Risk factors measuring impacts of improvements in WASH

1
Risk factors / measuring impacts of improvements
in WASH

• General introduction (1x45)
• Introduction to Pakistan case (1x45)
• Group work (1x45 today, 2x45Friday)
• Presentations by groups (2x45)

2
Quality of Water
Diarrhea
3
Quality of Water
Diarrhea
Quantity of Water
4
Quantity of Water
Diarrhea
Quality of Water
Sanitation
5
Quantity of Water
Diarrhea
Quality of Water
Sanitation
Hygiene Behavior
6
Quantity of Water
Diarrhea
Quality of Water
Sanitation
Hygiene Behavior
Eye and Skin Infections
7
Quantity of Water
Diarrhea
Quality of Water
Sanitation
Hygiene Behavior
Worm Infections
Eye and Skin Infections
8
Quantity of Water
Diarrhea
Malnutrition
Quality of Water
Sanitation
Hygiene Behavior
Worm Infections
Eye and Skin Infections
9
Are studies / HIE needed?

• Resource allocation
• Levels of service
• Public health what can we do with the resources
  we have
• Community medicine how can we best implement it
• Epidemiology scientific base

10
How to do HIE?

• 1975 World Bank Panel of Experts
• 1980s critical reviews of impact studies
• But in the mean time case control design, better
  understanding of pathogenic agents responsible
  for diarrhea

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Exposure
Outcome
Diarrhea
Poor water supply
Confounders
How to measure exposure? How to measure
outcome? How to account for confounding
variables? Need for indicators
12
Outcome of watsan projects

• Output product or service provided
• Effect change in knowledge, attitudes and
  practices
• Impact change in health status

13
WHO / UNICEF Global Water Supply and Sanitation
Assessment 2000

• Improved sanitation
• Connection to a public sewer
• Connection to septic system
• Pour-flush latrine
• Simple pit latrine
• Ventilated Improved Latrine

• Improved water supply
  
• Household connection
• Public standpipe
• Borehole
• Protected dug well
• Protected spring
• Rainwater collection

• Not improved water supply
• Unprotected well
• Unprotected spring
• Vendor-provided water
• Bottled water
• Tanker truck-provided water

• Not improved sanitation
• Bucket latrines (where excreta
• are manually removed)
• Public latrines
• Open / uncovered latrines

14
Basic WASH requirements

• A minimum quantity of safe water of 20 liters per
  person per day
• A limited number of key hygiene practices that
  are essential to good health feces disposal of
  young children and handwashing
• Disposing of human waste

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Public Private Partnershipon Handwashing

• Diarrheal diseases kill 2 to 3 million children
  in developing countries every year
• These deaths are preventable
• Handwashing with soap alone could cut deaths in
  half
• Handwashing with soap combined with adequate
  sanitation could almost eradicate diarrheal
  disease

16
Outcome variables

• Diarrhea morbidity
• Diarrhea mortality
• Nutritional status
• Intestinal nematodes strongly related to
  sanitation
• Eye infections trachoma, strongly related to
  availability of water and hygiene
• Skin infections
• Guinea worm only disease which is exclusively
  transmitted trough infected drinking water

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Nutritional status

• Height-for-age indicator of cumulative effect of
  undernutrition
• More objective than diarrhea
• Small sample size
• Cross-sectional study design possible

18
Diarrhea morbidity

• How to measure diarrhea frequency incidence,
  prevalence, longitudinal prevalence
• Case definition perceived symptoms, laboratory
  diagnosis
• Recall 1 month, 1 week, 24 hours?

19
Choice of indicators
Relevance
Validity
Efficiency

• Increase efficiency
• restrict to only small children
• focus on seasonal diarrhea peaks