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Mamo BG, Novotný J. Promotion of market-based sanitation in Ethiopia: a case study from Wolaita zone. Health Promot Int 2024; 39:daae034. [PMID: 38597720 PMCID: PMC11005767 DOI: 10.1093/heapro/daae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024] Open
Abstract
Ethiopia increased the availability of latrines notably, but the sanitation facilities rarely meet hygienic standards. Therefore, the market-based sanitation (MBS) programme has been implemented across the country for nearly a decade to expand the market and boost the demand for hygienic sanitation products and services. While it does not seem that the MBS would bring any notable change in sanitation conditions so far, its implementation challenges are not adequately understood. To address this gap, this article delves into the grassroots-level implementation of MBS in the Wolaita zone. The study relies on qualitative data gathered through interviews with various stakeholders, examining both demand- and supply-side challenges. Some issues identified were external to MBS implementation, such as high inflation and an unstable political and security situation in Ethiopia. Additionally, the study reveals that more general deficiencies of the Ethiopian health extension program, including the stress and discouragement of local change agents (health extension workers, health development army members) due to workloads and low remuneration, have adversely impacted MBS delivery. The implementation of MBS has also not effectively addressed the affordability of hygienic sanitation products. On the supply side, economic constraints and organizational inefficiencies have hindered the development of the sanitation market, preventing it from reaching a critical mass. Our research suggests that MBS alone will not suffice to improve sanitation in Ethiopia.
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Affiliation(s)
- Biruk Getachew Mamo
- Department of Social Geography and Regional Development, Faculty of Science, Charles University, Albertov 6, 128 00 Prague 2, Czechia
| | - Josef Novotný
- Department of Social Geography and Regional Development, Faculty of Science, Charles University, Albertov 6, 128 00 Prague 2, Czechia
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Households' access to an improved latrine and its associated factors among households of sanitation marketing products users and non-users, Northeast Amhara, Ethiopia. Heliyon 2022; 8:e11325. [PMID: 36387461 PMCID: PMC9647351 DOI: 10.1016/j.heliyon.2022.e11325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 07/29/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
Sanitation marketing is an approach to increase access to the improved latrine on a large scale which helps households to promote proper utilization of sanitary facilities. It helps to close the huge sanitation access gap in developing countries like Ethiopia. This study aimed to assess households' access to an improved latrine and its associated factors among sanitation marketing product users and non-users in Dessie Zuria District, Northeast Amhara, Ethiopia. A community-based comparative cross-sectional study was conducted among 640 households, in 2021. Multi-stage sampling techniques and a structured questionnaire were used. Data were checked, coded, and entered into Epi-info version 7 and exported to Statistical Package for Social Sciences version 23.0 for analysis. Binary logistic regression was employed to determine factors associated with improved latrine access. The study revealed that overall 59.8% of the households had access to improved latrines. Of this, 75.2% (95% Confidence Interval (CI): 70, 80) of households were Sanitation marketing products users; and 44.2% (95% CI: 39, 50) of households were from non-users of Sanitation marketing products. Being female household head, Adjusted Odds Ratio (AOR = 4.3, 95% CI: 1.69, 10.59); urban residence, AOR = 2.5, 95% CI: 1.23, 5.19; water access, AOR = 3.3, 95% CI: 1.63, 6.57 were significantly associated with access to the improved latrine in sanitation marketing products users households, while being a female household head, AOR = 7.3, 95% CI: 3.68, 14.39; urban residence, AOR = 2.8, 95% CI: 1.64, 4.77; water access, AOR = 2.4, 95% CI: 1.44, 4.10 were significantly associated with access to the improved latrine in non-user households of sanitation marketing products. Access to improved latrines is still a big problem in both households of sanitation marketing product users and sanitation marketing product non-users. Gender, residence, water access, supportive supervision, knowledge, and availability of sanitation hardware stores were found to be significant predictors of household access to an improved latrine. Hence, evaluating policies and strategies of sanitation marketing approach on improved sanitation facilities is recommended.
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Barrington DJ, Sindall RC, Shaylor EL. Learning from Failure in Environmental and Public Health Research. ENVIRONMENTAL HEALTH INSIGHTS 2022; 16:11786302221104067. [PMID: 35694431 PMCID: PMC9178970 DOI: 10.1177/11786302221104067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 03/24/2022] [Indexed: 06/15/2023]
Affiliation(s)
- Dani J Barrington
- School of Population and Global Health, The University of Western Australia, Crawley, WA, Australia
| | | | - Esther L Shaylor
- UNICEF Product Innovation Center, Supply Division, Copenhagen, Denmark
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Carrard N, MacArthur J, Leahy C, Soeters S, Willetts J. The water, sanitation and hygiene gender equality measure (WASH-GEM): Conceptual foundations and domains of change. WOMENS STUDIES INTERNATIONAL FORUM 2022. [DOI: 10.1016/j.wsif.2022.102563] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Robinson HJ, Barrington DJ. Drivers of menstrual material disposal and washing practices: A systematic review. PLoS One 2021; 16:e0260472. [PMID: 34860828 PMCID: PMC8641861 DOI: 10.1371/journal.pone.0260472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 11/10/2021] [Indexed: 11/26/2022] Open
Abstract
Background Disposal and washing facilities and services for menstrual materials are often designed based upon technical specifications rather than an in-depth understanding of what drives peoples’ choices of practices. Objectives and data sources This systematic review identified and summarised the main behavioural drivers pertaining to the choice of disposal and washing practices of menstrual materials through the thematic content analysis and study appraisal of 82 publications (80 studies) on menstrual health and hygiene published since 1999, reporting the outcomes of primary research across 26 countries. Results Disposal and washing behaviours are primarily driven by the physical state of sanitation facilities; however, this is intrinsically linked to taboos surrounding and knowledge of menstruation. Implications Using reasons given for disposal and washing practices by menstruators or those who know them well, or inferred by authors of the reviewed studies, we identify the key considerations needed to design facilities and services which best suit the desired behaviours of both planners and those who menstruate. Inclusivity The term menstruators is used throughout to encompass all those mentioned in the studies reviewed (girls and women); although no studies explicitly stated including non-binary or transgender participants, this review uses inclusive language that represents the spectrum of genders that may experience menstruation. Registration The review protocol is registered on PROSPERO: 42019140029.
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Affiliation(s)
| | - Dani Jennifer Barrington
- University of Leeds, Leeds, West Yorkshire, United Kingdom
- The University of Western Australia, Crawley, Western Australia, Australia
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Vernon N, Myers J. Acknowledging and Learning from Different Types of Failure. ENVIRONMENTAL HEALTH INSIGHTS 2021; 15:11786302211018095. [PMID: 34158799 PMCID: PMC8186116 DOI: 10.1177/11786302211018095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/14/2021] [Indexed: 06/13/2023]
Abstract
The challenges faced in sanitation and hygiene programmes are numerous and complex. Failures are inevitable. From our experience of working on rapid action learning and research in this sector we have found that when mistakes are shared they are usually those which were uncontrollable and unanticipated i.e. somebody else's fault. In this perspectives piece we propose a typology of failure alongside criteria for research and learning processes that prioritises timeliness, relevance and actionability. We argue that these can be used together to identify and reflect on failures (and successes) quickly. We provide some practical suggestion for different stakeholders to support a shift towards a more open and reflexive sector, where all types of failures can be shared broadly.
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Affiliation(s)
| | - Jamie Myers
- Jamie Myers, The Sanitation Learning Hub at the Institute of Development Studies, Library Road, Falmer, BN1 9RE, UK.
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Ross I, Cumming O, Dreibelbis R, Adriano Z, Nala R, Greco G. How does sanitation influence people's quality of life? Qualitative research in low-income areas of Maputo, Mozambique. Soc Sci Med 2021; 272:113709. [PMID: 33517125 PMCID: PMC7938219 DOI: 10.1016/j.socscimed.2021.113709] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/09/2020] [Accepted: 01/14/2021] [Indexed: 01/18/2023]
Abstract
Preventing infectious disease has often been the primary rationale for public investment in sanitation. However, broader aspects of sanitation such as privacy and safety are important to users across settings, and have been linked to mental wellbeing. The aim of this study is to investigate what people most value about sanitation in low-income areas of Maputo, Mozambique, to inform a definition and conceptual model of sanitation-related quality of life. Our approach to qualitative research was rooted in economics and applied the capability approach, bringing a focus on what people had reason to value. We undertook 19 in-depth interviews and 8 focus group discussions. After eliciting attributes of "a good life" in general, we used them to structure discussion of what was valuable about sanitation. We applied framework analysis to identify core attributes of sanitation-related quality of life, and used pile-sorting and triad exercises to triangulate findings on attributes' relative importance. The five core attributes identified were health, disgust, shame, safety, and privacy. We present a conceptual model illustrating how sanitation interventions might improve quality of life via changes in these attributes, and how changes are likely to be moderated by conversion factors (e.g. individual and environmental characteristics). The five capability-based attributes are consistent with those identified in studies of sanitation-related insecurity, stress and motives in both rural and urban areas, which is supportive of theoretical generalisability. Since two people might experience the same toilet or level of sanitation service differently, quality of life effects of interventions may be heterogeneous. Future evaluations of sanitation interventions should consider how changes in quality of life might be captured.
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Affiliation(s)
- Ian Ross
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom; Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
| | - Oliver Cumming
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
| | - Robert Dreibelbis
- Department of Disease Control, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
| | - Zaida Adriano
- WE Consult, Tomás Ribeiro street 177, Maputo, Mozambique.
| | - Rassul Nala
- Instituto Nacional de Saúde, Distrito de Marracuene, Estrada Nacional 1, Maputo, Mozambique.
| | - Giulia Greco
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, United Kingdom.
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Yeboah-Antwi K, MacLeod WB, Biemba G, Sijenyi P, Höhne A, Verstraete L, McCallum CM, Hamer DH. Improving Sanitation and Hygiene through Community-Led Total Sanitation: The Zambian Experience. Am J Trop Med Hyg 2020; 100:1005-1012. [PMID: 30793687 DOI: 10.4269/ajtmh.18-0632] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
In 2012, approximately 5.6 million Zambians did not have access to improved sanitation and around 2.1 million practiced open defecation. The Zambia Sanitation and Hygiene Program (ZSHP), featuring community-led total sanitation, began in November 2011 to increase the use of improved sanitation facilities and adopt positive hygiene practices. Using a pre- and post-design approach with a population-level survey, after 3 years of implementation, we evaluated the impact of ZSHP in randomly selected households in 50 standard enumeration areas (representing 26 of 65 program districts). We interviewed caregivers of children younger than 5 years old (1,204 and 1,170 female caregivers at baseline and end line, respectively) and inspected household toilet facilities and sites for washing hands. At end line, 80% of households had access to improved sanitation facilities versus 64.1% at baseline (prevalence ratio [PR] = 1.25; 95% CI: 1.18-1.31) and 14.1% did not have a toilet facility compared with 19.4% at baseline. At end line, 10.6% of households reported living in an open defecation-free certified village compared with 0.3% at baseline (PR = 32.0; 95% CI: 11.9-86.4). In addition, at end line, 33.4% of households had a specific place for washing hands and 61.4% of caregivers reported handwashing with a washing agent after defecation or before preparing food compared with 21.1% (PR = 1.59; 95% CI: 1.39-1.82) and 55.2% (PR = 1.11; 95% CI: 1.04-1.19) at baseline, respectively. Community-led total sanitation implementation in Zambia led to improvements in access to improved sanitation facilities, reduced open defecation, and better handwashing practices. There is however a need for enhanced investment in sanitation and hygiene promotion.
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Affiliation(s)
- Kojo Yeboah-Antwi
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | - William B MacLeod
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | | | - Patrick Sijenyi
- Water, Sanitation and Hygiene Section, United Nations International Children's Emergency Fund (UNICEF) Zambia, Lusaka, Zambia
| | - Alexandra Höhne
- Water, Sanitation and Hygiene Section, United Nations International Children's Emergency Fund (UNICEF) Zambia, Lusaka, Zambia
| | - Lavuun Verstraete
- Water, Sanitation and Hygiene Section, United Nations International Children's Emergency Fund (UNICEF) Zambia, Lusaka, Zambia
| | - Caitryn M McCallum
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | - Davidson H Hamer
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts.,Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts
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Tidwell JB, Chipungu J, Chilengi R, Curtis V, Aunger R. Using a theory-driven creative process to design a peri-urban on-site sanitation quality improvement intervention. BMC Public Health 2019; 19:565. [PMID: 31088432 PMCID: PMC6518808 DOI: 10.1186/s12889-019-6898-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 04/25/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Behavior change interventions have been developed by drawing from many different theories using design processes of varying specificity. We describe the development of a behavior change intervention to improve on-site peri-urban sanitation quality in Lusaka, Zambia using the Behavior Centered Design (BCD) framework to explain the results of the process applied to improving the quality of shared peri-urban sanitation and compare them to similar interventions. METHODS We used the BCD behavioral determinants model to synthesize the data from our literature review and formative research. Then, we partnered with creative professionals using a design process to develop a theory-driven on-site peri-urban sanitation intervention. Particular attention was paid to the implications of using BCD for intervention development on improving its effectiveness, increasing the contributions to knowledge for other behaviors and settings, and advancing the discipline of applied behavioral science. RESULTS Based on findings from a literature review and formative research, we designed an intervention to encourage landlords to improve their toilets by making them more accessible, desirable, hygienic, and sustainable. The intervention involved landlords meeting in facilitated groups every 2 weeks with individual follow-up after each meeting. The meetings presented surprising "hidden camera"-style videos to reveal tenants' perspectives, used participatory activities to help landlords reevaluate the benefits they would derive from improving sanitation on their plots, and provided practical guidance and mechanisms to facilitate the performance of construction and cleaning behaviors. CONCLUSIONS Using the BCD framework provided an easy-to-follow intervention design process. The resulting intervention is highly creative and multi-faceted, with each element having a theoretical role in an explicit theory of change. The development of this theory-driven intervention advances applied behavioral science by facilitating evaluation of each of the behavior change techniques and the overall delivery mechanism hypothesized to change the target behaviors. This informs the adaptation of these findings to improving on-site sanitation in other settings and the iterative development of the BCD model, which can be used to more effectively change other behaviors.
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Affiliation(s)
- James B. Tidwell
- London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Jenala Chipungu
- Center for Infectious Disease Research in Zambia, Plot 34620, Alick Nkhata Road, Lusaka, Zambia
| | - Roma Chilengi
- Center for Infectious Disease Research in Zambia, Plot 34620, Alick Nkhata Road, Lusaka, Zambia
| | - Val Curtis
- London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
| | - Robert Aunger
- London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT UK
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Tidwell JB, Terris-Prestholt F, Quaife M, Aunger R. Understanding demand for higher quality sanitation in peri-urban Lusaka, Zambia through stated and revealed preference analysis. Soc Sci Med 2019; 232:139-147. [PMID: 31085398 DOI: 10.1016/j.socscimed.2019.04.046] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 04/27/2019] [Accepted: 04/30/2019] [Indexed: 11/18/2022]
Abstract
Poor peri-urban sanitation is a significant public health problem, likely to become more important as the world rapidly urbanizes. However, little is known about the role of consumer demand in increasing peri-urban sanitation quality, especially for tenants using shared sanitation as only their rental choices can be observed in the market. We analyzed data on existing housing markets collected between 9 Jun and 6 Jul 2017 using the Hedonic Pricing Method (HPM) to capture the percentage of rent attributable to sanitation quality (n = 933). We also conducted discrete choice experiments (DCEs) to obtain willingness to pay (WTP) estimates for specific sanitation components (n = 1087), and explored the implications by estimating the proportion of plots for which improved sanitation quality would generate a higher return on investment for landlords than building a place for an additional tenant to live. The HPM attributed 18% of rental prices to sanitation (∼US$8.10 per month), but parameters for several components were poorly specified due to collinearity and low overall prevalence of some products. DCEs revealed that tenants were willing to pay $2.20 more rent per month for flushing toilets on plots with running water and $3.39 more per month for solid toilet doors, though they were willing to pay little for simple hole covers and had negative WTP for adding locks to doors (-$1.04). Solid doors and flushing toilets had higher rent increase to cost ratios than other ways landlords commonly invested in their plots, especially as the number of tenant households on a plot increased. DCEs yielded estimates generally consistent with and better specified than HPM and may be useful to estimate demand in other settings. Interventions leveraging landlords' profit motives could lead to significant improvements in peri-urban sanitation quality, reduced diarrheal disease transmission, and increased well-being without subsidies or infrastructure investments by government or NGOs.
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Affiliation(s)
- James B Tidwell
- London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom.
| | - Fern Terris-Prestholt
- London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom
| | - Matthew Quaife
- London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom
| | - Robert Aunger
- London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, United Kingdom
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Brewis A, Wutich A, du Bray MV, Maupin J, Schuster RC, Gervais MM. Community hygiene norm violators are consistently stigmatized: Evidence from four global sites and implications for sanitation interventions. Soc Sci Med 2019; 220:12-21. [DOI: 10.1016/j.socscimed.2018.10.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/22/2018] [Accepted: 10/23/2018] [Indexed: 10/28/2022]
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Anthonj C, Fleming L, Godfrey S, Ambelu A, Bevan J, Cronk R, Bartram J. Health Risk Perceptions Are Associated with Domestic Use of Basic Water and Sanitation Services-Evidence from Rural Ethiopia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15102112. [PMID: 30261590 PMCID: PMC6210827 DOI: 10.3390/ijerph15102112] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 09/17/2018] [Accepted: 09/19/2018] [Indexed: 12/15/2022]
Abstract
We examine factors associated with the use of basic water supply and sanitation services as part of an integrated community-based nutrition programme which included a drinking water, sanitation and hygiene (WaSH) intervention and emphasise findings related to health risk perceptions. Data were collected from 2658 households in four regions in Ethiopia with a cross-sectional survey in WaSH intervention areas, as well as in control areas, where the intervention was not implemented. The data were analysed using bivariate and multivariable regression analysis. Awareness of health risk factors related to inadequate WaSH was high in the programme area. The use of basic water and sanitation services was associated with several health risk perceptions: Perceiving water quality as good increased the odds of using basic water services as opposed to believing the water quality was poor (OR 3.94; CI 3.06–5.08; p ≤ 0.001). Believing that drinking unsafe water was the main cause for diarrhoea increased the odds of using basic water services (OR 1.48; CI 1.20–1.81; p ≤ 0.001). In the WaSH intervention group, the use of basic sanitation was more likely than in the control group. The use of basic sanitation was associated with households who had previously received sanitation training, as opposed to such who had not (OR 1.55; CI 1.22–1.97; p ≤ 0.001). Perceiving dirty space as the main cause of diarrhoea (OR 1.81; CI 1.50–2.19; p ≤ 0.001), and privacy when using a latrine (OR 2.00; CI 1.67–2.40; p ≤ 0.001), were associated with higher odds of using basic sanitation. Households that indicated a disadvantage of owning a latrine was maintenance costs were less likely to use basic sanitation (OR 0.49; CI 0.38–0.63; p ≤ 0.001). Risk perceptions were important determinants of use of basic services. The findings point to risk perceptions motivating the application of positive WaSH-related and health-protective behaviours. This suggests that well-designed health risk communication strategies may be effective for engaging households in healthy WaSH behaviour.
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Affiliation(s)
- Carmen Anthonj
- Water Institute, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Lisa Fleming
- Water Institute, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Samuel Godfrey
- Water, Sanitation and Hygiene (WASH), UNICEF Ethiopia, P.O. Box 1169, Addis Ababa, Ethiopia.
| | - Argaw Ambelu
- Department of Environmental Health Sciences & Technology, Jimma University, P.O. Box 378, Jimma, Ethiopia.
| | - Jane Bevan
- Water, Sanitation and Hygiene (WASH), UNICEF Ethiopia, P.O. Box 1169, Addis Ababa, Ethiopia.
| | - Ryan Cronk
- Water Institute, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA.
| | - Jamie Bartram
- Water Institute, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC 27599, USA.
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