The Theory and Practice of Handwashing Habits

At the 2014 UNC Water and Health Conference, the USAID funded WASHplus Project’s Monitoring and Evaluation Advisor, Orlando Hernandez, coordinated a panel session entitled “The Theory and Practice of Handwashing Habits.”  Organized by WASHplus and institutional partners WSP, LSHTM and PPPHW, the panel session focused on the seven principles of habit formation, explored how they could be applied to the handwashing arena, and discussed applications where enabling products have been developed and tried as cues to guide practices and habit formation. Potential implications for future handwashing programs were discussed, beyond the mere creation of cues. A summary of the panel session is provided below:

Diarrheal disease accounts for 11% of child mortality worldwide. Yet, there is a cost-effective way of reducing diarrheal disease in children under five and in turn reduce child mortality: handwashing with soap at critical junctures, especially among caretakers, grouped into two large categories, before food handling and after contact with fecal matter. Handwashing with soap at such junctures can reduce diarrheal incidence by up to 43%.

Handwashing promotion has been an important part of many WASH interventions and such programs have been able to increase handwashing practices among target populations using a variety of approaches. More recently, these approaches rely on conceptual framework that argue in favor of using psychosocial determinants and emotional appeals. Such frameworks have their origin in reflective psychology which suggests that behavior is volitional and guided by factors internal to the individual.

Handwashing programs constructed on reflective psychology theories and models have proven effective to generate behavior change. However, is there any evidence that they have been useful in helping to maintain the practice overtime? Research on the sustainability of handwashing practices overtime is inconclusive. Yet, interpretations of findings overtime suggests that factors in the context in which individuals behave may be partially responsible for their perdurance.

A couple of studies argue in favor of the presence of water and soap as contributing factors to handwashing sustainability. Such suggestions point in the direction of the science of habits which proposes that factors initiating practices are not the same as those that maintain them. Whereas reflective psychological models may explain the practice of new behaviors, reflexive models offer an explanation for keeping them alive.

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“Are you still pouring your WASH investments down the drain?”

WWW 2015

At Stockholm World Water Week 2014, the USAID funded WASHplus Project in partnership with PPPHW, Wateraid and Plan International organized a side event entitled ‘Are you still pouring your WASH investments down the drain?” The meeting promoted the importance of hygiene in the post-2015 agenda including both handwashing with soap. The purpose  was to alert practitioners and donors that investments in infrastructure will not be able to reap desired benefits if done alone without including hygiene, both handwashing with soap and menstrual hygiene management. It was argued that in addition to health and nutrition benefits associated with the hygiene practices advocated, there are other issues to be considered: economic, educational and equity.

On behalf of WASHplus, Dr. Orlando Hernandez, Monitoring and Evaluation Advisor, presented the findings of a recent analysis on the economic cost implications when handwashing is not addressed. Data for Kenya were presented showing that the Kenyan economy could save $153 million/per year given the disease aversion effects of handwashing. This amount is equivalent just over 50% of the Fiscal Year 2013 USAID investment in Kenya and about one third of the central Kenya government health budget in 2012. The analysis was performed by FHI 360 health economists using a methodology developed by Guy Hutton under the Economics of Sanitation Initiative under WSP sponsorship.

view the full presentation here.

What to do with infant poo? The blind spot of the blind spot

Reblogged from http://www.communityledtotalsanitation.org/blog/what-do-infant-poo-blind-spot-blind-spot

infant poo

After a few years researching and working on sanitation, I feel (felt) that I have a good knowledge about the topic, or at least good knowledge of most of it and a clear picture of the areas I should learn more about. Moreover as a shit-worker I –and probably most of us in the sector– have developed a sort of pride or even vanity about being a herald of a neglected cause…

Last week at the UNC Water and Health Conference I was humbled and even slightly embarrassed when I ‘discovered’ the world of children’s faeces in an exciting side session: “What to Do with Infant Poo? Evidence-based Programming to support safe disposal of young children’s faeces”. Convened by WSP, UNICEF and USAID / WASHPlus Project, the session included presentations of experiences from Kenya, Bangladesh and Cambodia, followed by group work on ways forward.

It is not that I ignored everything about child faeces; I had read something, had had some coincidental observations while staying in Indian villages, where I also included the issue partially in household surveys by gathering information of individuals’ defecation practices. But overall my knowledge was limited to the fact that child faeces have more pathogens than adult shit, and therefore should be disposed of safely; I had not fully acknowledged the complexities of the issue and kind of took for granted that improvements in adult sanitation would automatically lead to better management of child faeces. I was thus struck by a study in Bangladesh (by ICDDR,B), a country where adult open defecation is minimal, that showed that only 11-14% of children’s faeces are disposed of in latrines.

I had also not reflected about of the different defecation practices by age groups (my nephew is still in the nappy-phase) which vary country to country and require specific approaches. In Cambodia, for instance, Watershed’s research has shown that children up to six months, not having control over their bowels, rely on nappies (either disposable or reusable –more or less rudimentary). From seven months to two years they generally defecate openly, mostly in the courtyard. From two to five years they start using the potty or the latrine if available.

Finally, I had not given much thought either to how the different choices impact the environment and the implications in terms of solid and liquid waste management. In Cambodia again, in villages with high latrine coverage, when potties are used, in 92% of the cases these are emptied in latrines. Faeces in the courtyard are removed with a scoop or an improvised tool, just to be thrown farther away or in the trash. Baby’s disposable nappies always end up in the trash, which is mostly burnt or buried. Cloth diapers –used by 30%– are emptied in the latrines and then cleaned, but the resulting wastewater is again disposed of in or near the courtyard.

So what to do about children faeces?

The Bangladesh experience was based in supporting caregivers in potty training and promoting the best potty after a test of different models available in the local markets. In Cambodia, efforts have been made to develop potty designs that are more stable than those traditionally used, which small children cannot use on their own. In parallel, WSP and UNICEF are developing 25 country profiles summarising available data on child faeces disposal and providing ideas to strengthen safe practices.

These emergent efforts are very interesting… but very scarce. We need more people and more organisations that engage in this topic and contribute take children faeces out of the blind spot. Please share your thoughts and any related experience you know about!

Celebration Marks End of Open Defecation in Three Villages in Mopti Region, Mali

The WASHplus Project, funded by the United States Government via USAID, triggers change in sanitation practices through the community-led total sanitation (CLTS) approach with a “plus” component that includes an emphasis on hand washing with soap after using the toilet. In Mali the plus component also signifies supply-side interventions to develop and promote low-cost latrine models appropriate to the unique environmental conditions in each district coupled with training community-based masons to build robust latrines using local materials. To complement the CLTS-driven approach in rural areas, WASHplus is beginning a sanitation marketing activity to engage materials suppliers and local entrepreneurs to market a line of aspirational sanitation products in Mopti’s urban areas. The WASHplus project is led by FHI 360 globally. In Mali, WASHplus activities are implemented through CARE International and two Malian NGOs, YAG-TU and Sahel Eco.

Recently the WASHplus Project in Mali organized public ceremonies to certify Open Defecation Free (ODF) status of three villages in the Mopti Region. These villages, each of which are located in priority areas for USAID’s Feed the Future and Global Health initiatives, were recognized as being the first in their municipality to reach ODF status.

From September 25th to 27th 2014, the USAID/Mali Director Gary Juste, accompanied by the Governor of Mopti Region, and the National Director of Sanitation led certification ceremonies in three villages in the presence of national and regional authorities, the CARE Mali Country Director, as well as local officials and residents from the villages. All three villages reached or exceeded the targeted criteria for certifications. The village of Allaye-Daga built 31 latrines against a target of 28. Wendeguele achieved 150% of their latrine target, and Kanikombole built 28 latrines against a target of 10. Local community leaders, women and youth all recognized the importance of the project and the impact safe disposal of human feces with have on the health and nutritional status of the populations, especially children under five. In the village of Allaye Daga, there was not a single latrine before the project, but now everybody uses latrines and the community has adopted social conventions to deal with noncompliance with ODF standards.

Photos from the certification ceremonies are posted below. These photos and description of the certification ceremonies were originally published on the USAID website here: http://www.usaid.gov/news-information/photo-gallery/certification-end-open-air-defecation-ceremony and here: http://www.usaid.gov/mali/news/usaid-promotes-hygiene-and-sanitation-through-innovative-approach

The Mayor of Sio hands out certificate to the village chief
The Mayor of Sio handing certificate over to the chief of the village of Wendeguele. Photo credit: USAID Mali.
Youth in Kanikombole vow to abide by hygiene and sanitation standards
Youth in Kanikombole vow to abide by hygiene and sanitation standards. Photo credit: USAID Mali.
USAID WASH Adviser engages communities on WASH
USAID WASH Adviser engages communities on WASH. Photo credit: USAID Mali.
Girls stood up against open-air defecation
Community-Led Total Sanitation benefits girls in Kanikombole. Photo credit: USAID Mali.
Communities in KaniKombole recognize USAID through a special award handed out to USAID WASH Advisor (Right)
Communities in KaniKombole recognize USAID through a special award handed out to USAID/Mali WASH Advisor (Right). Photo credit: USAID Mali.
USAID/Mali Director and Mopti Governor pose after unveiling the certification plaque. Photo credit: USAID Mali.
USAID Director (right), WASH Adviser (midlle), and Health Office Director
USAID/Mali Director (right), WASH Adviser (middle), and Health Office Director. Photo credit: USAID Mali.
There is the toilet!! Mopti Governor and USAID Director pointing to it
There is the toilet!! Mopti Governor and USAID/Mali Director pointing to it. Photo credit: USAID Mali.
USAID Director and Mopti Governor unveil certification sign board in Wendeguele
USAID/Mali Director and the Governor of Mopti unveil the certification sign board in Wendeguele. Photo credit: USAID Mali.
Mopti Governor and USAID Director visit a latrin under construction
Certification of End-of-open air defecation ceremony: Mopti Governor and USAID/Mali Director visit a latrine under construction. Photo Cresit: USAID Mali
USAID Director hand out certification for Allaye-Daga to Mopti Governor
USAID/Mali Director hand out certification for Allaye-Daga to Mopti Governor. Photo credit: USAID Mali.
USAID Director admires certification plaque for Allaye-Daga
USAID/Mali Director admires certification plaque for Allaye-Daga. Photo credit: USAID Mali.

Highlights from the University of North Carolina 2014 Water and Health Conference

WASHplus had a significant presence at the UNC Water and Health Conference held in October 2014. Staff participated in or lead panels on topics ranging from the theory and practice of habit formation as it relates to hand washing to HIV and MHM to integrating WASH into nutrition. WASHplus also presented a poster on its approach to collecting, curating, and disseminating WASH sector knowledge and information. Links to WASHplus staff presentations at UNC materials can be found here.

WASHplus Presentations at 2014 UNC Water & Health Conference 

Below are highlights from the conference, compiled by WASHplus. 

WATER

Water Systems and Household Water Treatment and Storage 

  • Vestergaard has developed a water filter that may be used by vendors in developing countries to sell treated water to consumers. This unit has a cost of US$310, but they are attempting to have vendors recover the cost by selling water through jerrycan users as well as consumers that may be interested in buying cups of safe water. The jerrycan sales include a jerrycan swap program component which allows water sellers to exchange a consumer-owned jerrycan with one clean one offered by the vendor through this program.
  • Edema Ajomo from the Water Institute at UNC suggested that the following factors influencing the sustainability and scale-up of HWTS programs:
    • User preferences: culture and norms may determine people’s choices (“Black-colored filters are evil because everything that is that color is evil’; “I just cannot stand the smell of chlorinated water”.
    • Integration and collaboration: piggy-back HWTS interventions with other interventions already with known track in the field (‘Add HWTS lecture to a sanitation lecture or promotion activity”) and seek inter-ministerial collaboration
    • Have clear standards, certification and regulation procedures for HWTS
    • Availability of resources: address financial resources needed for consumers to buy promoted HWTS products, but also ensure that there are trained human resources and the necessary supply chain to repair/replace technologies purchased by consumers
  • A study from Bangladesh on POU suggested that direct observation of water treatment in homes may provide a more accurate picture of practices as opposed to chlorine residuals which is considered a more objective measure than self-reports.

Public Financing for Water System Services

IRC, WSUP, and Tremolet Consulting have formed a working group exploring avenues for public financing for WASH services at the local government level. Their work suggests that both taxes and tariffs will need to grow at local governance levels in order to support water services in the long term. The focus of the working group is exploring methods of growing those, or other, revenue streams to finance the life cycle costs of water and sanitation delivery systems.

WSUP is currently conducting research on the role of advocacy at the local level, as well as some experimentation with “sanitation surcharges” attached to municipal water fees in order to cover district government costs of monitoring, enforcing, and supporting sanitation (i.e., a tax that supports the Environment Health Department to conduct its duties).

Water Point Mapping

This was an interesting presentation from the MWA based on their Lazos de Agua work in Central America. They used AKVO-FLOW for a baseline on 1009 households which categorized results into four areas based on the water service level ladder defined by IRC – quantity, quality, accessibility, reliability. The visuals on results were very arresting – for example, you could see what locations scored high on certain dimensions of service but when all four dimensions were considered, few were receiving high levels of water service.

The Global Water Challenge is attempting to compile a global database of all water points (whether collected by govt. NGO, researcher, etc.). They are currently working on a core data set based on what they found to be common denominators.

SANITATION

What To Do with Infant Poo!

Session jointly sponsored by UNICEF, the Water & Sanitation Program of the World Bank, and the USAID/WASHplus Project.

Although the impact of poor sanitation is often measured on children under five, little is known about what happens to the feces OF children under 5. Most sanitation interventions target adults and school aged children.

A reanalysis of DHS/MICS data by UNICEF and the Water & Sanitation Program of the World Bank shows that only 39%-47% of caregivers in 78 low and middle income countries reported using an improved type of feces disposal for their children under five (Null & Reese, 2012 and 2013). Poor, rural and younger children are most at risk for unsafe disposal and its associated impacts.

There are only a few programs focusing on young children’s sanitation, and we have little evidence base for effective strategies for safe disposal of child feces. Significant knowledge gaps must be filled before comprehensive practical evidence-based policy and program guidance will be available. Some organizations and experts are working to fill that gap and have published a number of recommendations and possible methods for incorporating child feces management into existing programs.

The standing room only session at UNC began with a brief overview of the findings from the DHS analysis, and focused on giving an overview of programs and policies by governments and organizations throughout the world which have been implemented to increase the safe management of child feces. Leaders of these programs presented their work in small participatory group discussions. Two sub-sessions focused on the WASH Benefits studies in Kenya and Bangladesh, large RCTs that among other variables are looking at the uptake and impact of several ‘enabling’ technologies for improved infant feces management, technologies like child potties and pooper scoopers to dump open air child feces into the latrine. A third session by the USAID WASHplus project shared the WASHplus experience in Bangladesh, where they are beginning to identify a series of ‘small doable actions’ by age cohort (infant, toddler, young child) to facilitate safe disposal of feces. The last of four sessions focused on the work of WaterShed in Cambodia, also highlighting a range of ‘enabling technologies’ including potties and child-friendly squat mats, to encourage improved infant feces management and document the outcome of these improved practices. WaterShed was successful in improving practices through the use of promotion and enabling technologies.

The final part of the session invited participants to critique a series of recommended actions, organized by categories of increasing demand, improving supply and strengthening the enabling environment. These actions are based on the available evidence base, which though still not comprehensive, allow for pioneering programming to move forward the best practice in this emerging area. Based on participant input, they will be revised and disseminated to guide programming globally.

Confronting the Challenge: Sanitation Behavior Change in Rural North India

Convened by Bill and Melinda Gates Foundation plus the RICE Institute from Emory

Despite large government and NGO programs, despite substantially increased public spending on sanitation, and despite sustained economic growth, open defecation is declining slowly in rural “Hindi heartland” north India. If the international community is going to stop open defecation by 2030 as advocated by the SDGs under discussion, the preference for open defecation that exists in India will have to be addressed. Widespread resistance to using simple latrines in the rural north Indian plains states is a human development challenge, which others refer to as a crisis, and a serious puzzle: this is an area of the world where open defecation is most common and where high population density most raises the human and economic costs of open defecation. And 80% of rural households in India are believed to practice open defecation.

Evidence is now accumulating from many sources that north Indian states present a unique challenge: what worked in Bangladesh, Southeast Asia, or sub-Saharan Africa is unlikely to work here. Below are some of the possible explanations why:

Many people prefer defecating in the open, and believe it is healthier and nicer.

  • Many people may be willing to accept a latrine that they can repurpose, but they have little desire to use one.
  • Millions of households have working latrines that some household members use, but others do not. This is not captured in household-level survey data.
  • Rural north Indian villages are deeply socially fragmented. Any approach that depends on villagers coming together as a “community” will likely fail. In Indian English, the word “community” means common caste or religious group, not geographic neighbors.
  • Many people believe that the proper, religiously pure, and socially acceptable place to put feces is far from one’s own house.
  • Open defecation is an accepted part of life. Indeed, for some people, pit latrines are a disgusting notion!

Rural north India is not “just one place” or “merely one part of a big country,” and concern ourselves with other pockets where open defecation remains but is in the process of going away. How can we learn, tinker, and experiment in Northern India? How can we adjust what worked elsewhere to the different context of rural north India? How can we prevent millions of child deaths and stunted bodies and lives?​ The answer may partially lie in being consumer oriented and in getting the consumers’ voice be heard instead of implementing vertical sanitation programs which may fail.

Evidence of the Efficacy, or Lack Thereof, of CLTS

A number of evaluations examining the health impact of CLTS implementation were conducted, all of which suggest limited ability to trace CLTS back to concrete health metrics. Tom Clausen of Emory/LSHTM did a large randomized control trial on WaterAid’s heavily subsidized sanitation work in India as promoted by the Indian government’s Total Sanitation Campaign, and found no significant health impact: no change in diarrhea, anthropometric measurements such as stunting, or intestinal worm infection. The study found that latrines were being used by less than 70% of the community members (perhaps due to the nature of the approach). It was therefore not surprising that the RCT, despite costing 4.2M dollars to complete, did not detect any change in health outcomes. The findings support the notion that sanitation coverage must reach close to 100% in order to reduce pathogen transmission from the environment to the level which results in health impacts.

Amy Pickering of Stanford did a large 2-year trial of UNICEF’s CLTS work in Mali. She found no effect on diarrhea in ODF certified communities, but did find a significant effect on stunting. The difference in their findings may be due to population density, and baseline sanitation status in Mali vs. India. In essence, CLTS impact goes a longer way in Mali, where population density and baseline sanitation is lower.

Why is CLTS Successful?

The UNC Water Institute has conducted a series of studies with PLAN, looking at the enabling factors for successful CLTS, as well as modalities of CLTS that result in greater and sustained ODF certification among communities. Overall, research suggests that CLTS (even combined with sanitation marketing and other approaches) is not an intervention that works everywhere.

CLTS appears most effective in areas where baseline sanitation coverage is low, but has diminishing returns as sanitation coverage is higher/increased. Similarly, while it does create demand for unimproved toilets, it only minimally impacts uptake of improved toilets and returns are diminishing as coverage increases. As such, it may not be the most appropriate intervention in communities that have even 50% latrine coverage. It is increasingly clear that CLTS needs to be considered more dynamic – what are the various modalities of CLTS that we can implement based on the community and environmental factors.

HYGIENE

The Theory and Practice of Handwashing Habits, organized by USAID/WASHplus and partners including the Water and Sanitation Program, London School of Hygiene & Tropical Medicine, and the Global Public Private Partnership for Handwashing with Soap.

This session focused on the seven principles of habit formation, explored how they could be applied to the handwashing arena, and discussed applications where enabling products have been developed and tried as cues to guide practices and habit formation. Potential implications for future handwashing programs were discussed, beyond the mere creation of cues.

Diarrheal disease accounts for 11% of child mortality worldwide. Yet, there is a cost-effective way of reducing diarrheal disease in children under five and in turn reduce child mortality: handwashing with soap at critical junctures, especially among caretakers, grouped into two large categories, before food handling and after contact with fecal matter. Handwashing with soap at such junctures can reduce diarrheal incidence by up to 43%.

Handwashing promotion has been an important part of many WASH interventions and such programs have been able to increase handwashing practices among target populations using a variety of approaches. More recently, these approaches rely on conceptual framework that argue in favor of using psychosocial determinants and emotional appeals. Such frameworks have their origin in reflective psychology which suggests that behavior is volitional and guided by factors internal to the individual.

Handwashing programs constructed on reflective psychology theories and models have proven effective to generate behavior change. However, is there any evidence that they have been useful in helping to maintain the practice overtime? Research on the sustainability of handwashing practices overtime is inconclusive. Yet, interpretations of findings overtime suggests that factors in the context in which individuals behave may be partially responsible for their perdurance.

A couple of studies argue in favor of the presence of water and soap as contributing factors to handwashing sustainability. Such suggestions point in the direction of the science of habits which proposes that factors initiating practices are not the same as those that maintain them. Whereas reflective psychological models may explain the practice of new behaviors, reflexive models offer an explanation for keeping them alive.

Discovering, Collecting and Curating WASH Sector Knowledge and Information

Launch of Peri-Urban WASH Activity in Benin

women try out hand washing stations

To take advantage of the buzz around Global Handwashing Day in October, WASHplus/Benin organized an official program launch in Enagnon, one of the peri-urban neighborhoods where it is implementing a hygiene and water treatment activity. The event called together project community outreach workers, political and religious leadership, women’s cooperatives, school children, USAID and its key sector partners, with animation by traditional music and theater groups, to mobilize for improving WASH in urban areas. The Ministry of Health served as the convener, as the program is closely tied to its efforts to produce an urban WASH strategy. Attendance was robust—400 people participated in the festivities. The culmination of the event was a visit to the demonstration stands where participants could learn how to make various models of tippy taps and correctly use Aquatabs to safeguard their drinking water.