Knowledge, Attitudes, and Practices on Fecal-Oral Disease Prevention and Social Acceptability of Compost Latrines in Nyamugo Health Area, Bukavu, Democratic Republic of the Congo: Mixed Methods Formative Study.

BACKGROUND: Fecal-oral diseases remain a major public health challenge in sub-Saharan Africa, where sanitation infrastructure is limited and cultural barriers hinder improved practices. Compost latrines are promoted as ecological solutions, but their acceptability is uncertain.

OBJECTIVE: This study assessed household knowledge, attitudes, and practices regarding fecal-oral disease prevention in Nyamugo, Democratic Republic of the Congo, and explored perceptions of compost latrine acceptability. The aim was to identify enabling factors and barriers, including cultural and economic determinants, to inform integrated interventions.

METHODS: A mixed methods cross-sectional design was used. Quantitative data were collected from 432 households through structured questionnaires, and qualitative insights were obtained via focus groups and key informant interviews. Chi-square and logistic regression analyses examined associations between knowledge, attitudes, and practices indicators and sociodemographic variables. Both significant and nonsignificant results were reported for transparency.

RESULTS: Households demonstrated partial knowledge of fecal-oral diseases. Cholera was widely recognized (367/412, 88.9%), while hookworm and poliomyelitis were rarely mentioned. Preventive methods such as sanitation (285/412, 69.2%) and hand hygiene (224/412, 54.4%) were the most frequently cited, with education significantly increasing the odds of sanitation knowledge (odds ratio [OR] 2.1, 95% CI 1.4-3.2). Attitudes revealed strong recognition of fecal hazard prevention (397/422, 94.2%), yet compost latrine acceptability remained low (178/422, 42.2%). Regression confirmed that higher education increased favorable attitudes (OR 1.9, 95% CI 1.2-3.0). Qualitative findings highlighted persistent cultural taboos, with latrines described as "impure" or "shameful." Practices were inconsistent. Although 88% (380/432) of the households owned latrines, only 30.3% (115/380) maintained them hygienically, and open defecation persisted in 31.7% (137/432). Larger household size predicted open defecation (OR 1.8, 95% CI 1.2-2.7), while education was associated with improved hygiene (OR 2.3, 95% CI 1.4-3.6). Compost latrines were not used. Diarrheal episodes in children younger than 5 years were reported in 38.7% (167/432) of the households, with unimproved water sources significantly increasing risk (OR 2.4, 95% CI 1.5-3.8). Qualitative testimonies reinforced these findings, emphasizing poverty, lack of infrastructure, and cultural resistance as barriers.

CONCLUSIONS: This study confirms a persistent gap between knowledge and practice in fecal-oral disease prevention. Cultural taboos and economic constraints limit compost latrine adoption, even among educated households. Nevertheless, participants expressed openness to adoption if external support-through subsidies, training, and sensitization-was provided. Public health interventions should integrate financial support, cultural dialogue, and infrastructure strengthening to sustainably reduce diarrheal disease burden. Future research should assess the long-term impacts of compost latrine adoption, explore cost-effectiveness, and evaluate behavior change strategies.