The Relationship Between Distance to Water Source and Moderate-to-Severe Diarrhea in the Global Enterics Multi-Center Study in Kenya, 2008-2011

Factors that influence safe water drinking practices among older persons in slums of Kampala: Analyzing disparities in boiling water

INTRODUCTION

Safe drinking water practice is a key public health promotion strategy for reducing the spread of waterborne diseases. The purpose of this study was to investigate the factors that influence boiling water practice among older persons in informal settlements of Kampala.

METHODS

We collected primary data on "Access to safe water and health services among older persons in informal settlements of Kampala in October 2022. The study interviewed 593 men and women aged 60 years and older. The Complementary log-log multivariable technique was used to establish the association between boiling water practice and selected independent variables.

RESULTS

The results show that nearly 8% of the respondents did not boil their water for drinking. The findings show that the female older persons had increased odds of boiling water to make it safe for drinking compared to their male counterparts (OR = 1.859, 95% CI = 1.384-2.495). Other factors associated with boiling water practice among older persons in the informal settlements of Kampala were; living alone, quality of house, and type of water source.

CONCLUSION

Basing on our findings, we find that older women are more likely to use safe drinking water practice (boiling) compared to the male older persons. Health education majorly targeting older men about the importance and health benefits associated with safe water drinking practices should be prioritized by policy makers. There is need to improve housing conditions of older persons to minimize typhoid, diarrhea and other health risks associated with drinking unsafely managed water.

Demographic dynamics of waterborne disease and perceived associated WASH factors in Bushenyi and Sheema districts of South-Western Uganda

Water remains a significant player in spreading pathogens, including those associated with neglected tropical diseases. The implications of socio-demographic delineations of water quality, sanitation, and hygiene ("WASH") interventions are on the downswing. This study assessed waterborne diseases and perceived associated WASH factors in the Bushenyi and Sheema districts of South-Western Uganda. This study examines the linear relationship between WASH and identifies the association of specific demographic factors as well as their contributions/correlations to waterborne disease in the study area. A structured qualitative and quantitative data collection approach was adopted in face-to-face questionnaire-guided interviews of 200 respondents on eight surface water usage. Most participants, 65.5%, were females and had a higher score of knowledge of WASH (71%), 68% score on the improper practice of WASH, and 64% score on unsafe water quality. Low score for basic economic status was (57%), report of common diarrhoea was (47%), and a low incidence of waterborne disease outbreaks (27%). The principal component analysis (PCA) depicts the knowledge and practice of WASH to have a strong positive correlation (r = 0.84, p < 0.001; r = 0.82, p < 0.001); also economic status positively correlated with grade of water source, knowledge, and practice of WASH (correlation coefficient = 0.72; 0.99; 0.76 and p-values = 0.001; < 0.001; < 0.001 respectively). Occupation (p = 0.0001, OR = 6.798) was significantly associated with knowledge and practice of WASH, while age (r = -0.21, p < 0.001) was negatively associated with knowledge and practice of WASH. The basic economic status explains why "low economic population groups" in the remote villages may not effectively implement WASH, and diarrhoea was common among the population. Diarrhoea associated with unsafe water quality and improper practice of WASH is common among the study population, and there is a low incidence of waterborne disease outbreaks. Therefore, government, stakeholders, and non-governmental organisations should work together to promote proper practice of WASH conditions to limit the occurrence of diarrhoea and prevent potential waterborne disease outbreaks.

Fluence-based QMRA model for bacterial photorepair and regrowth in drinking water after decentralized UV disinfection

Ultraviolet disinfection is a promising solution for decentralized drinking water systems such as communal water taps. A potential health risk is enzymatic photorepair of pathogens after UV disinfection, which can result in regrowth of pathogens. Even though photorepair is a known issue, no formal risk assessments have been conducted for photorepair after UV disinfection in drinking water. The main objective was to construct a quantitative microbial risk assessment (QMRA) of photorepair after UV disinfection of drinking water in a decentralized system. UV disinfection and photorepair kinetics for E. coli were modelled using reproducible fluence-based determinations. Impacts of water collection patterns, and wavelength-dependent water container material transmittance, sunlight intensity, and photorepair enzyme absorbance were quantified. After UV disinfection by 16 or 40 mJ/cm² of < 5-log microorganisms per L, risk of infection did not exceed 1-in-10,000 under conditions permitting E. coli photorepair. Risk from photorepair was less than 1-in-10,000 for photorepair light exposure < 0.75 h throughout the day for UV fluence 16 mJ/cm² or greater. UV disinfection followed by solar disinfection surpassing photoreactivation during storage reduced risk below 1-in-10,000 for photorepair light exposure > 2.5 h between modelled times of 9 AM - 3 PM. The model can be expanded to other pathogens as UV fluence and photorepair fluence response kinetics become available, and this QMRA can be used to inform the placement of community water access points to reduce risk of photorepair and ensure adequate shelf life of UV disinfected water under safe storage conditions.

Gender and Other Vulnerabilities to Water–Energy Accessibility in Rural Households of Katsina State, Northern Nigeria

Water and energy are essential resources for all people. However, despite the availability of sufficient water and energy resources, men and women continue to be subject to unequal rights to both water and energy in terms of access, allocation, gathering, and quality of resources. Socio-economic parameters, which include gender, income, and location, are determinant factors of water and cooking energy accessibility in this study. The research aims to assess the accessibility of water and cooking fuels across female-headed households, and evaluate particular vulnerabilities and challenges faced by women and children in rural areas of Katsina State in circumstances of water and energy insecurities. A study involving a questionnaire covering 550 rural households across 11 areas in Katsina State, north-western Nigeria, was conducted. A Pearson product correlation analysis was performed to measure the strength of association between the respondents educational level and income. A chi-square test of independence was carried out to measure the degree of dependence of the households’ resources accessibility. The authors assessed the disproportionate threats and health risks linked to fetching water and gathering of fuel resources. The research findings indicate that water and energy uncertainty among women in rural households is due to unequal responsibilities associated with water- and energy-related household duties that are potentially linked to disadvantages for females, including violence, security threats, diseases, and disempowerment. To address these challenges, water and energy interventions, and important pathways for beneficial change, are proposed for rural regions in sub-Saharan Africa. This should lead to more gender equity associated with water and energy.

Diarrhoea among Children Aged under Five Years and Risk Factors in Informal Settlements: A Cross-Sectional Study in Cape Town, South Africa

Background: There is limited data on the association between diarrhoea among children aged under five years (U5D) and water use, sanitation, hygiene, and socio-economics factors in low-income communities. The study investigated U5D and the associated risk factors in the Zeekoe catchment in Cape Town, South Africa. Methods: A cross-sectional study was conducted in 707 households in six informal settlements (IS) two formal settlements (FS) (March–June 2017). Results: Most IS households used public taps (74.4%) and shared toilets (93.0%), while FS households used piped water on premises (89.6%) and private toilets (98.3%). IS respondents had higher average hand-washing scores than those of FS (0.04 vs. −0.14, p = 0.02). The overall U5D prevalence was 15.3% (range: 8.6%–24.2%) and was higher in FS than in IS (21.2% vs. 13.4%, respectively, p = 0.01). Water storage >12 h was associated with increasing U5D (OR = 1.88, 95% CI 1.00–3.55, p = 0.05). Water treatment (OR = 0.57, 95%CI 0.34–0.97, p = 0.04), good hand-washing practices (OR = 0.59, 95%CI 0.42–0.82, p = 0.002) and Hepatitis A vaccination (OR = 0.51, 95%CI 0.28–0.9, p = 0.02) had significant preventing effects on U5D. Conclusions: The study highlights that good hygiene practice is a key intervention against U5D in informal settlements. The promotion of hand-washing, proper water storage, and hygienic breastfeeding is highly recommended.

Distance to water source in early childhood affects growth: a cohort study

OBJECTIVES

Approximately 165 million children aged <5 years are at risk of low height-for-age. This study explored whether water quality and distance to water source affected short- and long-term growth, and the critical time windows of such effects.

STUDY DESIGN

This study used data from the China Health and Nutrition Survey (CHNS), which was a cohort study performed in 15 Chinese provinces.

METHODS

Data from the CHNS between 1989 and 2011 were examined. Three cohorts of children who were enrolled at 0-2 years of age in 1989, 1993, and 2000 provided sufficient data for this study. Child height was measured by physicians, and household water supply, including the water quality (safe or unsafe) and distance to the source (in-yard or out-yard), was assessed using a questionnaire when the children were 0-2, 4-6, and 11-13 years of age. Multiple regressions were performed to analyse the associations between water quality and distance to the source at various ages, and height at that age and older ages, with and without adjusting for the household water supply at previous ages. Multiple informant models were created using a generalised estimating equation and these were used to assess whether the exposure coefficients were equal across the three age periods.

RESULTS

A total of 1192 children were included. Water quality was not significantly associated with height over the three age periods. An out-yard water source at the age of 0-2 years was not associated with child height at that age, but it was inversely associated with child height at ages 4-6 and 11-13 years (β = -1.605, 95% confidence interval [CI]: -2.490 to -0.720, and β = -2.817, 95% CI: -4.411 to -1.224, respectively), after adjusting for sociodemographic and economic covariates and baseline child height. Distance to the water source at age 4-6 and 11-13 years was not significantly associated with height. However, significant differences were observed in the associations between distance to water source across the three age periods and height at age 4-6 and 11-13 years (p_int = 0.064 and 0.069, respectively).

CONCLUSIONS

Distance to the water source in early, but not later, childhood exerted a long-term effect on child height. When the water quality is good, efforts should be made to shorten the distance to the source to improve child health and growth.

The interrelationship between water access, exclusive breastfeeding and diarrhea in children: a cross-sectional assessment across 19 African countries

Background

Access to an improved water supply and practicing exclusive breastfeeding are essential for improving maternal and child health outcomes. However, few studies have been equipped to assess the interdependencies between access to improved water, practicing exclusive breastfeeding, and child health. The primary aim of our study was to assess whether access to an improved water supply and water-fetching were associated with mothers’ practice of exclusive breastfeeding.

Methods

We analyzed data on 247 090 mothers with children 5 months old or less using Multiple Indicator Cluster Surveys from 19 African countries. Multivariable logistic regression was used to estimate the relationship between our exposures and exclusive breastfeeding practice, while meta-analytic methods were used to pool adjusted estimates across 19 countries.

Results

The prevalence of exclusive breastfeeding ranged from 22% in Nigeria to 70% in Malawi. Pooled results showed water-fetching was not associated with exclusive breastfeeding (adjusted prevalence odds ratios (aPOR) = 1.04, 95% confidence interval (CI) = 0.89, 1.21). Access to an improved water source was also not associated with exclusive breastfeeding (aPOR = 1.06, 95% CI = 0.94, 1.21). Across all countries many women were spending a significant amount of time water-fetching each day (mean time varied from 20 minutes in Ghana to 115 minutes in Mauritania). Exclusively breastfed children had 33% lower odds of diarrhea than those who were not exclusively breastfed (aPOR = 0.67, 95% CI = 0.56, 0.78).

Conclusion

Our study is the first to assess the relationship between access to improved water supply, water-fetching and exclusive breastfeeding. We found that access to water supply and time spent by mothers fetching water were not associated with exclusive breastfeeding practice, even though mothers spent significant time fetching water.

The interrelationship between water access, exclusive breastfeeding and diarrhea in children: a cross-sectional assessment across 19 African countries

BACKGROUND

Access to an improved water supply and practicing exclusive breastfeeding are essential for improving maternal and child health outcomes. However, few studies have been equipped to assess the interdependencies between access to improved water, practicing exclusive breastfeeding, and child health. The primary aim of our study was to assess whether access to an improved water supply and water-fetching were associated with mothers' practice of exclusive breastfeeding.

METHODS

We analyzed data on 247 090 mothers with children 5 months old or less using Multiple Indicator Cluster Surveys from 19 African countries. Multivariable logistic regression was used to estimate the relationship between our exposures and exclusive breastfeeding practice, while meta-analytic methods were used to pool adjusted estimates across 19 countries.

RESULTS

The prevalence of exclusive breastfeeding ranged from 22% in Nigeria to 70% in Malawi. Pooled results showed water-fetching was not associated with exclusive breastfeeding (adjusted prevalence odds ratios (aPOR) = 1.04, 95% confidence interval (CI) = 0.89, 1.21). Access to an improved water source was also not associated with exclusive breastfeeding (aPOR = 1.06, 95% CI = 0.94, 1.21). Across all countries many women were spending a significant amount of time water-fetching each day (mean time varied from 20 minutes in Ghana to 115 minutes in Mauritania). Exclusively breastfed children had 33% lower odds of diarrhea than those who were not exclusively breastfed (aPOR = 0.67, 95% CI = 0.56, 0.78).

CONCLUSION

Our study is the first to assess the relationship between access to improved water supply, water-fetching and exclusive breastfeeding. We found that access to water supply and time spent by mothers fetching water were not associated with exclusive breastfeeding practice, even though mothers spent significant time fetching water.

Childhood Malnutrition and the Association with Diarrhea, Water supply, Sanitation, and Hygiene Practices in Kersa and Omo Nada Districts of Jimma Zone, Ethiopia

BACKGROUND

Inadequate water supply, sanitation, hygiene practices, and diarrhea are related to malnutrition, but there is limited evidence in Ethiopia about their association. Thus, the objective of this study was to describe childhood malnutrition and the association with diarrhea, water supply, sanitation and hygiene practices.

METHODS

A case-control study design was performed from December 2018 to January 2019 in Kersa and Omo Nada districts of the Jimma Zone, Ethiopia. Both children aged 6 to 59 months were chosen randomly from malnourished and well-nourished children in 128 cases and 256 controls, respectively. Bodyweight, length/height, mid-upper arm circumference, and presence of edema of the children were measured according to the WHO references. Then, the nutritional status of the children was identified as a case or control using the cutoff points recommended by the WHO. To see the association-dependent and independent variables, logistic regression analysis was used.

RESULTS

A total of 378 children were included in this study (98.44%). Malnutrition was significantly increased among children who delayed breastfeeding initiation(AOR = 3.12; 95% CI: 1.62-6.00), had diarrhea (AOR = 9.22; 95% CI: 5.25-16.20), were living in households indexed as the poorest (AOR = 2.50; 95% CI: 1.12-5.62), defecated in a pit latrine without slab/open pit (AOR = 2.49; 95% CI: 1.17-5.30), collecting drinking water from less than/equal to 1 km distance (AOR = 4.77; 95% CI: 1.01-22.71) and sometimes practiced hand washing at the critical times (AOR = 2.58; 95% CI: 1.16-5.74) compared with their counterparts. However, lactating during the survey (AOR = 0.35; 95% CI: 0.18-0.67), water collection from unprotected sources (AOR = 0.22; 95% CI: 0.05-0.95) and collection and disposal of under-5 children feces elsewhere (AOR = 0.06; 95% CI: 0.01-0.49) significantly reduced the likelihood of malnutrition.

CONCLUSIONS

Early initiation of exclusive breastfeeding, diarrhea prevention, and the use of improved latrine and handwashing practices at critical times could be important variables to improve the nutritional status of children.

The role of piped water supplies in advancing health, economic development, and gender equality in rural communities

In rural areas of sub-Saharan Africa, one in eight households obtain drinking water from a piped system; the rest fetch water from improved and unimproved sources located at some distance from their homes. This task falls primarily to women and girls, creating time poverty and risks to safety and health. In this paper, we present a conceptual model that elaborates the mechanisms linking access to piped water with food security and long-term economic impacts. These hypotheses were tested in a quasi-experimental study of four villages in rural Zambia using a combination of household surveys, Global Positioning System transponders, and water meters to measure time spent fetching water, water consumption, and how water was being utilized for domestic and productive activities. Households receiving the piped water intervention spent a median of 3.8 h per week less fetching water, savings that accrued primarily to women and girls. Household water consumption increased 32%, which was used for both domestic and productive uses. Increases in the frequency of gardening and the size of garden plots in treatment households were observed. Households receiving piped water reported being happier, healthier, and having more time to participate in work inside or outside the home. We find that piped water supplies can promote the economic development and well-being of rural households, with particular benefits to women and girls, conditional upon pricing and management models that ensure sustainable service.

Evaluating self-reported measures and alternatives to monitor access to drinking water: A case study in Malawi

Monitoring access to drinking water is complex, especially in settings where on premises water supply is not available. Although self-reported data are generally used to estimate coverage of access to drinking water, the relationship between self-reported time travelled and true time travelled is not well known in the context of water fetching. Further, water fetching is likely to impact the quantity and quality of water a household uses, but data and measures supporting this relationship are not well documented. The objective of this study was to appraise the validity and reliability of self-reported measurements used to estimate access coverage. A case study was conducted in Malawi to enhance understanding of the self-reported measures and alternatives available to assess and monitor access to drinking water in view of generating global estimates. Self-reported data were compared with objective observations and direct measurements of water quantity, quality and accessibility. Findings from this study highlight the variations between different measures such as self-reported and recorded collection time and raise awareness with regard to the use of self-reported data in the context of fetching water. Alternatives to self-reported indicators such as GPS-based or direct observations could be considered in surveys in view of improving data accuracy and global estimates.

Assessing the Impacts of Relative Wealth and Geospatial Factors on Water Access in Rural Nepal: A Community Case Study

As one of the poorest nations, citizens of Nepal lack access to safe, affordable, and sufficient drinking water. While many nationwide studies have been performed at a country or regional level in Nepal to determine regions of the highest vulnerability, this study uniquely recognizes the economic heterogeneity within a single rural village and assesses the impact of household socioeconomic status on water access at the intracommunity level. Household surveys in a rural village setting provided the information for a locally-informed relative wealth index. A spatial analysis determined suitable locations for future installation of improved water sources to prioritize water access for the community’s most vulnerable households. Three sites were shown to be optimal for future water source construction. This study provides a blueprint to assess water inequalities within a single village and incorporate forward-thinking development approaches to water access.

Measuring the resilience of health systems in low- and middle-income countries: a focus on community resilience

The concept of community resilience has gained considerable attention in the global health discussions since the Ebola outbreak of West Africa in 2014–2015. However, there are no measurement models to quantify community resilience. Without measurement models, it is unclear how to test strategies for building community resilience or to describe their likely intended and unintended results and their impact on health outcomes. We propose a measurement model for community resilience with relevant constructs and indicators to measure these constructs. We conducted a scoping review, systematically searching, screening and selecting relevant articles from two bibliographic databases (PUBMED and Google Scholar) for literature using search terms such as “resilience”, “community resilience” and “health systems resilience”. We screened 500 papers, then completed a full text review of 112 identified as relevant based on their title and abstract. A total of 27 papers and reports were retained for analysis. We then aggregated and synthesised the various definitions of community resilience and the frameworks for understanding these definitions. We identified key constructs from these frameworks and organised these constructs into domains and sub-domains. We proposed indicators to capture aspects of these domains and sub-domains and operationalised these indicators as a measurement model for quantifying community resilience in health systems. We propose a model with 20 indicators to assess community resilience. These indicators tap into various constructs from different theoretical frameworks of community resilience and are useful for assessing the level of knowledge, financial resources, and human, social and physical capital that are needed (or lacking) to respond to any types of shock, including health shock at the community level. This is an initial attempt to describe a multilevel measurement model for quantifying community resilience. This model will help to guide the development and testing of strategies for strengthening community resilience and will require further work to assess its relevance, reliability and validity in different LMIC settings.

Exploring geographical variations and inequalities in access to improved water and sanitation in Ethiopia: mapping and spatial analysis

Ensuring access to improved water and sanitation remains a public health challenge in Ethiopia. Exploring access to improved drinking-water supply and sanitation will help to track the progress towards achieving the Sustainable Development Goals. The aim of this study was to explore geographical variations and inequalities in access to improved drinking water and sanitation in Ethiopia. A total of 16,650 households from 643 enumeration areas of the recent Ethiopian Demographic and Health Survey 2016 data were extracted and included in the analysis. World Health Organization recommended definitions were used to measure indicators of improved drinking water and sanitation at enumeration areas. SaTScan™ software was used for spatial analysis using enumeration areas as centers for exploring geographical variations of improved water and sanitation. Absolute and relative inequalities were used to quantify regional inequalities in access to improved water and sanitation. Nationwide access to improved drinking water and sanitation in Ethiopia was 49.6% (95% CI: 48.4–50.7) and 6.3% (5.8–6.8), respectively, with large variations between and within regions (using the categories and definitions that were in effect for monitoring coverage in 2016). Access to improved drinking water ranged from 28.5% in Somali Region to 95.3% in Addis Ababa city whereas access to improved sanitation ranged from 1.7% in Amhara Region to 24% in Dire Dawa city. Households lacking access to improved water and sanitation were clustered in northern (Amhara Region) and southern (Southern Nations, Nationalities, and Peoples' Region) parts of Ethiopia. Most enumeration areas had very low level of access to improved drinking water and/or sanitation. This analysis demonstrated the existence of geographical variations and inequalities in access to improved drinking water and sanitation in Ethiopia. Therefore strategies to improve access for safe drinking water and sanitation should consider geographical variations and inequalities at a subnational scale.

Rural Ghanaian households are more likely to use alternative unimproved water sources when water from boreholes has undesirable organoleptic characteristics

Sustainable Development Goal (SDG) 6 aims to achieve universal access to safe drinking water sources. However, the health benefits of meeting this goal will only be fully realized if improved sources are used to the exclusion of unimproved sources. Very little is known about how rural African households balance the use of improved and unimproved water sources when multiple options are present. We assessed parallel use of untreated surface water and unimproved hand-dug wells (HDWs) in the presence of boreholes (BHs) using a semi-quantitative water use survey among 750 residents of 15 rural Ghanaian communities, distributed across three BH water quality clusters: control, high salinity, and high iron. Multivariate mixed effects logistic regression models were used to assess the impact of water quality cluster on the use of BHs, HDWs, and surface water, controlling for distance to the nearest source of each type. Reported surface water use was significantly higher in the high salinity and high iron clusters than in the control cluster, especially for water-intensive activities. Respondents in the non-control clusters had approximately eight times higher odds of clothes washing with surface water (p < 0.01) than in the control. Respondents in the high salinity cluster also had 4.3 times higher odds of drinking surface water (p < 0.05). BH use was high in all clusters, but decreased substantially when distance to the nearest BH exceeded 300 m (OR = 0.17-0.25, p < 0.001). Water use from all sources was inversely correlated with distance, with the largest effect observed on HDW use in multivariate models (OR = 0.02, p < 0.001). Surface water and HDW use will likely continue despite the presence of BHs when perceived groundwater quality is poor and other water sources are in close proximity. It is essential to account for naturally-occurring but undesirable groundwater quality parameters in rural water planning to ensure that SDG 6 is met and health benefits are realized.

Drinking water accessibility and quantity in low and middle-income countries: A systematic review

BACKGROUND

Increasing the quantity of water available for consumption and hygiene is recognized to be among the most efficient interventions to reduce the risk of water-related infectious diseases in low and middle-income countries. Such impacts are often associated with water supply accessibility (e.g. distance or collection time) and used to justify investment in improving access.

OBJECTIVE

To assess the relationship between the water source location and the quantity of water available in households from low and middle-income countries by identifying the effects of interventions aiming to improve access, and to compare the indicators and measures used to collect information.

METHODS

We systematically searched seven databases (i.e. Cairn, Cochrane Library, Embase, MEDLINE, PubMed, Web of Science, Women's Studies International) along with grey literature for articles reporting indicators and measures of accessibility and quantity. We found 6492 records, of which 20 studies were retained that met the review's inclusion criteria.

RESULTS

Most studies were conducted in rural settings and provided suggestive findings to describe an inverse relationship between accessibility and quantity. Overall, a wide range of indicators and measures were used to assess water accessibility and quantity in the selected studies along with their association. The lack of consistency raised concerns regarding comparability and reliability of these methods.

CONCLUSIONS

The review findings support the hypothesis that the quantity of water available in households is a function of the source location, but the inconsistency in study outcomes highlights the need to further investigate the strength and effects of the relationship.

Spatial Video Health Risk Mapping in Informal Settlements: Correcting GPS Error

Informal settlements pose a continuing health concern. While spatial methodologies have proven to be valuable tools to support health interventions, several factors limit their widespread use in these challenging environments. One such technology, spatial video, has been used for fine-scale contextualized mapping. In this paper, we address one of the limitations of the technique: the global positioning system (GPS) coordinate error. More specifically, we show how spatial video coordinate streams can be corrected and synced back to the original video to facilitate risk mapping. Past spatial video collections for the Mathare informal settlement of Kenya are used as an illustration as these data had been previously discarded because of excessive GPS error. This paper will describe the bespoke software that makes these corrections possible, and then will go on to investigate patterns in the coordinate error.

Diarrhoea, enteric pathogen detection and nutritional indicators among controls in the Global Enteric Multicenter Study, Kenya site: an opportunity to understand reference populations in case-control studies of diarrhoea

Given the challenges in accurately identifying unexposed controls in case–control studies of diarrhoea, we examined diarrhoea incidence, subclinical enteric infections and growth stunting within a reference population in the Global Enteric Multicenter Study, Kenya site. Within ‘control’ children (0–59 months old without diarrhoea in the 7 days before enrolment, n = 2384), we examined surveys at enrolment and 60-day follow-up, stool at enrolment and a 14-day post-enrolment memory aid for diarrhoea incidence. At enrolment, 19% of controls had ⩾1 enteric pathogen associated with moderate-to-severe diarrhoea (‘MSD pathogens’) in stool; following enrolment, many reported diarrhoea (27% in 7 days, 39% in 14 days). Controls with and without reported diarrhoea had similar carriage of MSD pathogens at enrolment; however, controls reporting diarrhoea were more likely to report visiting a health facility for diarrhoea (27% vs. 7%) or fever (23% vs. 16%) at follow-up than controls without diarrhoea. Odds of stunting differed by both MSD and ‘any’ (including non-MSD pathogens) enteric pathogen carriage, but not diarrhoea, suggesting control classification may warrant modification when assessing long-term outcomes. High diarrhoea incidence following enrolment and prevalent carriage of enteric pathogens have implications for sequelae associated with subclinical enteric infections and for design and interpretation of case–control studies examining diarrhoea.

Comparison of methods to estimate water access: a pilot study of a GPS-based approach in low resource settings

Background

Most water access studies involve self-reported measures such as time spent or simple spatial measures such as Euclidean distance from home to source. GPS-based measures of access are often considered actual access and have shown little correlation with self-reported measures. One main obstacle to widespread use of GPS-based measurement of access to water has been technological limitations (e.g., battery life). As such, GPS-based measures have been limited by time and in sample size.

Methods

The aim of this pilot study was to develop and test a novel GPS unit, (≤4-week battery life, waterproof) to measure access to water. The GPS-based method was pilot-tested to estimate number of trips per day, time spent and distance traveled to source for all water collected over a 3-day period in five households in south-western Uganda. This method was then compared to self-reported measures and commonly used spatial measures of access for the same households.

Results

Time spent collecting water was significantly overestimated using a self-reported measure, compared to GPS-based (p < 0.05). In contrast, both the GIS Euclidean distances to nearest and actual primary source significantly underestimated distances traveled, compared to the GPS-based measurement of actual travel paths to water source (p < 0.05). Households did not consistently collect water from the source nearest their home. Comparisons between the GPS-based measure and self-reported meters traveled were not made, as respondents did not feel that they could accurately estimate distance. However, there was complete agreement between self-reported primary source and GPS-based.

Conclusions

Reliance on cross-sectional self-reported or simple GIS measures leads to misclassification in water access measurement. This new method offers reductions in such errors and may aid in understanding dynamic measures of access to water for health studies.

An Analysis of Water Collection Labor among Women and Children in 24 Sub-Saharan African Countries

Background

It is estimated that more than two-thirds of the population in sub-Saharan Africa (SSA) must leave their home to collect water, putting them at risk for a variety of negative health outcomes. There is little research, however, quantifying who is most affected by long water collection times.

Objectives

This study aims to a) describe gender differences in water collection labor among both adults and children (< 15 years of age) in the households (HHs) that report spending more than 30 minutes collecting water, disaggregated by urban and rural residence; and b) estimate the absolute number of adults and children affected by water collection times greater than 30 minutes in 24 SSA countries.

Methods

We analyzed data from the Demographic Health Survey (DHS) and the Multiple Indicator Cluster Survey (MICS) (2005–2012) to describe water collection labor in 24 SSA countries.

Results

Among households spending more than 30 minutes collecting water, adult females were the primary collectors of water across all 24 countries, ranging from 46% in Liberia (17,412 HHs) to 90% in Cote d’Ivoire (224,808 HHs). Across all countries, female children were more likely to be responsible for water collection than male children (62% vs. 38%, respectively). Six countries had more than 100,000 households (HHs) where children were reported to be responsible for water collection (greater than 30 minutes): Burundi (181,702 HHs), Cameroon (154,453 HHs), Ethiopia (1,321,424 HHs), Mozambique (129,544 HHs), Niger (171,305 HHs), and Nigeria (1,045,647 HHs).

Conclusion

In the 24 SSA countries studied, an estimated 3.36 million children and 13.54 million adult females were responsible for water collection in households with collection times greater than 30 minutes. We suggest that accessibility to water, water collection by children, and gender ratios for water collection, especially when collection times are great, should be considered as key indicators for measuring progress in the water, sanitation and hygiene sector.

Prolonged episodes of acute diarrhea reduce growth and increase risk of persistent diarrhea in children

BACKGROUND & AIMS

Prolonged episodes of acute diarrhea (ProD; duration 7-13 days) or persistent diarrhea (PD; duration ≥14 days) are important causes of undernutrition, yet the epidemiology and nutritional impact of ProD are poorly understood.

METHODS

We conducted a 10-year cohort study of 414 children from a Brazilian shantytown who were followed from birth; data were collected on diarrhea, enteric pathogens, and anthropometry.

RESULTS

During 1276 child-years of observation, we recorded 3257 diarrheal episodes. ProD was twice as common as PD (12% and 5% of episodes, respectively); ProD and PD together accounted for 50% of all days with diarrhea. ProD was more common in infants whose mothers had not completed primary school (relative risk [RR], 2.1; 95% confidence interval: 1.02-2.78). Early weaning was associated with earlier onset of ProD (Spearman ρ = 0.309; P = .005). Infants with ProD were twice as likely to develop PD in later childhood (log rank, P = .002) compared with infants with only acute diarrhea (AD; duration <7 days), even after controlling for confounders. Children's growth was more severely stunted before their first episode of ProD, compared with AD (mean height-for-age Z score (HAZ) -0.81 vs -0.51, respectively, P < .05, unpaired t test). Following ProD, HAZ (ΔHAZ = -0.232) and weight-for-age (ΔWAZ = -0.26) significantly decreased (P < .005 in paired t tests). ProD was associated with Cryptosporidium and Shigella infections.

CONCLUSIONS

ProD accounts for significant morbidity and identifies children at risk of a vicious cycle of diarrhea and malnutrition. Further studies are needed to address the recognition and control of ProD and its consequences in resource-limited settings and assess its role in PD pathogenesis.