Study examines sustainability of CLTS programmes in Africa

Despite the widespread implementation of Community Led Total Sanitation (CLTS) programs and many claims of success, there has been very little systematic investigation into their sustainability.  A new study, which aims to change that, is creating a stir in the WASH sector.

A study commissioned by Plan International on the sustainability of CLTS programs in Africa revealed that 87% of the households still had a functioning latrine. This would indicate a remarkably low rate of reversion (13%) to open defecation (OD) or “slippage”.

However, if the criteria used to originally award open defecation free (ODF) status to villages are used, then the overall slippage rate increased dramatically to  92%. These criteria are:

• A functioning latrine with a superstructure
• A means of keeping flies from the pit (either water seal or lid)
• Absence of excreta in the vicinity of the house
• Hand washing facilities with water and soap or soap-substitute such as ash
• Evidence that the latrine and hand washing facilities were being used

“SuperAmma” campaign results in significant improvements in people’s handwashing behaviour

“SuperAmma” campaign results in significant improvements in people’s handwashing behaviour | Source: SHARE, Feb 27 2014 |

A unique handwashing campaign jointly funded by SHARE and the Wellcome Trust has shown for the first time that using emotional motivators – such as feelings of disgust and nurture – rather than health messages, can result in significant, long-lasting improvements in people’s handwashing behaviour, and could in turn help to reduce the risk of infectious diseases. 

“Every year, diarrhoea kills around 800,000 children under 5 years old. Handwashing with soap could prevent perhaps a third of these deaths”, explains study author Dr Val Curtis, from the London School of Hygiene & Tropical Medicine (LSHTM).

“Handwashing campaigns usually try to educate people with health messages about germs and diseases, but so far efforts to change handwashing behaviour on a large scale have had little success. Understanding the motivating factors for routine hand washing is essential to any initiative likely to achieve lasting behaviour change.”

An evaluation of the behaviour-change intervention, published by the Lancet Global Health journal today, shows that 6 months after the campaign was rolled out in 14 villages in rural India, rates of handwashing with soap increased by 31%, compared to communities without the programme, and were sustained for 12 months.

Tropical plant Moringa provides alternative to soap for handwashing

Moringa oleofera leaves and powder. Photo: New Flavor House Inc.

SHARE-funded research [1] has found that Moringa oleifera, a common plant in many tropical and subtropical countries, can be an effective handwashing product if used in the correct concentration. Laboratory tests show that the plant has antibacterial activity against different pathogen, but its potential effect as a hand washing product had not been studied before.

By testing the effect of Moringa oleifera leaf powder on hands artificially contaminated with E. coli and comparing this to the effect of non-medicated liquid soap, the researchers from the London School of Hygiene and Tropical Medicine and SBI Consulting Ltd in Mozambique found that four grams of Moringa oleifera powder had the same effect as non-medicated soap when used for hand washing.

The next step will be to try this product in real conditions and study its acceptability and convenience for potential users.

To take part in a discussion on the use of Moringa as soap visit the SuSanA  Forum.

SHARE stands for Sanitation and Hygiene Applied Research for Equity, and is a five year initiative (2010-2015) funded by the UK Department for International Development

[1] Torondel, B., Opare, D., Brandberg, B., Cobb, E. and Cairncross, S., 2014. Efficacy of Moringa oleifera leaf powder as a hand- washing product : a crossover controlled study among healthy volunteers. BMC complementary and alternative medicine, 14 (57), pp. 1-7.   doi:10.1186/1472-6882-14-57

Source: SHARE, 21 Feb 2014

UNICEF – Handwashing Promotion: Monitoring and Evaluation Module

Handwashing Promotion: Monitoring and Evaluation Module, 2013. UNICEF.

• Full text, pdf

Prepared by Jelena Vujcic, MPH and Pavani K. Ram, MD, University at Buffalo. 

This guide will walk you through planning and implementing monitoring and evaluation (M&E) for your handwashing promotion programme. Programmes that promote handwashing are diverse and vary in scope. The content of this module is designed to be adapted to a variety of programmes. In this guide, you will be introduced to:

• The 7 major steps of monitoring and evaluating handwashing promotion.
• Choosing indicators appropriate to the programme’s objectives.
• Collecting the necessary data, and sample questions for indicators relevant to handwashing advocacy, education and behaviour change.
• Health impact measurement and caveats for the inclusion of health impact assessment as part of an M&E plan.

How to Trigger for Handwashing with Soap

How to Trigger for Handwashing with Soap.  Frontiers of CLTS:  Innovations and Insights, Issue 02, January 2014.

• Full text, pdf

Author: Jolly Ann Maulit for UNICEF Malawi 

The Open Defecation Free (ODF) Malawi 2015 Strategy and National Hand Washing Campaign have been contributing to an increased focus on handwashing with soap (HWWS) in Malawi. This is a very positive development!

Some studies estimate that washing hands with soap can reduce diarrhoeal disease rates by up to 50 per cent and respiratory disease rates by up to 25 per cent. This makes handwashing with soap one of the most cost-effective interventions for reducing illness and preventable deaths among children in Malawi. It is therefore quite worthwhile for us to be working together to increase handwashing practices.

Since Community-Led Total Sanitation (CLTS) is our key intervention for sanitation and hygiene promotion in Malawi, it provides an excellent opportunity to facilitate handwashing behaviour change. However, up till now, the ‘triggering tools’ for achieving HWWS behaviour change from CLTS have not been well known by implementers in Malawi. The purpose of this document is to outline several practical tools which can be used as a part of CLTS in order to trigger realisation among communities of the importance of handwashing with soap, as well as eliminating open defecation.

 

 

 

Annotated Bibliography of 2013 Handwashing Studies

An Annotated Bibliography of 2013 Handwashing Studies

This annotated bibliography was compiled by WASHplus and contains citations and abstracts to 20 peer-review handwashing studies that were published from January through September 2013. Links are also provided to the abstract or full-text for each article. Please email WASHplus if you have additional studies to include. 

JOURNAL ARTICLES, BY PUBLICATION DATE

SEPTEMBER 2013

1 — Handwashing before Food Preparation and Child Feeding: A Missed Opportunity for Hygiene Promotion. Am J Trop Med Hyg, Sep 2013. F Nizame. (Abstract)
From 50 randomly selected villages in Bangladesh, we collected quantitative and qualitative data on handwashing linked to child feeding to integrate handwashing promotion into a young child complementary feeding program. Most participants cited the unavailability of soap and water near the cooking place as a barrier to handwashing before food preparation. Most caregivers ranked nurturing messages as the best motivator to encourage handwashing with soap.

2–Designing a Handwashing Station for Infrastructure-Restricted Communities in Bangladesh Using the Integrated Behavioural Model for Water, Sanitation and Hygiene Interventions (IBM-WASH). BMC Public Health, Sep 2013. K Hulland. (Full text)
Handwashing stations — a dedicated, convenient location where both soap and water are available for handwashing — are associated with improved handwashing practices. Our aim was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour. Factors that influenced selection of candidate designs were market availability of low cost, durable materials that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity, ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific handwashing station designs. A number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal.

3–A Qualitative Evaluation of Hand Drying Practices among Kenyans. PLoS One, Sept 2013. B Person. (Full text)
Recommended disease prevention behaviors of hand washing, hygienic hand drying, and covering one’s mouth and nose in a hygienic manner when coughing and sneezing appear to be simple behaviors but continue to be a challenge to successfully promote and sustain worldwide. We conducted a qualitative inquiry to better understand current hand drying behaviors associated with activities of daily living, and mouth and nose covering practices, among Kenyans. We conducted 7 focus group discussions; 30 in-depth interviews; 10 structured household observations; and 75 structured observations in public venues in the urban area of Kisumu; rural communities surrounding Kisumu; and a peri-urban area outside Nairobi, Kenya. Using a grounded theory approach, we transcribed and coded the narrative data followed by thematic analysis of the emergent themes. Hand drying, specifically on a clean towel, was not a common practice among our participants. Most women dried their hands on their waist cloth, called a leso, or their clothes whether they were cooking, eating or cleaning the nose of a young child. If men dried their hands, they used their trousers or a handkerchief.

Designing a handwashing station for infrastructure-restricted communities in Bangladesh

Designing a handwashing station for infrastructure-restricted communities in Bangladesh using the integrated behavioural model for water, sanitation and hygiene interventions (IBM-WASH). BMC Public Health, Sept 2013, 13:877.

• Full text

Kristyna RS, et al.

Background – In Bangladesh diarrhoeal disease and respiratory infections contribute significantly to morbidity and mortality. Handwashing with soap reduces the risk of infection; however, handwashing rates in infrastructure-restricted settings remain low. Handwashing stations — a dedicated, convenient location where both soap and water are available for handwashing — are associated with improved handwashing practices. Our aim was to identify a locally feasible and acceptable handwashing station that enabled frequent handwashing for two subsequent randomized trials testing the health effects of this behaviour.

Methods – We conducted formative research in the form of household trials of improved practices in urban and rural Bangladesh. Seven candidate handwashing technologies were tested by nine to ten households each during two iterative phases. We conducted interviews with participants during an introductory visit and two to five follow up visits over two to six weeks, depending on the phase. We used the Integrated Behavioural Model for Water, Sanitation and Hygiene (IBM-WASH) to guide selection of candidate handwashing stations and data analysis. Factors presented in the IBM-WASH informed thematic coding of interview transcripts and contextualized feasibility and acceptability of specific handwashing station designs.

Results – Factors that influenced selection of candidate designs were market availability of low cost, durable materials that were easy to replace or replenish in an infrastructure-restricted and shared environment. Water storage capacity, ease of use and maintenance, and quality of materials determined the acceptability and feasibility of specific handwashing station designs. After examining technology, psychosocial and contextual factors, we selected a handwashing system with two different water storage capacities, each with a tap, stand, basin, soapy water bottle and detergent powder for pilot testing in preparation for the subsequent randomized trials.

Conclusions – A number of contextual, psychosocial and technological factors influence use of handwashing stations at five aggregate levels, from habitual to societal. In interventions that require a handwashing station to facilitate frequent handwashing with soap, elements of the technology, such as capacity, durability and location(s) within the household are key to high feasibility and acceptability. More than one handwashing station per household may be required. IBM-WASH helped guide the research and research in-turn helped validate the framework.

Handwashing With Soap Can Help Us Achieve the Millennium Development Goals

Handwashing With Soap Can Help Us Achieve the Millennium Development Goals by Myriam Sidibe, Global Social Mission Director, Unilever-Lifebuoy | Source: Huffington Post blog, July 6, 2013

Being able to live a clean, active and healthy life should be a basic human right. Yet, this is not a privilege that everyone has — a point underscored by two high level reports last week.

Myriam Sidibe is Lifebuoy’s Global Social Mission Director.

UNICEF’s latest report reminds us that pneumonia and diarrhoea are the biggest killers of children globally, causing the deaths of approximately two million children under the age of five, every year. Meanwhile the World Health Organisation (WHO) reported that despite significant progress, the world is unlikely to meet the fourth Millennium Development Goal – to reduce child mortality by two-thirds from 1990 levels.

Both reports come at a critical point in time: the world has less than three years to scale-up efforts to achieve the Millennium Development Goals. At Unilever we want to scale-up our own efforts on this front.

UNICEF’s report points to areas where business can help achieve the fourth Millennium Development Goal. Not only can diarrhoea and pneumonia be prevented through basic best practices, including frequent handwashing with soap at key occasions, but also more awareness raising campaigns could reduce deaths caused by pneumonia by 30 percent and diarrhoea by 60 percent — potentially saving more than two million children by 2015. This would be a significant progress in the aim to achieve the fourth Millennium Development Goal and reduce infant mortality.

Although we’re seeing a steady increase in awareness raising campaigns that demonstrate the link between health and good hygiene — from the WHO’s Clean Care is Safe Care programme through to the Global Public Private Partnership for Handwashing with Soap – more needs to be done to ensure that governments prioritise hygiene education programmes.

WASH for Life grants for the HappyTap and six other innovations

WaterSHED’s Vietnamese HappyTap. Photo: WaterSHED

The HappyTap, a low-cost handwashing device for the Vietnamese market, is one of seven innovations to receive a grant from the WASH for Life Partnership. This US$ 17 million initiative is co-funded by the Bill & Melinda Gates Foundation and USAID’s Development Innovation Ventures (DIV).

In 2010, with USAID support, the WaterSHED program teamed with the Water and Sanitation Program (WSP) to develop and market a new handwashing device. The design came from IDEO.org, which itself has received a WASH for Life grant for Clean Kumasi, an digitally-supported approach to Community-Led Total Sanitation (CLTS). Together with Water and Sanitation for the Urban Poor (WSUP), IDEO.org is working to combat open defecation in Kumasi, Ghana using mobile phones and open-source mapping.

Examples of signs posted to prompt residents to flash Clean Kumasi. Photo: IDEO.org

Save Lives, Clean your Hands – BRAC video

The BRAC WASH programme in Bangladesh has produced a new handwashing promotion video. It shows slides of handwashing promotion sessions for different groups (children, adolescent girls, women, men), as well as for schools, village WASH committees and mosques (imams).

The video was released on 5 May to coincide with the World Health Organization’s (WHO) annual global campaign  to promote better hand hygiene in health care.