shared sanitation and diarrhea: evidence from 51 countries
DESCRIPTION
SHARED SANITATION AND DIARRHEA: EVIDENCE FROM 51 COUNTRIES. James A. Fuller Department of Epidemiology University of Michigan School of Public Health Co-authors: Thomas Clasen , Marike Heijnen , Joseph Eisenberg. Shared Facilities. C urrently classified by JMP as ‘unimproved’ due to: - PowerPoint PPT PresentationTRANSCRIPT
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SHARED SANITATION AND DIARRHEA: EVIDENCE FROM 51
COUNTRIESJames A. FullerDepartment of EpidemiologyUniversity of Michigan School of Public Health
Co-authors: Thomas Clasen, Marike Heijnen, Joseph Eisenberg
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Shared Facilities
Currently classified by JMP as ‘unimproved’ due to: Accessibility Cleanliness
Little evidence linking sharing to diarrhea
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Research Questions1. Is a child more likely to have diarrhea if
his/her household uses a shared facility (compared to a facility that is not shared)?
2. Is there a safe threshold for the number of households using a facility (i.e. < 5)
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Demographic and Health Surveys 51 Surveys
Children < 5
Diarrhea prevalence in the past 2 weeks
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Potential ConfoundersChild-level variables
Age Health Card
Household-level variables Toilet facility (improved/unimproved, ignoring sharing) Water source (improved/unimproved) Ownership of assets (refrigerator, bicycle, motorcycle/scooter) Mother’s education (6 categories) Mother’s age (6 categories) Number of children < 5 in the household Urban/Rural
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Unadjusted (Crude) EffectsSharing is harm
fulSharing is protective
PROTECTIVE IN A FEW
NO EFFECT IN A FEW
HARMFUL IN MOST
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Adjusted EffectsSharing is harm
fulSharing is protective
ATTENUATION OF THE EFFECT
Adjusted for: Household assets, mother’s age, mother’s education, child’s health card
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Crude Prevalence Ratios
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Pooled Results
RegionCrude PR (95% CI)
Adjusteda PR (95% CI)
Africa 1.07 (1.03-1.10) 1.05 (1.01-1.09)Latin America and the Caribbean 1.11 (1.04-1.19) 1.02 (0.96-1.10)South-East Asia and Western Pacific 1.16 (1.06-1.26) 1.09 (1.00-1.18)Eastern Mediterranean and Europe 1.26 (1.11-1.42) 1.22 (1.08-1.38)
All Regions Combined 1.09 (1.06-1.12) 1.05 (1.02-1.08)PR, Prevalence Ratio; 95%CI, 95% confidence interval.aAdjusted for mother’s age, mother’s educational attainment, asset ownership, and whether the child has a health card.
“Modest” Effect
Attenuation
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Number of Households JMP is considering <5 HH as a safe
threshold
Different dose-response relationships have different policy implications
Not Shared
Shared with < 5
Shared with 5+
Not Shared
Shared with < 5
Shared with 5+
Not Shared
Shared with < 5
Shared with 5+
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Number of Households
RegionSharing Category Crude PR Adjusted PR
All Regions Combined < 5 HH 1.07 (1.04-1.11) 1.04 (1.00-1.07)5 or more HH 1.06 (1.00-1.12) 1.02 (0.97-1.08)
Africa < 5 HH 1.06 (1.02-1.10) 1.04 (1.00-1.08)5 or more HH 1.02 (0.96-1.09) 1.03 (0.97-1.09)
Latin Am & Car < 5 HH 1.08 (0.99-1.18) 1.02 (0.93-1.11)5 or more HH 1.14 (0.96-1.35) 1.01 (0.85-1.20)
SEA & WP < 5 HH 1.13 (1.02-1.25) 1.07 (0.96-1.18)5 or more HH 1.22 (1.02-1.48) 1.12 (0.93-1.36)
Eastern Med & Eur < 5 HH 1.21 (0.89-1.65) 1.14 (0.84-1.56)5 or more HH 1.71 (0.89-3.30) 1.75 (0.97-3.16)
Table 4. The number of households sharing a toilet facility and the prevalence ratios for diarrhea among children < 5 years of age. Data from 39 Demographic and Health Surveys, 2001-2011.
The 2 groups appear to be similar
Some evidence of a dose-response
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Summary Pooled analysis shows a modest effect
(5-10%)
Geographic heterogeneity
Confounding via socioeconomic status
Number of HH sharing has no clear effect
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Strengths of this approach Broad scope captures virtually every
sharing scenario and setting
Adjusting for confounders
Data is readily available
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Limitations Broad scope misses the details
Public vs. private ownership Cleanliness and Accessibility Fecal Sludge Management
Residual confounding