A study of the association between improved sanitation facilities and children's height in Lesotho

The impact of improved sanitation on the anthropometric status of children under 5 years in Lesotho was investigated using children recruited into a case-control study of diarrhoea morbidity. The children's height-for-age Z-scores were used as an indicator of chronic undernutrition. Classifying children as 'stunted' or 'adequately nourished' revealed some evidence of an association between latrine ownership and attained height. After allowing for confounding variables, the odds of stunting were 18 per cent lower among children in households with latrines (95 per cent confidence interval, 36 per cent lower to 3 per cent higher). More powerful analyses, using height-for-age as a continuous outcome variable, revealed that the mean height-for-age Z-score of children from households with a latrine was 0.27 standard deviations higher than that of children from households without a latrine (95 per cent c.i. = 0.12 to 0.42). These results suggest that the anthropometric status of children may be as responsive to improvements in sanitation facilities as diarrhoea morbidity in some settings.     

A case-control study of the impact of improved sanitation on diarrhoea morbidity in Lesotho

A health impact evaluation of the Rural Sanitation Pilot Project in Mohale's Hoek district, Lesotho, was conducted from October 1987 to September 1988. A clinic-based case-control design was used to investigate the impact of improved sanitation on diarrhoea morbidity in young children. The results indicate that under-5-year-olds from households with a latrine may experience 24% fewer episodes of diarrhoea than such children from households without a latrine (odds ratio = 0.76; 95% confidence interval, 0.58-1.01). The impact of latrines on diarrhoea was greater in those households that used more water, practised better personal hygiene, and where the mothers had a higher level of education or worked outside the home. In common with studies conducted in Malawi, Philippines, and Sri Lanka, little evidence was found that the relationship between latrine ownership and diarrhoea was confounded by socioeconomic status or environmental variables. For a sample of cases and controls, data on exposure status (presence or absence of a latrine) that were collected by interview at the clinics agreed closely with those obtained by observation during a home visit.     

Household latrine use, maintenance and acceptability in rural Zinder, Niger

We conducted a survey in rural Niger to assess use, maintenance and acceptability of household latrines one year after a subsidized promotion project. Standard interviews were conducted with 200 randomly selected project participants and a visual latrine inspection. Before the project, 21.5% (43/200) of households had latrines. After the first year, 100% of these households had at least one latrine. Overall, 2577 household latrines were built in the 50 targeted villages. Latrines were 'always' used by 92.5% of adults and 55% of children in the households. The latrines were adequately maintained: superstructure 93%, covers 74.5%, clean 70%. The main perceived advantages of latrine ownership were proximity/easy access (59.5%) and privacy (22.5%). The project demonstrated that the implementation of a household latrine promotion project is acceptable and feasible in rural Niger. Future promotion projects may develop local sanitation expertise and focus on perceived benefits--proximity and privacy--rather than health.     

Diarrhoea prevention in a high-risk rural Kenyan population through point-of-use chlorination, safe water storage, sanitation, and rainwater harvesting

Lack of access to safe water and sanitation contributes to diarrhoea moribidity and mortality in developing countries. We evaluated the impact of household water treatment, latrines, shallow wells, and rainwater harvesting on diarrhoea incidence in rural Kenyan children. We compared diarrhoea rates in 960 children aged <5 years in 556 households in 12 randomly selected intervention villages and six randomly selected comparison villages during weekly home visits over an 8-week period. On multivariate analysis, chlorinating stored water [relative risk (RR) 0.44, 95% confidence interval (CI) 0.28-0.69], latrine presence (RR 0.71, 95% CI 0.54-0.92), rainwater use (RR 0.70, 95% CI 0.52-0.95), and living in an intervention village (RR 0.31, 95% CI 0.23-0.41), were independently associated with lower diarrhoea risk. Diarrhoea risk was higher among shallow well users (RR 1.78, 95% CI 1.12-2.83). Chlorinating stored water, latrines, and rainwater use all decreased diarrhoea risk; combined interventions may have increased health impact.     

Effectiveness of a community-based water,sanitation, and hygiene (WASH) intervention in reduction of diarrhoea among under-five children: Evidence from a repeated cross-sectional study (2007–2015) in rural Bangladesh

Diarrhoea, the most common disease directly related to water, sanitation, and hygiene (WASH), still remains one of the most significant health problems among children under-five worldwide. In this reality, BRAC, the largest NGO in the world initiated a comprehensive WASH intervention in 50 upazilas (sub-districts) of Bangladesh in 2007 which was later scaled up to cover 150 upazilas in two subsequent phases. The intervention period of the programme was 2007–2011.The present study encompassed 30 upazilas of the first phase of intervention. The aim of the study was to investigate the effectiveness of this intervention on reduction of diarrhoea among under-five children, and to identify the factors associated with childhood diarrhoea. A repeated cross-sectional study design was followed, and a population-based survey was carried out on four occasions: baseline (2007), midline (2009), endline (2011), and post-endline (2015) among 4,775 households. This analysis considers only households having at least one under-five children.Absence of handwashing practice with soap after defecation and before eating food, unclean latrine condition, and unsafe disposal of child faeces were identified as significant risk factors associated with under-five diarrhoea from Log-binomial regression. The prevalence of under-five diarrhoea within the past 2 weeks of the survey declined from 13.7% at baseline to 3.6% at end-line (p < 0.001) in the WASH intervention area. However, the progress seemingly stalled after 2011, which may have occurred due to the lack of improvement in unsafe disposal of child faeces and unclean latrine condition after the intervention period.Study findings suggest that, to reduce the prevalence of childhood diarrhoea it is important to promote safe disposal of child faeces, maintaining cleanliness of latrines, and washing hand with soap at critical times, beyond merely increasing the sanitation coverage. Findings also underline the necessity of maintaining a small-scale monitoring component involving local community, such as a WatSan committee (a local committee comprising the user communities for supervising WASH related activities) for periodic monitoring at household level for a certain period after the program intervention works to make the behavioural change more sustainable and to keep the reduction rate of under-five diarrhoeal prevalence steady.     

Excreta disposal behaviour and latrine ownership in relation to the risk of childhood diarrhoea in Sri Lanka.

A case-control study of environmental and behavioural risk factors for childhood diarrhoea was conducted in Kurunegala district, Sri Lanka. From five hospitals, 2458 children aged less than 5 years and suffering from diarrhoea were recruited as clinic cases, and a further 4140 reporting with complaints other than diarrhoea were recruited as clinic controls. Community-based cross-sectional surveys were also conducted in three of the five areas served by these hospitals, and from these a further 1659 children were recruited as community controls. Children from households where excreta were reported to be disposed of in a latrine were less likely to have diarrhoea than children whose families improperly disposed of excreta. The results obtained from comparisons of cases with clinic controls (adjusted odds ratio [OR] 1.42, 95% confidence interval [CI] : 1.01-1.98), and of cases with community controls (OR 1.35, 95% CI : 0.85-2.13) were in agreement, suggesting that no important selection bias operated on this association. If the observed proportion (91%) of improper excreta disposal among the population could be reduced to 50%, 12% of childhood diarrhoea episodes would be prevented. Although latrine ownership may be a necessary condition for safe excreta disposal behaviour, diarrhoeal morbidity may only be reduced in Sri Lanka if behavioural changes take place concomitant with the construction of sanitation facilities.     

Assessment of latrine use and quality and association with risk of trachoma in rural Tanzania

The existing evidence regarding latrines and trachoma is inconclusive. Using more precise sanitation measures we examine the association between use and quality of latrines and risk of trachoma. We conducted a case-control study of 678 households (95 cases, 583 controls) in eight villages in Kongwa District, Tanzania. Case households were defined as having a sentinel child with clinical signs of trachoma. A latrine quality score was calculated based on seven indicators and case and control households were compared with respect to use and quality of latrines. Logistic regression analyses controlled for potential confounders. Latrine use was significantly greater in control households than in case households (90.4 vs. 76.8%, P=0.03). The protective effect of latrine use persisted even after controlling for household characteristics significant at P <0.20 (adjusted OR=0.56 [95% CI: 0.32-0.98]). Contrary to expectation, we did not find an inverse association between increasing latrine quality and decreasing odds of trachoma. Although latrine use in the communities was high, latrines, regardless of quality, were significantly associated with decreased risk of trachoma. These findings underscore the importance of achieving 100% latrine use in communities.     

Reduction in diarrhoeal diseases in children in rural Bangladesh by environmental and behavioural modifications

The impact of a water, sanitation and hygiene education intervention project on diarrhoeal morbidity in children under 5 years old was evaluated in a rural area of Bangladesh. Data were collected throughout 1984-1987, covering both pre- and post-intervention periods, from an intervention and a control area. The 2 areas were similar with respect to most socio-economic characteristics and baseline levels of diarrhoeal morbidity. The project showed a striking impact on the incidence of all cases of diarrhoea, including dysentery and persistent diarrhoea. By the end of the study period, children in the intervention area were experiencing 25% fewer episodes of diarrhoea than those in the control area. This impact was evident throughout the year, but particularly in the monsoon season, and in all age groups except those less than 6 months old. Within the intervention area, children from households living closer to handpumps or where better sanitation habits were practised experienced lower rates of diarrhoea. These results suggest that an integrated approach to environmental interventions can have a significant impact on diarrhoeal morbidity.     

Impact of drainage and sewerage on diarrhoea in poor urban areas in Salvador, Brazil

A longitudinal prospective study of the effect of drainage and sewerage systems on diarrhoea in children aged < 5 years was conducted in 9 poor urban areas of the city of Salvador (population 2.44 million) in north-east Brazil in 1989-90. Due to complex political and administrative reasons, 3 areas had benefited from drainage improvements, 3 from both drainage and sewerage improvements, and 3 from neither. An extensive questionnaire was applied to collect information on each child and on the conditions of the household, and mothers recorded diarrhoea episodes in their children aged < 5 years daily for 1 year, using calendars. Fortnightly home visits were made to collect the data. The incidence of diarrhoea in children in neighbourhoods with drainage was less than two-thirds, and in neighbourhoods with drainage and sewerage less than one-third, of the incidence in neighbourhoods with neither. After controlling for potential confounders, the proportion of children with 'frequent diarrhoea' showed the same significant trend across the study groups. Though the groups were not exactly comparable, more than one child was monitored per household, and it was not possible to rotate fieldworkers between study groups, the study provides evidence that community sanitation can have an impact on diarrhoeal disease, even without measures to promote hygiene behaviour.     

Effect of deep tube well use on childhood diarrhoea in Bangladesh

Objective

To determine whether the installation of deep tube wells to reduce exposure to groundwater arsenic in rural Bangladesh had an effect on the incidence of childhood diarrhoeal disease.

Methods

Episodes of diarrhoeal disease in children aged under 5 years that occurred on one specified day each month between 2005 and 2006 were reported to community health workers for six rural villages. A geographical information system containing details of household water use and sanitation in the villages was built using data obtained by a global positioning system survey. The information system also included health, spatial and demographic data. A field survey was carried out to determine whether households obtained drinking water from deep tube wells installed in 2005. The effect of deep tube well use on the incidence of childhood diarrhoea was assessed using a random effects negative binomial regression model.

Findings

The risk of childhood diarrhoea was 46% lower in the 179 households that used a deep tube well than in the 364 that used a shallow tube well (P = 0.032). Neither socioeconomic status, latrine density, population density nor study year had a significant influence on disease risk. The incidence of childhood diarrhoea declined dramatically between 2005 and 2006, irrespective of water source.

Conclusion

The introduction of deep tube wells to reduce arsenic in drinking water in rural Bangladesh had the additional benefit of lowering the incidence of diarrhoea among young children.     

Equity implications for sanitation from recent health and nutrition evidence

Recent evidence points to the possible underestimation of the health and nutrition impact of sanitation. Community sanitation coverage may first need to reach thresholds in the order of 60% or higher, to optimize health and nutrition gains. Increasing coverage of sanitation to levels below 60% of community coverage may not result in substantial gains. For example, moving Indonesia from 60% to 100% improved sanitation coverage could significantly reduce diarrhoea in children under 5 years old (by an estimated 24% reduction in odds ratio for child diarrhoea morbidity) with gains split equally by reaching underserved communities and the unserved within communities. We review the implications of these results across three levels of program implementation – from micro level approaches (that support communities to achieve open defecation-free status), to meso level (sub-national implementation) to macro level approaches for the national enabling environment and the global push to the Sustainable Development Goals. We found significant equity implications and recommend that future studies focus more extensively on community coverage levels and verified community open defecation free status rather than household access alone. Sanitation practitioners may consider developing phased approaches to improving water, sanitation and hygiene in communities while prioritizing the unserved or underserved.     

Health impact of water and sanitation infrastructure reconstruction programmes in eight Central American communities affected by Hurricane Mitch

In response to Hurricane Mitch, which struck Central America in October-November 1998, the American Red Cross (ARC) and the Centers for Disease Control and Prevention (CDC) collaborated on a 3-year evaluation of the public health impact of ARC's water, sanitation and hygiene education activities in eight study areas in Honduras, Nicaragua, El Salvador and Guatemala. The evaluation compared: 1) access to and use of water and sanitation facilities, 2) the use of hygienic behaviours, and 3) diarrhoeal prevalence in children younger than 3 years of age before (February 2000) and after (February 2002) the interventions had been implemented. The evaluation included household and key informant interviews designed to measure these three components. Water quality of community water sources and household water was evaluated by measuring levels of indicator bacteria. During the final survey, an infrastructure evaluation provided a review of the design, construction, and current operation and maintenance of the water systems and latrines. The integrated water and sanitation infrastructure interventions and hygiene education programmes implemented following Hurricane Mitch effectively decreased diarrhoea prevalence in the target communities.     

Myanmar experiences in sanitation and hygiene promotion: lessons learned and future directions

Recent activities in connection with the National Sanitation Week (NSW) and Social Mobilisation for Sanitation and Hygiene have contributed to a significant increase in access to sanitary means of excreta disposal, from 45% in 1997 to 67% in 2001. Handwashing with soap and water after defecation has also increased from 18% in 1996 to 43% in 2001. Success is attributable to high level political commitment, state or division level action and community mobilisation by village level authorities. Multi-level efforts such as mass media, planning workshops, training sessions and house-to-house visits by village authorities and health officials have raised greater awareness of sanitation and hygiene issues and led to construction of latrines on a self-help basis. The challenge ahead is to give greater attention to the 'hard to reach' who live in less accessible areas and are more resistant to change. The 2002 NSW has accordingly given special emphasis to activities in 73 of 324 townships where 50% or more of the households have no access to a sanitary latrine. The communication and social mobilisation package has been improved to upgrading unsanitary latrines and integrating handwashing more systematically with promotion of sanitary latrines. Programmatic follow-up to the NSW is being provided in selected townships through more intensive social mobilisation for 'hard to reach' households and activity-based school sanitation and hygiene education. This approach will contribute further towards improved hygienic practices and reduce diarrhoeal morbidity and mortality.     

Household Management of Childhood Diarrhoea: A Population-based Study in Nicaragua

Diarrhoea remains an important cause of mortality and morbidity among children in Nicaragua. As the majority of diarrhoeal cases are treated at home and appropriate household management can lessen severity of diarrhoea, the objective of this study was to examine household management of childhood diarrhoea. A simple random sample of households was selected from the Health and Demographic Surveillance Site-León. Parents or caretakers of children below five years of age, who developed diarrhoea (n=232), were surveyed about household diarrhoea management practices in 2011. Fifty-seven percent of children received oral rehydration therapy (ORT) in the home prior to visiting any health facility. We encountered certain practices in contradiction with WHO recommendations for the management of diarrhoea in communities: 41% of children were offered protein-rich foods less frequently during diarrhoeal episodes, 20% of children were nursed less frequently or not at all during diarrhoeal episodes, and zinc supplementation was recommended at only 39% of visits with healthcare providers. Our findings provide insights for efforts to improve the household management of childhood diarrhoea in Nicaragua.Key words: Child, Diarrhoea, Household management, Nicaragua     

Health impact of water and sanitation infrastructure reconstruction programmes in eight Central American communities affected by Hurricane Mitch

In response to Hurricane Mitch, which struck Central America in October–November 1998, the American Red Cross (ARC) and the Centers for Disease Control and Prevention (CDC) collaborated on a 3-year evaluation of the public health impact of ARC's water, sanitation and hygiene education activities in eight study areas in Honduras, Nicaragua, El Salvador and Guatemala. The evaluation compared: 1) access to and use of water and sanitation facilities, 2) the use of hygienic behaviours, and 3) diarrhoeal prevalence in children younger than 3 years of age before (February 2000) and after (February 2002) the interventions had been implemented. The evaluation included household and key informant interviews designed to measure these three components. Water quality of community water sources and household water was evaluated by measuring levels of indicator bacteria. During the final survey, an infrastructure evaluation provided a review of the design, construction, and current operation and maintenance of the water systems and latrines. The integrated water and sanitation infrastructure interventions and hygiene education programmes implemented following Hurricane Mitch effectively decreased diarrhoea prevalence in the target communities.     

Water supply, sanitation and diarrhoeal disease in Nicaragua: results from a case-control study

A case-control study of risk factors for child diarrhoeal disease was undertaken in a rural area of Nicaragua. Some 1229 children under the age of five were matched with an equal number of children of the same age presenting with other illnesses unrelated to water and sanitation. The main types of water supply were sampled at monthly intervals and tested for the presence of faecal coliforms in order to characterize their microbiological quality. In spite of marked differences in water quality between the different types of water supply, no relationship was found with diarrhoea morbidity. In contrast, there was a statistically significant association between water availability and diarrhoea morbidity. Children from homes with water supplies over 500 meters from the house had incidence rates of diarrhoea 34% higher than those of children from houses with their own water supply. Owning a latrine was not found to be significantly related to diarrhoea morbidity. A mother's level of schooling was inversely correlated with the frequency of diarrhoea in her children. A significant association was also found between the number of children under the age of five living in the house and the incidence of diarrhoea. These effects remained significant after controlling for confounding variables by conditional logistic regression.     

Assessment of Water Use and Sanitation Behavior in a Rural Area of Bangladesh

A health development project was established in a rural area of Bangladesh that entailed training village health promoters to provide health education and to motivate families to install tubewells and sanitary latrines. Following a 2-y period of project implementation, the authors sought to assess knowledge and practice of mothers and family members about use of safe water and household tubewells. A household survey in the project area was compared with a similar one in a nearby control area. Three-hundred households in each area were selected, and mothers were interviewed with a standard questionnaire. Significantly more mothers in the health development project area (45.7%) used tubewell water for domestic purposes than in the control area (32.8%). However, hygienic practices of mothers were inadequate. Sanitary latrines were present in less than 20% of households in both areas. Approximately 97% of mothers and 78% of adult family members always used household latrines. However, the use of household latrines by children was low (26.7%). There was no statistically significant difference in the use of household latrines between the project and control areas. The results showed an improvement in use of household tubewells in the project area; however, there was no improvement in sanitation practices of families in the project area. Health education alone, without improvement of socioeconomic status, is not effective in changing behavior.     

Assessment of water use and sanitation behavior of a rural area in Bangladesh

A health development project was established in a rural area of Bangladesh that entailed training village health promoters to provide health education and to motivate families to install tubewells and sanitary latrines. Following a 2-y period of project implementation, the authors sought to assess knowledge and practice of mothers and family members about use of safe water and household tubewells. A household survey in the project area was compared with a similar one in a nearby control area. Three-hundred households in each area were selected, and mothers were interviewed with a standard questionnaire. Significantly more mothers in the health development project area (45.7%) used tubewell water for domestic purposes than in the control area (32.8%). However, hygienic practices of mothers were inadequate. Sanitary latrines were present in less than 20% of households in both areas. Approximately 97% of mothers and 78% of adult family members always used household latrines. However, the use of household latrines by children was low (26.7%). There was no statistically significant difference in the use of household latrines between the project and control areas. The results showed an improvement in use of household tubewells in the project area; however, there was no improvement in sanitation practices of families in the project area. Health education alone, without improvement of socioeconomic status, is not effective in changing behavior.     

Lack of impact of a water and sanitation intervention on the nutritional status of children in rural Bangladesh

The nutritional impact of a water and sanitation intervention in a rural community of Bangladesh, comprising the provision of handpumps, construction of latrines and hygiene education was assessed. During 3 years, the quarterly anthropometric measures of about 200 children aged 12-35 months from the intervention community were compared with those of a similar number of children from a control area. The interventions reduced the incidence of diarrhoea by 25 per cent among the children less than 5 years of age. There was no significant difference in nutritional status, however, between the two groups of children. Moreover, within the intervention area, indicators of water and latrine use were not significantly related to the children's nutritional status. This suggests that either the obtained reduction of diarrhoea was not large enough to have an impact on nutritional status or that diarrhoea is not an important cause of malnutrition in this community.     

Modelling latrine diffusion in Benin: towards a community typology of demand for improved sanitation in developing countries

Latrine diffusion patterns across 502 villages in Benin, West Africa, were analysed to explore factors driving initial and increasing levels of household adoption in low-coverage rural areas of sub-Saharan Africa. Variables explaining adoption related to population density, size, infrastructure/services, non-agricultural occupations, road and urban proximity, and the nearby latrine adoption rate, capturing differences in the physical and social environment, lifestyles and latrine exposure involved in stimulating status/prestige and well-being reasons for latrine adoption. Contagion was most important in explaining adoption initiation. Cluster analysis revealed four distinct village typologies of demand for latrines which provide a framework for tailoring promotional interventions to better match the different sanitation demand characteristics of communities in scaling-up sanitation development and promotion programmes.