International Journal of Public Health

, Volume 63, Issue 2, pp 241–250 | Cite as

Water system unreliability and diarrhea incidence among children in Guatemala

  • Jennifer Trudeau
  • Anna-Maria Aksan
  • William F. Vásquez
Original Article



This article examines the effect of water system unreliability on diarrhea incidence among children aged 0–5 in Guatemala.


We use secondary data from a nationally representative sample of 7579 children to estimate the effects of uninterrupted and interrupted water services on diarrhea incidence. The national scope of this study imposes some methodological challenges due to unobserved geographical heterogeneity. To address this issue, we estimate mixed-effects logit models that control for unobserved heterogeneity by estimating random effects of selected covariates that can vary across geographical areas (i.e. water system reliability).


Compared to children without access to piped water, children with uninterrupted water services have a lower probability of diarrhea incidence by approximately 33 percentage points. Conversely, there is no differential effect between children without access and those with at least one day of service interruptions in the previous month. Results also confirm negative effects of age, female gender, spanish language, and garbage disposal on diarrhea incidence.


Public health benefits of piped water are realized through uninterrupted provision of service, not merely access. Policy implications are discussed.


Guatemala Diarrheal incidence Morbidity Tap water Service interruptions 


Compliance with ethical standards

Conflict of interest

We certify that there is no external funding for this research nor does any participant benefit from the results of the study.

Research involving human participants and/or animals

Our research utilizes secondary data that was previously collected in Guatemala.

Informed consent

Our research utilizes secondary data and thus does not require informed consent.


  1. Adams RJ, Howard N, Tucker G, Appleton S, Taylor AW, Chittleborough C, Gill T, Ruffin RE, Wilson DH (2009) Effects of area deprivation on health risks and outcomes: a multilevel, cross-sectional, Australian population study. Int J Public Health 54:183–192CrossRefPubMedGoogle Scholar
  2. Aiello AE, Coulborn RM, Perez V, Larson EL (2008) Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis. Am J Public Health 98(8):1372–1381. CrossRefPubMedPubMedCentralGoogle Scholar
  3. Alexander KT, Tesfaye Y, Dreibelbis R, Abaire B, Freeman MC (2015) Governance and functionality of community water schemes in Rural Ethiopia. Int J Public Health 60:977–986. CrossRefPubMedGoogle Scholar
  4. Brocklehurst C, Slaymaker T (2015) Continuity in drinking water supply. PLoS Med 12(10):e1001894. CrossRefPubMedPubMedCentralGoogle Scholar
  5. Brown J, Hien VT, McMahan L, Jenkins MW, Thie L, Liang K, Printy E, Sobsey MD (2013) Relative benefits of on-plot water supply over other ‘improved’ sources in Rural Vietnam. Trop Med Int Health 18:65–74. CrossRefPubMedGoogle Scholar
  6. Cairncross S, Valdmanis V (2006) Water supply, sanitation, and hygiene promotion. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M (eds) Disease Control Priorities in Developing Countries, 2nd edn. The International Bank for Reconstruction and Development/The World Bank, Washington (DC). Chapter 41. Available from: by Oxford University Press, New York
  7. Case A, Fertig A, Paxson C (2005) The lasting impact of childhood health and circumstance. J Health Econ 24(2):365–389CrossRefPubMedGoogle Scholar
  8. Checkley W, Buckley G, Gilman RH, Assis AM, Guerrant RL, Morris SS, Molbak K, Valentiner-Branth P, Lanata CF, Black RE (2008) The childhood malnutrition and infection network. Multi-country analysis of the effects of diarrhoea on childhood stunting. Int J Epidemiol 37(4):816–830. CrossRefPubMedPubMedCentralGoogle Scholar
  9. deWilde CK, Milman A, Flores Y, Salmerón J, Ray I (2008) An integrated method for evaluating community-based safe water programmes and an application in Rural Mexico. Health Policy Plann 23(6):452–464. CrossRefGoogle Scholar
  10. Edwards J (2002) Education and Poverty in Guatemala, World Bank Guatemala Poverty Assessment Program (GUAPA) Technical Paper No. 3Google Scholar
  11. Ejemot-Nwadiaro RI, Ehiri JE, Arikpo D, Meremikwu MM, Critchley JA (2015) Hand washing promotion for preventing diarrhea. Cochrane Database Syst Rev 9:1–95. Google Scholar
  12. Evans B, Bartram J, Hunter P, Williams AR, Geere J, Majuru B, Bates L, Fisher M, Overbo A, Schmidt W (2013) Public health and social benefits of at-house water supplies. University of Leeds, Leeds, pp 1–61Google Scholar
  13. Ferrer S, Strina A, Jesus SR, Ribeiro HC, Cairncross S, Rodrigues LC, Barreto M (2008) A hierarchical model for studying risk factors for childhood diarrhoea: a case-control study in a middle-income country. Int J Epidemiol 37(4):805–815CrossRefPubMedGoogle Scholar
  14. Gunther I, Schipper Y (2013) Pumps, germs and storage: the impact of improved water containers on water quality and health. Health Econ 22(7):757–774CrossRefPubMedGoogle Scholar
  15. Hunter PR, Zmirou-Navier D, Hartemann P (2009) Estimating the impact on health of poor reliability of drinking water interventions in developing countries. Sci Total Environ 407(8):2621–2624CrossRefPubMedGoogle Scholar
  16. Jeandron A, Saidi JM, Kapama A, Burhole M, Birembano F, Vandevelde T, Gasparrini A, Armstong B, Cairncross S, Ensink JHJ (2015) Water supply Interruptions and suspected cholera incidence: a time-series regression in the Democratic Republic of the Congo. PLOS Med 12(10):e1001893. CrossRefPubMedPubMedCentralGoogle Scholar
  17. Komarulzaman A, Smits J, de Jong E (2016) Clean water, sanitation and diarrhoea in Indonesia: effects of household and community factors. Glob Public Health. PubMedGoogle Scholar
  18. Lanata CF (2003) Studies of food hygiene and diarrhoeal disease. Int J Environ Health Res 13(Suppl 1):S175–S183CrossRefPubMedGoogle Scholar
  19. Majuru B, Mokoena MM, Jagals P, Hunter PR (2011) Health impact of small-community water supply reliability. Int J Hyg Environ Health 214(2):162–166CrossRefPubMedGoogle Scholar
  20. Majuru B, Suhrcke M, Hunter PR (2016) How do households respond to unreliable water supplies? A systematic review. Int J Environ Res Public Health 13(12):1222. CrossRefPubMedCentralGoogle Scholar
  21. Matsinhe NP, Juizo DL, Persson KM (2014) The effect of intermittent supply and household storage in the quality of drinking water in Maputo. J Water Manag Res 70:51–60Google Scholar
  22. McEwan PJ, Trowbridge M (2007) The achievement of indigenous students in Guatemalan primary schools. Int J Educ Dev 27(1):61–76CrossRefGoogle Scholar
  23. Melo MC, Taddei JA, Diniz-Santos DR, Vieira C, Carneiro NB, Melo RF, Silva LR (2008) Incidence of diarrhea in children living in urban slums in Salvador Brazil. Braz J Infect Dis 12(1):89–93CrossRefPubMedGoogle Scholar
  24. Prüss-Üstün A, Bos R, Gore F, Bartram J (2008) Safe water, better health: Costs, benefits, and sustainability of interventions to protect and promote health. World Health Organization, GenevaGoogle Scholar
  25. Rego RF, Moraes LRS, Dourado I (2005) Diarrhoea and garbage disposal in Salvador, Brazil. Trop R Soc Trop Med Hyg 99(1):48–54CrossRefGoogle Scholar
  26. Reller E, Mendoza C, Lopez M, Alvarez M, Hoekstra R, Olson C, Baier K, Keswick B, Luby S (2003) A randomized control trial of household-based flocculant-disinfectant drinking water treatment for diarrhea prevention in Rural Guatemala. Am J Trop Med Hyg 69(4):411–419PubMedGoogle Scholar
  27. Schouten T, Moriarty P (2003) Community water, community management: From system to service in Rural areas. ITDG Publishing, Rugby (UK)CrossRefGoogle Scholar
  28. SEGEPLAN (2015) Informe Final del cumplimiento de los objetivos de desarrollo del milenio. Secretaría de Planificación y Programación de la Presidencia (SEGEPLAN), GuatemalaGoogle Scholar
  29. Smiley SL (2016) Water availability and reliability in Dar es Salaam, Tanzania. J Dev Stud 52(9):1320–1334CrossRefGoogle Scholar
  30. Thompson J, Porras I, Tumwine J, Mujwahuzi M, Katui-Katua M, Johnstone N, Wood L (2000) Drawers of water ii: thirty years of change in domestic water use and environmental health in East Africa. International Institute for Environment and Development. Russell Press, NottinghamGoogle Scholar
  31. Vásquez WF (2013) An economic valuation of water connections under different approaches of service governance. Water Resources and Economics 2:17–29CrossRefGoogle Scholar
  32. Vásquez WF (2016a) An empirical analysis of household choices among water storage devices. Water Resour Rural Dev 8:12–24CrossRefGoogle Scholar
  33. Vásquez WF (2016b) La gestión de los servicios comunitarios de agua potable en Guatemala. In: Sánchez Medero G, Sánchez Medero R (eds) Guatemala: Gobierno, Gobernabilidad, Poder Local y Recursos Naturales. Tirant Humanidades, ValenciaGoogle Scholar
  34. Vásquez WF, Aksan A (2015) Water, sanitation, and diarrhea incidence among children: evidence from Guatemala. Water Policy 17:932–945CrossRefGoogle Scholar
  35. Waddington H, Snilstveit B, White H, Fewtrell L (2009) Water, sanitation and hygiene interventions to combat childhood diarrhea in developing countries. International Initiative for Impact Evaluation, New DelhiGoogle Scholar
  36. Wolf J, Pruss-Ustun A, Cumming O, Bartram J, Bonjour S et al (2014) Systematic review: assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression. Trop Med Int Health 19:928–942CrossRefPubMedGoogle Scholar
  37. World Health Organization (2015a) Global Burden of Disease: Disease burden estimates for 2000–2015. Accessed 7 February 2015
  38. World Health Organization (2015b) Country profiles on neonatal and child health. Accessed 5 February 2017
  39. World Health Organization (2015c) “Maternal, newborn, and child health score cards,” Accessed February 5, 2017

Copyright information

© Swiss School of Public Health (SSPH+) 2017

Authors and Affiliations

  • Jennifer Trudeau
    • 1
  • Anna-Maria Aksan
    • 2
  • William F. Vásquez
    • 2
  1. 1.Department of Business EconomicsSacred Heart UniversityFairfieldUSA
  2. 2.Department of EconomicsFairfield UniversityFairfieldUSA

Personalised recommendations