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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Background:
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).

Methods and Findings:
We conducted a cluster-randomized, controlled trial in 80 rural villages. Field staff collected baseline measures of sanitation conditions, behaviors, and child health (May–July 2009), and revisited households 21 months later (February–April 2011) after the program was delivered. The study enrolled a random sample of 5,209 children <5 years old from 3,039 households that had at least one child <24 months at the beginning of the study. A random subsample of 1,150 children <24 months at enrollment were tested for soil transmitted helminth and protozoan infections in stool. The randomization successfully balanced intervention and control groups, and we estimated differences between groups in an intention to treat analysis. The intervention increased percentage of households in a village with improved sanitation facilities as defined by the WHO/UNICEF Joint Monitoring Programme by an average of 19% (95% CI for difference: 12%–26%; group means: 22% control versus 41% intervention), decreased open defecation among adults by an average of 10% (95% CI for difference: 4%–15%; group means: 73% intervention versus 84% control). However, the intervention did not improve child health measured in terms of multiple health outcomes (diarrhea, HCGI, helminth infections, anemia, growth). Limitations of the study included a relatively short follow-up period following implementation, evidence for contamination in ten of the 40 control villages, and bias possible in self-reported outcomes for diarrhea, HCGI, and open defecation behaviors.

Conclusions:
The intervention led to modest increases in availability of IHLs and even more modest reductions in open defecation. These improvements were insufficient to improve child health outcomes (diarrhea, HCGI, parasite infection, anemia, growth). The results underscore the difficulty of achieving adequately large improvements in sanitation levels to deliver expected health benefits within large-scale rural sanitation programs.

Trial Registration: ClinicalTrials.gov NCT01465204

Please see later in the article for the Editors' Summary

Vyšlo v časopise: The Effect of India's Total Sanitation Campaign on Defecation Behaviors and Child Health in Rural Madhya Pradesh: A Cluster Randomized Controlled Trial. PLoS Med 11(8): e32767. doi:10.1371/journal.pmed.1001709
Kategorie: Research Article
prolekare.web.journal.doi_sk: https://doi.org/10.1371/journal.pmed.1001709

Souhrn

Zdroje

1. MaraD, LaneJ, ScottB, TroubaD (2010) Sanitation and health. PLoS Med 7: e1000363.

2. UNICEF, WHO (2012) World Health Organization and United Nations Children's Fund Joint Monitoring Programme for Water Supply and Sanitation (JMP). Progress on Drinking Water and Sanitation: 2012 Update. New York and Geneva: UNICEF and WHO.

3. Unicef, WHO (2009) Diarrhoea: Why children are still dying and what can be done. New York and Geneva: Unicef/WHO.

4. ClasenTF, BostoenK, SchmidtW-P, BoissonS, FungIC-H, et al. (2010) Interventions to improve disposal of human excreta for preventing diarrhoea. Cochrane Database Syst Rev 6: CD007180.

5. NormanG, PedleyS, TakkoucheB (2010) Effects of sewerage on diarrhoea and enteric infections: a systematic review and meta-analysis. Lancet Infect Dis 10: 536–544.

6. BarretoML, GenserB, StrinaA, TeixeiraMG, AssisAMO, et al. (2010) Impact of a city-wide sanitation programme in Northeast Brazil on intestinal parasites infection in young children. Environ Health Perspect Available: http://www.ncbi.nlm.nih.gov/pubmed/20705544. Accessed 20 November 2010.

7. Mascarini-SerraLM, TellesCA, PradoMS, MattosSA, StrinaA, et al. (2010) Reductions in the prevalence and incidence of geohelminth infections following a city-wide sanitation program in a Brazilian Urban Centre. PLoS Negl Trop Dis 4: e588.

8. ZiegelbauerK, SpeichB, MäusezahlD, BosR, KeiserJ, et al. (2012) Effect of sanitation on soil-transmitted helminth infection: systematic review and meta-analysis. PLoS Med 9: e1001162.

9. ChavasseDC, ShierRP, MurphyOA, HuttlySR, CousensSN, et al. (1999) Impact of fly control on childhood diarrhoea in Pakistan: community-randomised trial. Lancet 353: 22–25.

10. EmersonPM, LindsaySW, AlexanderN, BahM, DibbaS-M, et al. (2004) Role of flies and provision of latrines in trachoma control: cluster-randomised controlled trial. Lancet 363: 1093–1098.

11. EmersonPM, SimmsVM, MakaloP, BaileyRL (2005) Household pit latrines as a potential source of the fly Musca sorbens–a one year longitudinal study from The Gambia. Trop Med Int Health 10: 706–709.

12. CheckleyW, BuckleyG, GilmanRH, AssisAM, GuerrantRL, et al. (2008) Multi-country analysis of the effects of diarrhoea on childhood stunting. Int J Epidemiol 37: 816–830.

13. SchmidtW-P, BoissonS, GenserB, BarretoML, BaisleyK, et al. (2010) Weight-for-age z-score as a proxy marker for diarrhoea in epidemiological studies. J Epidemiol Community Health 64: 1074–1079.

14. HumphreyJH (2009) Child undernutrition, tropical enteropathy, toilets, and handwashing. Lancet 374: 1032–1035.

15. PrendergastA, KellyP (2012) Enteropathies in the developing world: neglected effects on global health. Am J Trop Med Hyg 86: 756–763.

16. CheckleyW, GilmanRH, BlackRE, EpsteinLD, CabreraL, et al. (2004) Effect of water and sanitation on childhood health in a poor Peruvian peri-urban community. Lancet 363: 112–118.

17. MiguelE, CamererC, CaseyK, CohenJ, EsterlingKM, et al. (2014) Promoting transparency in social science research. Science 343: 30–31.

18. Salvatore AL, Patil SR (2011) Scaling up rural sanitation: findings from the impact evaluation baseline survey in Madhya Pradesh, India. The Water and Sanitation Program, The World Bank. Washington (D.C.): The World Bank.

19. GhoshA, CairncrossS (2014) The uneven progress of sanitation in India. J Water, Sanitation & Hygiene for Devel 4: 15–22.

20. Report of the expert group to recommend the detailed methodology for identifcation of families living below poverty line in the urban areas (2012). Planning Commission, Perspective Planning Division, Government of India. Available: http://planningcommission.nic.in/reports/genrep/rep_hasim1701.pdf. Accessed 14 April 2014.

21. KarK, ChambersR (2008) Handbook on Community-Led Total Sanitation. Plan International (UK) Available: http://www.communityledtotalsanitation.org/resource/handbook-community-led-total-sanitation. Accessed 12 February 2013.

22. BaquiAH, BlackRE, YunusM, HoqueAR, ChowdhuryHR, et al. (1991) Methodological issues in diarrhoeal diseases epidemiology: definition of diarrhoeal episodes. Int J Epidemiol 20: 1057–1063.

23. ArnoldBF, GalianiS, RamPK, HubbardAE, BriceñoB, et al. (2013) Optimal recall period for caregiver-reported illness in risk factor and intervention studies: a multicountry study. Am J Epidemiol 177: 361–370.

24. GoldmanN, VaughanB, PebleyAR (1998) The use of calendars to measure child illness in health interview surveys. Int J Epidemiol 27: 505–512.

25. PaymentP, RichardsonL, SiemiatyckiJ, DewarR, EdwardesM, et al. (1991) A randomized trial to evaluate the risk of gastrointestinal disease due to consumption of drinking water meeting current microbiological standards. Am J Public Health 81: 703–708.

26. ColfordJM, WadeTJ, SandhuSK, van der LaanMJ, BrookhartMA, et al. (2005) A randomized, controlled trial of in-home drinking water intervention to reduce gastrointestinal illness. Am J Epidemiol 161: 472–482.

27. ColfordJM, HiltonJF, WrightCC, ArnoldBF, SahaS, et al. (2009) The Sonoma Water Evaluation Trial: a randomized drinking water intervention trial to reduce gastrointestinal illness in older adults. Am J Public Health 99: 1988–1995.

28. ArnoldB, AranaB, MäusezahlD, HubbardA, ColfordJM (2009) Evaluation of a pre-existing, 3-year household water treatment and handwashing intervention in rural Guatemala. Int J Epidemiol 38: 1651–1661.

29. GoveS (1997) Integrated management of childhood illness by outpatient health workers: technical basis and overview. The WHO Working Group on Guidelines for Integrated Management of the Sick Child. Bull World Health Organ 75 Suppl 1: 7–24.

30. LipsitchM, TchetgenET, CohenT (2010) Negative controls: a tool for detecting confounding and bias in observational studies. Epidemiology 21: 383–388.

31. WoodL, EggerM, GluudLL, SchulzKF, JϋniP, et al. (2008) Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study. BMJ 336: 601–605.

32. SchmidtW-P, CairncrossS (2009) Household water treatment in poor populations: is there enough evidence for scaling up now? Environ Sci Technol 43: 986–992.

33. Cogill B (2003) Anthropometric indicators measurement guide. Washington (D.C.): Food and Nutrition Technical Assistance Project, Academy for Educational Development.

34. De OnisM, OnyangoAW, Broeck JVden, ChumleaWC, MartorellR (2004) Measurement and standardization protocols for anthropometry used in the construction of a new international growth reference. Food Nutr Bull 25: S27–S36.

35. WHO (2006) WHO Child Growth Standards: length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and developments. Geneva: WHO.

36. WHO (2011) Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. Vitamin and Mineral Nutrition Information System. Geneva: WHO.

37. HelselDR (1990) Less than obvious - statistical treatment of data below the detection limit. Environ Sci & Technol 24: 1766–1774.

38. KatzN, ChavesA, PellegrinoJ (1972) A simple device for quantitative stool thick-smear technique in Schistosomiasis mansoni. Rev Inst Med Trop Sao Paulo 14: 397–400.

39. GarciaLS, ShimizuRY (1997) Evaluation of nine immunoassay kits (enzyme immunoassay and direct fluorescence) for detection of Giardia lamblia and Cryptosporidium parvum in human fecal specimens. J Clin Microbiol 35: 1526–1529.

40. Den HartogJ, RosenbaumL, WoodZ, BurtD, PetriWAJr (2013) Diagnosis of multiple enteric protozoan infections by enzyme-linked immunosorbent assay in the guatemalan highlands. Am J Trop Med Hyg 88: 167–171.

41. LubySP, AgboatwallaM, PainterJ, BillhimerWL, KeswickBH, et al. (2006) Combining drinking water treatment and hand washing for diarrhoea prevention, a cluster randomised controlled trial. Trop Med Int Health 11: 479–489.

42. FreedmanDA (2006) On the so-called “Huber sandwich estimator” and “robust standard errors.”. Am Stat 60: 299–302.

43. SchulzKF, GrimesDA (2005) Multiplicity in randomised trials I: endpoints and treatments. Lancet 365: 1591–1595.

44. ClasenT, BoissonS, RoutrayP, CummingO, JenkinsM, et al. (2012) The effect of improved rural sanitation on diarrhoea and helminth infection: design of a cluster-randomized trial in Orissa, India. Emerg Themes Epidemiol 9: 7.

45. ArnoldBF, NullC, LubySP, UnicombL, StewartCP, et al. (2013) Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale. BMJ Open 3: e003476.

46. Cameron L, Shah M, Olivia S (2013) Impact evaluation of a rural sanitation behavior change project in Indonesia. Washington (D.C.): The World Bank.

47. BarnardS, RoutrayP, MajorinF, PeletzR, BoissonS, et al. (2013) Impact of Indian Total Sanitation Campaign on latrine coverage and use: a cross-sectional study in Orissa three years following programme implementation. PLoS One 8: e71438.

48. PattanayakSK, YangJC, DickinsonKL, PoulosC, PatilSR, et al. (2009) Shame or subsidy revisited: social mobilization for sanitation in Orissa, India. Bull World Health Organ 8: 580–587.

49. ArnoldBF, KhushRS, RamaswamyP, LondonAG, RajkumarP, et al. (2010) Causal inference methods to study nonrandomized, preexisting development interventions. Proc Natl Acad Sci U S A 107: 22605–22610.

50. Galiani S, Gertler P, Orsola-Vidal A (2012) Promoting handwashing behavior in peru: the effect of large-scale mass-media and community level interventions. World Bank Policy Research Working Paper 6257. Washington (D.C.): The World Bank.

51. Chase C, Do Q-T (2012) Handwashing behavior change at scale: evidence from a randomized evaluation in Vietnam. World Bank Policy Research Working Paper 6207. Washington (D.C.): The World Bank.

52. HudaTMN, UnicombL, JohnstonRB, HalderAK, SharkerMAY, et al. (2012) Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh. Soc Sci Med 75: 604–611.

53. BiranA, SchmidtW-P, VaradharajanKS, RajaramanD, KumarR, et al. (2014) Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. Lancet Glob Health 2: e145–e154.

54. HuesoA, BellB (n.d.) An untold story of policy failure: the Total Sanitation Campaign in India. Water Policy 15: 1001–1017.

55. WaddingtonH, SnilstveitB (2009) Effectiveness and sustainability of water, sanitation, and hygiene interventions in combating diarrhoea. J Dev Eff 1: 295–335.

56. ClasenT, FabiniD, BoissonS, TanejaJ, SongJ, et al. (2012) Making sanitation count: Developing and testing a device for assessing latrine use in low-income settings. Environ Sci Technol 46: 3295–3303.

57. ThomasEA, BarstowCK, RosaG, MajorinF, ClasenT (2013) Use of remotely reporting electronic sensors for assessing use of water filters and cookstoves in rwanda. Environ Sci Technol 47: 13602–13610.