How were results measured?

Several indicators were used to measure results for the MapSan trial.

Primary outcome

The primary outcome of the study focused on the prevalence of enteric infections in children. This refers to how common stomach-related infections were among children, which can cause symptoms like diarrhoea, vomiting, or stomach pain. Researchers measured these infections using stool-based molecular methods, which involve analysing stool samples to detect the presence of harmful bacteria, viruses, or parasites that affect the digestive system.

Secondary outcomes

Secondary outcomes are additional measures that help provide a broader picture of the impact. These included:

1. Soil-transmitted helminth (STH) infections: these are infections caused by worms that live in the intestines, often spread through contaminated soil. To measure this, the researchers used the Kato-Katz technique, a method where stool samples are checked under a microscope to identify signs of intestinal worms.
2. Caregiver-reported diarrhoea in children: this refers to instances where parents or guardians reported their child experiencing diarrhoea, which is an important indicator of poor sanitation and hygiene.

Other indicators included

In addition to the health outcomes, the study also looked at other factors that could influence the success of the intervention:

1. Implementation fidelity: this refers to how well the intervention was carried out. It looks at whether the programme reached the right people and if they received all the planned support and services.
2. Participant response: this measures how the people involved in the study felt about the intervention, including their level of satisfaction and any feedback they provided.
3. Latrine-specific measures: these indicators focus on the condition of the toilets, such as how clean they were, how easy they were to access, and whether they provided privacy. Proper sanitation facilities are key to preventing infections, so these measures helped assess the overall effectiveness of the intervention.

The data collection process included the following key-elements:

Surveys

Surveys were conducted using mWater software to address aspects of the intervention implementation, participant behaviours and demographic characteristics. There were multiple respondents; caregivers of the children enrolled in the trial, an additional adult not enrolled in the trial and compound leaders. Caregiver surveys were used to determine if a child had diarrheal disease, defined as three or more loose or watery stools in a 24 hour period or any bloody stool.

Household visits

After study compounds were located, the households of the participating child were visited twice. On the first day, child anthropometry was measured, environmental samples collected and stool samples from the child were requested. On the second day, the stool samples were collected and a complete environmental swoop was done. De-worming was also offered.

Environmental sampling

Environmental compartments from intervention and control compounds were sampled to assess the compound-and household-level exposures. At each compound latrine, scientists collected flies, air samples, faecal sludge and any animal faeces. Swabs of the flooring, flies in the cooking area, prepared child’s food, stored drinking water, and water from the primary source were collected from a randomly selected household with enrolled children. Samples from public areas were also collected to monitor community pathogen circulation.

Biological sampling

Stool-based molecular detection was used to identify 27 pathogens commonly found in childhood infections globally.

Anthropometry

Child weight and recumbent length (for children under 24 months) or standing height (for children ages 24-60 months) were measured following WHO protocols. These measurements were transformed into age-adjusted 2-scores using WHO reference populations. Scores included: Height-for-age (HAZ), Weight-for-age (WAZ), Weight-for-height (WHZ).