Adaptive strategies to enhance water security and resilience in low- and middle-income countries: A critical review.

The water sector is facing unprecedented pressures as increased environmental and anthropogenic challenges, such as climate change and rapid urbanization, impact the availability and predictability of safe drinking water. There is a need for practitioners and policymakers to integrate water security and resilience (WS&R) factors into programming to sustain investments in drinking water systems to support associated economic, security, and public health benefits. In response to intensifying impacts from WS&R risks, communities around the world are developing adaptive strategies, and a critical review of these strategies may provide lessons that can be implemented at scale. In this critical review, we systematically screened over 9000 peer-reviewed and grey literature articles and extracted data from relevant studies that propose, pilot, and/or evaluate adaptations in low- and middle-income countries (LMICs) and evaluated the suitability of each adaptation for different contexts. We created a portfolio of adaptive strategies from over 75 LMICs to inform practitioners and policymakers in enhancing the resilience of drinking water systems. Over 20 adaptations were identified, including strategies such as stormwater management, wastewater reuse, non-revenue water reductions, water pricing, and public awareness campaigns. We categorized adaptations by function (improving water management, augmenting existing supplies, reducing water demand) and scale (household, municipal, regional) to provide recommendations tailored to local needs. For each adaptation, we highlighted associated strengths, weaknesses, barriers to adoption, and enabling environments for successful implementation. We propose a novel decision-support tool, called STEP WS&R, that provides a consistent and replicable process for informing high-level investment and policy choices around WS&R. This critical review presents recommendations for practitioners and policymakers to invest in WS&R adaptations, catered to shared risks and contexts.

Effects of environmental conditions on healthcare worker wellbeing and quality of care: A qualitative study in Niger.

Environmental conditions (water, sanitation, hygiene, waste management, cleaning, energy, building design) are important for a safe and functional healthcare environment. Yet their full range of impacts are not well understood. In this study, we assessed the impact of environmental conditions on healthcare workers' wellbeing and quality of care, using qualitative interviews with 81 healthcare workers at 26 small healthcare facilities in rural Niger. We asked participants to report successes and challenges with environmental conditions and their impacts on wellbeing (physical, social, mental, and economic) and quality of care. We found that all environmental conditions contributed to healthcare workers' wellbeing and quality of care. The norm in facilities of our sample was poor environmental conditions, and thus participants primarily reported detrimental effects. We identified previously documented effects on physical health and safety from pathogen exposure, but also several novel effects on healthcare workers' mental and economic wellbeing and on efficiency, timeliness, and patient centeredness of care. Key wellbeing impacts included pathogen exposure for healthcare workers, stress from unsafe and chaotic working environments, staff dissatisfaction and retention challenges, out-of-pocket spending to avoid stockouts, and uncompensated labor. Key quality of care impacts included pathogen exposure for patients, healthcare worker time dedicated to non-medical tasks like water fetching (i.e., reduced efficiency), breakdowns and spoilage of equipment and supplies, and patient satisfaction with cleanliness and privacy. Inefficiency due to time lost and damaged supplies and equipment likely have substantial economic value and warrant greater consideration in research and policy making. Impacts on staff retention and care efficiency also have implications for health systems. We recommend that future research and decision making for policy and practice incorporate more holistic impact measures beyond just healthcare acquired infections and reconsider the substantial contribution that environmental conditions make to the safety of healthcare facilities and strength of health systems.

Interventions to improve sanitation for preventing diarrhoea.

BACKGROUND: Diarrhoea is a major contributor to the global disease burden, particularly amongst children under five years in low- and middle-income countries (LMICs). As many of the infectious agents associated with diarrhoea are transmitted through faeces, sanitation interventions to safely contain and manage human faeces have the potential to reduce exposure and diarrhoeal disease. OBJECTIVES: To assess the effectiveness of sanitation interventions for preventing diarrhoeal disease, alone or in combination with other WASH interventions. SEARCH METHODS: We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, and Chinese language databases available under the China National Knowledge Infrastructure (CNKI-CAJ). We also searched the metaRegister of Controlled Trials (mRCT) and conference proceedings, contacted researchers, and searched references of included studies. The last search date was 16 February 2022. SELECTION CRITERIA: We included randomized controlled trials (RCTs), quasi-RCTs, non-randomized controlled trials (NRCTs), controlled before-and-after studies (CBAs), and matched cohort studies of interventions aimed at introducing or expanding the coverage and/or use of sanitation facilities in children and adults in any country or population. Our primary outcome of interest was diarrhoea and secondary outcomes included dysentery (bloody diarrhoea), persistent diarrhoea, hospital or clinical visits for diarrhoea, mortality, and adverse events. We included sanitation interventions whether they were conducted independently or in combination with other interventions. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed eligible studies, extracted relevant data, assessed risk of bias, and assessed the certainty of evidence using the GRADE approach. We used meta-analyses to estimate pooled measures of effect, described results narratively, and investigated potential sources of heterogeneity using subgroup analyses. MAIN RESULTS: Fifty-one studies met our inclusion criteria, with a total of 238,535 participants. Of these, 50 studies had sufficient information to be included in quantitative meta-analysis, including 17 cluster-RCTs and 33 studies with non-randomized study designs (20 NRCTs, one CBA, and 12 matched cohort studies). Most were conducted in LMICs and 86% were conducted in whole or part in rural areas. Studies covered three broad types of interventions: (1) providing access to any sanitation facility to participants without existing access practising open defecation, (2) improving participants' existing sanitation facility, or (3) behaviour change messaging to improve sanitation access or practices without providing hardware or subsidy, although many studies overlapped multiple categories. There was substantial heterogeneity amongst individual study results for all types of interventions. Providing access to any sanitation facility Providing access to sanitation facilities was evaluated in seven cluster-RCTs, and may reduce diarrhoea prevalence in all age groups (risk ratio (RR) 0.89, 95% confidence interval (CI) 0.73 to 1.08; 7 trials, 40,129 participants, low-certainty evidence). In children under five years, access may have little or no effect on diarrhoea prevalence (RR 0.98, 95% CI 0.83 to 1.16, 4 trials, 16,215 participants, low-certainty evidence). Additional analysis in non-randomized studies was generally consistent with these findings. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.79, 95% CI 0.66 to 0.94; 15 studies, 73,511 participants; children < 5 years: RR 0.83, 95% CI 0.68 to 1.02; 11 studies, 25,614 participants).  Sanitation facility improvement Interventions designed to improve existing sanitation facilities were evaluated in three cluster-RCTs in children under five and may reduce diarrhoea prevalence (RR 0.85, 95% CI 0.69 to 1.06; 3 trials, 14,900 participants, low-certainty evidence). However, some of these interventions, such as sewerage connection, are not easily randomized. Non-randomized studies across participants of all ages provided estimates that improving sanitation facilities may reduce diarrhoea, but may be subject to confounding (RR 0.61, 95% CI 0.50 to 0.74; 23 studies, 117,639 participants, low-certainty evidence). Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.65, 95% CI 0.55 to 0.78; 26 studies, 132,539 participants; children < 5 years: RR 0.70, 95% CI 0.54 to 0.91, 12 studies, 23,353 participants).  Behaviour change messaging only (no hardware or subsidy provided) Strategies to promote behaviour change to construct, upgrade, or use sanitation facilities were evaluated in seven cluster-RCTs in children under five, and probably reduce diarrhoea prevalence (RR 0.82, 95% CI 0.69 to 0.98; 7 studies, 28,909 participants, moderate-certainty evidence). Additional analysis from two non-randomized studies found no effect, though with very high uncertainty. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (RR 0.85, 95% CI 0.73 to 1.01; 9 studies, 31,080 participants). No studies measured the effects of this type of intervention in older populations.  Any sanitation intervention A pooled analysis of cluster-RCTs across all sanitation interventions demonstrated that the interventions may reduce diarrhoea prevalence in all ages (RR 0.85, 95% CI 0.76 to 0.95, 17 trials, 83,938 participants, low-certainty evidence) and children under five (RR 0.87, 95% CI 0.77 to 0.97; 14 trials, 60,024 participants, low-certainty evidence). Non-randomized comparisons also demonstrated a protective effect, but may be subject to confounding. Pooled estimates across randomized and non-randomized studies provided similar protective estimates (all ages: RR 0.74, 95% CI 0.67 to 0.82; 50 studies, 237,130 participants; children < 5 years: RR 0.80, 95% CI 0.71 to 0.89; 32 studies, 80,047 participants). In subgroup analysis, there was some evidence of larger effects in studies with increased coverage amongst all participants (75% or higher coverage levels) and also some evidence that the effect decreased over longer follow-up times for children under five years. There was limited evidence on other outcomes. However, there was some evidence that any sanitation intervention was protective against dysentery (RR 0.74, 95% CI 0.54 to 1.00; 5 studies, 34,025 participants) and persistent diarrhoea (RR 0.57, 95% CI 0.43 to 0.75; 2 studies, 2665 participants), but not against clinic visits for diarrhoea (RR 0.86, 95% CI 0.44 to 1.67; 2 studies, 3720 participants) or all-cause mortality (RR 0.99, 95% CI 0.89 to1.09; 7 studies, 46,123 participants). AUTHORS' CONCLUSIONS: There is evidence that sanitation interventions are effective at preventing diarrhoea, both for young children and all age populations. The actual level of effectiveness, however, varies by type of intervention and setting. There is a need for research to better understand the factors that influence effectiveness.

Health risks of solid waste management practices in rural Ghana: A semi-quantitative approach toward a solid waste safety plan.

Inadequate solid waste management (SWM) can lead to environmental contamination and human health risks. The health risks from poor SWM can vary based on specific practices and exposure pathways. Thus, it is necessary to adequately understand the local context. This information, however, is rarely available in low-resource settings, particularly in rural areas. A solid waste safety plan could be helpful in these settings for gathering necessary data to assess and minimize health risks. As a step in developing such a tool, a semi-quantitative health risk analysis of SWM practices in nine Ghanaian rural villages was undertaken. Data on SWM in each village were collected through qualitative field observations and semi-structured interviews with local stakeholders. SWM-related health risks were assessed using the collected data, similar case studies in the scientific literature and dialogue among an assembled team of experts. The analysis identified context-specific practices and exposure pathways that may present the most substantial health risks as well as targeted solutions for mitigation risks. A risk assessment matrix was developed to quantify SWM risks as low, medium, high, or very high based on the likelihood and severity of identified hazards. The highest SWM risks were identified from dumpsites and uncontrolled burying of solid waste. More specifically, a very high or high risk of infectious and vector-borne diseases from SWM in the villages was identified, both in the disposal of solid waste in dumpsites and uncontrolled burying of solid waste. Additionally, a very high or high risk of inhalation, ingestion or dermal contact with contaminants was found in the disposal of solid waste in dumpsites, open burning of waste and reuse of waste from dumpsites as compost. The results demonstrate the potential value of a solid waste safety plan and a parsimonious approach to collect key local data to inform its contents.

Contextual and psychosocial factors influencing caregiver safe disposal of child feces and child latrine training in rural Odisha, India.

Child feces are an important source of fecal exposure in household environments. Typically, one of two behaviors is necessary to mitigate this risk: either caregivers dispose of their children's feces into a latrine or children learn how to use a latrine. Although past studies have examined factors associated with these two behaviors collectively (i.e. "safe disposal"), there is a need to separately analyze these distinctive practices to better inform programming. This study aims to quantitatively examine contextual and psychosocial factors influencing caregiver safe disposal and, separately, child latrine training. We surveyed 791 primary female caregivers, who reported on 906 children <5 years old, across 74 villages in rural Odisha, India. At their last defecation event, 38% of children used the latrine and another 10% had their feces safely disposed of into the latrine. Since caregiver safe disposal was rare, we instead assessed safe disposal intention. We used linear regression and multilevel mixed effects models to examine contextual and psychosocial factors. For contextual factors, we found caregivers had stronger safe disposal intention when they came from wealthier households and had greater informational support, but weaker intention when their latrine was near the household. Caregivers more intensely practiced latrine training with their child when they themselves used the latrine for defecation, the latrine was fully intact, and they had greater instrumental support. For psychosocial factors, caregivers had stronger safe disposal intention when their households expected them to practice safe disposal, they felt strongly committed to the behavior, and had a plan for what to do when faced with a water shortage. Caregivers more intensely taught their child how to use the latrine when they believed their child was at risk of becoming sick if they practiced open defecation (OD); viewed child OD as unbeneficial; liked teaching their child; personally felt it was important for the child's father to help; felt confident in their ability to teach their child; and had greater action control over their training practice. Interestingly, caregivers put less effort into latrine training when they felt more concerned for their child's safety when the child defecated outside. These findings underscore the critical need to separately assess unique child feces management (CFM) practices and also provide a road map for practitioners on the types of behavior change strategies to consider in their CFM programming.

Global practices, geographic variation, and determinants of child feces disposal in 42 low- and middle-income countries: An analysis of standardized cross-sectional national surveys from 2016 - 2020.

BACKGROUND: Despite considerable progress improving water and sanitation access globally, unsafe child feces disposal remains common in many low- and middle-income countries (LMICs), posing an important health risk. The present study characterizes the current prevalence of child feces disposal practices and child latrine use across low- and middle-income countries and investigates determinants associated with appropriate disposal practices. METHODS: Data for children ranging from 0 through 4 years of age were analyzed from standardized and nationally-representative surveys of 42 LMICs collected from 2016 to 2020 to assess child feces disposal practices. We report child feces disposal in three categories: disposal in any type of latrine, disposal in an improved latrine, and disposal through means other than in a latrine. Survey weighted multiple Poisson regression models were used to explore factors associated with these practices. RESULTS: Data on 403,036 children (weighted N = 191 million) demonstrated that a minority (40.3%) of children have their feces disposed of in a latrine of any kind, and just 29% have feces disposed of in an improved latrine. Prevalence varied considerably by country and region. In adjusted analyses, both child feces disposal in any latrine and disposal in an improved latrine increased with child age, higher intra-country relative wealth, and urban living, and decreased with breastfeeding and shared sanitation facilities. Disposal in improved latrines additionally increased with access to higher levels of service for drinking water and higher mother's education. Nevertheless, the role of facility access alone was insufficient, as only about half of children with household access to any latrine or improved latrines had their feces disposed of in these facilities. Child latrine use among households with latrine access was also low and highly variable across countries. CONCLUSIONS: Children's feces in LMICs are infrequently disposed of in any latrine type, and even less frequently in improved latrines. In order to minimize health risks in LMICs, increased effort must be undertaken not just to increase sanitation coverage but to address these common barriers to safe child feces disposal and child latrine use.

Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: a systematic review and meta-analysis.

BACKGROUND: Estimates of the effectiveness of water, sanitation, and hygiene (WASH) interventions that provide high levels of service on childhood diarrhoea are scarce. We aimed to provide up-to-date estimates on the burden of disease attributable to WASH and on the effects of different types of WASH interventions on childhood diarrhoea in low-income and middle-income countries (LMICs). METHODS: In this systematic review and meta-analysis, we updated previous reviews following their search strategy by searching MEDLINE, Embase, Scopus, Cochrane Library, and BIOSIS Citation Index for studies of basic WASH interventions and of WASH interventions providing a high level of service, published between Jan 1, 2016, and May 25, 2021. We included randomised and non-randomised controlled trials conducted at household or community level that matched exposure categories of the so-called service ladder approach of the Sustainable Development Goal (SDG) for WASH. Two reviewers independently extracted study-level data and assessed risk of bias using a modified Newcastle-Ottawa Scale and certainty of evidence using a modified Grading of Recommendations, Assessment, Development, and Evaluation approach. We analysed extracted relative risks (RRs) and 95% CIs using random-effects meta-analyses and meta-regression models. This study is registered with PROSPERO, CRD42016043164. FINDINGS: 19 837 records were identified from the search, of which 124 studies were included, providing 83 water (62 616 children), 20 sanitation (40 799 children), and 41 hygiene (98 416 children) comparisons. Compared with untreated water from an unimproved source, risk of diarrhoea was reduced by up to 50% with water treated at point of use (POU): filtration (n=23 studies; RR 0·50 [95% CI 0·41-0·60]), solar treatment (n=13; 0·63 [0·50-0·80]), and chlorination (n=25; 0·66 [0·56-0·77]). Compared with an unimproved source, provision of an improved drinking water supply on premises with higher water quality reduced diarrhoea risk by 52% (n=2; 0·48 [0·26-0·87]). Overall, sanitation interventions reduced diarrhoea risk by 24% (0·76 [0·61-0·94]). Compared with unimproved sanitation, providing sewer connection reduced diarrhoea risk by 47% (n=5; 0·53 [0·30-0·93]). Promotion of handwashing with soap reduced diarrhoea risk by 30% (0·70 [0·64-0·76]). INTERPRETATION: WASH interventions reduced risk of diarrhoea in children in LMICs. Interventions supplying either water filtered at POU, higher water quality from an improved source on premises, or basic sanitation services with sewer connection were associated with increased reductions. Our results support higher service levels called for under SDG 6. Notably, no studies evaluated interventions that delivered access to safely managed WASH services, the level of service to which universal coverage by 2030 is committed under the SDG. FUNDING: WHO, Foreign, Commonwealth & Development Office, and National Institute of Environmental Health Sciences.

Study design and rationale for a cluster randomized trial of a safe child feces management intervention in rural Odisha, India.

BACKGROUND: Poor child feces management (CFM) is believed to be an important source of exposure to enteric pathogens that contribute to a large disease burden in low-income settings. While access to sanitation facilities is improving, national surveys indicate that even households with latrines often do not safely dispose of their child's feces. Working with caregivers in rural Odisha, India, we co-developed an intervention aimed at improving safe disposal of child feces and encouraging child latrine use at an earlier age. We describe the rationale for the intervention and summarize the protocol for a cluster randomized trial (CRT) to evaluate its effectiveness at changing CFM practices. METHODS: The intervention consists of six behavior change strategies together with hardware provision: wash basin and bucket with lid to aid safe management of soiled nappies and a novel latrine training mat to aid safe disposal and latrine training. The intervention will be offered at the village level to interested caregivers of children < 5 years of age by a community-based organization. Following a baseline survey, 74 villages were randomly allocated to either intervention or control arm. The primary outcome is caregiver reported safe disposal of child feces after last defecation, either by the caregiver disposing of the child's feces into the latrine or the child using the latrine, measured approximately four to six months following intervention delivery. Secondary outcomes include fecal contamination of household drinking water and the childs' hands. A process evaluation will also be conducted to assess intervention fidelity and reach, and explore implementer and participant feedback. DISCUSSION: This study addresses a crucial knowledge gap in sanitation by developing a scalable intervention to improve safe management of child feces. The behavior change strategies were designed following the Risks, Attitudes, Norms, Abilities and Self-Regulation (RANAS) approach, which has shown to be effective for other environmental behavior change interventions in low-income settings. The latrine training mat hardware is a novel design developed cooperatively and manufactured locally. The evaluation follows a rigorous CRT study design assessing the impact of the intervention on CFM behavior change, as well as fecal contamination of two sources of potential exposure. TRIAL REGISTRATION: This trial is registered at ISRCTN: ISRCTN15831099.

Experience of the COVID-19 Pandemic in Rural Odisha, India: Knowledge, Preventative Actions, and Impacts on Daily Life.

We conducted 131 semi-structured phone interviews with householders in rural Odisha, India to explore participants' COVID-19 related knowledge, perceptions, and preventative actions, as well as how the pandemic affected their daily life, economic and food security, and the village-level response. Interviews were conducted with 73 heads of household, 37 primary caregivers, and 21 members of village water and sanitation committees from 43 rural villages in Ganjam and Gajapati districts in Odisha state. The study took place between May-July 2020 throughout various lockdown restrictions and at a time when many migrant workers were returning to their villages and cases were rising. Most respondents could name at least one correct symptom of COVID-19 (75%), but there was lower knowledge about causes of the disease and high-risk groups, and overall COVID-19 knowledge was lowest among caregivers. Respondents reported high compliance with important preventative measures, including staying home as much as possible (94%), social distancing (91%), washing hands frequently (96%), and wearing a facial mask (95%). Additionally, many respondents reported job loss (31%), financial challenges (93%), challenges related to staying home whether as a preventative measure or due to lockdowns (57%), changes in types and/or amount of food consumed (61%), and adverse emotional effects as a result of the pandemic and lockdown. We also provide detailed summaries of qualitative responses to allow for deeper insights into the lived experience of villagers during this pandemic. Although the research revealed high compliance with preventative measures, the pandemic and associated lockdowns also led to many challenges and hardships faced in daily life particularly around job loss, economic security, food security, and emotional wellbeing. The results underscore the vulnerability of marginalized populations to the pandemic and the need for measures that increase resilience to large-scale shocks.

Municipal Solid Waste Management and Adverse Health Outcomes: A Systematic Review.

Municipal solid waste (MSW) can pose a threat to public health if it is not safely managed. Despite prior research, uncertainties remain and refurbished evidence is needed along with new approaches. We conducted a systematic review of recently published literature to update and expand the epidemiological evidence on the association between MSW management practices and resident populations' health risks. Studies published from January 2005 to January 2020 were searched and reviewed following PRISMA guidelines. Eligible MSW treatment or disposal sites were defined as landfills, dumpsites, incinerators, waste open burning, transfer stations, recycling sites, composting plants, and anaerobic digesters. Occupational risks were not assessed. Health effects investigated included mortality, adverse birth and neonatal outcomes, cancer, respiratory conditions, gastroenteritis, vector-borne diseases, mental health conditions, and cardiovascular diseases. Studies reporting on human biomonitoring for exposure were eligible as well. Twenty-nine studies were identified that met the inclusion criteria of our protocol, assessing health effects only associated with proximity to landfills, incinerators, and dumpsites/open burning sites. There was some evidence of an increased risk of adverse birth and neonatal outcomes for residents near each type of MSW site. There was also some evidence of an increased risk of mortality, respiratory diseases, and negative mental health effects associated with residing near landfills. Additionally, there was some evidence of increased risk of mortality associated with residing near incinerators. However, in many cases, the evidence was inadequate to establish a strong relationship between a specific exposure and outcomes, and the studies rarely assessed new generation technologies. Evidence gaps remain, and recommendations for future research are discussed.

Water, Sanitation, and Hygiene Practices and Challenges during the COVID-19 Pandemic: A Cross-Sectional Study in Rural Odisha, India.

Water, sanitation, and hygiene (WASH) practices emerged as a critical component to controlling and preventing the spread of the COVID-19 pandemic. We conducted 131 semistructured phone interviews with households in rural Odisha, India, to understand behavior changes made in WASH practices as a result of the pandemic and challenges that would prevent best practices. Interviews were conducted from May through July 2020 with 73 heads of household, 37 caregivers of children < 5 years old, and 21 members of village water and sanitation committees in villages with community-level piped water and high levels of latrine ownership. The majority of respondents (86%, N = 104) reported a change in their handwashing practice due to COVID-19, typically describing an increase in handwashing frequency, more thorough washing method, and/or use of soap. These improved handwashing practices remained in place a few months after the pandemic began and were often described as a new consistent practice after additional daily actions (such as returning home), suggesting new habit formation. Few participants (13%) reported barriers to handwashing. Some respondents also detailed improvements in other WASH behaviors, including village-level cleaning of water tanks and/or treatment of piped water (48% of villages), household water treatment and storage (17% of respondents), and household cleaning (41% of respondents). However, there was minimal change in latrine use and child feces management practices as a result of the pandemic. We provide detailed thematic summaries of qualitative responses to allow for richer insights into these WASH behavior changes during the pandemic. The results also highlight the importance of ensuring communities have adequate WASH infrastructure to enable the practice of safe behaviors and strengthen resilience during a large-scale health crisis.

Water, sanitation, and hygiene practices and challenges during the COVID-19 pandemic: a cross-sectional study in rural Odisha, India.

Water, sanitation, and hygiene (WASH) practices emerged as a critical component to controlling and preventing the spread of the COVID-19 pandemic. We conducted 131 semi-structured phone interviews with households in rural Odisha, India to understand behavior changes made in WASH practices as a result of the pandemic and challenges that would prevent best practices. Interviews were conducted from May-July 2020 with 73 heads of household, 37 caregivers of children less than five years old, and 21 members of village water and sanitation committees in villages with community-level piped water and high levels of latrine ownership. The majority of respondents (86%, N=104) reported a change in their handwashing practice due to COVID-19 or the related government lockdown, typically describing an increase in handwashing frequency, more thorough washing method, and/or use of soap. These improved handwashing practices remained in place a few months after the pandemic began and were often described as a new consistent practice after additional daily actions (such as returning home), suggesting new habit formation. Few participants (13%) reported barriers to handwashing. Some respondents also detailed improvements in other WASH behaviors including village-level cleaning of water tanks and/or treatment of piped water (48% of villages), household water treatment and storage (17% of respondents), and household cleaning (41% of respondents). However, there was minimal change in latrine use and child feces management practices as a result of the pandemic. We provide detailed thematic summaries of qualitative responses to allow for richer insights into these WASH behavior changes, or lack thereof, during the pandemic. The results also highlight the importance of ensuring communities have adequate WASH infrastructure to enable the practice of safe behaviors and strengthen resilience during a large-scale health crisis.

Child feces management practices and fecal contamination: A cross-sectional study in rural Odisha, India.

Safe child feces management (CFM) is likely critical for reducing exposure to fecal pathogens in and around the home, but the effectiveness of different CFM practices in reducing fecal contamination is not well understood. We conducted a cross-sectional study of households with children <6 years in rural Odisha, India, using household surveys (188 households), environmental sample analysis (373 samples for 80 child defecation events), and unstructured observation (33 households) to characterize practices and measure fecal contamination resulting from CFM-related practices, including defecation, feces handling and disposal, defecation area or tool cleaning, anal cleansing, and handwashing. For environmental sampling, we developed a sampling strategy that involved collecting samples at the time and place of child defecation to capture activity-level fecal contamination for CFM practices. Defecating on the floor or ground, which was practiced by 63.7% of children <6 years, was found to increase E. coli contamination on finished floors (p < 0.001) or earthen ground surfaces (p = 0.008) after feces were removed, even if paper was laid down prior to defecation. Use of unsafe tools (e.g., paper, plastic bag, straw/hay) to pick up child feces increased E. coli contamination on caregiver hands after feces handling (p < 0.0001), whereas the use of safe tools (e.g., potty, hoe, scoop) did not increase hand contamination. Points of contamination from cleaning CFM hardware and anal cleansing were also identified. The most common disposal location for feces of children <6 years was to throw feces into an open field (41.6%), with only 32.3% disposed in a latrine. Several households owned scoops or potties, but use was low and we identified shortcomings of these CFM tools and proposed alternative interventions that may be more effective. Overall, our results demonstrate the need for CFM interventions that move beyond focusing solely on feces disposal to address CFM as a holistic set of practices.

Enteric pathogens from water, hands, surface, soil, drainage ditch, and stream exposure points in a low-income neighborhood of Nairobi, Kenya.

Child exposure to fecal-oral pathogens occurs through several transmission pathways. However, the relative importance of different exposure points for pathogen transmission both inside and outside households is not well understood. We conducted a cross-sectional study in the urban slum of Kibera in Nairobi, Kenya, collecting 237 environmental samples from 40 households from source water, stored drinking water, caregiver hands, child hands, household surfaces, soil, standing water, open drainage ditches, and streams. We quantified the fecal indicator Escherichia coli and the enteric pathogens of adenovirus, Campylobacter jejuni, Shigella spp./enteroinvasive E. coli (EIEC), and Vibrio cholerae. At least one enteric pathogens was detected in 13% of household stored water, 47% of hand, 46% of table surface, 26% of plate surface, 75% of floor surface, 96% of soil, 56% of standing water, 77% of drainage ditch, and 100% of stream samples despite all households having access to a toilet or latrine. Our results provide evidence that children may be exposed to enteric pathogens from several exposure points, that domestic hygiene practices related to water treatment and child handwashing were associated with reduced pathogen detection in this setting, but household table and floor cleaning practices were not, that ownership or presence of chickens in the compound was associated with increased detection of C. jejuni inside households and on soil, that there were interactions among different transmission pathways for enteric pathogens, and that there were differential correlations between E. coli and enteric pathogens for different pathogens and environmental sample types. Additionally, V. cholerae was detected at several exposure points during a cholera outbreak. Overall, these results suggest that interventions that can disrupt many transmission pathways may be needed to reduce enteric pathogen exposure in this urban slum setting.

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

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

Child Defecation and Feces Disposal Practices and Determinants among Households after a Combined Household-Level Piped Water and Sanitation Intervention in Rural Odisha, India.

Latrine access alone may be insufficient to encourage households to dispose of young children's feces safely in a latrine, and little is known about the determinants of improved child feces disposal. We used longitudinal data collected at up to three timepoints for children less than 5 years of age from households in Odisha, India, which received a combined household-level piped water supply and sanitation intervention, but did not specifically promote the safe disposal of child feces. Among the 85% of intervention households who reported access to improved sanitation, we characterized child defecation and feces disposal practices by age, across time, and season, and assessed determinants of improved disposal. Feces from children less than 3 years of age was commonly picked up by caregivers but disposed of unsafely with garbage into open areas (56.3% of households) or in a drain/ditch (6.2%). Although children 3 and 4 years were more likely to use a latrine than younger children, their feces was also more likely to be left in the open if they did not defecate in a latrine. For children less than 5 years of age, most (84.7%) children's feces that was safely disposed of in a latrine was because of the children defecating in the latrine directly. Significant predictors for disposing of child feces in an improved latrine were the primary female caregiver reporting using a latrine to defecate, the child's age, and water observed at place for handwashing. These findings suggest that child feces interventions should focus on encouraging children to begin using a toilet at a younger age and changing the common behavior of disposing of young child's feces into open areas.

Child soil ingestion in rural Ghana - frequency, caregiver perceptions, relationship with household floor material and associations with child diarrhoea.

OBJECTIVES: The objectives of this work were to evaluate (i) the prevalence and frequency of caregiver-reported soil ingestion by children, (ii) whether household flooring material in the bedroom (earth vs. concrete) affected caregiver-reported soil ingestion, (iii) whether caregiver-reported soil ingestion was associated with caregiver-reported diarrhoea and (iv) caregivers' perceptions of their children ingesting soil. METHODS: We conducted 309 household surveys in northern Ghana, including 529 children under five (249 children aged 6-36 months), and measured faecal contamination in soil from 31 households. RESULTS: Among all children, 15% were reported to have directly ingested soil in the past week, including 28% of children aged 6-36 months. Among children reported to have ingested soil, the median frequency was 14 times in the past week, and the median amount of soil ingested each time was half a handful. There was no association between household floor material and whether the caregiver observed a child directly ingesting soil. After adjusting for household floor material and other potential confounding variables, caregiver-reported soil ingestion was associated with caregiver-reported diarrhoea for children under five [adjusted odds ratio (adj. OR) = 3.13, 95% confidence interval (CI) 2.76-3.55] and children aged 6-36 months (adj. OR = 2.61, 95% CI 2.01-3.39). Approximately 83% of caregivers whose children ingested soil reported they thought it was unsafe and were more likely to report stopping their child from ingesting soil, but these responses did not affect the quantity of soil ingested. CONCLUSIONS: Our results suggest direct soil ingestion is associated with diarrhoea independent of household floor material, and separate interventions may be necessary to prevent exploratory soil ingestion.

The effect of young children's faeces disposal practices on child growth: evidence from 34 countries.

OBJECTIVE: To characterize the relationship between child faeces disposal and child growth in low- and middle-income countries. METHODS: We analysed caregiver responses and anthropometric data from Demographic and Health Surveys (2005-2014) for 202 614 children under five and 82 949 children under two to examine the association between child faeces disposal and child growth. RESULTS: Child faeces disposal in an improved toilet was associated with reduced stunting for children under five [adjusted prevalence ratio (aPR) = 0.90, 95% confidence interval (CI) 0.89-0.92] and a 0.12 increase in height-for-age z-score (HAZ; 95% CI: 0.10-0.15) among all households. Among households with improved sanitation access, practicing improved child faeces disposal was still associated with a decrease in stunting (aPR = 0.94, 95% CI: 0.91-0.96) and a 0.09 increase in HAZ (95% CI: 0.06-0.13). Improved child faeces disposal was also associated with reductions in underweight and wasting, and an increase in weight-for-age z-score (WAZ), but not an increase in weight-for-height z-score (WHZ). Community coverage level of improved child faeces disposal was also associated with stunting, with 75-100% coverage associated with the greatest reduction in stunting. Child faeces disposal in an unimproved toilet was associated with reductions in underweight and wasting, but not stunting. CONCLUSIONS: Improved child faeces disposal practices could achieve greater reductions in child undernutrition than improving toilet access alone. Additionally, the common classification of child faeces disposal as 'safe' regardless of the type of toilet used for disposal may underestimate the benefits of disposal in an improved toilet and overestimate the benefits of disposal in an unimproved toilet.

Soil Ingestion is Associated with Child Diarrhea in an Urban Slum of Nairobi, Kenya.

Diarrhea is a leading cause of mortality in children under 5 years of age. We conducted a cross-sectional study of 54 children aged 3 months to 5 years old in Kibera, an urban slum in Nairobi, Kenya, to assess the relationship between caregiver-reported soil ingestion and child diarrhea. Diarrhea was significantly associated with soil ingestion (adjusted odds ratio = 9.9, 95% confidence interval = 2.1-47.5). Soil samples from locations near each household were also collected and analyzed for Escherichia coli and a human-associated Bacteroides fecal marker (HF183). Escherichia coli was detected in 100% of soil samples (mean 5.5 log colony forming units E. coli per gram of dry soil) and the Bacteroides fecal marker HF183 was detected in 93% of soil samples. These findings suggest that soil ingestion may be an important transmission pathway for diarrheal disease in urban slum settings.

Differences in field effectiveness and adoption between a novel automated chlorination system and household manual chlorination of drinking water in Dhaka, Bangladesh: a randomized controlled trial.

The number of people served by networked systems that supply intermittent and contaminated drinking water is increasing. In these settings, centralized water treatment is ineffective, while household-level water treatment technologies have not been brought to scale. This study compares a novel low-cost technology designed to passively (automatically) dispense chlorine at shared handpumps with a household-level intervention providing water disinfection tablets (Aquatab), safe water storage containers, and behavior promotion. Twenty compounds were enrolled in Dhaka, Bangladesh, and randomly assigned to one of three groups: passive chlorinator, Aquatabs, or control. Over a 10-month intervention period, the mean percentage of households whose stored drinking water had detectable total chlorine was 75% in compounds with access to the passive chlorinator, 72% in compounds receiving Aquatabs, and 6% in control compounds. Both interventions also significantly improved microbial water quality. Aquatabs usage fell by 50% after behavioral promotion visits concluded, suggesting intensive promotion is necessary for sustained uptake. The study findings suggest high potential for an automated decentralized water treatment system to increase consistent access to clean water in low-income urban communities.