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Meta-Analysis
. 2023 Jan 25;1(1):CD013328.
doi: 10.1002/14651858.CD013328.pub2.

Interventions to improve sanitation for preventing diarrhoea

Valerie Bauza  1 , Wenlu Ye  1   2 , Jiawen Liao  1   3 , Fiona Majorin  4 , Thomas Clasen  1
Affiliations
Meta-Analysis

Interventions to improve sanitation for preventing diarrhoea

Valerie Bauza et al. Cochrane Database Syst Rev. .

Abstract
in English, Korean

Background: Diarrhoea is a major contributor to the global disease burden, particularly amongst children under five years in low- and middle-income countries (LMICs). As many of the infectious agents associated with diarrhoea are transmitted through faeces, sanitation interventions to safely contain and manage human faeces have the potential to reduce exposure and diarrhoeal disease.

Objectives: To assess the effectiveness of sanitation interventions for preventing diarrhoeal disease, alone or in combination with other WASH interventions.

Search methods: We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, and Chinese language databases available under the China National Knowledge Infrastructure (CNKI-CAJ). We also searched the metaRegister of Controlled Trials (mRCT) and conference proceedings, contacted researchers, and searched references of included studies. The last search date was 16 February 2022.

Selection criteria: We included randomized controlled trials (RCTs), quasi-RCTs, non-randomized controlled trials (NRCTs), controlled before-and-after studies (CBAs), and matched cohort studies of interventions aimed at introducing or expanding the coverage and/or use of sanitation facilities in children and adults in any country or population. Our primary outcome of interest was diarrhoea and secondary outcomes included dysentery (bloody diarrhoea), persistent diarrhoea, hospital or clinical visits for diarrhoea, mortality, and adverse events. We included sanitation interventions whether they were conducted independently or in combination with other interventions.

Data collection and analysis: Two review authors independently assessed eligible studies, extracted relevant data, assessed risk of bias, and assessed the certainty of evidence using the GRADE approach. We used meta-analyses to estimate pooled measures of effect, described results narratively, and investigated potential sources of heterogeneity using subgroup analyses.

Main results: Fifty-one studies met our inclusion criteria, with a total of 238,535 participants. Of these, 50 studies had sufficient information to be included in quantitative meta-analysis, including 17 cluster-RCTs and 33 studies with non-randomized study designs (20 NRCTs, one CBA, and 12 matched cohort studies). Most were conducted in LMICs and 86% were conducted in whole or part in rural areas. Studies covered three broad types of interventions: (1) providing access to any sanitation facility to participants without existing access practising open defecation, (2) improving participants' existing sanitation facility, or (3) behaviour change messaging to improve sanitation access or practices without providing hardware or subsidy, although many studies overlapped multiple categories. There was substantial heterogeneity amongst individual study results for all types of interventions. Providing access to any sanitation facility Providing access to sanitation facilities was evaluated in seven cluster-RCTs, and may reduce diarrhoea prevalence in all age groups (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.73 to 1.08; 7 trials, 40,129 participants, low-certainty evidence). In children under five years, access may have little or no effect on diarrhoea prevalence (RR 0.98, 95% CI 0.83 to 1.16, 4 trials, 16,215 participants, low-certainty evidence). Additional analysis in non-randomized studies was generally consistent with these findings. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.79, 95% CI 0.66 to 0.94; 15 studies, 73,511 participants; children < 5 years: RR 0.83, 95% CI 0.68 to 1.02; 11 studies, 25,614 participants). Sanitation facility improvement Interventions designed to improve existing sanitation facilities were evaluated in three cluster-RCTs in children under five and may reduce diarrhoea prevalence (RR 0.85, 95% CI 0.69 to 1.06; 3 trials, 14,900 participants, low-certainty evidence). However, some of these interventions, such as sewerage connection, are not easily randomized. Non-randomized studies across participants of all ages provided estimates that improving sanitation facilities may reduce diarrhoea, but may be subject to confounding (RR 0.61, 95% CI 0.50 to 0.74; 23 studies, 117,639 participants, low-certainty evidence). Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.65, 95% CI 0.55 to 0.78; 26 studies, 132,539 participants; children < 5 years: RR 0.70, 95% CI 0.54 to 0.91, 12 studies, 23,353 participants). Behaviour change messaging only (no hardware or subsidy provided) Strategies to promote behaviour change to construct, upgrade, or use sanitation facilities were evaluated in seven cluster-RCTs in children under five, and probably reduce diarrhoea prevalence (RR 0.82, 95% CI 0.69 to 0.98; 7 studies, 28,909 participants, moderate-certainty evidence). Additional analysis from two non-randomized studies found no effect, though with very high uncertainty. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (RR 0.85, 95% CI 0.73 to 1.01; 9 studies, 31,080 participants). No studies measured the effects of this type of intervention in older populations. Any sanitation intervention A pooled analysis of cluster-RCTs across all sanitation interventions demonstrated that the interventions may reduce diarrhoea prevalence in all ages (RR 0.85, 95% CI 0.76 to 0.95, 17 trials, 83,938 participants, low-certainty evidence) and children under five (RR 0.87, 95% CI 0.77 to 0.97; 14 trials, 60,024 participants, low-certainty evidence). Non-randomized comparisons also demonstrated a protective effect, but may be subject to confounding. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.74, 95% CI 0.67 to 0.82; 50 studies, 237,130 participants; children < 5 years: RR 0.80, 95% CI 0.71 to 0.89; 32 studies, 80,047 participants). In subgroup analysis, there was some evidence of larger effects in studies with increased coverage amongst all participants (75% or higher coverage levels) and also some evidence that the effect decreased over longer follow-up times for children under five years. There was limited evidence on other outcomes. However, there was some evidence that any sanitation intervention was protective against dysentery (RR 0.74, 95% CI 0.54 to 1.00; 5 studies, 34,025 participants) and persistent diarrhoea (RR 0.57, 95% CI 0.43 to 0.75; 2 studies, 2665 participants), but not against clinic visits for diarrhoea (RR 0.86, 95% CI 0.44 to 1.67; 2 studies, 3720 participants) or all-cause mortality (RR 0.99, 95% CI 0.89 to1.09; 7 studies, 46,123 participants).

Authors' conclusions: There is evidence that sanitation interventions are effective at preventing diarrhoea, both for young children and all age populations. The actual level of effectiveness, however, varies by type of intervention and setting. There is a need for research to better understand the factors that influence effectiveness.

배경: 설사는 특히 저소득 및 중간 소득 국가(LMIC)의 5세 미만 어린이들 사이에서 전 세계 질병 부담의 주요 원인이다. 설사와 관련된 많은 감염원이 대변을 통해 전염되기 때문에 사람의 대변을 안전하게 관리하기 위한 위생 중재는 노출과 설사병을 줄일 수 있는 잠재력이 있다. 목적: 단독으로 또는 다른 WASH 중재와 함께 설사병 예방을 위한 위생 중재의 효과를 평가한다. 검색 전략: Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS 및 중국 국가 지식 인프라(CNKI‐CAJ)에서 사용 가능한 중국어 데이터베이스를 검색했다. 또한 통제된 시험의 메타 등록부( m RCT) 및 회의 절차를 검색하고, 연구자에게 연락하고, 포함된 연구의 참고 문헌을 검색했다. 마지막 검색 날짜는 2022년 2월 16일이었다. 선정 기준: 무작위 통제 시험(RCT), 준 RCT, 비무작위 통제 시험(NRCT), 전후 통제 연구(CBA), 모든 국가 또는 인구의 어린이 및 성인의 위생 시설 적용 범위 및/또는 사용을 도입하거나 확장하기 위한 중재의 일치 코호트 연구를 포함했다. 주요 관심 결과는 설사였으며 이차 결과에는 이질(피 섞인 설사), 지속적인 설사, 설사로 인한 병원 또는 임상 방문, 사망 및 부작용이 포함되었다. 독립적으로 수행되었는지 또는 다른 중재와 함께 수행되었는지 여부에 관계없이 위생 중재를 포함했다. 자료 수집 및 분석: 2명의 검토 저자가 독립적으로 적격 연구를 평가하고, 관련 데이터를 추출하고, 비뚤림 위험을 평가하고, GRADE 접근법을 사용하여 근거의 확실성을 평가했다. 메타 분석을 사용하여 합동 효과 측정치를 추정하고, 결과를 서술적으로 설명하고, 하위 그룹 분석을 사용하여 이질성의 잠재적 원인을 조사했다. 주요 결과: 총 238,535명이 참여하여 51건의 연구가 포함 기준을 충족했다. 이 중 50개의 연구는 17개의 군집 RCT와 비무작위 연구 설계를 사용한 33개의 연구(20개의 NRCT, 1개의 CBA 및 12개의 일치 코호트 연구)를 포함하여 정량적 메타 분석에 포함하기에 충분한 정보를 가지고 있었다. 대부분은 LMIC에서 수행되었으며 86%는 시골 지역에서 전체적으로 또는 부분적으로 수행되었다. 연구는 세 가지 광범위한 중재 유형을 다루었다: (1) 개방형 배변을 연습하는 기존 접근 권한이 없는 참여자에게 위생 시설에 대한 접근 제공, (2) 참여자의 기존 위생 시설 개선, 또는 (3) 장비나 보조금을 제공하지 않고 위생 접근 또는 관행을 개선하기 위한 행동 변화 메시지. 그러나 많은 연구가 여러 범주를 겹쳤다. 모든 유형의 중재에 대한 개별 연구 결과 간에 상당한 이질성이 있었다. 모든 위생 시설에 대한 접근 제공 위생 시설에 대한 접근성을 제공하는 것은 7개의 군집 RCT에서 평가되었으며 모든 연령대에서 설사 유병률을 줄일 수 있다(위험비(RR) 0.89, 95% 신뢰 구간(CI) 0.73~1.08, 7건의 임상시험, 40,129명의 참가자, 낮은 확실성 근거). 5세 미만 어린이의 경우 접근이 설사 유병률에 거의 또는 전혀 영향을 미치지 않을 수 있다(RR 0.98, 95% CI 0.83 ~ 1.16, 4건의 임상시험, 16,215명의 참가자, 근거 확실성 낮음). 비무작위 연구의 추가 분석은 일반적으로 이러한 결과와 일치했다. 무작위 및 비무작위 연구에 걸친 통합 추정치는 유사한 보호 추정치를 제공했다(모든 연령: RR 0.79, 95% CI 0.66~0.94; 15건의 연구, 73,511명의 참가자; 5세 미만 어린이: RR 0.83, 95% CI 0.68~1.02; 11건의 연구, 25,614명의 참가자). 위생시설 개선 기존 위생 시설을 개선하기 위해 고안된 중재는 5세 미만 아동의 3개 군집 RCT에서 평가되었으며 설사 유병률을 줄일 수 있다(RR 0.85, 95% CI 0.69 ~ 1.06; 3건의 임상시험, 14,900명의 참가자, 근거 확실성 낮음). 그러나 하수도 연결과 같은 이러한 중재 중 일부는 쉽게 무작위화되지 않는다. 모든 연령대의 참가자를 대상으로 한 비무작위 연구는 위생 시설을 개선하면 설사를 줄일 수 있지만 교란 요인이 될 수 있다는 추정치를 제공했다(RR 0.61, 95% CI 0.50 ~ 0.74; 23개 연구, 117,639명의 참가자, 근거 확실성 낮음). 무작위 및 비무작위 연구에 걸친 통합 추정치는 유사한 보호 추정치를 제공했다(모든 연령: RR 0.65, 95% CI 0.55~0.78; 26건의 연구, 132,539명의 참가자; 5세 미만 어린이: RR 0.70, 95% CI 0.54~0.91, 12건의 연구, 23,353명의 참가자). 행동 변화 메시지만 제공(장비 또는 보조금 제공 없음) 위생 시설을 건설, 업그레이드 또는 사용하기 위한 행동 변화를 촉진하는 전략은 5세 미만 아동의 7개 클러스터 RCT에서 평가되었으며 아마도 설사 유병률을 감소시킬 것이다(RR 0.82, 95% CI 0.69 ~ 0.98; 7개 연구, 28,909명의 참가자, 중간‐ 확실한 근거). 두 개의 비무작위 연구의 추가 분석에서는 불확실성이 매우 높지만 아무런 효과가 없는 것으로 나타났다. 무작위 및 비무작위 연구에서 통합된 추정치는 유사한 보호 추정치를 제공했다(RR 0.85, 95% CI 0.73~1.01; 9개 연구, 31,080명의 참가자). 고령 인구에서 이러한 유형의 중재의 효과를 측정한 연구는 없다. 모든 위생 중재 모든 위생 중재에 대한 클러스터‐RCT의 통합 분석은 중재가 모든 연령대(RR 0.85, 95% CI 0.76 ~ 0.95, 17건의 임상시험, 83,938명의 참가자, 낮은 근거 확실성) 및 5세 미만 어린이(RR 0.87, 95% CI 0.77 ~ 0.97, 14건의 시험, 60,024명의 참가자, 근거 확실성 낮음)에서 설사 유병률을 감소시킬 수 있음을 보여주었다. 비무작위 비교에서도 보호 효과가 입증되었지만 혼재될 수 있다. 무작위 및 비무작위 연구에 걸친 통합 추정치는 유사한 보호 추정치를 제공했다(모든 연령: RR 0.74, 95% CI 0.67~0.82; 50건의 연구, 237,130명의 참가자; 5세 미만 어린이: RR 0.80, 95% CI 0.71~0.89; 32건의 연구, 80,047명의 참가자). 하위 그룹 분석에서 모든 참가자의 적용 범위가 증가한(75% 이상의 적용 범위 수준) 연구에서 더 큰 효과에 대한 일부 근거가 있었고, 5세 미만 어린이에 대한 후속 조치 시간이 길어질수록 효과가 감소했다는 일부 근거도 있었다. 다른 결과에 대한 근거는 제한적이었다. 그러나 모든 위생 중재가 이질(RR 0.74, 95% CI 0.54 ~ 1.00; 5건의 연구, 34,025명의 참가자) 및 지속적인 설사(RR 0.57, 95% CI 0.43 ~ 0.75; 2건의 연구, 2665명의 참가자)를 예방한다는 일부 근거가 있었지만, 설사(RR 0.86, 95% CI 0.44 ~ 1.67; 2건의 연구, 3720명의 참가자) 또는 모든 원인으로 인한 사망(RR 0.99, 95% CI 0.89 ~1.09; 7건의 연구, 46,123명의 참가자)에 대한 진료소 방문은 예방되지 않는다는 일부 근거가 있었다. 연구진 결론: 위생 조치가 어린 아동과 모든 연령대의 설사 예방에 효과적이라는 근거가 있다. 그러나 실제 효과 수준은 중재 유형과 환경에 따라 다르다. 효과에 영향을 미치는 요인을 더 잘 이해하기 위한 연구가 필요하다.

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Conflict of interest statement

VB has no known conflicts of interest.

WY has no known conflicts of interest.

JL has no known conflicts of interest.

FM has no known conflicts of interest.

TC has no known conflicts of interest.

Figures

1
1
PRISMA flow diagram
2
2
Risk of bias summary for cluster‐RCT studies: review authors' judgements about each risk of bias item for each included cluster‐RCT study.
3
3
Risk of bias summary for non‐randomized study designs: review authors' judgements about each risk of bias item for each included non‐randomized study.
1.1
1.1. Analysis
Comparison 1: Providing access to any sanitation facility intervention versus control, Outcome 1: Diarrhoea: all ages
1.2
1.2. Analysis
Comparison 1: Providing access to any sanitation facility intervention versus control, Outcome 2: Diarrhoea: children < 5 years
1.3
1.3. Analysis
Comparison 1: Providing access to any sanitation facility intervention versus control, Outcome 3: Dysentery (bloody diarrhoea): children < 5 years (same for all ages)
1.4
1.4. Analysis
Comparison 1: Providing access to any sanitation facility intervention versus control, Outcome 4: Persistent diarrhoea: children < 5 years (same for all ages)
1.5
1.5. Analysis
Comparison 1: Providing access to any sanitation facility intervention versus control, Outcome 5: All‐cause mortality: all ages
1.6
1.6. Analysis
Comparison 1: Providing access to any sanitation facility intervention versus control, Outcome 6: All‐cause mortality: children < 5 years
1.7
1.7. Analysis
Comparison 1: Providing access to any sanitation facility intervention versus control, Outcome 7: Diarrhoea‐related mortality: children < 5 years (same for all ages)
2.1
2.1. Analysis
Comparison 2: Sanitation facility improvement intervention versus control, Outcome 1: Diarrhoea: all ages
2.2
2.2. Analysis
Comparison 2: Sanitation facility improvement intervention versus control, Outcome 2: Diarrhoea: children < 5 years
2.3
2.3. Analysis
Comparison 2: Sanitation facility improvement intervention versus control, Outcome 3: Dysentery (bloody stool): all ages
2.4
2.4. Analysis
Comparison 2: Sanitation facility improvement intervention versus control, Outcome 4: Persistent Diarrhoea ‐ Children <5 years
2.5
2.5. Analysis
Comparison 2: Sanitation facility improvement intervention versus control, Outcome 5: Clinic visits for diarrhoea: all ages
2.6
2.6. Analysis
Comparison 2: Sanitation facility improvement intervention versus control, Outcome 6: Clinic visits for diarrhoea: children < 5 years
2.7
2.7. Analysis
Comparison 2: Sanitation facility improvement intervention versus control, Outcome 7: All‐cause mortality: children < 5 years (same for all ages)
3.1
3.1. Analysis
Comparison 3: Behaviour change messaging only intervention versus control, Outcome 1: Diarrhoea: children < 5 years (same for all ages)
3.2
3.2. Analysis
Comparison 3: Behaviour change messaging only intervention versus control, Outcome 2: Dysentery (bloody stool): children < 5 years (same for all ages)
3.3
3.3. Analysis
Comparison 3: Behaviour change messaging only intervention versus control, Outcome 3: All‐cause mortality: all ages
3.4
3.4. Analysis
Comparison 3: Behaviour change messaging only intervention versus control, Outcome 4: All‐cause mortality: children < 5
3.5
3.5. Analysis
Comparison 3: Behaviour change messaging only intervention versus control, Outcome 5: Diarrhoea‐related mortality: all ages
3.6
3.6. Analysis
Comparison 3: Behaviour change messaging only intervention versus control, Outcome 6: Diarrhoea‐related mortality: children < 5
4.1
4.1. Analysis
Comparison 4: Any sanitation intervention, Outcome 1: Diarrhoea: all ages
4.2
4.2. Analysis
Comparison 4: Any sanitation intervention, Outcome 2: Diarrhoea: children < 5 years
4.3
4.3. Analysis
Comparison 4: Any sanitation intervention, Outcome 3: Dysentery (bloody stool): all ages
4.4
4.4. Analysis
Comparison 4: Any sanitation intervention, Outcome 4: Dysentery (bloody diarrhoea): children < 5 years
4.5
4.5. Analysis
Comparison 4: Any sanitation intervention, Outcome 5: Persistent diarrhoea: children < 5 years (same for all ages)
4.6
4.6. Analysis
Comparison 4: Any sanitation intervention, Outcome 6: Clinic visits for diarrhoea: all ages
4.7
4.7. Analysis
Comparison 4: Any sanitation intervention, Outcome 7: Clinic visits for diarrhoea: children < 5 years
4.8
4.8. Analysis
Comparison 4: Any sanitation intervention, Outcome 8: All‐cause mortality: all ages
4.9
4.9. Analysis
Comparison 4: Any sanitation intervention, Outcome 9: All‐cause mortality ‐ Children < 5 years
4.10
4.10. Analysis
Comparison 4: Any sanitation intervention, Outcome 10: Diarrhoea‐related mortality: all ages
4.11
4.11. Analysis
Comparison 4: Any sanitation intervention, Outcome 11: Diarrhoea‐related mortality: children < 5
5.1
5.1. Analysis
Comparison 5: Sub‐analysis: Sanitation only versus with other WASH interventions, Outcome 1: Sanitation only: diarrhoea ‐ all ages
5.2
5.2. Analysis
Comparison 5: Sub‐analysis: Sanitation only versus with other WASH interventions, Outcome 2: Sanitation only: diarrhoea: children < 5 years
5.3
5.3. Analysis
Comparison 5: Sub‐analysis: Sanitation only versus with other WASH interventions, Outcome 3: With other WASH interventions: diarrhoea ‐ all ages
5.4
5.4. Analysis
Comparison 5: Sub‐analysis: Sanitation only versus with other WASH interventions, Outcome 4: With other WASH interventions: diarrhoea ‐ children < 5 years
6.1
6.1. Analysis
Comparison 6: Sub‐analysis: Sanitation coverage, Outcome 1: Coverage < 75%: diarrhoea ‐ all ages
6.2
6.2. Analysis
Comparison 6: Sub‐analysis: Sanitation coverage, Outcome 2: Coverage < 75%: diarrhoea ‐ children < 5 years
6.3
6.3. Analysis
Comparison 6: Sub‐analysis: Sanitation coverage, Outcome 3: Coverage 75% or higher: diarrhoea ‐ all ages
6.4
6.4. Analysis
Comparison 6: Sub‐analysis: Sanitation coverage, Outcome 4: Coverage 75% or higher: diarrhoea ‐ children < 5 years
7.1
7.1. Analysis
Comparison 7: Sub‐analysis: Increase in coverage, Outcome 1: Coverage increase < 50%: diarrhoea ‐ all ages
7.2
7.2. Analysis
Comparison 7: Sub‐analysis: Increase in coverage, Outcome 2: Coverage increase < 50%: diarrhoea ‐ children < 5 years
7.3
7.3. Analysis
Comparison 7: Sub‐analysis: Increase in coverage, Outcome 3: Coverage increase 50% or more: diarrhoea ‐ all ages
7.4
7.4. Analysis
Comparison 7: Sub‐analysis: Increase in coverage, Outcome 4: Coverage increase 50% or more: diarrhoea ‐ children < 5 years
8.1
8.1. Analysis
Comparison 8: Sub‐analysis: Length of follow‐up, Outcome 1: 1 year or less: diarrhoea ‐ all ages
8.2
8.2. Analysis
Comparison 8: Sub‐analysis: Length of follow‐up, Outcome 2: 1 year or less: diarrhoea ‐ children < 5 years
8.3
8.3. Analysis
Comparison 8: Sub‐analysis: Length of follow‐up, Outcome 3: > 1 year to 2 years: diarrhoea ‐ all ages
8.4
8.4. Analysis
Comparison 8: Sub‐analysis: Length of follow‐up, Outcome 4: > 1 year to 2 years: diarrhoea ‐ children < 5 years
8.5
8.5. Analysis
Comparison 8: Sub‐analysis: Length of follow‐up, Outcome 5: 3 years or more: diarrhoea ‐ all ages
8.6
8.6. Analysis
Comparison 8: Sub‐analysis: Length of follow‐up, Outcome 6: 3 years or more: diarrhoea ‐ children < 5 years
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Cha 2017 {published data only}
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