Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection and malnutrition in India

Publication Details

Clasen, T, Boisson, S, Routray, P, Torondel, B, Bell, M, Cumming, O, Ensink, J, Freeman, M, Jenkins, M, Odagiri, M, Ray, S, Sinha, A, Suar, M, Schmidt, W, 2016. Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection and child malnutrition in India, 3ie Impact Evaluation Report 38. New Delhi: International Initiative for Impact Evaluation (3ie).

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Thomas Clasen, Sophie Boisson, Parimita Routray, Belen Torondel, Melissa Bell, Oliver Cumming, Jeroen Ensink, Matthew Freeman, Marion Jenkins, Mitsunori Odagiri, Subhajyoti Ray, Antara Sinha, Mrutyunjay Suar, Wolf-Peter Schm
Institutional affiliations
None specified
Grant-holding institution
None specified
South Asia
Health Nutrition and Population, Water and Sanitation
Rural Water and Sanitation
Gender analysis
Rural Water and Sanitation
Gender analysis
Equity Focus
None specified
Evaluation design
Randomised Control Trials (RCT)
3ie Series Report
3ie Funding Window
Open Window Round 2


This study assesses the effectiveness of basic sanitation programme to reduce diarrhoeal disease, improve nutritional status and lower the prevalence and intensity of worm infection in India.


Diarrhoeal diseases cause an estimated 1.8 million deaths per year and are responsible for 17 per cent of all deaths in children under 5 years in developing countries (WHO, 2008). Repeated episodes of diarrhoea and chronic infection in early childhood impair physical development and cognitive function, which in turn affects school attendance and performance. The study evaluates an intervention that involves mobilizing households in villages characterized by high levels of open defecation to build and use latrines in accordance with the Government of India’s Total Sanitation Campaign (Pattanayak, 2009). The study therefore seeks to answer an important policy question of whether such sanitation programmes work in this context.

Website : http://www.wateraid.org/india/

Research questions

The main research question for the study was to assess the effectiveness of a rural household sanitation intervention to prevent diarrhoea, soil-transmitted helminth infection, and child malnutrition. The primary outcomes of the study included 7-day prevalence of reported diarrhoea in children younger than 5 years and the secondary binary health outcomes (all age diarrhoea prevalence, helminths). Secondary health outcomes included Health of age z scores (HAZ) and weight for age Z scores (WAZ) were used. Geographic data were used to support a range of exploratory analyses accounting for actual latrine uptake, by geo referencing and mapping.


Intervention design

Implementation of the intervention was led by Wateraid India, a national affiliate of the UK-based NGO widely recognised for its work in water, sanitation and hygiene (wateraid.org) in collaboration with local NGOs. Implementation followed the government of India’s Total Sanitation Campaign (TSC). The TSC, recently expanded and renamed as Nirmal Bharat Abhiyan (NBA), was set up in 1999 to promote toilet construction and use in rural areas. The TSC programme provided subsidies for latrine construction to households who fall below the poverty line (BPL); it also uses community mobilisation and information, education and communication (IEC) activities to create demand and encourage latrine use. The intervention implemented in this study consisted of community mobilisation for acquisition and use of latrines over a 24-month surveillance period.

This study used a cluster-randomised controlled trial design which was conducted between May 20, 2010, and Dec 22, 2013, in 100 rural villages in Odisha, India. Households within villages were eligible if they had a child younger than 4 years or a pregnant woman. Villages were randomly assigned (1:1), with a computer-generated sequence, to undergo latrine promotion and construction or to receive no intervention (control). Randomisation was stratified by administrative block to ensure an equal number of intervention and control villages in each block. Masking of participants was not possible because of the nature of the intervention. However, households were not told explicitly that the purpose of enrolment was to study the effect of a trial intervention, and the surveillance team was different from the intervention team. The primary endpoint was 7-day prevalence of reported diarrhoea in children younger than 5 years. We did intention-to-treat and per-protocol analyses. This trial is registered with ClinicalTrials.gov, number NCT01214785.

Main findings

The study randomly assigned 50 villages to the intervention group and 50 villages to the control group. There were 4586 households (24 969 individuals) in intervention villages and 4894 households (25 982 individuals) in control villages. The intervention increased mean village-level latrine coverage from 9% of households to 63%, compared with an increase from 8% to 12% in control villages. Health surveillance data were obtained from 1437 households with children younger than 5 years in the intervention group (1919 children younger than 5 years), and from 1465 households (1916 children younger than 5 years) in the control group. 7-day prevalence of reported diarrhoea in children younger than 5 years was 8·8% in the intervention group and 9·1% in the control group (period prevalence ratio 0·97, 95% CI 0·83–1·12). 162 participants died in the intervention group (11 children younger than 5 years) and 151 died in the control group (13 children younger than 5 years).

Implications for policy and practice

Increased latrine coverage is generally believed to be effective for reducing exposure to faecal pathogens and preventing disease; however, our results show that this outcome cannot be assumed. As efforts to improve sanitation are being undertaken worldwide, approaches should not only meet international coverage targets, but should also be implemented in a way that achieves uptake, reduces exposure, and delivers genuine health gains.

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