Assessing the Impact of Community-Led Sanitation Programs on Diarrheal Disease Incidence in Rural Punjab
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Background: Childhood diarrhea remains associated with inadequate sanitation, unsafe feces disposal, and poor hygiene in rural Pakistan. Objective: To compare diarrheal incidence and related clinical outcomes among children younger than five years living in rural communities with and without active community-led sanitation programming. Methods: A longitudinal community-based cohort study enrolled 620 households, including 312 in sanitation-program communities and 308 in comparison communities. Baseline child, household, water, sanitation, and hygiene characteristics were recorded, and diarrheal episodes and healthcare outcomes were assessed during follow-up. Incidence was expressed per 100 child-months, and crude group comparisons were calculated from reported data. Results: Seventy-nine diarrheal episodes were recorded in sanitation-program communities and 141 in comparison communities. Reported incidence rates were 2.1 and 3.8 episodes per 100 child-months, respectively, corresponding to an approximate crude incidence-rate ratio of 0.55. Recurrent diarrhea occurred in 5.4% versus 12.7% of children, hospital visits in 7.1% versus 13.3%, intravenous fluid requirements in 3.5% versus 7.8%, and hospital admissions in 2.6% versus 5.5%. Conclusion: Community sanitation-program exposure was associated with lower recorded diarrheal incidence and reduced diarrhea-related healthcare utilization. The observational design and incomplete adjusted analysis precluded causal inference
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1. Wolf J, Hubbard S, Brauer M, et al. Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: a systematic review and meta-analysis. Lancet. 2022. doi:10.1016/S0140-6736(22)00937-0.
2. Fewtrell L, Kaufmann RB, Kay D, Enanoria W, Haller L, Colford JM Jr. Water, sanitation, and hygiene interventions to reduce diarrhoea in less developed countries: a systematic review and meta-analysis. Lancet Infect Dis. 2005;5(1):42–52. doi:10.1016/S1473-3099(04)01253-8.
3. Cairncross S, Hunt C, Boisson S, Bostoen K, Curtis V, Fung ICH, Schmidt WP. Water, sanitation and hygiene for the prevention of diarrhoea. Int J Epidemiol. 2010;39 Suppl 1:i193–i205. doi:10.1093/ije/dyq035.
4. Checkley W, Buckley G, Gilman RH, Assis AMO, Guerrant RL, Morris SS, et al. Multi-country analysis of the effects of diarrhoea on childhood stunting. Int J Epidemiol. 2008;37(4):816–830. doi:10.1093/ije/dyn099.
5. Ali M, Abbas F, Shah AA. Factors associated with prevalence of diarrhea among children under five years of age in Pakistan. Child Youth Serv Rev. 2021. doi:10.1016/j.childyouth.2021.106303.
6. Jabeen S, Saha UR, van Wesenbeeck CFA, Mushtaq K. An overview of diarrhea among infants and under-five in Punjab-Pakistan. J Pediatr Nurs. 2023;71:e28–e37. doi:10.1016/j.pedn.2023.04.011.
7. Sadiq K, Mir F, Jiwani U, Chanar S, Nathwani A, Jawwad M, et al. Risk factors for acute diarrhoea in children between 0 and 23 months of age in a peri-urban district of Pakistan: a matched case-control study. Int Health. 2023;15(3):281–288. doi:10.1093/inthealth/ihac022.
8. Qamar K, Nchasi G, Mirha HT, Siddiqui JA, Jahangir K, Shaeen SK, et al. Water sanitation problem in Pakistan: a review on disease prevalence, strategies for treatment and prevention. Ann Med Surg. 2022;82:104709. doi:10.1016/j.amsu.2022.104709.
9. Harter M, Mosch S, Mosler HJ. How does community-led total sanitation affect latrine ownership? A quantitative case study from Mozambique. BMC Public Health. 2018;18:387. doi:10.1186/s12889-018-5287-y.
10. Bushen G, Merga H, Tessema F. Effects of community-led total sanitation and hygiene implementation on diarrheal diseases prevention in children less than five years of age in South Western Ethiopia: a quasi-experimental study. PLoS One. 2022;17(4):e0265804. doi:10.1371/journal.pone.0265804.
11. Quattrochi JP, Coville A, Mvukiyehe E, et al. Effects of a community-driven water, sanitation and hygiene intervention on water and sanitation infrastructure, access, behaviour, and governance: a cluster-randomised controlled trial in rural Democratic Republic of Congo. BMJ Glob Health. 2021;6:e005030. doi:10.1136/bmjgh-2021-005030.
12. Pickering AJ, Djebbari H, Lopez C, Coulibaly M, Alzua ML. Effect of a community-led sanitation intervention on child diarrhoea and child growth in rural Mali: a cluster-randomised controlled trial. Lancet Glob Health. 2015;3(11):e701–e711. doi:10.1016/S2214-109X(15)00144-8.
13. Pickering AJ, Null C, Winch PJ, et al. The WASH Benefits and SHINE trials: interpretation of WASH intervention effects on linear growth and diarrhoea. Lancet Glob Health. 2019;7(8):e1139–e1146. doi:10.1016/S2214-109X(19)30268-2.
14. Black RE, Fischer Walker C. Do water, sanitation, and hygiene interventions prevent childhood diarrhea? J Infect Dis. 2020;221(8):1241–1243. doi:10.1093/infdis/jiz183.
15. Luby SP, Agboatwalla M, Painter J, Altaf A, Billhimer WL, Hoekstra RM. Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial. JAMA. 2004;291(21):2547–2554. doi:10.1001/jama.291.21.2547.
16. Luby SP, Agboatwalla M, Feikin DR, Painter J, Billhimer W, Altaf A, Hoekstra RM. Effect of handwashing on child health: a randomised controlled trial. Lancet. 2005;366(9481):225–233. doi:10.1016/S0140-6736(05)66912-7.
17. Luby SP, Agboatwalla M, Painter J, Altaf A, Billhimer W, Keswick B, Hoekstra RM. Combining drinking water treatment and hand washing for diarrhoea prevention: a cluster randomised controlled trial. Trop Med Int Health. 2006;11(4):479–489. doi:10.1111/j.1365-3156.2006.01592.x.
18. Das JK, Siddiqui F, Padhani ZA, Khan MH, Jabeen S, Mirani M, et al. Health behaviors and care seeking practices for childhood diarrhea and pneumonia in a rural district of Pakistan: a qualitative study. PLoS One. 2023;18(5):e0285868. doi:10.1371/journal.pone.0285868.
19. Qureshi S, Resham S, Hashmi M, Naveed AB, Haq Z, Ali SA. A retrospective review on antibiotic use in acute watery diarrhea in children in a tertiary care hospital of Karachi, Pakistan. PLoS One. 2021;16(7):e0253712. doi:10.1371/journal.pone.0253712.
20. Ijaz B, Iqbal K, Khursheed M, Zatoon G, Safdar A, Ghafoor M. Impact of socio-demographic factors in under-five children with acute diarrhea in tertiary care hospital. Ann Punjab Med Coll. 2024;18(4):284–288. doi:10.29054/apmc/2024.1515.
21. Gebremariam B, Hagos G, Abay M. Assessment of community led total sanitation and hygiene approach on improvement of latrine utilization in Laelay Maichew District, North Ethiopia: a comparative cross-sectional study. PLoS One. 2018;13(9):e0203458. doi:10.1371/journal.pone.0203458.
22. Crocker J, Saywell D, Bartram J. Sustainability of community-led total sanitation outcomes: evidence from Ethiopia and Ghana. Int J Hyg Environ Health. 2017;220(3):551–557. doi:10.1016/j.ijheh.2017.02.011.
23. Rogawski McQuade ET, Platts-Mills JA, Gratz J, et al. Impact of water quality, sanitation, handwashing, and nutritional interventions on enteric infections in rural Zimbabwe: the Sanitation Hygiene Infant Nutrition Efficacy trial. J Infect Dis. 2020;221(8):1379–1386. doi:10.1093/infdis/jiz179.
24. Luby SP, Agboatwalla M, Raza A, Sobel J, Mintz ED, Baier K, et al. Microbiologic effectiveness of hand washing with soap in an urban squatter settlement, Karachi, Pakistan. Epidemiol Infect. 2001;127(2):237–244. doi:10.1017/S0950268801005829.
25. Fatima M, Ünsal Ö. Geospatial analysis of diarrhoea determinants among children under five in Pakistan using multiscale geographically weighted regression. Appl Geogr. 2024;172:103434. doi:10.1016/j.apgeog.2024.103434.
26. Mulatu G, Ayana GM, Girma H, Mulugeta Y, Daraje G, Geremew A, et al. Association of drinking water and environmental sanitation with diarrhea among under-five children: evidence from Kersa demographic and health surveillance site, eastern Ethiopia. Front Public Health. 2022;10:962108. doi:10.3389/fpubh.2022.962108.
27. Cha S, Lee JE, Seo DS, Park BM, Mansiangi P, Hwang J, Lee J. Associations between household latrines and the prevalence of diarrhea in Idiofa, Democratic Republic of the Congo: a cross-sectional study. Am J Trop Med Hyg. 2017;97(2):460–468. doi:10.4269/ajtmh.16-0361.
28. Alebel A, Tesema C, Temesgen B, Gebrie A, Petrucka P, Kibret GD. Prevalence and determinants of diarrhea among under-five children in Ethiopia: a systematic review and meta-analysis. PLoS One. 2018;13(6):e0199684. doi:10.1371/journal.pone.0199684.
29. Zil-e-Huma, Tareen AM, Ullah K, Asmat TM, Samad A, Iqbal A, et al. Incidence of diarrheagenic Escherichia coli pathotypes in children suffering from diarrhea in tertiary care hospitals, Quetta, Pakistan. Pak J Zool. 2019;51(6):2015–2021. doi:10.17582/journal.pjz/2019.51.6.2015.2021.
30. Quattrochi JP, et al. Effects of a community-driven water, sanitation, and hygiene intervention on diarrhea, child growth, and local institutions: a cluster-randomized controlled trial in rural Democratic Republic of Congo. PLoS Med. 2025;22(3):e1004524. doi:10.1371/journal.pmed.1004524.