Rural Sanitation Sustainability Dynamics: Gaining Insight through Participatory and Simulation Modeling

Improved sanitation provides many benefits to human health and well-being and is integral to achieving Sustainable Development Goal Six. However, many nations, including most of sub-Saharan Africa, are not on track to meeting sanitation targets. Recognizing the inherent complexity of environmental health, we used systems thinking to study sanitation sustainability in Uganda. Our study participants, 37 sanitation actors in three rural districts, were engaged in interviews, group model building workshops, and a survey. The resulting model was parametrized and calibrated using publicly available data and data collected through the Uganda Sanitation for Health Activity. Our simulations revealed slippage from improved sanitation in all study districts, a behavior reflected in real interventions. This implies that systemic changes-changes to the rules and relationships in the system-may be required to improve sanitation outcomes in this context. Adding reinforcing feedback targeting households' perceived value of sanitation yielded promising simulation results. We conclude with the following general recommendations for those designing sanitation policies or interventions: (1) conceptualize sanitation systems in terms of reinforcing and balancing feedback, (2) consider using participatory and simulation modeling to build confidence in these conceptual models, and (3) design many experiments (e.g., simulation scenarios) to test and improve understanding.

Do Sanitation Marketing Activities Increase Households' Likelihoods of Reaching Improved Sanitation or Involving Women in Decision Making?

Poor sanitation causes 30% of diarrheal deaths globally, and much of the world has struggled to finance top-down interventions. Sanitation marketing is a demand-led approach that uses a mixture of social and commercial marketing methods and direct sales to households. However, little is known about its impacts on household decision making. This mixed-methods study uses data from eight focus groups and 86,666 household surveys from participants in a five-year sanitation marketing program in Uganda. Logistic regression models identified 10 variables predicting attainment of improved (limited or basic) sanitation and four variables predicting female involvement in decision making. Triggering session attendance increased chances of reaching improved sanitation by 15-28%, depending on who attended, and by 19% if the household found the session motivational. Although women were engaged in decision-making conversations, they were not viewed as primary decision makers, even in female-headed households. Women were more likely to become involved in decision making if they had attended triggering sessions with men (+70%) or engaged with sales promoters alone (+74%) or with men (+78%). For both outcomes, joint activity engagement was more effective than male or female engagement alone. This work highlights two sanitation marketing activities as pathways to improving latrine coverage and women's decision-making agency.

Effectiveness of SMS Technology on Timely Community Health Worker Follow-Up for Childhood Malnutrition: A Retrospective Cohort Study in sub-Saharan Africa

BACKGROUND

The Millennium Villages Project facilitated technology-based health interventions in rural under-resourced areas of sub-Saharan Africa. Our study examined whether data entry using SMS compared with paper forms by community health workers (CHWs) led to higher proportion of timely follow-up visits for malnutrition screening in under-5 children in Ghana, Rwanda, Senegal, and Uganda.

METHODS

Children under 5 years were screened for malnutrition every 90 days by CHWs using mid-upper arm circumference (MUAC) readings. CHWs used either SMS texts or paper forms to enter MUAC data. Reminder texts were sent at 15 days before follow-up was needed. Chi-square tests assessed proportion of timely follow-up visits within 90 days between SMS and paper groups. Logistic regression analysis was conducted in a step-wise multivariate model. Post-hoc power calculations were conducted to verify strength of associations.

RESULTS

SMS data entry was associated with a higher proportion of timely malnutrition follow-up visits compared with paper forms across all sites. The association was strongest with consistent SMS use over consecutive visits. SMS use at the first of 2 consecutive visits was most effective, highlighting the importance of SMS reminder alerts.

CONCLUSIONS

SMS technology with reminders increased timely CHW malnutrition screening visits for under-5 children in Ghana, Rwanda, Senegal, and Uganda, highlighting the importance of such technology for improving health worker behavior in low-resource settings.

The Millennium Villages Project: a retrospective, observational, endline evaluation

BACKGROUND

The Millennium Villages Project (MVP) was a 10 year, multisector, rural development project, initiated in 2005, operating across ten sites in ten sub-Saharan African countries to achieve the Millennium Development Goals (MDGs). In this study, we aimed to estimate the project's impact, target attainment, and on-site spending.

METHODS

In this endline evaluation of the MVP, we retrospectively selected comparison villages that best matched the project villages on possible confounding variables. Cross-sectional survey data on 40 outcomes of interest were collected from both the project and the comparison villages in 2015. Using these data, as well as on-site spending data collected during the project, we estimated project impacts as differences in outcomes between the project and comparison villages; target attainment as differences between project outcomes and prespecified targets; and on-site spending as expenditures reported by communities, donors, governments, and the project. Spending data were not collected in the comparison villages.

FINDINGS

Averaged across the ten project sites, we found that impact estimates for 30 of 40 outcomes were significant (95% uncertainty intervals [UIs] for these outcomes excluded zero) and favoured the project villages. In particular, substantial effects were seen in agriculture and health, in which some outcomes were roughly one SD better in the project villages than in the comparison villages. The project was estimated to have no significant impact on the consumption-based measures of poverty, but a significant favourable impact on an index of asset ownership. Impacts on nutrition and education outcomes were often inconclusive (95% UIs included zero). Averaging across outcomes within categories, the project had significant favourable impacts on agriculture, nutrition, education, child health, maternal health, HIV and malaria, and water and sanitation. A third of the targets were met in the project sites. Total on-site spending decreased from US$132 per person in the first half of the project (of which $66 was from the MVP) to $109 per person in the second half of the project (of which $25 was from the MVP).

INTERPRETATION

The MVP had favourable impacts on outcomes in all MDG areas, consistent with an integrated rural development approach. The greatest effects were in agriculture and health, suggesting support for the project's emphasis on agriculture and health systems strengthening. The project conclusively met one third of its targets.

FUNDING

The Open Society Foundations, the Islamic Development Bank, and the governments of Japan, South Korea, Mali, Senegal, and Uganda.

Capitalizing on the characteristics of mHealth to evaluate its impact

The field of mHealth has made significant advances in a short period of time, demanding a more thorough and scientific approach to understanding and evaluating its progress. A recent review of mHealth literature identified two primary research needs in order for mHealth to strengthen health systems and promote healthy behaviors, namely health outcomes and cost-benefits (Mechael et al., 2010 ). In direct response to the gaps identified in mHealth research, the aim of this paper is to present the study design and highlight key observations and next steps from an evaluation of the mHealth activities within the electronic health (eHealth) architecture implemented by the Millennium Villages Project (MVP) by leveraging data generated through mobile technology itself alongside complementary qualitative research and costing assessments. The study, funded by the International Development and Research Centre (IDRC) as part of the Open Architecture Standards and Information Systems research project (OASIS II) (Sinha, 2009 ), is being implemented on data generated by 14 MVP sites in 10 Sub-Saharan African countries including more in-depth research in Ghana, Rwanda, Tanzania, and Uganda. Specific components of the study include rigorous quantitative case-control analyses and other epidemiological approaches (such as survival analysis) supplemented by in-depth qualitative interviews spread out over 18 months, as well as a costing study to assess the impact of mHealth on health outcomes, service delivery, and efficiency.