Effect of a Community-led Total Sanitation Intervention on the Incidence and Prevalence of Diarrhea in Children in Rural Ethiopia: A Cluster-randomized Controlled Trial

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  • 1 Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom;
  • 2 Department of Global Development and Entrepreneurship, Graduate School of Global Development and Entrepreneurship, Handong Global University, Pohang, South Korea;
  • 3 Good Neighbors International, Mozambique, Maputo, Mozambique;
  • 4 Independent Consultant, Addis Ababa, Ethiopia;
  • 5 Public Health Institute, Addis Ababa, Ethiopia;
  • 6 Korea International Cooperation Agency, Seongnam-si, South Korea

We conducted a cluster-randomized trial in 48 rural villages of Ethiopia to assess the effect of community-led total sanitation (CLTS) on the diarrhea incidence of children. Twenty-four villages were randomly assigned to the intervention group and the other 24 were assigned to the control group. A CLTS intervention was implemented from January 2016 through January 2017. Baseline data collection was conducted during October and November 2015. At baseline, 906 children were recruited and followed-up until January 2017. These 906 children were randomly selected among all children in the 48 villages. To determine the 7-day period prevalence of diarrhea, four household-based surveys were conducted by independent data collectors at 3, 5, 9, and 10 months after the CLTS was initiated. To determine the incidence and longitudinal prevalence, the presence of daily diarrhea presence was recorded for 140 days using diary methods. The loss to follow-up rates were 95% for period prevalence and 93% for incidence and longitudinal prevalence. The incidence ratio and longitudinal prevalence ratio were 0.66 (95% confidence interval [CI], 0.45–0.97; P = 0.03) and 0.70 (95% CI, 0.52–0.95; P = 0.02) after adjusting for clustering and stratification. The relative risk of period prevalence was 0.66 (95% CI, 0.45–0.98; P = 0.04) at 3 months after initiation. Improved toilet coverage increased from 0.0% at baseline to 35.0% at 10 months in the intervention villages, whereas it increased from 0.7% to 2.8% in the control villages. Adherence to the intervention was comparable with that of previous studies; therefore, we suggest that the findings of this study are replicable.

Author Notes

Address correspondence to Seungman Cha, Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, Keppel Street, Bloomsbury, London WC1E 7HT, United Kingdom. E-mail: seungman.cha@lshtm.ac.uk

Authors’ addresses: Seungman Cha and Wolf-Peter Schmidt, Department of Disease Control, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, United Kingdom, E-mails: seungman.cha@lshtm.ac.uk and wolf-peter.schmidt@lshtm.ac.uk. Seungman Cha, Department of Global Development and Entrepreneurship, Graduate School of Global Development and Entrepreneurship, Handong Global University, 558 Handong-ro Buk-gu, Pohang Gyeongbuk 37554 Republic of Korea, E-mail: seungman.cha@handong.edu. Sunghoon Jung, Good Neighbors International, Mozambique, Maputo, Mozambique, E-mail: hoonie12@gmail.com. Dawit Belew Bizuneh, Independent Consultant, Addis Ababa, Ethiopia, E-mail: belewbizuneh@gmail.com. Tadesse Abera, Public Health Institute, Addis Ababa, Ethiopia, E-mail: tade842@gmail.com. Young-Ah Doh and Jieun Seong, Korea International Cooperation Agency, 825 Daewangpangyo-ro, Sujeong-gu, Seongnam-si, Gyeonggi-do, Republic of Korea, E-mails: yadoh@koica.go.kr and sje0115@koica.go.kr.

Financial support: This study was supported by the Korea International Cooperation Agency (KOICA) under “the Integrated Water and Sanitation project in Gurage zone, SNNPR state, Ethiopia (P2013-00139-2)”. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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