Multiple benefits and harms in water,       sanitation and hygiene interventions:       A re-review of a systematic review...
Water, sanitation and hygiene• Critical to wellbeing yet large gaps in coverage  persist• Designs still often fail to meet...
Re-review of Waddington et al 2009Systematic review: WASH impact on diarrhoea• Realist review of all evidence, including i...
Deliberation outcomes: “Likely” or “More than possible”                N=22• Is the intervention substantially more comple...
Is the intervention substantially morecomplex than considered by Waddington?• Kolahi et al 2009: sanitation in Tehran   – ...
Are impacts substantially understated if only diarrhoea outcome is considered?• Aziz et al 1990: water supply, sanitation ...
Are individual, household or community actions influencing benefits and harms?• Kremer et al 2009: water supply - Kenya   ...
Implications for health and development• Design and implementation of WASH interventions  – Plan for, incorporate agency  ...
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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 development' a joint event of LSHTM, LIDC and IDS held at Woburn House on 19 September 2012.

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

  1. 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. 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. 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. 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. 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. 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. 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. 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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