Category Archives: IYS Themes

Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study

The current issue of PLoS Medicine has an important review on sanitation and hygiene and also below is an analysis of the review by Jonny Crocker and Jamie Bartram.

Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children in the Global Enteric Multicenter Study, 2007–2011: Case-Control Study. PLoS Med, May 2016. Authors: Kelly K. Baker, Ciara E. O’Reilly, Myron M. Levine, Karen L., et al.

Full text: http://goo.gl/z0h9P0

Background – Diarrheal disease is the second leading cause of disease in children less than 5 y of age. Poor water, sanitation, and hygiene conditions are the primary routes of exposure and infection. Sanitation and hygiene interventions are estimated to generate a 36% and 48% reduction in diarrheal risk in young children, respectively. Little is known about whether the number of households sharing a sanitation facility affects a child’s risk of diarrhea. The objective of this study was to describe sanitation and hygiene access across the Global Enteric Multicenter Study (GEMS) sites in Africa and South Asia and to assess sanitation and hygiene exposures, including shared sanitation access, as risk factors for moderate-to-severe diarrhea (MSD) in children less than 5 y of age.

Methods/Findings – The GEMS matched case-control study was conducted between December 1, 2007, and March 3, 2011, at seven sites in Basse, The Gambia; Nyanza Province, Kenya; Bamako, Mali; Manhiça, Mozambique; Mirzapur, Bangladesh; Kolkata, India; and Karachi, Pakistan. Data was collected for 8,592 case children aged <5 y old experiencing MSD and for 12,390 asymptomatic age, gender, and neighborhood-matched controls. An MSD case was defined as a child with a diarrheal illness <7 d duration comprising ≥3 loose stools in 24 h and ≥1 of the following: sunken eyes, skin tenting, dysentery, intravenous (IV) rehydration, or hospitalization. Site-specific conditional logistic regression models were used to explore the association between sanitation and hygiene exposures and MSD. Most households at six sites (>93%) had access to a sanitation facility, while 70% of households in rural Kenya had access to a facility. Practicing open defecation was a risk factor for MSD in children <5 y old in Kenya. Sharing sanitation facilities with 1–2 or ≥3 other households was a statistically significant risk factor for MSD in Kenya, Mali, Mozambique, and Pakistan. Among those with a designated handwashing area near the home, soap or ash were more frequently observed at control households and were significantly protective against MSD in Mozambique and India.

Conclusions – This study suggests that sharing a sanitation facility with just one to two other households can increase the risk of MSD in young children, compared to using a private facility. Interventions aimed at increasing access to private household sanitation facilities may reduce the burden of MSD in children. These findings support the current World Health Organization/ United Nations Children’s Emergency Fund (UNICEF) system that categorizes shared sanitation as unimproved.

Interpreting the Global Enteric Multicenter Study (GEMS) Findings on Sanitation, Hygiene, and Diarrhea. PLoS Med, May 2016. Author: Jonny Crocker, Jamie Bartram

Full text: http://goo.gl/6SzZmr

The draft sanitation ladder for measuring SDG progress allows sharing of improved facilities by fewer than five households to count towards ending open defecation [19]. Higher rungs refer to private facilities and safe excreta management. The indicators also interpret access as including use, which was not included in GEMS. Future research should include indicators on use of facilities and excreta management.

Baker and colleagues provide valuable evidence that confirms that private sanitation often provides greater benefits than shared sanitation. Prior evidence suggests health benefits for use of any sanitation facility (including shared) when compared to open defecation [8–10]. This study will inform policy and programming, yet shared facilities may still have a role in addressing open defecation in challenging settings. For reasons beyond just health such as dignity and gender equity [20,21], we should advocate for private access whenever possible.

Baker and colleagues present the best dataset yet on diarrheal disease associated with sanitation and hygiene. They provide compelling evidence on sanitation and hygiene risk factors for MSD and variability in that risk. Importantly, they also demonstrate the feasibility and value of rigorous data collection on health outcomes, something that future studies should develop yet further.

Seeking Sanitation Success – Improve International

Seeking Sanitation Success | Source: Improve International, May 2 2016 |

The sanitation sector has evolved over decades.  Yet, in 2015, the target year for the Millennium Development Goals, much remains to be done: 2.4 billion people lack access to improved sanitation and almost 1 billion people practice open defecation, nine out of ten in rural areas (WHO/UNICEF, 2015). seeking-sanitation-success-fact-sheet-p1

While some attempts to determine what works over time have been made, comparable information is scarce.  This is an important gap to overcome, and to overcome quickly, because Sustainable Development Goal 6 (UN) aims “to ensure availability and sustainable management of water and sanitation for all” in just 14 years.

The purpose of this meta-evaluation was to attempt to identify which sanitation approaches in developing countries have been effective and sustainable, so that sector actors can position themselves for achieving universal sanitation services.

This work is divided into two phases: the desk review and expert consultation (Phase I) and in-depth country case studies (Phase II). The Seeking Sanitation Successes Fact Sheet  summarizes the output of Phase I, which recommended countries for Phase II. Please get in touch if you are interested in collaborating on the Phase II research.

Read the complete article.

Three out of five Ghanaians practice open defecation, UNICEF says

Three out of five Ghanaians practice open defecation, UNICEF says | Source: Pulse.com, April 30, 2016 |

Three out of five Ghanaians practice open defecation, UNICEF says, adding that Ghana could take 500 years to eliminate the practice due to the slow pace at which strategies, laws and interventions are being implemented. ghana-odf

Open defecation is the practice of attending natures call in the bush, at the beach, in drains and dump sites. The Chief Officer at the Water, Sanitation and Hygiene, WASH, Unit of UNICEF Ghana, David Duncan, notes that in the last 25 years, Ghana made one percent progress at eliminating the practice.

Duncan made these known at a workshop in Cape Coast for members of the Parliamentary Press Corps on open defecation. According to him, though the current pace is nothing to write home about, he was hopeful Ghana could achieve an Open Defecation Free society within the four-year national target if actions are expedited on all fronts.

Read the complete article.

Recent studies on sanitation acess & violence,and others

Below are links to the abstracts or full text of recently published articles:

Access to sanitation and violence against women: evidence from Demographic Health Survey (DHS) data in Kenya. Int J Environ Health Res. 2016 June.
Abstract: http://www.ncbi.nlm.nih.gov/pubmed/26593879

This study analyzed 2008 Kenya Demographic Health Survey’s data and found women who primarily practice open defecation (OD), particularly in disorganized communities, had higher odds of experiencing recent non-partner violence

Untangling the Impacts of Climate Change on Waterborne Diseases: a Systematic Review of Relationships between Diarrheal Diseases and Temperature, Rainfall, Flooding, and Drought. Environ Sci Technol. 2016 Apr 25.
Abstract: http://pubs.acs.org/doi/abs/10.1021/acs.est.5b06186

Key areas of agreement include a positive association between ambient temperature and diarrheal diseases, with the exception of viral diarrhea and an increase in diarrheal disease following heavy rainfall and flooding events. Insufficient evidence was available to evaluate the effects of drought on diarrhea. There is evidence to support the biological plausibility of these associations, but publication bias is an ongoing concern.

The Impact of a School-Based Water, Sanitation, and Hygiene Program on Absenteeism, Diarrhea, and Respiratory Infection: A Matched–Control Trial in Mali. Amer Jnl Trop Med Hyg, Current issue
Abstract – http://www.ajtmh.org/content/early/2016/04/21/ajtmh.15-0757.abstract

We found that a school-based WASH intervention can have a positive effect on reducing rates of illness, as well as absence due to diarrhea. However, we did not find evidence that these health impacts led to a reduction in overall absence. Higher absence rates are less likely attributable to the intervention than the result of an imbalance in unobserved confounders between study groups.

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SuSanA webinar monthly webinar 1: “Opportunities & challenges of achieving WASH behaviour change”

Published on Apr 28, 2016

The webinar brought together speakers who presented their perspectives on how we can improve WASH behavior change. First, we learnt about how we can do a better job of leveraging the influence of community leaders to change some of the social and cultural norms that prevent uptake of healthy WASH behaviors. The role of both formal and informal leaders was explored, as well as how to extend this collaboration beyond CLTS to incorporate it more into other WASH approaches.

Accelerating and sustaining behaviour change: New handbook launched at GSF learning event

This week, the Global Sanitation Fund (GSF) and the GSF-funded ‘Fonds d’Appui pour l’Assainissement’ (FAA) in Madagascar launched a new handbook on accelerating and sustaining the end of open defecation.

The handbook was launched during the GSF Learning Event in Antananarivo, Madagascar, inaugurated by Madagascar’s Minister of Water Sanitation and Hygiene, Roland Ravatomanga.

A community celebrating the creation of their ‘model latrine’ for others to replicate during a FUM session in Madagascar. Credit: WSSCC

A community celebrating the creation of their ‘model latrine’ for others to replicate during a FUM session in Madagascar. Credit: WSSCC

The ‘Follow-up MANDONA’ (FUM) handbook is a field guide for practitioners of Community-Led Total Sanitation (CLTS) – an empowering approach for improving sanitation and hygiene through collective behaviour change, rather than external subsidies or prescription. FUM aims to systematically engage communities after they have been initially ‘triggered’ and committed to ending open defecation.

‘Mandona’ is a Malagasy word which means ‘to push’. FUM brings the entire community together for a self-analysis of their sanitation situation, which then helps them immediately create models that prevent the ingestion of faeces. The approach harnesses the power of Natural Leaders to replicate these models across the community, which includes helping those that are least able, in order to advance to ODF status. By focusing on sustainable behaviour change, FUM is also a useful tool for addressing issues surrounding ‘slippage’, which relates to returning to previous unhygienic behaviours.

FUM was developed and refined by MIARINTSOA NGO, a sub-grantee of the FAA programme. Given the success of FUM in Madagascar and elsewhere, the GSF and FAA created the FUM handbook to provide a practical guide for how CLTS practitioners can implement the approach in their own contexts.

Download ‘Follow-up MANDONA: A field guide for accelerating and sustaining open defecation free communities’ (English/French)

The weeklong global event where the handbook was launched brings together implementing partners, WASH experts, and high-level government representatives from GSF-supported programmes. These actors are exchanging ideas and sharing best practices for achieving improved sanitation and hygiene behaviour at scale.

During the launch, WSSCC Executive Director Chris Williams highlighted how FUM is engraining the sustainability of sanitation and hygiene behaviour change in Madagascar and beyond. “Once a village, or an entire commune, has reached ODF status, the story isn’t over. In fact, the work continues. This important publication documents the innovations that Madagascar has put together to systematically follow-up with villages. FUM aims to ensure that the change in attitudes and creation of convictions that my ‘sanitation problem is your sanitation problem’ – ‘or my shit is your shit’ – is dealt with as a collective community effort.”

WSSCC Executive Director holds up the Follow-up MANDONA handbook at GSF Learning Event opening ceremony. Credit: WSSCC/Okechukwu Umelo

WSSCC Executive Director holds up the Follow-up MANDONA handbook at GSF Learning Event opening ceremony. Credit: WSSCC/Okechukwu Umelo

FUM has become one of FAA’s most important tools for empowering over 1.6 million people to live in open defecation free environments on their own terms. Due to its success in Madagascar, FUM has recently become a core strategy for national sanitation and hygiene programmes in Uganda, Nigeria, Benin, and Togo.

Community members in Nigeria agreeing to trigger their neighbours and help those who don’t have the means to build their own latrine. Credit: WSSCC

Community members in Nigeria agreeing to trigger their neighbours and help those who don’t have the means to build their own latrine. Credit: WSSCC

Kamal Kar, the Chairman of the CLTS Foundation, which has extensively supported the FAA programme to develop their CLTS approach, emphasized the importance of the handbook in sharing proven approaches to practitioners around the world: “I am glad that the Malagasy NGO, MIARINTSOA, with the help of the FAA programme, WSSCC and the GSF, has systematically documented their experience of post-triggering follow-up from their implementation of CLTS over the last 4-5 years. Publication of this Follow-up MANDONA handbook is indeed a step forward towards country-wide scaling up of good practice of CLTS in Madagascar and beyond.”

Eugène-De-Ligori-Rasamoelina,-Executive-Director-of-MIARINTSOA-NGO,-which-developed-and-refined-Follow-up-MANDONA---WSSCC

Eugène De Ligori Rasamoelina, Executive Director of MIARINTSOA NGO, which developed and refined Follow-up MANDONA. Credit: WSSCC

“I must say that the emergence of thousands of ODF villages in Madagascar, starting with my multiple support visits to the country since 2010 to strengthen the approach, is a brilliant example of quality CLTS implementation with its central philosophy of local empowerment. I believe that this handbook will be useful in understanding and ensuring post-triggering follow-up in CLTS for sustained behaviour change.”

Find out more about the Global Sanitation Fund on the WSSCC website.

Global Waters Radio: Darren Saywell on Community-Led Total Sanitation

Global Waters Radio: Darren Saywell on Community-Led Total Sanitation

Darren Saywell is Senior Director for the Water, Sanitation and Health Practice with Plan International USA, an international NGO with a presence in more than 70 countries around the world. darren_saywell

For the past four years, Plan International has teamed up with the Water Institute at the University of North Carolina on “Testing Community-led Total Sanitation (CLTS) Approaches for Scalability,” an operational research initiative funded by the Bill & Melinda Gates Foundation.

The project has conducted extensive analysis on the role and effectiveness of local actors in community-led total sanitation (CLTS) in 10 countries across Africa, Asia, and Latin America. It has collected hard evidence that attests to the methodology’s effectiveness in enabling large-scale sanitation behavior change.

In this conversation with Global Waters Radio Saywell talks about the key findings of the project to date and discusses why it is critical for the sanitation sector to replace anecdotal evidence on CLTS’ effectiveness with rigorous evidence.