Tag Archives: shared sanitation

Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study

The current issue of PLoS Medicine has an important review on sanitation and hygiene and also below is an analysis of the review by Jonny Crocker and Jamie Bartram.

Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study, 2007–2011: Case-Control Study. PLoS Med, May 2016. Authors: Kelly K. Baker, Ciara E. O’Reilly, Myron M. Levine, Karen L., et al.

Full text: http://goo.gl/z0h9P0

Background – Diarrheal disease is the second leading cause of disease in children less than 5 y of age. Poor water, sanitation, and hygiene conditions are the primary routes of exposure and infection. Sanitation and hygiene interventions are estimated to generate a 36% and 48% reduction in diarrheal risk in young children, respectively. Little is known about whether the number of households sharing a sanitation facility affects a child’s risk of diarrhea. The objective of this study was to describe sanitation and hygiene access across the Global Enteric Multicenter Study (GEMS) sites in Africa and South Asia and to assess sanitation and hygiene exposures, including shared sanitation access, as risk factors for moderate-to-severe diarrhea (MSD) in children less than 5 y of age.

Methods/Findings – The GEMS matched case-control study was conducted between December 1, 2007, and March 3, 2011, at seven sites in Basse, The Gambia; Nyanza Province, Kenya; Bamako, Mali; Manhiça, Mozambique; Mirzapur, Bangladesh; Kolkata, India; and Karachi, Pakistan. Data was collected for 8,592 case children aged <5 y old experiencing MSD and for 12,390 asymptomatic age, gender, and neighborhood-matched controls. An MSD case was defined as a child with a diarrheal illness <7 d duration comprising ≥3 loose stools in 24 h and ≥1 of the following: sunken eyes, skin tenting, dysentery, intravenous (IV) rehydration, or hospitalization. Site-specific conditional logistic regression models were used to explore the association between sanitation and hygiene exposures and MSD. Most households at six sites (>93%) had access to a sanitation facility, while 70% of households in rural Kenya had access to a facility. Practicing open defecation was a risk factor for MSD in children <5 y old in Kenya. Sharing sanitation facilities with 1–2 or ≥3 other households was a statistically significant risk factor for MSD in Kenya, Mali, Mozambique, and Pakistan. Among those with a designated handwashing area near the home, soap or ash were more frequently observed at control households and were significantly protective against MSD in Mozambique and India.

Conclusions – This study suggests that sharing a sanitation facility with just one to two other households can increase the risk of MSD in young children, compared to using a private facility. Interventions aimed at increasing access to private household sanitation facilities may reduce the burden of MSD in children. These findings support the current World Health Organization/ United Nations Children’s Emergency Fund (UNICEF) system that categorizes shared sanitation as unimproved.

Interpreting the Global Enteric Multicenter Study (GEMS) Findings on Sanitation, Hygiene, and Diarrhea. PLoS Med, May 2016. Author: Jonny Crocker, Jamie Bartram

Full text: http://goo.gl/6SzZmr

The draft sanitation ladder for measuring SDG progress allows sharing of improved facilities by fewer than five households to count towards ending open defecation [19]. Higher rungs refer to private facilities and safe excreta management. The indicators also interpret access as including use, which was not included in GEMS. Future research should include indicators on use of facilities and excreta management.

Baker and colleagues provide valuable evidence that confirms that private sanitation often provides greater benefits than shared sanitation. Prior evidence suggests health benefits for use of any sanitation facility (including shared) when compared to open defecation [8–10]. This study will inform policy and programming, yet shared facilities may still have a role in addressing open defecation in challenging settings. For reasons beyond just health such as dignity and gender equity [20,21], we should advocate for private access whenever possible.

Baker and colleagues present the best dataset yet on diarrheal disease associated with sanitation and hygiene. They provide compelling evidence on sanitation and hygiene risk factors for MSD and variability in that risk. Importantly, they also demonstrate the feasibility and value of rigorous data collection on health outcomes, something that future studies should develop yet further.

Policy Note: Should Public Toilets Be Part of Urban Sanitation Solutions for Poor Families Living in Slums?

Policy Note: Should Public Toilets Be Part of Urban Sanitation Solutions for Poor Families Living in Slums? April 2016. Emory University’s Center for Global Safe Water, Sanitation, and Hygiene.

Although households would prefer to have private facilities, conditions suggest that shared public toilets will, for the foreseeable future, continue to be the main available option for defecation in the slums of Accra. In this context, efforts are needed to improve existing and new public toilets to make them hygienic and safely managed in order to provide sanitation services that result in public health benefits.

Since public toilets do not meet the JMP criteria for an improved toilet, they also do not meet current government of Ghana standards. This in turn creates a disincentive for local governments to invest in public toilets and related safe management of the fecal sludge as part of their urban sanitation services.

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An Annotated Bibliography on Shared Sanitation Studies Published in 2015

An Annotated Bibliography on Shared Sanitation Studies Published in 2015

Below are links to the abstracts or full-text of 4 studies on shared sanitation that were published in 2015. We will continue to update this bibliography with 2016 reports and studies so please send us an email if you have studies to contribute.

1 – Soc Sci Med. 2015 Dec;147:72-9. doi: 10.1016/j.socscimed.2015.10.059.

 Effectiveness of group discussions and commitment in improving cleaning behaviour of shared sanitation users in Kampala, Uganda slums. Authors: Tumwebaze IK, Mosler HJ. (Abstract)

RATIONALE AND OBJECTIVE: Access to and use of hygienic shared sanitation facilities is fundamental in reducing the high risk of diseases such as diarrhoea and respiratory infections. We evaluated the effectiveness of group discussions and commitment in improving the cleaning behaviour of shared sanitation users in three urban slums in Kampala, Uganda. The study follows the risk, attitudes, norms, abilities and self-regulation (RANAS) model of behaviour change and some factors of the social dilemma theory.

METHODS: A pre-versus post-intervention survey was conducted in three slums of Kampala, Uganda, between December 2012 and September 2013. From the pre-intervention findings, users of dirty sanitation facilities were randomly assigned to discussions, discussions + commitment and control interventions. The interventions were implemented for 3 months with the aim of improving cleaning behaviour. This paper provides an analysis of 119 respondents who belonged to the intervention discussion-only (n = 38), discussions + commitment (n = 41) and the control (no intervention, n = 40) groups.

RESULTS: Compared to the control, discussions and discussions + commitment significantly improved shared toilet users’ cleaning behaviour. The rate of improvement was observed through behavioural determinants such as cleaning obligation, cleaning ease, cleaning approval and affective beliefs.

CONCLUSION: Our study findings show that group discussions and commitment interventions derived from RANAS model of behaviour change are effective in improving the shared sanitation users’ cleaning behaviour.

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The continuing conundrum of shared sanitation in slums

The continuing conundrum of shared sanitation in slums. OUPblog, Dec 28 2015.  by Marieke Heijnen.

An excerpt – Some have argued that shared sanitation facilities are the only solution in slums, due to space and cost limitations. But the discussion continues—some research argues that the focus should be less on the user of the shared facility, and more on the facility itself. Others note that sanitation provision needs to go beyond technology or user-numbers, and include factors of culture, affordability and ownership. Overall, research shows that a simple statement of ‘shared sanitation’ does not account for the diversity of shared sanitation found in different settings—the different ‘forms’ of shared sanitation and the lack of consensus on definitions complicates monitoring for international targets.

With increasing urbanisation, sanitation in slums will become a more pressing issue. Providing adequate, safe and accessible sanitation for all users in slums is a public health priority which requires a multifaceted approach, considering the actual facilities as well as increasing education and empowerment among the potential users. In addition, accountability from landlords and local government is essential. In order for shared sanitation facilities to be a sustainable step on the sanitation ladder, policy makers, programme implementers, and target communities must join forces to ensure the facilities are culturally appropriate, affordable, well-maintained, and user-friendly. Then hopefully, we can ensure that all facilities—whether shared or used by one household—provide the health, comfort, and privacy benefits that a toilet really should.

Read the complete article.


Shared sanitaion for the urban poor: understanding what works

The MapSan study aims to explore the links between sanitation, population density, and health outcomes in Maputo, Mozambique. The video describes a controlled, before-and-after trial of an urban sanitation intervention to reduce enteric infections in children:

Shared Sanitation versus Individual Household Latrines: A Systematic Review of Health Outcomes

Shared Sanitation versus Individual Household Latrines: A Systematic Review of Health Outcomes. PLoS One, April 2014.

Authors: Marieke Heijnen, Oliver Cumming, Rachel Peletz, Gabrielle Ka-Seen Chan, Joe Brown, Kelly Baker, Thomas Clasen.

Background: More than 761 million people rely on shared sanitation facilities. These have historically been excluded from international sanitation targets, regardless of the service level, due to concerns about acceptability, hygiene and access. In connection with a proposed change in such policy, we undertook this review to identify and summarize existing evidence that compares health outcomes associated with shared sanitation versus individual household latrines.

Methods and Findings: Shared sanitation included any type of facilities intended for the containment of human faeces and used by more than one household, but excluded public facilities. Health outcomes included diarrhoea, helminth infections, enteric fevers, other faecal-oral diseases, trachoma and adverse maternal or birth outcomes. Studies were included regardless of design, location, language or publication status. Studies were assessed for methodological quality using the STROBE guidelines. Twenty-two studies conducted in 21 countries met the inclusion criteria. Studies show a pattern of increased risk of adverse health outcomes associated with shared sanitation compared to individual household latrines. A meta-analysis of 12 studies reporting on diarrhoea found increased odds of disease associated with reliance on shared sanitation (odds ratio (OR) 1.44, 95% CI: 1.18–1.76).

Conclusion: Evidence to date does not support a change of existing policy of excluding shared sanitation from the definition of improved sanitation used in international monitoring and targets. However, such evidence is limited, does not adequately address likely confounding, and does not identify potentially important distinctions among types of shared facilities. As reliance on shared sanitation is increasing, further research is necessary to determine the circumstances, if any, under which shared sanitation can offer a safe, appropriate and acceptable alternative to individual household latrines.