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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?