Assessing longer-term effectiveness of a combined household-level piped water and sanitation intervention on child diarrhoea, acute respiratory infection, soil-transmitted helminth infection and nutritional status: a matched cohort study in rural Odisha, India

Heather Reese, Parimita Routray, Belen Torondel, Sheela S Sinharoy, Samir Mishra, Matthew C Freeman, Howard H Chang, Thomas Clasen, Heather Reese, Parimita Routray, Belen Torondel, Sheela S Sinharoy, Samir Mishra, Matthew C Freeman, Howard H Chang, Thomas Clasen

Abstract

Background: Open defecation is widespread in rural India, and few households have piped water connections. While government and other efforts have increased toilet coverage in India, and evaluations found limited immediate impacts on health, longer-term effects have not been rigorously assessed.

Methods: We conducted a matched cohort study to assess the longer-term effectiveness of a combined household-level piped water and sanitation intervention implemented by Gram Vikas (an Indian NGO) in rural Odisha, India. Forty-five intervention villages were randomly selected from a list of those where implementation was previously completed at least 5 years before, and matched to 45 control villages. We conducted surveys and collected stool samples between June 2015 and October 2016 in households with a child <5 years of age (n = 2398). Health surveillance included diarrhoea (primary outcome), acute respiratory infection (ARI), soil-transmitted helminth infection, and anthropometry.

Results: Intervention villages had higher improved toilet coverage (85% vs 18%), and increased toilet use by adults (74% vs 13%) and child faeces disposal (35% vs 6%) compared with control villages. There was no intervention association with diarrhoea [adjusted OR (aOR): 0.94, 95% confidence interval (CI): 0.74-1.20] or ARI. Compared with controls, children in intervention villages had lower helminth infection (aOR: 0.44, 95% CI: 0.18, 1.00) and improved height-for-age z scores (HAZ) (+0.17, 95% CI: 0.03-0.31).

Conclusions: This combined intervention, where household water connections were contingent on community-wide household toilet construction, was associated with improved HAZ, and reduced soil-transmitted helminth (STH) infection, though not reduced diarrhoea or ARI. Further research should explore the mechanism through which these heterogenous effects on health may occur.

Trial registration: ClinicalTrials.gov NCT02441699.

Keywords: Sanitation; diarrhoea; on-premise piped water; soil-transmitted helminth infection; stunting.

© The Author(s) 2019. Published by Oxford University Press on behalf of the International Epidemiological Association.

Figures

Figure 1.
Figure 1.
Village selection and profile of the study population across four rounds of data collection. The total number of individuals included at each stage of enrollment, follow-up and analysis is on the left in the intervention and control columns. The subset of the total population that is

References

    1. UNICEF and WHO. Progress and Sanitation and Drinking Water: 2015 Update and MDG Assessment Geneva, 2015. .
    1. Water and Sanitation Program. A Decade of the Total Sanitation Campaign: Rapid Assessment of Processes and Outcomes Vol. 1, 2010. .
    1. Garn JV, Sclar GD, Freeman MC. et al. The impact of sanitation interventions on latrine coverage and latrine use: a systematic review and meta-analysis. Int J Hyg Environ Health 2017;220:329–40.
    1. Patil SR, Arnold BF, Salvatore AL. et al. The effect of India’s total sanitation campaign on defecation behaviors and child health in rural Madhya Pradesh: a cluster randomized controlled trial. PLoS Med 2014;11:e1001709..
    1. Clasen T, Boisson S, Routray P. et al. Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial. Lancet Glob Heal 2014;2:e645–653.
    1. World Health Organization. Soil-Transmitted Helminthiasis. Number of Children (Pre-SAC and SAC) Requiring Preventative Chemotherapy for Soil-Transmitted Helminthiases, 2015. (20 April 2017, date last accessed).
    1. Ziegelbauer K, Speich B, Mäusezahl D, Bos R, Keiser J, Utzinger J.. Effect of sanitation on soil-transmitted helminth infection: systematic review and meta-analysis. PLoS Med 2012;9:e1001162.
    1. Strunz EC, Addiss DG, Stocks ME, Ogden S, Utzinger J, Freeman MC.. Water, sanitation, hygiene, and soil-transmitted helminth infection: a systematic review and meta-analysis. PLoS Med 2014;11:e1001620.
    1. United Nations Childrens Fund (UNICEF). One is Too Many: Ending Child Deaths from Pneumonia and Diarrhoea New York: UNICEF, 2016.
    1. Rabie T, Curtis V.. Handwashing and risk of respiratory infections: a quantitative systematic review. Trop Med Int Health 2006;11:258–67.
    1. Stelmach RD, Clasen T, Household water quantity and health: a systematic review. Int J Environ Res Public Health 2015; 12: 5954–974.
    1. Spears D, Ghosh A, Cumming O.. Open defecation and childhood stunting in India: an ecological analysis of new data from 112 districts. PLoS One 2013;8:e73784.
    1. Pickering AJ, Djebbari H, Lopez C, Coulibaly M, Alzua ML.. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial. Lancet Glob Heal 2015;3:e701–711.
    1. Fuller JA, Villamor E, Cevallos W, Trostle J, Eisenberg J.. I get height with a little help from my friends: herd protection from sanitation on child growth in rural Ecuador. Int J Epidemiol 2016;45:460–69.
    1. NFHS-4. National Family Health Survey 4 2015–2016: India Fact Sheet Mumbai, India, 2016. (1 May 2019, date last accessed).
    1. Schmidt W-P, Cairncross S, Barreto ML, Clasen T, Genser B.. Recent diarrhoeal illness and risk of lower respiratory infections in children under the age of 5 years. Int J Epidemiol 2009;38:766–72.
    1. Routray P, Schmidt W-P, Boisson S, Clasen T, Jenkins MW.. Socio-cultural and behavioural factors constraining latrine adoption in rural coastal Odisha: an exploratory qualitative study. BMC Public Health 2015;15:880..
    1. Reese H, Routray P, Torondel B. et al. Design and rationale of a matched cohort study to assess the effectiveness of a combined household-level piped water and sanitation intervention in rural Odisha, India. BMJ Open 2017;7:e012719.
    1. Arnold B, Arana B, Mäusezahl D, Hubbard A, Colford JM.. Evaluation of a pre-existing, 3-year household water treatment and handwashing intervention in rural Guatemala. Int J Epidemiol 2009;38:1651–661.
    1. Diamond A, Sekhon J.. Genetic matching for estimating causal effects. Rev Econ Stat 2012;95:932–45.
    1. Schmidt W-P, Luby SP, Genser B, Barreto ML, Clasen T.. Estimating the longitudinal prevalence of diarrhea and other episodic diseases: continuous versus intermittent surveillance. Epidemiology 2007;18:537–43.
    1. World Health Organization. The Treatment of Diarrhoea: A Manual for Physicians and Other Senior Health Workers, 4th Rev. Geneva, Switzerland, 2005. (5 May 2019, date last accessed).
    1. World Health Organization/The United Nations Children’s Fund (UNICEF). Ending Preventable Child Deaths from Pneumonia and Diarrhoea by 2025: The integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD); 2013. (5 May 2019, date last accessed).
    1. MEASURE DHS. DHS Model Questionnaires (14 May 2017, date last accessed).
    1. Lipsitch M, Tchetgen ET, Cohen T.. Negative controls: a tool for detecting confounding and bias in observational studies. Epidemiology 2010;21:383–88.
    1. de Onis M, Onyango AW, Van den Broeck J, Chumlea WC, Martorell R.. Measurement and standardization protocols for anthropometry used in the construction of a new international growth reference. Food Nutr Bull 2004;25(1 Suppl): S27–36.
    1. Cogill B. Anthropometric Indicators Measurement Guide. Revised Edition Washington, DC: Academy for Educational Development [AED], Food and Nutrition Technical Assistance, 2003: p. 92.
    1. WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards: Length/Height-For-Age, Weight-For-Age, Weight-For-Length, Weight-For-Height and Body Mass Index-For-Age: Methods and development Geneva, 2006. .
    1. Cheesbrough M, District Laboratory Practice in Tropical Countries. 2nd edn Cambridge: Cambridge University Press, 2009.
    1. Funk AL, Boisson S, Clasen T, Ensink J.. Comparison of Kato-Katz, ethyl-acetate sedimentation, and Midi Parasep® in the diagnosis of hookworm, Ascaris and Trichuris infections in the context of an evaluation of rural sanitation in India. Acta Trop 2013;126:265–68.
    1. Díaz-Ordaz K, Kenward MG, Cohen A, Coleman CL, Eldridge S.. Are missing data adequately handled in cluster randomised trials? A systematic review and guidelines. Clin Trials 2014;11:590–600.
    1. Lüdtke O, Robitzsch A, Grund S, Lüdtke O, Robitzsch A, Grund S.. Multiple imputation of missing data in multilevel designs: a comparison of different strategies. Psychol Methods 2017;22:141–65.
    1. Enders CK, Mistler SA, Keller BT.. Multilevel multiple imputation: a review and evaluation of joint modeling and chained equations imputation. Psychol Methods 2016;21:222–40.
    1. Filmer D, Pritchett LH.. Estimating wealth effects without expenditure data—or tears: an application to education enrollments in states of India. Demography 2001;38:115–32.
    1. Bassani DG, Corsi DJ, Gaffey MF, Barros A.. Local distributions of wealth to describe health inequalities in india: a new approach for analyzing nationally representative household survey data, 1992–2008. PLoS One 2014;9:e110694.
    1. Kolenikov S, Angeles G.. The Use of Discrete Data in PCA: Theory, Simulations, and Applications to Socioeconomic Indices. Chapel Hill: Chapel Hill Carolina Population Center, University of North Carolina, 2004, pp. 1–59.
    1. Arnold BF, Khush RS, Ramaswamy P. et al. Causal inference methods to study nonrandomized, preexisting development interventions. Proc Natl Acad Sci U S A 2010;107:22605–2610.
    1. Overbo A, Williams AR, Evans B, Hunter PR, Bartram J.. On-plot drinking water supplies and health: a systematic review. Int J Hyg Environ Health 2016;219:317–30.
    1. Freeman MC, Garn JV, Sclar GD. et al. The impact of sanitation on infectious disease and nutritional status: a systematic review and meta-analysis. Int J Hyg Environ Health 2017;220:329–40.
    1. Humphrey JH. Child undernutrition, tropical enteropathy, toilets, and handwashing. Lancet 2009;374:1032–035.
    1. Luby SP, Rahman M, Arnold BF. et al. Effect of water quality, sanitation, handwashing and nutritional interventions on diarrhoea and child linear growth in rural Bangladesh: A cluster randomized trial. Lancet Glob Heal 2018;6:e302–315.
    1. Null C, Stewart CP, Pickering AJ. et al. Effects of water quality, sanitation, handwashing, and nutritional interventions on diarrhoea and child growth in rural Kenya: a cluster randomised controlled trial. Lancet Glob Heal 2018;30490–0494.
    1. Sinha A, Nagel CL, Thomas E. et al. Assessing latrine use in rural India: A cross-sectional study comparing reported use and passive latrine use monitors. Am J Trop Med Hyg 2016;95:720–27.
    1. Arnold BF, Galiani S, Ram PK. et al. Optimal Recall Period for Caregiver-reported Illness in Risk Factor and Intervention Studies: A Multicountry Study. Am J Epidemiol 2013;177:361–70.
    1. Coffey D, Gupta A, Hathi P, Spears D, Srivastav N, Vyas S, Culture and the Health Transition: Understanding Sanitation Behavior in Rural North India Working Paper. 2015. Available at: .

Source: PubMed

Sponsoren und Mitarbeiter

Krankheiten

Drogeninterventionen

3
Abonnieren