Abstract
Access to safe water and basic sanitation and hygiene facilities (WASH) are important for childhood health globally. However, inequalities in WASH access persist, and local governments need to better understand the potential impact of scaling up WASH services on childhood health. Using 2011 Peru Demographic and Health Survey data as a case study, we applied a modified substitution estimator approach to assess the impact of scaling up access (20-100%) to WASH on diarrhea prevalence among children < 5 years. The modified substitution estimator approach can help identify population subgroups or areas where WASH interventions and sustained implementation could be most beneficial and reduce existing disparities. Using findings from a recent meta-analysis and computing bootstrapped estimates and 95% CIs, we examined inequalities in the effect of WASH on self-reported diarrhea by urbanicity, maternal education level, household wealth, and district of residence. Increasing access (100% change) to improved water sources, sanitation, and hygiene facilities reduced population-level prevalence of childhood diarrhea by 8.2% (95% CI: 4.1, 12.3), 5.5% (95% CI: 0.7, 9.8), and 5.2% (95% CI: 2.2, 8.1), respectively. In stratified analyses, increased access to improved water sources and hygiene facilities was associated with decreased prevalence of diarrhea, with the largest reduction in rural areas and households with lower maternal education and lower wealth. Our findings suggest targeted WASH implementation in Peru is needed in rural areas and among lower socioeconomic-status households. In addition, even low levels of change in overall WASH access may decrease diarrhea prevalence.