1. SHARED SANITATION AND DIARRHEA: EVIDENCE FROM 51 COUNTRIES James A. Fuller Department of Epidemiology University of Michigan School of Public Health Co-authors: Thomas Clasen, Marike Heijnen, Joseph Eisenberg

2. Shared Facilities  Currently classified by JMP as ‘unimproved’ due to:  Accessibility  Cleanliness  Little evidence linking sharing to diarrhea

3. Research Questions 1. Is a child more likely to have diarrhea if his/her household uses a shared facility (compared to a facility that is not shared)? 2. Is there a safe threshold for the number of households using a facility (i.e. < 5)

4. Demographic and Health Surveys  51 Surveys  Children < 5  Diarrhea prevalence in the past 2 weeks

5. Potential Confounders Child-level variables  Age  Health Card Household-level variables  Toilet facility (improved/unimproved, ignoring sharing)  Water source (improved/unimproved)  Ownership of assets (refrigerator, bicycle, motorcycle/scooter)  Mother’s education (6 categories)  Mother’s age (6 categories)  Number of children < 5 in the household  Urban/Rural

6. Unadjusted (Crude) Effects Sharing is harmful Sharing is protective PROTECTIVE IN A FEW NO EFFECT IN A FEW HARMFUL IN MOST

7. Adjusted Effects Sharing is harmful Sharing is protective Adjusted for: Household assets, mother’s age, mother’s education, child’s health card

8. Crude Prevalence Ratios

9. Pooled Results RegionCrude PR (95% CI)Adjusted a PR (95% CI) Africa1.07 (1.03-1.10)1.05 (1.01-1.09) Latin America and the Caribbean1.11 (1.04-1.19)1.02 (0.96-1.10) South-East Asia and Western Pacific1.16 (1.06-1.26)1.09 (1.00-1.18) Eastern Mediterranean and Europe1.26 (1.11-1.42)1.22 (1.08-1.38) All Regions Combined1.09 (1.06-1.12)1.05 (1.02-1.08) PR, Prevalence Ratio; 95%CI, 95% confidence interval. a Adjusted for mother’s age, mother’s educational attainment, asset ownership, and whether the child has a health card. “Modest” EffectAttenuation

10. Number of Households  JMP is considering <5 HH as a safe threshold  Different dose-response relationships have different policy implications

11. Number of Households RegionSharing CategoryCrude PRAdjusted PR All Regions Combined < 5 HH1.07 (1.04-1.11)1.04 (1.00-1.07) 5 or more HH1.06 (1.00-1.12)1.02 (0.97-1.08) Africa < 5 HH1.06 (1.02-1.10)1.04 (1.00-1.08) 5 or more HH1.02 (0.96-1.09)1.03 (0.97-1.09) Latin Am & Car < 5 HH1.08 (0.99-1.18)1.02 (0.93-1.11) 5 or more HH1.14 (0.96-1.35)1.01 (0.85-1.20) SEA & WP < 5 HH1.13 (1.02-1.25)1.07 (0.96-1.18) 5 or more HH1.22 (1.02-1.48)1.12 (0.93-1.36) Eastern Med & Eur < 5 HH1.21 (0.89-1.65)1.14 (0.84-1.56) 5 or more HH1.71 (0.89-3.30)1.75 (0.97-3.16) Table 4. The number of households sharing a toilet facility and the prevalence ratios for diarrhea among children < 5 years of age. Data from 39 Demographic and Health Surveys, 2001-2011. The 2 groups appear to be similar Some evidence of a dose-response

12. Summary  Pooled analysis shows a modest effect (5-10%)  Geographic heterogeneity  Confounding via socioeconomic status  Number of HH sharing has no clear effect

13. Strengths of this approach  Broad scope captures virtually every sharing scenario and setting  Adjusting for confounders  Data is readily available

14. Limitations  Broad scope misses the details  Public vs. private ownership  Cleanliness and Accessibility  Fecal Sludge Management  Residual confounding