Household Sanitation Facilities Research Articles

Undernutrition among children and its determinants across the parliamentary constituencies of India: a geospatial analysis.

In India, undernutrition among children has been extremely critical for the last few decades. Most analyses of undernutrition among Indian children have used the administrative boundaries of a state or a district level as a unit of analysis. This paper departs from such a practice and focuses instead on the political boundaries of a parliamentary constituency (PC) as the unit of analysis. The PC is a critical geopolitical unit where political parties and party candidates make election promises and implement programmes to improve the socio-economic condition of their electorate. A focus on child undernutrition at this level has the potential for greater policy and political traction and could lead to a paradigm shift in the strategy to tackle the problem by creating a demand for political accountability. Different dimensions and new approaches are also required to evaluate the socio-economic status and generate concrete evidence to find solutions to the problem. Given the significance of advanced analytical methods and models embedded into geographic information system (GIS), the current study, for the first time, uses GIS tools and techniques at the PC level, conducting in-depth analysis of undernutrition and its predictors. Hence, this paper examines the spatial heterogeneity in undernutrition across PCs by using geospatial techniques such as univariate and bivariate local indicator of spatial association and spatial regression models. The analysis highlights the high-low burden areas in terms of local hotspots and identifies the potential spatial risk factors of undernutrition across the constituencies. Striking variations in the prevalence of undernutrition across the constituencies were observed. Most of these constituencies that performed poorly both in terms of child nutrition and socio-economic indicators were located in the northern, western, and eastern parts of India. A statistically significant association of biological, socio-economic, and environmental factors such as women's body mass index, anaemia in children, poverty, household sanitation facilities, and institutional births was established. The results highlight the need to bring in a mechanism of political accountability that directly connects elected representatives to maternal and child health outcomes. The spatial variability and pattern of undernutrition indicators and their correlates indicate that priority setting in research may also be greatly influenced by the neighbourhood association.

Transition in availability of improved sanitation facilities and its effect on diarrhoeal disease in India: evidence from longitudinal data.

Poor sanitation, such as open defecation, is a major public health concern in India, causing diarrhoea and other infectious diseases. So far, few studies have linked poor sanitation with diarrhoea using longitudinal data. In this context, this study assesses the transition in availability of household sanitation facilities and its effect on diarrhoeal morbidity. We used two waves of longitudinal data from the India Human Development Survey, conducted in 2004-2005 and 2011-2012, and based on 34131 followed-up households using a two-stage stratified random sampling method. In the first stage, multinomial logistic regression was used to assess socio-economic factors contributing to the transition in the availability of household sanitation facilities. In the second stage, multivariate linear regression was performed to examine the effect of the change in the availability of household sanitation facilities on the prevalence of diarrhoeal morbidity. All the analysis in this study was carried out by using Stata version 13 software. The findings reveal that the practice of open defecation was continued to be higher among lower socio-economic households than better-off socio-economic households in both 2004-2005 and 2011-2012. The proportion of household members who fell sick due to diarrhoea morbidity has decreased significantly (β=-0.06, p<0.04) among households that switched from open defecation in 2004-2005 to improved sanitation facilities in 2011-12, compared to households that continued to practice open defecation in both periods (2004-2005 and 2011-2012). The share of household members who fell sick due to diarrhoeal morbidity was significantly lower (β=-0.09, p<0.001) among the households who adopted improved toilet facilities in both periods (2004-2005 and 2011-2012) as compared with the households who continued to defecate openly in both periods, net of other covariates. Our findings show that there is a need to strengthen existing policies focusing on lower socio-economic groups to improve sanitation and eliminate its related diseases. In particular, the ongoing 'Clean India Mission' should play a critical role in promoting sanitation for all.

Holding the State Accountable: Feminising Work and Responsibility

The article discusses an increasingly commonplace phenomenon whereby women take on the formidable challenge of holding state actors accountable for the survival and well-being of their working class and land-poor communities. Women provide the bottom-up pressure, be it through negotiations or agitational collective action, that pushes the state to fulfils its commitment to provide water, subsidised food, essential household commodities, public transport and sanitation facilities. This article argues that this labour is both skill-building and exhausting and points to its ‘irreducibly political’ nature. The article also discusses the parallels with the women members of self-help groups relentlessly conducting complex negotiations with multiple institutional actors in order to realise their policy entitlements of bank linkage and anti-poverty loans. While some forms of women’s action vis-à-vis state actors are collaborative in nature, others are more conflictual and confrontationist, depending on local contexts and conditions.

Barriers and bridges on water management in rural Mexico: from water-quality monitoring to water management at the community level.

Access to sufficient water of suitable quality represents a challenge for achieving several dimensions of sustainable development. Currently, water access is restricted to three of 10 persons globally. In rural areas of Mexico and other low-income countries, coverage could be even less due to the absence of formal supply; thus, rural communities usually perform water management. Surrounding community-based water management, various socio-ecological interactions emerge that determine access to water. Access to water will depend on the obstacles or capacities that arise within the socio-ecological system in which the community is immersed. This work identifies barriers and bridges to water access in a rural environment through mixed methods. The article draws on three case studies in southeastern Mexico by analyzing 90 questionnaires conducted at the household level and three focus groups in parallel with water quality analysis and its relationship with management practices. The barriers and bridges were classified into six water access challenges: (i) access to water in a sufficient quantity, (ii) access to water of adequate quality, (iii) access to water for household crop irrigation, (iv) hygiene and sanitation facilities, (v) collective organization, and (vi) climate variability. The main findings indicate that households’ water quantity and quality show deficiencies due to the lack of formal infrastructure and represent a health risk. Water fetching has the highest impact on women and children in poor rural areas, and it is a significant barrier to sustainable development. In contrast, the collective organization proved to be an essential bridge for water access in these communities.

Inequalities in the health, nutrition, and wellbeing of Afrodescendant women and children: A cross-sectional analysis of ten Latin American and Caribbean countries

Afrodescendants are systematically affected by discrimination in the Americas and few multi-country studies addressed ethnic inequalities in health and wellbeing in the region. We aimed to investigate gaps in coverage of key health outcomes and socioeconomic inequalities between Afrodescendants and non-Afrodescendants populations in Latin American and Caribbean countries. Using national household surveys (2011-2019) from ten countries, we analyzed absolute inequalities between Afrodescendants and a comparison group that includes non-Afrodescendants and non-Indigenous individuals (henceforth non-Afrodescendants) across 17 indicators in the continuum of reproductive, maternal, newborn, child, and adolescent health. These include indicators of family planning, antenatal care, delivery assistance, child nutrition, immunization coverage, child protection, access to improved water, sanitation and hygiene, adolescent fertility, and early childhood mortality. Inequalities between country-specific subgroups of Afrodescendants were also explored. The slope index of inequality was used to assess wealth-based inequalities within each ethnic group. Afrodescendants represented from 2·8% (Honduras) to 59·1% (Brazil) of the national samples. Of the 128 combinations of country and indicators with data, Afrodescendants fared worse in 78 (of which 33 were significant) and performed better in 50 (15 significant). More systematic disadvantages for Afrodescendants were found for demand for family planning satisfied, early marriage, and household handwashing and sanitation facilities. In contrast, Afrodescendants tended to present lower c-section rates and lower stunting prevalence. Honduras was the only country where Afrodescendants performed better than non-Afrodescendants in several indicators. Wealth gaps among Afrodescendants were wider than those observed for non-Afrodescendants for most indicators and across all countries. Gaps in health outcomes between Afrodescendants and non-Afrodescendants were observed in most countries, with more frequent disadvantages for the former although, in many cases, the gaps were reversed. Wealth inequalities within Afrodescendants tended to be wider than for non-Afrodescendants. Pan American Health Organization, Bill and Melinda Gates Foundation, and the Wellcome Trust.

Determining the Factors That Influence Stunting during Pandemic in Rural Indonesia: A Mixed Method.

Objective: Pandemic causes an increase in the poverty rate. The consequences will be many, including the birth of stunting babies. The COVID-19 pandemic has had an impact on stunting. Analyzing the factors that cause stunting during a pandemic will provide suggestions for effective stunting prevention strategies at the national, regional, community, and household levels. This study aims to determine the factors that influence stunting during the pandemic. Method: We use mixed methods. The respondents of this study were 152 mothers of the Maternal and Child Nutrition Security project, and the sampling technique is Cluster Sampling. Quantitatively using a baseline survey whose analysis uses multiple logistic regression to determine the unadjusted and adjusted odds ratio. The qualitative data used focus group discussions which were analyzed using Nvivo 12 with a questionnaire, and anthropometric measurements of children from surveyed households. Results: This study summarizes the multivariate analysis of stunting determinants in the pandemic era, revealing statistically significant interactions between household sanitation facilities and household water treatment. Significant risk factors for severe stunting during the pandemic were male gender, older child age, coming from a low socioeconomic quintile, not participating in prenatal care at a health facility, and mother’s involvement in choices about what to prepare for Community House. The FGDs identified misinformation about childcare and consumption of sweetened condensed milk as significant contributors to child malnutrition. Conclusions: Lack of sanitation facilities and untreated water are contributing factors. Water, sanitation, and hygiene initiatives must be included into Indonesian policies and programs to combat child stunting during a pandemic. The need for further research related to government assistance for improving toddler nutrition, as well as the relationship between WASH and linear development in early infancy should be explored.

Responsive Prediction Model of Stunting in Toddlers in Indonesia

Stunting is a global incident. The Report Global Nutrition Targets 2025 estimates that around 171 million to 314 million children under five year are stunted and 90% of them are in Asian countries including Indonesia. The purpose of this study was to develop responsive prediction index models ofstunting in toddler in Indonesia. Development of the index model used mathematical formulations using the TPB / SDGs indicator and food environment indicators. Time series-aggregate data were selected 14 variables based on data availability from 34 provinces in Indonesia in the span of 4 years (2015 - 2018). Furthermore, the index validation used the backward regression method with IBM SPSS Statistics version 22. The results showed that households with malaria incidence per 1000 people (X3), the population literacy rate is ≥15 years(X10), households have access to proper sanitation services (X13), and all methods of CPR for married couple aged 15-49 years (X14) was a responsive predictor of stunting in toddler in Indonesia. The index model was stated by the equation Ŷ=67,464-0,318X_9-0,571X_14-0,186X_12 with a R2 value of 49.9% and Radj value of 44.9%. Regarding the results of this study, it is suggested to consider the fulfillment of access to household sanitation facilities, specifically in resident area and vulnerable groups such as malaria endemic areas, increasing literacy, especially maternal literacy, and increasing use of all CPR way for EFA aged 15-49 years.

Influence of Maternal Exposure to Mass Media on Growth Stunting Among Children Under Five: Mediation Analysis Through the Water, Sanitation, and Hygiene Program.

BackgroundThe issue of malnutrition in the Democratic Republic of Congo is severe. Meanwhile, the Water, Sanitation, and Hygiene program has been demonstrated to be effective in reducing the rates of growth stunting among children.ObjectiveWe aimed to explore the association between maternal exposure to mass media and stunting in children through water, sanitation, and hygiene behaviors.MethodsMediation analysis was conducted using data from the 2018 Multiple Indicators Cluster Surveys.ResultsMothers’ exposures to television and the internet in the Democratic Republic of Congo significantly decreases the risk of stunting in children by 5% and 10%, respectively, mediated by household water, sanitation, and hygiene facilities and practices.ConclusionsThese findings could inform interventions and policies to reduce the rate of stunting rate children by promoting water, sanitation, and hygiene through mass media, especially through the internet and television.

Kepemilikan Fasilitas Sanitasi Dasar Rumah Tangga Di Desa Air Selumar Kecamatan Sijuk Kabupaten Belitung

Ownership of basic sanitation facilities of the house is one of the conditions of a healthy home. Health problems in the home environment can not be separated from the level of knowledge, attitude, income of the head of the family and the number of dependents of the head of the family. It is seen that there are still people who do not have thoughts about the importance of basic sanitation for their lives and there are still many people who do not have basic sanitation facilities. The purpose of this study is to find out the factors related to the ownership of basic household sanitation facilities in Selumar Water Village, Sijuk Subdistrict, Belitung Regency.This study uses observational analytics method with cross sectional approach. The samples in this study numbered 101 samples, using proportional random sampling method. Research instruments are questionnaires and checklists. Data analysis is performed using Chi square test. Bivariate analysis results show there is a relationship between the level of knowledge and the ownership of basic household sanitation facilities p value=0.000, there is a relationship between attitude with the ownership of basic household sanitation facilities p value=0.005, there is a relationship between the level of income and the ownership of basic household sanitation facilities p value=0.000, there is a relationship between the number of family members and the ownership of basic household sanitation facilities p value=0.016. The level of knowledge, attitude, income level and number of family members relates to the ownership of basic household sanitation facilities in Selumar Water Village, Sijuk Subdistrict, Belitung Regency

Household sanitation and menstrual hygiene management among women: Evidence from household survey under Swachh Bharat (Clean India) Mission in rural Odisha, India.

Introduction:Discussion on women empowerment without addressing their basic needs would be meaningless. As such, the needs of women and girls have been prioritized in global sanitation efforts including menstrual hygiene. However, there is little research on existing approaches on menstrual management. India’s most ambitious sanitation campaign named Swachh Bharat Mission or “Clean India Mission” aimed to achieve universal sanitation coverage in every single household, targeted to end open defecation by October 02, 2019. This study aimed to assess the women’s perception of household sanitation facilities and menstrual hygiene management experience in Odisha under Swachh Bharat Mission.Methods:The study is a community-based survey having cross-sectional in nature conducted among 700 rural women and girls aged 15–45 years in the Balesore district of Odisha state in India from January to April 2021. A multi-stage sampling method was adopted to select the study participants. Data was collected using a pretested questionnaire based on the Performance Monitoring and Accountability 2020 survey questionnaire and analyzed by SPSS version 25. Descriptive statistics was used to assess the household sanitation and menstrual hygiene management experience among women.Results:More than two-thirds (68.4%) of rural households use improved sanitation facilities. Around 30% of families have inadequate sanitation infrastructure, which means at least one household member defecates in the open space. Nearly 64.6% disposed of their menstrual absorbents in the bush or field, while 29.1% disposed in the river and 24.1% in the waste bin. Still, 40.6% of women were using clothes as menstrual absorbents, and 54.9% of the respondents reported washing their menstrual materials for re-use. Of those who washed and re-used, 99.2% said their re-use material was completely dry before re-use. About 69.7% of the respondents mentioned that they change their menstrual absorbents in sleeping areas at home. About 91% of the respondents reported that the place where they changed their menstrual absorbents was safe, clean, and private. Only 22.5% of women responded to having water and soap at their menstruation management area.Conclusion:The effort for improvements in sanitary techniques during menstruation is partly effective in creating healthy behavior. The current strategy for developing programs to adopt menstrual hygiene measures needs a bottom-up approach with women at the center. Components associated with menstrual hygiene management, such as women’s cleanliness, water supply, and the availability and accessibility of disposable sanitary napkins, should be given specific attention. It is essential to acknowledge the issues like toilet construction and behavior change communication to consolidate the gains in an era of “Clean India Mission.”

The Influence of Socioeconomic Status on the Prognosis and Profile of Patients Admitted for Acute Heart Failure during COVID-19 Pandemic: Overestimated Aspects or a Multifaceted Hydra of Cardiovascular Risk Factors?

Background: Heart failure (HF) is a complex clinical syndrome that represents a great burden on public health systems due to its increased prevalence, disability and mortality rates. There are multiple triggers that can induce or aggravate a preexisting HF, socioeconomic status (SES) emerging as one of the most common modifiable risk factors. Our study aimed to analyze the influence of certain SES indicators on the outcome, clinical aspects and laboratory parameters of patients with HF in North-Eastern Romania, as well as their relationship with other traditional cardiovascular risk factors. Methods: We conducted a prospective, single-center study comprising 120 consecutively enrolled patients admitted for acute HF. The evaluation of individual SES was based upon a standard questionnaire and evidence from official documents. Results: the patients’ age ranged between 18 and 94 years; Out of 120 patients, 49 (40.8%) were women and 71 (59.2%) were men, residing in rural 59 (49.2%) or urban 61 (50.8%) areas. 14.2% were university graduates, while 15.8% had only attended primary school. The majority of the patients are or were employed in the service sector (54.5%), followed by industry (29.2%) and agriculture (20%). The mean monthly income was 306.1 ± 177.4 euro, while the mean hospitalization cost was 2471.8 ± 2073.8 euro per patient. The individual income level was positively correlated with urban area of residence, adequate household sanitation facilities and healthcare access, and negatively associated with advanced age and previous hospitalizations due to HF. However, the individual financial situation was also positively correlated with the increased prevalence of certain cardiovascular risk factors, such as arterial hypertension, anemia or obesity, but not with total cholesterol or male gender. Concerning the direct impact of a poor economic status upon prognosis in the setting of acute HF, our results showed no statistically significant differences concerning the in-hospital or at 1-month follow-up mortality rates. Rather than inducing a direct impact on the short-term outcome, these findings concerning SES indicators are meant to enhance the implementation of policies aimed to provide adequate healthcare for people from all social layers, with a primary focus on modifiable cardiovascular risk factors.

HUBUNGAN MIGRASI TERHADAP TINGKAT KUALITAS SARANA SANITASI RUMAH TANGGA DI JAKARTA: ANALISIS DATA MIKRO SUSENAS 2017

Jakarta's population is influenced by dynamic population growth regarding high migration flows. Migrants can be a resource in urban development and a burden to the environment concerning population density. For instance, problems of housing provision and basic sanitation services. This study aims to identify the relationship of migration on the quality household sanitation facilities level in Jakarta. This study uses multinomial logistic regression as an analytical method by applying three migration relationships models to the quality level of household sanitation facilities. The source for the analysis is Susenas microdata of 2017. Research findings specifically indicate a significant influence of recent migration on the quality level of household sanitation facilities. It confirmed that migrant households who have stayed longer (migrant lifetime and non-migrant recent) have the opportunity to safe sanitation facilities. Similar opportunities apply to recent migrants with characteristics of older age, higher education, and high expenditure. Conversely, this study found the percentage of households within the lowest category that is identical to the lease housing status with improper living conditions. To reduce the number of the latter category, the local government needs preventive planning in dealing with migration flow. Therefore, migrants can have a comfortable life in the city.

Household sanitation access and risk for non-marital sexual violence among a nationally representative sample of women in India, 2015-16.

BackgroundLack of household sanitation, specifically toilet facilities, can adversely affect the safety of women and girls by requiring them to leave their households to defecate alone and at night, leaving them more vulnerable to non-marital sexual violence. This study analyzes the association between household sanitation access and past year victimization from non-marital sexual violence (NMSV) in India.MethodsWe analyzed 74,698 women age 15–49 from whom information on NMSV was collected in India's National Family Health Survey 2015–16 (NFHS-4). We used multivariable logistic regression to test the relationship between women's household sanitation access and recent NMSV experience, controlling for socioeconomics (SES;e.g., age, marital status, caste, wealth, employment), for the total sample and stratified by rural/urban, given lower access to sanitation and lower NMSV in rural contexts.ResultsWe found that 46.2% of households in our sample lacked their own private sanitation facilities (58.0% rural; 24.5% urban) and were forced to openly defecate (37.3%) or walk to a shared sanitation facility (8.9%), and 0.45% of women report NMSV in the last 12 months (0.33% rural; 0.68% urban). Our multivariable model indicated no significant association between having private household sanitation facilities and NMSV for the total sample, but stratified analyses indicate a significant association for rural but not urban women. In rural India, those who lack private household sanitation, compared to those with a household toilet, have significantly greater odds of NMSV (AOR = 2.45; p < 0.05). These findings persist after accounting for demographics including age and marital status, socio-economic factors related to marginalization (e.g., caste, wealth), women's employment, and the overall climate of the state.ConclusionFindings from this study support prior research suggesting that poor access to sanitation is associated with women's risk for NMSV in rural India. This may be via increased exposure, and/or as a marker for greater vulnerability to NMSV beyond what is explained by other SES indicators. Solutions can include increased access to private household sanitation and more targeted NMSV prevention in rural India.

Sanitation and Hygiene Practices in Small Towns in Tanzania: The Case of Babati District, Manyara Region.

.Formative research findings from the fast-growing Babati town were used to assess the prevalence of sanitation and hygiene practices among individuals and institutions and associated factors. A cross-sectional study involving household surveys, spot-checks, focus group discussions, in-depth interviews, and structured observations of behaviors showed that 90% of households have sanitation facilities, but 68% have safely managed sanitation services. The most common types of household sanitation facilities were pit latrines with slab (42%) followed by flush/pour flush toilets (32%). Therefore, the management of wastewater depends entirely on onsite sanitation systems. The majority of households (70%) do not practice proper hygiene behaviors. Thirteen percent of the households had handwashing stations with soap and water, handwashing practice being more common to women (38%) than men (18%). The reported handwashing practices during the four critical moments (handwashing with soap before eating and feeding, after defecation, after cleaning child’s bottom, and after touching any dirt/dust) differed from the actual/observed practices. Households connected to the town’s piped water supply were more likely to practice handwashing than those not directly connected. Sanitation and hygiene behaviors of the people in the study area were seen to be influenced by sociodemographic, cultural, and economic factors. The conditions of sanitation and hygiene facilities in public places were unsatisfactory. There is an urgent need to ensure that the sanitation and hygiene services and behaviors along the value chain (from waste production/source to disposal/end point) are improved both at the household level and in public places through improved sanitation services and the promotion of effective hygiene behavior change programs integrated into ongoing government programs and planning.

The improved and the unimproved: Factors influencing sanitation and diarrhoea in a peri-urban settlement of Lusaka, Zambia.

Accounting for peri-urban sanitation poses a unique challenge due to its high density, unplanned stature, with limited space and funding for conventional sanitation instalment. To better understand users, needs and inform peri-urban sanitation policy, our study used multivariate stepwise logistic regression to assess the factors associated with use of improved (toilet) and unimproved (chamber) sanitation facilities among peri-urban residents. We analysed data from 205 household heads in 1 peri-urban settlement of Lusaka, Zambia on socio-demographics (economic status, education level, marital status, etc.), household sanitation characteristics (toilet facility, ownership and management) and household diarrhoea prevalence. Household water, sanitation and hygiene (WASH) facilities were assessed based on WHO-UNICEF criteria. Of particular interest was the simultaneous use of toilet facilities and chambers, an alternative form of unimproved sanitation with focus towards all-in-one suitable alternatives. Findings revealed that having a regular income, private toilet facility, improved drinking water and handwashing facility were all positively correlated to having an improved toilet facility. Interestingly, both improved toilets and chambers indicated increased odds for diarrhoea prevalence. Odds of chamber usage were also higher for females and users of unimproved toilet facilities. Moreover, when toilets were owned by residents, and hygiene was managed externally, use of chambers was more likely. Findings finally revealed higher diarrhoea prevalence for toilets with more users. Results highlight the need for a holistic, simultaneous approach to WASH for overall success in sanitation. To better access and increase peri-urban sanitation, this study recommends a separate sanitation ladder for high density areas which considers improved private and shared facilities, toilet management and all-inclusive usage (cancelling unimproved alternatives). It further calls for financial plans supporting urban poor access to basic sanitation and increased education on toilet facility models, hygiene, management and risk to help with choice and proper facility use to maximize toilet use benefit.

Variation in E. coli concentrations in open drains across neighborhoods in Accra, Ghana: The influence of onsite sanitation coverage and interconnectedness of urban environments.

Alongside efforts to improve safe management of feces along the entire sanitation chain, including after the toilet, global sanitation efforts are focusing on universal access ‘basic’ services: onsite facilities that safely contain excreta away from human contact. Although fecal sludge management is improving in urban areas, open drains remain a common fate for feces in these often densely-populated neighborhoods in low-income countries. To-date, it is unclear to what extent complete coverage of onsite sanitation reduces fecal contamination in the urban environment and how fecal contamination varies within urban drains across neighborhoods by sanitation status within a city. We assessed how neighborhood levels of environmental fecal contamination (via spatially-representative sampling of open drains for E. coli) varied across four neighborhoods with varying income, type and coverage of household sanitation facilities, and population density in Accra, Ghana. Neighborhoods with very high sanitation coverage (≥89%) still had high (>4 log10 CFU/100 mL) E. coli concentrations in drains. Between-neighborhood variation in E. coli levels among the high coverage neighborhoods was significant: drain concentrations in neighborhoods with 93% and 89% coverage (4.7 (95% CI: 4.5, 4.9) & 4.9 (95% CI: 4.5, 5.3) log10 CFU/100 mL, respectively) were higher than in the neighborhood with 97% coverage (4.1 log10 CFU/100 mL, 95% CI: 3.8, 4.4 log10 CFU/100 mL). Compared with the highest coverage neighborhood, the neighborhood with lowest coverage (48%) also had higher E. coli concentrations (5.6 log10 CFU/100 mL, 95% CI: 5.3, 5.9 log10 CFU/100 mL). Although fecal contamination in open drains appeared lower in neighborhoods with higher onsite sanitation coverage (and vice versa), other factors (e.g. fecal sludge management, animals, population density) may affect drain concentrations. These results underscore that neighborhood-level onsite sanitation improvements alone may not sufficiently reduce fecal hazards to public health from open drains. These findings supporting the need for integrated, city-level fecal sludge management alongside multifaceted interventions to reduce fecal contamination levels and human exposure.

Water, sanitation, and hygiene practices mediate the association between women's empowerment and child length-for-age z-scores in Nepal.

In Nepal, more than one-third of children are stunted. Prior studies have shown that women's empowerment in agriculture is associated with child (<2years) length-for-age z-scores (LAZ) in Nepal. This study tests whether child dietary diversity (DD) and household water, sanitation, and hygiene (WASH) facilities and practices mediate the associations between women's empowerment and LAZ. With a cross-sectional dataset of 4,080 households from 240 rural communities across 16 districts of Nepal, we used ordinary least squares regression models to first estimate the associations between women's empowerment and LAZ for children 6 to 24months (n=1,402; our previous published analysis included all children <24months of age), using the Women's Empowerment in Agriculture Index's Five Domains of Empowerment subindex. We used standardized structural equation models to test whether child DD and/or household WASH mediated the association between women's empowerment and child LAZ. Overall, women's empowerment was positively associated with child LAZ (β=0.24, P=0.03), as found in our previous analyses. In the mediation analysis, women's empowerment was positively associated with WASH (β=0.78, P<0.001), and in turn child LAZ (β=0.09, P<0.001). Women's empowerment was not associated with DD, but DD was associated with LAZ (β=0.06, P=0.05). Empowered women had better WASH practices than nonempowered women, which translated into higher child LAZ. Child DD was not a mediating factor in the association between women's empowerment and child LAZ. More research is needed to explore other pathways by which women's empowerment may affect child nutrition outcomes.

Urban sanitation coverage and environmental fecal contamination: Links between the household and public environments of Accra, Ghana.

Exposure to fecal contamination in public areas, especially in dense, urban environments, may significantly contribute to enteric infection risk. This study examined associations between sanitation and fecal contamination in public environments in four low-income neighborhoods in Accra, Ghana. Soil (n = 72) and open drain (n = 90) samples were tested for E. coli, adenovirus, and norovirus. Sanitation facilities in surveyed households (n = 793) were categorized by onsite fecal sludge containment (“contained” vs. “uncontained”) using previous Joint Monitoring Program infrastructure guidelines. Most sanitation facilities were shared by multiple households. Associations between spatial clustering of household sanitation coverage and fecal contamination were examined, controlling for neighborhood and population density (measured as enumeration areas in the 2010 census and spatially matched to sample locations). E. coli concentrations in drains within 50m of clusters of contained household sanitation were more than 3 log-units lower than those outside of clusters. Further, although results were not always statistically significant, E. coli concentrations in drains showed consistent trends with household sanitation coverage clusters: concentrations were lower in or near clusters of high coverage of household sanitation facilities—especially contained facilities—and vice versa. Virus detection in drains and E. coli concentrations in soil were not significantly associated with clustering of any type of household sanitation and did not exhibit consistent trends. Population density alone was not significantly associated with any of the fecal contamination outcomes by itself and was a significant, yet inconsistent, effect modifier of the association between sanitation clusters and E. coli concentrations. These findings suggest clustering of contained household sanitation, even when shared, may be associated with lower levels of fecal contamination within drains in the immediate public domain. Further research is needed to better quantify these relationships and examine impacts on health.

Household sanitation is associated with lower risk of bacterial and protozoal enteric infections, but not viral infections and diarrhoea, in a cohort study in a low-income urban neighbourhood in Vellore, India.

ObjectiveThis study examined associations between household sanitation and enteric infection – including diarrhoeal‐specific outcomes – in children 0–2 years of age in a low‐income, dense urban neighbourhood.MethodsAs part of the MAL‐ED study, 230 children in a low‐income, urban, Indian neighbourhood provided stool specimens at 14–17 scheduled time points and during diarrhoeal episodes in the first 2 years of life that were analysed for bacterial, parasitic (protozoa and helminths) and viral pathogens. From interviews with caregivers in 100 households, the relationship between the presence (and discharge) of household sanitation facilities and any, pathogen‐specific, and diarrhoea‐specific enteric infection was tested through mixed‐effects Poisson regression models.ResultsFew study households (33%) reported having toilets, most of which (82%) discharged into open drains. Controlling for season and household socio‐economic status, the presence of a household toilet was associated with lower risks of enteric infection (RR: 0.91, 95% CI: 0.79–1.06), bacterial infection (RR: 0.87, 95% CI: 0.75–1.02) and protozoal infection (RR: 0.64, 95% CI: 0.39–1.04), although not statistically significant, but had no association with diarrhoea (RR: 1.00, 95% CI: 0.68–1.45) or viral infections (RR: 1.12, 95% CI: 0.79–1.60). Models also suggested that the relationship between household toilets discharging to drains and enteric infection risk may vary by season.ConclusionsThe presence of a household toilet was associated with lower risk of bacterial and protozoal enteric infections, but not diarrhoea or viral infections, suggesting the health effects of sanitation may be more accurately estimated using outcome measures that account for aetiologic agents.

Effects of neighbourhood and household sanitation conditions on diarrhea morbidity: Systematic review and meta-analysis.

Sanitation in neighbourhood and household domains can provide primary protection against diarrhea morbidity, yet their distinct health benefits have not been succinctly distinguished and reviewed. We present here the first systematic review and meta-analysis of the distinct effect of neighbourhood and household sanitation conditions on diarrhea morbidity. We identified studies reporting the effect of neighbourhood-level exposure to wastewater or household sanitation facilities on diarrhea, by performing comprehensive search on five databases, namely the Cochrane library, PubMed, Embase, Scopus and Web of Science, from the earliest date available to February 2015. Twenty-one non-randomized studies and one randomized controlled trial met the pre-determined inclusion criteria, consisting of six datasets on neighbourhood sanitation conditions (total 8271 subjects) and 20 datasets on household sanitation (total 20021 subjects). We calculated the pooled effect estimates of neighbourhood and household sanitation conditions on diarrhea morbidity using the inverse variance random-effects model. The pooled effect estimates showed that both neighbourhood sanitation conditions (odds ratio = 0.56, 95%CI: 0.40–0.79) and household sanitation (odds ratio = 0.64, 95%CI: 0.55–0.75) are associated with reduced diarrheal illness, and that the magnitudes of the associations are comparable. Evidence of risk of bias and heterogeneity were found in the included studies. Our findings confirm that both neighbourhood sanitation conditions and household sanitation are associated with considerable reduction in diarrhea morbidity, in spite of a number of methodological shortcomings in the included studies. Furthermore, we find evidence that neighbourhood sanitation conditions is associated with similar magnitude of reduction in diarrhea morbidity as household sanitation. The findings suggest that, in addition to household sanitation provision, dual emphasis on neighbourhood sanitation through public sanitation infrastructure provision and community-wide sanitation adoption is advisable for effective reduction of diarrheal disease burden.