Title: Open Defecation-Free slippage and its associated factors in Ethiopia: A systematic review

Abstract

Background: Recent studies have shown an increase in open defecation and slippage of open defecation-free certified villages in Ethiopia, despite significant progress in the country on sanitation programs. Hence, realizing existing facts, this study was conducted aiming at a critical review of the available literature and to provide consolidated data showing the level of slippage and its associated factors in Ethiopia. Methods: Systematic literature searches were performed from four international databases. The search involved articles published from December 2013 up to June 2019. Cochran’s Q and I2 test statistics were used to check heterogeneity among the studies. To negotiate heterogeneity from qualitative data, we used a mixed-method approach. The researchers also conducted publication bias assessment and sensitivity analysis. A random effect Metaanalysis was employed to determine the pooled estimates with a 95% confidence interval (CI). Data analysis was performed using the CMA V.3 software program. Results: After screening 1382 studies, 12 studies were finally included in this systematic review and meta-analysis. The estimated pooled rate of open defecation-free slippage in Ethiopia was 15.9% (95% CI 12.9% - 19.4%). The main contributing factors for open defecation-free slippage were lack of technical support, financial constraints, low-quality building materials, improper program implementation, and lack of sanitation marketing. Conclusion: It was estimated that one out of six Ethiopian households engaged in open defecation after they declared open defecation-free status, implying the low possibility of achieving the target sanitation for all in 2030. Therefore, the government of Ethiopia and its partners should better give special attention to the following options: 1) awareness for open defecation-free slippage, 2) integrate post-open defecation-free follow up in Community-Led Total Sanitation program, and 3) encourage studies on pro-poor improved sanitation technologies.