Community-Level Sanitation Coverage More Strongly Associated with Child Growth and Household Drinking Water Quality than Access to a Private Toilet in Rural Mali

Abstract

Sanitation access can provide positive externalities; for example, safe disposal of feces by one household prevents disease transmission to households nearby. However, little empirical evidence exists to characterize the potential health benefits from sanitation externalities. This study investigated the effect of community sanitation coverage versus individual household sanitation access on child health and drinking water quality. Using a census of 121 villages in rural Mali, we analyzed the association of community latrine coverage (defined by a 200 m radius surrounding a household) and individual household latrine ownership with child growth and household stored water quality. Child height-for-age had a significant and positive linear relationship with community latrine coverage, while child weight-for-age and household water quality had nonlinear relationships that leveled off above 60% coverage (p < 0.01; generalized additive models). Child growth and water quality were not associated with individual household latrine ownership. The relationship between community latrine coverage and child height was strongest among households without a latrine; for these households, each 10% increase in latrine coverage was associated with a 0.031 (p-value = 0.040) increase in height-for-age z-score. In this study, the level of sanitation access of surrounding households was more important than private latrine access for protecting water quality and child health.

Integrating water, sanitation, handwashing, and nutrition interventions to reduce child soil-transmitted helminth andGiardiainfections: a cluster-randomized controlled trial in rural Kenya

“…A recent trial in Cote d’Ivoire reported greater reduction in hookworm infection prevalence among communities that received a community-led total sanitation intervention (designed to reduce open defecation levels) integrated with community-wide MDA compared to community-wide MDA alone (32). A second explanation may be that sanitation interventions are more effective at interrupting environmental transmission of pathogens when they are implemented at the community level(33), whereas our intervention only improved sanitation access in compounds with enrolled pregnant women.…”

Does Basic Sanitation Prevent Diarrhea? Contextualizing Recent Intervention Trials through a Historical Lens

“…These two studies do not provide strong evidence for the effect of reaching high coverage with a latrine intervention on diarrhea. Observational research has found that community sanitation coverage is related to child height and stunting in Mali and Ecuador [9,10]. One observational study from national survey data in India found that community coverage was related to diarrhea [115], but another observational study found no effect of community coverage on diarrhea in Mali [9].…”

“…Observational research has found that community sanitation coverage is related to child height and stunting in Mali and Ecuador [9,10]. One observational study from national survey data in India found that community coverage was related to diarrhea [115], but another observational study found no effect of community coverage on diarrhea in Mali [9]. Additional theoretical model analysis has suggested that all benefits from sanitation interventions come from the indirect effects due to community coverage [116].…”

“…However, as is true for all intervention trials, generalizability of these results to other interventions and settings is limited [5][6][7]. For example, these household-level trials did not test the effect of sanitation at high community coverage, which has been shown to be an important predictor of intervention effectiveness [8][9][10]. Due to this question of generalizability, it is important to assess how these results fit into the history of sanitation evidence, while acknowledging that these studies reflect some of the most thorough examinations of sanitation and diarrhea ever conducted.…”

Introduction to the Importance of Sanitation

“…Clasen et al (2014) proposed that there were not clear health differences because over a third of households in the intervention communities did not have a latrine. Households without latrines may still contaminate the surrounding environment and water sources that have adverse health impacts on households in the same community with latrines (Harris et al, 2017). Moreover, presence of a latrine does not necessarily indicate use as other household members may still open defecate particularly children.…”