Women experience many motivational drivers for improving sanitation, but it is unclear how women’s role in household decision making affects whether a household opts for better sanitation. We analyzed the Kenya Demographic and Health Survey 2008/2009 with a representative sample of 4,556 married and cohabiting women to examine the association between women’s decision making power in relation to that of partners and the type of sanitation facilities used by household members. The independent effects of respondents’ education, employment status, and socioeconomic status on the type of sanitation facilities were also explored. The direct measurement of women’s ability to influence sanitation practice was not available. To address this problem, this study used proxy measures of women’s decision making power in the household. The results of this study revealed that women’s decision making power for major household purchases was positively associated with households having better sanitation (p< 0.05). The findings suggest that increased gender equity could potentially have spillover effects that result in more households opting to improve their sanitation conditions.

Handwashing (HW) with soap is considered the most cost-effective intervention for reducing the risk of child diarrhea, but reliable measurement of HW behaviors is difficult. This study examined the association between proxy HW measures and child diarrhea by analyzing nationally representative household survey data from 25 countries in sub-Saharan Africa (n = 212,492). The main explanatory variable was the HW ladder, representing a varying level of availability of HW materials in the household, and the outcome variable was a 2-week prevalence of child diarrhea. We estimated the prevalence ratio of child diarrhea between children with a basic HW station and without a HW place. Our analysis revealed that availability of water and soap at a HW place was associated with both increased and decreased prevalence ratios: 0.89 (95% CI 0.79–0.99) in Chad, 0.82 (0.69–0.97) in Mauritania, 1.30 (1.02–1.66) in Burkina Faso, and 1.67 (1.20–2.33) in Ghana. After controlling for country-fixed effects, the prevalence ratio was 0.95 (0.92–0.99), suggesting a protective effect of having a HW station with water and soap. Availability of HW resources is an important indicator to prevent child diarrhea, and HW promotion programs should be tailored to the unique context of each country.

Background

High-risk water, sanitation, and hygiene (WASH) practices are still prevalent in most low-income countries. Because of limited access to WASH, children may be put at an increased risk of diarrheal diseases.

Objectives

This study aims to 1) develop a new measure of WASH-induced burden, the WASH Resource Index (WRI), and estimate its correlation with child diarrhea and an additive index of high-risk WASH practices; 2) explore the geographic distribution of high-risk WASH practices, child diarrhea, and summary indices at the cluster level; and 3) examine the association between the WRI and child diarrhea at the individual level.

Design

A sample of 7,019 children from the Uganda Demographic and Health Survey 2011 were included in this study. Principal component analysis was used to develop a WRI, and households were classified as WASH poorest, poorer, middle, richer, and richest. A hot spot analysis was conducted to assess whether and how high-risk WASH practices and child diarrhea were geographically clustered. A potential association between the WRI and child diarrhea was examined through a nested regression analysis.

Results

High-risk WASH practices were clustered at geographically distant regions from Kampala. The 2-week prevalence of child diarrhea, however, was concentrated in Eastern and East Central regions where high-risk WASH practices were not prevalent. At the individual level, none of the high-risk WASH practices were significantly associated with child diarrhea. Being in the highest WASH quintile was, however, significantly associated with 24.9% lower prevalence of child diarrhea compared to being in the lowest quintile (p<0.05).

Conclusions

Only a weak association was found between the WRI and child diarrhea in this study. Future research should explore the potential utility of the WRI to examine WASH-induced burden.

In 2012, the Government of Indonesia and UNICEF launched a project within eastern provinces of Indonesia to scale up and strengthen a national hygiene and sanitation program called ‘Sanitasi Total Berbasis Masyarakat’. A formative study prior to the project was conducted to characterize sanitation and hygiene knowledge, attitudes, and practices (KAP) among 1,700 households in six rural Indonesian districts in 2014. Separate multivariate analyses for toilet ownership (outcome 1) and improved sanitation (outcome 2) were conducted with generalized linear models to assess the association between potential determinants and sanitation outcomes. Respondents who agreed that most people do not have a toilet in their community were associated with lower levels of toilet ownership compared to respondents who disagreed with the statement (p < 0.001). The perception that building a toilet is expensive was also associated with reduced toilet ownership in contrast to respondents without this perception (p < 0.001). Embarrassment and convenience were associated with ownership of improved sanitation versus those with shared or unimproved toilets. The study suggests that social norms play an important role in changing sanitation behaviors. Future research should aim to clarify the extent to which norms and other psychosocial factors can be used to influence sanitation practices.

Background

It is estimated that more than two-thirds of the population in sub-Saharan Africa (SSA) must leave their home to collect water, putting them at risk for a variety of negative health outcomes. There is little research, however, quantifying who is most affected by long water collection times.

Objectives

This study aims to a) describe gender differences in water collection labor among both adults and children (< 15 years of age) in the households (HHs) that report spending more than 30 minutes collecting water, disaggregated by urban and rural residence; and b) estimate the absolute number of adults and children affected by water collection times greater than 30 minutes in 24 SSA countries.

Methods

We analyzed data from the Demographic Health Survey (DHS) and the Multiple Indicator Cluster Survey (MICS) (2005-2012) to describe water collection labor in 24 SSA countries.

Results

Among households spending more than 30 minutes collecting water, adult females were the primary collectors of water across all 24 countries, ranging from 46% in Liberia (17,412 HHs) to 90% in Cote d'Ivoire (224,808 HHs). Across all countries, female children were more likely to be responsible for water collection than male children (62% vs. 38%, respectively). Six countries had more than 100,000 households (HHs) where children were reported to be responsible for water collection (greater than 30 minutes): Burundi (181,702 HHs), Cameroon (154,453 HHs), Ethiopia (1,321,424 HHs), Mozambique (129,544 HHs), Niger (171,305 HHs), and Nigeria (1,045,647 HHs).

Conclusion

In the 24 SSA countries studied, an estimated 3.36 million children and 13.54 million adult females were responsible for water collection in households with collection times greater than 30 minutes. We suggest that accessibility to water, water collection by children, and gender ratios for water collection, especially when collection times are great, should be considered as key indicators for measuring progress in the water, sanitation and hygiene sector.

Handwashing with soap is recognized as a cost-effective intervention to reduce morbidity and mortality associated with enteric and respiratory infections. This study analyzes rural Indonesian households' hygiene behaviors and attitudes to examine how motivations for handwashing, locations of handwashing space in the household, and handwashing moments are associated with handwashing with soap as potential determinants of the behavior. The analysis was conducted using results from a UNICEF cross-sectional study of 1700 households in six districts across three provinces of Indonesia. A composite measure of handwashing with soap was developed that included self-reported handwashing, a handwashing demonstration, and observed handwashing materials and location of facilities in the home. Prevalence ratios were calculated to analyze associations between handwashing with soap and hypothesized determinants of the behavior. Our results showed that determinants that had a significant association with handwashing with soap included: (1) a desire to smell nice; (2) interpersonal influences; (3) the presence of handwashing places within 10 paces of the kitchen and the toilet; and (4) key handwashing moments when hands felt dirty, including after eating and after cleaning child stools. This study concludes that handwashing with soap may be more effectively promoted through the use of non-health messages.

The Safe Water and AIDS Project (SWAP), a non-governmental organization in western Kenya, opened kiosks run as businesses by community health promoters (CHPs) to increase access to health products among poor rural families. We conducted a baseline survey in 2014 before kiosks opened, and a post-intervention follow-up in 2016, enrolling 1,517 households with children <18 months old. From baseline to follow-up, we observed increases in reported exposure to the SWAP program (3–11%, p = 0.01) and reported purchases of any SWAP product (3–10%, p < 0.01). The percent of households with confirmed water treatment (detectable free chlorine residual (FCR) >0.2 mg/ml) was similar from baseline to follow-up (7% vs. 8%, p = 0.57). The odds of reported diarrhea in children decreased from baseline to follow-up (odds ratios or OR: 0.77, 95% CI: 0.64–0.93) and households with detectable FCR had lower odds of diarrhea (OR: 0.53, 95% CI: 0.34–0.83). Focus group discussions with CHPs suggested that high product prices, lack of affordability, and expectations that products should be free contributed to low sales. In conclusion, modest reported increases in SWAP exposure and product sales in the target population were insufficient to impact health, but children in households confirmed to chlorinate their water had decreased diarrhea.