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SHARED SANITATION AND DIARRHEA: EVIDENCE FROM 51 COUNTRIES

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:

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SHARED SANITATION AND DIARRHEA: EVIDENCE FROM 51 COUNTRIES

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  1. 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, MarikeHeijnen, Joseph Eisenberg

  2. Shared Facilities • Currently classified by JMP as ‘unimproved’ due to: • Accessibility • Cleanliness • Little evidence linking sharing to diarrhea

  3. Research Questions • Is a child more likely to have diarrhea if his/her household uses a shared facility (compared to a facility that is not shared)? • Is there a safe threshold for the number of households using a facility (i.e. < 5)

  4. Demographic and Health Surveys • 51 Surveys • Children < 5 • Diarrhea prevalence in the past 2 weeks

  5. Potential Confounders Child-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

  6. Unadjusted (Crude) Effects PROTECTIVE IN A FEW HARMFUL IN MOST NO EFFECT IN A FEW Sharing is harmful Sharing is protective

  7. Adjusted Effects ATTENUATION OF THE EFFECT Sharing is harmful Sharing is protective Adjusted for: Household assets, mother’s age, mother’s education, child’s health card

  8. Crude Prevalence Ratios

  9. Pooled Results “Modest” Effect Attenuation

  10. Number of Households • JMP is considering <5 HH as a safe threshold • Different dose-response relationships have different policy implications

  11. Number of Households 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

  12. Summary • Pooled analysis shows a modest effect (5-10%) • Geographic heterogeneity • Confounding via socioeconomic status • Number of HH sharing has no clear effect

  13. Strengths of this approach • Broad scope captures virtually every sharing scenario and setting • Adjusting for confounders • Data is readily available

  14. Limitations • Broad scope misses the details • Public vs. private ownership • Cleanliness and Accessibility • Fecal Sludge Management • Residual confounding

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