Prediction of Low Community Sanitation Coverage Using Environmental and Sociodemographic Factors in Amhara Region, Ethiopia

William E. Oswald Department of Epidemiology, Emory University, Atlanta, Georgia.

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Aisha E. P. Stewart The Carter Center, Atlanta, Georgia.

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W. Dana Flanders Department of Epidemiology, Emory University, Atlanta, Georgia.

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Michael R. Kramer Department of Epidemiology, Emory University, Atlanta, Georgia.

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Tekola Endeshaw The Carter Center, Addis Ababa, Ethiopia.

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Mulat Zerihun The Carter Center, Addis Ababa, Ethiopia.

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Birhanu Melaku The Carter Center, Addis Ababa, Ethiopia.

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Eshetu Sata The Carter Center, Addis Ababa, Ethiopia.

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Demelash Gessesse The Carter Center, Addis Ababa, Ethiopia.

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Tesfaye Teferi The Carter Center, Addis Ababa, Ethiopia.
International Trachoma Initiative, Addis Ababa, Ethiopia.

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Zerihun Tadesse The Carter Center, Addis Ababa, Ethiopia.

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Birhan Guadie Amhara Regional Health Bureau, Bahir Dar, Ethiopia.

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Jonathan D. King The Carter Center, Atlanta, Georgia.
World Health Organization, Geneva, Switzerland.

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Paul M. Emerson The Carter Center, Atlanta, Georgia.
International Trachoma Initiative, Atlanta, Georgia.

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Elizabeth K. Callahan The Carter Center, Atlanta, Georgia.

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Christine L. Moe Hubert Department of Global Health, Center for Global Safe Water, Emory University, Atlanta, Georgia.

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Thomas F. Clasen Department of Environmental Health, Emory University, Atlanta, Georgia.

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This study developed and validated a model for predicting the probability that communities in Amhara Region, Ethiopia, have low sanitation coverage, based on environmental and sociodemographic conditions. Community sanitation coverage was measured between 2011 and 2014 through trachoma control program evaluation surveys. Information on environmental and sociodemographic conditions was obtained from available data sources and linked with community data using a geographic information system. Logistic regression was used to identify predictors of low community sanitation coverage (< 20% versus ≥ 20%). The selected model was geographically and temporally validated. Model-predicted probabilities of low community sanitation coverage were mapped. Among 1,502 communities, 344 (22.90%) had coverage below 20%. The selected model included measures for high topsoil gravel content, an indicator for low-lying land, population density, altitude, and rainfall and had reasonable predictive discrimination (area under the curve = 0.75, 95% confidence interval = 0.72, 0.78). Measures of soil stability were strongly associated with low community sanitation coverage, controlling for community wealth, and other factors. A model using available environmental and sociodemographic data predicted low community sanitation coverage for areas across Amhara Region with fair discrimination. This approach could assist sanitation programs and trachoma control programs, scaling up or in hyperendemic areas, to target vulnerable areas with additional activities or alternate technologies.

Author Notes

* Address correspondence to William E. Oswald, Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom. E-mail: william.oswald@lshtm.ac.uk

Financial support: William Oswald was supported by the Emory University Laney Graduate School, ARCS Foundation Atlanta, and the Global 2000 program of The Carter Center. This study was supported by the Lions-Carter Center Sight-First Initiative and was made possible by the generous support of the American people through the U.S. Agency for International Development (USAID) and the ENVISION project led by RTI International in partnership with The Carter Center.

Authors' addresses: William E. Oswald, W. Dana Flanders, and Michael R. Kramer, Department of Epidemiology, Emory University, Atlanta, GA, E-mails: william.oswald@lshtm.ac.uk, wflande@emory.edu, and mkram02@emory.edu. Aisha E. P. Stewart and Elizabeth K. Callahan, Trachoma Control Program, The Carter Center, Atlanta, GA, E-mails: aisha.stewart@cartercenter.org and kelly.callahan@cartercenter.org. Tekola Endeshaw, Mulat Zerihun, Birhanu Melaku, Eshetu Sata, Demelash Gessesse, and Zerihun Tadesse, Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia, E-mails: tekola.endeshaw@cartercenter.org, mulat.zerihun@cartercenter.org, birhanu.melaku@cartercenter.org, eshetu.sata@cartercenter.org, and zerihun.tadesse@cartercenter.org. Tesfaye Teferi, Trachoma Control Program, The Carter Center, Addis Ababa, Ethiopia, and International Trachoma Initiative, Addis Ababa, Ethiopia, E-mail: tteferi@taskforce.org. Birhan Guadie, Amhara Regional Health Bureau, Bahir Dar, Ethiopia, E-mail: guadiebirhan@yahoo.com. Jonathan D. King, Trachoma Control Program, The Carter Center, Atlanta, GA, and Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland, E-mail: king_jond@yahoo.com. Paul M. Emerson, International Trachoma Initiative, Atlanta, GA, and Trachoma Control Program, The Carter Center, Atlanta, GA, E-mail: pemerson@taskforce.org. Christine L. Moe, Hubert Department of Global Health, Center for Global Safe Water, Emory University, Atlanta, GA, E-mail: clmoe@emory.edu. Thomas F. Clasen, Department of Environmental Health, Emory University, Atlanta, GA, E-mail: thomas.f.clasen@emory.edu.

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