shared sanitation and diarrhea evidence from 51 countries
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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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