Analysis of shared sanitation facilities on health, safety, and user satisfaction outcomes in Madhya Pradesh, India.

1. Shared Sanitation in Madhya Pradesh, India
Kali Nelson, MPH Candidate
Department of Epidemiology and Biostatistics
The George Washington University

2. Outline
•Background
•Objectives
•Methods
•Results
•Discussion

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

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

5. 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/

6. 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

7. 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

8. Sanitation Ladder - India
http://www.wssinfo.org/fileadmin/user_upload/resources/IND_san.pdf
= open defecation
= other unimproved facilities
= shared
= improved
URBAN
RURAL
TOTAL

9. 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

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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

16. 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%)

17. 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%)

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. Conclusions
•Health outcomes
•Improved sanitation
•Shared facilities

26. Limitations
•Weak indicators
•Two-week diarrheal prevalence
•Number of households sharing
•Cross-sectional data

27. Strengths
•Large dataset
•One of first studies to analyze shared sanitation and user satisfaction

28. Discussion
•Number of households sharing
•How shared facilities affect user satisfaction
•Analysis of household survey data from Bangladesh, Tanzania, and Indonesia

29. 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

30. Questions?