in accessing improved drinking water and sanitation in India: a district-level spatial analysis. Prof Geogr. 2023;75(3):361–82. [Google Scholar]
- 11.Ghosh P, Hossain M, Alam A. Water, sanitation, and hygiene (WASH) poverty in India: a district-level geospatial assessment. Reg Sci Policy Pract. 2022;14(2):396–417. [Google Scholar]
- 12.Roy A, Rahaman M, Adhikary M, Kapasia N, Chouhan P, Das KC. Unveiling the spatial divide in open defecation practices across India: an application of spatial regression and Fairlie decomposition model. BMJ Open. 2023. 10.1136/bmjopen-2023-072507. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-5), 2019-21 IIPS, Mumbai, India. 2021. p.1-119. https://iipsindia.ac.in/content/national-family-health-survey-nfhs-5-india-report.
- 14.Roy A, Rahaman M, Chouhan P. Decomposing rural-urban gap in unsafe disposal practice of child stool in India using nationwide sample survey data. Sci Rep. 2024;14(1):6632. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Rahaman M, Roy A, Chouhan P, Rana MJ. Exploring drivers of unsafe disposal of child stool in India using hierarchical regression model. PLoS One. 2024;19(3):e0295788. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Demissie GD, Zerihun MF, Ekubagewargies DT, Yeshaw Y, Jemere T, Misganaw B, et al. Associated factors of safe child feces disposal in sub-Saharan Africa: evidence from recent demographic and health surveys of 34 sub-Saharan countries. PLoS One. 2023;18(2):e0281451. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Mugel SG, Clasen TF, Bauza V. Global practices, geographic variation, and determinants of child feces disposal in 42 low-and middle-income countries: an analysis of standardized cross-sectional national surveys from 2016–2020. Int J Hyg Environ Health. 2022;245:114024. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Nasim N, El-Zein A, Thomas J. A review of rural and peri-urban sanitation infrastructure in South-East Asia and the Western Pacific: highlighting regional inequalities and limited data. Int J Hyg Environ Health. 2022;244:113992. [DOI] [PubMed] [Google Scholar]
- 19.Seidu AA, Ahinkorah BO, Kissah-Korsah K, Agbaglo E, Dadzie LK, Ameyaw EK, et al. A multilevel analysis of individual and contextual factors associated with the practice of safe disposal of children’s faeces in sub-Saharan Africa. PLoS One. 2021;16(8):e0254774. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Anselin L, Li X, Koschinsky J. GeoDa, from the desktop to an ecosystem for exploring spatial data. Geogr Anal. 2022;54(3):439–66. [Google Scholar]
- 21.Caruso BA, Sclar GD, Routray P, Nagel CL, Majorin F, Sola S, et al. Effect of a low-cost, behaviour-change intervention on latrine use and safe disposal of child faeces in rural Odisha, India: a cluster-randomised controlled trial. Lancet Planet Health. 2022;6(2):e110-21. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Preeti PS, Sahoo SK, Biswas D, Dasgupta A. Unsafe disposal of child faeces: a community-based study in a rural block in West Bengal, India. J Prev Med Public Health. 2016;49(5):323. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Bawankule R, Singh A, Kumar K, Pedgaonkar S. Disposal of children’s stools and its association with childhood diarrhea in India. BMC Public Health. 2017;17:1–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Dwivedi LK, Banerjee K, Jain N, Ranjan M, Dixit P. Child health and unhealthy sanitary practices in India: evidence from recent round of National family health Survey-IV. SSM Popul Health. 2019;7:100313. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Department of Drinking Water & Sanitation Ministry of Jalshakti. Jal Jeevan Mission. 2025. https://jaljeevanmission.gov.in/.
- 26.Ghosh P, Hossain M, Alam J, Alam A. Neighbourhood level geospatial heterogeneity of WASH performance in Indian two metropolitan cities: Kolkata and Chennai. In: Urban environment and smart cities in asian countries: Insights for social, ecological, and technological sustainability. Cham: Springer International Publishing; 2023. p. 499–524. [Google Scholar]
- 27.Sahiledengle B, Teferu Z, Tekalegn Y, Awoke T, Zenbaba D, Bekele K, et al. Geographical variation and factors associated with unsafe child stool disposal in Ethiopia: a spatial and multilevel analysis. PLoS One. 2021;16(4):e0250814. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
This study used secondary data, which conducted by the DHS. The survey followed research ethical standards, including informed consent being obtained by all participants. The data is available in DHS website (https://dhsprogram.com/data/) based valid research proposal and user account.