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SHARED SANITATION AND DIARRHEA: EVIDENCE FROM 51 COUNTRIES James A. Fuller Department of Epidemiology University of Michigan School of Public Health Co-authors:

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Presentation on theme: "SHARED SANITATION AND DIARRHEA: EVIDENCE FROM 51 COUNTRIES James A. Fuller Department of Epidemiology University of Michigan School of Public Health Co-authors:"— Presentation transcript:

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 ( )1.05 ( ) Latin America and the Caribbean1.11 ( )1.02 ( ) South-East Asia and Western Pacific1.16 ( )1.09 ( ) Eastern Mediterranean and Europe1.26 ( )1.22 ( ) All Regions Combined1.09 ( )1.05 ( ) 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 ( ) 5 or more HH1.06 ( )1.02 ( ) Africa < 5 HH1.06 ( )1.04 ( ) 5 or more HH1.02 ( )1.03 ( ) Latin Am & Car < 5 HH1.08 ( )1.02 ( ) 5 or more HH1.14 ( )1.01 ( ) SEA & WP < 5 HH1.13 ( )1.07 ( ) 5 or more HH1.22 ( )1.12 ( ) Eastern Med & Eur < 5 HH1.21 ( )1.14 ( ) 5 or more HH1.71 ( )1.75 ( ) 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, 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


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