Effectiveness of a combined sanitation and household-level piped water intervention on infrastructure coverage, availability and use, environmental fecal contamination, and child health in rural Odisha, India: a matched cohort study Open Access
Reese, Heather (Fall 2017)
Abstract
Over half of the almost 1 billion people who practice open defecation live in India. While access to community water sources has improved in rural India, few households have on-site piped water. Although a primary motivation for water, sanitation and hygiene improvements is associated improvements in health, there is mixed evidence of effective interventions, especially in India.
We conducted a matched cohort study to evaluate a combined intervention, where household piped water connections were contingent on community-wide household toilet and bathing room construction, implemented in rural Odisha, India. Forty-five intervention villages were randomly selected from a list of those where the program was implemented, and matched to 45 control villages. We conducted surveys and observations, and collected stools and environmental samples (source water, drinking water, and rinses of children’s hands) between June 2015-October 2016 in households with a child under five (N=2398). Health surveillance included diarrhea, acute respiratory infection, soil-transmitted helminthiasis, and anthropometry to assess undernutrition. Source water, drinking water, and children’s hands were assayed for fecal indicator bacteria, and select waterborne pathogens.
Multilevel regression using generalized linear models was used to assess the effect of the intervention on WaSH coverage, availability and use; fecal environmental contamination; and child health. Compared to controls, intervention villages had substantially higher improved toilet coverage and use. Although the intervention was associated with higher access to piped water on the household premises, both study arms experienced intermittencies in water availability. Most source and drinking waters in both study arms were positive for E. coli, and there was no intervention effect on E. coli. in source water, drinking water, or on children’s hands. However, the intervention substantially reduced the prevalence of S. dysenteria and S. flexneri in source water (aRR: 0.59, 95% CI: 0.35, 0.97). Similarly, there was no intervention effect on child diarrhea or respiratory infection. However, compared to the control, children in intervention villages had lower odds of helminthiasis (aOR: 0.44, 95% CI: 0.18, 1.00) and improved HAZ (+0.17, 95% CI: 0.03-0.31). Future research should focus on the pathways through which these mixed effects on fecal environmental contamination and health outcomes occur.
Table of Contents
Chapter 1. Introduction..............................................................................................................1
Dissertation Aims........................................................................................................................4
Chapter 2. Diarrheal diseases, soil-transmitted helminthiasis, acute respiratory infection, and undernutrition: burden of disease, etiology, and preventative measures....................................6
Diarrheal diseases.......................................................................................................................6
Soil-transmitted helminthiasis....................................................................................................7
Acute respiratory infection.........................................................................................................9
Undernutrition ..........................................................................................................................10
Preventative measures ..................................................................................................... 11
Chapter 3. Water, sanitation and hygiene interventions.........................................................14
Piped water on household premises.........................................................................................15
Community-level sanitation.....................................................................................................18
Chapter 4. Design and rationale of a matched cohort study to assess the effectiveness of a combined household-level piped water and sanitation intervention in rural Odisha, India.....21
Abstract....................................................................................................................................22
Strengths and limitations of this study.....................................................................................23
Introduction..............................................................................................................................23
Methods............................................................................................................................. ......29
Statistical analyses...................................................................................................................42
Discussion................................................................................................................................44
Chapter 5. Effect of a combined household-level piped water and sanitation intervention on child diarrhea, acute respiratory infection, soil-transmitted helminthiasis, and nutritional status: a matched cohort study in rural Odisha, India........................................................................................49
Abstract.................................................................................................................................50
Introduction...........................................................................................................................51
Methods............................................................................................................................ ....52
Results ..................................................................................................................................58
Discussion..............................................................................................................................61
Chapter 6. The effect of a combined household piped water and sanitation intervention on fecal contamination of source water, household drinking water and children’s hands: a matched cohort study in Odisha, India.......................................................................................................................75
Abstract...............................................................................................................................76
Introduction.........................................................................................................................76
Materials and methods........................................................................................................79
Results and discussion........................................................................................................84
Chapter 7. Conclusion......................................................................................................103
Summary of findings.........................................................................................................103
Reflections on study limitations and the potential for improvements...............................107
Selection of households.....................................................................................................107
Matched design..................................................................................................................108
Intervention approach........................................................................................................110
Water distribution system..................................................................................................111
Measurement methods.......................................................................................................113
Quality control and data loss.............................................................................................114
Policy and program recommendations..............................................................................116
Recommendations for future research...............................................................................117
Appendix A. Description of outcome measurement........................................................121
Appendix B. Description of intervention infrastructure..................................................124
References.......................................................................................................................126
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