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Kouassi HAA, Andrianisa HA, Sossou SK, Traoré MB, Nguematio RM. Sustainability of facilities built under the Community-Led Total Sanitation (CLTS) implementation: Moving from basic to safe facilities on the sanitation ladder. PLoS One 2023; 18:e0293395. [PMID: 37972150 PMCID: PMC10653469 DOI: 10.1371/journal.pone.0293395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/11/2023] [Indexed: 11/19/2023] Open
Abstract
In the context of monitoring progress towards SDG target 6.2, a household is counted to have access to sanitation if it uses at least basic sanitation services. Several approaches have been employed to help rural communities to climb up the sanitation ladder such as Community-led Total Sanitation (CLTS), whose primary target is to end open defecation through behavior change. CLTS does not subsidize sanitation facilities, but let households build their own facilities. The types and sustainability of facilities when construction is entrusted to households without guidelines remain understudied. The contribution of CLTS in achieving SDG6.2 also have not been studied. This paper addresses these gaps. Conducted in the province of Sissili in Burkina Faso, our study involved interviewing CLTS implementers, government officials, and community stakeholders. Coupled with household surveys, the data was analyzed using SPSS and Excel software. Findings indicate that CLTS succeeded in motivating households to build latrines hence escalating latrine coverage from 29.51% in 2016 (pre-CLTS) to 90.44% in 2020 (post-CLTS) in the province. However, 97.53% of latrines built were unimproved pit latrines with superstructures and without/with wooden or clay slabs and no roof, of which 19.76% collapsed during the rainy season. During this period, sanitation access rate rose from 11.9% to 17.00%. The study has therefore revealed that CLTS significantly elevates latrine coverage, yet it does not guarantee a proportional rise in sanitation access. This discrepancy results from the type of technologies generated by CLTS, which are not considered in calculating the sanitation access rate due to their unimproved nature. Consequently, further exploration of social approaches is essential, amalgamating technical and engineering aspects. Beyond socio-economic considerations, the sustainability of CLTS and the achievement of access to adequate and safe sanitation also rely on the robustness and resilience of the implemented facilities.
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Affiliation(s)
- Hemez Ange Aurélien Kouassi
- Laboratoire Eaux, Hydro-Systèmes et Agriculture (LEHSA), Institut International d’Ingénierie de l’Eau et de l’Environnement (2iE), Ouagadougou, Burkina Faso
| | - Harinaivo Anderson Andrianisa
- Laboratoire Eaux, Hydro-Systèmes et Agriculture (LEHSA), Institut International d’Ingénierie de l’Eau et de l’Environnement (2iE), Ouagadougou, Burkina Faso
| | - Seyram Kossi Sossou
- Laboratoire Eaux, Hydro-Systèmes et Agriculture (LEHSA), Institut International d’Ingénierie de l’Eau et de l’Environnement (2iE), Ouagadougou, Burkina Faso
| | - Maïmouna Bologo Traoré
- Laboratoire Eaux, Hydro-Systèmes et Agriculture (LEHSA), Institut International d’Ingénierie de l’Eau et de l’Environnement (2iE), Ouagadougou, Burkina Faso
| | - Rikyelle Momo Nguematio
- Laboratoire Eaux, Hydro-Systèmes et Agriculture (LEHSA), Institut International d’Ingénierie de l’Eau et de l’Environnement (2iE), Ouagadougou, Burkina Faso
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Eliud GK, Kirimi LM, Mburugu KN. Influence of social factors on adoption of sanitation practices in rural areas: a mixed methods study in Nzaui, Kenya. Pan Afr Med J 2023; 46:16. [PMID: 38035153 PMCID: PMC10683173 DOI: 10.11604/pamj.2023.46.16.35770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/22/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction provision of adequate sanitation is among the common strategies of preventing sanitation-related diseases. However, provision of sanitation facilities may only be a sustainable solution if the population´s behavior changes and positive perception is embraced. This paper highlights the influence of social factors on adoption of sanitation practices. Methods convergent mixed methods design was employed. Quantitative data was gathered using structured questionnaires from 100 household heads selected using cluster and simple random techniques. Logistic regression analysis was performed to explore factors that influenced adoption of sanitation practices. Qualitative data was gathered from a purposively selected focus group and analyzed thematically. Results many (57%) of the participants were males. The average age for participants was 39 years, standard deviation (SD)=0.20. From the multivariable regression analysis with adjusted odds, household heads being aged 18-33 years (OR 1.76, 95% CI: 0.62-3.02, p=0.015) and safety of latrines (OR 1.72, 95% CI: 0.70-5.15, p<0.001) was associated with increased open defecation chances; whereas being a female (OR 0.16 95% CI: 0.06-1.81, P=0.01), availability of open spaces near households (OR 0.12, 95% CI: 0.05-1.13, p=0.30), and mason skills (OR 0.29, 95% CI: 0.13-1.65) were associated with reduced likelihood of open defecation practices. Further, being a female (OR 1.06, 95% CI: 0.18-3.16, p=0.043), having knowledge on safe sanitation (OR 1.01, 95% CI: 0.74-3.08, p=0.02), engaging skilled masons for toilet construction (OR 1.299, 95% CI: 1.01-8.95, p=0.005) and financial stability (OR 1.95, 95% CI: 0.98-23.40, P=0.032<0.001) were positively associated with adoption of improved toilets. Conclusion the sanitation status in the study area was mainly poor due to the influence of multiple factors like gender, absence of toilets, knowledge on safe sanitation, poverty, mason skills and toilet location in relation to safety. The findings showed the need for innovative planning approaches based on the social aspects of communities for progress in sanitation standards in rural areas. Such approaches should adhere to the sanitation hardware versus software components of communities to promote active utilization of the available toilets, construction of improved toilets and reduction of open defecation.
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Affiliation(s)
- Grace Kasiva Eliud
- Sanitation Research Institute, Meru University of Science and Technology, Meru, Kenya
| | - Lilian Mukiri Kirimi
- Sanitation Research Institute, Meru University of Science and Technology, Meru, Kenya
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Augsburg B, Baquero JP, Gautam S, Rodriguez-Lesmes P. Sanitation and marriage markets in India: Evidence from the Total Sanitation Campaign. JOURNAL OF DEVELOPMENT ECONOMICS 2023; 163:103092. [PMID: 37334279 PMCID: PMC10273184 DOI: 10.1016/j.jdeveco.2023.103092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/10/2023] [Accepted: 03/15/2023] [Indexed: 06/20/2023]
Abstract
This paper measures the additional value of sanitation within the marriage arrangement. We use data from the Indian human development household survey (IHDS) to model the marital decisions of men and women in rural India and to estimate the marital surplus (the gains from being married). We use the model to demonstrate that the government's Total Sanitation Campaign (TSC) increased marital surplus and changed marriage market outcomes for men and women. Decomposition reveals (i) that sanitation makes it more attractive to be in a marriage for both gender, and (ii) that TSC exposure led to a decrease in the wife's surplus share, implying a redistribution of gains within the marriage.
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Affiliation(s)
| | | | - Sanghmitra Gautam
- Department of Economics, Washington University in St Louis, United States of America
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Kouassi HAA, Andrianisa HA, Traoré MB, Sossou SK, Momo Nguematio R, Ymélé SSS, Ahossouhe MS. Review of the slippage factors from open defecation-free (ODF) status towards open defecation (OD) after the Community-Led Total Sanitation (CLTS) approach implementation. Int J Hyg Environ Health 2023; 250:114160. [PMID: 36958189 DOI: 10.1016/j.ijheh.2023.114160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/25/2023]
Abstract
Open-defecation (OD) is one of the most widespread sanitation practices in low-income countries. This practice often causes diarrheal diseases and 760,000 deaths per year. To eradicate OD, several approaches have been developed, including Community-Led-Total Sanitation (CLTS) which is a participatory and community approach. The specificity of CLTS is that it is managed by the community itself, as its name implies, and that no subsidies or financial contributions from outside the community are used in the construction of the facilities. Although, the CLTS is effective in the short-term for eradicating OD, the long-term results are not encouraging: Open-Defecation-Free (ODF) communities revert to OD or partially use latrines. The present research is based on literature review and authors investigation in Burkina Faso. It was conducted to provide a comprehensive understanding of the factors that affect the sustainability of ODF-status leading to slippage in communities. It was found that these factors can be grouped into five categories: behavioral and social, technological, organizational, and vulnerability factors. The last one, socio-political factors, is a contribution from the authors as it was not reported in the literature yet. The authors have proposed graphical synthesis of all the slippage factors and their associated categories in the ODF-communities. Finally, authors have suggested that to sustain ODF-status of communities: include all stages of the sanitation value chain (SVC) in the CLTS, the follow-up activities after achieving ODF-status must be planned well in advance, sanitation marketing should be developed and the sanctions against the practice of OD have to be reinforced. Governments and donors should pay particular attention to the following options: raising awareness and regular monitoring after ODF certification, encouraging research on sustainable and pro-poor sanitation technologies, and building the capacity of implementing actors including facilitators. While obtaining ODF status is materialized by a sign with the status on it, this paper drew the attention of CLTS implementers to the lack of materialization of slippage when it occurs, and the absence of studies on the evolution of the community sanitation scale after ODF-status.
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Affiliation(s)
- Hemez Ange Aurélien Kouassi
- Laboratoire Eau, Hydro-Systèmes et Agriculture (LEHSA), Institut International d'Ingénierie de l'Eau et de l'Environnement (2iE), 01 BP 594, Ouagadougou 01, Burkina Faso.
| | - Harinaivo Anderson Andrianisa
- Laboratoire Eau, Hydro-Systèmes et Agriculture (LEHSA), Institut International d'Ingénierie de l'Eau et de l'Environnement (2iE), 01 BP 594, Ouagadougou 01, Burkina Faso
| | - Maïmouna Bologo Traoré
- Laboratoire Eau, Hydro-Systèmes et Agriculture (LEHSA), Institut International d'Ingénierie de l'Eau et de l'Environnement (2iE), 01 BP 594, Ouagadougou 01, Burkina Faso
| | - Seyram Kossi Sossou
- Laboratoire Eau, Hydro-Systèmes et Agriculture (LEHSA), Institut International d'Ingénierie de l'Eau et de l'Environnement (2iE), 01 BP 594, Ouagadougou 01, Burkina Faso
| | - Rikyelle Momo Nguematio
- Laboratoire Eau, Hydro-Systèmes et Agriculture (LEHSA), Institut International d'Ingénierie de l'Eau et de l'Environnement (2iE), 01 BP 594, Ouagadougou 01, Burkina Faso
| | - Sidesse Sonia Saapi Ymélé
- Laboratoire Eau, Hydro-Systèmes et Agriculture (LEHSA), Institut International d'Ingénierie de l'Eau et de l'Environnement (2iE), 01 BP 594, Ouagadougou 01, Burkina Faso
| | - Mahugnon Samuel Ahossouhe
- Laboratoire Eau, Hydro-Systèmes et Agriculture (LEHSA), Institut International d'Ingénierie de l'Eau et de l'Environnement (2iE), 01 BP 594, Ouagadougou 01, Burkina Faso
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Hoo YR, Joseph G, Rivera R, Smets S, Nguyen H, Ljung P, Um S, Davis G, Albert J. Strategic complements: Poverty-targeted subsidy programs show additive benefits on household toilet purchases in rural Cambodia when coupled with sanitation marketing. PLoS One 2022; 17:e0269980. [PMID: 35704665 PMCID: PMC9200298 DOI: 10.1371/journal.pone.0269980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 06/01/2022] [Indexed: 11/19/2022] Open
Abstract
While poverty-targeted subsidies have shown promise as a means of reducing financial constraints on low-income populations to invest in new latrines, concerns have been raised about whether they may reduce demand for new latrines among non-eligible, non-poor populations, especially in geographically limited or closed markets. Using quasi experimental methods, we investigate the interaction effects of the "CHOBA" subsidy, a partial poverty-targeted monetary incentive to build a toilet, and a sanitation marketing program (SanMark) on new latrine uptake among households from different income segments in 110 rural villages across six Cambodian provinces. These programs were implemented either jointly with or independently. Overall, we find strong complementarity of the CHOBA subsidy with SanMark where the coupled implementation of the programs increased latrine uptake across all households as compared to exclusive deployment of the programs independently. Additionally, the CHOBA subsidy alone resulted in higher gains among the poor compared to SanMark suggesting that financial constraint is indeed a significant demand barrier for new latrines. The presence of the poverty-targeted subsidies did not reduce demand for new latrine purchases among ineligible households. Instead, we find some evidence for a positive spillover effect of subsidies on uptake of latrines among ineligible households in villages where both programs were implemented indicating that the presence of sanitation subsidies and the decision to purchase latrines among non-beneficiaries can be viewed as complements. We employ multivariate logistic regressions as well as further robustness checks to estimate the effects of the different interventions, with qualitatively consistent results.
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Affiliation(s)
- Yi Rong Hoo
- The World Bank, Washington, DC, United States of America
| | - George Joseph
- The World Bank, Washington, DC, United States of America
| | - Rafael Rivera
- John F. Kennedy School of Government, Harvard University, Cambridge, MA, United States of America
| | - Susanna Smets
- The World Bank, Washington, DC, United States of America
| | - Hanh Nguyen
- Thrive Networks / East Meets West, San Francisco, CA, United States of America
| | - Per Ljung
- Thrive Networks / East Meets West, San Francisco, CA, United States of America
| | - Sreymom Um
- Thrive Networks / East Meets West, San Francisco, CA, United States of America
| | - Georgia Davis
- Thrive Networks / East Meets West, San Francisco, CA, United States of America
| | - Jeff Albert
- Aquaya Institute, San Anselmo, CA, United States of America
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Trimmer JT, Kisiangani J, Peletz R, Stuart K, Antwi-Agyei P, Albert J, Khush R, Delaire C. The Impact of Pro-Poor Sanitation Subsidies in Open Defecation-Free Communities: A Randomized, Controlled Trial in Rural Ghana. ENVIRONMENTAL HEALTH PERSPECTIVES 2022; 130:67004. [PMID: 35674667 PMCID: PMC9176208 DOI: 10.1289/ehp10443] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 04/26/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND According to the World Health Organization/United Nations International Children's Fund Joint Monitoring Program, 494 million people practice open defecation globally. After achieving open defecation-free (ODF) status through efforts such as Community-Led Total Sanitation (CLTS), communities (particularly vulnerable households) may revert to open defecation, especially when toilet collapse is common and durable toilets are unaffordable. Accordingly, there is increasing interest in pro-poor sanitation subsidies. OBJECTIVES This study determined the impacts of a pro-poor sanitation subsidy program on sanitation conditions among the most vulnerable households and others in the community. METHODS In 109 post-ODF communities in Northern Ghana, we conducted a cluster randomized controlled trial to evaluate a pro-poor subsidy program that identified the most vulnerable households through community consultation to receive vouchers for durable toilet substructures. We surveyed households to assess toilet coverage, quality, and use before and after the intervention and tracked program costs. RESULTS Overall, sanitation conditions deteriorated substantially from baseline to endline (average of 21 months). In control communities (not receiving the pro-poor subsidy), open defecation increased from 25% (baseline) to 69% (endline). The subsidy intervention attenuated this deterioration (open defecation increased from 25% to only 54% in subsidy communities), with the greatest impacts among voucher-eligible households. Noneligible households in compounds with subsidized toilets also exhibited lower open defecation levels owing to in-compound sharing (common in this context). CLTS followed by the subsidy program would benefit more households than CLTS alone but would cost 21-37% more per household that no longer practiced open defecation or upgraded to a durable toilet. DISCUSSION Sanitation declines, often due to toilet collapse, suggest a need for approaches beyond CLTS alone. This subsidy program attenuated declines, but durable toilets likely remained unaffordable for noneligible households. Targeting criteria more closely aligned with sanitation inequities, such as household heads who are female or did not complete primary education, may help to generate greater and more sustainable impacts in Northern Ghana and, potentially, other contexts facing toilet collapse and limited market access. https://doi.org/10.1289/EHP10443.
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Affiliation(s)
| | | | | | | | - Prince Antwi-Agyei
- University of Energy and Natural Resources, Sunyani, Ghana
- NHance Development Partners Ltd., Kumasi, Ghana
| | - Jeff Albert
- Aquaya Institute, San Anselmo, California, USA
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Can open-defecation free (ODF) communities be sustained? A cross-sectional study in rural Ghana. PLoS One 2022; 17:e0261674. [PMID: 34995310 PMCID: PMC8740968 DOI: 10.1371/journal.pone.0261674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 11/30/2021] [Indexed: 01/01/2023] Open
Abstract
Community-led total sanitation (CLTS) is a widely used approach to reduce open defecation in rural areas of low-income countries. Following CLTS programs, communities are designated as open defecation free (ODF) when household-level toilet coverage reaches the threshold specified by national guidelines (e.g., 80% in Ghana). However, because sanitation conditions are rarely monitored after communities are declared ODF, the ability of CLTS to generate lasting reductions in open defecation is poorly understood. In this study, we examined the extent to which levels of toilet ownership and use were sustained in 109 communities in rural Northern Ghana up to two and a half years after they had obtained ODF status. We found that the majority of communities (75%) did not meet Ghana’s ODF requirements. Over a third of households had either never owned (16%) or no longer owned (24%) a functional toilet, and 25% reported practicing open defecation regularly. Toilet pit and superstructure collapse were the primary causes of reversion to open defecation. Multivariate regression analysis indicated that communities had higher toilet coverage when they were located further from major roads, were not located on rocky soil, reported having a system of fines to punish open defecation, and when less time had elapsed since ODF status achievement. Households were more likely to own a functional toilet if they were larger, wealthier, had a male household head who had not completed primary education, had no children under the age of five, and benefitted from the national Livelihood Empowerment Against Poverty (LEAP) program. Wealthier households were also more likely to use a toilet for defecation and to rebuild their toilet when it collapsed. Our findings suggest that interventions that address toilet collapse and the difficulty of rebuilding, particularly among the poorest and most vulnerable households, will improve the longevity of CLTS-driven sanitation improvements in rural Ghana.
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Freeman MC, Delea MG, Snyder JS, Garn JV, Belew M, Caruso BA, Clasen TF, Sclar GD, Tesfaye Y, Woreta M, Zewudie K, Gobezayehu AG. The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000056. [PMID: 36962125 PMCID: PMC10021625 DOI: 10.1371/journal.pgph.0000056] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/07/2021] [Indexed: 04/19/2023]
Abstract
Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.
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Affiliation(s)
- Matthew C. Freeman
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- * E-mail:
| | - Maryann G. Delea
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Jedidiah S. Snyder
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Joshua V. Garn
- School of Community Health Sciences, University of Nevada, Reno, Nevada, United States of America
| | | | - Bethany A. Caruso
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Thomas F. Clasen
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Gloria D. Sclar
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - Yihenew Tesfaye
- Department of Social Anthropology, Bahir Dar University, Bahir Dar, Ethiopia
| | - Mulat Woreta
- Emory Ethiopia, Bahir Dar and Addis Ababa, Ethiopia
| | | | - Abebe Gebremariam Gobezayehu
- Emory Ethiopia, Bahir Dar and Addis Ababa, Ethiopia
- School of Nursing, Emory University, Atlanta, Georgia, United States of America
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Nelson S, Drabarek D, Jenkins A, Negin J, Abimbola S. How community participation in water and sanitation interventions impacts human health, WASH infrastructure and service longevity in low-income and middle-income countries: a realist review. BMJ Open 2021; 11:e053320. [PMID: 34857572 PMCID: PMC8640661 DOI: 10.1136/bmjopen-2021-053320] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 11/14/2021] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE To understand how, and under what circumstances community participation in water and sanitation interventions impacts the availability of safe water and sanitation, a change in health status or behaviour and the longevity of water, sanitation and hygiene (WASH) resources and services. DESIGN Realist review. DATA SOURCES PubMed, Web of Science and Scopus databases were used to identify papers from low-income and middle-income countries from 2010 to 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Criteria were developed for papers to be included. The contribution of each paper was assessed based on its relevance and rigour (eg, can it contribute to context, mechanism or outcome, and is the method used to generate that information credible). ANALYSIS Inductive and deductive coding was used to generate context-mechanism-outcome configurations. RESULTS 73 studies conducted in 29 countries were included. We identified five mechanisms that explained the availability, change and longevity outcomes: (1) accountability (policies and procedures to hold communities responsible for their actions and outcomes of an intervention), (2) diffusion (spread of an idea or behaviour by innovators over time through communication among members of a community), (3) market (the interplay between demand and supply of a WASH service or resource), (4) ownership (a sense of possession and control of the WASH service or resource) and (5) shame (a feeling of disgust in one's behaviour or actions). Contextual elements identified included community leadership and communication, technical skills and knowledge, resource access and dependency, committee activity such as the rules and management plans, location and the level of community participation. CONCLUSIONS The findings highlight five key mechanisms impacted by 19 contextual factors that explain the outcomes of community water and sanitation interventions. Policymakers, programme implementers and institutions should consider community dynamics, location, resources, committee activity and practices and nature of community participation, before introducing community water and sanitation interventions.
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Affiliation(s)
- Sarah Nelson
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Dorothy Drabarek
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Aaron Jenkins
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
- School of Science, Edith Cowan University, Perth, Western Australia, Australia
| | - Joel Negin
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Seye Abimbola
- School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
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Chirgwin H, Cairncross S, Zehra D, Sharma Waddington H. Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies. CAMPBELL SYSTEMATIC REVIEWS 2021; 17:e1194. [PMID: 36951806 PMCID: PMC8988822 DOI: 10.1002/cl2.1194] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Background Lack of access to and use of water, sanitation and hygiene (WASH) cause 1.6 million deaths every year, of which 1.2 million are due to gastrointestinal illnesses like diarrhoea and acute respiratory infections like pneumonia. Poor WASH access and use also diminish nutrition and educational attainment, and cause danger and stress for vulnerable populations, especially for women and girls. The hardest hit regions are sub-Saharan Africa and South Asia. Sustainable Development Goal (SDG) 6 calls for the end of open defecation, and universal access to safely managed water and sanitation facilities, and basic hand hygiene, by 2030. WASH access and use also underpin progress in other areas such as SDG1 poverty targets, SDG3 health and SDG4 education targets. Meeting the SDG equity agenda to "leave none behind" will require WASH providers prioritise the hardest to reach including those living remotely and people who are disadvantaged. Objectives Decision makers need access to high-quality evidence on what works in WASH promotion in different contexts, and for different groups of people, to reach the most disadvantaged populations and thereby achieve universal targets. The WASH evidence map is envisioned as a tool for commissioners and researchers to identify existing studies to fill synthesis gaps, as well as helping to prioritise new studies where there are gaps in knowledge. It also supports policymakers and practitioners to navigate the evidence base, including presenting critically appraised findings from existing systematic reviews. Methods This evidence map presents impact evaluations and systematic reviews from the WASH sector, organised according to the types of intervention mechanisms, WASH technologies promoted, and outcomes measured. It is based on a framework of intervention mechanisms (e.g., behaviour change triggering or microloans) and outcomes along the causal pathway, specifically behavioural outcomes (e.g., handwashing and food hygiene practices), ill-health outcomes (e.g., diarrhoeal morbidity and mortality), nutrition and socioeconomic outcomes (e.g., school absenteeism and household income). The map also provides filters to examine the evidence for a particular WASH technology (e.g., latrines), place of use (e.g., home, school or health facility), location (e.g., global region, country, rural and urban) and group (e.g., people living with disability). Systematic searches for published and unpublished literature and trial registries were conducted of studies in low- and middle-income countries (LMICs). Searches were conducted in March 2018, and searches for completed trials were done in May 2020. Coding of information for the map was done by two authors working independently. Impact evaluations were critically appraised according to methods of conduct and reporting. Systematic reviews were critically appraised using a new approach to assess theory-based, mixed-methods evidence synthesis. Results There has been an enormous growth in impact evaluations and systematic reviews of WASH interventions since the International Year of Sanitation, 2008. There are now at least 367 completed or ongoing rigorous impact evaluations in LMICs, nearly three-quarters of which have been conducted since 2008, plus 43 systematic reviews. Studies have been done in 83 LMICs, with a high concentration in Bangladesh, India, and Kenya. WASH sector programming has increasingly shifted in focus from what technology to supply (e.g., a handwashing station or child's potty), to the best way in which to do so to promote demand. Research also covers a broader set of intervention mechanisms. For example, there has been increased interest in behaviour change communication using psychosocial "triggering", such as social marketing and community-led total sanitation. These studies report primarily on behavioural outcomes. With the advent of large-scale funding, in particular by the Bill & Melinda Gates Foundation, there has been a substantial increase in the number of studies on sanitation technologies, particularly latrines. Sustaining behaviour is fundamental for sustaining health and other quality of life improvements. However, few studies have been done of intervention mechanisms for, or measuring outcomes on sustained adoption of latrines to stop open defaecation. There has also been some increase in the number of studies looking at outcomes and interventions that disproportionately affect women and girls, who quite literally carry most of the burden of poor water and sanitation access. However, most studies do not report sex disaggregated outcomes, let alone integrate gender analysis into their framework. Other vulnerable populations are even less addressed; no studies eligible for inclusion in the map were done of interventions targeting, or reporting on outcomes for, people living with disabilities. We were only able to find a single controlled evaluation of WASH interventions in a health care facility, in spite of the importance of WASH in health facilities in global policy debates. The quality of impact evaluations has improved, such as the use of controlled designs as standard, attention to addressing reporting biases, and adequate cluster sample size. However, there remain important concerns about quality of reporting. The quality and usefulness of systematic reviews for policy is also improving, which draw clearer distinctions between intervention mechanisms and synthesise the evidence on outcomes along the causal pathway. Adopting mixed-methods approaches also provides information for programmes on barriers and enablers affecting implementation. Conclusion Ensuring everyone has access to appropriate water, sanitation, and hygiene facilities is one of the most fundamental of challenges for poverty elimination. Researchers and funders need to consider carefully where there is the need for new primary evidence, and new syntheses of that evidence. This study suggests the following priority areas:Impact evaluations incorporating understudied outcomes, such as sustainability and slippage, of WASH provision in understudied places of use, such as health care facilities, and of interventions targeting, or presenting disaggregated data for, vulnerable populations, particularly over the life-course and for people living with a disability;Improved reporting in impact evaluations, including presentation of participant flow diagrams; andSynthesis studies and updates in areas with sufficient existing and planned impact evaluations, such as for diarrhoea mortality, ARIs, WASH in schools and decentralisation. These studies will preferably be conducted as mixed-methods systematic reviews that are able to answer questions about programme targeting, implementation, effectiveness and cost-effectiveness, and compare alternative intervention mechanisms to achieve and sustain outcomes in particular contexts, preferably using network meta-analysis.
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Affiliation(s)
- Hannah Chirgwin
- International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
| | | | | | - Hugh Sharma Waddington
- London School of Hygiene and Tropical Medicine and International Initiative for Impact Evaluation (3ie)London International Development CentreLondonUK
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11
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Daniel D, Djohan D, Machairas I, Pande S, Arifin A, Al Djono TP, Rietveld L. Financial, institutional, environmental, technical, and social (FIETS) aspects of water, sanitation, and hygiene conditions in indigenous - rural Indonesia. BMC Public Health 2021; 21:1723. [PMID: 34551739 PMCID: PMC8459497 DOI: 10.1186/s12889-021-11800-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 09/09/2021] [Indexed: 11/16/2022] Open
Abstract
Background There is increasing recognition of the complexity underlying WASH conditions in developing countries. This article explores the complexity by assessing the vulnerability of a specific area to poor WASH conditions using a qualitative approach. Methods We present our findings for the district of East Sumba in Indonesia. This area is known as one of the poorest regions in Indonesia with inadequate WASH services, indigenous belief that hinder the practice of WASH-related behaviours, and has a high rate of children malnutrition. All the factors that contribute to poor WASH conditions were discussed through the lens of the Financial, Institutional, Environmental, Technological, and Social (FIETS) framework. We then summarised the factors and visualized the “system” using a mind map which shows how factors are interconnected and helps to find the root causes of poor WASH conditions. Results There are three main challenges that inhibit the improvement of WASH conditions in this area: inadequate institutional capacity, water scarcity, and poor socio-economic conditions. We found that a village leader is the most important actor who influences the sustainability of WASH services in this area and healthcare workers are influential WASH promoters. This study also shows how culture shapes people’s daily lives and institution performance, and influences the current WASH conditions in East Sumba. The mind map shows there is an overlap and interconnection between FIEST aspects and WASH conditions in the study area. Conclusion WASH conditions are influenced by many factors and are often interconnected with each other. Understanding this complexity is necessary to improve WASH conditions and sustain adequate WASH services in developing countries. Finally, WASH interventions have to be considerate of the prevailing cultural practices and should involve multidisciplinary stakeholders. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-11800-x.
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Affiliation(s)
- D Daniel
- Department of Water Management, Faculty of Civil Engineering and Geosciences, Delft University of Technology, Delft, the Netherlands. .,Department of Health Behaviour, Environment, and Social Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
| | - Dennis Djohan
- Department of Environmental Engineering, Faculty of Civil Engineering and Geosciences, Delft University of Technology, Delft, the Netherlands
| | - Ilias Machairas
- Department of Water Management, Faculty of Civil Engineering and Geosciences, Delft University of Technology, Delft, the Netherlands
| | - Saket Pande
- Department of Water Management, Faculty of Civil Engineering and Geosciences, Delft University of Technology, Delft, the Netherlands
| | - Arifin Arifin
- Department of Groundwater Engineering, Faculty of Earth Sciences and Technology, Bandung Institute of Technology, Bandung, Indonesia
| | - Trimo Pamudji Al Djono
- Department of Environmental Engineering, Sekolah Tinggi Teknologi Sapta Taruna, Jakarta, Indonesia
| | - Luuk Rietveld
- Department of Water Management, Faculty of Civil Engineering and Geosciences, Delft University of Technology, Delft, the Netherlands
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Successes, challenges, and support for men versus women implementers in water, sanitation, and hygiene programs: A qualitative study in rural Nepal. Int J Hyg Environ Health 2021; 236:113792. [PMID: 34144357 DOI: 10.1016/j.ijheh.2021.113792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/24/2021] [Accepted: 06/08/2021] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Women's active participation is important for inclusive water, sanitation, and hygiene (WaSH) programs, yet gender roles that limit women's access to formal education and employment may reduce their skills, experience, and capacity for implementation. This paper explores differences between men and women implementers of rural WaSH programs in implementation approaches, challenges, and sources of support for implementation, and success in achieving program quality outcomes. METHODS We interviewed 18 men and 13 women in community-based implementation roles in four districts of Nepal. We identified challenges and sources of support for implementation in four domains-informational, tangible, emotional, or companionship-following social support theory. We assessed successes at achieving intermediate implementation outcomes (e.g., adoption, appropriateness, sustainability) and long-term intervention outcomes (e.g., community cleanliness, health improvements). RESULTS Women used relational approaches and leveraged social ties to encourage behavior change, while men used formative research to identify behavior drivers and sanctions to drive behavior change. Women experienced stigma for working outside the home, which was perceived as a traditionally male role. Companionship and emotional support from other women and male community leaders helped mitigate stigma and lack of informational support. Women were also more likely to receive no or low financial compensation for work and had fewer opportunities for feedback and training compared to men. Despite lack of support, women were motivated to work by a desire to build their social status, gain new knowledge, and break conventional gender roles. CONCLUSIONS Both men and women perceived that women were more effective than men at mobilizing widespread, sustained WaSH improvements, which was attributed to their successes using relational approaches and leveraging social ties to deliver acceptable and appropriate messages. Their skills for motivating collective action indicate that they can be highly effective WaSH implementers despite lack of technical experience and training, and that women's active participation is important for achieving transformative community change.
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How Do Rural Communities Sustain Sanitation Gains? Qualitative Comparative Analyses of Community-Led Approaches in Cambodia and Ghana. SUSTAINABILITY 2021. [DOI: 10.3390/su13105440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Community-led Total Sanitation (CLTS) is a popular intervention for eliminating open defecation in rural communities. Previous research has explored the contextual and programmatic factors that influence CLTS performance. Less is known about the community-level conditions that sustain latrine coverage and use. We hypothesized three categories of community conditions underlying CLTS sustainability: (i) engagement of community leaders, (ii) follow-up intensity, and (iii) support to poor households. We evaluated these among communities in Cambodia and Ghana, and applied fuzzy-set Qualitative Comparative Analysis (fsQCA) to identify combinations of conditions that influenced current latrine coverage and consistent latrine use. In Cambodia, latrine coverage was highest in communities with active commune-level leaders rather than traditional leaders, and with leaders who used casual approaches for promoting latrine construction. Latrine use in Cambodia was less consistent among communities with intense commune engagement, higher pressure from traditional leaders, high follow-up and high financial support. In Ghana, by contrast, active leaders, high follow-up, high pro-poor support, and continued activities post-implementation promoted latrine coverage and consistent use. The different responses to CLTS programming emphasize that rural communities do not have homogenous reactions to CLTS. Accounting for community perceptions and context when designing community-led interventions can foster long-term sustainability beyond short-term achievement.
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Stuart K, Peletz R, Albert J, Khush R, Delaire C. Where Does CLTS Work Best? Quantifying Predictors of CLTS Performance in Four Countries. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2021; 55:4064-4076. [PMID: 33635639 DOI: 10.1021/acs.est.0c05733] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Improving the effectiveness of rural sanitation interventions is critical for meeting the United Nations' Sustainable Development Goals and improving public health. Community-led total sanitation (CLTS) is the most widely used rural sanitation intervention globally; however, evidence shows that CLTS does not work equally well everywhere. Contextual factors outside the control of implementers may partially determine CLTS outcomes, although the extent of these influences is poorly understood. In this study, we investigate the extent to which 18 contextual factors from readily available datasets can help predict the achievement and sustainability of open-defecation-free (ODF) status in Cambodia, Ghana, Liberia, and Zambia. Using multilevel logistic regressions, we found that the predictors of CLTS performance varied between countries, with the exception of small community size. Accessibility and literacy levels were correlated with CLTS outcomes, but the direction of correlation differed between countries. To translate findings into practical guidance for CLTS implementers, we used classification and regression trees to identify a "split point" for each contextual factor significantly associated with ODF achievement. We also identified the combinations of factors conducive to a minimum of 50% ODF achievement. This study demonstrates that publicly available, high-resolution datasets on accessibility, socioeconomic, and environmental factors can be leveraged to target CLTS activities to the most favorable contexts.
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Affiliation(s)
- Kara Stuart
- The Aquaya Institute, P.O. Box 21862, Nairobi 00505, Kenya
| | - Rachel Peletz
- The Aquaya Institute, P.O. Box 1603, San Anselmo, California 949797, United States
| | - Jeff Albert
- The Aquaya Institute, P.O. Box 1603, San Anselmo, California 949797, United States
| | - Ranjiv Khush
- The Aquaya Institute, P.O. Box 1603, San Anselmo, California 949797, United States
| | - Caroline Delaire
- The Aquaya Institute, P.O. Box 1603, San Anselmo, California 949797, United States
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Igaki S, Duc NTM, Nam NH, Nga TTT, Bhandari P, Elhamamsy A, Lotify CI, Hewalla ME, Tawfik GM, Mathenge PG, Hashizume M, Huy NT. Effectiveness of community and school-based sanitation interventions in improving latrine coverage: a systematic review and meta-analysis of randomized controlled interventions. Environ Health Prev Med 2021; 26:26. [PMID: 33627071 PMCID: PMC7903680 DOI: 10.1186/s12199-021-00934-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 01/07/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Approximately 1000 children die each year due to preventable water and sanitation-related diarrheal diseases. Six in 10 people lacked access to safely managed sanitation facilities in 2015. Numerous community- and school-based approaches have been implemented to eradicate open defecation practices, promote latrine ownership, improve situation sanitation, and reduce waterborne disease. Objective Given that current evidence for sanitation interventions seem promising, the aim of this study was to systematically summarize existing research on the effectiveness of community- and school-based randomized controlled sanitation intervention in improving (1) free open defecation (safe feces disposal), (2) latrine usage, (3) latrine coverage or access, and (4) improved latrine coverage or access. Methods Eight electronic databases were searched: PubMed, Scopus, WHO Global Health Library (GHL), Virtual Health Library (VHL), POPLINE, Web of Science, Cochrane, and Google Scholar up to 26 April 2019. Original randomized clinical trials addressing community-based or school-based intervention that reported feces disposal and latrine coverage were deemed eligible. More than two researchers independently contributed to screening of papers, data extraction, and bias assessment. We conducted a meta-analysis by random-effects model. The risk of bias was assessed by the Cochrane risk of bias tool. Results Eighteen papers that matched all criteria and 16 studies were included in the final meta-analysis. Compared to the control, the sanitation intervention significantly increased safe feces disposal (OR 2.19, 95% CI 1.51–3.19, p < 0.05, I2 = 97.28), latrine usage (OR 3.72, 95% CI 1.71–8.11, p < 0.05, I2 = 91.52), latrine coverage or access (OR 3.95, 95% CI 2.08–7.50, p < 0.05, I2 = 99.07), and improved latrine coverage or access (OR 3.68, 95% CI 1.52–8.91, p < 0.05, I2 = 99.11). A combination of education and latrine construction was more effective compared to educational intervention alone. Conclusion Our study showed strong evidence for both community- and school-based sanitation interventions as effective for the safe disposal of human excreta. The finding suggests major implications for health policy and design of future intervention in developing countries. Supplementary Information The online version contains supplementary material available at 10.1186/s12199-021-00934-4.
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Affiliation(s)
- Satoshi Igaki
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Nguyen Tran Minh Duc
- Online Research Club.,University of Medicine and Pharmacy, Ho Chi Minh City, 70000, Vietnam
| | - Nguyen Hai Nam
- Online Research Club.,Department of General Surgery, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, 70000, Vietnam
| | - Tran Thi Tuyet Nga
- Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Parshal Bhandari
- Department of Anesthesiology and Intensive Care, Post Graduate Medical Institute, Lahore General Hospital, Lahore, Pakistan
| | | | | | | | | | - Peterson Gitonga Mathenge
- Leading Program, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan.,Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Masahiro Hashizume
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.,Department of Pediatric Infectious Diseases, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Nguyen Tien Huy
- Institute of Research and Development, Duy Tan University, Da Nang, 550000, Vietnam. .,Department of Clinical Product Development, Institute of Tropical Medicine (NEKKEN), School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan.
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Elsamadony M, Fujii M, Miura T, Watanabe T. Possible transmission of viruses from contaminated human feces and sewage: Implications for SARS-CoV-2. THE SCIENCE OF THE TOTAL ENVIRONMENT 2021; 755:142575. [PMID: 33022459 PMCID: PMC7522648 DOI: 10.1016/j.scitotenv.2020.142575] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/15/2020] [Accepted: 09/20/2020] [Indexed: 05/18/2023]
Abstract
Humanity has experienced outbreaks by viruses such as severe acute respiratory syndrome coronavirus 1 (SARS-CoV-1) in 2003, Eastern respiratory syndrome coronavirus (MERS-CoV) in 2012, Ebola virus in 2014 and nowadays SARS-CoV-2. While clinicians seek for a vaccine to reduce the epidemic outbreak, environmental engineers need to understand consequence of virus entity in sewage given the reported persistency of viruses in human feces and sewage environments for more than days. Herein, we discuss about concerns associated with virus occurrence in human feces and sewage, with attention to the possible SARS-CoV-2 transmission routes, based on the review of recent studies on SARS-CoV-2 as well as the previous pandemic events. Given the reported environmental stability of coronavirus, the feces- and sewage-derived transmission routes may be of importance to prevent unprecedented spread of coronavirus disease 2019 (COVID-19) particularly in developing countries. However, so far, limited number of studies detected infectious SARS-CoV-2 even in human feces, whereas a number of virus RNA copies were identified in both feces and sewage specimens. Therefore, uncertainty remains in the possibility of this transmission pathway, and further investigation is warranted in future studies, for example, by increasing the number of specimens, examining the effectiveness of methods for viral viability test, considering the patient medical history, and so forth.
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Affiliation(s)
- Mohamed Elsamadony
- Department of Civil and Environmental Engineering, Tokyo Institute of Technology, Meguro-ku, Tokyo 152-8552, Japan; Department of Public Works Engineering, Faculty of Engineering, Tanta University, 31521 Tanta City, Egypt.
| | - Manabu Fujii
- Department of Civil and Environmental Engineering, Tokyo Institute of Technology, Meguro-ku, Tokyo 152-8552, Japan.
| | - Takayuki Miura
- Department of Environmental Health, National Institute of Public Health, 2-3-6 Minami, Wako, Saitama 351-0197, Japan.
| | - Toru Watanabe
- Faculty of Agriculture, Yamagata University, 1-23 Wakaba-machi, Tsuruoka, Yamagata 997-8555, Japan.
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Crocker J, Fuente D, Bartram J. Cost effectiveness of community led total sanitation in Ethiopia and Ghana. Int J Hyg Environ Health 2020; 232:113682. [PMID: 33360500 PMCID: PMC7873587 DOI: 10.1016/j.ijheh.2020.113682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/29/2020] [Accepted: 12/04/2020] [Indexed: 11/30/2022]
Abstract
We conducted cost effectiveness analyses of four different CLTS interventions implemented in Ethiopia and Ghana. In each country, a pilot approach in which additional local actors were trained in CLTS facilitation was compared to the conventional approach. Data were collected using bottom-up costing, household surveys, and observations. We assessed variability of cost effectiveness from a societal perspective for latrine ownership and latrine use outcomes in different contexts. Cost effectiveness ranged from $34–$1897 per household ($5.85–$563 per person) gaining access to a private latrine or stopping open defecation, depending on the intervention, context, and outcome considered. For three out of four interventions, CLTS appeared more cost effective at reducing open defecation than at increasing latrine ownership, although sensitivity analysis revealed considerable variation. The pilot approaches were more cost effective at reducing open defecation than conventional approaches in Ethiopia, but not in Ghana. CLTS has been promoted as a low-cost means of improving the ownership and use of sanitation facilities. In our study, the cost of CLTS per household gaining latrine access was slightly higher than in other studies, and the cost of CLTS per household stopping OD was slightly lower than in other studies. Our results show that aggregate measures mask considerable variability in costs and outcomes, and thus the importance of considering and reporting context and uncertainty in economic analysis of sanitation interventions.
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Affiliation(s)
- Jonny Crocker
- Department of Global Health, University of Washington, 325 9th Avenue (Box 359931), Seattle, WA, 98104, USA.
| | - David Fuente
- School of Earth, Ocean and Environment, University of South Carolina, Columbia, SC, USA
| | - Jamie Bartram
- Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, USA; University of Leeds, England
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Yeboah-Antwi K, MacLeod WB, Biemba G, Sijenyi P, Höhne A, Verstraete L, McCallum CM, Hamer DH. Improving Sanitation and Hygiene through Community-Led Total Sanitation: The Zambian Experience. Am J Trop Med Hyg 2020; 100:1005-1012. [PMID: 30793687 DOI: 10.4269/ajtmh.18-0632] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In 2012, approximately 5.6 million Zambians did not have access to improved sanitation and around 2.1 million practiced open defecation. The Zambia Sanitation and Hygiene Program (ZSHP), featuring community-led total sanitation, began in November 2011 to increase the use of improved sanitation facilities and adopt positive hygiene practices. Using a pre- and post-design approach with a population-level survey, after 3 years of implementation, we evaluated the impact of ZSHP in randomly selected households in 50 standard enumeration areas (representing 26 of 65 program districts). We interviewed caregivers of children younger than 5 years old (1,204 and 1,170 female caregivers at baseline and end line, respectively) and inspected household toilet facilities and sites for washing hands. At end line, 80% of households had access to improved sanitation facilities versus 64.1% at baseline (prevalence ratio [PR] = 1.25; 95% CI: 1.18-1.31) and 14.1% did not have a toilet facility compared with 19.4% at baseline. At end line, 10.6% of households reported living in an open defecation-free certified village compared with 0.3% at baseline (PR = 32.0; 95% CI: 11.9-86.4). In addition, at end line, 33.4% of households had a specific place for washing hands and 61.4% of caregivers reported handwashing with a washing agent after defecation or before preparing food compared with 21.1% (PR = 1.59; 95% CI: 1.39-1.82) and 55.2% (PR = 1.11; 95% CI: 1.04-1.19) at baseline, respectively. Community-led total sanitation implementation in Zambia led to improvements in access to improved sanitation facilities, reduced open defecation, and better handwashing practices. There is however a need for enhanced investment in sanitation and hygiene promotion.
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Affiliation(s)
- Kojo Yeboah-Antwi
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | - William B MacLeod
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | | | - Patrick Sijenyi
- Water, Sanitation and Hygiene Section, United Nations International Children's Emergency Fund (UNICEF) Zambia, Lusaka, Zambia
| | - Alexandra Höhne
- Water, Sanitation and Hygiene Section, United Nations International Children's Emergency Fund (UNICEF) Zambia, Lusaka, Zambia
| | - Lavuun Verstraete
- Water, Sanitation and Hygiene Section, United Nations International Children's Emergency Fund (UNICEF) Zambia, Lusaka, Zambia
| | - Caitryn M McCallum
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | - Davidson H Hamer
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts.,Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts
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Harter M, Inauen J, Mosler HJ. How does Community-Led Total Sanitation (CLTS) promote latrine construction, and can it be improved? A cluster-randomized controlled trial in Ghana. Soc Sci Med 2019; 245:112705. [PMID: 31838334 PMCID: PMC6983942 DOI: 10.1016/j.socscimed.2019.112705] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 09/11/2019] [Accepted: 11/26/2019] [Indexed: 11/08/2022]
Abstract
Rationale Open defecation is connected to poor health and child mortality, but billions of people still do not have access to safe sanitation facilities. Community-Led Total Sanitation (CLTS) promotes latrine construction to eradicate open defecation. However, the mechanisms by which CLTS works and how they can be improved remain unknown. The present study is the first to investigate the psychosocial determinants of CLTS in a longitudinal design. Furthermore, we tested whether CLTS can be made more effective by theory- and evidence-based interventions using the risks, attitudes, norms, abilities, and selfregulation (RANAS) model. Methods A cluster-randomized controlled trial of 3216 households was implemented in rural Ghana. Communities were randomly assigned to classic CLTS, one of three RANAS-based interventions, or to the control arm. Prepost surveys at 6-month follow-up included standardized interviews assessing psychosocial determinants from the RANAS model. Regression analyses and multilevel mediation models were computed to test intervention effects and mechanisms of CLTS. Results Latrine coverage increased pre-post by 67.6% in all intervention arms and by 7.9% in the control arm (p < .001). The combination with RANAS-based interventions showed non-significantly greater effects than CLTS alone. The effects of CLTS on latrine construction were significantly mediated by changes in four determinants: others' behaviour and approval, self-efficacy, action planning and commitment. Changes in vulnerability, severity, and barrier planning were positively connected to latrine construction but not affected by CLTS. Conclusion This study corroborates the effectiveness of CLTS in increasing latrine coverage, and additional activities can be improved further. Behaviour change techniques within CLTS that strengthened the relevant factors should be maintained. The study also recommends interventions based on the RANAS approach to improve CLTS. Further research is needed to understand the effects of RANAS-based interventions combined with CLTS at longer follow-up Randomized-controlled trial examined Community-Led Total Sanitation (CLTS) in Ghana. CLTS increased latrine coverage by 67.6%. CLTS achieved changes in psychosocial determinants based on a psychosocial model. Changes in psychosocial determinants explain success of CLTS. Changes in factors such as social norms explain why participants construct latrines.
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Affiliation(s)
- Miriam Harter
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Ueberlandstrasse 133, 8600, Dübendorf, Switzerland.
| | - Jennifer Inauen
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Ueberlandstrasse 133, 8600, Dübendorf, Switzerland; Department of Psychology, University of Bern, Fabrikstrasse 8, 3012, Bern, Switzerland.
| | - Hans-Joachim Mosler
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Ueberlandstrasse 133, 8600, Dübendorf, Switzerland.
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Harter M, Contzen N, Inauen J. The role of social identification for achieving an open-defecation free environment: A cluster-randomized, controlled trial of Community-Led Total Sanitation in Ghana. JOURNAL OF ENVIRONMENTAL PSYCHOLOGY 2019; 66:101360. [PMID: 31885413 PMCID: PMC6919339 DOI: 10.1016/j.jenvp.2019.101360] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 09/30/2019] [Accepted: 10/04/2019] [Indexed: 06/10/2023]
Abstract
Unsafe sanitation practices are a major source of environmental pollution and are a leading cause of death in countries of the Global South. One of the most successful campaigns to eradicate open defecation is "Community-Led Total Sanitation" (CLTS). It aims at shifting social norms towards safe sanitation practices. However, the effectiveness of CLTS is heterogeneous. Based on social identity theory, we expect CLTS to be most effective in communities with stronger social identification, because in these communities individuals should rather follow social norms. We conducted a cluster-randomized controlled trial with 3,216 households in 132 communities in Ghana, comparing CLTS to a control arm. Self-reported open defecation rates and social identification were assessed pre-post. Generalized Estimating Equations showed that CLTS achieved lower open defecation rates compared to controls. This effect was significantly stronger for communities with stronger average social identification. The results confirm the assumptions of social identity theory. They imply that pre-existing social identification needs to be considered for planning CLTS, and strengthened beforehand if needed.
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Affiliation(s)
- Miriam Harter
- Eawag, Swiss Federal Institute of Aquatic Science and Technology, Dübendorf, Switzerland
| | - Nadja Contzen
- University of Groningen, Department of Psychology, the Netherlands
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Setty K, Cronk R, George S, Anderson D, O'Flaherty G, Bartram J. Adapting Translational Research Methods to Water, Sanitation, and Hygiene. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E4049. [PMID: 31652610 PMCID: PMC6843932 DOI: 10.3390/ijerph16204049] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/04/2019] [Accepted: 10/06/2019] [Indexed: 12/20/2022]
Abstract
Translational research applies scientific techniques to achieve practical outcomes, connecting pure research and pure practice. Many translational research types have arisen since the mid-1900s, reflecting the need to better integrate scientific advancement with policy and practice. Water, sanitation, and hygiene (WaSH) development efforts have aimed to reduce morbidity and mortality and improve service delivery; thus, associated research has a strong orientation toward applied studies that use diverse methods to support decision-making. Drawing from knowledge that emerged to support other professional fields, such as manufacturing and clinical healthcare, we characterize different types of translational research and clarify nomenclature and principles. We describe study approaches relevant to translational research questions, and offer overarching recommendations, specific examples, and resources for further study as practical advice to professionals who seek to apply translational methods to WaSH problems. To enhance collective outcomes, professionals should mindfully align projects within the translational spectrum. We further recommend overarching good practices such as documenting intervention adaptations, overtly considering contextual factors, and better distinguishing efficacy from effectiveness research by replicating studies in different contexts. By consciously improving the compatibility and linkages between WaSH science and practice, this guide can accelerate urgently needed progress toward global development goals.
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Affiliation(s)
- Karen Setty
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
| | - Ryan Cronk
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
| | - Shannan George
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
| | - Darcy Anderson
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
| | - Għanja O'Flaherty
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
| | - Jamie Bartram
- The Water Institute at UNC and Department of Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 166 Rosenau Hall, CB #7431 Chapel Hill, NC 27599-7431, USA.
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Orgill-Meyer J, Pattanayak SK, Chindarkar N, Dickinson KL, Panda U, Rai S, Sahoo B, Singha A, Jeuland M. Long-term impact of a community-led sanitation campaign in India, 2005-2016. Bull World Health Organ 2019; 97:523-533A. [PMID: 31384071 PMCID: PMC6653825 DOI: 10.2471/blt.18.221572] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To evaluate the long-term impact of a community-led total sanitation campaign in rural India. METHODS Local organizations in Odisha state, India worked with researchers to evaluate a community-led total sanitation campaign, which aimed to increase the demand for household latrines by raising awareness of the social costs of poor sanitation. The intervention ran from February to March 2006 in 20 randomly-selected villages and 20 control villages. Within sampled villages, we surveyed a random subset of households (around 28 households per village) at baseline in 2005 and over the subsequent 10-year period. We analysed changes in latrine ownership, latrine functionality and open defecation among approximately 1000 households. We estimated linear probability models that examined differences between households in intervention and control villages in 2006, 2010 and 2016. FINDINGS In 2010, 4 years after the intervention, ownership of latrines was significantly higher (29.3 percentage points; 95% confidence interval, CI: 17.5 to 41.2) and open defecation was significantly lower (-6.8 percentage points; 95% CI: -13.1 to -1.0) among households in intervention villages, relative to controls. In 2016, intervention households continued to have higher rates of ever owning a latrine (26.3 percentage points; 95% CI: 20.9 to 31.8). However, latrine functionality and open defecation were no longer different across groups, due to both acquisition of latrines by control households and abandonment and deterioration of latrines in intervention homes. CONCLUSION Future research should investigate how to maintain and rehabilitate latrines and how to sustain long-term behaviour change.
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Affiliation(s)
- Jennifer Orgill-Meyer
- Department of Government and Public Health Program, Franklin and Marshall College, Lancaster, PA, United States of America (USA)
| | | | - Namrata Chindarkar
- Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore
| | | | | | | | | | | | - Marc Jeuland
- Sanford School of Public Policy, Duke University, Durham, USA
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Harter M, Lilje J, Mosler HJ. Role of Implementation Factors for the Success of Community-Led Total Sanitation on Latrine Coverage. A Case Study from Rural Ghana. ENVIRONMENTAL SCIENCE & TECHNOLOGY 2019; 53:5466-5472. [PMID: 30946581 PMCID: PMC6506797 DOI: 10.1021/acs.est.9b01055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 04/04/2019] [Indexed: 06/09/2023]
Abstract
Community-led total sanitation (CLTS) is an approach to improving sanitation to combat open defecation (OD). OD is a health threat to children under five. CLTS promotes the construction of latrines with the goal of declaring communities open defecation free. However, which factors of the implementation process are most important for the success has yet to be ascertained. The analysed sample comprised of 94 communities in rural Ghana, where CLTS was implemented and factors describing the implementation process of CLTS were assessed. Additionally, monitoring data from the implementation process were used. Multiple regression analysis revealed that latrine coverage was significantly related to attendance at the CLTS meeting, the number of supportive community leaders, the expectation of participants of receiving an incentive, and the number of follow-up visits. Implementers of CLTS should direct their attention to the processes following the community meeting. The success of CLTS can be improved by investing in follow-up visits, the support of local leaders, and the careful application of incentives.
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Affiliation(s)
- Miriam Harter
- Eawag,
Swiss Federal Institute of Aquatic Science and Technology, Ueberlandstrasse 133, 8600 Duebendorf, Switzerland
| | - Jonathan Lilje
- Eawag,
Swiss Federal Institute of Aquatic Science and Technology, Ueberlandstrasse 133, 8600 Duebendorf, Switzerland
| | - Hans-Joachim Mosler
- Eawag,
Swiss Federal Institute of Aquatic Science and Technology, Ueberlandstrasse 133, 8600 Duebendorf, Switzerland
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Brown J, Albert J, Whittington D. Community-Led Total Sanitation Moves the Needle on Ending Open Defecation in Zambia. Am J Trop Med Hyg 2019; 100:767-769. [PMID: 30860017 PMCID: PMC6447111 DOI: 10.4269/ajtmh.19-0151] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 02/20/2019] [Indexed: 01/13/2023] Open
Affiliation(s)
- Joe Brown
- School of Civil and Environmental Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | | | - Dale Whittington
- Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Department of City and Regional Planning, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
- Global Research Institute, University of Manchester, Manchester, United Kingdom
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Nunbogu AM, Harter M, Mosler HJ. Factors Associated with Levels of Latrine Completion and Consequent Latrine Use in Northern Ghana. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E920. [PMID: 30875779 PMCID: PMC6466048 DOI: 10.3390/ijerph16060920] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 03/05/2019] [Accepted: 03/06/2019] [Indexed: 11/16/2022]
Abstract
Open defecation is still a major health problem in developing countries. While enormous empirical research exists on latrine coverage, little is known about households' latrine construction and usage behaviours. Using field observation and survey data collected from 1523 households in 132 communities in northern Ghana after 16 months of implementation of Community Led Total Sanitation (CLTS), this paper assessed the factors associated with latrine completion and latrine use. The survey tool was structured to conform to the Risk, Attitude, Norms, Ability and Self-regulation (RANAS) model. In the analysis, we classified households into three based on their latrine completion level, and conducted descriptive statistics for statistical correlation in level of latrine construction and latrine use behaviour. The findings suggest that open defecation among households reduces as latrine construction approaches completion. Although the study did not find socio-demographic differences of household to be significantly associated with level of latrine completion, we found that social context is a significant determinant of households' latrine completion decisions. The study therefore emphasises the need for continuous sensitisation and social marketing to ensure latrine completion by households at lower levels of construction, and the sustained use of latrines by households.
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Affiliation(s)
- Abraham Marshall Nunbogu
- Department of Environmental and Social Science Research, Swiss Federal Institute of Aquatic Science and Technology, Urberlandstrasse 133, 8600 Dubendorf, Switzerland.
- Department of Geography and Environmental Management, University of Waterloo, 200 University Avenue West, Waterloo, ON N2L 3G1, Canada.
| | - Miriam Harter
- Department of Environmental and Social Science Research, Swiss Federal Institute of Aquatic Science and Technology, Urberlandstrasse 133, 8600 Dubendorf, Switzerland.
| | - Hans-Joachim Mosler
- Department of Environmental and Social Science Research, Swiss Federal Institute of Aquatic Science and Technology, Urberlandstrasse 133, 8600 Dubendorf, Switzerland.
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The Enabling Environment for Participation in Water and Sanitation: A Conceptual Framework. WATER 2019. [DOI: 10.3390/w11020308] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Participatory approaches are an important component of institutional frameworks for the governance of water resources and services. Studies on public participation in water management provide evidence for the outcomes of public participation and insights into the types of methods and the contexts under which participation can be meaningful. However, participatory processes are complex, and there is no single method by which to interpret, approach and implement them. This paper explores elements from the theory and practice of participation, applied to the management of water resources and water and sanitation services. Based on an in-depth literature review, we analyze the forms of participation in water and sanitation, their outcomes, as well as the contextual factors and procedural elements of participatory processes that affect their success. Contextual factors are those that are largely outside of the control of agencies or participants (e.g., demographics, history, and culture) or those that can only be influenced by management and institutional decisions in the mid- and long-term (e.g., the legal and institutional framework); while procedural elements are those over which agencies and participants have considerable control when designing and executing participatory efforts (e.g., representativeness and inclusivity, access to information, and opportunity to influence). We propose a framework that interrelates and integrates both contextual factors and procedural elements of participation. It, includes three additional aspects that are influenced by, and in turn influence, the context and the process: existing capacities for implementation of meaningful participatory processes, the resources that are allocated to them, and attitudes towards participatory processes. The framework helps conceptualize what we call the enabling environment for active, free, and meaningful participation in the delivery of water and sanitation services. By breaking down the complexities of participation, the framework supports practitioners and decision-makers to better design and implement participatory processes in water resources and water and sanitation services.
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Novotný J, Hasman J, Lepič M, Bořil V. PROTOCOL: Community-led total sanitation in rural areas of low- and middle-income countries: a systematic review of evidence on effects and influencing factors. CAMPBELL SYSTEMATIC REVIEWS 2018; 14:1-27. [PMID: 37131384 PMCID: PMC8427967 DOI: 10.1002/cl2.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
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Why do water quality monitoring programs succeed or fail? A qualitative comparative analysis of regulated testing systems in sub-Saharan Africa. Int J Hyg Environ Health 2018; 221:907-920. [PMID: 29861398 PMCID: PMC6041725 DOI: 10.1016/j.ijheh.2018.05.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/26/2018] [Accepted: 05/28/2018] [Indexed: 11/25/2022]
Abstract
Background Water quality testing is critical for guiding water safety management and ensuring public health. In many settings, however, water suppliers and surveillance agencies do not meet regulatory requirements for testing frequencies. This study examines the conditions that promote successful water quality monitoring in Africa, with the goal of providing evidence for strengthening regulated water quality testing programs. Methods and findings We compared monitoring programs among 26 regulated water suppliers and surveillance agencies across six African countries. These institutions submitted monthly water quality testing results over 18 months. We also collected qualitative data on the conditions that influenced testing performance via approximately 821 h of semi-structured interviews and observations. Based on our qualitative data, we developed the Water Capacity Rating Diagnostic (WaterCaRD) to establish a scoring framework for evaluating the effects of the following conditions on testing performance: accountability, staffing, program structure, finances, and equipment & services. We summarized the qualitative data into case studies for each of the 26 institutions and then used the case studies to score the institutions against the conditions captured in WaterCaRD. Subsequently, we applied fuzzy-set Qualitative Comparative Analysis (fsQCA) to compare these scores against performance outcomes for water quality testing. We defined the performance outcomes as the proportion of testing Targets Achieved (outcome 1) and Testing Consistency (outcome 2) based on the monthly number of microbial water quality tests conducted by each institution. Our analysis identified motivation & leadership, knowledge, staff retention, and transport as institutional conditions that were necessary for achieving monitoring targets. In addition, equipment, procurement, infrastructure, and enforcement contributed to the pathways that resulted in strong monitoring performance. Conclusions Our identification of institutional commitment, comprising motivation & leadership, knowledge, and staff retention, as a key driver of monitoring performance was not surprising: in weak regulatory environments, individuals and their motivations take-on greater importance in determining institutional and programmatic outcomes. Nevertheless, efforts to build data collection capacity in low-resource settings largely focus on supply-side interventions: the provision of infrastructure, equipment, and training sessions. Our results indicate that these interventions will continue to have limited long-term impacts and sustainability without complementary strategies for motivating or incentivizing water supply and surveillance agency managers to achieve testing goals. More broadly, our research demonstrates both an experimental approach for diagnosing the systems that underlie service provision and an analytical strategy for identifying appropriate interventions.
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Is Community-Led Total Sanitation connected to the rebuilding of latrines? Quantitative evidence from Mozambique. PLoS One 2018; 13:e0197483. [PMID: 29787594 PMCID: PMC5963780 DOI: 10.1371/journal.pone.0197483] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/03/2018] [Indexed: 11/19/2022] Open
Abstract
To reduce open defecation, many implementers use the intervention strategies of Community-Led Total Sanitation (CLTS). But CLTS focuses on latrine construction and does not include latrine maintenance and repair damage or collapse. Some households rebuild their latrine while others return to open defecation. The reasons why are unknown. Using data from a cross-sectional survey, this article shows how physical, personal, and social context factors and psychosocial factors from the RANAS model are associated with CLTS participation, and how these factors connect to latrine rebuilding. In 2015, heavy rains hit the north of Mozambique and many latrines collapsed. Subsequently, 640 household interviews were conducted in the affected region. Logistic regression and mediation analyses reveal that latrine rebuilding depends on education, soil conditions, social cohesion, and a feeling of being safe from diarrhea, the perception that many other community members own a latrine, and high confidence in personal ability to repair or rebuild a broken latrine. The effect of CLTS is mediated through social and psychosocial factors. CLTS already targets most of the relevant factors, but can still be improved by including activities that would focus on other factors not yet sufficiently addressed.
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Effect of an integrated intervention package of preventive chemotherapy, community-led total sanitation and health education on the prevalence of helminth and intestinal protozoa infections in Côte d'Ivoire. Parasit Vectors 2018; 11:115. [PMID: 29486790 PMCID: PMC6389068 DOI: 10.1186/s13071-018-2642-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 01/12/2018] [Indexed: 12/21/2022] Open
Abstract
Background Preventive chemotherapy with donated anthelminthic drugs is the cornerstone for the control of helminthiases. However, reinfection can occur rapidly in the absence of clean water and sanitation coupled with unhygienic behaviour. The purpose of this study was to assess the effect of an integrated package of interventions, consisting of preventive chemotherapy, community-led total sanitation (CLTS) and health education, on the prevalence of helminth and intestinal protozoa infections and on participants’ knowledge, attitude, practice and beliefs (KAPB) towards these diseases including water, sanitation and hygiene (WASH). Methods A cross-sectional survey was carried out in nine communities of south-central Côte d’Ivoire to assess people’s infection with helminths and intestinal protozoa and KAPB. Subsequently, interventions were targeted to five communities, while the remaining communities served as control. The intervention encouraged latrine construction and an evaluation was done 6–7 months later to determine open defecation status of the respective communities. Anthelminthic treatment was provided to all community members. A follow-up cross-sectional survey was conducted approximately one year later, using the same procedures. Results Overall, 810 people had complete baseline and follow-up data and were given anthelminthic treatment. The baseline prevalence of hookworm, Schistosoma haematobium, Trichuris trichiura, Schistosoma mansoni and Ascaris lumbricoides was 31.1%, 7.0%, 2.0%, 1.0% and 0.3%, respectively. Four of the five intervention communities were classified open-defecation free. For hookworm infection, we observed higher negative changes in terms of proportion of decrease (-0.10; 95% confidence interval (CI): - 0.16, -0.04) and higher egg reduction rate (64.9 vs 15.2%) when comparing intervention with control communities. For intestinal protozoa, prevalence reduction was higher in intervention compared to control communities (8.2 vs 2.6%) and WASH indicators and intervention outcomes associated with lower odds for infection at follow-up. The intervention significantly impacted on reported latrine use (before: 15.5%, after: 94.6%), open defecation in the community surroundings (before: 75.0%, after: 16.7%) and awareness for environmental contamination through open defecation (before: 20.4%, after: 52.2%). Conclusions An integrated package of interventions consisting of preventive chemotherapy, health education and CLTS reduces the prevalence of helminth and intestinal protozoa infection. Additional studies in other social-ecological settings are warranted to confirm our findings. Electronic supplementary material The online version of this article (10.1186/s13071-018-2642-x) contains supplementary material, which is available to authorized users.
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Venkataramanan V, Crocker J, Karon A, Bartram J. Community-Led Total Sanitation: A Mixed-Methods Systematic Review of Evidence and Its Quality. ENVIRONMENTAL HEALTH PERSPECTIVES 2018; 126:026001. [PMID: 29398655 PMCID: PMC6066338 DOI: 10.1289/ehp1965] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 11/21/2017] [Accepted: 11/24/2017] [Indexed: 05/21/2023]
Abstract
BACKGROUND Community-led total sanitation (CLTS) is a widely applied rural behavior change approach for ending open defecation. However, evidence of its impact is unclear. OBJECTIVES We conducted a systematic review of journal-published and gray literature to a) assess evidence quality, b) summarize CLTS impacts, and c) identify factors affecting implementation and effectiveness. METHODS Eligible studies were systematically screened and selected for analysis from searches of seven databases and 16 websites. We developed a framework to appraise literature quality. We qualitatively analyzed factors enabling or constraining CLTS, and summarized results from quantitative evaluations. DISCUSSION We included 200 studies (14 quantitative evaluations, 29 qualitative studies, and 157 case studies). Journal-published literature was generally of higher quality than gray literature. Fourteen quantitative evaluations reported decreases in open defecation, but did not corroborate the widespread claims of open defecation-free (ODF) villages found in case studies. Over one-fourth of the literature overstated conclusions, attributing outcomes and impacts to interventions without an appropriate study design. We identified 43 implementation- and community-related factors reportedly affecting CLTS. This analysis revealed the importance of adaptability, structured posttriggering activities, appropriate community selection, and further research on combining and sequencing CLTS with other interventions. CONCLUSIONS The evidence base on CLTS effectiveness available to practitioners, policy makers, and program managers to inform their actions is weak. Our results highlight the need for more rigorous research on CLTS impacts as well as applied research initiatives that bring researchers and practitioners together to address implementation challenges to improve rural sanitation efforts. https://doi.org/10.1289/EHP1965.
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Affiliation(s)
- Vidya Venkataramanan
- The Water Institute at University of North Carolina, Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonny Crocker
- The Water Institute at University of North Carolina, Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Andrew Karon
- The Water Institute at University of North Carolina, Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jamie Bartram
- The Water Institute at University of North Carolina, Department of Environmental Sciences and Engineering, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Odagiri M, Muhammad Z, Cronin AA, Gnilo ME, Mardikanto AK, Umam K, Asamou YT. Enabling Factors for Sustaining Open Defecation-Free Communities in Rural Indonesia: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14121572. [PMID: 29240667 PMCID: PMC5750990 DOI: 10.3390/ijerph14121572] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/14/2017] [Accepted: 12/08/2017] [Indexed: 12/31/2022]
Abstract
Community Approaches to Total Sanitation (CATS) programmes, like the Sanitasi Total Berbasis Masyarakat (STBM) programme of the Government of Indonesia, have played a significant role in reducing open defecation though still little is known about the sustainability of the outcomes. We assessed the sustainability of verified Open Defecation Free (ODF) villages and explored the association between slippage occurrence and the strength of social norms through a government conducted cross-sectional data collection in rural Indonesia. The study surveyed 587 households and held focus group discussions (FGDs) in six ODF villages two years after the government’s ODF verification. Overall, the slippage rate (i.e., a combination of sub-optimal use of a latrine and open defecation at respondent level) was estimated to be 14.5% (95% CI 11.6–17.3). Results of multivariate logistic regression analyses indicated that (1) weaker social norms, as measured by respondents’ perceptions around latrine ownership coverage in their community, (2) a lack of all-year round water access, and (3) wealth levels (i.e., not being in the richest quintile), were found to be significantly associated with slippage occurrence. These findings, together with qualitative analysis, concluded that CATS programmes, including a combination of demand creation, removal of perceived constraints through community support mechanisms, and continued encouragement to pursue higher levels of services with post-ODF follow-up, could stabilize social norms and help to sustain longer-term latrine usage in study communities. Further investigation and at a larger scale, would be important to strengthen these findings.
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Affiliation(s)
- Mitsunori Odagiri
- UNICEF Indonesia, World Trade Center 6 (10th Floor), Jalan Jenderal Sudirman Kav. 31, Jakarta 12920, Indonesia.
| | - Zainal Muhammad
- UNICEF Indonesia, Kupang Field Office, Gedung NTT Satu Data, Jl. Polisi Militer No. 2, Kupang 85111, Nusa Tenggara Timur, Indonesia.
| | - Aidan A Cronin
- UNICEF Indonesia, World Trade Center 6 (10th Floor), Jalan Jenderal Sudirman Kav. 31, Jakarta 12920, Indonesia.
| | | | - Aldy K Mardikanto
- National Development Planning Agency (Bappenas), Government of Indonesia, Jl. Taman Suropati No. 2, Menteng, Jakarta 10310, Indonesia.
| | - Khaerul Umam
- Planning, Research and Development Agency (Bapelitbang), Government of District of Alor, Jl. Bukit Doa Ayalon, Petleng, Alor Tengah Utara, Kabupaten Alor 85871, Nusa Tenggara Timur, Indonesia.
| | - Yameha T Asamou
- Alor District Health Office, Government of District of Alor, Jl. Profesor W.Z. Yohannes, Subo, Alor Selatan, Kabupaten Alor 85871, Nusa Tenggara Timur, Indonesia.
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Crocker J, Saywell D, Shields KF, Kolsky P, Bartram J. The true costs of participatory sanitation: Evidence from community-led total sanitation studies in Ghana and Ethiopia. THE SCIENCE OF THE TOTAL ENVIRONMENT 2017; 601-602:1075-1083. [PMID: 28599364 PMCID: PMC5536257 DOI: 10.1016/j.scitotenv.2017.05.279] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/25/2017] [Accepted: 05/31/2017] [Indexed: 05/06/2023]
Abstract
Evidence on sanitation and hygiene program costs is used for many purposes. The few studies that report costs use top-down costing methods that are inaccurate and inappropriate. Community-led total sanitation (CLTS) is a participatory behavior-change approach that presents difficulties for cost analysis. We used implementation tracking and bottom-up, activity-based costing to assess the process, program costs, and local investments for four CLTS interventions in Ghana and Ethiopia. Data collection included implementation checklists, surveys, and financial records review. Financial costs and value-of-time spent on CLTS by different actors were assessed. Results are disaggregated by intervention, cost category, actor, geographic area, and project month. The average household size was 4.0 people in Ghana, and 5.8 people in Ethiopia. The program cost of CLTS was $30.34-$81.56 per household targeted in Ghana, and $14.15-$19.21 in Ethiopia. Most program costs were from training for three of four interventions. Local investments ranged from $7.93-$22.36 per household targeted in Ghana, and $2.35-$3.41 in Ethiopia. This is the first study to present comprehensive, disaggregated costs of a sanitation and hygiene behavior-change intervention. The findings can be used to inform policy and finance decisions, plan program scale-up, perform cost-effectiveness and benefit studies, and compare different interventions. The costing method is applicable to other public health behavior-change programs.
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Affiliation(s)
- Jonny Crocker
- The Water Institute, University of North Carolina at Chapel Hill, 148 Rosenau Hall, CB #7431, Chapel Hill, NC 27599-7431, USA.
| | - Darren Saywell
- Plan International USA, 1255 23rd Swt NW Suite 300, Washington, DC 20037, USA
| | - Katherine F Shields
- The Water Institute, University of North Carolina at Chapel Hill, 148 Rosenau Hall, CB #7431, Chapel Hill, NC 27599-7431, USA
| | - Pete Kolsky
- The Water Institute, University of North Carolina at Chapel Hill, 148 Rosenau Hall, CB #7431, Chapel Hill, NC 27599-7431, USA
| | - Jamie Bartram
- The Water Institute, University of North Carolina at Chapel Hill, 148 Rosenau Hall, CB #7431, Chapel Hill, NC 27599-7431, USA
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The Role of Perceived Social Norms in Rural Sanitation: An Explorative Study from Infrastructure-Restricted Settings of South Ethiopia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 14:ijerph14070794. [PMID: 28714920 PMCID: PMC5551232 DOI: 10.3390/ijerph14070794] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 06/28/2017] [Accepted: 07/11/2017] [Indexed: 12/04/2022]
Abstract
The perception of social sanitation norms (PSSNs) around unacceptability of open defecation has been a key aspect of recent sanitation interventions. However, underlying mechanisms through which “reconstructed” PSSNs affect sanitation outcomes have been a black box. This explorative cross-sectional study examines direct and indirect links between PSSNs and sanitation safety using data from structured interviews and observations in 368 households in rural South Ethiopia. In addition to a positive association between PSSNs and sanitation safety, we propose and examine the following two mechanisms: First, we confirm a potentially adverse feedback of PSSNs on future sanitation safety by enhancing the emotional satisfaction with current sanitation practice (satisfaction independent of the functionality of sanitation facilities). Second, inspired by the social amplification/attenuation of risk framework, we demonstrate that PSSNs work as a “social filter” that can amplify or attenuate the effects of other variables targeted in sanitation interventions such as perceived health-related and non-health risks and benefits associated with open defecation and private latrine ownership, respectively, and factual hygiene and sanitation knowledge. These findings imply that PSSNs are not only important per se, but they are also important instrumentally because sanitation outcomes depend upon the capacity of social influences to shape the perception of sanitation risks and benefits and sanitation-related awareness in desirable ways. The mechanisms outlined in this paper as well as the sustainability of sanitation outcomes depend on whether and how social sanitation norms are internalized.
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Sinha A, Nagel CL, Schmidt WP, Torondel B, Boisson S, Routray P, Clasen TF. Assessing patterns and determinants of latrine use in rural settings: A longitudinal study in Odisha, India. Int J Hyg Environ Health 2017; 220:906-915. [PMID: 28529019 PMCID: PMC5484176 DOI: 10.1016/j.ijheh.2017.05.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 05/09/2017] [Accepted: 05/09/2017] [Indexed: 11/22/2022]
Abstract
Introduction Monitoring of sanitation programs is often limited to sanitation access and coverage, with little emphasis on use of the facilities despite increasing evidence of widespread non-use. Objectives We assessed patterns and determinants of individual latrine use over 12 months in a low- income rural study population that had recently received latrines as part of the Government of India’s Total Sanitation Campaign (TSC) in coastal Puri district in Odisha, India. Materials and methods We surveyed 1938 individuals (>3 years) in 310 rural households with latrines from 25 villages over 12 months. Data collection rounds were timed to correspond with the seasons. The primary outcome was reported use by each member of the household over the prior 48 h. We classified use into three categories—“never”, “sometimes” and “always/usually”. We also assessed consistency of use over six days across the three seasons (dry cold, dry hot, rainy). We explored the association between individual and household-level variables and latrine use in any given season and longitudinally using multinomial logistic regression. We also inquired about reasons for non-use. Results Overall, latrine use was poor and inconsistent. The average response probability at any given round of never use was 43.5% (95% CI = 37.9, 49.1), sometimes use was 4.6% (95% CI = 3.8, 5.5), and always/usual use was 51.9% (95% CI = 46.2, 57.5). Only two-thirds of those who reported always/usually using a latrine in round one reported the same for all three rounds. Across all three rounds, the study population was about equally divided among those who reported never using the latrine (30.1%, 95% CI = 23.0, 37.2), sometimes using the latrine (33.2%, 95% CI = 28.3, 38.1) and always/usually using the latrine (36.8%, 95% CI = 31.8, 41.8). The reported likelihood of always/usually versus never using the latrine was significantly greater in the dry cold season (OR = 1.50, 95% CI = 1.18, 1.89, p = 0.001) and in the rainy season (OR = 1.34, 95% CI = 1.07, 1.69, p = 0.012), than in the dry hot season. Across all three seasons, there was increased likelihood of always/usually and sometimes using the latrine versus never using it among females and where latrines had a door and roof. Older age groups, including those aged 41–59 years and 60+ years, and increase in household size were associated with a decreased likelihood of always/usually using the latrine versus never using it. The leading reason for non-use was a preference for open defecation. Conclusion Results highlight the low and inconsistent use of subsidized latrines built under the TSC in rural Odisha. This study identifies individual and household levels factors that may be used to target behavior change campaigns to drive consistent use of sanitation facilities by all.
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Affiliation(s)
- Antara Sinha
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom
| | - Corey L Nagel
- School of Public Health, Oregon Health and Science University, Portland, OR 97239, United States
| | - Wolf P Schmidt
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom
| | - Belen Torondel
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom
| | - Sophie Boisson
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom
| | - Parimita Routray
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom
| | - Thomas F Clasen
- Department of Environment Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, United States.
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Crocker J, Saywell D, Bartram J. Sustainability of community-led total sanitation outcomes: Evidence from Ethiopia and Ghana. Int J Hyg Environ Health 2017; 220:551-557. [PMID: 28522255 PMCID: PMC5475437 DOI: 10.1016/j.ijheh.2017.02.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 02/14/2017] [Indexed: 12/03/2022]
Abstract
We conducted a study to evaluate the sustainability of community-led total sanitation (CLTS) outcomes in Ethiopia and Ghana. Plan International, with local actors, implemented four CLTS interventions from 2012 to 2014: health extension worker-facilitated CLTS and teacher-facilitated CLTS in Ethiopia, and NGO-facilitated CLTS with and without training for natural leaders in Ghana. We previously evaluated these interventions using survey data collected immediately after implementation ended, and concluded that in Ethiopia health extension workers were more effective facilitators than teachers, and that in Ghana training natural leaders improved CLTS outcomes. For this study, we resurveyed 3831 households one year after implementation ended, and analyzed latrine use and quality to assess post-intervention changes in sanitation outcomes, to determine if our original conclusions were robust. In one of four interventions evaluated (health extension worker-facilitated CLTS in Ethiopia), there was an 8 percentage point increase in open defecation in the year after implementation ended, challenging our prior conclusion on their effectiveness. For the other three interventions, the initial decreases in open defecation of 8–24 percentage points were sustained, with no significant changes occurring in the year after implementation. On average, latrines in Ethiopia were lower quality than those in Ghana. In the year following implementation, forty-five percent of households in Ethiopia repaired or rebuilt latrines that had become unusable, while only 6% did in Ghana possibly due to higher latrine quality. Across all four interventions and three survey rounds, most latrines remained unimproved. Regardless of the intervention, households in villages higher latrine use were more likely to have sustained latrine use, which together with the high latrine repair rates indicates a potential social norm. There are few studies that revisit villages after an initial evaluation to assess sustainability of sanitation outcomes. This study provides new evidence that CLTS outcomes can be sustained in the presence of training provided to local actors, and strengthens previous recommendations that CLTS is not appropriate in all settings and should be combined with efforts to address barriers households face to building higher quality latrines.
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Affiliation(s)
- Jonny Crocker
- The Water Institute, University of North Carolina at Chapel Hill, USA.
| | | | - Jamie Bartram
- The Water Institute, University of North Carolina at Chapel Hill, USA
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