Publication: The Effect of India’s Total Sanitation Campaign on Defecation Behaviors and Child Health in Rural Madhya Pradesh: A Cluster Randomized Controlled Trial
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Published
2014-08-26
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2015-12-03
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Patil, Sumeet R.
Arnold, Benjamin F.
Salvatore, Alicia L.
Briceno, Bertha
Ganguly, Sandipan
Colford Jr., John M.
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Abstract
Poor sanitation is thought to be a major cause of enteric infections among young children. However, there are no previously published randomized trials to measure the health impacts of large-scale sanitation programs. India's Total Sanitation Campaign (TSC) is one such program that seeks to end the practice of open defecation by changing social norms and behaviors, and providing technical support and financial subsidies. The objective of this study was to measure the effect of the TSC implemented with capacity building support from the World Bank's Water and Sanitation Program in Madhya Pradesh on availability of individual household latrines (IHLs), defecation behaviors, and child health (diarrhea, highly credible gastrointestinal illness [HCGI], parasitic infections, anemia, growth).
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Publication A Randomized, Controlled Study of a Rural Sanitation Behavior Change Program in Madhya Pradesh, India(World Bank, Washington, DC, 2013-11)Poor sanitation and open defecation are thought to be a major cause of diarrhea and intestinal parasite infections among young children. In 1999, India launched the Total Sanitation Campaign with the goal of achieving universal toilet coverage in rural India by 2012. This paper reports on a cluster-randomized, controlled trial that was conducted in 80 rural villages in Madhya Pradesh to measure the effect of the program on toilet access, sanitation behavior, and child health outcomes. The study analyzed a random sample of 3,039 households and 5,206 children under five years of age. Field staff collected baseline measures of sanitation conditions, behavior, and child health, and re-visited households 21 months later. The analysis finds that implementation of the program activities was slower than the original timeline (only 35 percent of villages were triggered more than six months before the follow-up survey). Nevertheless, the Total Sanitation Campaign successfully increased toilet coverage by 19 percent in intervention villages compared with control villages (41 percent v. 22 percent), while reported open defecation decreased by 10 percent among adults (74 percent v. 84 percent). The intervention also led to some improvements in water quality and protozoan infection, but consistent improvements were not observed across multiple child health outcomes (diarrhea, helminth infections, child growth). However, the exposure period was likely to have been too short to result in any benefit of the sanitation interventions on child health. Given the large improvements in toilet construction documented, an additional follow-up survey with a longer period of exposure would yield valuable information on the effects of improved sanitation conditions on health outcomes.Publication Scaling Up Rural Sanitation : Findings from the Impact Evaluation Baseline Survey in Madhya Pradesh, India(World Bank, Washington, DC, 2011-03)In India, Water and Sanitation Program's (WSP's) global scaling up rural sanitation program is supporting the Government of India's (GoI) Total Sanitation Campaign (TSC) in two states: Himachal Pradesh and Madhya Pradesh. TSC is an ambitious countrywide, scaled-up rural sanitation program launched by the GoI in 1999, which seeks to attain an Open Defecation Free (ODF) India by 2012. In contrast to earlier, hardware-centric supply approaches to rural sanitation, TSC aims to generate demand for and adoption of improved sanitation at the community level. 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Although the data are limited in establishing causality, emerging trends indicate that gains in improved sanitation, likely to be brought about by TSC, could have positive impacts on the health and welfare of rural families, especially young children.Publication Fecal Indicator Bacteria along Multiple Environmental Transmission Pathways (Water, Hands, Food, Soil, Flies) and Subsequent Child Diarrhea in Rural Bangladesh(American Chemical Society, 2018-06-14)Enteric pathogens can be transmitted through multiple environmental pathways, yet little is known about the relative contribution of each pathway to diarrhea risk among children. We aimed to identify fecal transmission pathways in the household environment associated with prospectively measured child diarrhea in rural Bangladesh. We measured the presence and levels of Escherichia coli in tube wells, stored drinking water, pond water, child hand rinses, courtyard soil, flies, and food in 1843 households. Gastrointestinal symptoms among children ages 0–60 months were recorded concurrently at the time of environmental sample collection and again a median of 6 days later. Incident diarrhea (3 or more loose stools in a 24-h period) was positively associated with the concentration of E. coli on child hands measured on the first visit (incidence rate ratio [IRR] = 1.23, 95% CI 1.06, 1.43 for a log10 increase), while other pathways were not associated. In cross-sectional analysis, there were no associations between concurrently measured environmental contamination and diarrhea. Our findings suggest higher levels of E. coli on child hands are strongly associated with subsequent diarrheal illness rates among children in rural Bangladesh.Publication Sanitation and Externalities : Evidence from Early Childhood Health in Rural India(World Bank, Washington, DC, 2014-01)This paper estimates two sources of benefits related to sanitation infrastructure access on early childhood health: a direct benefit a household receives when moving from open to fixed-point defecation or from unimproved sanitation to improved sanitation, and an external benefit (externality) produced by the neighborhood's access to sanitation infrastructure. The paper uses a sample of children under 48 months in rural areas of India from the Third Round of District Level Household Survey 2007-08 and finds evidence of positive and significant direct benefits and concave positive external effects for both improved sanitation and fixed-point defecation. There is a 47 percent reduction in diarrhea prevalence between children living in a household without access to improved sanitation in a village without coverage of improved sanitation and children living in a household with access to improved sanitation in a village with complete coverage. One-fourth of this benefit is due to the direct benefit leaving the rest to external gains. Finally, all the benefits from eliminating open defecation come from improved sanitation and not other sanitation solutions.Publication Do Sanitation Improvements Reduce Fecal Contamination of Water, Hands, Food, Soil, and Flies? Evidence from a Cluster-Randomized Controlled Trial in Rural Bangladesh(American Chemical Society, 2018-09-26)Sanitation improvements have had limited effectiveness in reducing the spread of fecal pathogens into the environment. We conducted environmental measurements within a randomized controlled trial in Bangladesh that implemented individual and combined water treatment, sanitation, handwashing (WSH) and nutrition interventions (WASH Benefits, NCT01590095). Following approximately 4 months of intervention, we enrolled households in the trial’s control, sanitation and combined WSH arms to assess whether sanitation improvements, alone and coupled with water treatment and handwashing, reduce fecal contamination in the domestic environment. We quantified fecal indicator bacteria in samples of drinking and ambient waters, child hands, food given to young children, courtyard soil and flies. In the WSH arm, Escherichia coli prevalence in stored drinking water was reduced by 62% (prevalence ratio = 0.38 (0.32, 0.44)) and E. coli concentration by 1-log (Δlog10 = −0.88 (−1.01, −0.75)). The interventions did not reduce E. coli along other sampled pathways. Ambient contamination remained high among intervention households. Potential reasons include noncommunity-level sanitation coverage, child open defecation, animal fecal sources, or naturalized E. coli in the environment. Future studies should explore potential threshold effects of different levels of community sanitation coverage on environmental contamination.
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