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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

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


Shared facilities
Shared Facilities

  • Currently classified by JMP as ‘unimproved’ due to:

    • Accessibility

    • Cleanliness

  • Little evidence linking sharing to diarrhea


Research questions
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)


Demographic and health surveys
Demographic and Health Surveys

  • 51 Surveys

  • Children < 5

  • Diarrhea prevalence in the past 2 weeks


Potential confounders
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


Unadjusted crude effects
Unadjusted (Crude) Effects

PROTECTIVE IN A FEW

HARMFUL IN MOST

NO EFFECT IN A FEW

Sharing is harmful

Sharing is protective


Adjusted effects
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



Pooled results
Pooled Results

“Modest” Effect

Attenuation


Number of households
Number of Households

  • JMP is considering <5 HH as a safe threshold

  • Different dose-response relationships have different policy implications


Number of households1
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


Summary
Summary

  • Pooled analysis shows a modest effect (5-10%)

  • Geographic heterogeneity

  • Confounding via socioeconomic status

  • Number of HH sharing has no clear effect


Strengths of this approach
Strengths of this approach

  • Broad scope captures virtually every sharing scenario and setting

  • Adjusting for confounders

  • Data is readily available


Limitations
Limitations

  • Broad scope misses the details

    • Public vs. private ownership

    • Cleanliness and Accessibility

    • Fecal Sludge Management

  • Residual confounding


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