The Effect of India's Total Sanitation Campaign on Defecation Behaviors and Child Health in Rural Madhya Pradesh: A Cluster Randomized Controlled Trial
Open accessAbstract
BACKGROUND: Poor sanitation is thought to be a major cause of enteric infections among young children. However, there are no previously published randomized trials to measure the health impacts of large-scale sanitation programs. India's Total Sanitation Campaign (TSC) is one such program that seeks to end the practice of open defecation by changing social norms and behaviors, and providing technical support and financial subsidies. The objective of this study was to measure the effect of the TSC implemented with capacity building support from the World Bank's Water and Sanitation Program in Madhya Pradesh on availability of individual household latrines (IHLs), defecation behaviors, and child health (diarrhea, highly credible gastrointestinal illness [HCGI], parasitic infections, anemia, growth). METHODS AND FINDINGS: We conducted a cluster-randomized, controlled trial in 80 rural villages. Field staff collected baseline measures of sanitation conditions, behaviors, and child health (May-July 2009), and revisited households 21 months later (February-April 2011) after the program was delivered. The study enrolled a random sample of 5,209 children <5 years old from 3,039 households that had at least one child <24 months at the beginning of the study. A random subsample of 1,150 children <24 months at enrollment were tested for soil transmitted helminth and protozoan infections in stool. The randomization successfully balanced intervention and control groups, and we estimated differences between groups in an intention to treat analysis. The intervention increased percentage of households in a village with improved sanitation facilities as defined by the WHO/UNICEF Joint Monitoring Programme by an average of 19% (95% CI for difference: 12%-26%; group means: 22% control versus 41% intervention), decreased open defecation among adults by an average of 10% (95% CI for difference: 4%-15%; group means: 73% intervention versus 84% control). However, the intervention did not improve child health measured in terms of multiple health outcomes (diarrhea, HCGI, helminth infections, anemia, growth). Limitations of the study included a relatively short follow-up period following implementation, evidence for contamination in ten of the 40 control villages, and bias possible in self-reported outcomes for diarrhea, HCGI, and open defecation behaviors. CONCLUSIONS: The intervention led to modest increases in availability of IHLs and even more modest reductions in open defecation. These improvements were insufficient to improve child health outcomes (diarrhea, HCGI, parasite infection, anemia, growth). The results underscore the difficulty of achieving adequately large improvements in sanitation levels to deliver expected health benefits within large-scale rural sanitation programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT01465204. Please see later in the article for the Editors' Summary.
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“Further, there is considerable variation in the estimated effects of sanitation on health (Cameron et al 2022), with studies finding no (Patil et al 2014, Brice ˜ no et al 2017, Cameron et al 2021b) and positive (Dickinson et al 2015, Hammer and Spears 2016, Augsburg and Rodríguez-Lesmes 2018)…”
- Authors
- Patil, S. R., Arnold, B. F., Salvatore, A. L., Briceno, B., Ganguly, S., Colford, J. M., & Gertler, P. J.
- Affiliations
- University of California, Berkeley (US)
- Stanford Medicine (US)
- National Institute of Cholera and Enteric Diseases (IN)
- Corresponding author
- Patil, Sumeet R.
- ORCID
- Venue
- PLoS Medicine
- Publisher
- Public Library of Science (PLoS)
- Published
- 2014-08-26
- Volume
- 11
- Issue
- 8
- Pages
- e1001709
- ISSN
- 1549-1277 (ISSN-L)
- 1549-1676
- PMC
- PMC4144850
- OpenAlex
- W1980524096
- Cited by
- 487
- References
- 5
- Citations by year
- 2026: 8 · 2025: 22 · 2024: 29 · 2023: 28 · 2022: 50 · 2021: 44 · 2020: 68 · 2019: 63 · 2018: 43 · 2017: 54 · 2016: 38 · 2015: 30 · 2014: 9 · 2013: 1
- FWCI
- 40.67
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- cc-by
- Locations
- PLoS Medicine (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- eScholarship (California Digital Library) (submittedVersion)
- Figshare (submittedVersion, cc-by)
- Funders
- Bill and Melinda Gates Foundation
- World Bank Group
- Topics
- Health Sciences › Nursing › Nutrition and Dietetics › Child Nutrition and Water Access
- Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Global Maternal and Child Health
- Social Sciences › Safety Research › Poverty, Education, and Child Welfare
- Keywords
- Total Sanitation Campaign, open defecation, household latrines, sanitation programs, childhood diarrhea, soil-transmitted helminths, protozoan infection, anemia, child growth, child health, social norms, Water and Sanitation Program, sanitation subsidies, capacity building, gastrointestinal infections, program evaluation
- MeSH terms
- Anemia, Child Welfare, Child, Preschool, Defecation, Diarrhea, Female, Gastrointestinal Diseases, Growth, Humans, India, Infant, Infant Welfare, Male, Parasitic Diseases, Public Health, Rural Population, Sanitation, Toilet Facilities, Cluster Analysis
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