WASHplus Benin Carries Out Experimental Urban CLTS

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WASHplus with local implementing partner ABMS/PSI improves hygiene conditions through behavior change and community mobilization in two peri-urban neighborhoods of Cotonou, the largest city of Benin. Wedged between the Atlantic Ocean and lagoons, Cotonou is floodprone and its slum neighborhoods experience cholera outbreaks during the rainy season. After promoting handwashing with soap and chlorination of household drinking water in 1,700 households, the pressing issue of open defecation came up time and again. The few public latrines are rickety structures built over the lagoons, but most residents prefer open defecation to these unsafe facilities. WASHplus connected with the provincial office of the Ministry of Health (MOH) responsible for sanitation in these zones to join in a first-ever (for Benin) experiment in community-led total sanitation (CLTS) adapted for peri-urban settings.

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After adapting and testing CLTS tools for this new setting, all decision making and influential (social, religious, and governmental) persons from the two target neighborhoods were invited for an institutional “pre-triggering” prior to involving the entire community. They saw results of a simple survey situating the open defecation spots and public and household toilets. Community triggering was carried out on May 13. About 75 residents assembled in an open space, and two trained MOH facilitators led the group through the mapping exercise and a calculation of health-related household expenses. The Walk of Shame was not carried out as the event was far from the open defecation place. The result in urban areas is not necessarily a decision to construct latrines, and in this case, the group decided to create a special task force to follow up the decisions to destroy the open defecation places and work with the rest of the community to come up with solutions, especially concerning work with managers for the improvement of public latrines. The residents expressed a desire for modern toilets and said they were prepared to pay for them.

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CLTS in this setting is different from rural settings, where the local chief has the power to convene and order people to implement decisions. These neighborhoods are extremely heterogeneous. Also, open defecation is forbidden by law, and the residents were reluctant to admit to the practice or to identify the open defecation places, thus the pre-survey came in handy. The participation of the “chef quartier,” the highest ranking local official, provided assurances that the decisions will receive strict follow-up. Plans are underway to replicate the triggering in the other zones of this very extensive neighborhood.

WASHplus Year Five Annual Report, October 2015

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In its Year Five Annual Report, WASHplus has stories to tell, results to share, events to celebrate, and studies that add to the evidence base. WASHplus activities serve as the backdrop for many stories: the Zambian school girl who has access to privacy and menstrual supplies when she needs them, the Malian household that can now build an improved latrine on their rocky soil, the mother in Bangladesh who understands the importance of a feces-free environment, the Nepali home breathing cleaner air as it trials an improved cookstove. And perhaps more compelling than the individual stories are the results the project is beginning to record through endline data collection in Kenya and formative research on school enrollment and in Zambia. Providing water, sanitation, and hygiene (WASH) infrastructure to schools is having a notable impact on enrollment. Community-led total sanitation (CLTS) may be inoculating communities exposed to cholera. Numbers also tell the story of the project’s impact. Look for a snapshot of those figures throughout the report.

The conclusion of field activities in Uganda and Zambia this year provided opportunities to reflect, celebrate accomplishments through end-of-project (EOP) events, and share lessons learned. Several articles were published this year in peer-reviewed journals and others submitted on topics ranging from consumer preferences and willingness to pay for improved cookstoves to habit formation and costing of handwashing. WASHplus also played a key role in preparing the joint document on WASH and nutrition for publication and distribution.

WASHplus’s focus on integrating WASH into other development initiatives enabled the project to get in on the ground floor on subjects that are gaining traction at USAID and globally, such as WASH and nutrition, neglected tropical diseases, and MHM. This integration focus dovetailed nicely with the project’s mandate to serve a technical leadership role, and project staff had many opportunities this year to share its work and lessons from the field on a global stage, strategize with partners on important advocacy issues, inform policy, and develop guidance in multiple countries. Also toward that end, WASHplus launched its first two learning briefs on small doable actions and WASH and nutrition. This series details the variety of approaches WASHplus uses to improve WASH and household air pollution (HAP) across its portfolio of countries.

And finally, it’s been an exciting year for innovation with pilot projects underway in Ethiopia and Bangladesh focusing on sanitation marketing and sand envelopment. These two efforts will add to WASHplus’s body of knowledge on sanitation innovation and aligns closely with USAID’s global interest on the topic. WASHplus is also documenting its fecal sludge management work in Madagascar to tell the next chapter in that story.

The usefulness of a handwashing proxy in large household surveys

WASHplus’s Monitoring, Evaluation, Research, and Learning Advisor, Orlando Hernandez, co-authored a paper on the usefulness of a handwashing proxy in large household surveys. An abstract of the paper is provided below.

“Handwashing with soap is a cost-effective way of reducing diarrheal disease mortality in children under 5. Tracking this practice among child caretakers is a challenge, as the gold standard method – structured observations – is cumbersome, costly, and conducive to over-performance. The water, sanitation, and hygiene (WASH) field needs a valid, reliable proxy to track handwashing with soap in large surveys. This proxy is crucial as the new 2015–2030 Sustainable Development Goals (SDGs) may track hygiene. Using data from the Multiple Indicators Cluster Survey (MICS) and the Demographic Health Survey (DHS) from five countries, we conducted multivariate analyses to explore an association between the presence of functional handwashing stations (HWSs), (together with needed supplies) and the likelihood of lower reports of child diarrheal disease. A limited to moderate association exists in three of the five countries considered characterized by comparable rates of childhood diarrhea: Malawi, Sierra Leone, and Zimbabwe. The relationship was detected when controlling for potential confounding factors (other WASH elements, socio-demographic factors, nutrition practices, and immunization status) and when accounting for cluster effects. The likelihood of reported diarrhea among children under 5 increases when there is no HWS, just a handwashing device with no supplies or only water or only soap. The relationship is moderate in Malawi and less strong in Sierra Leone and Zimbabwe. No relationship was found in Ethiopia and Ghana. Further exploration of the usefulness of this proxy in other African and non-African contexts is warranted.”

Read the paper here.

Citation: Victoria Shelus and Orlando L. Hernandez, The usefulness of a handwashing proxy in large household surveys, Available Online 20 August 2015, DOI: 10.2166/washdev.2015.184

 

 

The Science of Habit: Creating Disruptive and Sticky Behavior Change in Handwashing Behavior

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Integrating basic science insights from psychology, cognitive science, and behavior change research, “The Science of Habit: Creating Disruptive and Sticky Behavior Change in Handwashing Behavior” presents six principles for creating greater initiation and maintenance of handwashing change. Read the new WASHplus report here.

Improving Nutrition, One Latrine at a Time: WASH 1,000 Strategy in Ghana Takes Hold

By Christa Elise Reynolds, Knowledge Management Officer, JSI Research & Training Institute, Inc. with USAID SPRING.

Gmangun Charles, of Kubone community in Ghana, shows off his household’s new latrine. (Photo by David Nunoo, SPRING/Ghana WASH Advisor)
Gmangun Charles, of Kubone community in Ghana, shows off his household’s new latrine. (Photo by David Nunoo, SPRING/Ghana WASH Advisor)

Toilets might not be the first thing you think of in conjunction with basic human nutrition, but inadequate sanitation poses a real danger for 2.5 billion people around the world. When crops become contaminated through open defecation, communities are at risk for disease outbreaks and chronic malnutrition.

This November 19, designated as World Toilet Day, we are reminded of the people lacking access to toilets and improved sanitation. About 1.1 billion people defecate in the open, according to UN-Water. Diarrheal disease, which can prevent nutrients from being absorbed, is a common outcome of improper human waste disposal. This is an issue in Ghana, where approximately 19,000 people die yearly from diarrhea. Nearly 90 percent of those deaths can be attributed to poor water, sanitation, and hygiene (WASH), according to the Water and Sanitation Program.

At the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project, funded by the U.S. Agency for International Development’s (USAID), we are working to improve nutrition through our “WASH 1,000 strategy,” a multifaceted approach stresses the importance of key household behaviors during the first 1,000 days, spanning the mother’s pregnancy to the child’s second birthday. Numerous factors influence a child’s well-being during this time. Our WASH 1,000 strategy focuses on four key behaviors: ensuring the child has a safe and clean play space, safely disposing of human and animal feces, handwashing at critical times, and using only boiled or treated water for the child’s consumption.

Mobilizing communities to build latrines is one of the first steps toward improving sanitation. Working with country partners, we facilitated discussions about the importance of latrines and sanitation in communities in the northern and upper eastern regions of Ghana, and participants have been receptive to the ideas. Installing tippy taps, or simple handwashing stations, near latrines and in households promotes handwashing after using the latrine and before meals, another WASH 1,000 goal.

“I am happy that I and my family do not defecate in the open again. I have restored my lost dignity,” said Gmangun Charles, a resident of the Kubone community in the Mion District of Ghana, who recently constructed a latrine for his household’s use.

Since February 2015, 47 household latrines have been built in the Kubone community. After learning about the benefits of using latrines, residents are increasing community awareness of open defecation’s health risks and shaming those who refuse latrines.

The link between open defecation, hygiene, and nutrition is not obvious and many community members may not be aware of the connection. Because people in the northern and upper eastern regions of Ghana often defecate on farm fields and near water sources, crops can become contaminated. Children might be exposed to human and animal feces while playing, which can lead to infection and diarrhea. Eating with unwashed hands can cause further contamination. Properly built latrines and use of tippy taps reduce this health risk. These latrines are a source of pride for the community members who build them, 14-year old Emmanuel Loteba said.

Though the idea of feces getting into our foods is disgusting, I also felt guilty because we all defecate openly in this village. We were told that the best way to avoid contaminating our food and to live healthy lifestyles is to build household latrines,” Loteba commented.

Loteba lives in Boagnab Yare, a community in Ghana’s upper east region, where diarrheal disease and low nutritional absorption are common. He learned about the WASH 1,000 strategy through one of our trainings. In the Kugbar-Bulug community, another of our WASH 1,000 Ghana sites, 19 of 28 households have already built household latrines. Kwame Awin, a local farmer, is happy with his new latrine because he and his family can finally eat fresh beans from their fields without risking contamination.

World Toilet Day highlights the sanitation needs of billions of people around the world who can’t wait for better hygiene. By encouraging a more holistic understanding of nutrition as it is impacted by WASH, our work in Ghana has begun changing perceptions of latrines and sanitation in the country’s northern and upper eastern regions. SPRING continues to promote WASH 1,000 behaviors to communities and trainers so that they may improve sanitation access, nutrition, and health.

ABOUT THE AUTHOR/ PROJECT: Christa Elise Reynolds is a Knowledge Management Officer working on the USAID SPRING project at JSI Research & Training Institute, Inc. Funded by USAID, the Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) project strengthens country efforts to scale up high-impact nutrition practices and policies. To learn more about SPRING visit the project website at www.spring-nutrition.org and follow @SPRINGProject2 on Twitter.

DISCLAIMER: The contents of this blog post are the responsibility of JSI, and do not necessarily reflect the views of USAID or the United States Government. SPRING’s work is made possible by the generous support of the American people through the United States Agency for International Development (USAID) under the terms of the Cooperative Agreement AID-OAA-A-11-00031 (SPRING), managed by JSI Research & Training Institute, Inc. (JSI).

What the H is the big deal with hygiene?

On October 21, 2015, the Global Public-Private Partnership for Handwashing (PPPHW) and FHI 360 co-hosted a hygiene advocacy event, “What the “H” is the big deal with hygiene?” The event focused on why the “H” in WASH should be silent no longer and how we can help build and maintain the momentum around this crucial component of health and development both in the Sustainable Development Goals (SDGs) and beyond. The event was live streamed and a recording will be made available on the PPPHW website. You can follow the live twitter feed from the learning event here.

Forty attendees from NGOs, universities, and multilateral institutions learned about how Global Handwashing Day was marked around the world, why a hygiene indicator should be included in the Global Goals, and how habits can be leveraged for behavior change. Attendees learned from experts why handwashing matters as we begin to work on the Global Goals, what is new in this old behavior, and how the latest in hygiene behavior change can be applied more widely. To kick off the event, Hanna Washburn, Director of the PPPHW Secretariat spoke on the status of hygiene and why handwashing matters,in the upcoming Global Goals.

WASHplus’s Deputy Director and Behavior Change Specialist Julia Rosenbaum spoke on the latest in hygiene behavior change. Julia’s talk focused on the science of habit as a crucial tool for making hygiene the norm. She spoke about habit formation and how we can make handwashing reflexive (a habit), not reflective. During her presentation Julia also discussed the six underlying principles of a strategy for creating handwashing habits to trigger cues & practice.

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Handwashing Resources from WASHplus

Make it a habitOn Global Handwashing Day and every day we dedicate ourselves to increasing awareness and understanding about the importance of handwashing with soap to prevent diseases and save lives. Please see below handwashing resources developed by WASHplus on: the small doable approach to handwashing; how to make tippy taps for handwashing; making a habit of handwashing; and integrating WASH  into nutrition and HIV programs.

HANDWASHING RESOURCES

sda thumbnailSmall Doable Actions: A Feasible Approach to Behavior Change, Learning Brief, 2015. This brief takes a look at how WASHplus has applied the Small Doable Action approach to handwashing, water treatment, improved sanitation, menstrual hygiene management, and food hygiene.

habitHandwashing and the Science of Habit, Webinar, 2014.  This webinar emphasizes ways to apply the basic science of habit and behavior change to real world health interventions and program delivery, with a focus on behavior change for handwashing with soap.

WASH HIVIntegrating Safe Water, Sanitation, and Hygiene into HIV Programmes: A Training and Resource Pack for Uganda, 2014. This training manual teaches the four key WASH practices: safely transporting, treating, storing, and serving drinking water; safe handling and disposal of feces; safe handling and disposal of menstrual blood; and handwashing with soap (or ash) and water.

WASH nutritionIntegrating Safe Water, Sanitation, and Hygiene into Infant and Child Nutrition Programmes: A Training and Resource Pack for Uganda, 2014. This resource pack can  aid health workers in helping household and community members to overcome, or change, the many daily obstacles to improved water, sanitation, and hygiene (WASH) practices in the home.

tippy tap makingHow to Make Other Types of Tippy Taps, 2014. This pamphlet shows how to make Tippy Taps for handwashing from mineral water bottles, tin cans, and hollow tubes. The tippy tap is a hands free way to wash your hands and is especially appropriate for areas where there is no running water.

Nutrition and Handwashing

This post is a re-blog and first appeared on the Global Public Private Partnership for Handwashing (PPPHW) website here.

March 22, 2015

By Layla McCay, Secretariat Director, the Global Public-Private Partnership for Handwashing (PPPHW)

Love is in the air – or rather, in the water. This World Water Day, nutrition and handwashing with soap may be the hottest ‘celebrity couple’. The two have been enjoying a close relationship for years, so what has propelled them into the public eye, as seen in recent developments such as the new policy in India mandating handwashing before the midday meal in schools? The answer is integration.

Integration means linking different sectors together to leverage synergies and achieve greater impact than could be achieved working alone. It is also the latest buzzword in international development. At first glance, nutrition and handwashing may not seem like obvious bedfellows. One is about ensuring affordable access to adequately nutritious food; the other is about soap, water and turning a behavior into a habit to prevent infections. But in fact, nutrition and handwashing are closely linked.

The World Health Organization (WHO) tells us that 50 percent of child undernutrition cases are due to repeated diarrhea and intestinal infections caused by poor sanitation and hygiene conditions or by a lack of safe water. This means that handwashing with soap is a critical determinant for achieving and maintaining good nutrition. It plays an important part in preventing micronutrient deficiencies, stunting, wasting and nutrition-related deaths. To properly address child undernutrition, we need to address hygiene.

We know that good nutrition is about more than consuming nutritious foods; it’s about the body’s ability to absorb nutrients. If people don’t wash their hands before handling food, disease-carrying germs have a direct route into their mouth and down into their gut where they can inhibit the body’s ability to use the food’s nutrients. In fact, germs can directly consume nutrients before they even get into the body.[i] They can also directly damage the intestinal lining (a condition called environmental enteropathy), which contributes to nutrients being lost in feces instead of being absorbed.[ii] Germs can furthermore irritate the gut lining so that toxins can get inside and cause inflammation – using up nutrients in the process.[iii] Since children who are undernourished are more susceptible to developing diarrhea when they come into contact with disease-causing germs, lack of handwashing and undernutrition can become a vicious cycle.

Good handwashing with soap can prevent nearly half of all cases of childhood diarrhea. It is also estimated that drinking clean water and handwashing with soap can reduce the loss of nutrients through diarrhea, and reduce stunting in children under the age of five by up to 15 percent.[iv],[v] Handwashing with soap should be an integral part of nutrition programs, and this World Water Day, let’s think seriously about their integration. #Wateris fundamental to good nutrition through handwashing. It’s time for handwashing and nutrition to take their relationship to the next level.

This World Water Day share what water means to you by using #WaterIs on social media. 

[i] Solomons NW. Pathways to the impairment of human nutritional status by gastrointestinal pathogens. Parasitology 1993; 107:S19–35.

[ii] Solomons NW. Pathways to the impairment of human nutritional status by gastrointestinal pathogens. Parasitology 1993; 107:S19–35.

[iii] Sharp TM, Estes MK. An inside job: subversion of the host secretory pathway by intestinal pathogens. Curr Opin Infect Dis 2010; 23:464–9.

[iv] Fenn, B. et al. (2012). An evaluation of an operations research project to reduce childhood stunting in a food-insecure area in Ethiopia. Public Health Nutrition, 15(9), 1746-1754.

[v]  Dangour, A. D. et al. (2013). Interventions to improve water quality and supply, sanitation and hygiene practices, and their effects on the nutritional status of children. The Cochrane Library.

Small Doable Actions: Simple Steps That People Can Take to Improve WASH

Small doable actions are simple steps that people can take to improve WASH in their communities!

Benin: Disappearing Tippy Taps, WASH Partout

Benin tippy tap

WASHplus’s peri-urban hygiene improvement project in Benin, being implemented by partner ABMS/PSI, encourages households to build their own tippy taps to facilitate handwashing. Outreach workers noted that tippy taps were disappearing shortly after installation. An inquiry revealed that children were appropriating the tippy taps to use as toys, for lack of better options. In a recent quarterly progress review meeting in two target neighborhoods, outreach workers consulted community leaders and household representatives to come up with solutions. As a result, the group decided to adopt more permanent handwashing stations using 25-liter jerry cans, and install them in the public toilets open to everyone, but which had lacked handwashing facilities.

In another development, in the spirit of “WASH Partout” (WASH Everywhere), the Benin program has branched out from promoting handwashing and water treatment at household level to promotion at the local schools. During a hands-on training, teachers learned how to make different models of tippy taps and incorporate handwashing into their hygiene lessons at school. The schools and staff from implementing partner ABMS/PSI seized the opportunity to formulate criteria and a point system to certify schools as WASH-Friendly.