Understanding the Challenges of Improving Sanitation and Hygiene Outcomes in a Community Based Intervention: A Cross-Sectional Study in Rural Tanzania

Prevalence and predictors of diarrhea among children under five in Ghana

BACKGROUND

Globally, childhood diarrhea is a major public health concern. Despite numerous interventions that have been put in place to reduce its incidence over the years, childhood diarrhea remains a problem and is the fourth leading cause of child mortality in Ghana. This study examined the predictors of diarrhea among children under the age of five in Ghana.

METHODS

Data from the 2014 Ghana Demographic and Health survey, a cross-sectional survey, was used for the purpose of this study. A total of 2,547 children under the age of five were included in this study. Logistic regression analysis was performed to establish the factors associated with childhood diarrhea and ascertain explanatory variables.

RESULTS

The prevalence of diarrhea was 11.7%. Male children (13.4%) and those living in rural areas (12%), particularly in the Brong Ahafo region (17%) recorded the highest prevalence of diarrhea. Children aged 6 to 35 months of age, maternal age and education, sex of children and region of residence were the predictors of diarrhea among children under the age of five years in this study.

CONCLUSION

To lessen the prevalence of diarrhea among children under five in Ghana, existing interventions must be evaluated in the context of the predictors identified. Based on observations deduced from this study, the Ministry of Health, Ghana Health Service and other health regulatory agencies should intensify monitoring and awareness in the various regions, particularly in the transition and savannah zones on the causes, risk factors, and methods of preventing diarrhea in children under five. Various stakeholders including government and non-governmental organizations should take into account the predictors of diarrhea identified in the design of interventions to effectively reduce morbidity and mortality associated with childhood diarrhea.

Water, sanitation, and hygiene implications of large-scale recycling of treated municipal wastewater in semi-arid regions

Access to water, sanitation, and hygiene (WaSH) is crucial for national development, as it improves human health and fulfills a fundamental need. This study examines the impact of a large-scale groundwater (GW) recharge scheme using secondary treated wastewater (STW) on WaSH characteristics and identifies the major determinants of improved WaSH charecteristics in drought-hit regions of Kolar district, southern India. The study quantifies improved WaSH practices by comparing WaSH characteristics between impacted areas (influenced by STW) and non-impacted areas (not influenced by STW) of Kolar, using household survey data. Pearson's chi-square and student's t-test are used to verify differences between WaSH characteristics. Furthermore, a composite WaSH score is formulated, and a hierarchical stepwise multiple linear regression model is constructed to identify major determinants of improved WaSH scores. The results show that impacted areas have better WaSH characteristics, including daily water supply by gram panchayat, enhanced toilet uses among all family members, bathing patterns, cloth washing practices, toilet cleaning patterns, and water consumption per capita per day. The maximum and minimum WaSH scores of impacted areas were 17.50 and 6.50, respectively, while those of non-impacted areas were 14 and 4.5. This study finds that improved water availability, quality, and security due to daily water supply at the household level are the major determinants of improved WaSH practices. These results can inform policymakers in designing sanitation and hygiene improvement policies that integrate water recycling projects in drought-hit areas.

The dynamics of household water security and treatment practices: a population-based, cross-sectional study in Osun State, Southwest Nigeria

A minimum of basic water supply service is pertinent to improving living standards and water-dependent quality of life indices. In Nigeria, 14% have access to safely managed drinking water services, though approximately 30% of water pumps and schemes are likely to fail within 12 months of construction. This study aims to determine household water security and its predictors in Osun State, Nigeria. The cross-sectional study recruited 548 households through a five-stage sampling technique and used a semi-structured questionnaire for data collection. Results were presented by descriptive and inferential statistics, while binary logistic regression identified water-security predictors at P_ά 0.05. Hand-dug wells (27.7%) and motorized boreholes (21.2%) were the predominant household drinking water sources. A total of 43.7% of households were water-secured while 35.2% of water sources were within residential settlements. A total of 25.1% of households experienced water scarcity, and 27.2% of households treat drinking water mainly by chlorination (56.7%) and boiling (14.7%). A total of 21.2%, 64.2%, and 9% of households, respectively, have safely managed basic and limited water supply services. Drinking water sources were associated with house ownership (p = 0.001) and residence period (p = 0.025) while water treatment was associated with gender (p = 0.010) and wealth (p = 0.0001). Age (p = 0.002) and wealth (p = 0.0001) are predictors of household water security. Two-fifths of households were water-secured, highlighting the dearth of potable water supply services and the need to incorporate strategic predictors of household water security in the existing national and state-level water resources regulations.

Frameworks for selecting appropriate rural sanitation technology options in low- and middle-income countries: a critical review

Several rural technology options exist on the sanitation market with different characteristics, yet project failures in some developing countries were attributable to inappropriate technology choices. Frameworks that are used to select sanitation technology options (hard copy, computer programmes) were developed by researchers and project implementers. They vary in design and application as there is no standard format. This appears to create a gap between science and practice. Frameworks should have some key elements needed to select appropriate sanitation technologies. We evaluated 12 available frameworks (2000-2019) used to select sanitation technologies in rural communities of low- and middle-income countries against 22 assessment criteria derived from literature. Criteria that were not fully addressed by some of the reviewed frameworks (scores of 8-50%) included equity, sanitation demand, sanitation behaviour change, ongoing contact, replicability, framework limitations, personnel selection and flexibility. Addressing such limitations may assist in future framework development.

Barriers and facilitators to Water, Sanitation and Hygiene (WaSH) practices in Southern Africa: A scoping review

A healthy and a dignified life experience requires adequate water, sanitation, and hygiene (WaSH) coverage. However, inadequate WaSH resources remain a significant public health challenge in many communities in Southern Africa. A systematic search of peer-reviewed journal articles from 2010 –May 2022 was undertaken on Medline, PubMed, EbscoHost and Google Scholar from 2010 to May 2022 was searched using combinations of predefined search terms with Boolean operators. Eighteen peer-reviewed articles from Southern Africa satisfied the inclusion criteria for this review. The general themes that emerged for both barriers and facilitators included geographical inequalities, climate change, investment in WaSH resources, low levels of knowledge on water borne-diseases and ineffective local community engagement. Key facilitators to improved WaSH practices included improved WaSH infrastructure, effective local community engagement, increased latrine ownership by individual households and the development of social capital. Water and sanitation are critical to ensuring a healthy lifestyle. However, many people and communities in Southern Africa still lack access to safe water and improved sanitation facilities. Rural areas are the most affected by barriers to improved WaSH facilities due to lack of WaSH infrastructure compared to urban settings. Our review has shown that, the current WaSH conditions in Southern Africa do not equate to the improved WaSH standards described in SDG 6 on ensuring access to water and sanitation for all. Key barriers to improved WaSH practices identified include rurality, climate change, low investments in WaSH infrastructure, inadequate knowledge on water-borne illnesses and lack of community engagement.

Assessing Hygienic Status, Sanitation Issues, and Associated Problems in Dambi Dollo Town, Oromia Regional State, Ethiopia

The pollutants discharged untreated into water bodies become a challenge in Ethiopia. This study aims to assess sanitation and hygiene status and the associated problems. A total of 500 households were selected using a systematic random sampling technique. Questionnaires, interviews, and site observation were employed. The absence of public and communal latrines had been seen as the constraint. The present study confirmed that waste disposal management has serious problems. In conclusion, these findings revealed that part of the households are living in communities with the town-owned poor sanitary facilities and that further studies are encouraged on waste disposal management.

Improved Water and Waste Management Practices Reduce Diarrhea Risk in Children under Age Five in Rural Tanzania: A Community-Based, Cross-Sectional Analysis

Diarrhea remains a significant cause of morbidity and mortality among children in developing countries. Water, sanitation, and hygiene practices (WASH) have demonstrated improved diarrhea-related outcomes but may have limited implementation in certain communities. This study analyzes the adoption and effect of WASH-based practices on diarrhea in children under age five in the rural Busiya chiefdom in northwestern Tanzania. In a cross-sectional analysis spanning July-September 2019, 779 households representing 1338 under-five children were surveyed. Among households, 250 (32.1%) reported at least one child with diarrhea over a two-week interval. Diarrhea prevalence in under-five children was 25.6%. In per-household and per-child analyses, the strongest protective factors against childhood diarrhea included dedicated drinking water storage (OR 0.25, 95% CI 0.18−0.36; p < 0.001), improved waste management (OR 0.37, 95% CI 0.27−0.51; p < 0.001), and separation of drinking water (OR 0.38, 95% CI 0.24−0.59; p < 0.001). Improved water sources were associated with decreased risk of childhood diarrhea in per-household analysis (OR 0.72, 95% CI 0.52−0.99, p = 0.04), but not per-child analysis (OR 0.83, 95% CI 0.65−1.05, p = 0.13). Diarrhea was widely treated (87.5%), mostly with antibiotics (44.0%) and oral rehydration solution (27.3%). Targeting water transportation, storage, and sanitation is key to reducing diarrhea in rural populations with limited water access.

Monitoring the Impact of National Sanitation and Hygiene Programme for Rural Communities in Chamwino (Tanzania)

The Sustainable Development Goals promulgate access to sanitation and hygiene for all and the end to open defecation in the framework of the human right to sanitation. Tanzania has one of the lowest levels of access to sanitation, with increasing open defecation. Ending open defecation has been identified as a top priority for reducing global inequalities in WASH (water, sanitation and hygiene). In this context, the coordinated work of NGOs, universities and governments developed a hygiene and sanitation programme (UMATA), whose methodologies and lessons learnt are ready to be scaled up. This research analyses the information collected from more than 21,000 households and discusses the challenges of monitoring and tracking the degree of achievement of the Sustainable Development Goals and the human right to sanitation. A characterisation of the hygiene and sanitation situation and the degree of adoption of different latrine types was assessed before (baseline) and after (follow-up) the implementation of the UMATA programme using the WHO/UNICEF JMP (Joint Monitoring Programme for Water Supply, Sanitation and Hygiene) metrics and approach. This allowed evaluating the efficacy of the strategy implemented in Tanzania to reduce open defecation that led to a decrease from 40.7% to 9.70% in the monitored period. Finally, we discuss the critical economic factors affecting the adoption and sustainability of improved sanitation systems.

Interventions promoting uptake of water, sanitation and hygiene (WASH) technologies in low- and middle-income countries: An evidence and gap map of effectiveness studies

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.

Narrative Review of Primary Preventive Interventions against Water-Borne Diseases: Scientific Evidence of Health-EDRM in Contexts with Inadequate Safe Drinking Water

Waterborne diseases account for 1.5 million deaths a year globally, particularly affecting children in low-income households in subtropical areas. It is one of the most enduring and economically devastating biological hazards in our society today. The World Health Organization Health Emergency and Disaster Risk Management (health-EDRM) Framework highlights the importance of primary prevention against biological hazards across all levels of society. The framework encourages multi-sectoral coordination and lessons sharing for community risk resilience. A narrative review, conducted in March 2021, identified 88 English-language articles published between January 2000 and March 2021 examining water, sanitation, and hygiene primary prevention interventions against waterborne diseases in resource-poor settings. The literature identified eight main interventions implemented at personal, household and community levels. The strength of evidence, the enabling factors, barriers, co-benefits, and alternative measures were reviewed for each intervention. There is an array of evidence available across each intervention, with strong evidence supporting the effectiveness of water treatment and safe household water storage. Studies show that at personal and household levels, interventions are effective when applied together. Furthermore, water and waste management will have a compounding impact on vector-borne diseases. Mitigation against waterborne diseases require coordinated, multi-sectoral governance, such as building sanitation infrastructure and streamlined waste management. The review showed research gaps relating to evidence-based alternative interventions for resource-poor settings and showed discrepancies in definitions of various interventions amongst research institutions, creating challenges in the direct comparison of results across studies.

Embracing challenging complexity: exploring handwashing behavior from a combined socioecological and intersectional perspective in Sierra Leone

Background

Handwashing with soap is a cost-effective, efficient health behavior to prevent various diseases. Despite its immense health benefits, the lowest prevalence of handwashing is found in low-income countries. Here, its practice is not only determined by individual behavior, but also heavily shaped by deprivations in the social and structural ecology. Moreover, handwashing barriers are not equally experienced as overlapping social identities (e.g., age and gender) intersect and create inequities between members of different social groups. To embrace the complexities of handwashing beyond individual-level behavior and singular social identities, a combined socioecological and intersectional perspective is employed. This multi-level approach with regards to intersecting privileges and disadvantages serves as a basis to promote this highly important health behavior.

Methods

This study used a qualitative, theory-based approach and combined data from two samples: experts in health promotion (n = 22) and local citizens stratified by gender and rural/urban location (n = 56). Data was collected in face-to-face interviews in Sierra Leone between November 2018 and January 2019 and analyzed using thematic analysis and typology of the qualitative data.

Results

The conceptualization of multi-level determinants of handwashing within a socioecological model showed the high relevance of inhibiting social and structural factors for handwashing practice. By establishing seven distinguishing social identity dimensions, data demonstrates that individuals within the same social setting yet with distinct social identities experience strikingly differing degrees of power and privileges to enact handwashing. While a local leader is influential and may also change structural-level determinants, a young, rural wife experiences multiple social and structural constraints to perform handwashing with soap, even if she has high handwashing intentions.

Conclusion

This study provides a holistic analytical framework for the identification of determinants on multiple levels and accumulating intersections of socially produced inequalities for handwashing and is applicable to other health topics. As the exploration of handwashing was approached from a solution-focused instead of a problem-focused perspective, the analysis can guide multi-level intervention approaches (e.g., using low-cost, participatory activities at the community level to make use of the available social capital).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11923-1.

Implementing trachoma control programmes in marginalised populations in Tanzania: A qualitative study exploring the experiences and perspectives of key stakeholders

Background

Despite aspects of the SAFE strategy for reducing trachoma in Tanzania have been somewhat successful, the disease still persists in marginalised communities even with repeated trachoma control interventions. This study aims to understand the facilitators and barriers associated with implementing trachoma control programmes in these communities, from the perspective of non-governmental organisations (NGOs).

Methods

Participants were the representatives of NGOs who had knowledge and experience in the implementation of trachoma control programmes. Data was collected using in-depth, semi-structured interviews guided by a topic guide, which was updated after each interview using a constant comparative method. Interviews were audio-recorded and then transcribed verbatim. Thematic analysis was done inductively. Codes were generated from the transcripts and then clustered into themes.

Findings

The context within marginalised communities often acted as a perceived barrier to successful implementation of control programmes. This included poor environmental cleanliness, lack of trust, poor disease knowledge and traditional lifestyles. Community values could either be a facilitator or a barrier, depending on the scenario. The anatomical location of the disease and the poor understanding of the disease progression also served as barriers. Considerations affecting decision-making among NGO’s include financial feasibility, community needs and whether the quality of the intervention could be improved. NGOs felt that the collaboration and the opportunity to learn from other organisations were beneficial aspects of having different actors. However, this also resulted in variability in the effectiveness of interventions between districts.

Conclusion

NGOs should focus on behaviour change and health education that is tailored to marginalised communities and seek innovative ways to implement trachoma intervention programmes whilst being minimally intrusive to the traditional way of life. Partners should also implement ways to ensure high quality programmes are being provided, by increasing staff accountability and compensating volunteers fairly.

Trachoma is a neglected tropical disease caused by the bacterium Chlamydia trachomatis and can result in blindness if left untreated. The World Health Organisation devised the SAFE strategy (Surgery, Antibiotics, Facial Cleanliness and Environmental Improvements) to combat this disease. In Tanzania, many trachoma control interventions are implemented by non-governmental organisations (NGOs). The disease still persists in areas with marginalised, including Maasai, despite repeated interventions. These communities are often difficult to reach due to their livelihoods and local beliefs. This study investigates the facilitators and barriers to implementing interventions within hard to reach communities from the perspectives of NGOs. Findings will provide insight on how NGOs implement and ensure their programmes are effective, whilst being mindful of the intrinsic factors important to the community, which will inform improvements and alterations in trachoma interventions.

High Prevalence of Stunting and Anaemia Is Associated with Multiple Micronutrient Deficiencies in School Children of Small-Scale Farmers from Chamwino and Kilosa Districts, Tanzania

Inadequate macro- and micronutrient nutrition and its consequences, such as anaemia, iron and vitamin deficiency, and growth retardation, could particularly affect children of small-scale farmers. In the present cross-sectional study, 666 school children aged 5-10 years from villages of Chamwino and Kilosa districts were studied for associations between nutritional and micronutrient status and dietary intake. The overall prevalence of stunting, underweight, and overweight was 28.1, 14.4, and 5%, while that of anaemia and deficiency of iron (ID), vitamin A (VAD), and zinc (ZnD) was 42.9, 29.3, 24.9, and 26.4%, respectively. Dietary recalls (24h) revealed that, except of iron (74%), only small proportions of children reached the recommended daily micronutrient intakes: 4% for zinc, 19% for vitamin A, and 14-46% for B vitamins. Stunting was highly associated with wasting in both districts and with VAD in Chamwino. Anaemia was predicted by ID, VAD, and ZnD in Chamwino and by elevated infection markers, C-reactive protein (CRP) and α-1 glycoprotein (AGP), in Kilosa. Overall, elevated CRP and/or AGP increased the risk while higher serum carotenoids indicating a diet of more fruit and vegetables reduced the risk of VAD. The significantly lower prevalence of anaemia and ID in Chamwino was related to higher iron and vitamin A intake and the consumption of mainly bulrush millet with dark green leafy vegetables compared to maize or rice with legumes in Kilosa. Nutrition and hygiene education integrated with home and school garden programmes could reduce the multiple burdens of anaemia; micronutrient deficiencies and infections; and, in the long term, the prevalence of stunting.

Improving Uptake and Sustainability of Sanitation Interventions in Timor-Leste: A Case Study

Open defecation (OD) is still a significant public health challenge worldwide. In Timor-Leste, where an estimated 20% of the population practiced OD in 2017, increasing access and use of improved sanitation facilities is a government priority. Community-led total sanitation (CLTS) has become a popular strategy to end OD since its inception in 2000, but evidence on the uptake of CLTS and related interventions and the long-term sustainability of OD-free (ODF) communities is limited. This study utilized a mixed-methods approach, encompassing quantitative monitoring and evaluation data from water, sanitation, and hygiene (WASH) agencies, and semi-structured interviews with staff working for these organizations and the government Department of Environmental Health, to examine sanitation interventions in Timor-Leste. Recommendations from WASH practitioners on how sanitation strategies can be optimized to ensure ODF sustainability are presented. Whilst uptake of interventions is generally good in Timor-Leste, lack of consistent monitoring and evaluation following intervention delivery may contribute to the observed slippage back to OD practices. Stakeholder views suggest that long-term support and monitoring after ODF certification are needed to sustain ODF communities.

Knowledge, Attitude, and Practices on Water, Sanitation, and Hygiene among Rural Residents in Tigray Region, Northern Ethiopia

Background

Poor hygienic practices, inadequate water supply, and poor sanitary conditions play a major role in the spread of infectious diseases. Lack of knowledge, attitude, and practices (KAP) on WASH is one of the most imperative causes for transmission of infectious diseases. Therefore, the aim of this study was to assess knowledge, attitude, and practice of rural residents on water, sanitation, and hygiene in Tigray, Ethiopia.

Methods

A community-based cross-sectional study was conducted from June to July 2018. Multistage cluster sampling technique was used to collect data from 759 households in Tigray region, Northern Ethiopia. A standardized questionnaire was used to collect data on knowledge, attitude, and practice on water, sanitation, and hygiene (WASH). Descriptive data analysis was done to present the study findings.

Results

The response rate was 99.6%, and 574 (75.9%) of the respondents were females. Good knowledge, favorable attitude, and good practice on WASH were observed in 42.2% (95% CI: 38.7%, 45.7%), 48.5% (95% CI: 44.9%, 52.0%), and 49.2% (95% CI: 45.6%, 52.7%) of the respondents, respectively.

Conclusions

Poor knowledge, unfavorable attitude, and poor practice on WASH were common amongst the residents in rural Tigray, Northern Ethiopia. Therefore, the health extension programs at primary health care should be revitalized in a way that can enhance the interventional measures to improve knowledge, attitude, and practice on WASH.

Waste to Carbon: Biocoal from Elephant Dung as New Cooking Fuel

The paper presents, for the first time, the results of fuel characteristics of biochars from torrefaction (a.k.a., roasting or low-temperature pyrolysis) of elephant dung (manure). Elephant dung could be processed and valorized by torrefaction to produce fuel with improved qualities for cooking. The work aimed to examine the possibility of using torrefaction to (1) valorize elephant waste and to (2) determine the impact of technological parameters (temperature and duration of the torrefaction process) on the waste conversion rate and fuel properties of resulting biochar (biocoal). In addition, the influence of temperature on the kinetics of the torrefaction and its energy consumption was examined. The lab-scale experiment was based on the production of biocoals at six temperatures (200–300 °C; 20 °C interval) and three process durations of the torrefaction (20, 40, 60 min). The generated biocoals were characterized in terms of moisture content, organic matter, ash, and higher heating values. In addition, thermogravimetric and differential scanning calorimetry analyses were also used for process kinetics assessment. The results show that torrefaction is a feasible method for elephant dung valorization and it could be used as fuel. The process temperature ranging from 200 to 260 °C did not affect the key fuel properties (high heating value, HHV, HHVdaf, regardless of the process duration), i.e., important practical information for proposed low-tech applications. However, the higher heating values of the biocoal decreased above 260 °C. Further research is needed regarding the torrefaction of elephant dung focused on scaling up, techno-economic analyses, and the possibility of improving access to reliable energy sources in rural areas.