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Shame or subsidy revisited: social mobilization for sanitation in Orissa, India
Pattanayak,Subhrendu K; Yang,Jui-Chen; Dickinson,Katherine L; Poulos,Christine; Patil,Sumeet R; Mallick,Ranjan K; Blitstein,Jonathan L; Praharaj,Purujit;
Bulletin of the World Health Organization , 2009, DOI: 10.1590/S0042-96862009000800013
Abstract: objective: to determine the effectiveness of a sanitation campaign that combines "shaming" (i.e. emotional motivators) with subsidies for poor households in rural orissa, an indian state with a disproportionately high share of india's child mortality. methods: using a cluster-randomized design, we selected 20 treatment and 20 control villages in the coastal district of bhadrak, rural orissa, for a total sample of 1050 households. we collected sanitation and health data before and after a community-led sanitation project, and we used a difference-in-difference estimator to determine the extent to which the campaign influenced the number of households building and using a latrine. findings: latrine ownership did not increase in control villages, but in treatment villages it rose from 6% to 32% in the overall sample, from 5% to 36% in households below the poverty line (eligible for a government subsidy) and from 7% to 26% in households above the poverty line (not eligible for a government subsidy). conclusion: subsidies can overcome serious budget constraints but are not necessary to spur action, for shaming can be very effective by harnessing the power of social pressure and peer monitoring. through a combination of shaming and subsidies, social marketing can improve sanitation worldwide.
Impact of Indian Total Sanitation Campaign on Latrine Coverage and Use: A Cross-Sectional Study in Orissa Three Years following Programme Implementation  [PDF]
Sharmani Barnard, Parimita Routray, Fiona Majorin, Rachel Peletz, Sophie Boisson, Antara Sinha, Thomas Clasen
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0071438
Abstract: Background Faced with a massive shortfall in meeting sanitation targets, some governments have implemented campaigns that use subsidies focused on latrine construction to overcome income constraints and rapidly expand coverage. In settings like rural India where open defecation is common, this may result in sub-optimal compliance (use), thereby continuing to leave the population exposed to human excreta. Methods We conducted a cross-sectional study to investigate latrine coverage and use among 20 villages (447 households, 1933 individuals) in Orissa, India where the Government of India’s Total Sanitation Campaign had been implemented at least three years previously. We defined coverage as the proportion of households that had a latrine; for use we identified the proportion of households with at least one reported user and among those, the extent of reported use by each member of the household. Results Mean latrine coverage among the villages was 72% (compared to <10% in comparable villages in the same district where the Total Sanitation Campaign had not yet been implemented), though three of the villages had less than 50% coverage. Among these households with latrines, more than a third (39%) were not being used by any member of the household. Well over a third (37%) of the members of households with latrines reported never defecating in their latrines. Less than half (47%) of the members of such households reported using their latrines at all times for defecation. Combined with the 28% of households that did not have latrines, it appears that most defecation events in these communities are still practiced in the open. Conclusion A large-scale campaign to implement sanitation has achieved substantial gains in latrine coverage in this population. Nevertheless, gaps in coverage and widespread continuation of open defecation will result in continued exposure to human excreta, reducing the potential for health gains.
Evaluation of a water, sanitation, and hygiene education intervention on diarrhoea in northern Pakistan
Nanan,D.; White,F.; Azam,I.; Afsar,H.; Hozhabri,S.;
Bulletin of the World Health Organization , 2003, DOI: 10.1590/S0042-96862003000300005
Abstract: objective: inadequate water and sanitation services adversely affect the health and socioeconomic development of communities. the water and sanitation extension programme (wasep) project, undertaken in selected villages in northern pakistan between 1997 and 2001, was designed to deliver an integrated package of activities to improve potable water supply at village and household levels, sanitation facilities and their use, and awareness and practices about hygiene behaviour. methods: a case-control study was conducted during july-september 2001 to evaluate whether, after selected confounders were controlled for, children aged <6 years with diarrhoea were more or less likely to reside in villages that participated in the project than in villages that did not participate. descriptive and logistic regression analyses were performed. findings: children not living in wasep villages had a 33% higher adjusted odds ratio for having diarrhoea than children living in wasep villages (adjusted odds ratio, 1.331; p<0.049). boys had 25% lower odds of having diarrhoea than girls (adjusted odds ratio, 0.748; p<0.049). a 2.6% decrease was found in the odds of diarrhoea for every yearly increase in the mother's age (adjusted odds ratio, 0.974; p<0.044) and a 1.4% decrease for every monthly increase in the child's age (adjusted odds ratio, 0.986; p<0.001). conclusions: the findings in this study may help refine the approach to future water, sanitation, and hygiene initiatives in northern pakistan. the integrated approach taken by wasep, which incorporates engineering solutions with appropriate education to maximize facility usage and improve hygiene practices, is a useful example of how desired health benefits can be obtained from projects of this type.
Evaluation of a water, sanitation, and hygiene education intervention on diarrhoea in northern Pakistan  [cached]
Nanan D.,White F.,Azam I.,Afsar H.
Bulletin of the World Health Organization , 2003,
Abstract: OBJECTIVE: Inadequate water and sanitation services adversely affect the health and socioeconomic development of communities. The Water and Sanitation Extension Programme (WASEP) project, undertaken in selected villages in northern Pakistan between 1997 and 2001, was designed to deliver an integrated package of activities to improve potable water supply at village and household levels, sanitation facilities and their use, and awareness and practices about hygiene behaviour. METHODS: A case-control study was conducted during July-September 2001 to evaluate whether, after selected confounders were controlled for, children aged <6 years with diarrhoea were more or less likely to reside in villages that participated in the project than in villages that did not participate. Descriptive and logistic regression analyses were performed. FINDINGS: Children not living in WASEP villages had a 33% higher adjusted odds ratio for having diarrhoea than children living in WASEP villages (adjusted odds ratio, 1.331; P<0.049). Boys had 25% lower odds of having diarrhoea than girls (adjusted odds ratio, 0.748; P<0.049). A 2.6% decrease was found in the odds of diarrhoea for every yearly increase in the mother's age (adjusted odds ratio, 0.974; P<0.044) and a 1.4% decrease for every monthly increase in the child's age (adjusted odds ratio, 0.986; P<0.001). CONCLUSIONS: The findings in this study may help refine the approach to future water, sanitation, and hygiene initiatives in northern Pakistan. The integrated approach taken by WASEP, which incorporates engineering solutions with appropriate education to maximize facility usage and improve hygiene practices, is a useful example of how desired health benefits can be obtained from projects of this type.
Effect of Household-Based Drinking Water Chlorination on Diarrhoea among Children under Five in Orissa, India: A Double-Blind Randomised Placebo-Controlled Trial  [PDF]
Sophie Boisson ,Matthew Stevenson,Lily Shapiro,Vinod Kumar,Lakhwinder P. Singh,Dana Ward,Thomas Clasen
PLOS Medicine , 2013, DOI: 10.1371/journal.pmed.1001497
Abstract: Background Boiling, disinfecting, and filtering water within the home can improve the microbiological quality of drinking water among the hundreds of millions of people who rely on unsafe water supplies. However, the impact of these interventions on diarrhoea is unclear. Most studies using open trial designs have reported a protective effect on diarrhoea while blinded studies of household water treatment in low-income settings have found no such effect. However, none of those studies were powered to detect an impact among children under five and participants were followed-up over short periods of time. The aim of this study was to measure the effect of in-home water disinfection on diarrhoea among children under five. Methods and Findings We conducted a double-blind randomised controlled trial between November 2010 and December 2011. The study included 2,163 households and 2,986 children under five in rural and urban communities of Orissa, India. The intervention consisted of an intensive promotion campaign and free distribution of sodium dichloroisocyanurate (NaDCC) tablets during bi-monthly households visits. An independent evaluation team visited households monthly for one year to collect health data and water samples. The primary outcome was the longitudinal prevalence of diarrhoea (3-day point prevalence) among children aged under five. Weight-for-age was also measured at each visit to assess its potential as a proxy marker for diarrhoea. Adherence was monitored each month through caregiver's reports and the presence of residual free chlorine in the child's drinking water at the time of visit. On 20% of the total household visits, children's drinking water was assayed for thermotolerant coliforms (TTC), an indicator of faecal contamination. The primary analysis was on an intention-to-treat basis. Binomial regression with a log link function and robust standard errors was used to compare prevalence of diarrhoea between arms. We used generalised estimating equations to account for clustering at the household level. The impact of the intervention on weight-for-age z scores (WAZ) was analysed using random effect linear regression. Over the follow-up period, 84,391 child-days of observations were recorded, representing 88% of total possible child-days of observation. The longitudinal prevalence of diarrhoea among intervention children was 1.69% compared to 1.74% among controls. After adjusting for clustering within household, the prevalence ratio of the intervention to control was 0.95 (95% CI 0.79–1.13). The mean WAZ was similar among children of the
The Effect of India's Total Sanitation Campaign on Defecation Behaviors and Child Health in Rural Madhya Pradesh: A Cluster Randomized Controlled Trial  [PDF]
Sumeet R. Patil ,Benjamin F. Arnold,Alicia L. Salvatore,Bertha Briceno,Sandipan Ganguly,John M. Colford Jr,Paul J. Gertler
PLOS Medicine , 2014, DOI: 10.1371/journal.pmed.1001709
Abstract: Background Poor sanitation is thought to be a major cause of enteric infections among young children. However, there are no previously published randomized trials to measure the health impacts of large-scale sanitation programs. India's Total Sanitation Campaign (TSC) is one such program that seeks to end the practice of open defecation by changing social norms and behaviors, and providing technical support and financial subsidies. The objective of this study was to measure the effect of the TSC implemented with capacity building support from the World Bank's Water and Sanitation Program in Madhya Pradesh on availability of individual household latrines (IHLs), defecation behaviors, and child health (diarrhea, highly credible gastrointestinal illness [HCGI], parasitic infections, anemia, growth). Methods and Findings We conducted a cluster-randomized, controlled trial in 80 rural villages. Field staff collected baseline measures of sanitation conditions, behaviors, and child health (May–July 2009), and revisited households 21 months later (February–April 2011) after the program was delivered. The study enrolled a random sample of 5,209 children <5 years old from 3,039 households that had at least one child <24 months at the beginning of the study. A random subsample of 1,150 children <24 months at enrollment were tested for soil transmitted helminth and protozoan infections in stool. The randomization successfully balanced intervention and control groups, and we estimated differences between groups in an intention to treat analysis. The intervention increased percentage of households in a village with improved sanitation facilities as defined by the WHO/UNICEF Joint Monitoring Programme by an average of 19% (95% CI for difference: 12%–26%; group means: 22% control versus 41% intervention), decreased open defecation among adults by an average of 10% (95% CI for difference: 4%–15%; group means: 73% intervention versus 84% control). However, the intervention did not improve child health measured in terms of multiple health outcomes (diarrhea, HCGI, helminth infections, anemia, growth). Limitations of the study included a relatively short follow-up period following implementation, evidence for contamination in ten of the 40 control villages, and bias possible in self-reported outcomes for diarrhea, HCGI, and open defecation behaviors. Conclusions The intervention led to modest increases in availability of IHLs and even more modest reductions in open defecation. These improvements were insufficient to improve child health outcomes (diarrhea, HCGI, parasite
Effect of Sanitation on Soil-Transmitted Helminth Infection: Systematic Review and Meta-Analysis  [PDF]
Kathrin Ziegelbauer equal contributor,Benjamin Speich equal contributor,Daniel M?usezahl,Robert Bos,Jennifer Keiser,Jürg Utzinger
PLOS Medicine , 2012, DOI: 10.1371/journal.pmed.1001162
Abstract: Background In countries of high endemicity of the soil-transmitted helminth parasites Ascaris lumbricoides, Trichuris trichiura, and hookworm, preventive chemotherapy (i.e., repeated administration of anthelmintic drugs to at-risk populations) is the main strategy to control morbidity. However, rapid reinfection of humans occurs after successful deworming, and therefore effective preventive measures are required to achieve public health goals with optimal efficiency and sustainability. Methods and Findings We conducted a systematic review and meta-analysis to assess the effect of sanitation (i.e., access and use of facilities for the safe disposal of human urine and feces) on infection with soil-transmitted helminths. PubMed, Embase, ISI Web of Science, and the World Health Organization Library Database were searched without language restrictions and year of publication (search performed until December 31, 2010). Bibliographies of identified articles were hand-searched. All types of studies reporting data on sanitation availability (i.e., having access at own household or living in close proximity to sanitation facility), or usage, and soil-transmitted helminth infections at the individual level were considered. Reported odds ratios (ORs) of the protective effect of sanitation on soil-transmitted helminth infections were extracted from the papers or calculated from reported numbers. The quality of published studies was assessed with a panel of criteria developed by the authors. Random effects meta-analyses were used to account for observed heterogeneity. Thirty-six publications, consisting of 39 datasets, met our inclusion criteria. Availability of sanitation facilities was associated with significant protection against infection with soil-transmitted helminths (OR = 0.46 to 0.58). Regarding the use of sanitation, ORs of 0.54 (95% confidence interval [CI] 0.28–1.02), 0.63 (95% CI 0.37–1.05), and 0.78 (95% CI 0.60–1.00) were determined for T. trichiura, hookworm, and A. lumbricoides, respectively. The overall ORs, combining sanitation availability and use, were 0.51 (95% CI 0.44–0.61) for the three soil-transmitted helminths combined, 0.54 (95% CI 0.43–0.69) for A. lumbricoides, 0.58 (95% CI 0.45–0.75) for T. trichiura, and 0.60 (95% CI 0.48–0.75) for hookworm. Conclusions Despite a number of limitations (e.g., most studies used a cross-sectional design and were of low quality, with potential biases and considerable heterogeneity), our results reveal that sanitation is associated with a reduced risk of transmission of helminthiases to humans. Access to
Shared Sanitation versus Individual Household Latrines: A Systematic Review of Health Outcomes  [PDF]
Marieke Heijnen, Oliver Cumming, Rachel Peletz, Gabrielle Ka-Seen Chan, Joe Brown, Kelly Baker, Thomas Clasen
PLOS ONE , 2014, DOI: 10.1371/journal.pone.0093300
Abstract: Background More than 761 million people rely on shared sanitation facilities. These have historically been excluded from international sanitation targets, regardless of the service level, due to concerns about acceptability, hygiene and access. In connection with a proposed change in such policy, we undertook this review to identify and summarize existing evidence that compares health outcomes associated with shared sanitation versus individual household latrines. Methods and Findings Shared sanitation included any type of facilities intended for the containment of human faeces and used by more than one household, but excluded public facilities. Health outcomes included diarrhoea, helminth infections, enteric fevers, other faecal-oral diseases, trachoma and adverse maternal or birth outcomes. Studies were included regardless of design, location, language or publication status. Studies were assessed for methodological quality using the STROBE guidelines. Twenty-two studies conducted in 21 countries met the inclusion criteria. Studies show a pattern of increased risk of adverse health outcomes associated with shared sanitation compared to individual household latrines. A meta-analysis of 12 studies reporting on diarrhoea found increased odds of disease associated with reliance on shared sanitation (odds ratio (OR) 1.44, 95% CI: 1.18–1.76). Conclusion Evidence to date does not support a change of existing policy of excluding shared sanitation from the definition of improved sanitation used in international monitoring and targets. However, such evidence is limited, does not adequately address likely confounding, and does not identify potentially important distinctions among types of shared facilities. As reliance on shared sanitation is increasing, further research is necessary to determine the circumstances, if any, under which shared sanitation can offer a safe, appropriate and acceptable alternative to individual household latrines.
Water, Sanitation, Hygiene, and Soil-Transmitted Helminth Infection: A Systematic Review and Meta-Analysis  [PDF]
Eric C. Strunz ,David G. Addiss,Meredith E. Stocks,Stephanie Ogden,Jürg Utzinger,Matthew C. Freeman
PLOS Medicine , 2014, DOI: 10.1371/journal.pmed.1001620
Abstract: Background Preventive chemotherapy represents a powerful but short-term control strategy for soil-transmitted helminthiasis. Since humans are often re-infected rapidly, long-term solutions require improvements in water, sanitation, and hygiene (WASH). The purpose of this study was to quantitatively summarize the relationship between WASH access or practices and soil-transmitted helminth (STH) infection. Methods and Findings We conducted a systematic review and meta-analysis to examine the associations of improved WASH on infection with STH (Ascaris lumbricoides, Trichuris trichiura, hookworm [Ancylostoma duodenale and Necator americanus], and Strongyloides stercoralis). PubMed, Embase, Web of Science, and LILACS were searched from inception to October 28, 2013 with no language restrictions. Studies were eligible for inclusion if they provided an estimate for the effect of WASH access or practices on STH infection. We assessed the quality of published studies with the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. A total of 94 studies met our eligibility criteria; five were randomized controlled trials, whilst most others were cross-sectional studies. We used random-effects meta-analyses and analyzed only adjusted estimates to help account for heterogeneity and potential confounding respectively. Use of treated water was associated with lower odds of STH infection (odds ratio [OR] 0.46, 95% CI 0.36–0.60). Piped water access was associated with lower odds of A. lumbricoides (OR 0.40, 95% CI 0.39–0.41) and T. trichiura infection (OR 0.57, 95% CI 0.45–0.72), but not any STH infection (OR 0.93, 95% CI 0.28–3.11). Access to sanitation was associated with decreased likelihood of infection with any STH (OR 0.66, 95% CI 0.57–0.76), T. trichiura (OR 0.61, 95% CI 0.50–0.74), and A. lumbricoides (OR 0.62, 95% CI 0.44–0.88), but not with hookworm infection (OR 0.80, 95% CI 0.61–1.06). Wearing shoes was associated with reduced odds of hookworm infection (OR 0.29, 95% CI 0.18–0.47) and infection with any STH (OR 0.30, 95% CI 0.11–0.83). Handwashing, both before eating (OR 0.38, 95% CI 0.26–0.55) and after defecating (OR 0.45, 95% CI 0.35–0.58), was associated with lower odds of A. lumbricoides infection. Soap use or availability was significantly associated with lower infection with any STH (OR 0.53, 95% CI 0.29–0.98), as was handwashing after defecation (OR 0.47, 95% CI 0.24–0.90). Observational evidence constituted the majority of included literature, which limits any attempt to make causal inferences. Due to underlying
The Influence Of Environmental Sanitation Practices And Hygiene On The Incidence Of Diarrhoea – The Case Of Koforidua Municipality, Ghana
E Asenso-Mensah, AO Awoyemi, ENL Browne
African Journal of Clinical and Experimental Microbiology , 2009,
Abstract: A case-control study was done using a convenience sample of 100 pairs of mothers and children (less than five years old) divided into two groups; the first group made of children with diarrhoea and their mothers (case group) and the second group made up of mothers and children who did not have diarrhoea (control). A structured interview schedule and review of routine data were used to collect data. Only 12.5% of children less than six months in the case group were exclusively being breastfed compared with 75% of the control group. 56% of the cases used water from unprotected wells for domestic activity while 70% of the control group used pipe- borne water. Also 24% of the case group did not cover stored water while 76% of the control group covered stored water. This demonstrated poor food and water safety. Only 10% of cases had access to flushing water closets for human excreta disposal while the remaining 90% either used pit latrines or disposal into surrounding bushes. It was recommended that good amenities for the disposal of refuse in the communities be provided by the government and the delivery of pipe-borne water be made more regular to the inhabitants Further, appropriate education in simple language is to be offered by health personnel especially at Ante-Natal Clinic and on radio stations and mothers are to be encouraged to put into practice what they learn about the treatment and prevention of diarrhoea. African Journal of Clinical and Experimental Microbiology Vol. 10 (1) 2009: pp. 56-63
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