Study design and Protocol
The present study protocol is being reported following the reporting guidance provided in the PreferredReporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) statement [11] (Additional file 1)and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline will be followed during the systematic review [12].The four phases that were drawn from the PRISMA flow chart (Figure 1) will be documented in the results to show the study selection processfrom initially identified records to finally included studies[13].The present protocol has been registered within the PROSPERO database (registration ID: CRD42020189034). Any amendments made to this protocol will be outlined and reported in the final manuscript.
Criteria used for selecting studies
Inclusion criteria for selected studies will be articles conducted in low-income and middle-income countries and written in English, articles thatinvolve under-five years of age children regardless of sex, ethnicity, and socio-economic status and observational studies (cross-sectional studies, case-control studies, and cohort studies) that examined the association between unsafe disposals of child feces and reported diarrhea.However, we will excludethe study’s findings of reviews, editorials, case series and case reports,and inconsistent outcome measures.Additionally, we will exclude studies published in languages other than English, before the year 2000.
Outcome of interest
The primary outcome of this review will be pooledmagnitude of unsafe disposal of child feces and the secondary outcome of this study will be the estimate of the association of child feces disposal practices and reported diarrhea.Child feces disposal was defined based on the WHO/ UNICEF JMP for water supply & Sanitation definition [14] as safe disposal if households responded by saying collected and disposed of in a latrine or buried it, and as unsafe disposal,if they said put into a drain or ditch, thrown into the garbage or left in the open. Whereas diarrhea defined as three or more loose or watery stools during 24 hours or any loose stool that contained blood or mucus.
Information sources and search strategy
Electronic databasessuch as PubMed, Science Direct, Cochrane Library databases,and Ovid Medline will be searched to identify relevant literature for this review. Additionally, we will hand search Google search engine, Google Scholar, and references of other studies. The literature search will be carried out by the first author in October 2020. The search strategy will be limited to studies published in English language literature. We will apply Medical Subject Headings terms from PubMed, and combined keywords to identify studies in the databases.We will use keywords terms and combinations with MESH terms as described below. A full search strategy for PubMed is detailed in Table 1.
Table 1. Search strategy for the PubMed database
S /No
|
Search set PubMed databases
|
1.
|
"Feces"[Mesh] OR "feces"[tw] OR "faeces"[tw] OR"faecal"[tw] OR "fecal"[tw] OR "excreta"[tw] OR "stool"[tw] OR "stools"[tw]]
|
2.
|
dispos*[tw] OR "excrement"[tw] OR "defecation"[tw] OR manag*[tw] OR remov*[tw] OR "Waste Management"[Mesh]
|
3.
|
"babies"[tw] OR "baby"[tw] OR "boy"[tw] OR "boys"[tw] OR "Child, Preschool"[Mesh] OR "Child"[Mesh] OR child*[tw] OR "girl"[tw] OR "girls"[tw] OR infan*[tw] OR "Infant, Newborn"[Mesh] OR "Infant"[Mesh] OR "kid"[tw] OR "kids"[tw] OR "less than 5"[tw] OR "less than five"[tw] OR neonat*[tw] OR new-born*[tw] OR newborn*[tw] OR "pediatric"[tw] OR pre school*[tw] OR preschool*[tw] OR toddler*[tw] OR "under 5"[tw] OR "under five"[tw] OR "under fives"[tw]
|
4.
|
“diarrhea”[MeSH] OR “diarrhea”[tw] OR “diarrheas”[tw] OR “diarrhea”[tw] OR “diarrhoea”[tw]
|
5.
|
(Africa* [tw] OR Asia*[tw] OR Caribbean* [tw] OR West Indi*[tw] OR South America*[tw] OR Latin America*[tw] OR Central America*[tw]) AND("poverty"[MeSH] OR “low income population”[tw]“Developing” [tw] OR less* developed[tw] OR“under developed”[tw] OR“underdeveloped”[tw] OR“middle income”[tw] OR low*income[tw] OR “underserved”[tw] OR“under served”[tw] OR“deprived”[tw] OR poor*[tw])AND (countr* [tw] OR nation[tw] OR population[tw] OR world[tw])
|
6.
|
1 AND 2 AND 3 AND 4 AND 5
|
Mesh=Medical subject headings, tw=text word
Study selection process
The searched results will be export to Mendeley Desktop reference management software version 1.19.5(Mendeley Ltd., Elsevier, Netherlands) and then duplicate excluded. The screening of studies will be conducted bytwo independent review authors. The articles found by searches in databases will be evaluated for inclusion at three levels, i.e., by title, then by abstract, and finally by full-text. The full-text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Discrepancies will be discussed between reviewers and refine inclusion criteria. For the screening of articles at the full-text level, rejection of an article will be decided by the review team upon the suggestion of the first reader. The details regarding the final decision of the inclusion of articles will be clarified and archived in a database. In case of uncertainty in the decision to include or exclude an article, the reviewer will include this article for the next level of screening. The documents without abstracts will be screened at the full-text level. A list of articles excluded at the full-text level will be provided in the systematic review, accompanied by reasons for exclusion.
Data extraction
The adapted JBI data extraction formwill be used to extract the characteristics of the studies and status of child feces disposal practices and the odds ratios that showed the association of unsafe disposal of child feces and reported diarrhea. A standardized excel sheet will be created and information from the standardized review forms will be transferred to be readily available for the systematic review. For each study, authors’ nameand year of publication, country of origin and set of included studies, type of study included, sample size, description of child feces disposal practices, and results of included studies will be extracted by two reviewers. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Evaluation of study quality
The methodological quality of all studies that meet the selection criteria will be evaluated independently by two authors using the Joanna Briggs Institute (JBI) Critical Appraisal tools[15]. Each study will be assessed individually and independently by the two reviewers, both at the outcome and study level to generate an overall risk of bias score. The reviewers will assign each study as critical, serious, moderate, or low risk of bias via the judgment of the gathered information. If there is limited information, then the risk of bias will be categorized as “no information” or we will contact the corresponding authors for complete information and clarity of primary studies.The rating for each bias criterion of the two authors will then compare. Disagreements between the two authors on individual bias criteria will be identified and discussed in an attempt to reach a consensus.
Data synthesis and statistical analysis
The individual studies will be concisely described using a summary table. The summary table particularly describes the characteristics of the included studies and the main findings.Based on the summary table, we will conduct a narrative synthesis first to describe the characteristics of the included studies and the main findings. Then, meta-analysis will be conducted using a random effector fixed effect when at least three studies are comparable in design and protocol using Stata version 16 (College Station, TX 77845, USA). The overall magnitude of child feces disposal practices and its 95% CI will be calculated from standard error (SE) and magnitude of child feces disposal practices of each included study. For studies that did not present a SE, it will be calculated using the formula; SE = √ (p× (1−p)/n). The calculated SE and magnitude of each study will then be entered into Stata software to calculate the overall prevalence and its 95% CI.Similarly, the association between child feces disposal practices and reported diarrhea will be summarized using statistical estimates of effect size, odds ratio (OR),and 95% CI of the study factors.We will perform subgroup analyses according to the possible characteristics of the studies andthe quality of the study included.
Heterogeneity will be assessed statistically using a chi-square test (Q-test) for statistics and inverse variance index (I2) [16]. I2 values will be classified as follows: no relevant heterogeneity (0–25%), moderate heterogeneity (25– 50%), and significant heterogeneity.The data will be considered homogeneous if I2 ≤50%. Fixed effects models will be used to produce summary ORs and 95% CIs where heterogeneity did not exist. If statistical heterogeneity did exist, then random-effects models will be applied.Forest plots will be generated to present the pooled estimates with 95% CI. A funnel plot and Egger’s test of publication bias will be used to assess publication bias. Symmetrical funnel plot as well as insignificant Egger’s test will be taken as evidence for no serious publication bias. Trim and fill techniques will be considered for substantial publication bias. A sensitivity analysis will be repeated after excluding one study to observe the impact of the individual study on the pooled estimate.
Assessment of the quality of the evidence
The quality of evidence of the outcomes will be assessed with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach using GRADEPro GDT version 3.6.1 /2019 (McMaster University, ON, Canada) [17, 18]. According to GRADE, evidence quality assessment is performed for each outcome, and the combined available evidence is considered. The GRADE approach will classify the quality of the evidence into four levels: high, moderate, low, and very low based on the comprehensive assessment of inconsistency, indirect evidence (not generalizable), inaccuracy, and publication bias. These levels represent confidence in the estimation of the treatment effects presented. The level of evidence and strength of recommendation will be determined by discussion involving all authors.