Sanitation, community environments, and childhood diarrhoea in rural Zimbabwe

Childhood diarrhoea can be transmitted within the household and community environments. This study examined the effect of partial latrine coverage on diarrhoeal morbidity at the household and community levels. Weekly morbidity data on 272 children, aged less than five years, were collected for 45 weeks from October 1996 to August 1997 in two neighbouring semi-arid communities in rural Zimbabwe. The communities were similar except for sanitation. In Community A, 62% of the children lived in households with a latrine, and in Community B, there was no sanitation. Diarrhoeal morbidity was 68% lower in Community A than in Community B. In addition, the children from the households in Community A without a latrine had lower diarrhoeal morbidity than the children in Community B. The inter-community difference in diarrhoeal morbidity was likely to be due to the latrines and associated hygiene education interrupting intra- and inter-household transmission of diarrhoea. The latrines reduced faecal contamination of the community environment, and as diarrhoeal morbidity fell, contact between infectives and susceptibles within the community would also have fallen. The neighbourhoods in Community A where the adjacent households did not have sanitation had higher diarrhoeal morbidity than in the neighbourhoods where one household did have sanitation. The results of the study suggest that sanitation programmes, which share building costs between the state and individuals, i.e. households, and hence, do not achieve complete coverage in a community, benefit the whole community, because the households that cannot afford a latrine experience lower diarrhoeal morbidity due to the safer community environment.     

Sanitation in rural communities in Bangladesh

Household sanitation in developing countries, especially in the rural areas, is poor. An evaluation of what was achieved in this regard during the 1980-90 decade of safe water supply for all was carried out in the present study. It was observed that even where a safe water supply and sanitary latrines were provided, people did not always use them. While 23% of the studied households had sanitary latrines, children in about 11.5% of these households did not use them and women in about 6% of households did not use them for micturition at night. Not a single house in the study area could fulfil all the criteria of sanitary housing in a strict sense; for example, although 34.5% of the households had tubewells, only 11.5% of them had a satisfactory level of water usage. Since socioeconomic conditions and education influence the level of sanitation, improvements in both are required.     

Sustainability of community-led total sanitation outcomes: Evidence from Ethiopia and Ghana

We conducted a study to evaluate the sustainability of community-led total sanitation (CLTS) outcomes in Ethiopia and Ghana. Plan International, with local actors, implemented four CLTS interventions from 2012 to 2014: health extension worker-facilitated CLTS and teacher-facilitated CLTS in Ethiopia, and NGO-facilitated CLTS with and without training for natural leaders in Ghana. We previously evaluated these interventions using survey data collected immediately after implementation ended, and concluded that in Ethiopia health extension workers were more effective facilitators than teachers, and that in Ghana training natural leaders improved CLTS outcomes. For this study, we resurveyed 3831 households one year after implementation ended, and analyzed latrine use and quality to assess post-intervention changes in sanitation outcomes, to determine if our original conclusions were robust. In one of four interventions evaluated (health extension worker-facilitated CLTS in Ethiopia), there was an 8 percentage point increase in open defecation in the year after implementation ended, challenging our prior conclusion on their effectiveness. For the other three interventions, the initial decreases in open defecation of 8–24 percentage points were sustained, with no significant changes occurring in the year after implementation. On average, latrines in Ethiopia were lower quality than those in Ghana. In the year following implementation, forty-five percent of households in Ethiopia repaired or rebuilt latrines that had become unusable, while only 6% did in Ghana possibly due to higher latrine quality. Across all four interventions and three survey rounds, most latrines remained unimproved. Regardless of the intervention, households in villages higher latrine use were more likely to have sustained latrine use, which together with the high latrine repair rates indicates a potential social norm. There are few studies that revisit villages after an initial evaluation to assess sustainability of sanitation outcomes. This study provides new evidence that CLTS outcomes can be sustained in the presence of training provided to local actors, and strengthens previous recommendations that CLTS is not appropriate in all settings and should be combined with efforts to address barriers households face to building higher quality latrines.     

Sustainability and acceptability of latrine provision in The Gambia

All households in 32 villages were provided with improved pit latrines as part of a trachoma control programme in a rural part of The Gambia. Latrine provision was externally driven and was not in response to a request from the communities involved. Materials were provided for free and labour was paid for. To assess durability and acceptability we conducted a follow-up study 25-47 months after construction. Before the intervention only 32% of households in these villages had access to any type of latrine; at follow-up this had risen to 95%. On visual inspection 585/666 latrines (87.3%) were usable and 510 (87.2% of those usable) were currently used. During interviews 566/637 latrine owners (89%) said they were either happy or very happy with their latrines, and 620 (97.3%) reported that they would make a new latrine of some kind when the current one was full or unusable. We interpret these data to suggest that externally driven latrine provision, without additional health education, to an area with poor latrine coverage can result in high, sustainable levels of uptake and generate future demand for sanitation.     

Assessment of Water Use and Sanitation Behavior in a Rural Area of Bangladesh

A health development project was established in a rural area of Bangladesh that entailed training village health promoters to provide health education and to motivate families to install tubewells and sanitary latrines. Following a 2-y period of project implementation, the authors sought to assess knowledge and practice of mothers and family members about use of safe water and household tubewells. A household survey in the project area was compared with a similar one in a nearby control area. Three-hundred households in each area were selected, and mothers were interviewed with a standard questionnaire. Significantly more mothers in the health development project area (45.7%) used tubewell water for domestic purposes than in the control area (32.8%). However, hygienic practices of mothers were inadequate. Sanitary latrines were present in less than 20% of households in both areas. Approximately 97% of mothers and 78% of adult family members always used household latrines. However, the use of household latrines by children was low (26.7%). There was no statistically significant difference in the use of household latrines between the project and control areas. The results showed an improvement in use of household tubewells in the project area; however, there was no improvement in sanitation practices of families in the project area. Health education alone, without improvement of socioeconomic status, is not effective in changing behavior.     

Assessment of water use and sanitation behavior of a rural area in Bangladesh

A health development project was established in a rural area of Bangladesh that entailed training village health promoters to provide health education and to motivate families to install tubewells and sanitary latrines. Following a 2-y period of project implementation, the authors sought to assess knowledge and practice of mothers and family members about use of safe water and household tubewells. A household survey in the project area was compared with a similar one in a nearby control area. Three-hundred households in each area were selected, and mothers were interviewed with a standard questionnaire. Significantly more mothers in the health development project area (45.7%) used tubewell water for domestic purposes than in the control area (32.8%). However, hygienic practices of mothers were inadequate. Sanitary latrines were present in less than 20% of households in both areas. Approximately 97% of mothers and 78% of adult family members always used household latrines. However, the use of household latrines by children was low (26.7%). There was no statistically significant difference in the use of household latrines between the project and control areas. The results showed an improvement in use of household tubewells in the project area; however, there was no improvement in sanitation practices of families in the project area. Health education alone, without improvement of socioeconomic status, is not effective in changing behavior.     

Sustainability of a water, sanitation and hygiene education project in rural Bangladesh: a 5-year follow-up.

An integrated water supply, sanitation and hygiene (WSH) education intervention project was run by the International Centre for Diarrhoeal Disease Research, Bangladesh, over the period 1983-87. In the intervention area the project provided handpumps, pit latrines, and hygiene education to about 800 households. The control population did not receive any interventions, but had access to the usual government and private WSH facilities. After 1987 no external support was provided to maintain these provisions. A cross-sectional follow-up survey, which was carried out in 1992, involved about 500 randomly selected households from the intervention and control areas. In 1992 about 82% of the pumps were still in good functional condition and of these, 94% had been functioning well in 1987. Fewer latrines were functional in 1992 (64%) than at the end of 1987 (93%). In the former intervention area about 84% of the adults were using sanitary latrines in 1992 compared with only 7% in the control area. Knowledge related to disease transmission, however, was poor and similar in both areas. People claimed that they used the WSH facilities to improve the quality of their lives. The prevalence of diarrhoeal diseases in the 1992 survey among the control population was about twice that among those in the intervention area.     

Myanmar experiences in sanitation and hygiene promotion: lessons learned and future directions

Recent activities in connection with the National Sanitation Week (NSW) and Social Mobilisation for Sanitation and Hygiene have contributed to a significant increase in access to sanitary means of excreta disposal, from 45% in 1997 to 67% in 2001. Handwashing with soap and water after defecation has also increased from 18% in 1996 to 43% in 2001. Success is attributable to high level political commitment, state or division level action and community mobilisation by village level authorities. Multi-level efforts such as mass media, planning workshops, training sessions and house-to-house visits by village authorities and health officials have raised greater awareness of sanitation and hygiene issues and led to construction of latrines on a self-help basis. The challenge ahead is to give greater attention to the 'hard to reach' who live in less accessible areas and are more resistant to change. The 2002 NSW has accordingly given special emphasis to activities in 73 of 324 townships where 50% or more of the households have no access to a sanitary latrine. The communication and social mobilisation package has been improved to upgrading unsanitary latrines and integrating handwashing more systematically with promotion of sanitary latrines. Programmatic follow-up to the NSW is being provided in selected townships through more intensive social mobilisation for 'hard to reach' households and activity-based school sanitation and hygiene education. This approach will contribute further towards improved hygienic practices and reduce diarrhoeal morbidity and mortality.     

Monitoring progress of the role of integration of environmental health education with water and sanitation services in changing community behaviours

The health benefits of clean water, improved sanitation and better hygiene are now more recognized than ever before. The objective of the present study focused on monitoring the progress of behavioural changes towards appropriate behaviours related to water, environment and sanitation (WES). This was achieved through assessing the baseline community behaviours towards WES, exploring to what extent community hygienic behaviours had changed towards desirable and sustainable behaviours, through monitoring progress. The expected behavioural changes are results of an integrated package; safe water supply, sanitation, and hygiene education interventions produced by governmental and non-governmental organizations. The monitoring progress consisted of three household surveys that were administered over three years in four Egyptian districts within three Governorates; Fayoum, Beni Suef, and El-Menia. Behavioural changes were detected through special observation checklist indicators. These indicators were 7, 6, and 9 indicators each for personal hygienic behaviours, proper handling of drinking water, and proper use and maintenance of simple constructed sanitary latrines. The results from the baseline to mid-term and final surveys suggested improvement in the majority of the household behaviours towards the desirable behaviours. The proportions of the householders who practiced desirable behaviours were not to the same levels in the four districts. The results provide support to the concept that integrated interventions can produce a significant sustainable improvement in health promotion.     

Environment, wealth, inequality and the burden of disease in the Accra metropolitan area, Ghana

The study examines environmental problems and adverse impacts on the health of urban households in the Accra metropolitan area, Ghana. Accra is faced with severe inadequacy of urban infrastructure in the face of rapid population growth in the metropolis. More than half of the city's population do not have access to solid waste collection services. Only 39.8% of households have indoor pipe and over 35.0% of households depend on unsanitary public latrines whilst 2.5% do not have access to toilet facilities. Human excrement, garbage and wastewater are usually deposited in surface drains, open spaces and streams in poor neighbourhoods. The resultant poor sanitation has serious health impacts as more than half of reported diseases are related to poor environmental sanitation. The majority of households depend on solid fuels for cooking and this leads to indoor air pollution and high incidence of respiratory infections. Poor households bear a disproportionately large share of the burden of environmental health hazards than their wealthy counterparts, due to their particular vulnerability resulting from inadequate access to environmental health facilities and services.     

Assessment of latrine use and quality and association with risk of trachoma in rural Tanzania

The existing evidence regarding latrines and trachoma is inconclusive. Using more precise sanitation measures we examine the association between use and quality of latrines and risk of trachoma. We conducted a case-control study of 678 households (95 cases, 583 controls) in eight villages in Kongwa District, Tanzania. Case households were defined as having a sentinel child with clinical signs of trachoma. A latrine quality score was calculated based on seven indicators and case and control households were compared with respect to use and quality of latrines. Logistic regression analyses controlled for potential confounders. Latrine use was significantly greater in control households than in case households (90.4 vs. 76.8%, P=0.03). The protective effect of latrine use persisted even after controlling for household characteristics significant at P <0.20 (adjusted OR=0.56 [95% CI: 0.32-0.98]). Contrary to expectation, we did not find an inverse association between increasing latrine quality and decreasing odds of trachoma. Although latrine use in the communities was high, latrines, regardless of quality, were significantly associated with decreased risk of trachoma. These findings underscore the importance of achieving 100% latrine use in communities.     

A need for community education in development: The Mit Abu El Kom case

A quasi-experimental study was performed in Mit Abu El Kom Village, Egypt, where one-quarter of the 500 village households had been provided with new housing and indoor water and sanitation facilities and where, prior to this provision, water and sanitation facilities were inadequate or nonexistent among all households. No community health education had taken place among relocatees (subjects) or nonrelocatees (controls) in conjunction with the provision of water and sanitation facilities. This study investigated if subjects' access and exposure to facilities had alone been sufficient to significantly alter their relevant knowledge, attitudes and practices as compared to controls. This was accomplished primarily through structured household interview. Given that women are traditionally most affected by facilities and most effective in matters related to household health, one adult female from each sampled household was the respondent, totalling 123 for subjects and 111 for controls. Between-group comparisons of responses revealed overall nonsignificant differences in knowledge and attitudes and that respondent age and sex had no significant overall impact on responses. Age and sex were also discounted as affecting variables in within-group response analyses. Some significant changes in practices had occurred among subjects. However, these mainly resulted out of convenience and their potential benefits were often denigrated by changes which had not occurred or had not continued. The data indicate a need for community health education if health-related benefits of water and sanitation facilities are to be realized, and specifically indicate the need to address the educational needs of all village women.     

Do multi-sectoral development programmes affect health? A Bolivian case study

This cross-sectional study, carried out in Inquisivi, Bolivia, a rural area where Save the Children/US works, tests the hypothesis that participation in multisectoral development programmes results in improved health behaviours and better health outcomes. To test this hypothesis, four groups of households were compared: those participating in Save the Children's health-only programmes; those with access to health and micro-enterprise credit or health and literacy programmes; those participating in all three programmes (health, credit and literacy); and households from comparison communities (no access to any of Save the Children's programmes). Data come from a stratified sample of 499 households in the altiplano, foothills and valleys of the Andes. Findings reported here suggest that there is no clear association between participation in one or more of Save the Children's programmes and parents' actions to prevent and treat diarrhoea. Additionally, the point prevalence of diarrhoea was similar for all four groups. However, children of individuals participating in health, credit and literacy were significantly less likely than children from comparison communities to be malnourished or at risk of becoming malnourished, even after controlling for such potentially confounding factors as social class, source of drinking water, and the availability of health facilities.     

Effect of water supply and sanitation on the prevalence and intensity of Ascaris lumbricoides among pre-school-age children in Ajebandele and Ifewara,Osun State,Nigeria

The relationship between Ascaris lumbricoides infection and provisions for safe water supply and excreta disposal was investigated in Ajebandele and Ifewara, 2 peri-urban communities near Ile-Ife, Osun State, Nigeria, from September 1998 to December 1999. Although there were more facilities for safe water supply (pipe-borne and shallow wells) and sanitation (flush toilets and pit latrines) in Ajebandele than in Ifewara, they were not evenly distributed and only a few families, mainly in Ajebandele, were well provided for. Our results indicated that the prevalence of A. lumbricoides was significantly higher in Ifewara (21.2%) than in Ajebandele (13.1%), and within villages was much lower in houses with tap water and flush toilets. However, the mean intensity of infection was unexpectedly higher in Ajebandele (166.5 +/- 692.0) than in Ifewara (153.1 +/- 485.8) suggesting that the present level of investment in Ajebandele is probably not sufficient to reduce morbidity. These findings confirm suggestions that there is a threshold level of investment below which interventions on water supply and sanitation may not significantly improve human health. Sustainable ascariasis control in the study communities will require significant improvements to existing water supplies and sanitation facilities and any future interventions should incorporate a programme of health education to ensure that the facilities provided are properly used and hygienically maintained.     

Women's participation in rural credit programmes in Bangladesh and their demand for formal health care: is there a positive impact?

Within the overall aim of poverty alleviation, development efforts have included credit and self-employment programmes. In Bangladesh, the major beneficiaries of such group-based credit programmes are rural women who use the loans to initiate small informal income-generating activities. This paper explores the benefits of women's participation in credit programmes on their own health seeking. Using data from a sample of 1798 households from rural Bangladesh, conducted in 1991-1992 through repeated random sampling of 87 districts covered by Grameen Bank, Bangladesh Rural Advancement Committee (BRAC) and Bangladesh Rural Development Board (BRDB), this paper addresses the question: does women's participation in credit programmes significantly affect their use of formal health care? A non-unitary household preference model is suggested to test the hypothesis that women's empowerment through participation in these programmes results in greater control of resources for their own demand for formal health care. The analysis controls for endogeneity due to self-selection and other unobserved village level factors through the use of a weighted two stage instrumental variable approach with village level fixed effects. The findings indicate a positive impact of women's participation in credit programmes on their demand for formal health care. The policy simulations on the results of this study highlight the importance of credit programmes as a health intervention in addition to being a mechanism for women's economic empowerment.     

青海农村学校饮水与环境卫生现状

目的了解青海省农村学校饮用水与厕所卫生状况,探索农村学校改水改厕对策和方法。方法按"青海省农村学校水与环境卫生现状调查方案"的要求,对青海省6个县的60所学校和1 872名学生进行调查。结果 76.7%的学校采用集中式供水,23.3%的学校为独立供水,50.0%的学校饮用水不合格;学生饮水33.0%从家中自带,33.1%由学校提供,14.5%喝生水。93.3%的学校厕所为旱厕,40.0%的学校没有教师专用厕所,78.3%的厕所没有可使用的洗手设施,63.3%的厕所粪池无盖;厕所粪便63.3%用土掩埋,3.3%排入下水道,1.7%直接排入河塘。结论青海省农村学校饮用水和厕所均存在卫生安全隐患。需加大农村学校尤其是半农半牧区学校的改水改厕工作力度,加强学生健康教育工作。     

Health impact of water and sanitation infrastructure reconstruction programmes in eight Central American communities affected by Hurricane Mitch

In response to Hurricane Mitch, which struck Central America in October-November 1998, the American Red Cross (ARC) and the Centers for Disease Control and Prevention (CDC) collaborated on a 3-year evaluation of the public health impact of ARC's water, sanitation and hygiene education activities in eight study areas in Honduras, Nicaragua, El Salvador and Guatemala. The evaluation compared: 1) access to and use of water and sanitation facilities, 2) the use of hygienic behaviours, and 3) diarrhoeal prevalence in children younger than 3 years of age before (February 2000) and after (February 2002) the interventions had been implemented. The evaluation included household and key informant interviews designed to measure these three components. Water quality of community water sources and household water was evaluated by measuring levels of indicator bacteria. During the final survey, an infrastructure evaluation provided a review of the design, construction, and current operation and maintenance of the water systems and latrines. The integrated water and sanitation infrastructure interventions and hygiene education programmes implemented following Hurricane Mitch effectively decreased diarrhoea prevalence in the target communities.     

A case-control study of the effect of environmental sanitation on diarrhoea morbidity in Malawi.

A case-control design has been applied in the evaluation of improved environmental sanitation on diarrhoeal diseases in rural Malawi. The study demonstrates the feasibility of using such an approach to evaluate two levels of water supply and sanitation service quickly and at moderate cost. Sample sizes would need to be increased substantially to evaluate multiple levels of service or to investigate interactions between water supply and sanitation. The results indicate that children living in families who use good quality water supplies and latrines experience 20% less diarrhoea as reported to the health clinics during the warm, rainy season.     

Health impact of water and sanitation infrastructure reconstruction programmes in eight Central American communities affected by Hurricane Mitch

In response to Hurricane Mitch, which struck Central America in October–November 1998, the American Red Cross (ARC) and the Centers for Disease Control and Prevention (CDC) collaborated on a 3-year evaluation of the public health impact of ARC's water, sanitation and hygiene education activities in eight study areas in Honduras, Nicaragua, El Salvador and Guatemala. The evaluation compared: 1) access to and use of water and sanitation facilities, 2) the use of hygienic behaviours, and 3) diarrhoeal prevalence in children younger than 3 years of age before (February 2000) and after (February 2002) the interventions had been implemented. The evaluation included household and key informant interviews designed to measure these three components. Water quality of community water sources and household water was evaluated by measuring levels of indicator bacteria. During the final survey, an infrastructure evaluation provided a review of the design, construction, and current operation and maintenance of the water systems and latrines. The integrated water and sanitation infrastructure interventions and hygiene education programmes implemented following Hurricane Mitch effectively decreased diarrhoea prevalence in the target communities.     

实施WES项目对农村环境卫生的影响

目的 了解实施水与环境卫生(WES)项目对农村环境卫生的影响。方法 在实施WES项目的县选择8个改厕村和1个未改厕(对照)村调查户厕内苍蝇密度、蛆密度和臭度,同时按照统一调查表调查农民卫生知识、行为、改厕满意度。结果 改厕户的卫生厕所苍蝇密度、蛆密度和臭度均低于未改厕户的旧式厕所,差异均有显著性(P<0.05)。实施WES项目的村居民卫生知识水平、卫生行为和习惯均优于未开展WES项目的村。改厕户居民对卫生厕所的满意度高达94.8％。结论 实施WES项目提高了农村环境卫生整体水平。