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

doi:10.1093/ije/dyz157

Abstract

BackgroundOpen 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.MethodsWe 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.ResultsIntervention 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).ConclusionsThis 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.

Highlights

Over 2.4 billion people lack access to improved sanitation, and almost one billion people practice open defecation—over half of whom reside in India.[1]
Poor nutritional outcomes are linked with enteric pathogen exposure, with both underweight and stunting associated with poor household and community-level sanitation.[12,13,14]
A total of 1123 households in the intervention villages, and 1275 households in the control villages were enrolled over the four study rounds (Figure 1)

Summary

Introduction

Over 2.4 billion people lack access to improved sanitation, and almost one billion people practice open defecation—over half of whom reside in India.[1]. The government of India has implemented a succession of large-scale sanitation campaigns across the country.[2] With a focus on reducing open defecation, these efforts emphasized toilet construction at the possible expense of sustained coverage and use.[3] Health evaluations of these programmes have shown limited impact, possibly due to sub-optimal increases in community-level sanitation coverage and use.[2,4,5]. 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.

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