title: Exploring changes in open defecation prevalence in sub-Saharan Africa based on national level indices.
abstract: BACKGROUND
  In sub-Saharan Africa, it is estimated that 215 million people continue to engage in open defecation. This practice facilitates the transmission of diarrheal diseases - one of the leading causes of mortality in children under 5 in sub-Saharan Africa. The main purpose of this study is to: estimate changes in open defecation prevalence between 2005 and 2010 across countries in sub-Saharan Africa; examine the association between national level indices and changes in open defecation prevalence; and assess how many countries can achieve 'open defecation free status' by 2015.
  
  
  METHODS
  After applying selection criteria, this study analyzed country-level data for 34 sub-Saharan African countries. Seven country-level indices were collected: 1) presence of a national sanitation policy; 2) budget line for sanitation; 3) budget allocated to sanitation; 4) annual per capita GDP; 5) GDP growth; 6) implementation of total sanitation approaches; and 7) per capita aid disbursement for water supply and sanitation. The relationships between these country-level indices and the change in open defecation from 2005 to 2010 were investigated using Wilcoxon Signed-Rank test and Spearman's rank correlation test.
  
  
  RESULTS
  Only 3 countries (i.e. Ethiopia, Angola and Sao Tome and Principe) decreased open defecation by 10% or more between 2005 and 2010. No significant associations were observed between the change in open defecation prevalence and all of national level indices except per capita aid disbursement. Per capita aid disbursement for water and sanitation was positively associated with a reduction in open defecation (p-value = 0.02) for a subset of 29 low-income countries from 2005 to 2010. Only one country in our analysis, Angola, is on track to end open defecation by 2015 based on their performance between 2000 and 2010.
  
  
  CONCLUSIONS
  Most of the national level indices, including a country's economic status, were not associated with the change in the open defecation prevalence. Based on current trends, the goal of ending open defecation in the majority of sub-Saharan African countries by 2015 will not be achieved. Our findings may be limited by the exploratory nature of this analysis, and future research is required to identify and characterize national level factors specific to reducing open defecation in sub-Saharan Africa.
authors.affiliation: Department of Environmental and Occupational Health, School of Public Health and Health Services, The George Washington University, 2100 M St, NW, Suite 203M, Washington, DC 20037, USA.
authors.forename: Deise I
authors.initials: DI
authors.lastname: Galan
authors.forename: Seung-Sup
authors.initials: SS
authors.lastname: Kim
authors.forename: Jay P
authors.initials: JP
authors.lastname: Graham
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D017281:Cost of Illness; D003672:Defecation; D003967:Diarrhea / Q000209:etiology; D004784:Environmental Monitoring; D005260:Female; D014943:Global Health / Q000592:standards; D006291:Health Policy; D006801:Humans; D008297:Male; D015995:Prevalence; D012499:Sanitation / Q000191:economics / Q000379:methods / Q000592:standards*; D014871:Water Microbiology; D014881:Water Supply / Q000191:economics / Q000592:standards*