Socio-economic aspects of improved sanitation in slums: a review

An index of access to essential infrastructure to identify where physical distancing is impossible

To identify areas at highest risk of infectious disease transmission in Africa, we develop a physical distancing index (PDI) based on the share of households without access to private toilets, water, space, transportation, and communication technology and weight it with population density. Our results highlight that in addition to improving health systems, countries across Africa, especially in the western part of Africa, need to address the lack of essential domestic infrastructure. Missing infrastructure prevents societies from limiting the spread of communicable diseases by undermining the effectiveness of governmental regulations on physical distancing. We also provide high-resolution risk maps that show which regions are most limited in protecting themselves. We find considerable spatial heterogeneity of the PDI within countries and show that it is highly correlated with detected COVID-19 cases. Governments could pay specific attention to these areas to target limited resources more precisely to prevent disease transmission.

Lack of private infrastructure remains a major challenge potentially hampering a societies’ ability to contain the transmission of communicable diseases. Areas at high risk in Africa are identified based on access to essential basic infrastructure.

Spatial heterogeneity of neighborhood-level water and sanitation access in informal urban settlements: A cross-sectional case study in Beira, Mozambique

Rapid urbanization, resulting in population growth within informal settlements, has worsened exclusion and inequality in access to water and sanitation (WASH) services in the poorest and most marginalized communities. In this study, we describe the heterogeneity in water service satisfaction and WASH access in low-income, peri-urban neighborhoods of Beira, Mozambique, and examine whether this heterogeneity can be explained by distance to water distribution mains. Using spatial statistics and regression analyses, we identify spatial heterogeneity in household WASH access, as well as consumer-reported satisfaction with water services (services, pressure, quality, and sufficient quantity). We find that as distance from the water main increased, both access to an improved water source at the household and satisfaction with water pressure decreases, and water supply intermittency increases, controlling for household density and socioeconomic status. The odds of a household having access to a water source at the household or on the compound decreases with every 100-meter increase in distance from a water main pipe (odds ratio [OR] 0.87, 95% confidence interval [CI]: 0.82, 0.92). Satisfaction with water services also decreases with every 100-meter increase in distance from a water main pipe (OR: 0.80; 95% CI: 0.69, 0.94). Days of availability in the past week decreases by a factor of 0.22 for every 100-meter increase in distance from the water main (95% CI: −0.29, −0.15). Findings from this study highlight the unequal household access to water and sanitation in urban informal settlements, even within low-income neighborhoods. Describing this heterogeneity of access to water services, sanitation, and satisfaction—and the factors influencing them—can inform stakeholders and guide the development of infrastructural solutions to reduce water access inequities within urban settings.

Socio-Economic Aspects of Centralized Wastewater System for Rural Settlement under Conditions of Eastern Poland

This paper presents a case study concerning multivariate analysis, including social and financial aspects, as well as environmental impacts, of the organized sanitation development under conditions of the selected rural settlement in Poland. Three technologically up-to-date variants of sanitary sewerage network concepts with the different assumed sewage transport, i.e., pressure, pressure-gravity and gravity, were proposed together with the investment and operation and maintenance costs estimation. The willingness-to-accept (WTA) and willingness-to-pay (WTP) survey was used to analyze the level of social acceptance and involvement. The financial analysis covered two economic and cost-efficiency dynamic indicators, benefits–costs ratio (BCR) and dynamic generation cost (DGC), commonly used to support the decision-making process. The environmental aspects were assessed by the possible anthropopressure caused by sewerage leakage and odor emissions. Results of the WTA and WTP survey presented a significant level of acceptance and involvement of the local population to sustain the improved sanitation. The determined values of DGC indicated low cost-efficiency of the gravity system, while obtained values of BCR for all variants and the actual regional sewage fees showed the low profitability of improved sanitation, i.e., BCR < 1.0. All studied sanitation systems were assessed positively due to their environmental impacts. The performed studies showed that, despite the declared willingness to accept the organized sanitation and to pay the sewage fees, the economical sustainability of the proposed designs is doubtful over the longer time duration due to the significant capital and operation costs affecting the sewerage payment value.

Women 'holding it' in urban India: Toilet avoidance as an under-recognized health outcome of sanitation insecurity

Emerging research on sanitation challenges in the Global South increasingly uncovers health and social impacts by gender, particularly lack of sanitation safety. Women may employ strategies to avoid urination or defecation ('holding it') in the absence of safe sanitation, but the practice is not well understood. We quantitatively analyze survey data on women from urban slums across three cities in Maharashtra, India whose households constructed a toilet through an intervention programme. We assess relationships between household versus shared sanitation, perceptions of safety, and women's toilet avoidance behaviours, including diet restriction. At baseline, women have more than three times the odds of reporting avoidance behaviours if they perceive a community toilet to be unsafe, even after controlling for other factors. Household water insecurity is also instrumental in the relationship between avoidance and lack of safety. Finally, avoidance exhibits a significant and major drop upon provision of a household toilet. This study provides substantial support for the prevalence of habitual toilet avoidance among vulnerable urban women without access to safe sanitation. We conclude with recommendations for policy approaches and call for more attention to the health repercussions of habitual toilet avoidance among women as a consequence of sanitation insecurity.

Effects of seasonality on access to improved water in Benue State, Nigeria

Many people switch sources of drinking water and sanitation between seasons, yet such shifts are not reflected in the reporting of access to improved water and sanitation services by the Joint Monitoring Programme (JMP). Drawing on quantitative and qualitative data collected from urban and rural sites in dry and rainy seasons in Benue state, Nigeria, this study highlights the importance of seasonal variations in water access and quality. Water testing showed that water sources had higher levels of contamination with coliforms, nitrate and chloride in the dry season than the wet season. The contamination of water from these pollutants is above WHO standards and believed to come mainly from pit latrines. Semi-structured interviews revealed that many people who use improved water and sanitation facilities in the rainy season sometimes switch to poorer quality unimproved sources in the dry season. Travel times for collecting water as well as waiting times also significantly increased in the dry season. It is recommended that this important seasonality element is factored into JMP data collection and reporting.

Relationships Among Toilet Sharing, Water Source Locations, and Handwashing Places Without Observed Soap: A Cross-Sectional Study of the Richest Households in Bangladesh

BACKGROUND

A high percentage of the richest households in Bangladesh lack soap at their handwashing places, a problem that is typically considered to be one of the poor.

OBJECTIVE

We investigated toilet sharing practices, locations of water sources, and relevant sociodemographic factors associated with the observed handwashing places that lack soap in the richest (ninth wealth decile) households in Bangladesh.

METHODS

We used data from the 2017-18 Bangladesh Demographic and Health Survey (BDHS). Logistic regression technique was used to investigate how toilet sharing practices, water source locations, and different sociodemographic factors were associated with observed handwashing places without soap.

RESULTS

We found that 25.8% of the richest households were observed to have no soap at their handwashing places. Of these households, those that shared their toilets with another household were 4.6 times (95% CI 3.15-6.60) more likely to observe handwashing places without soap as compared with those that did not share their toilets. Further, the richest households were 4.2 times (95% CI 2.38-7.33) more likely to observe handwashing places without soap if they collected water from their own yard or plot, and 7.1 times (95% CI 3.61-13.97) more likely to observe handwashing places without soap if they collected water from elsewhere in comparison to the reference group that collected water from their own dwelling.

CONCLUSION

Sharing toilet with other households and location of main water source are associated with handwashing places without observed soap in the richest households in Bangladesh. These results can inform discussions of water availability and soap-handwashing-related policy and program development.

Determinants of transitions in water and sanitation services in two urban slums of Nairobi: A multi-state modeling approach

Access to improved water, sanitation, and hygiene (WASH) services at the household level remains a good strategy to improve the health and well-being of individuals. Informal settlements, such as urban slums, are at risk of the spread of diseases due to the relative lack of access to safe, clean drinking water and basic sanitation, as well as poor hygiene. Global initiatives, such as the Sustainable Development Goals (SDGs) adopted by the United Nations, are aimed at transitioning households and communities from unimproved to sustained improved states of WASH services. To deepen understanding of the time dynamics between states of WASH services in the Nairobi Urban and Demographic Surveillance System (NUHDSS), this study employs the multi-state transition model to assess the influence of potential risk factors on these transitions. Results indicated that study sites, wealth tertile, age of household head, poverty status, the ethnicity of household head, household ownership, and food security were associated with household transitions of WASH services. There was a lower probability for households to transition from unimproved to improved toilet services than the reverse transition, but a higher chance for households to transition from unimproved to improved water and garbage services. The estimated average time that households spent in the unimproved and improved states before transitioning were, respectively, 35 months and 9 months for toilet services, 7 months and 66 months for water services, and 16 months and 19 months for garbage services. Thus, households tend to remain longer in the unimproved state of toilet and garbage services, and when in the improved states, they transition back relatively faster compared to water services. In conclusion, sanitation services in Nairobi informal settings remain largely unsatisfactory as transitions to improved services are not sustained. It is therefore important for governments, policy-makers, and stakeholders to put in place policies and interventions targeting vulnerable households for improved and sustained WASH services.

Assessment of sanitation service gap in urban slums for tackling COVID-19

Coronavirus disease 2019 (COVID-19), caused by Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), has been declared as a global pandemic by the World Health Organization (WHO). As the disease is highly infectious, the Global South countries are in a vulnerable situation with high urban population density and lack of Water, Sanitation, and Hygiene (WASH) services. The situation for the urban slum dwellers and low-income group clusters are becoming worse. Lack of health and sanitation service availability has already been an issue for them before the beginning of the pandemic. So, it is predictable that adopting this massive global pandemic is a critical challenge for them. This paper assesses the sanitation service gap in urban slums, which has become a severe challenge to tackle due to COVID-19. The study areas of this research are the Ranarmath slum and the Khema slum of Khulna city, Bangladesh. The SERVQUAL model has been used to identify the quality of sanitation service available in these informal residential settlements. The interpretation of questionnaire survey data from the two slums reveals that one slum lacks Assurance and Empathy, where the other slum lacks Tangibility and Responsiveness. However, the Tangibility, Reliability, and Responsiveness condition of both slums are flawed with the lack of latrine functionalities and services from concerned authorities. The incompatibility of the condition has been identified by evaluating the WHO's different sanitation management policy for COVID-19. The research concludes that sanitation services like handwashing facilities and water supply availability in the latrine directly related to COVID-19 prevention are indigent for these slums.

Decreased human respiratory syncytial virus activity during the COVID-19 pandemic in Japan: an ecological time-series analysis

BACKGROUND

Non-pharmaceutical interventions (NPIs), such as sanitary measures and travel restrictions, aimed at controlling the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), may affect the transmission dynamics of human respiratory syncytial virus (HRSV). We aimed to quantify the contribution of the sales of hand hygiene products and the number of international and domestic airline passenger arrivals on HRSV epidemic in Japan.

METHODS

The monthly number of HRSV cases per sentinel site (HRSV activity) in 2020 was compared with the average of the corresponding period in the previous 6 years (from January 2014 to December 2020) using a monthly paired t-test. A generalized linear gamma regression model was used to regress the time-series of the monthly HRSV activity against NPI indicators, including sale of hand hygiene products and the number of domestic and international airline passengers, while controlling for meteorological conditions (monthly average temperature and relative humidity) and seasonal variations between years (2014-2020).

RESULTS

The average number of monthly HRSV case notifications in 2020 decreased by approximately 85% (p < 0.001) compared to those in the preceding 6 years (2014-2019). For every average ¥1 billion (approximately £680,000/$9,000,000) spent on hand hygiene products during the current month and 1 month before there was a 0.29% (p = 0.003) decrease in HRSV infections. An increase of average 1000 domestic and international airline passenger arrivals during the previous 1-2 months was associated with a 3.8 × 10^- 4% (p < 0.001) and 1.2 × 10^- 3% (p < 0.001) increase in the monthly number of HRSV infections, respectively.

CONCLUSIONS

This study suggests that there is an association between the decrease in the monthly number of HRSV cases and improved hygiene and sanitary measures and travel restrictions for COVID-19 in Japan, indicating that these public health interventions can contribute to the suppression of HRSV activity. These findings may help in public health policy and decision making.

Using path analysis to test theory of change: a quantitative process evaluation of the MapSan trial

BACKGROUND

Although theory-driven evaluations should have empirical components, few evaluations of public health interventions quantitatively test the causal model made explicit in the theory of change (ToC). In the context of a shared sanitation trial (MapSan) in Maputo, Mozambique, we report findings of a quantitative process evaluation assessing intervention implementation, participant response and impacts on hypothesised intermediary outcomes on the pathway to trial health outcomes. We examine the utility of path analysis in testing intervention theory using process indicators from the intervention's ToC.

METHODS

Process data were collected through a cross-sectional survey of intervention and control compounds of the MapSan trial > 24-months post-intervention, sampling adult residents and compound leaders. Indicators of implementation fidelity (dose received, reach) and participant response (participant behaviours, intermediary outcomes) were compared between trial arms. The intervention's ToC (formalised post-intervention) was converted to an initial structural model with multiple alternative pathways. Path analysis was conducted through linear structural equation modelling (SEM) and generalised SEM (probit model), using a model trimming process and grouped analysis to identify parsimonious models that explained variation in outcomes, incorporating demographics of respondents and compounds.

RESULTS

Among study compounds, the MapSan intervention was implemented with high fidelity, with a strong participant response in intervention compounds: improvements were made to intermediary outcomes related to sanitation 'quality' - latrine cleanliness, maintenance and privacy - but not to handwashing (presence of soap / soap residue). These outcomes varied by intervention type: single-cabin latrines or multiple-cabin blocks (designed for > 20 users). Path analysis suggested that changes in intermediary outcomes were likely driven by direct effects of intervention facilities, with little contribution from hygiene promotion activities nor core elements expected to mediate change: a compound sanitation committee and maintenance fund. A distinct structural model for two compound size subgroups (≤ 20 members vs. > 20 members) explained differences by intervention type, and other contextual factors influenced specific model parameters.

CONCLUSIONS

While process evaluation found that the MapSan intervention achieved sufficient fidelity and participant response, the path analysis approach applied to test the ToC added to understanding of possible 'mechanisms of change', and has value in disentangling complex intervention pathways.

TRIAL REGISTRATION

MapSan trial registration: NCT02362932 Feb-13-2015.

Cholera outbreak investigation, Bhadola, Delhi, India, April-May 2018

BACKGROUND

In the Gangetic plains of India, including Delhi, cholera is endemic. On 10 May 2018, staff at the north Delhi district surveillance unit identified a laboratory-confirmed cholera outbreak when five people tested positive for Vibrio cholerae O1 Ogawa serotype in Bhadola. We investigated to identify risk factors and recommend prevention measures.

METHODS

We defined a case as ≥3 loose stools within 24 h in a Bhadola resident during 1 April-29 May 2018. We searched for cases house-to-house. In a 1 : 1 unmatched case control study, a control was defined as an absence of loose stools in a Bhadola resident during 1 April-29 May 2018. We selected cases and controls randomly. We tested stool samples for Vibrio cholerae by culture. We tested drinking water for fecal contamination. Using multivariable logistic regression we calculated adjusted ORs (aORs) with 95% CIs.

RESULTS

We identified 129 cases; the median age was 14.5 y, 52% were females, 27% were hospitalized and there were no deaths. Symptoms were abdominal pain (54%), vomiting (44%) and fever (29%). Among 90 cases and controls, the odds of illness were higher for drinking untreated municipal water (aOR=2.3; 95% CI 1.0 to 6.2) and not knowing about diarrhea transmission (aOR=4.9; 95% CI 1.0 to 21.1). Of 12 stool samples, 6 (50%) tested positive for Vibrio cholerae O1 Ogawa serotype. Of 15 water samples, 8 (53%) showed growth of fecal coliforms.

CONCLUSIONS

This laboratory-confirmed cholera outbreak associated with drinking untreated municipal water and lack of knowledge of diarrhea transmission triggered public health action in Bhadola, Delhi.

Re-conceptualizing sustainable urban sanitation in Uganda: why the roots of 'Slumification' must be dealt with

Background

Country-wide urbanization in Uganda has continued amidst institutional challenges. Previous interventions in the water and sanitation sector have not addressed the underlying issues of a poorly managed urbanization processes. Poor urbanisation is linked to low productivity, urban poverty, unemployment, limited capacity to plan and offer basic services as well as a failure to enforce urban standards.

Methods

This ethnographic study was carried out in three urban centres of Gulu, Mbarara and Kampala. We explored relationships between urban livelihoods and sustainable urban sanitation, using the economic sociology of urban sanitation framework. This framework locates the urbanization narrative within a complex system entailing demand, supply, access, use and sustainability of slum sanitation. We used both inductive and deductive thematic analysis.

Results

More than any other city in Uganda, Kampala was plagued with poor sanitation services characterized by a mismatch between demand and the available capacity for service provision. Poor slum sanitation was driven by; the need to escape rural poverty through urban migration, urban governance deficits, corruption and the survival imperative, poor service delivery and lack of capacity, pervasive (urban) informality, lack of standards: ‘to whom it may concern’ attitudes and the normalization of risk as a way of life. Amidst a general lack of affordability, there was a critical lack of public good conscience. Most urbanites were trapped in poverty, whereby economic survival trumped for the need for meeting desirable sanitation standards.

Conclusions

Providing sustainable urban livelihoods and meeting sanitation demands is nested within sustainable livelihoods. Previous interventions have labored to fix the sanitation problem in slums without considering the drivers of this problem. Sustainable urban livelihoods are critical in reducing slums, improving slum living and curtailing the onset of slumification. Urban authorities need to make urban centres economically vibrant as an integral strategy for attaining better sanitation standards.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11029-8.

Happiness in marginalized populations: a community-based study in South Central Iran

Background

Happiness has multiple levels and determinants in different communities, cultures, and social groups. The current study aimed to investigate happiness and its main determinants in slums in south central Iran.

Methods

This community-based, cross-sectional study was conducted with the participation of adults at least 18 years of age living in the biggest slum area in Shiraz, south central Iran. To determine levels of happiness, participants were asked to complete the Persian version of the GHQ28 questionnaire and a checklist based on the 2017 World Happiness Report. Data was analyzed using SPSS software version 19. A p-value less than 0.05 was considered significant.

Results

The mean age of the participants was 42.06 ± 16.34 years. Overall, 542 participants (45 %) were females, 257 (21.3 %) were illiterate, 678 (56.3 %) were married, and 495 (41.1 %) were unemployed and lived with their household. The happiness score, according to the Cantril ladder score, was 6.41 ± 2 (out of a total score of 10). Happiness was not correlated with gender (p = 0.37) or immigration (p = 0.06). Lower levels of happiness were seen in older adults (r=− 0.12, p < 0.001), illiterates (p = 0.03), the unemployed (p < 0.001), and people separated from their spouses (p < 0.001). Job satisfaction (p < 0.001, r = 0.47), total general health (p < 0.001, r=-0.36) and hope (p < 0.001, r = 0.41) were significantly correlated with happiness. Social support (< 0.001) and sufficient income and satisfaction (p < 0.001) were related with a higher score of happiness.

Conclusions

Marital status, smoking, employment and job satisfaction, social support and trust, feelings of insecurity in the neighborhood, hope for the future, facing violence, and income satisfaction were the main determinants of happiness in the Sang Siah slum area.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40359-021-00545-2.

Ex-ante quantification of nutrient, total solids, and water flows in sanitation systems

To prioritise sustainable sanitation systems in strategic sanitation planning, indicators such as local appropriateness or resource recovery have to be known at the pre-planning phase. The quantification of resource recovery remains a challenge because existing substance flow models require large amounts of input data and can therefore only be applied for a few options at a time for which implementation examples exist. This paper aims to answer two questions: How can we predict resource recovery and losses of sanitation systems ex-ante at the pre-planning phase? And how can we do this efficiently to consider the entire sanitation system option space? The approach builds on an existing model to create all valid sanitation systems from a set of conventional and emerging technologies and to evaluate their appropriateness for a given application case. It complements the previous model with a Substance Flow Model (SFM) and with transfer coefficients from a technology library to quantify nutrients (phosphorus and nitrogen), total solids (as an indicator for energy and organics), and water flows in sanitation systems ex ante. The transfer coefficients are based on literature data and expert judgement. Uncertainties resulting from the variability of literature data or ignorance of experts are explicitly considered, allowing to assess the robustness of the model output. Any (future) technologies or additional products can easily be added to the library. The model is illustrated with a small didactic example showing how 12 valid system configurations are generated from a few technologies, and how substance flows, recovery ratios, and losses to soil, air, and water are quantified considering uncertainties. The recovery ratios vary between 0 and 28% for phosphorus, 0-10% for nitrogen, 0-26% for total solids, and 0-12% for water. The uncertainties reflect the high variability of the literature data but are comparable to those obtained in studies using a conventional post-ante material flow analysis (generally about 30% variability at the scale of a an urban area). Because the model is fully automated and based on literature data, it can be applied ex-ante to a large and diverse set of possible sanitation systems as shown with a real application case. From the 41 technologies available in the library, 101,548 systems are generated and substance flows are modelled. The resulting recovery ratios range from nothing to almost 100%. The two examples also show that recovery depend on technology interactions and has therefore to be assessed for all possible system configurations and not at the single technology level only. The examples also show that there exist trade-offs among different types of reuse (e.g. energy versus nutrients) or different sustainability indicators (e.g. local appropriateness versus resource recovery). These results show that there is a need for such an automated and generic approach that provides recovery data for all system configurations already at the pre-planning phase. The approach presented enables to integrate transparently the best available knowledge for a growing number of sanitation technologies into a planning process. The resulting resource recovery and loss ratios can be used to prioritise resource efficient systems in sanitation planning, either for the pre-selection or the detailed evaluation of options using e.g. MCDA. The results can also be used to guide future development of technology and system innovations. As resource recovery becomes more relevant and novel sanitation technologies and system options emerge, the approach presents itself as a useful tool for strategic sanitation planning in line with the Sustainable Development Goals (SDGs).

Where Shared Sanitation is the Only Immediate Option: A Research Agenda for Shared Sanitation in Densely Populated Low-Income Urban Settings

Shared sanitation is not currently accepted within the international normative definitions of "basic" or "safely managed" sanitation. We argue that pro-poor government strategies and investment plans must include high-quality shared sanitation as an intermediate step in some densely populated urban areas. User experience must be considered in establishing the definition of high quality. We call for additional research on effective interventions to reach these quality standards and for the development of rigorous measures applicable to global monitoring.

Strategies to Connect Low-Income Communities with the Proposed Sewerage Network of the Dhaka Sanitation Improvement Project, Bangladesh: A Qualitative Assessment of the Perspectives of Stakeholders

In Bangladesh, approximately 31% of urban residents are living without safely managed sanitation, the majority of whom are slum residents. To improve the situation, Dhaka Water Supply and Sewerage Authority (DWASA) is implementing the Dhaka Sanitation Improvement Project (DSIP), mostly funded by the World Bank. This study assessed the challenges and opportunities of bringing low-income communities (LICs) under a sewerage connection within the proposed sewerage network plan by 2025. We conducted nine key-informant interviews from DWASA and City Corporation, and 23 focus-group discussions with landlords, tenants, and Community Based Organisations (CBOs) from 16 LICs near the proposed catchment area. To achieve connections, LICs would require improved toilet infrastructures and have to be connected to main roads. Construction of large communal septic tanks is also required where individual toilet connections are difficult. To encourage connection in LICs, income-based or area-based subsidies were recommended. For financing maintenance, respondents suggested monthly fee collection for management of the infrastructure by dividing bills equally among sharing households, or by users per household. Participants also suggested the government’s cooperation with development-partners/NGOs to ensure sewerage connection construction, operation, and maintenance and prerequisite policy changes such as assuring land tenure.

Developing sanitation planning options: A tool for systematic consideration of novel technologies and systems

To provide access to sustainable sanitation for the entire world population, novel technologies and systems have been developed. These options are often independent of sewers, water, and energy and therefore promise to be more appropriate for fast-growing urban areas. They also allow for resource recovery and and are adaptable to changing environmental and demographic conditions what makes them more sustainable. More options, however, also enhance planning complexity. Structured decision making (SDM) can help balance opposing interests. Yet, most of the current research focuses on the selection of a preferred option, assuming that a set of appropriate options is available. There is a lack of reproducible methods for the identification of sanitation system planning options that can consider the growing number of available technology and the many possible system configurations. Additionally, there is a lack of data, particularly for novel options, to evaluate the various sustainability criteria for sanitation.To overcome this limitation, we present a novel software supported approach: the SANitation sysTem Alternative GeneratOr (Santiago). To be optimally effective, Santiago is required to be integrated into an SDM approach. In this paper, we present all the elements that such an integration requires and illustrate these methods at the case of Arba Minch, a fast growing town in Ethiopia. Based on this example and experiences from other cases, we discuss the lessons learnt and present the advantages potentially brought by Santiago for sanitation planning The integration requires four elements: a set of technologies to be looked at, decision objectives for sustainable sanitation, screening criteria to evalute technology appropriateness, and about the technologies and the casea. The main output is a set of sanitation system options that is locally appropriate, diverse in order to reveal trade-offs, and of a manageable size. To support the definition of decision objectives, we developed a generic objective hierarchy for sustainable sanitation. Because one of the main challenges lies in the quantification of screening criteria, we established the data for 27 criteria and 41 technologies in a library.The case studies showed, that if the integration is successful, then Santiago can provide substantial benefits: (i) it is systematic and reproducible; (ii) it opens up the decision space with novel and potentially more appropriate solutions; (iii) it makes international data accessible for more empirical decision making; (iv) it enables decisions based on strategic objectives in line with the sustainable development goals; (v) it allows to prioritise appropriate and resource efficient systems right from the beginning (vi) and it contributes to a more citywide inclusive approach by birding strategic objectives with an area-based appropriateness assessment. The here presented approach enables the prioritisation of appropriate and resource efficient sanitation technologies and systems in strategic planning. Thereby this approach contributes to SDG 6.2, 6.3, and 11, sustainable sanitation for all.

Conventional Sewer Systems Are Too Time-Consuming, Costly and Inflexible to Meet the Challenges of the 21st Century

There is an urgent need for innovation in the sanitation sector because the conventional model (toilet-to-sewer-to-treatment) is too time-consuming and costly, and alternatives are lacking. We estimate the challenge ahead by developing scenarios for 60 of the fastest-growing urban conglomerates in the World. We find that the majority would need to build out their sewer systems at a rate that is ten to 50 times higher than the highest rate for any project in the World Bank’s database, which is unrealistic. We also carry out a case study of Lagos, Nigeria, which suggests that, in any given year, 14–37% of Lagos State’s budget would need to be invested to provide sanitation to the presently underserviced population while keeping up with population growth, which also is unrealistic. Our study provides clear evidence that the conventional model for sanitation is unworkable for rapidly growing urban areas. We conclude there is an urgent need to encourage and fund projects that promote innovations that can tackle the three core challenges: can be built sufficiently quickly, are flexible, and affordable. This is not likely to happen unless the future generation is systematically trained and educated to creatively support innovation in sustainable sanitation.

Variation in E. coli concentrations in open drains across neighborhoods in Accra, Ghana: The influence of onsite sanitation coverage and interconnectedness of urban environments

Alongside efforts to improve safe management of feces along the entire sanitation chain, including after the toilet, global sanitation efforts are focusing on universal access 'basic' services: onsite facilities that safely contain excreta away from human contact. Although fecal sludge management is improving in urban areas, open drains remain a common fate for feces in these often densely-populated neighborhoods in low-income countries. To-date, it is unclear to what extent complete coverage of onsite sanitation reduces fecal contamination in the urban environment and how fecal contamination varies within urban drains across neighborhoods by sanitation status within a city. We assessed how neighborhood levels of environmental fecal contamination (via spatially-representative sampling of open drains for E. coli) varied across four neighborhoods with varying income, type and coverage of household sanitation facilities, and population density in Accra, Ghana. Neighborhoods with very high sanitation coverage (≥89%) still had high (>4 log10 CFU/100 mL) E. coli concentrations in drains. Between-neighborhood variation in E. coli levels among the high coverage neighborhoods was significant: drain concentrations in neighborhoods with 93% and 89% coverage (4.7 (95% CI: 4.5, 4.9) & 4.9 (95% CI: 4.5, 5.3) log10 CFU/100 mL, respectively) were higher than in the neighborhood with 97% coverage (4.1 log10 CFU/100 mL, 95% CI: 3.8, 4.4 log10 CFU/100 mL). Compared with the highest coverage neighborhood, the neighborhood with lowest coverage (48%) also had higher E. coli concentrations (5.6 log10 CFU/100 mL, 95% CI: 5.3, 5.9 log10 CFU/100 mL). Although fecal contamination in open drains appeared lower in neighborhoods with higher onsite sanitation coverage (and vice versa), other factors (e.g. fecal sludge management, animals, population density) may affect drain concentrations. These results underscore that neighborhood-level onsite sanitation improvements alone may not sufficiently reduce fecal hazards to public health from open drains. These findings supporting the need for integrated, city-level fecal sludge management alongside multifaceted interventions to reduce fecal contamination levels and human exposure.

Review of drivers and barriers of water and sanitation policies for urban informal settlements in low-income and middle-income countries

This study examined drivers and barriers of water, sanitation, and hygiene (WASH) policies in urban informal settlements in low and middle-income countries. We conducted a search of peer-reviewed and grey literature published between January 2000 and April 2018. We organized evidence into six domains of drivers and barriers: economic, spatial, social, institutional, political, and informational. Key drivers included donor prioritization and collective action, while key barriers included social exclusion, lack of land or dwelling tenure status, the political economy of decision-making, and insufficient data. Ensuring responsive water and sanitation policies for informal settlements will require inter-disciplinary collaboration and both top-down and bottom-up approaches.

Sanitation for Low-Income Regions: A Cross-Disciplinary Review

Sanitation research focuses primarily on containing human waste and preventing disease; thus, it has traditionally been dominated by the fields of environmental engineering and public health. Over the past 20 years, however, the field has grown broader in scope and deeper in complexity, spanning diverse disciplinary perspectives. In this article, we review the current literature in the range of disciplines engaged with sanitation research in low- and middle-income countries (LMICs). We find that perspectives on what sanitation is, and what sanitation policy should prioritize, vary widely. We show how these diverse perspectives augment the conventional sanitation service chain, a framework describing the flow of waste from capture to disposal. We review how these perspectives can inform progress toward equitable sanitation for all [i.e., Sustainable Development Goal (SDG) 6]. Our key message is that both material and nonmaterial flows-and both technological and social functions-make up a sanitation "system." The components of the sanitation service chain are embedded within the flows of finance, decision making, and labor that make material flows of waste possible. The functions of capture, storage, transport, treatment, reuse, and disposal are interlinked with those of ensuring equity and affordability. We find that a multilayered understanding of sanitation, with contributions from multiple disciplines, is necessary to facilitate inclusive and robust research toward the goal of sanitation for all.

Opportunities and barriers to effective operation and maintenance of public toilets in informal settlements: perspectives from toilet operators in Kampala

Although classified by the Joint Monitoring Programme (JMP) as unimproved sanitation facilities, public toilets still play a critical role in eliminating open defecation in informal settlements. We explored perspectives of toilet operators on opportunities and barriers to operation and maintenance (O&M) of public toilets in informal settlements. A cross-sectional study design was used. Up to 20 in-depth interviews were used to obtain data on the experiences of public toilet operators. Thematic content analysis was used. Ressults show that opportunities for improving O&M include; operation of public toilets is a source of livelihood; operators are knowledgeable on occupational risks, and the community is involvedin sanitation activities. Barriers to effective O&M include; high operation costs, failure to break even and a lack of investments in occupational health Therefore, there is need to recognise the significance of public toilets as a viable alternative to open defecation in areas where ownership of private sanitation facilities is difficult. Failure to observe the health and safety of toilet operators may further compromise O&M.

Microbial Source Tracking Using 16S rRNA Amplicon Sequencing Identifies Evidence of Widespread Contamination from Young Children's Feces in an Urban Slum of Nairobi, Kenya

Child exposure to fecal contamination remains common in low- and middle-income countries after sanitation interventions. Unsafe disposal of children's feces may contribute to this continued exposure, but its relative importance to domestic fecal contamination is not well understood. To address this gap, we interviewed and collected environmental samples (drinking water, caregiver hands, child hands, surfaces, soil, open drainage ditches, standing water, streams) from 40 households in Kibera, an urban slum in Nairobi, Kenya. To track young children's feces (<3 years old) separately from other human-associated fecal sources, we validated distance-based and Bayesian (SourceTracker) microbial source tracking methods using amplicon-based sequencing of the 16S rRNA gene. Contamination by young children's feces could be identified and distinguished separately from older child/adult feces with high sensitivity and specificity in water and soil. Among environmental samples, young children's feces were almost always identified as the dominant source of human fecal contamination inside households (hands, surfaces) whereas older children/adult feces were often identified as the dominant source outside households (standing water, streams, soil). Markers for young children's feces were also detected in standing water and streams, and markers for both fecal sources were equally likely to be dominant in open ditches. These results establish motivation for sanitation interventions that directly address child feces management.

WASH practices and its association with nutritional status of adolescent girls in poverty pockets of eastern India

BACKGROUND

Water, Sanitation, and Hygiene (WASH) practices may affect the growth and nutritional status among adolescents. Therefore, this paper assesses WASH practices and its association with nutritional status among adolescent girls.

METHODS

As a part of an intervention programme, this study is based on baseline cross-sectional data. It was conducted between May 2016-April 2017 in three Indian states (Bihar, Odisha, and Chhattisgarh). From a sample of 6352 adolescent girls, information on WASH practices, accessibility to health services and anthropometric measurements (height, weight and mid upper arm circumference (MUAC)) was collected. Descriptive statistics were used to examine WASH practices, and nutritional status among adolescent girls. Determinants of open defecation and menstrual hygiene were assessed using logistic regression. Association between WASH and nutritional status of adolescent girls was determined using linear regression.

RESULTS

Findings showed 82% of the adolescent girls were practicing open defecation and 76% were not using sanitary napkins. Significant predictors of open defecation and non use of sanitary napkin during menstruation were non Hindu households, households with poorer wealth, non availability of water within household premise, non visit to Anganwadi Centre, and non attendance in Kishori group meetings. One-third of adolescent girls were stunted, 17% were thin and 20% had MUAC < 19 cm. Poor WASH practices like water facility outside the household premise, unimproved sanitation facility, non use of soap after defecation had significant association with poor nutritional status of adolescent girls.

CONCLUSIONS

Concerted convergent actions focusing on the provision of clean water within the household premise, measures to stop open defecation, promotion of hand washing, accessibility of sanitary napkins, poverty alleviation and behavior change are needed. Health, nutrition and livelihood programmes must be interspersed, and adolescents must be encouraged to take part in these programmes.

Theory-driven formative research on on-site, shared sanitation quality improvement among landlords and tenants in peri-urban Lusaka, Zambia

Rapid, unplanned urbanization in low-income countries is leading to increasing problems of dealing with human waste. On-site sanitation systems are often rudimentary, unhygienic, and poorly maintained. In-depth, on-site interactive interviews were conducted with 33 landlords and 33 tenants in a neighborhood in peri-urban Lusaka to understand on-site, shared sanitation quality improvement behaviors and preferences. Respondents were asked about housing characteristics, toilet histories, and financial decision-making. Improved, shared toilets were common (79%), but many were of low quality and poorly cleaned. Poor coordination among tenants, barriers to communication between landlords and tenants, and landlords viewing sanitation as a required basic service to provide instead of something for which tenants will pay more rent all limit the quality of sanitation in this setting. Landlord-directed interventions targeting non-health motivations for sanitation improvement and introducing effective cleaning systems may increase peri-urban sanitation quality.

Urban Water Management Paradigms in Chinese Cities

Three paradigms used in China to deal with urban water issues are compared. The analysis focuses on their definition and objectives, the role of different stakeholders, the issues they deal with and the possible solutions suggested. The use of these paradigms in Chinese cities is compared on different dimensions to conclude when and where they can be used for which purpose. The paradigms differ substantially in their scope (from the narrow focus of the sponge city paradigm to the broad goals of eco-city paradigms) and in terms of the governance mechanisms used to coordinate between different actors. The resilient and sponge paradigms mainly use government structures to achieve their objectives, while the idea is to also involve the private sector (certainly in case of the sponge city paradigm). This has not happened most of the times because project money had to be spent in time. In the eco-cities approach the citizens want to be involved through newly created governance structures. In resilient cities potential victims may be involved. Resilient and eco-city initiatives emphasize the involvement of stakeholders, while in the sponge cities approach the initiative is often taken by local government. Finally, in terms of expected solutions, the paradigms want to avoid disaster, create an eco-city or improve water management. Only in the case of eco-cities there is more space for different water management practices and using alternative technologies. Water-related technologies are available, generating energy from wastewater or underground water and diminishing the dependence on fossil fuels.

Demand for improved sanitation in an urban informal settlement in India: role of the local built environment

Sanitation uptake is a pressing challenge, especially in India, and sanitation demand in urban informal settlements and slums has been understudied relative to rural areas. Given the spatial and socioeconomic disadvantage of these settings, research suggests that the built environment may relate to sanitation demand, but this has not been tested. This study utilizes data on a large urban informal settlement in Maharashtra, India, examining built environment predictors including housing security, water access, and proximity to existing common sanitation, in association with sanitation demand. Results indicate that household size, home ownership, individual household water sources, and open defecation avoidance are significantly associated with interest in a toilet. Further, interactions between (1) water source and home ownership, and (2) open defecation and distance to shared sanitation, are associated with interest in a toilet. These findings support the role of the built environment in shaping sanitation demand in urban informal settlements.

Effect of a behaviour change intervention on the quality of peri-urban sanitation in Lusaka, Zambia: a randomised controlled trial

BACKGROUND

Poor sanitation in peri-urban areas is a growing public health problem. We tested a scalable, demand-side behaviour change intervention to motivate landlords to improve the quality of shared toilets within their plots.

METHODS

We did a residential plot-randomised controlled trial in a peri-urban community in Lusaka, Zambia. We enrolled adult resident landlords on plots where at least one tenant lived. We allocated landlords 1:1 to intervention and control arms on the basis of a random number sequence. The intervention was developed using the Behaviour Centred Design approach and consisted of a series of group meetings designed to motivate sanitation quality improvement as a way to build wealth and reduce on-plot conflict; no subsidies or materials were provided. The control group received no intervention. The four primary outcomes were having a rotational cleaning system in place (to improve hygiene); having a solid door on the toilet used by tenants with an inside lock (for privacy); having an outside lock (for security); and having a sealed toilet (to reduce smell and contamination). We measured outcomes 1 month before the start of the intervention and 4 months after the end of the intervention. Data collectors measuring outcomes were blinded to group assignment. We analysed outcomes by intention to treat, including all landlords with study-end results. Because the outcomes were assumed to not be independent, we used a family-wise error rate of 0·05 to calculate an adjusted significance level of 0·0253. This study was registered with ClinicalTrials.gov, number NCT03174015.

FINDINGS

Between June 9 and July 6, 2017, 1085 landlords were enrolled and randomly assigned to the intervention (n=543) or the control group (n=542). The intervention was delivered from Aug 1, 2017, and evaluated from Feb 15 to March 5, 2018. Analysis was based on the 474 intervention and 454 control landlords surveyed at study end. The intervention was associated with improvements in the prevalence of cleaning rotas (relative risk 1·16, 95% CI 1·05-1·30; p=0·0011), inside locks (1·34, 1·10-1·64; p=0·00081), outside locks (1·27, 1·06-1·52; p=0·0028), and toilets with simple covers or water seals (1·25, 1·04-1·50; p=0·0063).

INTERPRETATION

It is possible to improve the structural quality and cleanliness of shared sanitation by targeting landlords with a scalable, theory-driven behaviour change intervention without subsidy or provision of the relevant infrastructure.

FUNDING

Sanitation and Hygiene Applied Research for Equity.

A mixed-methods study of women's sanitation utilization in informal settlements in Kenya

While access to safe sanitation is a global issue, there are large disparities in access. Women living in informal settlements, in particular, are disproportionately affected by lack of access to sanitation. Without adequate sanitation, these women may resort to unsafe strategies to manage their sanitation needs, but limited research has focused specifically on this issue. Qualitative and quantitative data were collected from women in the Mathare informal settlement in Nairobi, Kenya in 2016. A latent class analysis (LCA) using the quantitative data yielded five distinct sanitation profiles (SP) among women in Mathare. In-depth interviews and sanitation walks with women added further detail about the characteristics of and motivations underlying each profile. Women’s sanitation profiles in these settlements are complex. A majority of women in this study utilized an unsafe method of disposal at least once in a 24-hour period that increased their risk of direct exposure to waste and harmful pathogens.

Pit latrine fill-up rates: variation determinants and public health implications in informal settlements, Nakuru-Kenya

Background

Pit latrine operational management and sludge accumulation rate, presents a challenging sanitation problem in low-income urban settlements. However, these challenges have been under-researched. This study was carried out between December 2014 and September 2015 in Nakuru, Kenya. Its objectives were to determine pit latrine management activities and content accumulation rates.

Methods

A longitudinal design was used to study 100 households and their respective pit latrines. Sludge accumulation in 73 pit latrines was monitored for 10 months using a digital laser range-finder. Data analysis included normality testing and descriptive statistics. Differences in fill up across and within the study areas were analysed using one-way analysis of variance and the Fisher’s Exact Test used to determine areas with significant differences.

Results

Sixty-one percent of the pit latrines were used as solid waste disposal points while 45% of the respondents had no hygiene awareness. The annual fill-up rate and individual sludge contribution were 0.87 ± 0.20 m³ and 41.82 l respectively. The sludge accumulation rates across the study areas had statistically significant mean differences (p < 0.05).

Conclusion

Operational management and design affect the fill-up rates and post fill-up management operations. This study argues for a need to link information and awareness to users, construction artisans, property owners and local authorities on appropriate vault volumes and management practices. Linking the variables would ensure efficient sanitation service delivery and public health protection.

Drivers of women's sanitation practices in informal settlements in sub-Saharan Africa: a qualitative study in Mathare Valley, Kenya

Despite evidence suggesting women are disproportionately affected by the lack of adequate and safe sanitation facilities around the world, there is limited information about the factors that influence women's ability to access and utilize sanitation, especially in sub-Saharan Africa. The purpose of this study was to explore factors influencing women's sanitation practices in informal settlements in Nairobi, Kenya. Information from 55 in-depth interviews conducted in 2016 with 55 women in Mathare Valley Informal Settlement in Nairobi was used to carry out cross-case, thematic analysis of women's common sanitation routines. Women identified neighborhood disorganization, fear of victimization, lack of privacy, and cleanliness/dirtiness of facilities as important factors in the choices they make about their sanitation practices. This suggests that future sanitation-related interventions and policies may need to consider strategies that focus not only on toilet provision or adoption but also on issues of space and community dynamics.

Generation of sanitation system options for urban planning considering novel technologies

The identification of appropriate sanitation systems is particularly challenging in developing urban areas where local needs are not met by conventional solutions. While structured decision-making frameworks such as Community-Led Urban Environmental Sanitation (CLUES) can help facilitate this process, they require a set of sanitation system options as input. Given the large number of possible combinations of sanitation technologies, the generation of a good set of sanitation system options is far from trivial. This paper presents a procedure for generating a set of locally appropriate sanitation system options, which can then be used in a structured decision-making process. The systematic and partly automated procedure was designed (i) to enhance the reproducibility of option generation; (ii) to consider all types of conventional and novel technologies; (iii) to provide a set of sanitation systems that is technologically diverse; and (iv) to formally account for uncertainties linked to technology specifications and local conditions. We applied the procedure to an emerging small town in Nepal. We assessed the appropriateness of 40 technologies and generated 17,955 appropriate system options. These were classified into 16 system templates including on-site, urine-diverting, biogas, and blackwater templates. From these, a subset of 36 most appropriate sanitation system options were selected, which included both conventional and novel options. We performed a sensitivity analysis to evaluate the impact of different elements on the diversity and appropriateness of the set of selected sanitation system options. We found that the use of system templates is most important, followed by the use of a weighted multiplicative aggregation function to quantify local appropriateness. We also show that the optimal size of the set of selected sanitation system options is equal to or slightly greater than the number of system templates. As novel technologies are developed and added to the already large portfolio of technology options, the procedure presented in this work may become an essential tool for generating and exploring appropriate sanitation system options.

Shared latrines in Maputo, Mozambique: exploring emotional well-being and psychosocial stress

BACKGROUND

Approximately 18% of Sub-Saharan Africa's urban population relies on shared sanitation facilities, which are shared by one or more households. While there is growing recognition of sanitation's relationship with stress and well-being - particularly among women - most research has focused on rural populations and the transition from open defecation and/or unimproved latrines to private shared sanitation. This study explores sanitation-related stressors among users of both improved and unimproved shared sanitation facilities.

METHODS

This study was nested within the larger MapSan health impact trial (Trial Registration: NCT02362932). Participants were recruited from the control arm of the trial (Traditional Latrine (TL) users) and intervention arm, which received one of two improved shared sanitation facilities - Shared Latrines (SL) shared by up to 20 individuals and Community Sanitation Blocks (CSBs) shared by more than 20 individuals. Sampling was informed by a life stage perspective to reflect diversity in sanitation needs and experiences within the population. Data included 96 in-depth interviews, 7 focus group discussions, and 25 unstructured observations. Data collection and analysis followed a Grounded Theory approach, which was used to identify the key domains of sanitation-related stress among participants. A semi-structured tool was applied to all female interview transcripts to assess the frequency and severity of key stressors.

RESULTS

Participants reported stress due to: lack of safety; lack of privacy; disgust about the latrine condition; and collective action failure in terms of managing the latrine, often causing neighborhood conflict or unhygienic sanitation conditions. Fewer SL and CSB users reported specific stress domains and - with the exception of perceived safety - reported fewer severe stressors. The leading cause of stress reduction due to the intervention was decreased disgust followed by increased privacy and safety.

CONCLUSIONS

Our data suggest that "improved", shared facilities can reduce stress when proper maintenance and management systems are in place. Private, shared sanitation only had limited impact on users' perceptions of safety, particularly at night, suggesting that safety concerns extend beyond the physical latrine structure. Our research demonstrates that factors including latrine location and neighborhood violence are important determinants of safety perceptions and corresponding psychosocial stress.

Urban sanitation coverage and environmental fecal contamination: Links between the household and public environments of Accra, Ghana

Exposure to fecal contamination in public areas, especially in dense, urban environments, may significantly contribute to enteric infection risk. This study examined associations between sanitation and fecal contamination in public environments in four low-income neighborhoods in Accra, Ghana. Soil (n = 72) and open drain (n = 90) samples were tested for E. coli, adenovirus, and norovirus. Sanitation facilities in surveyed households (n = 793) were categorized by onsite fecal sludge containment ("contained" vs. "uncontained") using previous Joint Monitoring Program infrastructure guidelines. Most sanitation facilities were shared by multiple households. Associations between spatial clustering of household sanitation coverage and fecal contamination were examined, controlling for neighborhood and population density (measured as enumeration areas in the 2010 census and spatially matched to sample locations). E. coli concentrations in drains within 50m of clusters of contained household sanitation were more than 3 log-units lower than those outside of clusters. Further, although results were not always statistically significant, E. coli concentrations in drains showed consistent trends with household sanitation coverage clusters: concentrations were lower in or near clusters of high coverage of household sanitation facilities-especially contained facilities-and vice versa. Virus detection in drains and E. coli concentrations in soil were not significantly associated with clustering of any type of household sanitation and did not exhibit consistent trends. Population density alone was not significantly associated with any of the fecal contamination outcomes by itself and was a significant, yet inconsistent, effect modifier of the association between sanitation clusters and E. coli concentrations. These findings suggest clustering of contained household sanitation, even when shared, may be associated with lower levels of fecal contamination within drains in the immediate public domain. Further research is needed to better quantify these relationships and examine impacts on health.

The Territorial Dimension of Sewage Networks: the Case of Recreio dos Bandeirantes, Rio de Janeiro, Brazil

The urban suburbs of Brazilian cities have grown without an adequate sanitation infrastructure. Different social groups try to overcome these shortcomings seeking local sanitation alternatives at individual or community levels, contrasting with the universal model of sewage networks. This study was developed in the suburban neighborhood of Recreio dos Bandeirantes, Rio de Janeiro, Brazil, in order to analyze the installation process of the sewage system under a territorial approach. Data facilitated the construction of territorial schemes related to conflicts during the implementation of sewage networks in this neighborhood, where middle class groups and favela residents coexist with environmental preservation areas, beaches and commercial activities. This work revealed the need for contextualized sanitation information made available by the Brazilian Institute of Geography and Statistics (IBGE) and state sewage collection company, which conceal these conflicts or the representation of residents about their sanitation problems. Overlapping territorial managing functions should be considered as one of the factors responsible for the conflicts identified in the neighborhood. Further studies are suggested as methodological complementation and data update.

Context matters: a multicountry analysis of individual- and neighbourhood-level factors associated with women's sanitation use in sub-Saharan Africa

OBJECTIVES

To identify cross-national trends in factors associated with women's sanitation use in sub-Saharan Africa.

METHODS

Using data from Demographic and Health Surveys conducted in 14 SSA countries between 2008 and 2014, we modelled women's sanitation use in relation to various individual- and neighbourhood-level factors.

RESULTS

Substantial variation exists between countries in the strength and direction of factors associated with sanitation use. Particularly significant associations across the region included access to different water sources, years of education, family size, age, living in a female-headed household, being married and wealth. Neighbourhood-level poverty, ethnic diversity and urbanisation were important factors in a majority of countries.

CONCLUSIONS

International development goals for sanitation are frequently framed in terms of availability, implicitly suggesting that if facilities are accessible, they will be used. A more nuanced view that takes into account not only the existence of facilities but also the factors influencing their use is needed to understand the dynamics of women's sanitation use in the region. Policies focused on availability may not yield the desired public health benefits from improved sanitation in sub-Saharan Africa. Context-relevant factors must be addressed concurrently to achieve sanitation development goals.

Viral diversity and abundance in polluted waters in Kampala, Uganda

Waterborne viruses are a significant cause of human disease, especially in developing countries such as Uganda. A total of 15 virus-selective samples were collected at five sites (Bugolobi Wastewater Treatment Plant (WWTP) influent and effluent, Nakivubo Channel upstream and downstream of the WWTP, and Nakivubo Swamp) in July and August 2016. Quantitative PCR and quantitative RT-PCR was performed to determine the concentrations of four human viruses (adenovirus, enterovirus, rotavirus, and hepatitis A virus) in the samples. Adenovirus (1.53*10⁵-1.98*10⁷ copies/L) and enterovirus (3.17*10⁵-8.13*10⁷ copies/L) were found to have the highest concentrations in the samples compared to rotavirus (5.79*10¹-3.77*10³ copies/L) and hepatitis A virus (9.93*10²-1.11*10⁴ copies/L). In addition, next-generation sequencing and metagenomic analyses were performed to assess viral diversity, and several human and vertebrate viruses were detected, including Herpesvirales, Iridoviridae, Poxviridae, Circoviridae, Parvoviridae, Bunyaviridae and others. Effluent from the wastewater treatment plant appears to impact surface water, as samples taken from surface water downstream of the treatment plant had higher viral concentrations than samples taken upstream. Temporal fluctuations in viral abundance and diversity were also observed. Continuous monitoring of wastewater may contribute to assessing viral disease patterns at a population level and provide early warning of potential outbreaks using wastewater-based epidemiology methods.

Fecal sludge management in developing urban centers: a review on the collection, treatment, and composting

The problems posed by fecal sludge (FS) are multidimensional because most cities rapidly urbanize, which results in the increase in population, urban settlement, and waste generation. Issues concerning health and waste treatment have continued to create alarming situations. These issues had indeed interfered with the proper steps in managing FS, which contaminates the environment. FS can be used in agriculture as fertilizer because it is an excellent source of nutrients. The recent decline in crop production due to loss of soil organic component, erosion, and nutrient runoff has generated interest in the recycling of FS into soil nutrients through stabilization and composting. However, human feces are considerably liable to spread microorganisms to other persons. Thus, sanitation, stabilization, and composting should be the main objectives of FS treatment to minimize the risk to public and environmental health. This review presents an improved FS management (FSM) and technology option for soil amendment that is grouped into three headings, namely, (1) collection, (2) treatment, and (3) composting. On the basis of the literature review, the main problems associated with the collection and treatment of FS, such as inadequate tools and improper treatment processes, are summarized, and the trends and challenges that concern the applicability of each of the technologies in developing urban centers are critically reviewed. Stabilization during pretreatment before composting is suggested as the best method to reduce pathogens in FS. Results are precisely intended to be used as a support for decisions on policies and strategies for FSM and investments for improved treatment facilities.

Decision-making on shared sanitation in the informal settlements of Kisumu, Kenya

Unlike most quantitative studies that investigate decision-making on investing in sanitation, this study adopted a qualitative approach to investigate decision-making on shared sanitation in the informal settlements of Kisumu city, in Kenya. Using a grounded theory approach, landlords and tenants were interviewed to identify sanitation decisions, individuals involved in decision-making and factors influencing decision-making. The results indicate that the main sanitation decisions are on investment, emptying, repair and cleaning. Landlords make investment, emptying and repair decisions, while tenants make cleaning decisions. Absentee landlords are less involved in most decision-making compared to live-in landlords, who rarely consult tenants in decision-making. Tenants make decisions after consultations with a third party and often collectively with other tenants. Sanitation interventions in informal settlements should thus, target landlords and tenants, with investment efforts being directed at landlords and maintenance efforts at tenants.

The Influence of Household- and Community-Level Sanitation and Fecal Sludge Management on Urban Fecal Contamination in Households and Drains and Enteric Infection in Children

Urban sanitation necessitates management of fecal sludge inside and outside the household. This study examined associations between household sanitation, fecal contamination, and enteric infection in two low-income neighborhoods in Vellore, India. Surveys and spatial analysis assessed the presence and clustering of toilets and fecal sludge management (FSM) practices in 200 households. Fecal contamination was measured in environmental samples from 50 households and household drains. Enteric infection was assessed from stool specimens from children under 5 years of age in these households. The two neighborhoods differed significantly in toilet coverage (78% versus 33%) and spatial clustering. Overall, 49% of toilets discharged directly into open drains (“poor FSM”). Children in households with poor FSM had 3.78 times higher prevalence of enteric infection when compared with children in other households, even those without toilets. In the neighborhood with high coverage of household toilets, children in households with poor FSM had 10 times higher prevalence of enteric infection than other children in the neighborhood and drains in poor FSM clusters who had significantly higher concentrations of genogroup II norovirus. Conversely, children in households with a toilet that contained excreta in a tank onsite had 55% lower prevalence of enteric infection compared with the rest of the study area. Notably, households with a toilet in the neighborhood with low toilet coverage had more fecal contamination on floors where children played compared with those without a toilet. Overall, both toilet coverage levels and FSM were associated with environmental fecal contamination and, subsequently, enteric infection prevalence in this urban setting.

Influence of community satisfaction with individual happiness: comparative study in semi-urban and rural areas of Tikapur, Nepal

Happiness is a subjective indicator of overall living conditions and quality of life. Recently, community- and national-level investigations connecting happiness and community satisfaction were conducted. This study investigated the effects of community satisfaction on happiness in Nepal. A factor analysis was employed to examine 24 items that are used to measure community satisfaction, and a multiple regression analysis was conducted to investigate the effects of these factors on happiness. In semi-urban areas, sanitation showed a positive relationship with happiness. In rural areas, edu-medical services were negatively related to happiness, while agriculture was positively related. Gender and perceived health were closely associated with happiness in rural areas. Both happiness and satisfaction are subjective concepts, and are perceived differently depending on the socio-physical environment and personal needs. Sanitation, agriculture (food) and edu-medical services were critical factors that affected happiness; however, the results of this study cannot be generalized to high-income countries.

Examining the relationship between socio-economic status, WASH practices and wasting

Childhood wasting is a global problem and is significantly more pronounced in low and middle income countries like Bangladesh. Socio Economic Status (SES) and Water, Sanitation and Hygiene (WASH) practices may be significantly associated with wasting. Most previous research is consistent about the role of SES, but the significance of WASH in the context of wasting remains ambiguous. The effect of SES and WASH on weight for length (WHZ) is examined using a Structural Equation Model (SEM) to explicitly describe the direct and indirect role of WASH in the context of SES.A nationally representative survey of 10,478 Bangladeshi children under 5 were examined. An expert defined SEM was used to construct latent variables for SES and WASH. The SEM included a direct pathway from SES to WHZ and an indirect pathway from SES to WHZ via WASH along with regression of relevant covariates on the outcome WHZ and the latent variables. Both SES (p<0.01) and WASH (p<0.05) significantly affect WHZ. SES (p<0.01) also significantly affects WASH. Other structural components showed that child's age (p<0.01) affects WHZ and types of residence (p<0.01) affects SES. WASH practices at least partially mediate the association between SES and wasting status. WASH and SES are both significantly associated with WHZ.

Early testing of new sanitation technology for urban slums: The case of the Blue Diversion Toilet

The toilets used most in informal urban settlements have detrimental consequences for the environment and human health due to the lack of proper collection and treatment of toilet waste. Concepts for safe, sustainable and affordable sanitation systems exist, but their feasibility and acceptance have to be investigated at an early stage of development, which is difficult due to the high costs of building working models. In this paper, we present an approach to estimate acceptance in a valid and representative form with only one working model, and apply it to test an innovative zero-emission toilet with recycling of wash water. Four basic principles were specified for investigation and nine hypotheses formulated to test the feasibility and acceptance of these principles: source separation of urine and feces with subsequent collection for resource recovery; provision of wash water in a separate cycle with on-site recovery through a membrane bioreactor; a convenient and attractive overall design; and a financially sustainable business plan. In Kampala (Uganda), in 2013, data was collected from 22 regular users, 308 one-time users and a representative sample of 1538 participants. Qualitative data was collected from the users, who evaluated their likes, perceived benefits, social norms and expected ease of use based on verbal and visual information. Most of the hypotheses were confirmed, indicating the feasibility and acceptance of the basic principles. Source separation and on-site water recovery were found to be feasible and accepted, provided users can be convinced that the emptying service and water recovery process work reliably. In the survey, the toilet was evaluated favorably and 51% of the participants agreed to be placed on a bogus waiting list. However, some design challenges were revealed, such as the size of the toilet, hiding feces from view and improving the separation of urine and water.

Adopt or Adapt: Sanitation Technology Choices in Urbanizing Malawi

This paper presents the results of a mixed-methods study examining adaptation strategies that property owners in low-income, rapidly urbanizing areas in Malawi adopt to address the limitations of pit latrines, the most common method of disposing human excreta. A particular challenge is lack of space for constructing new latrines as population density increases: traditional practice has been to cap full pits and simply move to a new site, but increasing demands on space require new approaches to extend the service life of latrines. In this context, we collected data on sanitation technology choices from January to September 2013 through 48 in-depth interviews and a stated preference survey targeting 1,300 property owners from 27 low-income urban areas. Results showed that property owners with concern about space for replacing pit latrines were 1.8 times more likely to select pit emptying service over the construction of new pit latrines with a slab floor (p = 0.02) but there was no significant association between concern about space for replacing pit latrines and intention to adopt locally promoted, novel sanitation technology known as ecological sanitation (ecosan). Property owners preferred to adapt existing, known technology by constructing replacement pit latrines on old pit latrine locations, reducing the frequency of replacing pit latrines, or via emptying pit latrines when full. This study highlights potential challenges to adoption of wholly new sanitation technologies, even when they present clear advantages to end users. To scale, alternative sanitation technologies for rapidly urbanising cities should offer clear advantages, be affordable, be easy to use when shared among multiple households, and their design should be informed by existing adaptation strategies and local knowledge.

Sanitation investments in Ghana: An ethnographic investigation of the role of tenure security, land ownership and livelihoods

BACKGROUND

Ghana's low investment in household sanitation is evident from the low rates of improved sanitation. This study analysed how land ownership, tenancy security and livelihood patterns are related to sanitation investments in three adjacent rural and peri-urban communities in a district close to Accra, Ghana's capital.

METHODS

Qualitative data was gathered for this comparative ethnographic study over seven months, (June, 2011-January, 2012) using an average of 43 (bi-weekly) participant observation per community and 56 in-depth interviews. Detailed observational data from study communities were triangulated with multiple interview material and contextual knowledge on social structures, history of settlement, land use, livelihoods, and access to and perceptions about sanitation.

RESULTS

This study shows that the history of settlement and land ownership issues are highly correlated with people's willingness and ability to invest in household sanitation across all communities. The status of being a stranger i.e. migrant in the area left some populations without rights over the land they occupied and with low incentives to invest in sanitation, while indigenous communities were challenged by the increasing appropriation of their land for commercial enterprises and for governmental development projects. Interview responses suggest that increasing migrant population and the high demand for housing in the face of limited available space has resulted in general unwillingness and inability to establish private sanitation facilities in the communities. The increasing population has also created high demand for cheap accommodation, pushing tenants to accept informal tenancy agreements that provided for poor sanitation facilities. In addition, poor knowledge of tenancy rights leaves tenants in no position to demand sanitation improvements and therefore landlords feel no obligation or motivation to provide and maintain domestic sanitation facilities.

CONCLUSIONS

The study states that poor land rights, the history of settlements, in-migration and insecure tenancy are key components that are associated with local livelihoods and investments in private sanitation in rapidly changing rural and peri-urban communities of Ghana. Sanitation policy makers and programme managers must acknowledge that these profound local, ethnic and economic forces are shaping people's abilities and motivations for sanitation investments.

Seasonal variations and shared latrine cleaning practices in the slums of Kampala city, Uganda

Background

The effect of seasons on health outcomes is a reflection on the status of public health and the state of development in a given society. Evidence shows that in Sub-Saharan Africa, most infectious diseases flourish during the wet months of the year; while human activities in a context of constrained choices in life exacerbate the effects of seasons on human health. The paper argues that, the wet season and when human activities are at their peak, sanitation is most dire poor slum populations.

Methods

A shared latrine cleaning observation was undertaken over a period of 6 months in the slums of Kampala city. Data was collected through facility observations, user group meetings, Focus group discussions and, key informant interviews. The photos of the observed sanitation facilities were taken and assessed for facility cleanliness or dirt. Shared latrine pictures, observations, Focus Group Discussion, community meetings and key informant interviews were analysed and subjected to an analysis over the wet, dry and human activity cycles before a facility was categorised as either ‘dirty’ or ‘clean’.

Results

Human activity cycles also referred to as socio-economic seasons were, school days, holidays, weekends and market days. These have been called ‘impure’ seasons, while the ‘pure’ seasons were the wet and dry months: improved and unimproved facilities were negatively affected by the wet seasons and the peak seasons of human activity. Wet seasons were associated with, mud and stagnant water, flooding pits and a repugnant smell from the latrine cubicle which made cleaning difficult. During the dry season, latrines became relatively cleaner than during the wet season. The presence of many child(ren) users during school days as well as the influx of market goers for the roadside weekly markets compromised the cleaning outcomes for these shared sanitation facilities.

Conclusion

Shared latrine cleaning in slums is impacted by seasonal variations related to weather conditions and human activity. The wet seasons made the already bad sanitation situation worse. The seasonal fluctuations in the state of shared slum sanitation relate to a wider malaise in the population and an implied capacity deficit among urban authorities. Poor sanitation in slums is part of a broader urban mismanagement conundrum pointing towards the urgent need for multiple interventions aimed at improving the general urban living conditions well beyond sanitation.

User perceptions of and willingness to pay for household container-based sanitation services: experience from Cap Haitien, Haiti

Household-level container-based sanitation (CBS) services may help address the persistent challenge of providing effective, affordable sanitation services for which low-income urban households are willing to pay. Little is known, however, about user perceptions of and demand for household CBS services. This study presents the results of a pilot CBS service programme in Cap Haitien, Haiti. One hundred and eighteen households were randomly selected to receive toilets and a twice-weekly collection service. After three months, changes in these households' satisfaction with their sanitation situation, along with feelings of pride, modernity and personal safety, were compared to 248 households in two comparison cohorts. Following the service pilot, 71 per cent of participating households opted to continue with the container-based sanitation service as paying subscribers. The results from this study suggest that, in the context of urban Haiti, household CBS systems have the potential to satisfy many residents' desire for safe, convenient and modern sanitation services.

Current state and trends of access to sanitation in Ethiopia and the need to revise indicators to monitor progress in the Post-2015 era

BACKGROUND

Investigating the current level and trends of access and identifying the underlying challenges to sanitation system development will be useful in determining directions developing countries are heading as they plan to promote sustainable development goals (post 2015 agenda). This research investigates the status and trends of access to improved sanitation coverage (ISC) in relation to the MDG target in Ethiopia with the aim of identifying prevailing constraints and suggesting the way forward in the post-MDG era.

METHOD

We examined data from a nationwide inventory conducted in accordance with the sanitation ladder at the national level and from a household survey in randomly selected urban slums in Addis Ababa. The inventory data were analyzed and interpreted using the conceptual model of the sanitation ladder. We used administrative reports and survey results to plot the time trend of the ISC.

RESULTS

The data from the nationwide inventory of sanitation facilities, which are presented along the sanitation ladder reveal that more than half of the Ethiopian population (52.1%) still used unimproved sanitation facilities in 2014. The majority (35.6%) practiced open defecation, implying that the country is far from the MDG target for access to improved sanitation (56%). Most people in urban slums (88.6%) used unimproved sanitation facilities, indicating that the urban poor did not receive adequate sanitation services. Trend analysis shows that access to ISC has increased, but Central Statistical Authority (CSA) data reveal a decline. This discrepancy is due to differences in data collection methods and tools. Dry pit latrines are the most widely used toilet facilities in Ethiopia, accounting for about 97.5% of the ISC.

CONCLUSION

The sanitation coverage is far from the MDG target and the majority of the population, mainly the urban poor, are living in a polluted environment, exposed to water and sanitation-related diseases. The sanitation coverage estimates might be even lower if proper utilization, regular emptying, and fecal sludge management (FSM) of dry pit latrines were considered as indicators. In order to enhance sanitation services for all in the post-MDG era, urgent action is required that will establish proper monitoring and evaluation systems that can measure real access to ISC.

Slum Sanitation and the Social Determinants of Women's Health in Nairobi, Kenya

Inadequate urban sanitation disproportionately impacts the social determinants of women's health in informal settlements or slums. The impacts on women's health include infectious and chronic illnesses, violence, food contamination and malnutrition, economic and educational attainment, and indignity. We used household survey data to report on self-rated health and sociodemographic, housing, and infrastructure conditions in the Mathare informal settlement in Nairobi, Kenya. We combined quantitative survey and mapping data with qualitative focus group information to better understand the relationships between environmental sanitation and the social determinants of women and girls' health in the Mathare slum. We find that an average of eighty-five households in Mathare share one toilet, only 15% of households have access to a private toilet, and the average distance to a public toilet is over 52 meters. Eighty-three percent of households without a private toilet report poor health. Mathare women report violence (68%), respiratory illness/cough (46%), diabetes (33%), and diarrhea (30%) as the most frequent physical burdens. Inadequate, unsafe, and unhygienic sanitation results in multiple and overlapping health, economic, and social impacts that disproportionately impact women and girls living in urban informal settlements.