Impact of Shared Sanitation Facilities in Madhya Pradesh, India (2012)

Shared Sanitation in Madhya Pradesh, India

Kali Nelson, MPH Candidate Department of Epidemiology and Biostatistics The George Washington University

Outline

• Background

• Objectives

• Methods

• Results

• Discussion

http://www.nationsonline.org/oneworld/india_map.html

http://www.wssinfo.org/definitions-methods/watsan-categories/

http://thefarthesthousecall.files.wordpress.com/2011/04/vip-latrine.jpg

IMPROVED VENTILATED IMPROVED

PIT (VIP) LATRINE

UNIMPROVED HANGING LATRINE

http://www.flickr.com/photos/waterdotorg/3695499855/sizes/l/in/photostream/

Background: Global Sanitation Trends

• Millennium Development Goals Sanitation Target: 75% covered with sustainable access to improved sanitation by 2015 1

• 37% of the global population lacked access to improved sanitation 2

• 15% of the global population practiced open defecation 2

• 86% rural

1 WHO/UNICEF 2006, 2 WHO/UNICEF 2012

Sanitation in India • 66% of India lacked access to improved

sanitation 1

• 42% urban

• 77% rural

• 51% of India practiced open defecation 1

• 14% urban

• 67% rural

• Madhya Pradesh 2

• 2006 - 27% households with toilets

• 2010 - 54% households with toilets 1 WHO/UNICEF 2012, 2 WHO/UNICEF 2011

Sanitation Ladder - India

http://www.wssinfo.org/fileadmin/user_upload/resources/IND_san.pdf

= open defecation

= other unimproved facilities

= shared

= improved

URBAN RURAL TOTAL

Background: Shared Sanitation

• Shared sanitation definition

• In 2010, 11% of the global population utilized shared sanitation

• 39% rural

• Shared sanitation in India: 9% in 2010

• 19% urban

• 4% rural

Background: Health Outcomes • Research on shared sanitation is very limited:

• Alexandria, Egypt: infection with soil-transmitted helminthes 1

• Rural Tanzania: trachoma risk 2

• Dhaka, Bangladesh: parasite and diarrheal disease prevalence 3

• Botswana, Ghana, and Zambia: infection with intestinal parasites 4

• Bhopal, India: open defecation 5

• Urban Bangladesh: weight-for-height scores 6

1 Curtale, et. al., 1998 2 Montgomery, et. al., 2010 3 Khan, 1987

4 Feachem, et. al., 1983 5 Biran, et. al., 2011 6 WHO/UNICEF 2012

Objectives

• Describe sanitation access among households in Madhya Pradesh, India.

• Analyze the relationship between sanitation access and diarrheal disease prevalence, safety of female users, cleanliness, and user satisfaction.

• Recommend changes to the current definition of improved sanitation based on research results.

Methods

• World Bank Water and Sanitation Program

Global Scaling Up Rural Sanitation intervention

• 2009 baseline survey

• Cross-sectional study of Impact Evaluation survey:

• Household questionnaire

• Children < 5 years health questionnaire

Methods

• Sanitation facility characteristics

• Sanitation status

• Sharing status

• Health outcome

• Two-week prevalence of diarrheal disease

• 3 or more bowel movements per day

• Cleanliness outcome

• Presence of flies

Methods

• Female safety outcomes

• Safety of sanitation facility during the day

• Safety of sanitation facility during the night

• Privacy

• Satisfaction with sanitation facility

• Potential confounders

Data Analysis

• Descriptive statistics

• Pearson’s Chi-square tests for association among sanitation variables and health, safety, and cleanliness outcomes

• Logistic regression analysis

• Proportional Odds Model

Descriptive Statistics Madhya Pradesh n (%)

Survey data

Households 1,978

Children 3,464

Sanitation status

Improved 261 (14.1%)

Unimproved 1,856 (85.9%)

Sharing status

Not shared 253 (12.8%)

Shared 1,717 (87.2%)

Health Outcome

Two-week diarrheal disease

prevalence

510 (14.7%)

Madhya Pradesh n (%)

Female safety

Daytime 968 (49.0%)

Nighttime 452 (22.9%)

Privacy 542 (27.5%)

Cleanliness – presence of flies

Always 1,671 (84.5%)

Sometimes 201 (10.2%)

Rarely 104 (5.3%)

Satisfaction

Satisfied 774 (39.3%)

Not satisfied 1,193 (60.7%)

Child Health Results

Variable Outcome modeled Odds

Ratio

95%

Confidence

Interval

Shared Shared (v. not shared) 1.534 0.765, 3.074

Location Household latrine/ less

than 10 min. (v. no

designated area)

1.328 0.761, 2.319

Location More than 10 min. (v. no

designated area)

1.408 1.032, 1.921*

Visible feces One or more (v. none) 0.522 0.353, 0.773*

Feces odor Yes (v. no) 1.264 0.857, 1.864

Logistic regression for two-week diarrheal disease prevalence among children

*Statistically significant at p < 0.05

Safety Results

Variable Outcome modeled Odds

Ratio

95%

Confidence

Interval

Sanitation

status

Improved (v.

unimproved)

14.921 3.695, 60.247*

Sharing

status

Not shared (v.

shared)

3.119 1.016, 9.573*

Toilet

location

Household latrine/

less than 10 min. (v.

no designated area)

0.927 0.511, 1.684

Logistic regression for female safety – daytime

*Statistically significant at p < 0.05

Safety Results

Variable Outcome modeled Odds

Ratio

95%

Confidence

Interval

Sanitation

status

Improved (v.

unimproved)

30.438 7.388,

125.409*

Sharing

status

Not shared (v.

shared)

1.830 0.581, 5.767

Toilet

location

Household latrine/

less than 10 min. (v.

no designated area)

5.663 2.778, 11.546*

Toilet

location

More than 10 min. (v.

no designated area)

1.995 1.233, 3.228*

Logistic regression for female safety – nighttime

*Statistically significant at p < 0.05

Safety Results

*Statistically significant at p < 0.05

Variable Outcome modeled Odds

Ratio

95%

Confidence

Interval

Sanitation

status

Improved (v.

unimproved)

15.824 4.874, 51.379*

Sharing

status

Not shared (v.

shared)

3.981 1.468, 10.796*

Toilet

location

Household latrine/

less than 10 min. (v.

no designated area)

3.892 2.008, 7.545*

Toilet

location

More than 10 min. (v.

no designated area)

1.955 1.315, 2.907*

Logistic regression for female privacy

Cleanliness Results

Variable Outcome modeled Odds

Ratio

95%

Confidence

Interval

Sanitation

status

Improved (v.

unimproved)

5.221 1.963, 13.883*

Sharing status Not shared (v. shared) 2.449 1.036, 5.790*

Toilet location Household latrine/ less

than 10 min. (v. no

designated area)

6.248 2.588, 15.086*

Toilet location More than 10 min. (v.

no area)

1.992 1.014, 3.911*

Visible feces None (v. one or more) 1.286 0.719, 2.302

Feces odor No (v. yes) 0.693 0.385, 1.246

Open pit/ open

drain nearby

No (v. yes) 1.269 0.823, 1.958

*Statistically significant at p < 0.05

Proportional Odds Model for presence of flies

Satisfaction Results

Variable Outcome modeled Odds

Ratio

95%

Confidence

Interval

Sanitation

status

Improved (v.

unimproved)

1.085 0.270, 4.353

Sharing status Not shared (v. shared) 9.897 2.713, 36.097*

Presence of

flies

Rarely (v. always) 1.931 0.559, 6.673

Presence of

flies

Sometimes (v. always) 0.721 0.362, 1.436

Toilet location Household latrine/ less

than 10 min. (v. no

designated area)

0.662 0.326, 1.346

Toilet location More than 10 min. (v.

no designated area)

0.381 0.271, 0.536*

Logistic regression for satisfaction

*Statistically significant at p < 0.05

Satisfaction Results

Variable Outcome modeled Odds

Ratio

95%

Confidence

Interval

Feces odor No (v. yes) 1.094 0.674, 1.775

Open pit/ open

drain nearby

No (v. yes) 0.541 0.386, 0.757*

Visible feces None (v. one or more) 0.496 0.298, 0.827*

Female safety

– day

Yes (v. no) 6.489 4.539, 9.276*

Female safety

– night

Yes (v. no) 1.496 0.940, 2.382

Female privacy Yes (v. no) 1.397 0.903, 2.163

Logistic regression for satisfaction

*Statistically significant at p < 0.05

Conclusions

• Health outcomes

• Improved sanitation

• Shared facilities

Limitations

• Weak indicators

• Two-week diarrheal prevalence

• Number of households sharing

• Cross-sectional data

Strengths

• Large dataset

• One of first studies to analyze shared sanitation and user satisfaction

Discussion

• Number of households sharing

• How shared facilities affect user satisfaction • Analysis of household survey data from

Bangladesh, Tanzania, and Indonesia

Acknowledgments

• Dr. Angelo Elmi

Dept. of Epidemiology and Biostatistics

• Dr. Jay Graham

Dept. of Environmental and Occupational Health

• Craig Kullmann

World Bank Water and Sanitation Program

• Prof. Ann Goldman

Dept. of Epidemiology and Biostatistics

Questions?