An Individual-Level Meta-Analysis Assessing the Impact of Community-Level Sanitation Access on Child Stunting, Anemia, and Diarrhea

Evidence from DHS and MICS Surveys

Citation: Larsen DA, Grisham T, Slawsky E, Narine L (2017) An individual-level meta-analysis assessing the impact of community-level sanitation access on child stunting, anemia, and diarrhea: Evidence from DHS and MICS surveys. PLoS Negl Trop Dis 11(6): e0005591. https://doi.org/10.1371/journal.pntd.0005591
Published: June 8, 2017

Abstract
Background: A lack of access to sanitation is an important risk factor child health, facilitating fecal-oral transmission of pathogens including soil-transmitted helminthes and various causes of diarrheal disease. We conducted a meta-analysis of cross-sectional surveys to determine the impact that community-level sanitation access has on child health for children with and without household sanitation access.
Methodology/Principal findings: Using 301 two-stage demographic health surveys and multiple indicator cluster surveys conducted between 1990 and 2015 we calculated the sanitation access in the community as the proportion of households in the sampled cluster that had household access to any type of sanitation facility. We then conducted exact matching of children based on various predictors of living in a community with high access to sanitation. Using logistic regression with the matched group as a random intercept we examined the association between the child health outcomes of stunted growth, any anemia, moderate or severe anemia, and diarrhea in the previous two weeks and the exposure of living in a community with varying degrees of community-level sanitation access. For children with household-level sanitation access, living in a community with 100% sanitation access was associated with lowered odds of stunting (adjusted odds ratio [AOR] = 0.97, 95%; confidence interval (CI) = 0.94–1.00; n = 14,153 matched groups, 1,175,167 children), any anemia (AOR = 0.73; 95% CI = 0.67–0.78; n = 5,319 matched groups, 299,033 children), moderate or severe anemia (AOR = 0.72, 95% CI = 0.68–0.77; n = 5,319 matched groups, 299,033 children) and diarrhea (AOR = 0.94; 95% CI = 0.91–0.97); n = 16,379 matched groups, 1,603,731 children) compared to living in a community with < 30% sanitation access. For children without household-level sanitation access, living in communities with 0% sanitation access was associated with higher odds of stunting (AOR = 1.04, 95% CI = 1.02–1.06; n = 14,153 matched groups, 1,175,167 children), any anemia (AOR = 1.05, 95% CI = 1.00–1.09; n = 5,319 matched groups, 299,033 children), moderate or severe anemia (AOR = 1.04, 95% CI = 1.00–1.09; n = 5,319 matched groups, 299,033 children) but not diarrhea (AOR = 1.00, 95% CI = 0.98–1.02; n = 16,379 matched groups, 1,603,731 children) compared to children without household-level sanitation access living in communities with 1–30% sanitation access.
Conclusions/Significance: Community-level sanitation access is associated with improved child health outcomes independent of household-level sanitation access. The proportion of children living in communities with 100% sanitation access throughout the world is appallingly low. Ensuring sanitation access to all by 2030 will greatly improve child health.

Author summary: A lack of access to a sanitation facility, i.e. a toilet and/or latrine, leads to numerous health challenges such as parasitic worms and environmental enteropathy. Parasitic worms are transmitted through human feces and cause multiple health complications in children including anemia and child growth stunting. Environmental enteropathy occurs with repeated and long-term inflammation of the small intestine which then reduces nutrient uptake and can cause child growth stunting, anemia and diarrhea. One-sixth of the world population has no access to any type of sanitation facility, and are therefore at higher risk of these challenges. Scientific literature on the impacts of sanitation typically examines household access to sanitation rather than community-level access to sanitation. We used national survey data to assess the impact that community-level access to sanitation has on child health, both for children with access to a sanitation facility and children without access to a sanitation facility. We found that a lack of sanitation access in the community is a significant risk factor for anemia and child growth stunting, but not for incidence of diarrhea. This risk decreases if a child has access to a sanitation facility, but even among those children with a sanitation facility poor sanitation access in the community is still a risk factor for anemia, child growth stunting and diarrhea. In addition to improving household access to adequate sanitation, community-level sanitation access needs to be addressed to improve child health. These results will add impetus to the Sustainable Development Goal to ensure sanitation access for all by 2030.

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