Sumeet Patil and colleagues conduct a cluster randomized controlled trial to measure the effect of India's Total Sanitation Campaign in Madhya Pradesh on the availability of individual household latrines, defecation behaviors, and child health.
Please see later in the article for the Editors' Summary
Poor sanitation is thought to be a major cause of enteric infections among young children. However, there are no previously published randomized trials to measure the health impacts of large-scale sanitation programs. India's Total Sanitation Campaign (TSC) is one such program that seeks to end the practice of open defecation by changing social norms and behaviors, and providing technical support and financial subsidies. The objective of this study was to measure the effect of the TSC implemented with capacity building support from the World Bank's Water and Sanitation Program in Madhya Pradesh on availability of individual household latrines (IHLs), defecation behaviors, and child health (diarrhea, highly credible gastrointestinal illness [HCGI], parasitic infections, anemia, growth).
Methods and Findings
We conducted a cluster-randomized, controlled trial in 80 rural villages. Field staff collected baseline measures of sanitation conditions, behaviors, and child health (May–July 2009), and revisited households 21 months later (February–April 2011) after the program was delivered. The study enrolled a random sample of 5,209 children <5 years old from 3,039 households that had at least one child <24 months at the beginning of the study. A random subsample of 1,150 children <24 months at enrollment were tested for soil transmitted helminth and protozoan infections in stool. The randomization successfully balanced intervention and control groups, and we estimated differences between groups in an intention to treat analysis. The intervention increased percentage of households in a village with improved sanitation facilities as defined by the WHO/UNICEF Joint Monitoring Programme by an average of 19% (95% CI for difference: 12%–26%; group means: 22% control versus 41% intervention), decreased open defecation among adults by an average of 10% (95% CI for difference: 4%–15%; group means: 73% intervention versus 84% control). However, the intervention did not improve child health measured in terms of multiple health outcomes (diarrhea, HCGI, helminth infections, anemia, growth). Limitations of the study included a relatively short follow-up period following implementation, evidence for contamination in ten of the 40 control villages, and bias possible in self-reported outcomes for diarrhea, HCGI, and open defecation behaviors.
The intervention led to modest increases in availability of IHLs and even more modest reductions in open defecation. These improvements were insufficient to improve child health outcomes (diarrhea, HCGI, parasite infection, anemia, growth). The results underscore the difficulty of achieving adequately large improvements in sanitation levels to deliver expected health benefits within large-scale rural sanitation programs.
Please see later in the article for the Editors' Summary
Diarrheal diseases are linked with the deaths of hundreds of thousands of young children each year in resource-limited countries. Infection with enteric pathogens (organisms such as bacteria, viruses, and parasites that infect the human intestine or gut) also affects the health and growth of many young children in these countries. A major contributor to the transmission of enteric pathogens is thought to be open defecation, which can expose individuals to direct contact with human feces containing infectious pathogens and also contaminate food and drinking water. Open defecation can be reduced by ensuring that people have access to and use toilets or latrines. Consequently, programs have been initiated in many resource-limited countries that aim to reduce open defecation by changing behaviors and by providing technical and financial support to help households build improved latrines (facilities that prevent human feces from re-entering the environment such as pit latrines with sealed squat plates; an example of an unimproved facility is a simple open hole). However, in 2011, according to the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation, more than 1 billion people (15% of the global population) still defecated in the open.
Why Was This Study Done?
Studies of sewerage system provision in urban areas suggest that interventions that prevent human feces entering the environment reduce diarrheal diseases. However, little is known about how rural sanitation programs, which usually focus on providing stand-alone sanitation facilities, affect diarrheal disease, intestinal parasite infections, anemia (which can be caused by parasite infections), or growth in young children. Governments and international donors need to know whether large-scale rural sanitation programs improve child health before expending further resources on these interventions or to identify an urgency to improve the existing program design or implementation so that they deliver the health impact. In this study, the researchers investigate the effect of India's Total Sanitation Campaign (TSC) on the availability of individual household latrines, defecation behaviors, and child health in rural Madhya Pradesh, one of India's less developed states. Sixty percent of people who practice open defection live in India and a quarter of global child deaths from diarrheal diseases occur in the country. India's TSC, which was initiated in 1999, includes activities designed to change social norms and behaviors and provides technical and financial support for latrine building. So far there are no published studies that rigorously evaluated whether the TSC improved child health or not.
What Did the Researchers Do and Find?
A cluster randomized controlled trial randomly assigns groups of people to receive the intervention under study and compares the outcomes with a control group that does not receive the intervention. The researchers enrolled 5,209 children aged under 5 years old living in 3,039 households in 80 rural villages in Madhya Pradesh. Half of the villages (40), chosen at random, were included in the TSC (the intervention). Field staff collected data on sanitation conditions, defecation behaviors, and child health from caregivers in each household at the start of the study and after the TSC implementation was over in the intervention villages. A random subsample of children was also tested for infection with enteric parasites. The intervention increased the percentage of households in a village with improved sanitation facilities by 19% on average. Specifically, 41% of households in the intervention villages had improved latrines on average compared to 22% of households in the control villages. The intervention also decreased the proportion of adults who self-reported open defecation from 84% to 73%. However, the intervention did not improve child health measured on the basis of multiple health outcomes, including the prevalence of gastrointestinal illnesses and intestinal parasite infections, and growth.
What Do These Findings Mean?
These findings indicate that in rural Madhya Pradesh, the TSC implemented with support from the WSP only slightly increased the availability of individual household latrines and only slightly decreased the practice of open defecation. Importantly, these findings show that these modest improvements in sanitation and in defecation behaviors were insufficient to improve health outcomes among children. The accuracy of these findings may be limited by various aspects of the study. For example, several control villages actually received the intervention, which means that these findings probably underestimate the effect of the intervention under perfect conditions. Self-reporting of defecation behavior, availability of sanitation facilities, and gastrointestinal illnesses among children may also have biased these findings. Finally, because TSC implementation varies widely across India, these findings may not apply to other Indian states or variations in the TSC implementation strategies. Overall, however, these findings highlight the challenges associated with achieving large enough improvement in access to sanitation and correspondingly large reductions in the practice of open defecation to deliver health benefits within large-scale rural sanitation programs.
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001709.
This study is further discussed in a PLOS Medicine
Perspective by Clarissa Brocklehurst
A PLOS Medicine Collection on water and sanitation is available
The World Health Organization (WHO) provides information on water, sanitation, and health (in several languages), on diarrhea (in several languages), and on intestinal parasites (accessed through WHO's web page on neglected tropical diseases); the 2009 WHO/UNICEF report “Diarrhea: why children are still dying and what can be done”, is available online for download
The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation monitors progress toward improved global sanitation; its 2014 update report is available online
The children's charity UNICEF, which protects the rights of children and young people around the world, provides information on water, sanitation, and hygiene, and on diarrhea (in several languages)