Integrating Disease Control Strategies: Balancing Water Sanitation and Hygiene Interventions to Reduce Diarrheal Disease Burden

Eisenberg, Joseph N.S.; Scott, James C.; Porco, Travis C.

doi:10.2105/ajph.2006.086207

Cited by 114 publications

(114 citation statements)

References 26 publications

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“…They provide evidence that in some populations it is not necessary to combine improvements in water supply, sanitation, and hygiene conditions to achieve very low levels of child diarrhea (35,36). We infer (although have not tested) that field open defecation is not a primary transmission pathway of diarrhea-causing pathogens for children <5 y old in this population.…”

Section: Discussionmentioning

confidence: 81%

Causal inference methods to study nonrandomized, preexisting development interventions

Arnold

Khush

Padmavathi

et al. 2010

Proc. Natl. Acad. Sci. U.S.A.

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Empirical measurement of interventions to address significant global health and development problems is necessary to ensure that resources are applied appropriately. Such intervention programs are often deployed at the group or community level. The gold standard design to measure the effectiveness of communitylevel interventions is the community-randomized trial, but the conditions of these trials often make it difficult to assess their external validity and sustainability. The sheer number of community interventions, relative to randomized studies, speaks to a need for rigorous observational methods to measure their impact. In this article, we use the potential outcomes model for causal inference to motivate a matched cohort design to study the impact and sustainability of nonrandomized, preexisting interventions. We illustrate the method using a sanitation mobilization, water supply, and hygiene intervention in rural India. In a matched sample of 25 villages, we enrolled 1,284 children <5 y old and measured outcomes over 12 mo. Although we found a 33 percentage point difference in new toilet construction [95% confidence interval (CI) = 28%, 39%], we found no impacts on height-for-age Z scores (adjusted difference = 0.01, 95% CI = −0.15, 0.19) or diarrhea (adjusted longitudinal prevalence difference = 0.003, 95% CI = −0.001, 0.008) among children <5 y old. This study demonstrates that matched cohort designs can estimate impacts from nonrandomized, preexisting interventions that are used widely in development efforts. Interpreting the impacts as causal, however, requires stronger assumptions than prospective, randomized studies.impact evaluation | study design | propensity score matching | communityled total sanitation | open defecation

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Section: Discussionmentioning

confidence: 81%

Causal inference methods to study nonrandomized, preexisting development interventions

Arnold

Khush

Padmavathi

et al. 2010

Proc. Natl. Acad. Sci. U.S.A.

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“…Simulation studies suggest that complementarities, independence or substitution are all possible, depending on the context and interventions combined (Eisenberg et al 2012, Eisenberg, Scott, andPorco 2007). Some observational studies have found evidence for positive interactions, in particular that the benefits of clean water are greater when sanitary conditions are good (VanDerslice and Briscoe 1995).…”

Section: A the Consequences Of Clean Water And Sanitation For Human mentioning

confidence: 99%

Toilets Can Work: Short and Medium Run Health Impacts of Addressing Complementarities and Externalities in Water and Sanitation

Duflo

Greenstone

Guiteras

et al. 2015

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Poor water quality and sanitation are leading causes of mortality and disease in developing countries. However, interventions providing toilets in rural areas have not substantially improved health, likely because of incomplete coverage and low usage. This paper estimates the impact of an integrated water and sanitation improvement program in rural India that provided household-level water connections, latrines, and bathing facilities to all households in approximately 100 villages. The estimates suggest that the intervention was effective, reducing treated diarrhea episodes by 30-50%. These results are evident in the short term and persist for 5 years or more. Poor sanitation is widely considered a major obstacle to well-being in many parts of the world.An estimated 748 million people lack access to improved sources of water, and more than 2.5 billion lack improved sanitation (WHO -UNICEF 2014). In India, open defecation is still practiced by 65% of the rural population and only 14% of the rural population have piped-in water to the household (WHO -UNICEF 2014). By some estimates, lack of safe water, inadequate sanitation, and poor hygiene practices cause 1.1 million deaths from diarrhea each year, representing 1.5% of the global burden of disease ), similar to HIV-AIDS. Open defecation in India may be responsible for approximately 9% of total infant mortality, or 6.5 deaths per 1,000 infants per year (Geruso and Spears 2015).This challenge to well-being has not gone unnoticed. Bill Gates talks of "reinventing the toilet" and has put the weight of his foundation behind this effort (Bill & Melinda Gates Foundation 2011, Gates III 2012. Building on his 2013 campaign statement "pehle shauchalaya, phir devalaya" However, the evidence that increasing sanitation coverage alone in rural areas would reduce diarrhea and save lives is surprisingly thin. Infrastructure-based (i.e. connected to sewerage) solutions have proved effective in urban environments when combined with improvements in water supply (Cutler and Miller 2006, Galiani, Gertler, andSchargrodsky 2005). However, interventions promoting on-site sanitation without sewerage, as is typically implemented in rural and other low-density settings, have not been as effective as sewerage (Wolf et al. 2014). Two recent cluster-randomized trials evaluating sanitation-only interventions in rural India, one in Orissa ) and the other in Madhya Pradesh (Patil et al. 2014) find only modest impacts of latrine construction on latrine usage, and no impacts on health.Part of the issue is that these sanitation-focused efforts have not fully taken on board two factors that play a key role in water and sanitation: complementarities and externalities. Epidemiological complementarities between water and sanitation interventions may arise because there are multiple pathways for transmission of water-borne disease (Clasen et al. 2007, Waddington andSnilstveit 2009). A behavioral complementarity can occur if providing water encourages latrine use -1 without convenient access to...

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“…Second, processes lead to both intended and unintended outcomes; an understanding of how something does or does not work is important for maintenance of success and for adjustment of the intervention as needed to improve function and results. Finally, processes can also be considered actual gains (outcomes) in the intervention if they put in place practices or structures that will advance the overall efforts or make them more sustainable over time 22,24 . Indeed, some have suggested that the quality of the processes used to address complex problems may be important benchmarks for progress toward solving them 19 .…”

Section: Designmentioning

confidence: 99%

“…While physical infrastructure challenges can themselves be complicated 1,3,19 , implementation of solutions and their sustained efficacy, critical to success and sustainability over time, can become complex. A lack of personnel knowledgeable in engineering and health, un-planned communities, unclear leadership, cultural and value systems of those who benefit from safe drinking water interventions, individual behaviors, and the resource and fiscal challenges imposed by poverty may all be barriers locally, and the extent of their combined impact on drinking water programs is not well understood 15,17,20,21,22 . Such environmental health problems have been deemed "wicked" 23 because of the complex web of social, economic, cultural and political issues that influence what might otherwise be considered "tame" problems, or those more clearly definable and solvable by mechanistic, discipline-specific analytic means.…”

Section: Introductionmentioning

confidence: 99%

Applying Evaluative Thinking to a Community-Engaged Safe Drinking Water Project in Peri-Urban Guatemala

Tendick-Matesanz

Ahonen

Zellner

et al. 2015

IJSLE

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-A large number of safe drinking water programs fail to create long-lasting solutions because safe drinking water problems are complex and necessitate multiple kinds of expertise at several levels of influence over often long periods of time to succeed. Such work is especially challenging in a service-learning context. Process-oriented ways of working such as evaluative thinking and community engagement may be useful ways to frame iterative phases of work on drinking water projects. Here we describe our use of both in an interdisciplinary university student project to develop and implement collaborative plans for a safe drinking water intervention in peri-urban Guatemala, complications related to its implementation, and measures and sources of data for evaluating health, energy, and cost outcomes over time. We also assess our successes and failures to date. Though full implementation of the intervention has not been achieved and work is ongoing, we provide this report as an outline which other groups pursuing public health engineering projects may find useful.

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Integrating Disease Control Strategies: Balancing Water Sanitation and Hygiene Interventions to Reduce Diarrheal Disease Burden

Abstract: Our findings provide guidance in understanding how to best reduce and eliminate diarrheal disease through integrated control strategies.

Cited by 114 publications

References 26 publications

Causal inference methods to study nonrandomized, preexisting development interventions

Causal inference methods to study nonrandomized, preexisting development interventions

Toilets Can Work: Short and Medium Run Health Impacts of Addressing Complementarities and Externalities in Water and Sanitation

Applying Evaluative Thinking to a Community-Engaged Safe Drinking Water Project in Peri-Urban Guatemala

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