Sanitation Interventions Research Articles

Influence of community-level sanitation coverage and population density on environmental fecal contamination and child health in a longitudinal cohort in rural Bangladesh.

BackgroundHousehold-level sanitation interventions have had limited effects on child health or environmental contamination, potentially due to low community coverage. Higher community-level coverage with safely managed sanitation can reduce opportunities for disease transmission.MethodsWe estimated associations between community sanitation coverage, environmental fecal contamination, and child health among 360 compounds in the control arm of the WASH Benefits trial in rural Bangladesh (NCT01590095). In each compound, we enumerated E. coli in environmental samples and recorded the 7-day prevalence of caregiver-reported diarrheal disease and acute respiratory infections (ARI) in children under five. We observed indicators of latrine access and quality among all neighboring compounds within 100 m of study compounds. We defined community coverage as the proportion of neighboring compounds with (1) at least one latrine, and (2) exclusively hygienic latrines (improved facility observed to safely contain feces), within both 50 m and 100 m of study compounds. We assessed effect modification by population density and season.ResultsAdjusted for confounders, study compounds surrounded by 100% coverage of at least one latrine per compound within 50 m had slightly lower log10E. coli counts in stored water (Δlog = −0.13, 95% CI -0.26, −0.01), child hand rinses (Δlog = −0.13, 95% CI -0.24, −0.02), and caregiver hand rinses (Δlog = −0.16, 95% CI -0.29, −0.03) and marginally lower prevalence of diarrheal disease (prevalence ratio [PR] = 0.82, 95% CI 0.64, 1.04) and ARI (PR = 0.84, 95% CI 0.69, 1.03) compared to compounds surrounded by <100% coverage. Effects were similar but less pronounced at 100 m. At higher population densities, community latrine coverage was associated with larger reductions in E. coli on child and caregiver hands and prevalence of diarrheal disease. Coverage with exclusively hygienic latrines was not associated with any outcome.ConclusionHigher community sanitation coverage was associated with reduced fecal contamination and improved child health, with stronger effects at highly local scales (50m) and at high population densities. Our findings indicate that the relationship between community sanitation coverage, environmental contamination, and child health varies by definition of coverage, distance, and population density. This work highlights significant uncertainty around how to best measure sanitation coverage and the expected health effects of increasing sanitation coverage using a specific metric. Better understanding of community-level sanitation access is needed to inform policy for implementing sanitation systems that effectively protect community health.

Econometry Modeling in Analyzing the Determinants of Increasing Life Expectation Rate

Human capital is a term that refers to human self-development in the fields of education, health, and other potentials for increasing productivity. These efforts will be realized if there is awareness, willingness, and ability to live healthily in everyone. This study aimed to analyze the Econometric Model in increasing Life Expectancy with Environmental Sanitation, Health Services, and Immunization Interventions in West Nusa Tenggara. This research was carried out in 10 the Regency/City of West Nusa Tenggara Province, using econometric modeling, namely performing panel data regression with eviews 11 as an analytical tool. The results of econometric modeling found that the life expectancy in West Nusa Tenggara in 2035 was 0.57 months under normal conditions. After intervention with the environmental sanitation variable, the life expectancy in 2035 was 1.08 months, meaning there was an increase of 0.4 months; Health variables, especially delivery assistance carried out by health workers, become the main priority in the model, which can increase life expectancy by 11 months three weeks six days; and the increase in Life Expectancy in West Nusa Tenggara from the aspect of community behavior.

Specific Nucleic AcId Ligation for the detection of Schistosomes: SNAILS.

Schistosomiasis, also known as bilharzia or snail fever, is a debilitating neglected tropical disease (NTD), caused by parasitic trematode flatworms of the genus Schistosoma, that has an annual mortality rate of 280,000 people in sub-Saharan Africa alone. Schistosomiasis is transmitted via contact with water bodies that are home to the intermediate host snail which shed the infective cercariae into the water. Schistosome lifecycles are complex, and while not all schistosome species cause human disease, endemic regions also typically feature animal-infecting schistosomes that can have broader economic and/or food security implications. Therefore, the development of species-specific Schistosoma detection technologies may help to inform evidence-based local environmental, food security and health systems policy making. Crucially, schistosomiasis disproportionally affects low- and middle-income (LMIC) countries and for that reason, environmental screening of water bodies for schistosomes may aid with the targeting of water, sanitation, and hygiene (WASH) interventions and preventive chemotherapy to regions at highest risk of schistosomiasis transmission, and to monitor the effectiveness of such interventions at reducing the risk over time. To this end, we developed a DNA-based biosensor termed Specific Nucleic AcId Ligation for the detection of Schistosomes or 'SNAILS'. Here we show that 'SNAILS' enables species-specific detection from genomic DNA (gDNA) samples that were collected from the field in endemic areas.

The Effect of Improved Sanitation on Linear Growth Amongst Children Living in Developing Countries: a Systematic Review

Constant exposure to poor sanitation contribute to the environmental enteric dysfunction-a disorder that is frequently implicated as a cause of linear growth failure. We aimed to evaluate the efficacy of water, sanitation, and hygiene (WaSH) interventions on linear growth amongst children aged 0-24 months. We reviewed fourteen studies retrieved from AMED, CINAHL, DOAJ, PubMed, PsycINFO, Google Scholar, and EMBASE databases following guidelines developed by PROSPERO and COCHRANE. The screening process was summarized using a PRISMA flow diagram, and the methodologies were critically appraised by a Mixed Method Appraisal Tool. No difference was seen in mean height for age Z-score (0.01, 95% CI-0.16 to 0.18) between children who received WaSH interventions and those who did not. Only 5 studies reported a significant association between WaSH and child linear growth (P &lt; 0.001). All combination intervention studies include in this review did not establish any significant benefit of WaSH and nutrition integration. Although robust sanitation coverage could be an important component amongst proven interventions to stimulate linear growth, stunted growth is embedded within myriad determinants beyond improved sanitation. More research is needed to quantify the complementary effect of WaSH and nutrition co-programming. This systematic review was registered in the PROSPERO database with registration number CRD42022322462.

Preconditions, processes and structures: Interorganisational collaboration in the provision of post-disaster water, sanitation and hygiene (WASH) services

Emergency water, sanitation, and hygiene (WASH) interventions are critical to avoid transmission of infectious diseases and limit susceptibility to disease-bearing vectors. Non-Governmental Organisations (NGOs) play a critical role in developing WASH programs, working with government organisations (GOs), specifically during the post-disaster phase, whether during recovery or reconstruction periods. Developing effective collaboration between GOs and NGOs can form a well-focused relationship leading to effective outcomes. Lack of collaboration may result in negative outcomes, including significant infrastructure destruction, loss of life and property, and lack of access to WASH service. The aim of the paper is to identify the factors influencing collaboration between GOs and NGOs to provide WASH services in the post-disaster phase. The research methodology is underpinned by qualitative approach using data collected using semi-structured interviews. The result obtained from analysing data from thirty interviewees support the preconditions, processes, and structural factors of collaboration.The findings suggest that the increasing complexity of disasters and the lack of capacity of GOs alone to manage these disasters have created interdependency between GO and NGOs. Moreover, good relationship history and a shared vison between GOs and NGOs are key preconditions for effective collaboration. The structures for effective GO-NGO collaboration require good coordination, good legislation, and an administrative system with legitimised coordinators/administrators, backed up by clear descriptions of the roles and responsibilities of stakeholders. The processes relating to planning, developing mutual understanding, communication, and cooperation is key for collaboration between GOs and NGOs. Furthermore, the findings identified trust and power as the mediator factors integrating with the precondition, process, and structure variables for GO-NGO collaboration for the effective delivery of public services in times of crisis.

Qualitative and Quantitative Analysis of Latrine Management Approaches in Internally Displaced Persons Camps in Myanmar.

Water, sanitation, and hygiene (WASH) interventions provide dignity and prevent disease transmission. Sanitary facility provision (e.g., latrines) is a key WASH priority in all phases of humanitarian response. Currently, there are evidence gaps on field effectiveness of sanitation approaches, particularly in protracted crises. Thus, we conducted a qualitative and quantitative evaluation of sanitation approaches in internally displaced persons (IDP) camps in Myanmar. We conducted 36 focus group discussions, 65 household surveys, and 32 key informant interviews in Rakhine and Kachin states; results were analyzed qualitatively. We found family-shared, gender-segregated latrines were the preferred approach. Acceptance was a result of gender segregation, followed by lighting, state of repair, cleanliness, design, and distance from household. Contextual factors influencing sanitation approach development and acceptance were cultural and religious beliefs, community cohesion, camp size, livelihood access, land ownership and availability, and responding agency type. Overall, sanitation approaches generally met IDP needs; however, access was limited for children, the elderly, and people with special needs (including persons with disabilities). We recommend implementers of latrine programs in protracted contexts conduct community consultations, consider gender segregation, be flexible in considering context-specific solutions, prioritize access and dignity, and be inclusive of vulnerable groups.

Sanitation Pattern and its Impact on Child in Relation to their Diarrheal Disease of two Upazilla under Satkhira District

The sanitation pattern is not so good in rural areas of Bangladesh. About 2.2 million children died of diarrhea disease around the world and these deaths represent approximately 15% of all child deaths under the age of five in developing countries. For this study, two rural areas of Satkhira District of Bangladesh were selected. The information was collected from households that had children under 5 years old. The majority of the locals are illiterate and impoverished. They have a low income and are not well aware of sanitation and children’s diarrhea. Most people use tubewell water for drinking purposes and others use ponds, rivers and hand pump water for domestic purposes. Water, sanitation, and hygiene interventions reduce diarrheal disease on average by between one-quarter and one-third. New sanitary solutions are required, and the process of acquiring latrines and sewers must be facilitated and supported both legislatively and financially. Public authorities must continue to be responsible for the provision of water that is free of fecal contaminants. In the private domain, hygiene promotion should focus on the elimination of human stools from the domestic environment. We should ensure safe sanitation, clean water and a hygienic environment for children and their survival.&#x0D; Environ. Sci. &amp; Natural Resources, 13(1&amp;2): 100-109, 2020

Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: a systematic review and meta-analysis

SummaryBackgroundEstimates of the effectiveness of water, sanitation, and hygiene (WASH) interventions that provide high levels of service on childhood diarrhoea are scarce. We aimed to provide up-to-date estimates on the burden of disease attributable to WASH and on the effects of different types of WASH interventions on childhood diarrhoea in low-income and middle-income countries (LMICs).MethodsIn this systematic review and meta-analysis, we updated previous reviews following their search strategy by searching MEDLINE, Embase, Scopus, Cochrane Library, and BIOSIS Citation Index for studies of basic WASH interventions and of WASH interventions providing a high level of service, published between Jan 1, 2016, and May 25, 2021. We included randomised and non-randomised controlled trials conducted at household or community level that matched exposure categories of the so-called service ladder approach of the Sustainable Development Goal (SDG) for WASH. Two reviewers independently extracted study-level data and assessed risk of bias using a modified Newcastle-Ottawa Scale and certainty of evidence using a modified Grading of Recommendations, Assessment, Development, and Evaluation approach. We analysed extracted relative risks (RRs) and 95% CIs using random-effects meta-analyses and meta-regression models. This study is registered with PROSPERO, CRD42016043164.Findings19 837 records were identified from the search, of which 124 studies were included, providing 83 water (62 616 children), 20 sanitation (40 799 children), and 41 hygiene (98 416 children) comparisons. Compared with untreated water from an unimproved source, risk of diarrhoea was reduced by up to 50% with water treated at point of use (POU): filtration (n=23 studies; RR 0·50 [95% CI 0·41–0·60]), solar treatment (n=13; 0·63 [0·50–0·80]), and chlorination (n=25; 0·66 [0·56–0·77]). Compared with an unimproved source, provision of an improved drinking water supply on premises with higher water quality reduced diarrhoea risk by 52% (n=2; 0·48 [0·26–0·87]). Overall, sanitation interventions reduced diarrhoea risk by 24% (0·76 [0·61–0·94]). Compared with unimproved sanitation, providing sewer connection reduced diarrhoea risk by 47% (n=5; 0·53 [0·30–0·93]). Promotion of handwashing with soap reduced diarrhoea risk by 30% (0·70 [0·64–0·76]).InterpretationWASH interventions reduced risk of diarrhoea in children in LMICs. Interventions supplying either water filtered at POU, higher water quality from an improved source on premises, or basic sanitation services with sewer connection were associated with increased reductions. Our results support higher service levels called for under SDG 6. Notably, no studies evaluated interventions that delivered access to safely managed WASH services, the level of service to which universal coverage by 2030 is committed under the SDG.FundingWHO, Foreign, Commonwealth & Development Office, and National Institute of Environmental Health Sciences.

Interventions to improve water, sanitation, and hygiene for preventing soil-transmitted helminth infection.

BackgroundIt is estimated that 1.5 billion people are infected with soil‐transmitted helminths (STHs) worldwide. Re‐infection occurs rapidly following deworming, and interruption of transmission is unlikely without complementary control efforts such as improvements in water, sanitation, and hygiene (WASH) access and behaviours.ObjectivesTo assess the effectiveness of WASH interventions to prevent STH infection.Search methodsWe used standard, extensive Cochrane search methods. The latest search date was 19 October 2021.Selection criteriaWe included interventions to improve WASH access or practices in communities where STHs are endemic. We included randomized controlled trials (RCTs), as well as trials with an external control group where participants (or clusters) were allocated to different interventions using a non‐random method (non‐RCTs). We did not include observational study designs. Our primary outcome was prevalence of any STH infection. Prevalence of individual worms was a secondary outcome, including for Ascaris lumbricoides, Trichuris trichiura, hookworm (Ancylostoma duodenale or Necator americanus), or Strongyloides stercoralis. Intensity of infection, measured as a count of eggs per gram of faeces for each species, was another secondary outcome.Data collection and analysisTwo review authors independently reviewed titles and abstracts and full‐text records for eligibility, performed data extraction, and assessed risk of bias using the Cochrane risk of bias assessment tool for RCTs and the EPOC tool for non‐RCTs. We used a random‐effects meta‐analysis to pool study estimates. We used Moran’s I² statistic to assess heterogeneity and conducted subgroup analyses to explore sources of heterogeneity. We assessed the certainty of the evidence using the GRADE approach.Main resultsWe included 32 studies (16 RCTs and 16 non‐RCTs) involving a total of 52,944 participants in the review. Twenty‐two studies (14 RCTs (16 estimates) and eight non‐RCTs (11 estimates)) reported on our primary outcome, prevalence of infection with at least one STH species. Twenty‐one studies reported on the prevalence of A lumbricoides (12 RCTs and 9 non‐RCTs); 17 on the prevalence of T trichiura (9 RCTs and 8 non‐RCTs); 18 on the prevalence of hookworm (10 RCTs and 8 non‐RCTs); and one on the prevalence of S stercoralis (1 non‐RCT). Sixteen studies measured the intensity of infection for an individual STH type. Ten RCTs and five non‐RCTs reported on the intensity of infection of A lumbricoides; eight RCTs and five non‐RCTs measured the intensity of infection of T trichiura; and eight RCTs and five non‐RCTs measured the intensity of hookworm infection. No studies reported on the intensity of infection of S stercoralis.The overall pooled effect estimates showed that the WASH interventions under study may result in a slight reduction of any STH infection, with an odds ratio (OR) of 0.86 amongst RCTs (95% confidence interval (CI) 0.74 to 1.01; moderate‐certainty evidence) and an OR of 0.71 amongst non‐RCTs (95% CI 0.54 to 0.94; low‐certainty evidence). All six of the meta‐analyses assessing individual worm infection amongst both RCTs and non‐RCTs had pooled estimates in the preventive direction, although all CIs encapsulated the null, leaving the possibility of the null or even harmful effects; the certainty of the evidence ranged from very low to moderate. Individual studies assessing intensity of infection showed mixed evidence supporting WASH. Subgroup analyses focusing on narrow specific subsets of water, sanitation, and hygiene interventions did very little to elucidate which interventions might be better than others. Data on intensity of infection (e.g. faecal egg count) were reported in a variety of ways across studies, precluding the pooling of results for this outcome.We did not find any studies reporting adverse events resulting from the WASH interventions under study or from mass drug administration (MDA).Authors' conclusionsWhilst the available evidence suggests that the WASH interventions under study may slightly protect against STH infection, WASH also serves as a broad preventive measure for many other diseases that have a faecal oral transmission route of transmission. As many of the studies were done in addition to MDA/deworming (i.e. MDA was ongoing in both the intervention and control arm), our data support WHO recommendations for implementation of improvements to basic sanitation and adequate access to safe water alongside MDA. The biological plausibility for improved access to WASH to interrupt transmission of STHs is clear, but WASH interventions as currently delivered have shown impacts that were lower than expected. There is a need for more rigorous and targeted implementation research and process evaluations in order that future WASH interventions can better provide benefit to users. Inconsistent reporting of the intensity of infection underscores the need to define the minimal, standard data that should be collected globally on STHs to enable pooled analyses and comparisons.

Stunting Status and Exposure to Infection and Inflammation in Early Life Shape Antibacterial Immune Cell Function Among Zimbabwean Children

BackgroundChildren who are stunted (length-for-age Z-score<-2) are at greater risk of infectious morbidity and mortality. Previous studies suggest that stunted children have elevated inflammatory biomarkers, but no studies have characterised their capacity to respond to new infections (i.e., their immune function). We hypothesised that antibacterial immune function would differ between stunted and non-stunted children and relate to their health and environment during early life.MethodsWe enrolled a cross-sectional cohort of 113 HIV-negative children nested within a longitudinal cluster-randomised controlled trial of household-level infant and young child feeding (IYCF) and water, sanitation and hygiene (WASH) interventions in rural Zimbabwe (SHINE; Clinical trials registration: NCT01824940). Venous blood was collected at 18 months of age and cultured for 24 h without antigen or with bacterial antigens: heat-killed Salmonella typhimurium (HKST) or Escherichia coli lipopolysaccharide (LPS). TNFα, IL-6, IL-8, IL-12p70, hepcidin, soluble (s)CD163, myeloperoxidase (MPO) and IFNβ were quantified in culture supernatants by ELISA to determine antigen-specific immune function. The effect of stunting status and early-life exposures (anthropometry, inflammation at 18 months, maternal health during pregnancy, household WASH) on immune function was tested in logit and censored log-normal (tobit) regression models.ResultsChildren who were stunted (n = 44) had higher proportions (86.4% vs. 65.2%; 88.6% vs. 73.4%) and concentrations of LPS-specific IL-6 (geometric mean difference (95% CI): 3.46 pg/mL (1.09, 10.80), p = 0.035) and IL-8 (3.52 pg/mL (1.20, 10.38), p = 0.022) than non-stunted children (n = 69). Bacterial antigen-specific pro-inflammatory cytokine concentrations were associated with biomarkers of child enteropathy at 18 months and biomarkers of systemic inflammation and enteropathy in their mothers during pregnancy. Children exposed to the WASH intervention (n = 33) produced higher LPS- (GMD (95% CI): 10.48 pg/mL (1.84, 60.31), p = 0.008) and HKST-specific MPO (5.10 pg/mL (1.77, 14.88), p = 0.003) than children in the no WASH group (n = 80). There was no difference in antigen-specific immune function between the IYCF (n = 55) and no IYCF groups (n = 58).ConclusionsAntibacterial immune function among 18-month-old children in a low-income setting was shaped by their stunting status and prior exposure to maternal inflammation and household WASH. Heterogeneity in immune function due to adverse exposures in early life could plausibly contribute to infection susceptibility.

Neighbors’ use of water and sanitation facilities can affect children’s health: a cohort study in Mozambique using a spatial approach

BackgroundImpact evaluation of most water, sanitation and hygiene (WASH) interventions in health are user-centered. However, recent research discussed WASH herd protection – community WASH coverage could protect neighboring households. We evaluated the effect of water and sanitation used in the household and by household neighbors in children’s morbidity and mortality using recorded health data.MethodsWe conducted a retrospective cohort including 61,333 children from a district in Mozambique during 2012–2015. We obtained water and sanitation household data and morbidity data from Manhiça Health Research Centre surveillance system. To evaluate herd protection, we estimated the density of household neighbors with improved facilities using a Kernel Density Estimator. We fitted negative binomial adjusted regression models to assess the minimum children-based incidence rates for every morbidity indicator, and Cox regression models for mortality.ResultsHousehold use of unimproved water and sanitation displayed a higher rate of outpatient visit, diarrhea, malaria, and anemia. Households with unimproved water and sanitation surrounded by neighbors with improved water and sanitation high coverage were associated with a lower rate of outpatient visit, malaria, anemia, and malnutrition.ConclusionHousehold and neighbors’ access to improve water and sanitation can affect children’s health. Accounting for household WASH and herd protection in interventions’ evaluation could foster stakeholders’ investment and improve WASH related diseases control.Graphical Distribution of main water and sanitation facilities used during study period.

Using choice modelling to identify popular and affordable alternative interventions for schistosomiasis in Uganda

AbstractSchistosomiasis is caused by a vector-borne parasite, commonly found in low- and middle-income countries. People become infected by direct contact with contaminated water through activities such as collecting water, bathing and fishing. Water becomes contaminated when human waste is not adequately contained. We administered a discrete choice experiment to understand community preferences for interventions that would reduce individuals' risk of contracting, or transmitting, Schistosoma mansoni. These focused on water access, sanitation and hygiene (WASH) interventions. We compared interventions that target behaviours that mainly put oneself at higher risk versus behaviours that mainly put others at risk. We used two payment vehicles to quantify what individuals are willing to give up in time and/or labour for interventions to be implemented. Key findings indicate that new sources of potable water and fines on open defecation are the highest valued interventions.

Adaptation of Water, Sanitation, and Hygiene Interventions: A Model and Scoping Review of Key Concepts and Tools.

Safe water, sanitation, and hygiene (WaSH) is important for health, livelihoods, and economic development, but WaSH programs have often underdelivered on expected health benefits. Underperformance has been attributed partly to poor ability to retain effectiveness following adaptation to facilitate WaSH programs' implementation in diverse contexts. Adaptation of WaSH interventions is common but often not done systematically, leading to poor outcomes. Models and frameworks from the adaptation literature have potential to improve WaSH adaptation to facilitate implementation and retain effectiveness. However, these models and frameworks were designed in a healthcare context, and WaSH interventions are typically implemented outside traditional health system channels. The purpose of our work was to develop an adaptation model tailored specifically to the context of WaSH interventions. We conducted a scoping review to identify key adaptation steps and identify tools to support systematic adaptation. To identify relevant literature, we conducted a citation search based on three recently published reviews on adaptation. We also conducted a systematic database search for examples of WaSH adaptation. We developed a preliminary model based on steps commonly identified across models in adaptation literature, and then tailored the model to the WaSH context using studies yielded by our systematic search. We compiled a list of tools to support systematic data collection and decision-making throughout adaptation from all included studies. Our model presents adaptation steps in five phases: intervention selection, assessment, preparation, implementation, and sustainment. Phases for assessment through sustainment are depicted as iterative, reflecting that once an intervention is selected, adaptation is a continual process. Our model reflects the specific context of WaSH by including steps to engage non-health and lay implementers and to build consensus among diverse stakeholders with potentially competing priorities. We build on prior adaptation literature by compiling tools to support systematic data collection and decision-making, and we describe how they can be used throughout adaptation steps. Our model is intended to improve program outcomes by systematizing adaptation processes and provides an example of how systematic adaptation can occur for interventions with health goals but that are implemented outside conventional health system channels.

Diarrheal Disease Awareness Is Associated with Caregiver Handwashing with Soap in the Democratic Republic of the Congo (REDUCE Program).

Diarrhea is one of the leading causes of childhood illness and a major cause of infant and child mortality globally. In the Reducing Enteropathy, Undernutrition, and Contamination in the Environment (REDUCE) prospective cohort study, we investigated the association between diarrheal disease awareness and handwashing with soap among caregivers of children under 5 years of age. A total of 259 caregivers of children under 5 years of age in Walungu Territory, South Kivu, Democratic Republic of the Congo (DRC), were administered an open-ended questionnaire assessing awareness of diarrheal disease transmission and prevention, and key times to wash hands with soap. An overall diarrhea awareness score was developed based on the responses to these items. Five-hour structured observation of handwashing behaviors was conducted at the 6-month follow-up. Diarrheal disease awareness among caregivers was low. Only 32% of caregivers were able to correctly identify a method of diarrhea prevention. The median diarrhea awareness score was three out of 10 (SD: 1.7, range: 0-9). During structured observation, 9% of caregivers washed their hands with soap at a food-related event and 9% washed their hands with soap at a stool-related event. Higher diarrheal disease awareness was associated with an increased odds of handwashing with soap at food-related events (odds ratio: 1.40, 95% confidence interval: 1.03, 1.90). Our findings emphasize the need for targeted water, sanitation, and hygiene interventions to increase diarrhea awareness to facilitate handwashing with soap among caregivers of children under 5 years in rural DRC.

Evaluations of water, sanitation and hygiene interventions should not use diarrhoea as (primary) outcome.

Water, sanitation and hygiene interventions have been the subject of cluster trials of unprecedented size, scale and cost in recent years. However, the question ‘what works in water, sanitation, hygiene (WASH)?’ remains poorly understood. Evaluations of community interventions to prevent infectious disease typically use lab-confirmed infection as a primary outcome; however, WASH trials mostly use reported diarrhoea. While diarrhoea is a significant source of morbidity, it is subjected to significant misclassification error with respect to enteric infection due to the existence of non-infectious diarrhoea and asymptomatic infection. We show how this may lead to bias of estimated effects of interventions from WASH trials towards no effect. The problem is further compounded by other biases in the measurement process. Alongside testing for infection of the gut, an examination of the causal assumptions underlying WASH interventions present several other reliable alternative and complementary measurements and outcomes. Contemporary guidance on the evaluation of complex interventions requires researchers to take a broad view of the causal effects of an intervention across a system. Reported diarrhoea can fail to even be a reliable measure of changes to gastrointestinal health and so should not be used as a primary outcome if we are to progress our knowledge of what works in WASH.

Effects of community-led total sanitation and hygiene implementation on diarrheal diseases prevention in children less than five years of age in South Western Ethiopia: A quasi- experimental study.

BackgroundLack of improved sanitation is the most important contributing factor to diarrheal disease among under-five children in low and middle-income countries. There was no study to identify the effect of Community-Led Total Sanitation and Hygiene intervention on diarrheal diseases in the study area. Hence, this study was designed with the aim of finding the effects of Community-led Total Sanitation and Hygiene implementation for preventing diarrhea among under-five children.MethodsA community-based Quasi-Experimental study was conducted among a sample of 846 households selected from intervention (kersa) and comparison (mana) districts using the four-stage random cluster-sampling method. A Semi-structured questionnaire was used to collect data. The collected data was cleaned, coded, and entered into EpiData version 3.1 and exported to SPSS version 20 for analysis. Difference-in Difference method with McNemar’s tests was used to compare the prevalence of diarrhea between the intervention and comparison districts, and the significance of change between the pre-test and post-test was declared at p-value less than 0.05 with 95% confidence interval.ResultsThe intervention led to decreased diarrhea prevalence [pp = -8.2, 95% CI: -15.9, -0.5], increased latrine ownership [pp = 5.6, 95% CI: 0.5, 10.8], and increased latrine utilization [pp = 10.7, 95% CI: 4.7, 16.6] in intervention district at post-test compared to the baseline; while the presence of handwashing facility near the latrine, home-based water treatment, and proper water storage and handling practice were decreased at post-test compared to the baseline.ConclusionImplementation of Community-Led Total Sanitation improved sanitation and hygiene status of community that resulted in the reduction of diarrhea diseases in under-five children. Further implementation, evaluation, and scale-up of the interventions are needed to reduce diarrheal disease in under-five children.

Escherichia coli Ingested via Food May Overshadow the Positive Effects of Clean Drinking Water: An Example from Dhaka.

The minimal health impact observed in large-scale water sanitation and hygiene (WASH) intervention studies motivated us to investigate the contribution of contaminated food and drinking water to the total daily Escherichia coli load ingested by the average adult in a low-income, urban area. Leftover food (food left at room temperature for more than 6 hours) from 32 households was collected eight times at 6-week intervals in 2014-2015 in the low-income area of Arichpur, Dhaka, Bangladesh. In total, 117 samples were obtained from four food types: fish, lentils, rice, and vegetables, which comprise approximately 85.2% of the average adult's personal daily food consumption. Samples were analyzed for E. coli using selective chromogenic media. For an average adult, the daily consumption of the four food types at mean contamination levels of E. coli can contribute 4.45 log colony-forming units (cfu)/day (95% confidence interval 4.06-4.84). Drinking water quality was measured 211 times at the point of drinking, with a mean, median, and maximum contamination of 1.9, 1.2, and 2.82 log E. coli cfu/100 mL, respectively. If the typical adult in Arichpur were able to drink water with 0 E. coli cfu/100 mL, it would only remove <5.2% of the total E. coli ingested per day with a mean-contaminated diet. These approximations may suggest why insignificant effects have been observed for water quality interventions in similar, low-hygiene settings. In Arichpur, the E. coli contribution from drinking water to the total E. coli load was insufficient to exert a substantial effect.

Community Participation and Multidimensional Child Growth: Evidence from the Vietnam Young Lives Study

BackgroundCommunity participation has the potential to improve the effects of interventions and reduce inequalities in child growth. Multidimensional indicators capture such effects and inequalities. ObjectivesThe objective of this study was to measure the association between multidimensional child growth and community participation in 2 nutrition-sensitive interventions. MethodsA Multidimensional Index of Child Growth was calculated with the 5-y-old cohort of the Vietnam Young Lives Survey. Young Lives is a unique dataset that has information on community participation in the design and implementation stages of 2 interventions: a health and a water, sanitation, and hygiene (WASH) intervention. Community participation during the interventions was recorded retrospectively with interviews at the household level. Ordinary least-squares and quantile regressions were estimated using data on 240 children. A Multidimensional Index of Child Advantage, sex, and location (urban/rural) were included as control covariates. ResultsA positive association (post hoc statistical power = 0.859) was estimated for community participation during the design stage of the WASH intervention, particularly for the most deprived children (P < 0.05). Negative effects were estimated for the health intervention during the design stage (P < 0.05) and no significant effects were found for community participation during the implementation stage of the interventions. Instead of the physical dimension, the significant associations in the design stage were related to the nonphysical dimension of child growth. Inequalities in multidimensional growth were found for children living in rural areas, but not for girls. ConclusionsThe association between community participation and multidimensional child growth is indicative of the importance of community participation during the design phase of interventions, in particular for the nonphysical dimensions of child growth related to social and psychological factors. The benefits of participation were greater for urban children compared with rural children, which deserves further attention.

Identifying transferable lessons from cholera epidemic responses by M\xe9decins Sans Fronti\xe8res in Mozambique, Malawi and the Democratic Republic of Congo, 2015\u20132018: a scoping review

BackgroundCholera epidemics occur frequently in low-income countries affected by concurrent humanitarian crises. Evaluations of these epidemic response remains largely unpublished and there is a need to generate evidence on response efforts to inform future programmes. This review of MSF cholera epidemic responses aimed to describe the main characteristics of the cholera epidemics and related responses in these three countries, to identify challenges to different intervention strategies based on available data; and to make recommendations for epidemic prevention and control practice and policy.MethodsCase studies from the Democratic Republic of Congo, Malawi and Mozambique were purposively selected by MSF for this review due to the documented burden of cholera in each country, frequency of cholera outbreaks, and risk of humanitarian crises. Data were extracted on the characteristics of the epidemics; time between alert and response; and, the delivery of health and water, sanitation and hygiene interventions. A Theory of Change for cholera response programmes was built to assess factors that affected implementation of the responses.Results and conclusions20 epidemic response reports were identified, 15 in DRC, one in Malawi and four in Mozambique. All contexts experienced concurrent humanitarian crises, either armed conflict or natural disasters. Across the settings, median time between the date of alert and date of the start of the response by MSF was 23 days (IQR 14–41). Almost all responses targeted interventions community-wide, and all responses implemented in-patient treatment of suspected cholera cases in either established health care facilities (HCFs) or temporary cholera treatment units (CTUs). In three responses, interventions were delivered as case-area targeted interventions (CATI) and four responses targeted households of admitted suspected cholera cases. CATI or delivery of interventions to households of admitted suspected cases occurred from 2017 onwards only. Overall, 74 factors affecting implementation were identified including delayed supplies of materials, insufficient quantities of materials and limited or lack of coordination with local government or other agencies. Based on this review, the following recommendations are made to improve cholera prevention and control efforts: explore improved models for epidemic preparedness, including rapid mobilisation of supplies and deployment of trained staff; invest in and strengthen partnerships with national and local government and other agencies; and to standardise reporting templates that allow for rigorous and structured evaluations within and across countries to provide consistent and accessible data.

Gender dynamics of community-led total sanitation interventions in Mpwapwa District, Tanzania

ABSTRACT Gender equity is an important element of health promotion and is vital to ensuring that the benefits and burdens of participation in health promotion activities are fairly distributed. Yet, the gendered consequences of participatory interventions are often overlooked. This is particularly relevant for water and sanitation initiatives, given that women are generally responsible for maintaining domestic hygiene and procuring water. This study uses a qualitative approach to assess the gender dynamics of participation in community-led total sanitation (CLTS) activities in Mpwapwa District, Tanzania. We used semi-structured interviews and focus-group discussions to investigate men’s and women’s involvement in health promotion initiatives and their key motivators for and challenges to participation. We interviewed 77 community members from four villages and analysed the responses using qualitative content analysis. The study supports the notion that participation reinforces gender inequity and reproduces gendered norms due to activity-specific participation, women’s passive participation within activities, and their limited opportunities for decision-making. However, there were also indications that participation provided a platform to increase the status of women, prioritise women’s needs and demand a stronger position in decision making within the household and the community. CLTS organisers should, therefore, harness the opportunity to address gender inequalities within the community.