New WSSCC resource! EQND Handbook for CLTS Facilitators

The Equality and Non-discrimination (EQND) and Community-led Total Sanitation (CLTS) Handbook provides practical guidance for ensuring that behaviour change interventions leave no one behind.

Drawing on experience from across the sector, this handbook is specifically targeted towards those implementing or supervising CLTS interventions at the community level. Key features include:

• A summary of EQND principles
• Step-by-step guidance on applying these principles during pre-triggering, triggering meetings, and post-triggering follow-up visits
• Annexes with practical tools, templates, and resources.

Two other documents of excellent reference include the Human Rights Principles and Terminology – Equality and Non-Discrimination: Supporting the Human Rights to Water and Sanitation (WSSCC, SNV and UTS) and Guidance and Tips for learning from people who may be most disadvantaged during the programme process (WSSCC) both collated by Sarah House.

As well, check out new resources published by the CLTS Knowledge Hub:

• Nine ideas for Gender Transformative WASH programming.
• Frontiers 10: Equality and non-discrimination (EQND) in sanitation programmes at scale (Part 1 of 2)
• Frontiers 13: Support mechanisms to strengthen equality and non-discrimination (EQND) in rural sanitation (Part 2 of 2).   

Development and Application of Novel Caregiver Hygiene Behavior Measures Relating to Food Preparation, Handwashing, and Play Environments in Rural Kenya

Development and Application of Novel Caregiver Hygiene Behavior Measures Relating to Food Preparation, Handwashing, and Play Environments in Rural Kenya. Int. J. Environ. Res. Public Health 2018, 15(9), 1994; https://doi.org/10.3390/ijerph15091994

Exposure to fecal pathogens results in both acute and chronic sequalae in young children. Diarrhea causes nearly 20% of all under-five mortality, while even sub-clinical enteric infections may lead to growth shortfalls. Stunting affects nearly 165 million children globally and results in lifelong and intergenerational effects for the world’s poorest populations. 

Caregiver hygiene behaviors, such as those surrounding handwashing and food preparation, play a critical role in exposure to fecal pathogens; standard metrics to assess these behaviors are warranted to provide a means of quantifying the impact these behaviors have on enteric infections and to evaluate the success or failure of interventions and programs.

This paper documents the development of three novel caregiver hygiene behavior measures: hygienic food preparation and storage, handwashing at key times, and provision of a safe play environment for children under two years.

We developed these measures using formative qualitative work, survey creation and deployment theoretically underpinned by the COM-B model of behavior change, and exploratory and confirmatory factor analysis.

The final measure for hygienic food preparation and storage includes 10 items across two factors; the final measure for handwashing at key times includes 15 items across three factors; and the final measure for safe play environment contains 13 items across three factors.

Future researchers may employ these measures to assess caregiver behaviors in other populations, identify specific behavioral dimensions that should be the focus of interventions, and evaluate interventions and programs

WSSCC Releases New Global Sanitation Fund Equality and Non-Discrimination Study

How can WASH programmes leave no one behind, as called for in the Sustaionable Development Goals? WSSCC’s new study, Scoping and Diagnosis of the Global Sanitation Fund’s Approach to Equality and Non-Discrimination, helps answer this question.

The study reveals that many people who may be considered disadvantaged have benefited positively from WSSCC’s Global Sanitation Fund (GSF)-supported programmes, particularly in open defecation free verified areas. In addition, a range of positive outcomes and impacts related to empowerment, safety, convenience, ease of use, self-esteem, health, dignity, an improved environment and income generation were reported by people who may be considered disadvantaged.

Photo Credit: WSSCC

However, the study finds that GSF has not yet systematically integrated EQND throughout the programme cycle. Across all countries, there are people who have either fallen through the net or whose lives have become more difficult after being unduly pressured, or after taking out loans and selling assets to build toilets. More proactive attention is needed throughout the programme cycle to build on current successes and ensure that people are not left behind or harmed through the actions or omissions of supported programmes.

GSF is in the process of putting the study’s recommendations into practice through revised guidelines, minimum standards, practical tools and other mechanisms.

Download the full study, plus a summarized version with GSF reflections, and annexes

Is Exposure to Animal Feces Harmful to Child Nutrition and Health Outcomes? A Multicountry Observational Analysis

Is Exposure to Animal Feces Harmful to Child Nutrition and Health Outcomes? A Multicountry Observational Analysis. Amer Jnl Trop Med & Hyg, Dec 2016.

• Full text

Authors: Derek Headey, Phuong Nguyen, et . al.

It has recently been hypothesized that exposure to livestock constitutes a significant risk factor for diarrhea and environmental enteric disorder in young children, which may significantly contribute to undernutrition. To date, though, very little research has documented the extent of exposure to animal feces and whether this exposure is associated with child anthropometry in large samples and diverse settings.

This study investigates these issues using data from the Alive and Thrive study conducted in rural areas of Ethiopia, Bangladesh, and Vietnam. These surveys used spot-checks to collect data on proxies of hygiene behaviors such as the cleanliness of mothers, young children, and the homestead environment, including the presence of animal feces. Animal feces were visible in 38–42% of household compounds across the three countries and were positively associated with household livestock ownership and negatively associated with maternal and child cleanliness.

One-sided tests from multivariate least squares models for children 6–24 months of age indicate that the presence of animal feces is significantly and negatively associated with child height-for-age z scores in Ethiopia, Bangladesh, and in a pooled sample, but not in Vietnam.

There is also suggestive evidence that animal feces may be positively associated with diarrhea symptoms in Bangladesh. The results in this article, therefore, contribute to a growing body of evidence suggesting that animal ownership may pose a significant risk to child nutrition and health outcomes in developing countries.

Learning, progress and innovation: Sanitation and hygiene promotion in Madagascar

Learn how the Global Sanitation Fund-supported programme in Madagascar is promoting sustainability and achieving strong sanitation and hygiene results trough a cycle of learning, progress and innovation.

Download the complete case study or explore the sections below:

The national context

Photo: Members of a local sanitation and hygiene advocacy group in the fokontany of Anjalazala celebrate achieving open defecation free status. Credit: FAA/Nirina Roméo Andriamparany

The latest report from the Joint Monitoring Programme of the United Nations Children’s Fund and World Health Organization highlights revealing statistics on Madagascar’s sanitation and hygiene situation. Approximately 12 percent of the country’s population have access to improved sanitation, while 18 percent have access to shared sanitation that is unimproved, and 30 percent have access to other types of unimproved sanitation. Furthermore, 40 percent defecate in the open. Ensuring improved sanitation and hygiene for all remains a major challenge in the country, but innovations from local partners supported by the Global Sanitation Fund (GSF) are vigorously helping to transform this situation.
Learn more

The CLTS journey

Photo: ‘Triggering’ children in the commune of Mangarano, using the open defecation mapping tool. Credit: FAA/Fano Randriamanantsoa

In rural Madagascar, CLTS is the preferred approach for eliminating open defecation, and these actions also drive overall improvements in sanitation and hygiene. CLTS was introduced in the country in 2008, following its success in Asia. The crux of the approach lies in creating an enabling environment in which communities become self-reliant and improve their own sanitation and hygiene situation without external help.

Video: CLTS ‘triggering in action

CLTS focuses on igniting change in sanitation and hygiene behavior within whole communities, rather than constructing toilets through subsidies. During this social awakening, or ‘triggering’ process in Madagascar, the community looks for visible faeces in their environment. When people realize they are eating faeces this provokes disgust, shame and impacts on dignity. The community then makes and immediate decision to end open defecation. These steps are highlighted in the above video.
Learn more

Innovations in sanitation and hygiene behaviour change methods
As the first GSF programme, the Fonds d’Appui pour l’Assainissement (FAA) was the testing ground for various approaches based on the essence of CLTS, which helped to drive the programme’s learning and sharing culture. Sub-grantees have utilized a range of approaches within local communities, sharing their challenges and success with the larger FAA team. Through FAA’s strong learning and sharing system, many of these approaches have been evaluated for their potential to be implemented on a larger scale, and some have become best practices, both within and outside of Madagascar. This case study highlights three best practice approaches evaluated and utilized by the FAA programme: Follow-up MANDONA, local and institutional governance and sanitation marketing.

Follow-up MANDONA

Inspired by CLTS triggering approaches, Follow-up MANDONA is aimed at helping communities speed up their achievement of open defecation free status and initiate the development of local governance mechanisms for sustainability.
Learn more

Read the full article on the WSSCC website.

The disgust box: a novel approach to illustrate water contamination with feces

Below are links to 5 Aug 2015 studies on digust, handwashing and maternal mortality, handwashing and NTDs, water quality awareness and breastfeeding and household characteristics and diarrhea.

The disgust box: a novel approach to illustrate water contamination with feces. Health & Science Bulletin, June 2015.

Link: http://goo.gl/3xDeen

Inadequate drinking water, sanitation and hand hygiene are responsible for approximately 800,000 deaths per year in low and middle-income countries. We evaluated the benefits of a behaviour change communication method to motivate water treatment practices in urban low income communities in Dhaka. We used a device called the ‘Disgust Box’ to provide a vivid demonstration of how piped water is contaminated with faeces to motivate people to chlorinate water. Most of the respondents were able to recall the demonstration at both four-month and one year qualitative assessments. At four months, the majority of participants stated that they still felt disgusted by the demonstration and mentioned it as a motivator for water chlorination. However, after one year, despite being able to recall the demonstration, disgust was no longer mentioned as a motivator to chlorinate water. The Disgust Box has the potential to be an effective communication method to motivate water treatment but additional research is necessary to establish a more sustainable approach to reinforce behaviour change.

Using Observational Data to Estimate the Effect of Hand Washing and Clean Delivery Kit Use by Birth Attendants on Maternal Deaths after Home Deliveries in Rural Bangladesh, India and Nepal. PLoS One, Aug 2015. Authors: Nadine Seward, et al.

Link: http://goo.gl/02uiRi

Our evidence suggests that hand washing in delivery is critical for maternal survival among home deliveries in rural South Asia, although the exact magnitude of this effect is uncertain due to inherent biases associated with observational data from low resource settings. Our findings indicating kit use does not improve maternal survival, suggests that the soap is not being used in all instances that kit use is being reported.

Assessment of water, sanitation, and hygiene practices and associated factors in a Buruli ulcer endemic district in Benin (West Africa). BMC Public Health, Aug 2015.

Link: http://goo.gl/CZvJPJ

BU is an important conditions in the district of Lalo with 917 new cases detected from 2006 to 2012. More than 49 % of the household surveyed used unimproved water sources for their daily needs. Only 8.7 % of the investigated household had improved sanitation facilities at home and 9.7 % had improved hygiene behavior. The type of housing as an indicator of the socioeconomic status, the permanent availability of soap and improved hygiene practices were identified as the main factors positively associated with improved sanitation status.

Can WASH deliver more than just sanitation?

Through successful WASH intervention, communities access a new service that improves their quality of life, and also learn about equity and inclusion.

Blog by development expert Suvojit Chattopadhyay

The abysmal state of access to safe water and sanitation facilities in the developing world is currently a major cause for alarm; 580,000 children die every year from preventable diarrheal diseases. This is due largely to the 2.5 billion people around the globe who do not have access to safe sanitation. Not only can an effective WASH intervention save lives, it can also engineer changes in the social fabric of communities that adopt these behavioural changes. This points to a key attribute of a successful WASH intervention – that through these programmes, communities not only access a new service that improves their quality of life, but they also learn from being part of a concrete intervention that emphasises equity and inclusion.

Let me explain how. Safe sanitation is essentially ‘total’. In a community, even one family practising open defecation puts the health of other families at risk. Also, unsafe sanitation practices pollute local potable and drinking water sources in the habitations. Together, this can undo any gains from partial coverage of WASH interventions. This much is now widely accepted by sanitation practitioners around the world. However, there remains a serious challenge when it comes to the implementation of this concept.

When a community is introduced to a WASH-focused behaviour change campaign, there are often variations in the levels of take-up in different families. This could be because of several barriers – financial ability, cultural beliefs, education levels, etc. In response, external agencies have many options. They can focus more on families in their behaviour change campaigns, offer them material and financial support or incentives, or exert peer pressure (which may in some cases become coercive, etc).

However, the best approach – whether facilitated by an external agent or not – is for a community to devise a collective response. The issue should be framed as a collective action problem that requires solving for the creation of a public good. In many instances, communities have come together to support the poorest families – social engineering at its finest. At its best, recognising the needs of every member of a community will lead to a recognition of the challenges that the typically marginalised groups face. It is this recognition that could prompt a rethink of social norms and relationships.

Read the full article on the WSSCC Guardian partner zone.

Raise your hand for hygiene: Sign on to call for a global hygiene indicator in the SDGs!

Join the call for a global-level hygiene indicator in the Sustainable Development Goals! Source: Global Public-Private Partnership for Handwashing

The issue: The Post-2015 Sustainable Development Goals are the successors to the Millennium Development Goals; a draft was published, and the details of the SDGs are being negotiated now. Hygiene is essential for achieving global development, and is therefore included as a target as part of Goal 6. Countries will commit to demonstrating progress on achieving the targets by reporting on indicators. However, in the recent list of global-level indicators being considered by the UN Statistical Commission, hygiene has been deleted. This is likely because the decision makers want a shorter list of indicators. However, demoting hygiene to a huge, secondary list of ‘optional’ indicators will not give hygiene the priority needed for the SDGs to have real impact on both hygiene and the areas that it influences—such as health, education, and equity.

Objective: The JMP Communications and Advocacy Group is coordinating delivery of a persuasive message about the importance of hygiene to encourage decision makers and stakeholders to act and recommend the reinstatement of a hygiene indicator in the list of global-level indicators for the SDGs.

Audience: This letter will be sent to members of the UN Statistical Commission and others who may have the opportunity to influence discussions and decisions around the SDG Indicators process.

Global Sanitation Fund reports large-scale advances in sanitation and hygiene in 13 countries

Lucie Obiokang with the toilet she built after being triggered.

A new report shows that the Global Sanitation Fund (GSF) has supported governments and hundreds of their national partners in 13 countries, stretching from Cambodia to Senegal, to enable 7 million people in more than 20,500 communities to end open defecation.   

These results are published in the GSF’s latest Progress Report (link to report; link to photos), which highlights cumulative results from the start of the fund until the end of 2014. Nationally-led programmes supported by the GSF have enabled:

• 4.2 million people with improved toilets
• 7 million people and more than 20,500 communities to be open-defecation free
• 8 million people with handwashing facilities

Currently, 2.5 billion people, or 40% of the global population, lack access to decent sanitation. Of those, more than a billion defecate in the open. Diarrheal disease, largely caused by poor sanitation and hygiene, is a leading cause of malnutrition, stunting and child mortality, claiming nearly 600,000 under-5 lives every year. Inadequate facilities also affect education and economic productivity and impact the dignity and personal safety of women and girls.

Established by the Water Supply and Sanitation Collaborative Council (WSSCC), the GSF funds behaviour change activities to help large numbers of poor people in the hardest-to-reach areas attain safe sanitation and adopt good hygiene practices. These activities are community-led, support national efforts, and bring together a diverse group of stakeholders in order to address, at a large scale, the severe deficiencies in access to sanitation and hygiene.

The GSF is a pooled financing mechanism with the potential to further accelerate access to sanitation for hundreds of millions of people over the next 15 years. Between 2013 and 2014 alone, the GSF reported an almost 90 percent increase in the number of people living open-defecation free in target regions of 13 countries[1] across Africa and Asia. During this same period, the GSF has also supported a 55 percent increase in the number of people with access to improved toilets in those same areas. The United Nations system has identified global funds as an important tool to enable member countries to achieve their national development targets, including those for sanitation and hygiene.[2]

“These results prove that we are moving closer to our vision of a world where everybody has sustained sanitation and hygiene, supported by safe water,” said Chris Williams, Executive Director of WSSCC.  “This is a crucial step towards achieving better health, reducing poverty and ensuring environmental sustainability for the most marginalized people in the world.”

These GSF results have been achieved due to the work of more than 200 partners, including executing agencies and sub-grantees composed of representatives from governments, international organizations, academic institutions, the United Nations and civil society. One of the strongest success factors in the GSF approach is that it allows flexibility for countries to develop their programmes within the context of their own institutional framework and according to their own specific sanitation and hygiene needs, sector capacity and stakeholders. This implementation methodology is used to reach large numbers of households in a relatively short period of time and is vital for scaling up safe sanitation and hygiene practices.

“GSF is one of the few funds for government-led, donor-funded sanitation and hygiene programmes,” said Williams. “It can uniquely serve as a catalyst to the wider sector as a model that is replicable for others interested in large-scale behaviour change.”

Reaching scale has required that sub-grantees can identify influential, strategic communities, and make effective use of natural leaders, religious and local leaders, or hundreds of others who serve as individual sanitation and hygiene champions. GSF supported programmes apply a local delivery mechanism that engages households in thousands of villages, which enables people to make informed decisions about their sanitation and hygiene behaviour that can improve their health, education and productivity.

The report also highlights the GSF’s impact on national programmes. In Uganda, there are now more than 1.4 million people living in open-defecation free (ODF) environments, thanks to GSF-funded activities, and close to three million people have been reached by hygiene messages as a result of decentralized local government intervention. In Madagascar, over 1.3 million people are now living in ODF environments – in all 22 of the countries regions – and India’s GSF-supported programme has over 782,000 people with handwashing facilities.

“Access to improved sanitation has to be a sustainable reality for every person in the community, regardless of age, gender or disability, in order for the health and other benefits to be enjoyed by all,” said David Shimkus, Programme Director of the GSF. “This report shows that GSF-supported programmes are making major strides in achieving improved sanitation and hygiene for the most vulnerable, and all stakeholders will continue to work together to ensure such progress continues.”

The Governments of Australia, Finland, the Netherlands, Sweden, Switzerland and the United Kingdom have contributed to the GSF since its establishment in 2008. Close to $105 million has been committed for 13 country programmes, which aim to reach 36 million people.

[1] Benin, Cambodia, Ethiopia, India, Kenya, Madagascar, Malawi, Nepal, Nigeria, Senegal, Tanzania, Togo and Uganda.

[2] See draft outcome document for the forthcoming Addis Ababa Accord of the Third International Conference on Financing for Development, and the UN Sustainable Development Solutions Network Financing for Sustainable Development report and its Role of Global Funds in a Post-2015 Development Framework.

WASHplus Weekly: Focus on Hygiene

WASHplus Weekly – Issue 190| May 8, 2015 | Focus on Hygiene

This issue focuses on hygiene advocacy, hygiene promotion, and hygiene in emergency settings. Included are webinars; a toolkit; a literature review from the Global Public-Private Partnership for Handwashing; a blog post by Orlando Hernandez, USAID/WASHplus project; IRC and BRAC reports on handwashing promotion; World Health Organization (WHO) hygiene guidelines for Ebola and other emergencies; and other studies and resources. 

WEBINARS

Healing Hands: The Role of Hand Hygiene in Healthcare Globally. May 2015. Global Public-Private Partnership for Handwashing (PPPHW). Link
PPPHW hosted this webinar to discuss the importance of hand hygiene in health care, the challenges of achieving good hand hygiene, and lessons for improving hand hygiene in health care settings. The speakers included Benedetta Allegranzi, the WHO’s Lead for the Clean Care is Safer Care program, Cyrus Engineer, director of the Healthcare Management Program at Towson University, and Robert Aunger from the London School of Hygiene and Tropical Medicine.

Handwashing and Global Food Hygiene: A World Health Day Webinar. April 2015. PPPHW. Link
This webinar explores why food hygiene matters for child health in the global context. It includes a case study from the London School of Hygiene and Tropical Medicine about a creative food and handwashing behavior change intervention in Nepal; WASHplus’s Julia Rosenbaum talks about small doable actions; and UNICEF discusses the successes and challenges associated with its group handwashing and mid-day meal program in India.

TOOLKITS

Hygiene Advocacy Toolkit, 2015. PPPHW. Link
Developed by PPPHW, in cooperation with the UNICEF/WHO Joint Monitoring Programme’s Advocacy and Communications Group, this hygiene advocacy toolkit is an evidence-based resource that outlines why hygiene must be a priority in the post-2015 development agenda and beyond. The role of hygiene in the global development agenda is misunderstood. This toolkit seeks to address any confusion and provide the necessary facts and talking points to successfully advocate for the inclusion of hygiene in the Post-2015 Sustainable Development Goals.

Community Handwashing Guide: Utilizing Available Resources to Initiate a Handwashing Intervention. World Med Health Policy, Mar 2014. MP Sandhu. Link (The full text of this article can be downloaded free of charge through May 2015.)
In this article, the current handwashing recommendations and their applicability to hygiene interventions in developing nations were examined. The results of this review suggested that a new handwashing paradigm is needed to address the varying resources available for hand hygiene. Thus, a novel community handwashing guide was developed. This guide emphasizes the importance of increasing access to physical handwashing resources in developing communities, and can be applied to communities regardless of their socioeconomic status. The community handwashing guide promotes sustainable, incremental improvements in hygiene within a community, and is a more feasible approach than previous recommendations.

LITERATURE REVIEWS

Handwashing Research Summary: What We Learned about Handwashing in the First Quarter of 2015.  L McCay, PPPHW. Link
Between January and March 2015, 16 relevant peer-reviewed handwashing studies were published. This review discusses studies on the benefits of handwashing, measurement of handwashing behavior, handwashing “hardware,” and other topics.

Improving Household Food Hygiene in a Development Context, 2015. M Woldt, FANTA. Link
This literature review presents information on foodborne disease and key areas and considerations at the household level to reduce foodborne contaminants in developing countries. Recommendations on potential programmatic and research activities related to foodborne disease are also included.