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

Abstract

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.

Keywords: Latrine; Meta-analysis; Sanitation; Systematic review.

Fig. 1

Flow chart of the search and review procedure for the systematic review

Fig. 2

Forest plot of safe feces disposal

Fig. 3

Assessment of publication bias using Begg’s funnel plot

Fig. 4

Forest plot of latrine usage

Fig. 5

Forest plot of latrine coverage or access

Fig. 6

Forest plot of latrine coverage or access group by intervention content

Fig. 7

Forest plot of improved latrine coverage or access

Fig. 8

Characteristics of risk of bias