Improved Child Feces Management Mediates Reductions in Childhood Diarrhea from an On-Site Sanitation Intervention: Causal Mediation Analysis of a Cluster-Randomized Trial in Rural Bangladesh

BACKGROUND

The WASH benefits Bangladesh trial multi-component sanitation intervention reduced diarrheal disease among children < 5 years. Intervention components included latrine upgrades, child feces management tools, and behavioral promotion. It remains unclear which components most impacted diarrhea.

METHODS

We conducted mediation analysis within a subset of households (n = 720) from the sanitation and control arms. Potential mediators were categorized into indicators of latrine quality, latrine use practices, and feces management practices. We estimated average causal mediation effects (ACME) as prevalence differences (PD), defined as the intervention's effect on diarrhea through its effect on the mediator.

RESULTS

The intervention improved all indicators compared to controls. We found significant mediation through multiple latrine use and feces management practice indicators. The strongest mediators during monsoon seasons were reduced open defecation among children aged < 3 and 3-8 years, and increased disposal of child feces into latrines. The strongest mediators during dry seasons were access to a flush/pour-flush latrine, reduced open defecation among children aged 3-8 years, and increased disposal of child feces into latrines. Individual mediation effects were small (PD = 0.5-2 percentage points) compared to the overall intervention effect but collectively describe significant mediation pathways.

DISCUSSION

The effect of the WASH Benefits Bangladesh sanitation intervention on diarrheal disease was mediated through improved child feces management and reduced child open defecation. Although the intervention significantly improved latrine quality, relatively high latrine quality at baseline may have limited benefits from additional improvements. Targeting safe child feces management may increase the health benefits of rural sanitation interventions.

Assessing sustained uptake of latrine and child feces management interventions: Extended follow-up of a cluster-randomized controlled trial in rural Bangladesh 1-3.5 years after intervention initiation

BACKGROUND

Sanitation interventions typically result in modest increases in latrine access, and any gains in latrine access and use are often not sustained over time. Sanitation programs also rarely include child-focused interventions such as potties. We aimed to assess the sustained effect of a multi-component sanitation intervention on access to and use of latrines and child feces management tools in rural Bangladesh.

METHODS

We conducted a longitudinal substudy nested within the WASH Benefits randomized controlled trial. The trial provided latrine upgrades, child potties and sani-scoops for feces removal, along with behavior change promotion to encourage use of the delivered hardware. Promotion visits to intervention recipients were frequent during the first 2 years after intervention initiation, decreased in frequency between years 2-3, and ceased after 3 years. We enrolled a random subset of 720 households from the sanitation and control arms of the trial in a substudy and visited them quarterly between 1 and 3.5 years after intervention initiation. At each visit, field staff recorded sanitation-related behaviors through spot-check observations and structured questionnaires. We assessed intervention effects on observed indicators of hygienic latrine access, potty use and sani-scoop use and investigated whether these effects were modified by duration of follow-up, ongoing behavior change promotion and household characteristics.

RESULTS

The intervention increased hygienic latrine access from 37% among controls to 94% in the sanitation arm (p < 0.001). Access among intervention recipients remained high 3.5 years after intervention initiation, including periods with no active promotion. Gains in access were higher among households with less education, less wealth and larger number of residents. The intervention increased availability of child potties from 29% among controls to 98% in the sanitation arm (p < 0.001). However, fewer than 25% of intervention households reported exclusive child defecation in a potty or had observed indicators of potty and sani-scoop use, and gains in potty use declined over the follow-up period, even with ongoing promotion.

CONCLUSION

Our findings from an intervention that provided free products and intensive initial behavior change promotion suggest a sustained increase in hygienic latrine access up to 3.5 years after intervention initiation but infrequent use of child feces management tools. Studies should investigate strategies to ensure sustained adoption of safe child feces management practices.

Latrine utilization and associated factors in East Gojjam Zone, North-West Ethiopia: A community-based cross-sectional study

Objective

This research was aimed at assessing latrine utilization and associated factors in East Gojjam Zone, North West Ethiopia.

Methods

A community-based cross-sectional study was conducted on households of East Gojjam Zone, from 1 February to 30 May 2021. Multistage cluster sampling technique was used to select 806 study participants into the study. Data were collected through pretested structured interview questionnaires and direct observation. Collected data were entered and cleaned using EPI info version 7.2 and analysed using SPSS version 23 software package. Bivariable and multivariable logistic regression was employed to assess association of the variables and controlling the effect of confounders, respectively. P value less than 0.05 was taken as statistically significant.

Results

The overall latrine utilization in East Gojjam Zone was found to be 45.4% (95% confidence interval = 42.2-49.1). Occupation (adjusted odds ratio = 2.248, 95% confidence interval = 1.037-4.876), participating in model family training (adjusted odds ratio = 2.481, 95% confidence interval = 1.802-3.415), water availability (adjusted odds ratio = 2.456, 95% confidence interval = 1.514-3.983), and type of latrine (adjusted odds ratio = 2.013, 95% confidence interval 1.648-2.972) had statistically significant association with latrine utilization.

Conclusion

Latrine utilization in East Gojjam Zone was found to be low relative to other studies and the country's plan. It is very far apart from the Ethiopian latrine coverage and utilization plan (100%). Occupational status, participated in the model family training, water availability, and type of toilet were significantly associated with toilet utilization. Encouraging private latrine construction with accessibility of water and all households participating in model family training may increase latrine utilization in East Gojjam Zone. Further observational study triangulated with qualitative research should be conducted to provide more strong evidence for further improvement of household latrine utilization status in East Gojjam Zone.

Spatio-temporal pattern of latrine distribution in reintroduced Cuvier's gazelles (Gazella cuvieri): an assessment in a Mediterranean forest reserve

Knowledge about the factors affecting the number of active latrines (NAL) of reintroduced Cuvier’s gazelles (Gazella cuvieri Ogilby, 1841) is of a crucial step aiming at understanding their distributional dynamics and their habitats preference. Here, we used six random 500-m transects to assess the effect of season, microhabitat, and management variables on the spatio-temporal pattern of latrines in the Tergou forest reserve (TFR). Our results showed that, in this reserve, NAL is mainly governed by the interaction between season and distance to the nearest developed runway, being higher at the farthest distances from the runway in autumn and the closest distances to it in summer and winter. Variation partitioning analysis confirmed this pattern as the interaction between season and distance to the nearest developed runway explains 82% (p = 0.001) of the total variance in NAL. The distance to the nearest fence also contributes, but marginally, in influencing the NAL in this forest enclosure. For the species’ management and conservation, it is recommended to dispose of sandy open ground areas especially in forest reserves to ensure ideal conditions for reintroduced gazelles. The pursuit of monitoring is necessary to understand mechanisms governing the distributional dynamics of Cuvier’s gazelles more deeply. As any enclosure, the TFR would offer a good opportunity for consolidating and improving the knowledge on this vulnerable mammal species in the view of a successful release in the wild.

A 12-year follow-up of intestinal schistosomiasis in pre-school-aged children in Assoni Village, Eastern Senegal

Background

To monitor the prevalence of schistosomiasis in school-aged children (SAC), the National Bilharzia Control Program (PNLB) was set up by the Senegalese authorities; however, geographically isolated Bedik ethnic groups that did not benefit from this program were found to be heavily infected with Schistosoma mansoni. This observation led us to implement a new schistosomiasis control program in 2008 under the aegis of the non-governmental organization “Le Kaïcedrat” and in partnership with the PNLB/WHO to monitor the prevalence of schistosomiasis in this area. In the village of Assoni, where 100% of SAC were infected, analysis of the stools of pre-school-aged children (PSAC) showed that they were massively infected, so we decided to focus our program on them.

Methods

From 2008 to 2020, we (i) monitored the prevalence of S. mansoni in PSAC in Assoni using double-stool smear preparation, (ii) treated the infected PSAC with a standard dose of praziquantel 40 mg/kg, (iii) ran educational campaigns each year in the village, and (iv) built latrines to improve sanitation and reduce schistosomiasis transmission. Linear regression was used to examine the trend in the annual schistosomiasis prevalence and a two-sided of Chi-squared test was used to compare prevalence between the different age groups of PSAC.

Results

We observed an extremely high prevalence of schistosomiasis (78%) in PSAC before implementation of the program in 2008. Contamination occurred in very young children, as 64.3% of children under 2 years old were infected. Moreover, prevalence increased with age and reached 96.8% in children 4 to < 6 years old. Our annual interventions in Assoni Village raised awareness among villagers that water bodies were areas of significant infestation, allowed the building of 88 latrines and led to a decrease in prevalence in PSAC as only 11% of these children were infected in 2020.

Conclusion

Our study allowed Assoni to be the first village in Senegal to treat PSAC since 2014, but only on an individual basis. It also shows that schistosomiasis is difficult to eradicate and that multi-sectorial actions are required to keep its prevalence at a low level.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40249-021-00867-8.

Effectiveness of community and school-based sanitation interventions in improving latrine coverage: a systematic review and meta-analysis of randomized controlled interventions

Introduction

Approximately 1000 children die each year due to preventable water and sanitation-related diarrheal diseases. Six in 10 people lacked access to safely managed sanitation facilities in 2015. Numerous community- and school-based approaches have been implemented to eradicate open defecation practices, promote latrine ownership, improve situation sanitation, and reduce waterborne disease.

Objective

Given that current evidence for sanitation interventions seem promising, the aim of this study was to systematically summarize existing research on the effectiveness of community- and school-based randomized controlled sanitation intervention in improving (1) free open defecation (safe feces disposal), (2) latrine usage, (3) latrine coverage or access, and (4) improved latrine coverage or access.

Methods

Eight electronic databases were searched: PubMed, Scopus, WHO Global Health Library (GHL), Virtual Health Library (VHL), POPLINE, Web of Science, Cochrane, and Google Scholar up to 26 April 2019. Original randomized clinical trials addressing community-based or school-based intervention that reported feces disposal and latrine coverage were deemed eligible. More than two researchers independently contributed to screening of papers, data extraction, and bias assessment. We conducted a meta-analysis by random-effects model. The risk of bias was assessed by the Cochrane risk of bias tool.

Results

Eighteen papers that matched all criteria and 16 studies were included in the final meta-analysis. Compared to the control, the sanitation intervention significantly increased safe feces disposal (OR 2.19, 95% CI 1.51–3.19, p < 0.05, I² = 97.28), latrine usage (OR 3.72, 95% CI 1.71–8.11, p < 0.05, I² = 91.52), latrine coverage or access (OR 3.95, 95% CI 2.08–7.50, p < 0.05, I² = 99.07), and improved latrine coverage or access (OR 3.68, 95% CI 1.52–8.91, p < 0.05, I² = 99.11). A combination of education and latrine construction was more effective compared to educational intervention alone.

Conclusion

Our study showed strong evidence for both community- and school-based sanitation interventions as effective for the safe disposal of human excreta. The finding suggests major implications for health policy and design of future intervention in developing countries.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12199-021-00934-4.

Hygienic Risk Exposures Across Ethnic Groups in Rural Areas of Guangxi, China: Prevalence, Associated Factors, and Perceptions of Policy

BACKGROUND

Controlling hygienic risk exposures (HREs) is important for reducing acute respiratory infection or parasitic infection; however, studies across vulnerable ethnicities are limited. This study aimed to identify the prevalence and associated factors of HREs and perception on HRE policies among ethnic groups in Guangxi, China.

METHODS

A community-based cross-sectional study was conducted in rural areas of Guangxi, China, among Han majority and Zhuang, Yao, Miao, Dong, Mulao, and Maonan minorities. The prevalence of HREs and perceptions concerning the HRE policies were presented using descriptive statistics. Associated factors were analyzed using a logistic regression model, and adjusted prevalence ratios and 95% confidence interval were calculated.

RESULTS

High prevalence of HREs on hand and soil hygiene were found in all ethnicities. Miao minority had the highest prevalence of HREs, particularly in poor hand washing (74.1%), infrequent nail clipping (90.4%), and outdoor soil contact (92.7%), compared with the others. Prevalence of HREs in some ethnic minority groups were significantly different from those in Han majority after adjusted with other significant factors. Village leaders were more aware of existing national and community regulations related to HREs than household heads. Village leaders and household heads of almost all ethnic groups perceived high policy's compliance in their village or household on avoiding fertilizing with farmyard manure.

CONCLUSIONS

HREs were prevalent in all ethnic groups, especially in Miao minority. Ethnicity, one of social determinants, was significantly associated with HREs. Raising awareness at both the village and household levels on HREs is needed for all ethnic groups.

Prevalence of Baylisascaris procyonis in raccoon latrines in southern Ontario, Canada

Raccoon latrines represent sites of potential infection by the zoonotic parasite Baylisascaris procyonis for wildlife and humans. Our objective was to determine the prevalence of B. procyonis at raccoon latrine sites in southern Ontario. Thirty raccoon latrines were sampled between June - July 2018; multiple scats were collected and homogenized to form a representative sample of each latrine. To determine the presence or absence of B. procyonis eggs in each sample, we used the Cornell-Wisconsin centrifugal floatation technique. Twenty-three percent (7/30) of homogenized samples tested positive for B. procyonis. Eggs per gram of feces ranged from 1 to 388 (median = 1.28, IQR = 0.32-232.5). Baylisascaris procyonis positive latrines were found in conservation areas heavily used by people, which may represent a possible source of exposure for humans in these areas.

Factors associated with latrine utilization among model and non-model families in Laelai Maichew Woreda, Aksum, Tigray, Ethiopia: comparative community based study

Objective

The study was conducted on 313 model and 313 non model households to assess latrine utilization and factors affecting among model and non-model families.

Result

About 225 (71.9%) model and 144 (46%) non-model participants declared that they utilize their latrine which gave the overall utilization rate of 369 (58.9%). Households with primary and above education were two times (AOR = 2.03, 95% CI 1.427, 4.638) more likely to utilize latrine as compared with illiterate households. Cleanness of the latrine was also found to be associated with latrine utilization in both model and non-model families. Age, type of latrine, latrine supper structure, cleanness and observable soap near the latrine in model families and age, educational status, occupation, latrine privacy and cleanness in non-model families were identified as a statistical significant factor for latrine utilization.

Human Parasites in Medieval Europe: Lifestyle, Sanitation and Medical Treatment

Parasites have been infecting humans throughout our evolution. However, not all people suffered with the same species or to the same intensity throughout this time. Our changing way of life has altered the suitability of humans to infection by each type of parasite. This analysis focuses upon the evidence for parasites from archaeological excavations at medieval sites across Europe. Comparison between the patterns of infection in the medieval period allows us to see how changes in sanitation, herding animals, growing and fertilizing crops, the fishing industry, food preparation and migration all affected human susceptibility to different parasites. We go on to explore how ectoparasites may have spread infectious bacterial diseases, and also consider what medieval medical practitioners thought of parasites and how they tried to treat them. While modern research has shown the use of a toilet decreases the risk of contracting certain intestinal parasites, the evidence for past societies presented here suggests that the invention of latrines had no observable beneficial effects upon intestinal health. This may be because toilets were not sufficiently ubiquitous until the last century, or that the use of fresh human faeces for manuring crops still ensured those parasite species were easily able to reinfect the population.

[Can we overcome schistosomiasis? A Senegalese example]

The authors report the results of controlling schistosomiasis in 53 villages from Ninefecha area-(Kedougou District, East Senegal) within Schistosomiasis National Control Program partnership. The four aims were: i) praziquantel treatment of 3324 children 6-14 years old, ii) installation of a laboratory for children prevalence annual monitoring (random draw one in three), iii) health education of the concerned people ("sensitization"), iiii) construction of latrines. 900 latrines are required and 649 have been built. The initial prevalence (2006) of 44% for S. mansoni and 4% for S. haematobium are now respectively 1.9% and 1.4% (2013). The program must be continuous as shown in the Assoni village: a prevalence study in children 0-5 years old, for which praziquantel is not recommended, reveals an infestation rate for S. mansoni of 78% in 2008 and of 47% in 2012. This age group is an important parasite reservoir and health education of parents is absolutely necessary. A permanent and effective center like Ninefescha hospital for distribution of praziquantel, sensitization meetings and latrines control is essential for the success of the program.