shared sanitation and diarrhea: evidence from 51 countries james a. fuller department of...
TRANSCRIPT
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
Currently classified by JMP as ‘unimproved’ due to: Accessibility Cleanliness
Little evidence linking sharing to diarrhea
Research Questions
1. 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)
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) EffectsSharin
g is
harm
ful
Sharin
g is
pro
tectiv
e
PROTECTIVE IN A FEW
NO EFFECT IN A FEW
HARMFUL IN MOST
Adjusted EffectsSharin
g is
harm
ful
Sharin
g is
pro
tectiv
e
ATTENUATION OF THE EFFECT
Adjusted for: Household assets, mother’s age, mother’s education, child’s health card
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 S
hare
d
Sh
are
d w
ith <
5
Sh
are
d w
ith 5
+
Not S
hare
d
Sh
are
d w
ith <
5
Sh
are
d w
ith 5
+
Not S
hare
d
Sh
are
d w
ith <
5
Sh
are
d w
ith 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