Category Archives: Research

Recent WASH research – July 18, 2017

WASHwatch – Water, Sanitation and Hygiene Maps – Projections of use of basic and safely managed sanitation 2000-2030. These maps have been produced by the WASHwatch team, based on data from WHO/UNICEF’s 2017 Progress Report on Drinking Water, Sanitation, and Hygiene. All data points after 2015 are WASHwatch calculations using the average rates of progress between 2000 and 2015.

Household sanitation is associated with lower risk of bacterial and protozoal enteric infections, but not viral infections and diarrhoea, in a cohort study in a low-income urban neighbourhood in Vellore, India. TMIH, July 17, 2017. The presence of a household toilet was associated with lower risk of bacterial and protozoal enteric infections, but not diarrhoea or viral infections, suggesting the health effects of sanitation may be more accurately estimated using outcome measures that account for aetiologic agents.

Identifying behavioural determinants for interventions to increase handwashing practices among primary school children in rural Burundi and urban Zimbabwe. BMC Research Notes, July 14, 2017. This article presents the development of a school handwashing programme in two different sub-Saharan countries that applies the RANAS (risk, attitudes, norms, ability, and self-regulation) systematic approach to behaviour change.

Sanitation practices and perceptions in Kakuma refugee camp, Kenya: Comparing the status quo with a novel service-based approach. PLoS One, July 13, 2017. This study used qualitative and quantitative methods to design, implement, and pilot a novel sanitation system in Kakuma refugee camp, Kenya. An initial round of 12 pre-implementation focus group discussions (FGDs) were conducted with Dinka and Somali residents to understand sanitation practices, perceptions, and needs.

Menstrual hygiene management among Bangladeshi adolescent schoolgirls and risk factors affecting school absence: results from a cross-sectional survey. BMJ Open, July 2017. Risk factors for school absence included girl’s attitude, misconceptions about menstruation, insufficient and inadequate facilities at school, and family restriction.

Assessing development assistance for child survival between 2000 and 2014: A multi-sectoral perspective. PLoS One, July 11, 2017. Aid for water and sanitation grew from 4.17 billion ($0.86 per capita) in 2000 to 7.27 billion ($1.23 per capita) in 2014 with an average annual growth rate of 5.0%. During this period, the top 10 countries received largest amount of aid (India, China, Viet Nam, Iraq, Morocco, Tanzania, Bangladesh, Jordan, Indonesia, and Ethiopia) accounted for 35% of total aid in water and sanitation (S8 Table), and nine of them were Countdown countries.


Recent WASH research – July 14, 2017


Counting how many people have water, sanitation and hygiene. WASHwatch, July 13, 2017.
New data from UNICEF/WHO estimate the percentage of the global population using at least a basic level of service for drinking water and sanitation to be 89% and 68%, respectively. Stuart Kempster, WaterAid’s Policy Analyst for Monitoring and Accountability, looks into what we can tell from the estimates.

Habit Formation and Rational Addiction: A Field Experiment in Handwashing. Reshmaan Hussam, December 2016.
Motivated by scholarship that suggests handwashing is habitual, we design, implement and analyze a randomized field experiment aimed to test the main predictions of the rational addiction model.

Assessing Women’s Negative Sanitation Experiences and Concerns: The Development of a Novel Sanitation Insecurity Measure. Int. J. Environ. Res. Public Health, July 11, 2017.
We developed a sanitation insecurity measure to capture the range and frequency of women’s sanitation-related concerns and negative experiences. The final sanitation insecurity measure includes 50 items across seven factors that reflect the physical environment, the social environment, and individual-level constraints. This measure will enable researchers to evaluate how sanitation insecurity affects health and to determine if and how sanitation interventions ameliorate women’s concerns and negative experiences associated with sanitation.

Prediction of Human Development from Environmental Indicators. Social Indicators Research, July 8, 2017. The results showed that exposure to unsafe sanitation, access to drinking water, tree cover loss, unsafe water quality, wastewater treatment level, and household air pollution are excellent predictors of human development index of a population. This tool can help stakeholders to monitor and control indicators attributed to good health and well-being, quality education, clean water and sanitation, decent work and economic growth, sustainable cities and communities and life on land sustainable development goals.


Effects of sanitation on cognitive development and school absence: A systematic review. International Journal of Hygiene and Environmental Health, July 1, 2017.
While studies to date provide some support for positive effects from sanitation on cognitive development, the effects on school absence are uncertain. Differences in effects may be due to differences in study settings, type of sanitation exposure and most notably in outcome definitions.

Switching to sanitation: Understanding latrine adoption in a representative panel of rural Indian households. Social Science & Medicine, July 6, 2017.
Among rural households that defecated in the open in 2005, we investigate what baseline properties and what changes over time are associated with switching to latrine use between 2005 and 2012.

Animal feces contribute to domestic fecal contamination: Evidence from E. coli measured in water, hands, food, flies and soil in Bangladesh. Environ. Sci. Technol., July 7, 2017.
We provide empirical evidence of fecal transmission in the domestic environment despite on-site sanitation. Animal feces contribute to fecal contamination, and fecal indicator bacteria do not strictly indicate human fecal contamination when animals are present.

Recent WASH research – July 6, 2017


Editorial: Limited services? The role of shared sanitation in the 2030 Agenda for Sustainable Development. JWASH for Dev. In press. There is no reason to stop investing in shared sanitation. ‘Safely managed’ represents a standard countries should aspire to. However, the 2030 Agenda and the human rights recognise the need for intermediate steps and for reducing inequalities. This calls for prioritising investments in high-quality shared toilets in dense informal settlements where it is the only viable option (short of rehousing) for improving sanitation services.

Assessment of the Acceptability and Feasibility of Child Potties for Safe Child Feces Disposal in Rural Bangladesh. AJTMH, June 2017. Residents of this rural Bangladeshi community accepted the child potties and caregivers found them to be a feasible means of managing child feces. The color, shape, design, and size of the potty influenced its acceptability and use. These residents reported that regular use of the potty improved the household’s physical environment and caregiver and child personal hygiene.

Associations between Household Latrines and the Prevalence of Diarrhea in Idiofa, Democratic Republic of the Congo: A Cross-Sectional Study. AJTMH, June 2017. We have observed the profound protective effect of latrines with a superstructure. This study demonstrates that latrines are associated with significant improvements in health even when they do not fully meet the conditions of improved latrines.

More Poop, More Precision: Improving Epidemiologic Surveillance of Soil-Transmitted Helminths with Multiple Fecal Sampling using the Kato–Katz Technique. AJTMH, July 2017. Our findings show that analysis of an additional fecal sample led to increases of 23%, 26%, and 100% for Ascaris lumbricoides, Trichuris trichiura, and hookworm prevalence, respectively.

Integrated surveillance of antimicrobial resistance in foodborne bacteria: Application of a One Health approach. WHO, 2017. This guidance document is to assist countries and other stakeholders in the establishment and development of programmes of integrated surveillance of antimicrobial resistance in the foodborne bacteria (i.e., bacteria commonly transmitted by food) by taking a One Health approach.

Improving water, sanitation and hygiene in health-care facilities, Liberia. WHO Bulletin, July 2017. National leadership was important to identify a vision and to create an enabling environment for changing the perception of water, sanitation and hygiene in health-care provision. The involvement of health workers was central to address basic infrastructure and hygiene practices in health-care facilities.


Exposure–response relationship of neighbourhood sanitation and children’s diarrhea. Trop Med Intl Health, July 2017. Our findings suggest that neighbourhood sanitation plays a key role in reducing diarrhoeal diseases and that increase in sanitation coverage may only have minimal impact on diarrhoeal illness, unless sufficiently high coverage is achieved.

Behaviour change intervention to improve shared toilet maintenance and cleanliness in urban slums of Dhaka: a cluster-randomised controlled trial. TMIH, early view. In one of few efforts to promote shared toilet cleanliness, intervention compounds were significantly more likely to have cleaner toilets after six months. Future research might explore how residents can self-finance toilet maintenance, or employ mass media to reduce per-capita costs of behaviour change.

If I do not have enough water, then how could I bring additional water for toilet cleaning?! Addressing water scarcity to promote hygienic use of shared toilets in Dhaka, Bangladesh. TMIH, June 27, 2017. Our pilot demonstrates the potential efficacy of low-cost water storage and behavior change communications to improve maintenance of and user satisfaction with shared toilets in urban slum settings.

Recent WASH research – June 30, 2017


Status of water sector regulation in the Middle East and North Africa. World Bank, June 2017. This desk study is a first step intended to provide some basic information on selected countries that will serve as a foundation for determining where further support in the area of regulatory reform might be best concentrated. The authors review the status of regulatory institutions and practices in five MENA countries which were chosen to include different historic and legal frameworks and fragile/conflict states as well as those that are attempting broader sector reform

Bureaucratic blockages : water, civil servants, and community in Tanzania. World Bank, June 2017. How do civil servants in district water and sanitation departments address problems of water access in rural communities in Tanzania? What are the bureaucratic procedures they follow? How do the bureaucratic procedures around formulating budgets, managing money, and interacting with communities impede or enhance their ability to manage water projects? This report addresses these and related questions.

Performance of Water Utilities in Africa. World Bank, 2017. This report looks into how African utilities are doing using a data panel of about 120 utilities in low- and middle-income countries in Africa, which represent about 53 percent of the urban population served by piped network services and covered 14 countries in different parts of Africa.

Groundwater and poverty in sub-Saharan Africa: a short investigation highlighting outstanding knowledge gaps. UPGro Research, 2017. A short study was undertaken in the first quarter of 2017 by the UPGro research programme, to investigate the linkages between groundwater and poverty. The study consisted of four main tasks: a literature review; an overview of UPGro’s contribution to the understanding of groundwater-poverty relationships; three sets of analyses of relevant data; and an investigation into groundwater in selected urban settings.

Ebola virus disease fact sheet. WHO, June 2017. Community engagement is key to successfully controlling outbreaks. Good outbreak control relies on applying a package of interventions, namely case management, infection prevention and control practices, surveillance and contact tracing, a good laboratory service, safe burials and social mobilisation.

Assessing patterns and determinants of latrine use in rural settings: A longitudinal study in Odisha, India. International Journal of Hygiene and Environmental Health, July 2017. 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.

Positive steps with negative studies in the WASH sector. Lancet Global Health, July 2017. By agreeing to publish negative results, journals continue the fight against publication bias by choosing to publish well designed, implemented, and reported studies, even in the face of negative findings. Such negative studies are frequently disappointing to the authors, funders, and implementing organisations. Allowing methodologically sound but disappointingly negative results to receive widespread attention through publication in high-impact journals is the only way that the WASH sector can move forward to find interventions that truly are effective and to jettison conventional wisdom about effective programmes.


Household sanitation is associated with lower risk of bacterial and protozoal enteric infections, but not viral infections and diarrhea, in a cohort study in a low-income urban neighborhood in Vellore, India. Trop Med Int Health. 2017 Jun 27. doi: 10.1111/tmi.12915. The presence of a household toilet was associated with lower risk of bacterial and protozoal enteric infections, but not diarrhea or viral infections, suggesting the health effects of sanitation may be more accurately estimated using outcome measures that account for etiologic agents.

June 26, 2017 – Recent WASH research


Handwashing in 51 Countries: Analysis of Proxy Measures of Handwashing Behavior in Multiple Indicator Cluster Surveys and Demographic and Health Surveys, 2010–2013. Am Jnl Trop Med & Hygiene, June 12, 2017.

The objective of this analysis is to describe global handwashing patterns using two proxy indicators for handwashing behavior from 51 DHS and MICS surveys conducted in 2010–2013: availability of soap anywhere in the dwelling and access to a handwashing place with soap and water. We found large disparities for both indicators across regions, and even among countries within the same World Health Organization region.

Food safety in developing countries: research gaps and opportunities. Feed the Future, 2017.
There are four major lines of defense against FBD: Improving the safety of inputs; Improving the chemical and microbiological safety of raw foodstuffs; Using food processing technologies that mitigate risk (pasteurization and irradiation) and prevent contamination; Behaviour change aimed at food handlers, including home-based food handlers.

A re-assessment of the safety of silver in household water treatment: rapid systematic review of mammalian in vivo genotoxicity studies. Environmental Health, June 20, 2017.

With the available evidence it is not possible to be definitive about risks to human health from oral exposure to silver particulates. However, the balance of evidence suggests that there should be concerns especially when considering the evidence from jewellery workers. There is an urgent need to determine whether people exposed to particulate silver as part of drinking water treatment have evidence of DNA damage.

Towards sustainable utilisation of water resources: a comprehensive analysis of Ghana’s National Water Policy. Water Policy, June 2017.

This paper evaluates the policy to highlight its strengths and weaknesses, to inform possible future review and guide new policy development in developing countries or troubleshoot existing policies. It draws on a framework based on three thematic areas distilled from global water policy development guidelines.


Clean water, clean hands or new vaccines? Journal of Infection, June 2017.

Water/sanitation/hygiene professionals have attempted, with only limited success, to reduce fecal exposure and human disease in the absence of definitive civil engineering approaches. Medical professionals have worked to develop vaccines against some of the most important fecal oral pathogens. Each of these approaches needs further development and adaptation

Recent WASH research


Global status report on water safety plans: A review of proactive risk assessment and risk management practices to ensure the safety of drinking-water. WHO, June 2017. Based on information gathered from 118 countries representing every region of the globe, this report provides a picture of WSP uptake worldwide.

Incorporating the life cycle approach into WASH policies and programmes: A systematic review. 3ieimpact, 2017. This systematic review assesses the extent to which WASH policies, programmes and projects in eleven priority countries have been inclusive of different population segments during the MDG period.

Journal articles

Effect of community health clubs on child diarrhoea in western Rwanda: cluster-randomised controlled trial. Lancet Global Health, June 2017. Community health clubs, in this setting in western Rwanda, had no effect on caregiver-reported diarrhoea among children younger than 5 years.

Is there a difference in prevalence of helminths between households using ecological sanitation and those using traditional pit latrines? A latrine based cross sectional comparative study in Malawi. BMC Research Notes, June 2017. There was no significant difference between overall prevalence of helminths between households using EcoSan and those using traditional pit latrines. However, Ascaris lumbricoides was significantly higher in households using EcoSan latrines.

A methodologic framework for modeling and assessing biomarkers of environmental enteropathy as predictors of growth in infants: an example from a Peruvian birth cohort. AJCN, June 2017. Of the 3 fecal biomarkers studied, 2 that related to intestinal function—AAT and myeloperoxidase—were associatedwith small but highly statistically significant differences in future statural growth trajectories in infants.

Trends of improved water and sanitation coverage around the globe between 1990 and 2010: inequality among countries and performance of official development assistance. Global Health Action, June 12, 2017.

Challenges in developing methods for quantifying the effects of weather and climate on water-associated diseases: A systematic review. PLoS NTDs, June 12, 2017.

Estimation of packaged water consumption and associated plastic waste production from household budget surveys.  Environ. Res. Lett., at press

A pilot-scale microwave technology for sludge sanitization and drying. Science of The Total Environment, December 2017.

Behavioral influences on risk of exposure to fecal contamination in low-resource neighborhoods in Accra, Ghana. Journal of Water and Health, June 2017.

The true costs of participatory sanitation

Plan International USA and The Water Institute at UNC have conducted the first study to present comprehensive, accurate, disaggregated costs of a WaSH behaviour-change programme.  The study calculated programme costs, and local investments for four community-led total sanitation (CLTS) interventions in Ghana and Ethiopia.

CLTS cost study highlights.jpg

Jonny Crocker, Darren Saywell, Katherine F. Shields, Pete Kolsky, Jamie Bartram, The true costs of participatory sanitation : evidence from community-led total sanitation studies in Ghana and Ethiopia. Science of The Total Environment, vol. 601–602, 1 Dec 2017, pp: 1075-1083. DOI: 10.1016/j.scitotenv.2017.05.279 [Open access]


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 behaviour-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 behaviour-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 behaviour-change programs.