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Multiple benefits and harms in water, sanitation and hygiene interventions: A re-review of a systematic review
Multiple benefits and harms in water, sanitation and hygiene interventions: A re-review of a systematic review
Multiple benefits and harms in water, sanitation and hygiene interventions: A re-review of a systematic review
Multiple benefits and harms in water, sanitation and hygiene interventions: A re-review of a systematic review
Multiple benefits and harms in water, sanitation and hygiene interventions: A re-review of a systematic review
Multiple benefits and harms in water, sanitation and hygiene interventions: A re-review of a systematic review
Multiple benefits and harms in water, sanitation and hygiene interventions: A re-review of a systematic review
Multiple benefits and harms in water, sanitation and hygiene interventions: A re-review of a systematic review
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Multiple benefits and harms in water, sanitation and hygiene interventions: A re-review of a systematic review

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Michael Loevinsohn of the Institute of Development Studies presents findings of an innovative re-review of a systematic review of WASH interventions. Presented at 'Synthesising across health and …

Michael Loevinsohn of the Institute of Development Studies presents findings of an innovative re-review of a systematic review of WASH interventions. Presented at 'Synthesising across health and development' a joint event of LSHTM, LIDC and IDS held at Woburn House on 19 September 2012.

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  • 1. Multiple benefits and harms in water, sanitation and hygiene interventions: A re-review of a systematic reviewMichael Loevinsohn1, Lyla Mehta1, Katie Cuming2, Alan Nicol1,Oliver Cumming3 and Jeroen Ensink3  19 September 2012, Woburn House, Tavistock Square 1 IDS; 2 DFID; 3 LSHTM
  • 2. Water, sanitation and hygiene• Critical to wellbeing yet large gaps in coverage persist• Designs still often fail to meet needs in health and other domains• “Health” and “development” disciplinary/ practice communities remain disconnected H0 : Important gains possible from bridging this divide
  • 3. Re-review of Waddington et al 2009Systematic review: WASH impact on diarrhoea• Realist review of all evidence, including info not analysed by article and/or SR authors• Theory-based – public health: understandings of key mechanisms – development: understandings of individual and collective agency (esp. common property, gender, sustainable livelihood theory)• Excluded study designs with little context• 1 health, 1 development researcher reviewed each article, then deliberated on 4 questions
  • 4. Deliberation outcomes: “Likely” or “More than possible” N=22• Is the intervention substantially more complex than considered by Waddington et al? 18.2%• Are impacts substantially understated if only diarrhoea outcome is considered? 45.5%• Are actions by individuals, households or communities substantially influencing the benefits and harms experienced? 50.0%• Would these other impacts substantially affect the level, distribution or sustainability of the diarrhoea morbidity outcome? 45.5 %
  • 5. Is the intervention substantially morecomplex than considered by Waddington?• Kolahi et al 2009: sanitation in Tehran – Large improvement in maternal education in treated but not control neighbourhoods (analysis of background data) – Suggests an independent intervention – Better maternal care may have contributed to reduced diarrhoea, complicating attribution• Moraes et al 2003: sanitation in Salvador – Beyond sewers, treated got land title, better water supply – More water may have contributed to reduced diarrhoea – Better off areas were treated, visibly exacerbating inequalities
  • 6. Are impacts substantially understated if only diarrhoea outcome is considered?• Aziz et al 1990: water supply, sanitation - Bangladesh – Women use pumps to irrigate kitchen gardens – Better nutrition may contribute to reduced diarrhoea – Women prize “improved QoL”; may also increase commitment to maintain system, enhancing sustainability• Ahmed et al 2003: hygiene - Bangladesh – Field workers discourage bottle-feeding due to diarrhoea risk but reduced milk intake increases stunting – Stunting known to increase diarrhoea mortality, other developmental effects. – Intervention’s impact more than possibly reduced
  • 7. Are individual, household or community actions influencing benefits and harms?• Kremer et al 2009: water supply - Kenya – Control HHs use improved springs in treated area – Diarrhoea reduced in control areas, diminishes apparent effect of intervention• “Contamination” evident in 3 other articles – Control people getting hold of or treated people actively spreading the intervention – Considered mostly as an estimation problem – Little thought given to harnessing these efforts to enhance impact and sustainability
  • 8. Implications for health and development• Design and implementation of WASH interventions – Plan for, incorporate agency – Enhance capacity to manage multiple benefits and harms• Evaluation methods and practice – More realistic designs e.g. incorporating spread – More attention to processes and context• Systematic reviews and the knowledge economy – Create demand for evaluation of innovative designs – Commission SRs focused not on mean effects but e.g. conditions under which exceptional results are realized

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