Access to water and sanitation among people with disabilities: results from cross-sectional surveys in Bangladesh, Cameroon, India and Malawi.

OBJECTIVES: To assess access to adequate water, sanitation and hygiene (WASH) among people with disabilities at the household and individual level. DESIGN: Cross-sectional surveys. SETTING: Data were included from five district-level or regional-level surveys: two in Bangladesh (Bangladesh-1, Bangladesh-2), and one each in Cameroon, Malawi and India. PARTICIPANTS: 99 252 participants were sampled across the datasets (range: 3567-75 767), including 2494 with disabilities (93-1374). OUTCOME: Prevalence of access to WASH at household and individual level. DATA ANALYSIS: Age/sex disaggregated disability prevalence estimates were calculated accounting for survey design. The Unicef/WHO Joint Monitoring Programme definitions were used to classify facilities as improved/unimproved. Multivariable logistic regression was undertaken to compare between households with/without a person with a disability, and to identify predictors of access among people with disabilities. RESULTS: There were no differences in access to improved sanitation or water sources between households with/without members with disabilities across the datasets. In Bangladesh-2, households including a person with a disability were more likely to share facilities with other households (OR 1.3, 95% CI 1.1 to 1.5). Households with people with disabilities were more likely to spend >30 min (round-trip) collecting drinking water than households without in both Cameroon (OR 1.8, 95% CI 1.0 to 3.4) and India (OR 2.3, 95% CI 1.2 to 4.7). Within households, people with disabilities reported difficulties collecting water themselves (23%-80% unable to) and accessing the same sanitation facilities as other household members, particularly without coming into contact with faeces (up to 47% in Bangladesh-2). These difficulties were most marked for people with more severe impairments. CONCLUSIONS: People with disabilities may not have poorer access to WASH at the household level, but may have poorer quality of access within their households. Further programmatic work is needed to ensure WASH facilities are inclusive of people with disabilities.

Interventions to improve disposal of human excreta for preventing diarrhoea.

BACKGROUND: Diarrhoeal diseases are a leading cause of mortality and morbidity, especially among young children in low-income countries, and are associated with exposure to human excreta. OBJECTIVES: To assess the effectiveness of interventions to improve the disposal of human excreta for preventing diarrhoeal diseases. SEARCH STRATEGY: We searched the Cochrane Infectious Disease Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in The Cochrane Library; MEDLINE; EMBASE; LILACS; the metaRegister of Controlled Trials (mRCT); and Chinese-language databases available under the Wan Fang portal, and the China National Knowledge Infrastructure (CNKI-CAJ). We also handsearched relevant conference proceedings, and contacted researchers and organizations working in the field, as well as checking references from identified studies. SELECTION CRITERIA: Randomized, quasi-randomized, and non-randomized controlled trials (RCTs) were selected, comparing interventions aimed at improving the disposal of human excreta to reduce direct or indirect human contact with no such intervention. Cluster (eg at the level of household or community) controlled trials were included. DATA COLLECTION AND ANALYSIS: We determined study eligibility, extracted data, and assessed methodological quality in accordance with the methods prescribed by the protocol. We described the results and summarized the information in tables. Due to substantial heterogeneity among the studies in terms of study design and type of intervention, no pooled effects were calculated. MAIN RESULTS: Thirteen studies from six countries covering over 33,400 children and adults in rural, urban, and school settings met the review's inclusion criteria. In all studies the intervention was allocated at the community level. While the studies reported a wide range of effects, 11 of the 13 studies found the intervention was protective against diarrhoea. Differences in study populations and settings, in baseline sanitation levels, water, and hygiene practices, in types of interventions, study methodologies, compliance and coverage levels, and in case definitions and outcome surveillance limit the comparability of results of the studies included in this review. The validity of most individual study results are further compromised by the non-random allocation of the intervention among study clusters, an insufficient number of clusters, the lack of adjustment for clustering, unclear loss to follow-up, potential for reporting bias and other methodological shortcomings. AUTHORS' CONCLUSIONS: This review provides some evidence that interventions to improve excreta disposal are effective in preventing diarrhoeal disease. However, this conclusion is based primarily on the consistency of the evidence of beneficial effects. The quality of the evidence is generally poor and does not allow for quantification of any such effect. The wide range of estimates of the effects of the intervention may be due to clinical and methodological heterogeneity among the studies, as well as to other important differences, including exposure levels, types of interventions, and different degrees of observer and respondent bias. Rigorous studies in multiple settings are needed to clarify the potential effectiveness of excreta disposal on diarrhoea.

Water, sanitation and hygiene for the prevention of diarrhoea.

BACKGROUND: Ever since John Snow's intervention on the Broad St pump, the effect of water quality, hygiene and sanitation in preventing diarrhoea deaths has always been debated. The evidence identified in previous reviews is of variable quality, and mostly relates to morbidity rather than mortality. METHODS: We drew on three systematic reviews, two of them for the Cochrane Collaboration, focussed on the effect of handwashing with soap on diarrhoea, of water quality improvement and of excreta disposal, respectively. The estimated effect on diarrhoea mortality was determined by applying the rules adopted for this supplement, where appropriate. RESULTS: The striking effect of handwashing with soap is consistent across various study designs and pathogens, though it depends on access to water. The effect of water treatment appears similarly large, but is not found in few blinded studies, suggesting that it may be partly due to the placebo effect. There is very little rigorous evidence for the health benefit of sanitation; four intervention studies were eventually identified, though they were all quasi-randomized, had morbidity as the outcome, and were in Chinese. CONCLUSION: We propose diarrhoea risk reductions of 48, 17 and 36%, associated respectively, with handwashing with soap, improved water quality and excreta disposal as the estimates of effect for the LiST model. Most of the evidence is of poor quality. More trials are needed, but the evidence is nonetheless strong enough to support the provision of water supply, sanitation and hygiene for all.

Extending the critical aspects of the water access indicator using East Africa as an example.

The United Nations has declared 2005-2015 the Fresh Water Decade in which more people than ever before will gain access to water. Despite acknowledging that water quantity is important to health, so far only water quality is used in monitoring the Millennium Development Goals. This study examines the changes in national access figures when both water quality and quantity are taken into account to determine access. Using East Africa as an example shows that the number of people with access to water for the region decreased by 9% (7% urban and 10% rural). The largest difference in access is observed in Eritrea 25% (11% urban and 36% rural). Reduction is higher in rural areas. However, significant reduction in access is also observed in urban Ethiopia (14%). In conclusion, the indicators for access to water would be better articulated by adding water quantity to the indicator which currently only includes water quality, while the Demographic Health Survey and Multiple Indicator Cluster Survey routinely collects information on both aspects.

Optimisation of the T-square sampling method to estimate population sizes.

Population size and density estimates are needed to plan resource requirements and plan health related interventions. Sampling frames are not always available necessitating surveys using non-standard household sampling methods. These surveys are time-consuming, difficult to validate, and their implementation could be optimised. Here, we discuss an example of an optimisation procedure for rapid population estimation using T-Square sampling which has been used recently to estimate population sizes in emergencies. A two-stage process was proposed to optimise the T-Square method wherein the first stage optimises the sample size and the second stage optimises the pathway connecting the sampling points. The proposed procedure yields an optimal solution if the distribution of households is described by a spatially homogeneous Poisson process and can be sub-optimal otherwise. This research provides the first step in exploring how optimisation techniques could be applied to survey designs thereby providing more timely and accurate information for planning interventions.

Optimization of household survey sampling without sample frames.

There are a few sampling methods available to survey households in situations where sample frames are either unavailable or are unreliable. The most popular of these methods is the expanded programme of immunization (EPI) sampling method, which has been used in low-income countries. The purpose of this paper is to explain how mathematical programming can be used to optimize EPI and other household survey sampling methods in these situations.