How community participation in water and sanitation interventions impacts human health, WASH infrastructure and service longevity in low-income and middle-income countries: a realist review

Preferences and valuation of small-scale wastewater treatment system maintenance using discrete choice method: Case of community-managed system in Jakarta, Indonesia

The focus of public service delivery on sustainability and universal access has enabled the enactment of many community-based programs in Indonesia. However, relevant studies that examine the willingness to pay among households that utilize community-managed facilities are lacking, despite it being one of the most important factors for maintenance and a strong indicator of commitment. In the present study, we aimed to estimate household users' preferences and willingness to pay (WTP) to understand their demand for related services. It estimates household user preferences and willingness to pay to understand the demand for related services through a choice experiment. By comparing all service attributes, the results highlight that users derive the highest utility if they updated reactors and pipelines, and, conversely, if the responsible authority is changed. The desire for quality improvement and service expansion were confirmed using this model. The mixed model estimated a willingness to pay of 0.03-3.13 USD for average users, depending on the attributes. Our findings confirm that families who belong to a community that operates a decentralized system derive greater benefits from improved maintenance; thus, they are willing to pay more to enjoy the service. Notably, at its core, a community-managed system, such as the Sanimas Program, is a co-production initiative between multiple levels of government institutions and local residents. Therefore, maintenance actions should involve resource- and payment-intensive efforts, such as half-year sanitary desludging and system replacement owing to deterioration and hazards. Policy regulations that correct the distribution of roles among partners for maintaining the system should be initiated. These findings provide evidence for the government's commitment to the community and could help convince other stakeholders to redirect their attention to supporting sustainable system performance.

Leveraging public awareness and behavioural change for entrepreneurial waste management

This article takes us into the world of municipal solid waste entrepreneurs, revealing how public awareness campaigns and behavioural change efforts intertwine with entrepreneurial endeavours. Through conversations with 11 key participants-entrepreneurs from four geopolitical zones of Nigeria and a senior management figure from the Lagos State Waste Management Authority-I hear firsthand accounts of the challenges they face and their strategies to transform waste into opportunity. Guided by the theory of planned behaviour, this study sheds light on how these entrepreneurs perceive the role of public awareness in shaping waste management behaviour and driving business innovation. From their stories, a common theme emerges: the need to educate the public about responsible waste practices while developing creative business models that engage communities. Concepts like "freemium-to-premium" offerings are explored as ways to break through psychological barriers and inspire wider participation in waste management initiatives. These voices illustrate how awareness campaigns are not only about fostering environmental responsibility, but also about creating pathways for entrepreneurial growth, ultimately contributing to a more sustainable and circular economy. This study contends that public awareness extends beyond mere knowledge; it acts as a form of infrastructure in its own right. Rather than being just an end goal, awareness becomes a vital foundation in the pursuit of improved waste management practices, serving as a key driver for meaningful environmental action.

Water, sanitation, and hygiene (WASH) practices in Africa: exploring the effects on public health and sustainable development plans

BACKGROUND

Suboptimal water, sanitation, and hygiene (WASH) practices constitute a serious public health risk, affecting one-third of the world's population. Remarkable progress has been made to improve WASH; however, challenges remain, with rapid population growth adding pressure on WASH systems. This study explores the current state of WASH practices and diseases in Africa, identifies challenges, and proposes public health recommendations for sustainable implementation.

MAIN BODY

The staggering burden of WASH-related diseases in low- and middle-income countries (LMICs), particularly in Africa, threatens public health, with millions of deaths and disability-adjusted life years (DALYs) attributed to poor WASH practices annually. Notable challenges plaguing WASH practices in the region include poverty, malnutrition, poor data reporting, illiteracy, climate change, and poor healthcare financing. This results in adverse health consequences, including waterborne infections like cholera, typhoid, dysentery, and diarrheal diseases. Additionally, neglected tropical diseases (NTDs) such as intestinal worms, schistosomiasis, trachoma, lost productivity, and environmental pollution from soil and underground water contamination have been implicated. Geographical disparities, cultural norms, and inadequate funding further complicate efforts to improve WASH infrastructure and practices. Globally concerted efforts are required to address these issues and permit WASH practices to protect human health by preventing infectious diseases and contributing to economic growth. Strong financial frameworks, skills training, and tools like WASH Fit are recommended for a stronger WASH approach in Africa.

CONCLUSION

The consequences of poor WASH extend beyond public health, impacting economic growth, gender equality, and environmental sustainability. WaterAid's policy recommendations prioritizing government administration, institutional capacity enhancement, and more financial resources are expedient.

Inclusion of persons living with disabilities in a district-wide sanitation programme: A cross-sectional study in rural Malawi

Community-led total sanitation (CLTS) is embraced as a key strategy to achieve universal sanitation coverage (Sustainable Development Goal 6.2). Although inclusion is identified as a predictor of CLTS success, people living with disabilities are often excluded from community sanitation programmes and there is limited research exploring CLTS participation amongst people living with disabilities. This study aims to explore the extent to which people living with disabilities participated in a CLTS intervention delivered in rural Malawi using standard approaches. This cross-sectional study was conducted in the Chiradzulu district of Malawi. A household questionnaire was administered to collect information about CLTS participation. Multivariable logistic regression was performed to compare participation in different CLTS activities between households with (n = 80) and without a member with a disability (n = 167), and between household members with (n = 55) and without a disability (n = 226). No difference in CLTS participation was observed at the household-level, but there were marked differences in CLTS participation between household members with and without a disability. Household members without a disability felt they could give more input in triggering activities (OR = 3.72, 95%CI 1.18-11.73), and reported higher participation in the transect walk (OR = 4.03, 95%CI 1.45-11.18), community action planning (OR = 2.89, 95%CI 1.36-6.13), and follow-up visits (OR = 3.37, 95%CI 1.78-6.40) compared to household members with disabilities. There was no difference in the likelihood of being invited to triggering (OR = 0.98, 95%CI 0.41-2.36), attending triggering (OR = 2.09, 95%CI 0.98-4.46), or participating in community mapping (OR = 2.38, 95%CI 0.71-7.98) between household members with and without a disability. This study revealed intra-household inequalities in CLTS participation. To improve participation in CLTS interventions, facilitators should be trained on action steps to make CLTS more inclusive. Further research could include an in-depth analysis of predictors of CLTS participation amongst people living with disabilities, including disability types, severity and age.

Strengthening rural community water safety planning in Pacific Island countries: evidence and lessons from Solomon Islands, Vanuatu, and Fiji

Pacific Island Countries (PICs) collectively have the lowest rates of access to safely managed or basic drinking water and sanitation globally. They are also the least urbanised, have dynamic socioeconomic and increasing climate-linked challenges. Community-based water managers need to respond to variability in water availability and quality caused by a range of hazards. Water Safety Planning (WSP), a widely adopted approach to assessing water supply, offers a risk-based approach to mitigating both existing and future hazards. WSP is adaptable, and making modifications to prescribed WSP to adapt it to the local context is common practice. Within the Pacific Community Water Management Plus research project, we used formative research and co-development processes to understand existing local modifications, whether further modifications are required, and, to develop additional modifications to WSP in Fiji, Vanuatu and Solomon Islands. The types of additional local modifications we recommend reflect the unique context of PICs, including adjusting for community management of water supplies and required collective action, community governance systems, levels of social cohesion in communities, and preferred adult-learning pedagogies. Incorporating modifications that address these factors into future WSP will improve the likelihood of sustained and safe community water services in Pacific and similar contexts.

Community-based surveillance of infectious diseases: a systematic review of drivers of success

Introduction

Community-based surveillance may improve early detection and response to disease outbreaks by leveraging the capacity of community members to carry out surveillance activities within their communities. In 2021, the WHO published a report detailing the evidence gaps and research priorities around community-centred approaches to health emergencies. In response, we carried out a systematic review and narrative synthesis of the evidence describing the drivers of success of community-based surveillance systems.

Methods

We included grey literature and peer-reviewed sources presenting empirical findings of the drivers of success of community-based surveillance systems for the detection and reporting of infectious disease-related events. We searched for peer-reviewed literature via MEDLINE, EMBASE, Global Health, SCOPUS and ReliefWeb. We carried out grey literature searches using Google Search and DuckDuckGo. We used an evaluation quality checklist to assess quality.

Results

Nineteen sources (17 peer-reviewed and 2 grey literature) met our inclusion criteria. Included sources reported on community-based surveillance for the detection and reporting of a variety of diseases in 15 countries (including three conflict settings). The drivers of success were grouped based on factors relating to: (1) surveillance workers, (2) the community, (3) case detection and reporting, (4) and integration.

Discussion

The drivers of success were found to map closely to principles of participatory community engagement with success factors reflecting high levels of acceptability, collaboration, communication, local ownership, and trust. Other factors included: strong supervision and training, a strong sense of responsibility for community health, effective engagement of community informants, close proximity of surveillance workers to communities, the use of simple and adaptable case definitions, quality assurance, effective use of technology, and the use of data for real-time decision-making. Our findings highlight strategies for improving the design and implementation of community-based surveillance. We suggest that investment in participatory community engagement more broadly may be a key surveillance preparedness activity.

PROSPERO registration number

CRD42022303971.

Assessing the Climate Resilience of Community-Managed Water Supplies in Ethiopia and Nepal

Understanding the resilience of water supplies to climate change is becoming an urgent priority to ensure health targets are met. Addressing systemic issues and building the resilience of community-managed supplies, which serve millions of people in rural LMIC settings, will be critical to improve access to safe drinking water. The How Tough is WASH (HTIW) framework to assess resilience was applied to community-managed water supplies in Ethiopia and Nepal to assess the effectiveness of this framework in field conditions. The resilience of these water supplies was measured along six domains—the environment, infrastructure, management, institutional support, community governance and supply chains—that can affect how they respond to climate change effects. We found that the HTIW framework provided an objective measure of resilience and could be used to rank water supplies in order of priority for action. We also found that systemic issues could be identified. The tools and methods used in the framework were easy to deploy by field research teams. The water supplies studied in Ethiopia and Nepal had low to moderate resilience to climate change. Service management and institutional support were weak in both countries. The data from Ethiopia and Nepal suggests that many water supplies in rural and small-town communities are unlikely to be resilient to future climate change without increased investment and support. The use of simple frameworks such as HTIW will be important in supporting decisions around such investments by identifying priority communities and actions.

Self-reliance or social accountability? The raison d'être of community health committees in Nigeria

Social justice requires that communities demand social accountability. We conducted this study to inform ongoing efforts to facilitate social accountability through community health committees in Nigeria. We theorised that committees may see themselves in two ways - as outwardly-facing ('social accountability') and/or as inwardly-facing ('self-reliance'). We analysed the minutes of their meetings, alongside interviews and group discussions with committee members, community members, health workers, and health managers in four states across Nigeria. The committees' raison d'être reflects a bias for self-reliance in three ways. First, seen as a platform for the community to co-finance health services, members tend to be the local elite who can make financial contributions. Second, in a one-sided relationship, they function more to achieve the goals of governments (e.g. to improve the uptake of services), than of the community (e.g. rights-based demands for government support). Third, their activities in the community reflect greater concern to ensure that their community makes the most of what the government has already provided (e.g. helping to drive the uptake of existing services) than asking for more. Optimising the committees for social accountability may require support by actors who do not have conflicts of interests in ensuring that they have the necessary information and strategies to demand social accountability.