Water and Sanitation Access for Children in Alabama Free

We conducted this study in the Lowndes, Wilcox, and Perry counties located in the Alabama Black Belt. Data from the 2020 US Census³⁰  and County Health Rankings and Road Maps³¹  indicate that these counties are rural, sparsely populated (mean population 9500), predominantly African American (70%), and have high rates of children living in poverty (mean 37%). Many (mean 15%) reside in households with at least 1 of 4 housing problems: overcrowding, high housing costs, lack of kitchen facilities, or lack of plumbing facilities according to data from 2015 to 2019,³¹  as well as face access challenges to healthcare (mean number of persons per primary care physicians 5387:1).^30 ,31  These 3 counties were chosen as the study setting because of the 2017 publication suggesting endemic hookworm infection in Lowndes county,²⁷  a household survey conducted in 2017 documenting high rates of inadequate household sanitation in Wilcox county,²⁶  and the highly publicized failures of the sewer treatment facility in Uniontown in Perry County.^32 ,33 

Community based participatory research methodology formed the foundation of this project.

Community based participatory research is characterized by collaboration among community members, researchers, and community organizations to achieve health equity through social action. Our target communities and research questions were informed by pre-existing community relationships and prior work conducted. Several local community organizations in these counties had identified issues with safe water and adequate sanitation as a major local concern. We conducted several focus groups, first with members of local nonprofits and then with community members. These focus groups were listening sessions to orient the research team to the community, the primary concerns of the community, and the language and approaches needed for effective engagement. We designed the informed consent document and the survey instrument (Supplemental Fig 2) with input from these focus groups. We hired a program coordinator and team members from the 3 counties to recruit and enroll participants. The primary aim of the survey instrument was to identify risk factors for STH infections. These infections require fecal contamination of the surrounding soil as well as behaviors that result in contact with contaminated soil. The survey instrument included questions regarding the household sanitation type, reports of sewage contamination in and around the home, and whether a water bill was paid. We limited the number of questions asked and attempted to phrase questions to mitigate distrust and encourage participation.

Recruitment included several strategies. The predominant method was through word-of-mouth through existing social networks. We identified key community leaders that we believed had access to the most vulnerable residents that we were attempting to engage with. Additionally, we distributed flyers throughout the counties and placed advertisements in local newspapers, social media, and the radio. Households with children between the ages of 2 and 18 years of age who had resided in 1 of the 3 counties were eligible for enrollment. Initially, participants were invited to enrollment events hosted at various community locations, such as after-school centers and church halls. The research team members met with the participants and explained the purpose of the study. After obtaining written informed consent from guardians and assent of children aged 7 years and older, the guardians were asked to complete a short survey on paper. After social distancing requirements with the coronavirus disease 2019 pandemic, outdoor enrollment events were hosted where study packets were distributed to interested participants, who were then asked to mail back the signed consent forms and completed surveys in self-addressed postage-paid mailers.

A regional federally qualified health center was approached to participate in the program. This organization operates 7 community health centers in 5 contiguous county regions, including Wilcox and Perry counties. A 10 question survey was distributed to be completed by providers at each clinic location using Survey Monkey. Questions included practice location, patient populations served, services offered, awareness of “straight-piping,” perception of health risk related to sewage exposure, and practice around testing and treatment of gastrointestinal infection. (Supplemental Fig 3).

An online course on sanitation and health was offered to local health providers through direct e-mail invitations and via the Health Alert Network from the Alabama Department of Public Health. (https://www.alabamapublichealth.gov/bcd/2022-han.html) Data were gathered from a precourse quiz of 5 questions related to intestinal parasitic diseases to assess baseline provider knowledge.

Data were logged in from case report forms into REDCap (https://www.project-redcap.org) and were analyzed using SAS 9.4.

Geospatial maps were created using geographic information system GIS software (Esri ArcPro 2.8). Participant residential address locations with attributes related to well water and sanitation types were geocoded using ArcPro and Esri StreetMap Premium. Maps were cartographically designed to maintain participant privacy using heat maps to display a general distribution rather than exact locations. Responses from provider surveys and the pretest knowledge checks of the online education course were gathered and summarized.

This study was approved by the Institutional Review Board of the University of Alabama at Birmingham (IRB No. 300002219), Georgia Institute of Technology (H19021), and the University of North Carolina Chapel Hill (20-3212), and was reviewed by the Centers for Disease Control and Prevention, which provided funding for the work and conducted consistent with applicable federal laws and policies.

This study was funded by the Center for Disease Control and Prevention.

A total of 771 surveys were completed by eligible participants from 442 unique households between December 12, 2019 and August 10, 2022. The demographic characteristics of the enrolled children are shown in Table 1. Based on the 2020 census data, the percentage of children enrolled by county was 5.7% of children in Lowndes County, 13% in Perry County, and 13.3% in Wilcox County. A disproportionate number of children identified as African-American (over 90%), whereas according to 2020 US Census data, African-Americans accounted for 70% of the population in these counties. This likely reflects the racial disparity of households in poverty in these counties.

The summary statistics of responses from unique children enrolled regarding household sanitation type, sewage contamination, water bill payment, and outdoor exposure are presented in Table 2.

The type of household sanitation reported varied by county, with Perry County having the highest percentage reporting a sewer connection at 48%, whereas septic tanks were the most common type in Lowndes and Wilcox counties at 57% and 49%, respectively. The higher percentage of homes connected to sewers in Perry County was because of the recruitment of households from Uniontown, one of the main towns in Perry County, served by a conventional wastewater treatment facility with long-standing documented failures. Respondents in all 3 counties reported the practice of “straight piping,” or direct discharge of domestic wastewater to the surface: 9% in Lowndes, 7% in Perry, and 18% in Wilcox counties. Indicating not knowing the type of sanitation was relatively common between 13% and 20%. Well water use was also relatively common, at between 11% and 16%. A total of 57 children surveyed lived in homes where respondents reported that raw sewage contaminated their property (either in the house, or the yard) in the preceding year.

The distribution of homes by sanitation type demonstrates residents resorting to “straight pipes” within the geographic limits of mainline sewer connections, and certainly the practice appears widespread throughout the county. (Fig 1)

Of the healthcare providers in the surveyed region, we received responses from 6 of the 7 practices. When asked to indicate provider-type that work within their respective clinics, 60% reported physicians, 90% reported nurse practitioners, and 55% reported nurses. Regarding the type of care provided, 70% responded that they provided care for children, 90% for the elderly, and none of them provided prenatal care.

In terms of provider knowledge regarding types of household sewage disposal in the region, 6 of 11 reported public sewers, 6 of 11 reported private septic tanks, and 5 of 11 said they were unsure. Of note, not a single provider reported knowledge of the practice of “straight piping.”

When asked about the health impact of improper sewage disposal on patients’ health, 1 of 11 reported a minimal negative impact, 2 of 11 reported a negative impact, 2 of 11 indicated a strong negative impact, and 6 of 11 indicated that they were unsure of the impact. Only 5 of the 11 providers reported routinely screening patients for intestinal infections, with 5 reporting screening for acute gastroenteritis, 2 of 5 reported routinely screening for Giardia, 1 of 5 reported screening for ova and parasites, and none reported screening for cryptosporidium.

A total of 44 participants were enrolled in the online Sanitation Health course, completing a precourse quiz comprising 5 questions. The overall pass rate was 54%. Eighty-two percent correctly recognized poor health outcomes linked to inadequate household sewage disposal, 52% correctly identify STH, 27% correctly recognized strongyloidiasis as being endemic to the United States, 80% correctly identified albendazole as the treatment of choice for ascariasis, and 27% correctly identified fatigue as the most frequently experienced symptom associated with a human hookworm infection.

Despite widespread and longstanding failures of safe water and sanitation in Alabama’s Black Belt, we found a general lack of awareness among local health providers and insufficient knowledge of the diagnosis and treatment of sanitation-related infections, such as soil transmitted helminthiasis.

A growing body of literature has documented water and sanitation hardships that affect poor communities across the United States.^{9 ,10 ,13 ,14}  The manner in which this affects particular communities depends on the location. Water and sanitation hardships disproportionately burdens communities that are rural and poor, which are the same communities facing a myriad of other hardships, including access to healthcare and food insecurity. To address the profound health disparities affecting children in the United States, it is imperative that healthcare providers caring for children are aware of the living conditions of the children they serve and ask specifically about water and sanitation hardship, beyond questions of the ability to pay utility bills and potential lead exposure. None of the current commonly used SDOH screening tools used in the United States incorporate questions assessing access to safe drinking water or sanitation.³⁴ 

This cross-sectional study of household level data on water and sanitation access in 3 rural counties with high rates of poverty demonstrate that many children in these counties reside in homes with clear sanitation access challenges. A strength of this study was the community-engaged approach that resulted in high rates of participation and self-reporting of the practice of “straight-pipes,” an illegal practice that could incur penalties. We were also able to gather data from local health providers to assess local knowledge and practice related to water and sanitation challenges in the region.

This study had several limitations. The data analyzed for this study were obtained from surveys completed for each child enrolled and not by household. Although we attempted to clarify discrepant reports of sanitation type by household, misclassification may persist that would influence results. The data on sanitation type were based on self-reports, with a high percentage of respondents reporting an unknown type of sanitation. This weakens the accuracy of the data, as respondents may misclassify sanitation type by not knowing the differences or under-reporting certain types because of concerns of drawing attention to an illegal practice that may incur penalties. Children invited to participate were not randomly selected and our sampling method has selection bias that will influence our results. Our community partners specifically focused recruitment in communities where housing challenges, and/or water and wastewater access challenges were known to them. African-American children maybe over-represented in this sample because of selection bias, and the results would not be representative of the county as a whole. On our survey we asked whether households paid a water bill, using this as a proxy for obtaining water from a utility. We then attempted to ask respondents who reported not paying a water bill with a follow-up phone call to determine whether they had a private well. The indirect questioning was in an attempt to determine water usage in communities with high levels of distrust and potential stigma around lack of access to services. Our results on well-water use, therefore needs to be interpreted with caution, as we were not able to directly determine well-water consumption. These challenges have been specifically documented in Alabama and may not be generalizable to other parts of the United States.

Water and sanitation issues have been a growing concern in the United States, particularly among policy organizations, over the past 20 years. The Water Infrastructure Network published a report in 2004 citing a gap of $23 billion between available funding and needed water and sanitation infrastructure investments. It is unclear whether the 2022 Bipartisan Infrastructure Bill will have sufficient funds to bridge this gap, or whether investments will reach historically underfunded communities such as the Alabama Black Belt. The contamination of the Flint Michigan’s water supply leading to elevated blood lead levels in children illustrates the vulnerability of children to environmental hazards and how infrastructure funding decisions impact health.³⁵  Our study illustrates the widespread challenges of safe access to water and sanitation in a historically disadvantaged community in the Alabama Black Belt. Before our study, emphasis was placed on STH being the primary health outcome of concern linked to sanitation failures in the rural American Southeast, however this has not been found in recent studies.²⁸ ,^36 –38  Evaluating health outcomes in children facing sanitation access challenges in high income countries such as the United States is likely different than in low and middle income countries and warrants further research beyond prevalence of gastrointestinal infections.

We thank our community partners, including, BAMAKids Inc., West Central Alabama Community Health Improvement League, Sewing Seeds of Hope, John Paul Jones Hospital, Black Belt Unincorporated Wastewater Program, AmeriCorps Volunteers in Service to America, Sherri Bradley, Perman Hardy, Ethel Johnson, Janice Robinson, Jasmine S. Kennedy, Sheryl Threadgill-Mattews, and, Sally McGhee; and Sydney Poulson for database management; and Ariann Nassel for geocoding and map creation.

SDOH

social drivers of health

STH

soil transmitted helminth