Determinants of quality of shared sanitation facilities in informal settlements: case study of Kisumu, Kenya

The effect of dwelling size on the mental health and quality of life of female caregivers living in informal tiny homes in Hong Kong

BACKGROUND

Although the adverse impact of substandard informal housing has been widely documented, most studies concentrated on developing societies, thereby leaving informal housing in developed regions underexplored. This study examines Hong Kong, where limited dwelling size is a distinctive feature that characterises informal housing, to explore the impact of housing informality on mental health, with a particular focus on dwelling size. It centers on subdivided units (SDUs), which are tiny compartments partitioned from a large domestic quarter, to understand how housing informality and housing size affect the mental well-being of female caregivers, who typically bear the brunt of the housework.

METHODS

In partnership with nongovernment organisations in three SDU-abundant districts, this mixed-methods study conducted a survey on 413 female caregivers aged 18-65 and qualitative research combining ethnographic observations and in-depth interviews on 36 families living in SDUs in Hong Kong between 2021 and 2023. The mental health outcomes and health-related quality of life (HRQoL) of the participants were assessed by using the Depression, Anxiety, and Stress Scale-21 and a EuroQol-5 Dimension-5 Level questionnaire.

RESULTS

Depression, anxiety and stress were prevalent across the female caregivers living in SDUs (12.4%), as well as a significantly lower HRQoL compared with that of the general population (0.882 vs. 0.919). Findings showed that a total floor area smaller than 13.0 m2 was associated with increased likelihood of experiencing anxiety and depression and reduced HRQoL. Cramped living space adversely affected the caregivers' well-being through the 1) physical, 2) relational and 3) personal aspects of home experiences. Negative experiences at home can cause housework burnout, exacerbate family conflicts and lead to feelings of repression and low self-efficacy.

CONCLUSIONS

This study contributes to the understanding of the consequences of housing informality in diverse geographical contexts and illuminates the effect of dwelling size by identifying the mechanisms through which housing size can affect the mental well-being of residents, which may vary depending on their family status. The findings yield important policy implications, including the need to establish a minimum space standard for subdivided residential dwellings and ensure equitable access to community spaces for deprived families.

Shared sanitation in informal settlements: A systematic review and meta-analysis of prevalence, preferences, and quality

Shared sanitation facilities are not considered a type of basic sanitation by the WHO/UNICEF Joint Monitoring Programme (JMP), though they may be the only alternative to open defecation in urban informal settlements. Additionally, JMP indicators for sanitation do not cover aspects related to the quality of shared sanitation, such as those outlined in the Human Right to Water and Sanitation (HRTWS) framework. Data on the prevalence of shared sanitation within informal settlement areas is limited, and there is a need to understand user preferences, experiences, and barriers to the use of shared sanitation to inform effective policy and practice. This systematic review aims to summarize the prevalence and number of households sharing sanitation in informal settlements globally, as well as user experiences and barriers to successful implementation of shared sanitation. We included studies available in English and published after January 1, 2000. We retrieved 4741 articles from seven databases and included a total of 167 relevant publications. Among included studies, 54 reported the prevalence of shared sanitation in informal settlements, and 138 studies reported on user perceptions and experiences related to shared sanitation quality. A meta-analysis of studies reporting the prevalence of shared sanitation in informal settlements globally revealed an estimated overall prevalence of 67% [95% CI: 61%-73%]. Commonly reported user preferences included cleanliness to promote continued use of shared facilities, privacy with a lockable door, facilities for menstrual hygiene management, safety and protection against violence, 24/7 access, proper lighting, and shared responsibility for facility management - which align with the HRTWS framework and represent barriers to shared sanitation use. Based on the findings of this review, we recommend including the number of households or people sharing a sanitation facility in monitoring of shared sanitation quality, locating sanitation facilities within compounds, where applicable, and promoting safety, dignity, and privacy of all users in the development of shared sanitation quality indicators.

Analysis of incidence, intensity, and gender perspective of multidimensional urban poverty in Kenya

Poverty continues to be one of the biggest challenges facing many economies worldwide, and its incidences and intensities are very high in developing economies. This paper utilized the Alkire-Foster (AF) method to compute the multidimensional poverty index (MPI) and analyze the incidence and intensity of multidimensional poverty among urban households in Kenya. The findings indicated that 8.7 % of urban households are multidimensionally deprived in 33.3 % of the selected dimensional indicators. Also, the results showed that over 50 % of urban households are deprived of drinking water and sanitation services. In addition, the findings revealed that higher poverty incidence, intensity, and urban multidimensional poverty exist among female-headed households, old household headships, and households residing in peri-urban regions. The Probit regression analysis indicated that large household size, number of children under five years, household head age, gender, marital status, urban food insecurity, health status, and residing in Malaria endemic zone are significant positive predictors of urban multidimensional poverty. On the other hand, an increase in the number of educated women, owners of insurance coverage, agricultural land, and wealthy and home-owning households is linked to a decline in urban multidimensional poverty. The paper professes that policymakers should cautiously consider household socioeconomic differences while designing poverty alleviation policies.

Protocol for the PATHOME study: a cohort study on urban societal development and the ecology of enteric disease transmission among infants, domestic animals and the environment

INTRODUCTION

Global morbidity from enteric infections and diarrhoea remains high in children in low-income and middle-income countries, despite significant investment over recent decades in health systems and water and sanitation infrastructure. Other types of societal development may be required to reduce disease burden. Ecological research on the influence of household and neighbourhood societal development on pathogen transmission dynamics between humans, animals and the environment could identify more effective strategies for preventing enteric infections.

METHODS AND ANALYSIS

The 'enteric pathome'-that is, the communities of viral, bacterial and parasitic pathogens transmitted from human and animal faeces through the environment is taxonomically complex in high burden settings. This integrated cohort-exposure assessment study leverages natural socioeconomic spectrums of development to study how pathome complexity is influenced by household and neighbourhood infrastructure and hygiene conditions. We are enrolling under 12-month-old children in low-income and middle-income neighbourhoods of two Kenyan cities (Nairobi and Kisumu) into a 'short-cohort' study involving repeat testing of child faeces for enteric pathogens. A mid-study exposure assessment documenting infrastructural, behavioural, spatial, climate, environmental and zoonotic factors characterises pathogen exposure pathways in household and neighbourhood settings. These data will be used to inform and validate statistical and agent-based models (ABM) that identify individual or combined intervention strategies for reducing multipathogen transmission between humans, animals and environment in urban Kenya.

ETHICS AND DISSEMINATION

The protocols for human subjects' research were approved by Institutional Review Boards at the University of Iowa (ID-202004606) and AMREF Health Africa (ID-ESRC P887/2020), and a national permit was obtained from the Kenya National Commission for Science Technology and Innovation (ID# P/21/8441). The study was registered on Clinicaltrials.gov (Identifier: NCT05322655) and is in pre-results stage. Protocols for research on animals were approved by the University of Iowa Animal Care and Use Committee (ID 0042302).

Environmental determinants of access to shared sanitation in informal settlements: a cross-sectional study in Abidjan and Nairobi

BACKGROUND

Universal access to basic sanitation remains a global challenge, particularly in low- and middle-income countries. Efforts are underway to improve access to sanitation in informal settlements, often through shared facilities. However, access to these facilities and their potential health gains-notably, the prevention of diarrheal diseases-may be hampered by contextual aspects related to the physical environment. This study explored associations between the built environment and perceived safety to access toilets, and associations between the latter and diarrheal infections.

METHODS

A cross-sectional study was carried out between July 2021 and February 2022, including 1714 households in two informal settlements in Abidjan (Côte d'Ivoire) and two in Nairobi (Kenya). We employed adjusted odds ratios (aORs) obtained from multiple logistic regressions (MLRs) to test whether the location of the most frequently used toilet was associated with a perceived lack of safety to use the facility at any time, and whether this perceived insecurity was associated with a higher risk of diarrhea. The MLRs included several exposure and control variables, being stratified by city and age groups. We employed bivariate logistic regressions to test whether the perceived insecurity was associated with settlement morphology indicators derived from the built environment.

RESULTS

Using a toilet outside the premises was associated with a perceived insecurity both in Abidjan [aOR = 3.14, 95% confidence interval (CI): 1.13-8.70] and in Nairobi (aOR = 57.97, 95% CI: 35.93-93.53). Perceived insecurity to access toilets was associated with diarrheal infections in the general population (aOR = 1.90, 95% CI: 1.29-2.79 in Abidjan, aOR = 1.69, 95% CI: 1.22-2.34 in Nairobi), but not in children below the age of 5 years. Several settlement morphology features were associated with perceived insecurity, namely, buildings' compactness, the proportion of occupied land, and angular deviation between neighboring structures.

CONCLUSIONS

Toilet location was a critical determinant of perceived security, and hence, must be adequately addressed when building new facilities. The sole availability of facilities may be insufficient to prevent diarrheal infections. People must also be safe to use them. Further attention should be directed toward how the built environment affects safety.

Environmental and behavioural exposure pathways associated with diarrhoea and enteric pathogen detection in 5-month-old, periurban Kenyan infants: a cross-sectional study

OBJECTIVES

The aim of this study was to test whether household environmental hygiene and behavioural conditions moderated associations between diarrhoea and enteric pathogen detection in infants 5 months of age in Kenya and pathogen sources, including latrine access, domestic animal co-habitation and public food sources.

DESIGN

Cross-sectional study utilising enrolment survey data of households participating in the Safe Start cluster-randomised controlled trial .

SETTING

Kisumu, Kenya.

PARTICIPANTS

A total of 898 caregivers with 5-month (22 week ± 1 week) aged infants were enrolled in the study and completed the enrolment survey.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcomes were (1) caregiver-reported 7-day diarrhoea prevalence and (2) count of types of enteric viruses, bacteria and parasites in infant stool. Exposures and effect modifiers included water access and treatment, cohabitation with domestic animals, sanitation access, handwashing practices, supplemental feeding, access to refrigeration and flooring.

RESULTS

Reported handwashing after handling animals (adjusted odds ratio (aOR)=0.20; 95% CI=0.06 to 0.50) and before eating (aOR=0.44; 95% CI=0.26 to 0.73) were strongly associated with lower risk of caregiver-reported diarrhoea, while cohabitation with animals (aOR=1.54; 95% CI=1.01 to 2.34) living in a household with vinyl-covered dirt floors (aOR=0.60; 95% CI=0.45 to 0.87) were strongly associated with pathogen codetection in infants. Caregiver handwashing after child (p=0.02) or self-defecation (p=0.03) moderated the relationship between shared sanitation access and infant exposure to pathogens, specifically private latrine access was protective against pathogen exposure of infants in households, where caregivers washed hands after defecation. In the absence of handwashing, access to private sanitation posed no benefits over shared latrines for protecting infants from exposure.

CONCLUSION

Our evidence highlights eliminating animal cohabitation and improving flooring, postdefecation and food-related handwashing, and safety and use of cow milk sources as interventions to prevent enteric pathogen exposure of young infants in Kenya.

TRIAL REGISTRATION NUMBER

NCT03468114.

Determinants of diarrhoeal disease in children living in low-income households in a periurban community in Cape Town, South Africa

Background. Water, sanitation and hygiene are critically important in reducing morbidity and mortality from childhood diarrhoeal disease and malnutrition in low-income settings.Objectives. To assess the association of diarrhoeal disease with factors relating to domestic hygiene, the environment, sociodemographic status and anthropometry in children <2 years of age.Methods. This was a case-control study conducted in a periurban community 35 km from the centre of Cape Town, South Africa. The study included 100 children with diarrhoeal disease and 100 age-matched controls without diarrhoea, who were recruited at primary healthcare clinics. Sociodemographic status, environmental factors and domestic hygiene were assessed using a structured questionnaire; anthropometry was assessed using the World Health Organization’s child growth standards. Univariate and multivariate logistic regression analyses were performed to identify the factors associated with diarrhoea. Results. The results of the univariate logistic regression showed significant susceptibility to diarrhoea in study cases compared with controls when the caregiver was ≥25 years old (odds ratio (OR) 1.82; 95% confidence interval (CI) 1.02 - 3.23; p=0.042); when children were in day care or cared for by a family member or a relative than when cared for by their mother (OR 1.97; 95% CI 1.06 - 3.65; p=0.032); and when the mothers were employed rather than at home (OR 2.23; 95% CI 1.21 - 4.12; p=0.01). Multivariate logistic regression analysis was used to identify predictors of diarrhoea, which entailed relaxing the inclusion criteria for the univariate analysis variables (p<0.25). The predictors significantly associated with diarrhoea were household problems relating to rat infestation (OR 2.44; 95% CI 1.13 - 5.28; p=0.027); maternal employment (OR 2.47; 95% CI 1.28 - 4.76; p=0.007); and children in day care or cared for by a relative (OR 2.34; 95% CI 1.21 - 4.54; p=0.01). Significantly more of the mothers who were employed than those who were unemployed had children in day care or cared for by a relative.Conclusion. Practices relating to employment, childcare and the domestic environment were significant predictors of diarrhoea. Effective policy implementation on water, sanitation and domestic hygiene could prevent diarrhoeal disease and reduce its impact on children’s growth, especially during the annual diarrhoeal surge season in this and similar periurban communities.

Determinants of diarrhoeal infections among users of shared sanitation in informal settlements in Durban, South Africa

Diarrhoeal disease continues to be a major health problem in many parts of the world, especially in developing countries, mainly due to the lack of access to sanitation, water, and hygienic living conditions. Identifying the determinants of diarrhoeal infections continues to be a challenge in developing countries. In this study, we ascertained the factors behind diarrhoea among inhabitants of informal settlements in the city of Durban, South Africa. Prevalence of diarrhoea in the study area varied between 7-year historical clinical records and data collected during the current study (primary data), with the primary data giving the highest monthly prevalence odds ratio (POR) up to 18.1 (±1.6)%. The main factors associated with diarrhoeal infections were open defaecation (POR = 1.8; 95% confidence interval (CI): 0.9-3.12), use of shared sanitation (POR = 1.7; 95%; CI: 1.05-2.26), and exposure to faecal matter around the homes (POR = 1.69; 95% CI: 1.25-3.10). Several other factors were also determined to be associated with diarrhoeal infections, such as hygiene practices in the communities, the non-treatment of water before use, and the presence of solid waste and faecal materials around the households. This study shows that diarrhoeal disease infections in informal settlements could be multifactorial; therefore, a multifactorial approach is needed to reduce these infections. These could include improving education on hygiene practices within the home setting as well as in public places, such as the community ablution blocks.

Female-friendly toilets in schools in Burkina Faso: A mixed-methods study using photo-elicitation

Background

An absence of gender-sensitive sanitation facilities in schools and the negative effects this has on girls has been widely discussed among advocacy groups, though less examined in academic spheres. Drawing on triangulated data, we outline current challenges and respondent-driven solutions to enhance the female-friendly nature of toilets in a context of extreme poverty.

Methods

This mixed-methods study was informed by the tenets of human-centred design. We first quantitatively assessed facilities in 14 secondary schools in the Kossi Province of Burkina Faso. We then collected qualitative data, including 15 focus group discussions and 53 in-depth interviews among schoolgirls, mothers, teachers and key informants. We applied photo-elicitation, a novel method, to explore perceptions of facilities and the desirability and feasibility of interventions to improve gender-friendly sanitation facilities.

Results

No school met international water, sanitation and hygiene (WASH) standards for schools. Roughly one third of schools did not have water and, when present, there was no reliable way to use it within the toilet complex. Schoolgirls shared feelings of shame and stress when menstruating at school, and said that they would avoid using school toilets, if possible. Schoolgirls described water access as the most urgent need to address, followed by fostering privacy and facilitating cleanliness within facilities. Mothers and teachers mostly aligned with these priorities, while key informants additionally emphasised the need to raise awareness on both general and menstrual hygiene and to develop maintenance systems. Photo-elicitation engaged and empowered participants to pinpoint priorities and concrete solutions, namely a need for doors and locks, water containers and cleaning materials.

Conclusions

WASH needs in many schools remain unmet. Women and girls should be involved in decision-making across stages of intervention design and implementation. Young women's voices merit greater inclusion in academic literature. Future interventions should enhance access to water and privacy. Future research could explore maintenance and monitoring strategies to develop guidance on sustainable solutions.

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.

Associations between water, sanitation, and depression among older people in Ghana: empirical evidence from WHO-SAGE Wave 2 survey

BACKGROUND

While depression is the most frequent psychiatric disorder among the older adults, the use of water and sanitation has been associated with both physical and psychological adverse outcomes. We investigated the associations of water and sanitation with depressive symptoms among older adults in Ghana.

METHODS

The study used data from 4,735 participants in the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) Wave 2 of adults aged ≥50 years. Major depressive episode (MDE) was assessed using the World Mental Health Survey version of the Composite International Diagnostic Interview and we classified water and sanitation sources based on the Joint Monitoring Program. Multivariate logistic regressions evaluated the associations.

RESULTS

Approximately 7.3% of respondents reported a MDE, 90% and 78% used improved water sources and sanitation facilities respectively, and 77% shared sanitation facilities. Individuals who used unimproved water sources and unimproved sanitation were 1.6 and 1.3 times more likely to report MDE respectively. Also, sex-based analysis showed that the effect of the use of unimproved water and sanitation on depression was much appreciable and more substantial among women compared to men.

CONCLUSIONS

The findings suggest the importance of water and sanitation to the well-being of older people, particularly among women. Policies targeted at improving the mental health in old age should include water and sanitation.

Qualitative and Quantitative Analysis of Latrine Management Approaches in Internally Displaced Persons Camps in Myanmar

Water, sanitation, and hygiene (WASH) interventions provide dignity and prevent disease transmission. Sanitary facility provision (e.g., latrines) is a key WASH priority in all phases of humanitarian response. Currently, there are evidence gaps on field effectiveness of sanitation approaches, particularly in protracted crises. Thus, we conducted a qualitative and quantitative evaluation of sanitation approaches in internally displaced persons (IDP) camps in Myanmar. We conducted 36 focus group discussions, 65 household surveys, and 32 key informant interviews in Rakhine and Kachin states; results were analyzed qualitatively. We found family-shared, gender-segregated latrines were the preferred approach. Acceptance was a result of gender segregation, followed by lighting, state of repair, cleanliness, design, and distance from household. Contextual factors influencing sanitation approach development and acceptance were cultural and religious beliefs, community cohesion, camp size, livelihood access, land ownership and availability, and responding agency type. Overall, sanitation approaches generally met IDP needs; however, access was limited for children, the elderly, and people with special needs (including persons with disabilities). We recommend implementers of latrine programs in protracted contexts conduct community consultations, consider gender segregation, be flexible in considering context-specific solutions, prioritize access and dignity, and be inclusive of vulnerable groups.

Identification of enteroviruses along Lake Victoria shoreline - a potential indicator of sewage pollution

Enteric viruses are mainly transmitted by the faecal-oral route and have been linked to several diseases including gastroenteritis and respiratory infections. Their presence in surface waters has been exacerbated by pollution from a variety of point sources such as sewage discharge. We studied the occurrence of enteroviruses in water samples from Lake Victoriain Kenya to investigate if there was a link between sewage pollution and detection of enteroviruses (EVs) to build a baseline for an enteric viruses monitoring platform for this region. We analysed 216 samples collected over 6 months from six different locations along the Homa Bay Pier. The six sampling locations comprised of three sites (P3, P5, P6) located <500 m from a local sewage treatment plant and pit latrines while three other sites (P1, P2, P4) were located at approximately 0.5 to 3 Km. EVs were concentrated using glass wool adsorption elution protocol and identified using the nested reverse transcription-polymerase chain reaction. The odds ratio was performed to determine whether the location of the sources of sewage pollution near the lake was associated with the EVs contamination. Five out of 108 (5 %) samples collected from the sites (P3, P5 and P6 were EV positive, while 2 % (2/108) of samples from P1, P2 and P4 were EV positive. The presence of the EVs was associated with the distance from the possible sources of faecal contamination (odds ratio 20.28 and 4.86, confidence interval 2.42, and 0.95) for pit latrines and the sewage treatment plant respectively. The result from this study indicates that sewage discharge at the shoreline of Lake Victoria may have been the source of EVs contamination. Data from this study could significantly contribute to informing risk management on sewage pollution in Lake Victoria and it is important to continue monitoring this lake for potentially pathogenic enteric viruses.

Shared but Clean Household Toilets: What Makes This Possible? Evidence from Ghana and Kenya

Shared sanitation facilities are not considered as basic sanitation owing to cleanliness and accessibility concerns. However, there is mounting evidence that some shared household toilets have a comparable level of service as private toilets. This study examined the factors that contribute to the quality of shared household toilets in low-income urban communities in Ghana and Kenya. The study design comprised household surveys and field inspections. Overall, 843 respondents were interviewed, and 838 household shared sanitation facilities were inspected. Cleanliness scores were computed from the facility inspections, while a total quality score was calculated based on 13 indicators comprising hygiene, privacy, and accessibility. Regression analyses were conducted to determine predictors of cleanliness and the overall quality of the shared sanitation facilities. More than four out of five (84%) shared toilets in Ghana (N = 404) were clean, while in Kenya (N = 434), nearly a third (32%) were clean. Flush/pour-flush toilets were six times (p < 0.01 aOR = 5.64) more likely to be clean. A functional outside door lock on a toilet facility and the presence of live-in landlords led to a threefold increase (p < 0.01 aOR = 2.71) and a twofold increase (p < 0.01 aOR = 1.92), respectively in the odds of shared sanitation cleanliness. Sanitation facilities shared by at most five households (95% CI: 6−7) were generally clean. High-quality shared toilets had live-in landlords, functional door locks, and were water-dependent. Further studies on innovative approaches to maintaining the quality of these high-quality shared toilets are needed to make them eligible for classification as basic sanitation considering the increasing reliance on the facilities.

Climate variability, water supply, sanitation and diarrhea among children under five in Sub-Saharan Africa: a multilevel analysis

Climate variability is expected to increase the risk of diarrhea diseases, a leading cause of child mortality and morbidity in Sub-Saharan Africa (SSA). The risk of diarrhea is more acute when populations have poor access to improved water and sanitation. This study seeks to determine individual and joint effects of climate variation, water supply and sanitation on the occurrence of diarrhea among children under five in SSA using multilevel mixed-effect Poisson regression including cross-level interaction. We merged 57 Demographic and Health Surveys (DHS) from 25 SSA countries covering the period 2000-2019 with climatic data from the DHS geolocation databases. The results of the research indicate that 77.7% of the variation in the occurrence of diarrhea in Sub-Saharan households is due to climatic differences between clusters. Also, a household residing in a cluster with a high incidence of diarrhea is 1.567 times more likely to have diarrhea cases than a household from a cluster with a low incidence. In addition, when average temperature and rainfall increase, households using unimproved sanitation or unimproved water have more cases of diarrhea. For SSA, the results of the multilevel analysis suggest the adoption at both levels; macro (national) and micro (household), of climate change adaption measures in the water sector to reduce the prevalence of diarrhea.

Fecal Sludge Management in Low Income Settlements: Case Study of Nakuru, Kenya

Introduction: In order to meet the sustainable development goals targets of sanitation, countries aim to increase access to safely managed sanitation services for its citizens. Safely managed sanitation services refers to improved sanitation technologies that are not shared with other households and where excreta is treated and disposed; or stored, transported and treated off-site. In most Sub-Saharan Africa (SSA) countries, on-site sanitation facilities such as latrines and septic tanks are common, with low-income urban settlements mainly using pit latrines. However, little is documented about the management of sludge from these facilities, especially in low income settlements in secondary and emerging cities. This lack of data is a major hindrance to public health, development and planning efforts by governments and planning agencies. This study specifically assesses practices and challenges along the sanitation value chain related to containment, emptying, transportation, treatment and recycling of fecal sludge. Methods: The study was carried out in low income settlements in Nakuru, a secondary city in Kenya. Over half the population in Nakuru live in low income areas and majority of these residents use pit latrines. A case study design was selected for this study and data was collected using qualitative methods. Data was collected through In-depth interviews and Focus Group Discussions using in depth interview guide and focus group discussion guides that had questions on sanitation practices along the value chain, challenges, opportunities available, and recommendations for improvement. Analysis was done through content analysis by reading the transcripts multiple times to gain a sense of the flow of the discussion. Thereafter, coding was done by following emergent issues and thereafter categories were identified which formed the basis for providing a picture of FWM practices in the settlements. Results: On site sanitation facilities are dominant in the settlements, but they are few and are shared by several households. These facilities were unclean, and they filled up at a fast rate because of the high number of users. The latrines were emptied by manual emptiers who used mechanized equipment but complemented with manual emptying using buckets. Sludge was transported to a central collection point using large and small scale means of transportation, before transfer to the treatment site for final treatment and disposal. Various stakeholders are involved in capacity building of emptiers as well as in the transportation, treatment and disposal of fecal sludge in the settlements. Challenges along the stages of the value chain included negative community perceptions and attitudes toward fecal sludge management. Conclusion: The results highlight the need to address the challenges along the chain by involvement of state and non-state actors. Low income areas have high populations and thus contribute huge amounts of fecal sludge. Deliberate efforts to consolidate such data from low income areas will result in availability of data, and informed decision making for stakeholders at national and international levels.

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.

Diarrhoea among Children Aged under Five Years and Risk Factors in Informal Settlements: A Cross-Sectional Study in Cape Town, South Africa

Background: There is limited data on the association between diarrhoea among children aged under five years (U5D) and water use, sanitation, hygiene, and socio-economics factors in low-income communities. The study investigated U5D and the associated risk factors in the Zeekoe catchment in Cape Town, South Africa. Methods: A cross-sectional study was conducted in 707 households in six informal settlements (IS) two formal settlements (FS) (March–June 2017). Results: Most IS households used public taps (74.4%) and shared toilets (93.0%), while FS households used piped water on premises (89.6%) and private toilets (98.3%). IS respondents had higher average hand-washing scores than those of FS (0.04 vs. −0.14, p = 0.02). The overall U5D prevalence was 15.3% (range: 8.6%–24.2%) and was higher in FS than in IS (21.2% vs. 13.4%, respectively, p = 0.01). Water storage >12 h was associated with increasing U5D (OR = 1.88, 95% CI 1.00–3.55, p = 0.05). Water treatment (OR = 0.57, 95%CI 0.34–0.97, p = 0.04), good hand-washing practices (OR = 0.59, 95%CI 0.42–0.82, p = 0.002) and Hepatitis A vaccination (OR = 0.51, 95%CI 0.28–0.9, p = 0.02) had significant preventing effects on U5D. Conclusions: The study highlights that good hygiene practice is a key intervention against U5D in informal settlements. The promotion of hand-washing, proper water storage, and hygienic breastfeeding is highly recommended.

Characteristics of sanitation and hygiene facilities in a slum community in Kampala, Uganda

Background

This study assessed characteristics of sanitation and hygiene facilities in a slum community in Kampala, Uganda.

Methods

We conducted a household-based cross-sectional study among 395 households in Kasubi slum using a semi-structured questionnaire and observational checklist to collect data.

Results

Almost 98.0% (387/395) of households owned a sanitation facility and 77.0% (298/387) shared it with other households. The most common type of sanitation facility was a pit latrine with slab (66.9% [259/387]). Most (90.5% [305/337]) latrines had a door or shutter, a roof (92.9% [313/337]) and a depth >1.5 m (68.2% [229/337]). Overall, 21.3% (84/395) and 65.6% (259/395) of households had improved and functional sanitation facilities, respectively. Only 16.5% (65/395) of the households had a hand-washing facility. Student-led (adjusted prevalence rate [PR] 2.67 [95% confidence interval [CI] 1.83–3.94]) and households that owned their house (adjusted PR 2.17 [95% CI 1.33–3.53]) were 2.67 and 2.17 times more likely to have improved sanitation facilities, respectively. Households that owned their house (adjusted PR 1.90 [95% CI 1.18–3.05]) were 1.9 times more likely to possess a hand-washing facility.

Conclusions

The coverage of improved sanitation and hygiene facilities was low. The majority of households were using a shared pit latrine with a slab that had no hand-washing facility. Sanitation and hygiene interventions should prioritize improving sanitation and hygiene facilities.

Acceptability of urine diversion dry toilets in Dollo Ado refugee camp, Ethiopia

Given the increasing frequency and duration of humanitarian emergencies worldwide, there is a need to identify a greater range of effective and contextually appropriate water, sanitation and hygiene (WASH) interventions. Typical sanitation systems may be poorly suited for some of the conditions in which humanitarian emergencies can occur, such as in drought-prone regions. Urine-diversion dry toilets (UDDTs) are one potential alternative sanitation option which can be used in these conditions. Between 2014 and 2016, the U.S. Centers for Disease Control and Prevention (CDC) partnered with local agencies to evaluate the acceptability of UDDTs in a refugee camp in Ethiopia. The overall goals were to provide evidence regarding the level of adoption and satisfaction with UDDTs in this emergency context and the factors associated with satisfaction. Two cross-sectional surveys were conducted 18-months apart, using a stratified design to sample UDDT and latrine users for comparison. The proportion who reported to use their UDDT consistently was 88.8% (95% CI 85.1-92.5) in the first survey and 93.4% (95% CI 90.6-96.2) in the second survey. Reported satisfaction levels were significantly higher among respondents in the second survey (p < 0.0001), where 97.0% (95% CI 95.1-98.9) of respondents stated either that they were mostly or very satisfied with their UDDT. There was no significant difference detected in satisfaction between UDDT and latrine users (p = 0.28). Using a multivariable logistic regression model, we identified several factors associated with a higher level of satisfaction with UDDTs. Those who had previously (before coming to the camp) used a pit latrine (AOR = 4.2; 95% CI 1.4-12.7) or had no sanitation system (AOR = 2.4; 95% CI 1.3-4.4) relative to a pour-flush toilet, had a clean UDDT (AOR = 2.8; 95% CI 1.7-4.6), had been in the camp for a longer time period (AOR = 2.3; 95% CI 1.7-3.0), did not share their UDDT (AOR = 1.8; 95% CI 1.0-3.0) and had used their UDDT for a longer time period (AOR = 1.7; 95% CI 1.2-2.4) had higher odds of satisfaction. The findings demonstrate that UDDTs have been effectively introduced and utilized in this context and this may have implications for other humanitarian settings where they can be similarly managed.

Leaving no stone unturned in light of the COVID-19 faecal-oral hypothesis? A water, sanitation and hygiene (WASH) perspective targeting low-income countries

The human coronavirus disease (COVID-19) is now a global pandemic. Social distancing, hand hygiene and the use of personal protective equipment dominate the current fight against COVID-19. In developing countries, the need for clean water provision, sanitation and hygiene has only received limited attention. The current perspective examines the latest evidence on the occurrence, persistence and faecal-oral transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the etiological agent causing COVID-19. Evidence shows that SARS-CoV-2 proliferate in the human gastrointestinal system, and is shed via faeces. SARS-CoV-2 can survive and remain viable for up to 6 to 9 days on surfaces. Recent wastewater-based epidemiological studies from several countries also detected SARS-CoV-2 RNA in raw wastewaters. Shell disorder analysis shows that SARS-CoV-2 has a rigid outer shell conferring resilience, and a low shell disorder conferring moderate potential for faecal-oral transmission. Taken together, these findings point to potential faecal-oral transmission of SARS-CoV-2, which may partly explain its rapid transmission. Three potential mechanisms may account for SARS-CoV-2 faecal-oral transmission: (1) untreated contaminated drinking water, (2) raw and poorly cooked marine and aquatic foods from contaminated sources, (3) raw wastewater-based vegetatble production systems (e.g., salads) and aquaculture, and (4) vector-mediated transmission from faecal sources to foods, particularly those from open markets and street vending. SARS-CoV-2 faecal-oral transmission could be particularly high in developing countries due to several risk factors, including; (1) poor drinking water, wastewater and sanitation infrastructure, (2) poor hygiene and food handling practices, (3) unhygienic and rudimentary funeral practices, including home burials close to drinking water sources, and (4) poor social security and health care systems with low capacity to cope with disease outbreaks. Hence, clean drinking water provision, proper sanitation, food safety and hygiene could be critical in the current fight against COVID-19. Future research directions on COVID-19 faecal-oral transmission are highlighted.

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.

Determinants of diarrhea in children under the age of five in Afghanistan: a secondary analysis of the Afghanistan Demographic and Health Survey 2015

Diarrhea is the second leading cause of under-five mortality and globally accounts for 526,000 child deaths every year. Afghanistan, with 33,000 child deaths in 2012, was ranked 8^th among nations, with the highest under-five deaths being from pneumonia and diarrhea. This study aimed to identify the determinants of diarrhea in children under the age of five in Afghanistan. A secondary data analysis of the Afghanistan Demographic and Health Survey (AfDHS) 2015 was focused on diarrhea in children under the age of five. The dataset of the AfDHS 2015 was used for the analysis. The subjects for this study were 30,238 under-five children. A logistic regression model was applied to examine the determinants of childhood diarrhea. This study found that 7,921 (26.2%) out of 30,238 under-five children had diarrhea within the two weeks preceding the survey. Higher maternal education accompanied a lower risk of childhood diarrhea with an adjusted odds ratio (AOR) of 0.70 (P<0.01) than did no education. Flush toilets (AOR=0.84, P<0.01) and traditional dry vaults (AOR=0.83, P<0.001) were less likely associated with diarrhea compared with pit latrines. Tube wells, public taps, and unprotected wells and springs were sources of drinking water with a higher risk of diarrhea than piped water. This study identified that the type of toilet facility, source of drinking water, age of the child, and maternal education were important determinants of under-five diarrhea. Intervention programs concerning improved sanitation facilities, sources of drinking water, and raising women’s level of education and health awareness are important.

Barriers and opportunities for cleanliness of shared sanitation facilities in low-income settlements in Kenya

Background

The sharing of sanitation facilities is a common practice in low-income areas in sub-Saharan Africa. However, shared sanitation is currently categorized as a limited sanitation service, and may therefore not count towards meeting the global goals. These shared facilities are often the only option available for most residents in low-income settlements, and improving their cleanliness and overall management is key to reducing open defecation and risk of disease. This study sought to investigate barriers and opportunities for improved cleanliness of shared sanitation facilities in low-income settlements of Kisumu city, Kenya.

Methods

Thirty-nine in-depth interviews and 11 focus group discussions were held with residents – mainly tenants and landlords – of a low-income settlement in Kisumu. Analysis followed a thematic approach to define the problem, specify the target behaviour and identify the changes needed.

Results

Sanitation facilities were mainly pit latrines, typically shared among landlords and tenants. Participants singled out behavioural (poor use of the shared toilets) and social (lack of cooperation in cleaning) challenges that led to unclean shared toilets. Available opportunities for improvement included instituting clear cleaning plans, improving communication among users, and enhanced problem-solving mechanisms between landlords and tenants. These approaches could form the basis for designing intervention strategies for improving the cleanliness of shared sanitation facilities.

Conclusion

The results highlight the need to focus on social aspects for improvement of cleanliness in shared sanitation facilities in low-income settlements. Through a social approach, shared sanitation facilities can be managed appropriately to provide the millions of low-income residents in Kenya an opportunity to access sanitation. This study provides further evidence on approaches for improved management of shared sanitation facilities in line with the World Health Organization’s (WHO) Joint Monitoring Program’s (JMP) recommendation for high quality shared facilities.

Understanding the Barriers and Opportunities for Effective Management of Shared Sanitation in Low-Income Settlements-The Case of Kumasi, Ghana

Improved sanitation for all is a daunting task for low-income countries, and shared toilets often provide an alternative to private household sanitation for most urban residents. This study sought to provide better understanding of the existing barriers and opportunities for improved management of shared sanitation. The study used focus group discussions and in-depth interviews with 70 users (landlords and tenants) of shared sanitation in Kumasi, Ghana to assess barriers and opportunities of "high-quality" shared sanitation. The commonly used toilet facilities were dry toilets-Kumasi Ventilated Improved Pit latrine and Ventilated Improved Pit latrines; and flush systems-water closet and pour flush connected to septic tanks. Between 2 and 21 households, or 4 and 84 people, shared one facility. Participants' description of "high-quality" (Ideal) shared sanitation was centred on cleanliness, user behaviour, smell, and user crowding. They also identified challenges of shared sanitation as overcrowded users, poor user behaviours, conflicts among users, and high cost associated with frequent desludging. However, opportunities for improvement included users' preference for shared toilets due to enjoyed benefits, existing facility management practices, and mutual understanding among users (tenants and landlords). Interventions and policy guidelines to influence behaviour change of shared sanitation users are proposed and are intended to be delivered by local government and users.

Slum Health: Arresting COVID-19 and Improving Well-Being in Urban Informal Settlements

The informal settlements of the Global South are the least prepared for the pandemic of COVID-19 since basic needs such as water, toilets, sewers, drainage, waste collection, and secure and adequate housing are already in short supply or non-existent. Further, space constraints, violence, and overcrowding in slums make physical distancing and self-quarantine impractical, and the rapid spread of an infection highly likely. Residents of informal settlements are also economically vulnerable during any COVID-19 responses. Any responses to COVID-19 that do not recognize these realities will further jeopardize the survival of large segments of the urban population globally. Most top-down strategies to arrest an infectious disease will likely ignore the often-robust social groups and knowledge that already exist in many slums. Here, we offer a set of practice and policy suggestions that aim to (1) dampen the spread of COVID-19 based on the latest available science, (2) improve the likelihood of medical care for the urban poor whether or not they get infected, and (3) provide economic, social, and physical improvements and protections to the urban poor, including migrants, slum communities, and their residents, that can improve their long-term well-being. Immediate measures to protect residents of urban informal settlements, the homeless, those living in precarious settlements, and the entire population from COVID-19 include the following: (1) institute informal settlements/slum emergency planning committees in every urban informal settlement; (2) apply an immediate moratorium on evictions; (3) provide an immediate guarantee of payments to the poor; (4) immediately train and deploy community health workers; (5) immediately meet Sphere Humanitarian standards for water, sanitation, and hygiene; (6) provide immediate food assistance; (7) develop and implement a solid waste collection strategy; and (8) implement immediately a plan for mobility and health care. Lessons have been learned from earlier pandemics such as HIV and epidemics such as Ebola. They can be applied here. At the same time, the opportunity exists for public health, public administration, international aid, NGOs, and community groups to innovate beyond disaster response and move toward long-term plans.

Human fecal contamination of water, soil, and surfaces in households sharing poor-quality sanitation facilities in Maputo, Mozambique

Identifying the origin of fecal contamination can support more effective interventions to interrupt enteric pathogen transmission. Microbial source tracking (MST) assays may help to identify environmental routes of pathogen transmission although these assays have performed poorly in highly contaminated domestic settings, highlighting the importance of both diagnostic validation and understanding the context-specific ecological, physical, and sociodemographic factors driving the spread of fecal contamination. We assessed fecal contamination of compounds (clusters of 2-10 households that share sanitation facilities) in low-income neighborhoods of urban Maputo, Mozambique, using a set of MST assays that were validated with animal stool and latrine sludge from study compounds. We sampled five environmental compartments involved in fecal microbe transmission and exposure: compound water source, household stored water and food preparation surfaces, and soil from the entrance to the compound latrine and the entrances to each household. Each sample was analyzed by culture for the general fecal indicator Escherichia coli (cEC) and by real-time PCR for the E. coli molecular marker EC23S857, human-associated markers HF183/BacR287 and Mnif, and GFD, an avian-associated marker. We collected 366 samples from 94 households in 58 compounds. At least one microbial target (indicator organism or marker gene) was detected in 96% of samples (353/366), with both E. coli targets present in the majority of samples (78%). Human targets were frequently detected in soils (59%) and occasionally in stored water (17%) but seldom in source water or on food surfaces. The avian target GFD was rarely detected in any sample type but was most common in soils (4%). To identify risk factors of fecal contamination, we estimated associations with sociodemographic, meteorological, and physical sample characteristics for each microbial target and sample type combination using Bayesian censored regression for target concentration responses and Bayesian logistic regression for target detection status. Associations with risk factors were generally weak and often differed in direction between different targets and sample types, though relationships were somewhat more consistent for physical sample characteristics. Wet soils were associated with elevated concentrations of cEC and EC23S857 and odds of detecting HF183. Water storage container characteristics that expose the contents to potential contact with hands and other objects were weakly associated with human target detection. Our results describe a setting impacted by pervasive domestic fecal contamination, including from human sources, that was largely disconnected from the observed variation in socioeconomic and sanitary conditions. This pattern suggests that in such highly contaminated settings, transformational changes to the community environment may be required before meaningful impacts on fecal contamination can be realized.

Slums, Space, and State of Health-A Link between Settlement Morphology and Health Data

Approximately 1 billion slum dwellers worldwide are exposed to increased health risks due to their spatial environment. Recent studies have therefore called for the spatial environment to be introduced as a separate dimension in medical studies. Hence, this study investigates how and on which spatial scale relationships between the settlement morphology and the health status of the inhabitants can be identified. To this end, we summarize the current literature on the identification of slums from a geographical perspective and review the current literature on slums and health of the last five years (376 studies) focusing on the considered scales in the studies. We show that the majority of medical studies are restricted to certain geographical regions. It is desirable that the number of studies be adapted to the number of the respective population. On the basis of these studies, we develop a framework to investigate the relationship between space and health. Finally, we apply our methodology to investigate the relationship between the prevalence of slums and different health metrics using data of the global burden of diseases for different prefectures in Brazil on a subnational level.

Latrine Structure, Design, and Conditions, and the Practice of Open Defecation in Lodwar Town, Turkana County, Kenya: A Quantitative Methods Research

BACKGROUND

Poor latrine conditions, structure, and design may deter latrine use and provoke reversion to open defecation (OD). Statistics show that only 18% of the households in Turkana County, Kenya, have access to a latrine facility with most of these facilities in poor structural designs and poor hygienic conditions, which encourages rampant OD practices.

AIM

This article reports on quantitative aspects of a larger cross-sectional survey to assess latrine structure, design, and conditions, and the practice of OD in Lodwar.

METHODS

An observational study was carried out to examine latrine conditions, structure, and design in Lodwar, Kenya. A standardized questionnaire was also used to collect quantitative data. Stratified random sampling technique was employed to select respondents for this study with the sample drawn from 4 administrative units of Lodwar town covering the low-, medium-, and high-income households. Data were managed using Statistical Packages for Social Science (SPSS) software.

RESULTS

Nineteen percent of the sampled households did not possess a latrine facility at their homesteads with 73% of the latrines constructed using poor materials (mud, mats, polythene bags, and grass). Twenty percent of the respondents were scared of using a latrine with the main reason being loose soils that do not support strong constructions. Eighty-seven percent of the respondents agreed that the presence of feces on the latrine floor encouraged the practice of OD and 321 (80%) respondents stated that the latrine construction materials influenced latrine ownership and its subsequent use.

CONCLUSIONS

Respondents attributed rampant OD practices to poor latrine structure, design, and conditions. In addition, rampant cases of latrine sharing result in latrine filthiness, which eventually encourages OD practice. Inequality in sanitation, among counties, should be addressed in Kenya. The government should take charge of provision of good-quality communal latrines to the less-privileged societies like Turkana. Community empowerment and introduction of a small fee for cleaning and maintenance of these facilities will also improve their conditions. Ending the practice of OD will lead to increased positive public health and environmental outcomes in the study area.

The association of water carriage, water supply and sanitation usage with maternal and child health. A combined analysis of 49 Multiple Indicator Cluster Surveys from 41 countries

BACKGROUND

Millions of people carry water home from off-plot sources each day and lack improved sanitation. Research on the health outcomes associated with water fetching is limited, and with usage of improved sanitation is inconclusive.

OBJECTIVES

To analyse the association of water fetching, unimproved water supplies, and usage of improved sanitation facilities with indicators of women's and children's health.

METHODS

49 Multiple Indicator Cluster Surveys from 41 countries were merged, creating a data set of 2,740,855 people from 539,915 households. Multilevel, multivariable analyses were conducted, using logistic regression for binary outcomes, negative binomial regression for count data and ordinary linear regression for linear data. We adjusted for confounding factors and accounted for clustering at survey, cluster and household level.

RESULTS

Compared to households in which no-one collects water, water fetching by any household member is associated with reduced odds of a woman giving birth in a health care facility (OR 0.88 to 0.90). Adults collecting water is associated with increased relative risk of childhood death (RR 1.04 to 1.05), children collecting water is associated with increased odds of diarrheal disease (OR 1.10 to 1.13) and women or girls collecting water is associated with reduced uptake of antenatal care (β-0.04 to -0.06) and increased odds of leaving a child under five alone for one or more hours, one or more days per week (OR 1.07 to 1.16). Unimproved water supply is associated with childhood diarhhoea (OR 1.05), but not child deaths, or growth scores. When the percentage of people using improved sanitation is more than 80% an association with reduced childhood death and stunting was observed, and when more than 60%, usage of improved sanitation was associated with reduction of diarhhoea and acute undernutrition.

CONCLUSION

Fetching water is associated with poorer maternal and child health outcomes, depending on who collects water. The percentage of people using improved sanitation seems to be more important than type of toilet facility, and must be high to observe an association with reduced child deaths and diarhhoea. Water access on premises, and near universal usage of improved sanitation, is associated with improvements to maternal and child health.

Experiences of capacity strengthening in sanitation and hygiene research in Africa and Asia: the SHARE Research Consortium

The Sanitation and Hygiene Applied Research for Equity (SHARE) Research Programme consortium is a programme funded by the United Kingdom Department for International Development (DFID) that aims to contribute to achieving universal access to effective, sustainable, and equitable sanitation and hygiene worldwide. The capacity development component is an important pillar for this programme and different strategies were designed and implemented during the various phases of SHARE. This paper describes and reflects on the capacity-building strategies of this large multi-country research consortium, identifying lessons learnt and proposing recommendations for future global health research programmes. In the first phase, the strategy focused on increasing the capacity of individuals and institutions from low- and middle-income countries in conducting their own research. SHARE supported six PhD students and 25 MSc students, and organised a wide range of training events for different stakeholders. SHARE peer-reviewed all proposals that researchers submitted through several rounds of funding and offered external peer-review for all the reports produced under the partner's research platforms. In the second phase, the aim was to support capacity development of a smaller number of African research institutions to move towards their independent sustainability, with a stronger focus on early and mid-career scientists within these institutions. In each institution, a Research Fellow was supported and a specific capacity development plan was jointly developed.Strategies that yielded success were learning by doing (supporting institutions and postgraduate students on sanitation and hygiene research), providing fellowships to appoint mid-career scientists to support personal and institutional development, and supporting tailored capacity-building plans. The key lessons learnt were that research capacity-building programmes need to be driven by local initiatives tailored with support from partners. We recommend that future programmes seeking to strengthen research capacity should consider targeted strategies for individuals at early, middle and later career stages and should be sensitive to other institutional operations to support both the research and management capacities.

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.

Sanitation in Rural India: Exploring the Associations between Dwelling Space and Household Latrine Ownership

In 2017, the Joint Monitoring Programme estimated that 520 million people in India were defecating in the open every day. This is despite efforts made by the government, Non-Governmental Organizations (NGOs), and multilaterals to improve latrine coverage throughout India. We hypothesize that this might be because current interventions focus mostly on individual-level determinants, such as attitudes and beliefs, instead of considering all possible social determinants of latrine ownership. Given this, we ask two questions: what is the association between the amount of dwelling space owned by households in rural India and their likelihood of toilet ownership and what proportion of the variation in household latrine ownership is attributable to villages and states? We used multilevel modeling and found significant associations between the amount of household dwelling space and the likelihood of latrine ownership. Furthermore, considerable variation in latrine ownership is attributable to villages and states, suggesting that additional research is required to elucidate the contextual effects of villages and states on household latrine ownership. Thus, sanitation interventions should consider household dwelling space and village and state context as important social determinants of latrine ownership in rural India. Doing so could bolster progress towards Sustainable Development Goal (SDG) 6.

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.

Shared Sanitation Management and the Role of Social Capital: Findings from an Urban Sanitation Intervention in Maputo, Mozambique

Shared sanitation—sanitation facilities shared by multiple households—is increasingly common in rapidly growing urban areas in low-income countries. However, shared sanitation facilities are often poorly maintained, dissuading regular use and potentially increasing disease risk. In a series of focus group discussions and in-depth interviews, we explored the determinants of shared sanitation management within the context of a larger-scale health impact evaluation of an improved, shared sanitation facility in Maputo, Mozambique. We identified a range of formal management practices users developed to maintain shared sanitation facilities, and found that management strategies were associated with perceived latrine quality. However—even within an intervention context—many users reported that there was no formal system for management of sanitation facilities at the compound level. Social capital played a critical role in the success of both formal and informal management strategies, and low social capital was associated with collective action failure. Shared sanitation facilities should consider ways to support social capital within target communities and identify simple, replicable behavior change models that are not dependent on complex social processes.

Fecal Fingerprints of Enteric Pathogen Contamination in Public Environments of Kisumu, Kenya, Associated with Human Sanitation Conditions and Domestic Animals

Young children are infected by a diverse range of enteric pathogens in high disease burden settings, suggesting pathogen contamination of the environment is equally diverse. This study aimed to characterize across- and within-neighborhood diversity in enteric pathogen contamination of public domains in urban informal settlements of Kisumu, Kenya, and to assess the relationship between pathogen detection patterns and human and domestic animal sanitation conditions. Microbial contamination of soil and surface water from 166 public sites in three Kisumu neighborhoods was measured by enterococcal assays and quantitative reverse transcription polymerase chain reaction (qRT-PCR) for 19 enteric pathogens. Regression was used to assess the association between observed sanitary indicators of contamination with enterococci and pathogen presence and concentration, and pathogen diversity. Seventeen types of pathogens were detected in Kisumu public domains. Enteric pathogens were codetected in 33% of soil and 65% of surface water samples. Greater pathogen diversity was associated with the presence of domestic animal feces but not with human open defecation, deteriorating latrines, flies, or disposal of human feces. Sanitary conditions were not associated with enterococcal bacteria, specific pathogen concentrations, or "any pathogen". Young children played at 40% of observed sites. Managing domestic animal feces may be required to reduce enteric pathogen environmental contamination in high-burden settings.

Within-Compound Versus Public Latrine Access and Child Feces Disposal Practices in Low-Income Neighborhoods of Accra, Ghana

In crowded urban settlements in low-income countries, many households rely on shared sanitation facilities. Shared facilities are not currently considered "improved sanitation" because of concerns about whether hygiene conditions sufficiently protect users from the feces of others. Prevention of fecal exposure at a latrine is only one aspect of sanitary safety. Ensuring consistent use of latrines for feces disposal, especially child feces, is required to reduce fecal contamination in households and communities. Household crowding and shared latrine access are correlated in these settings, rendering latrine use by neighbors sharing communal living areas as critically important for protecting one's own household. This study in Accra, Ghana, found that household access to a within-compound basic latrine was associated with higher latrine use by children of ages 5-12 years and for disposal of feces of children < 5 years, compared with households using public latrines. However, within-compound access was not associated with improved child feces disposal by other caregivers in the compound. Feces was rarely observed in household compounds but was observed more often in compounds with latrines versus compounds relying on public latrines. Escherichia coli and human adenovirus were detected frequently on household surfaces, but concentrations did not differ when compared by latrine access or usage practices. The differences in latrine use for households sharing within-compound versus public latrines in Accra suggest that disaggregated shared sanitation categories may be useful in monitoring global progress in sanitation coverage. However, compound access did not completely ensure that households were protected from feces and microbial contamination.

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.

Sanitation facilities, hygienic conditions, and prevalence of acute diarrhea among under-five children in slums of Addis Ababa, Ethiopia: Baseline survey of a longitudinal study

BACKGROUND

In developing countries, children under the age of five years who live in slums are highly vulnerable to diarrhea. However, there is a paucity of information on the relationship between sanitation facilities and hygienic conditions to acute diarrhea among under-five children in slum areas of Addis Ababa, Ethiopia. Therefore, this study examines the sanitation facilities and hygienic conditions in the slums of Addis Ababa and identifies the main factors significantly associated with acute diarrhea among children aged 0-50 months in those slums.

METHODS

A community-based cross-sectional household survey was carried out between September and November 2014, that then served as the baseline survey of a longitudinal study. For this survey, 697 children aged 0-50 months were recruited from two slum districts in Addis Ababa. A pre-tested structured questionnaire and an observational checklist were used for data collection. Multivariable logistic regression analysis was used to identify sanitation facilities and hygiene-related factors that were significantly associated with acute diarrhea by controlling potential confounding effects of selected socio-demographic factors. Adjusted odds ratio (AOR) with corresponding 95% confidence interval (CI) was used to quantify the strength of association.

MAIN FINDINGS

The prevalence of acute diarrhea among children aged 0-50 months in the study area was 11.9% and 94.6% of the sanitation facilities were unimproved. Sharing of a sanitation facility by six or more households (AOR = 4.7; 95% CI: 2.4-9.4), proximity of sanitation facilities within 15 meters of homes (AOR = 6.6; 95% CI: 2.5-17.0), presence of feces (AOR = 3.9; 95% CI: 1.5-10.3) and flies (AOR = 2.5; 95% CI: 1.3-5.0) on the floor of and/or around sanitation facilities, and presence of uncollected garbage inside house compounds (AOR = 3.2; 95% CI: 1.2-8.4) were significantly associated with acute diarrhea.

CONCLUSION

This study reveals the slum environment to be high risk for diarrhea due to close proximity of sanitation facilities to homes, sharing of sanitation facilities, and poor hygiene of the sanitation facilities and housing compounds. We recommend the development of a comprehensive diarrheal disease prevention program that focuses on improving the cleanliness of the sanitation facilities and housing compounds. Increasing the number of improved sanitation facilities at an appropriate distance from houses is also essential in order to reduce the number of households that share one latrine.