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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: - PowerPoint PPT Presentation
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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
Shared Facilities
Currently classified by JMP as ‘unimproved’ due to: Accessibility Cleanliness
Little evidence linking sharing to diarrhea
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)
Demographic and Health Surveys 51 Surveys
Children < 5
Diarrhea prevalence in the past 2 weeks
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
Unadjusted (Crude) EffectsSharing is harm
fulSharing is protective
PROTECTIVE IN A FEW
NO EFFECT IN A FEW
HARMFUL IN MOST
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
Crude Prevalence Ratios
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
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+
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
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 Broad scope captures virtually every
sharing scenario and setting
Adjusting for confounders
Data is readily available
Limitations Broad scope misses the details
Public vs. private ownership Cleanliness and Accessibility Fecal Sludge Management
Residual confounding