Hi Elisabeth,

I have not been able to find much. See the attached papers. They provide mixed signal. We all know that prima facie, improved sanitation would lead to improved health. However, studies with RCT (randomised control trials) suggest that the evidence is not conclusive. Are we missing something?

Dinesh


Dinesh Mehta
Professor Emeritus
CEPT University, Navrangpura, Ahmedabad-380009, Gujarat, India
www.pas.org.in
f fb.com/pas.cept | in linkedin.com/in/pascept

Dear Zvi,

Thanks for these inputs and for pointing us to the relevant Wikipedia article on clinical study design (would you say it's a good Wikipedia article)?

I wish we could somehow attract more public health professionals to our SuSanA network, as there is so much for us to learn. Time and time again us sanitation people are disappointed when study results show once again that some sanitation improvements did not have the desired health impacts, or that at least it was too difficult to prove beyond doubt... And these RCTs are very expensive to carry out, too!

Here is the sub-category on the forum where previous discussions on this topic have been grouped:
forum.susana.org/research-on-health-bene...-improved-sanitation

Regards,
Elisabeth

P.S. Dinesh: as you started this thread, have you found some information in the meantime that you found useful and that could perhaps be shared here? That would be great.

en.wikipedia.org/wiki/Clinical_study_design

I wanted to note, that while randomized clinical trials are indeed the 'golden standard' of epidemiological research, there are other methods that are easier to apply to such questions. Such methods are before/after studies (comparing changes to health before and after an intervention, compared to areas where the intervention was not performed based on historical data), ecological studies (comparing regions or countries with different rates of the behavior under study and the health outcomes), or even cross sectional studies which assess behavior and health at the same time.

I know not whether such designs have been tried, and regardless of the study design, impact of a single factor such as hand washing or open defecation on health outcome like diarrhea is going to be very difficult to demonstrate (because many of the health behaviors are going to be correlated with one another and because external factors - floods, droughts, wars, political unrest, etc. - make the data noisy and hard to analyze), but I am sure some of the data may be available for study.

BTW, I am also not sure about the ethics of the situation. Just because intuition tells us something should work, the proof is in the pudding. Economists make a living showing that most programs do not work (see the works of Angus Deaton and Esther Duflo). The point being that a program such as hand washing promotion can ethically be applied to some villages and not to others if we suspect the impact is insignificant. If we find out that although people wash hands properly and avoid fecal/oral contamination, they still have as many cases of diarrhea, we would look elsewhere for the cause (perhaps drinking water is contaminated at the source, or there is a breach between sewage and water pipes, or food source is contaminated), and in doing so will both reduce incidence of the disease, and direct the funds towards something (that is demonstrably more effective).

Just my two cents, as an MPH.

Hi Dinesh,

I would say yes and no. We are seeing more and more studies where researchers are doing randomized controlled trials (RCTs) on figuring out health impacts from improved sanitation. But it's incredibly hard to prove anything. One reason is that in some of the trials sanitation interventions are not far reaching enough (e.g. not the entire community is covered, or handwashing is not covered etc.). We all know intuitively that hygiene and sanitation is super important for health, particularly when it comes to newborns, babies and young children. But to prove this with data, and for an entire community, is not easy. Even doing scientific trials (those RCTs) is not easy, for ethical reasons (e.g. can we "withhold" hygiene measures for young children just to prove the impact?)

I haven't seen any studies looking at FSM (fecal sludge management) in particular.

Could you tell us a bit more about the background to your question?

Please also see these forum threads, and feel free to contribute to them:

forum.susana.org/26-health-issues-and-co...ent-kenya-bangladesh
It's a grant funded by the BMGF: Benefits of water quality, sanitation, handwashing and nutritional interventions for health and child development (Kenya, Bangladesh)

"The trials are currently conducting their final round of outcome measurement. We anticipate primary results in late 2016 (Bangladesh) and mid 2017 (Kenya)."

and this one:
forum.susana.org/26-health-issues-and-co...al-burden-of-disease
The elusive effect of water and sanitation on the global burden of disease

and this one:
forum.susana.org/26-health-issues-and-co...-by-emory-university
No evidence that this sanitation programme in rural Odisha prevented diarrhoea, soil-transmitted helminth infection, or child malnutrition (study led by Emory University)

There is a sub-category on the forum dealing with this topic:
forum.susana.org/research-on-health-bene...-improved-sanitation
(it is called: Research on health benefits with improved sanitation)

Regards,
Elisabeth

Are there 'before and after' studies that show impact of FSM practices on health?