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Table of contents
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- Econometrics of Risk | SpringerLink
Our analysis included study households and census-only households. A village consisted of 48 households on average [range of 27—].
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The mean latrine coverage within a village based on census data was Histograms showing household density and the percent latrine coverage surrounding study households within a m radius are provided in Figure S1. Study households had an average of 7. Ninety-three percent of households reported that children in the household practiced open defecation as their main defection location. Sixty-one percent of households reported that a nonchild household member practiced open defecation.
Forty-two percent of households reported using a private latrine. Eleven percent of households had access to a latrine with a concrete slab connected to a septic tank or a ventilated improved pit latrine. Children were on average Household characteristics, child health, and water quality statistics are provided in Table 1. Table 1. In our study, household-level access to a latrine was associated with lower open defecation prevalence.
Comparisons of open defecation behavior by age group and sanitation access type are provided in Tables S1 and S2. Child health and anthropometric data were collected in households with at least one child under the age of 5, for a total of children. The association between diarrhea and household latrine ownership was no longer significant when an interaction between latrine ownership and latrine coverage was included Tables S3 and S4. Open defecation at the household level was not significantly associated with any child health outcomes Table S5.
The localized polynomial for height-for-age and stunting indicated a linear relationship with latrine coverage, while localized polynomials of weight-for-age, weight-for-height, underweight, and wasting suggested nonlinear relationships with community latrine coverage in a m radius Figure S2. For weight-for-age z -scores and underweight prevalence, second-order regression models including an interaction between community-level sanitation and household sanitation identified a statistically significant relationship with community latrine coverage; there was not a statistically significant association with weight-for-height z -scores or wasting Tables S3 and S4.
Individual household latrine ownership was not associated with child growth and did not have a significant moderating effect on latrine coverage for any of the health outcomes. Marginal effect estimates showed a marginally significant decrease in diarrhea prevalence for household latrine ownership of 2. The results of these regressions were not significantly different between male and female children for any health outcomes Tables S6 and S7. Table 2. The generalized additive models confirmed community latrine coverage was significantly associated with child height and weight, while household latrine ownership was not significantly associated wasting prevalence was not significantly associated with either household latrine ownership or community latrine coverage Table 3.
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Clear nonlinear trends were observed in the generalized additive model results for underweight, weight-for-height, and weight-for-age child health measures Figures 1 and 2. High Resolution Image. Table 3. Household stored water samples had a geometric mean of MPN E. Forty-two percent of households collected drinking water from an improved source. Stored water quality summary statistics are provided in Table 1. Household stored water quality as indicated by E.
A higher percentage of households practicing open defecation in a m radius had a statistically significant association with increased E.
Open defecation at the household level was not associated with E. Generalized additive model results showed a reduction in E. Generalized additive models did not show any significant association between latrine ownership or latrine coverage and total coliform concentrations Table 3. No association was detected between sanitation coverage and drinking water source quality as indicated by E.
A recent study analyzing the effect of community sanitation coverage in rural Ecuador used a m radius definition of community. Radii of less than m were not useful in the study area due to low household density. These alternative models did not yield statistically different results; however, the 1 km radius did generate qualitatively different associations between weight-for-age and community latrine coverage and between weight-for-height and community latrine coverage.
This difference was less apparent for binary outcomes of underweight and wasting Tables S11 and S Community latrine coverage was positively associated with child height and weight, while self-reported community open defecation rates were negatively associated with child growth.
In contrast, individual household latrine ownership did not have statistically significant associations with child health in our study population.
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We found no significant difference in results when an interaction term between community sanitation coverage and household latrine ownership was included, indicating the association between child health and community latrine coverage did not significantly differ depending on individual household latrine ownership. Notably, the marginal effects of increasing community latrine coverage were greater for households that did not own a latrine, indicating the importance of accounting for this interaction.
Our findings are consistent with a recent study in rural Ecuador that identified reduced stunting prevalence in communities with overall improved sanitation access yet found no impact of individual household improved latrine ownership on stunting. Notably, the Ecuador study site had very low open defecation rates; our study is able to contribute new evidence for the health benefits of communities transitioning from prevalent open defecation to basic latrine usage.
The generalized additive modeling results supported a linear relationship for child height and a nonlinear relationship for child weight. High variability in the data presents some uncertainty at high levels of coverage for both stunting and underweight prevalence. Household stored water quality was found to improve with increased community latrine coverage and less open defecation near the household. This finding supports the hypothesis that water contamination is one pathway through which sanitation coverage affects child growth.
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Contamination of drinking water stored in the home has been shown in other studies to be a risk factor for child diarrhea regardless of source water quality; 25, 26, 31, 32 this contamination risk could increase if the nearby environment has higher fecal contamination from persistent open defecation within a community. For example, increased hand fecal contamination has previously been found to be associated with unimproved sanitation access as well as high levels of fecal contamination in stored drinking water. This study has some important limitations.
The cross-sectional data set limits the identification of causal relationships. Stunting has been found to occur largely from prebirth to two years of age; 35 however, we only had data on concurrent sanitation conditions and health previous exposure to sanitation infrastructure was not known. Confounding variables, such as wealth or education, could have contributed to overestimation of the reported associations. However, controlling for wealth and literacy at the household level and at the community level defined either by village boundaries or by a m radius did not significantly alter our results Tables S3 and S Community-level wealth and education averages were used by Fuller et al.
We also were not able to account for distance of open defecation location from the index household. Prior research has also shown that open defecation or unimproved sanitation may present greater risk to child growth in densely populated areas. The relatively low population density in rural Mali may explain some of the variation between our findings and those from rural India, where population density was higher. The post sustainable development goals aim for a complete end to open defecation and universal access to private improved sanitation infrastructure.
Previous studies identified lower thresholds of sanitation coverage, yet they either focused on diarrhea prevalence as the primary health indicator or examined transitions from unimproved sanitation to improved sanitation infrastructure.
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While our findings may not apply to settings with higher population densities, they indicate that access to basic sanitation is the first step to protect child health in a rural setting. The positive sanitation externalities identified in this study justify efforts to increase access to basic sanitation infrastructure, even if open defecation cannot be fully eliminated in the immediate future.
Supporting Information. The authors declare no competing financial interest. Google Scholar There is no corresponding record for this reference. Estimating the burden of disease from water, sanitation, and hygiene at a global level Environ. Health Perspect. Environmental health perspectives , 5 , ISSN: We estimated the disease burden from water, sanitation, and hygiene at the global level taking into account various disease outcomes, principally diarrheal diseases.
The disability-adjusted life year DALY combines the burden from death and disability in a single index and permits the comparison of the burden from water, sanitation, and hygiene with the burden from other risk factors or diseases. We divided the world's population into typical exposure scenarios for 14 geographical regions. We then matched these scenarios with relative risk information obtained mainly from intervention studies.
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We estimated the disease burden from water, sanitation, and hygiene to be 4. Because we based these estimates mainly on intervention studies, this burden is largely preventable. Other water- and sanitation-related diseases remain to be evaluated. This preliminary estimation of the global disease burden caused by water, sanitation, and hygiene provides a basic model that could be further refined for national or regional assessments. This significant and avoidable burden suggests that it should be a priority for public health policy.
Burden of disease from inadequate water, sanitation and hygiene in low- and middle-income settings: A retrospective analysis of data from countries Trop. Health , 19 8 — DOI: OBJECTIVE: To estimate the burden of diarrhoeal diseases from exposure to inadequate water, sanitation and hand hygiene in low- and middle-income settings and provide an overview of the impact on other diseases.
METHODS: For estimating the impact of water, sanitation and hygiene on diarrhoea, we selected exposure levels with both sufficient global exposure data and a matching exposure-risk relationship. Global exposure data were estimated for the year , and risk estimates were taken from the most recent systematic analyses. We estimated attributable deaths and disability-adjusted life years DALYs by country, age and sex for inadequate water, sanitation and hand hygiene separately, and as a cluster of risk factors. Uncertainty estimates were computed on the basis of uncertainty surrounding exposure estimates and relative risks.
RESULTS: In , , diarrhoea deaths were estimated to be caused by inadequate drinking water and , deaths by inadequate sanitation. The most likely estimate of disease burden from inadequate hand hygiene amounts to , deaths. In total, , diarrhoea deaths are estimated to be caused by this cluster of risk factors, which amounts to 1. In children under 5 years old, , deaths could be prevented, representing 5.
It also underscores the need for better data on exposure and risk reductions that can be achieved with provision of reliable piped water, community sewage with treatment and hand hygiene. Child undernutrition, tropical enteropathy, toilets, and handwashing Lancet , — DOI: The impoverished gut--a triple burden of diarrhoea, stunting and chronic disease Nat.
Nature reviews. More than one-fifth of the world's population live in extreme poverty, where a lack of safe water and adequate sanitation enables high rates of enteric infections and diarrhoea to continue unabated. Diarrhoea in children from impoverished areas during their first 2 years might cause, on average, an 8 cm growth shortfall and 10 IQ point decrement by the time they are years old.
A child's height at their second birthday is therefore the best predictor of cognitive development or 'human capital'.
To this 'double burden' of diarrhoea and malnutrition, data now suggest that children with stunted growth and repeated gut infections are also at increased risk of developing obesity and its associated comorbidities, resulting in a 'triple burden' of the impoverished gut.