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.

Effect of a low-cost, behaviour-change intervention on latrine use and safe disposal of child faeces in rural Odisha, India: a cluster-randomised controlled trial.

BACKGROUND: Uptake of Government-promoted sanitation remains a challenge in India. We aimed to investigate a low-cost, theory-driven, behavioural intervention designed to increase latrine use and safe disposal of child faeces in India. METHODS: We did a cluster-randomised controlled trial between Jan 30, 2018, and Feb 18, 2019, in 66 rural villages in Puri, Odisha, India. Villages were eligible if not adjacent to another included village and not designated by the Government to be open-defecation free. All latrine-owning households in selected villages were eligible. We assigned 33 villages to the intervention via stratified randomisation. The intervention was required to meet a limit of US$20 per household and included a folk performance, transect walk, community meeting, recognition banners, community wall painting, mothers' meetings, household visits, and latrine repairs. Control villages received no intervention. Neither participants nor field assessors were masked to study group assignment. We estimated intervention effects on reported latrine use and safe disposal of child faeces 4 months after completion of the intervention delivery using a difference-in-differences analysis and stratified results by sex. This study is registered at ClinicalTrials.gov, NCT03274245. FINDINGS: We enrolled 3723 households (1807 [48·5%] in the intervention group and 1916 [51·5%] in the control group). Analysis included 14 181 individuals (6921 [48·8%] in the intervention group and 7260 [51·2%] in the control group). We found an increase of 6·4 percentage points (95% CI 2·0-10·7) in latrine use and an increase of 15·2 percentage points (7·9-22·5) in safe disposal of child faeces. No adverse events were reported. INTERPRETATION: A low-cost behavioural intervention achieved modest increases in latrine use and marked increases in safe disposal of child faeces in the short term but was unlikely to reduce exposure to faecal pathogens to a level necessary to achieve health gains. FUNDING: The Bill & Melinda Gates Foundation and International Initiative for Impact Evaluation.

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.

Caregiver social support and child toilet training in rural Odisha, India: What types of support facilitate training and how?

Studies show positive impacts of social support on childcare practices, but there is limited research on child toilet training. Social support with toilet training may be especially important for rural Indian caregivers as this is a new childcare practice for many and mothers face an already demanding workload. The aim of this study was to examine the role of social support in toilet training using mediation and conditional process analyses. We surveyed 570 caregivers of children <5 years old living in rural Odisha, India. We found certain types of support aid toilet training through three mechanisms: directly, by improving self-efficacy, and by buffering against stress. Informational and instrumental support had a positive direct effect on toilet training while emotional support had no effect. Instrumental support also aided toilet training indirectly through bolstering a caregiver's perceived self-efficacy. These effects of instrumental support were not moderated by the caregiver's support network size. Additionally, we found perceived stress had a negative indirect effect on caregivers' toilet training efforts through diminishing self-efficacy, but this effect was buffered (i.e. moderated) by social support. These findings offer useful programmatic insights and expand the evidence-base on how social support functions to another childcare practice and cultural context.

The impact of a demand-side sanitation and hygiene promotion intervention on sustained behavior change and health in Amhara, Ethiopia: A cluster-randomized trial.

Behaviors related to water, sanitation, and hygiene (WASH) are key drivers of infectious disease transmission, and experiences of WASH are potential influencers of mental well-being. Important knowledge gaps exist related to the content and delivery of effective WASH programs and their associated health impacts, particularly within the contexts of government programs implemented at scale. We developed and tested a demand-side intervention called Andilaye, which aimed to change behaviors related to sanitation, personal hygiene, and household environmental sanitation. This theory-informed intervention was delivered through the existing Ethiopian Health Extension Programme (HEP). It was a multilevel intervention with a catalyzing event at the community level and behavior change activities at group and household levels. We randomly selected and assigned 50 kebeles (sub-districts) from three woredas (districts), half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). We collected data on WASH access, behavioral outcomes, and mental well-being. A total of 1,589 households were enrolled into the study at baseline; 1,472 households (94%) participated in an endline assessment two years after baseline, and approximately 14 months after the initiation of a multi-level intervention. The intervention did not improve construction of latrines (prevalence ratio [PR]: 0.99; 95% CI: 0.82, 1.21) or handwashing stations with water (PR: 0.96; 95% CI: 0.72, 1.26), or the removal of animal feces from the compound (PR: 1.10; 95% CI: 0.95, 1.28). Nor did it impact anxiety (PR: 0.90; 95% CI: 0.72, 1.11), depression (PR: 0.83; 95% CI: 0.64, 1.07), emotional distress (PR: 0.86; 95% CI: 0.67, 1.09) or well-being (PR: 0.90; 95% CI: 0.74, 1.10) scores. We report limited impact of the intervention, as delivered, on changes in behavior and mental well-being. The effectiveness of the intervention was limited by poor intervention fidelity. While sanitation and hygiene improvements have been documented in Ethiopia, behavioral slippage, or regression to unimproved practices, in communities previously declared open defecation free is widespread. Evidence from this trial may help address knowledge gaps related to challenges associated with scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. Trial registration: This trial was registered with clinicaltrials.gov (NCT03075436) on March 9, 2017.

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.

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.

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.

Community Perceptions of a Multilevel Sanitation Behavior Change Intervention in Rural Odisha, India.

While latrine coverage is increasing in India, not all household members use their latrines. Cost-effective, culturally appropriate, and theory-informed behavior change interventions are necessary to encourage sustained latrine use by all household members. We qualitatively examined community perceptions of sanitation interventions broadly, along with specific impressions and spillover of community-level activities of the Sundara Grama latrine use behavior change intervention in rural Odisha, India. We conducted sixteen sex-segregated focus group discussions (n = 152) in three intervention and three nonintervention villages and thematically analyzed the data. We found Sundara Grama was well-received by community members and considered educative, but perceptions of impact on latrine use were mixed and varied by activity. Intervention recruitment challenges prevented some, such as women and households belonging to lower castes, from attending activities. Spillover occurred in one of two nonintervention villages, potentially due to positive relations within and between the nonintervention village and nearby intervention village. Community-level sanitation initiatives can be hindered by community divisions, prioritization of household sanitation over community cleanliness, and perceptions of latrine use as a household and individual issue, rather than common good. Community-centered sanitation interventions should assess underlying social divisions, norms, and perceptions of collective efficacy to adapt intervention delivery and activities.

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.

Sanitation and Collective Efficacy in Rural Cambodia: The Value Added of Qualitative Formative Work for the Contextualization of Measurement Tools.

Community-level action may be required to achieve the levels of sanitation uptake necessary for health gains. Evidence suggests that collective action is influenced by collective efficacy (CE)-a group's belief in its abilities to organize and execute action to achieve common goals. The extent to which it is necessary to fully contextualize existing CE measurement tools, in order to conduct meaningful assessments of the factors influencing CE perceptions, is not well understood. This study examines the value added of contextualizing an existing CE measurement tool using qualitative formative research. We employed a modified grounded theory approach to develop a contextualized CE framework based on qualitative data from rural Cambodian villages. The resulting framework included sub-constructs that were pertinent for the rural Cambodian context for which an existing, hypothesized framework did not account: perceived risks/benefits, action knowledge, shared needs/benefits, and external accountability. Complex confirmatory factor analyses indicated that contextualized models fit the data better than hypothesized models for women and men. This study demonstrates that inductive, qualitative research allows community-derived factors to enhance existing tools for context-specific CE measurement. Additional research is needed to determine which CE factors transcend contexts and could, thus, form the foundation of a general CE measurement tool.

Design of a parallel cluster-randomized trial assessing the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia: Andilaye study protocol.

BACKGROUND: Unimproved water, sanitation, and hygiene (WASH) behaviors are key drivers of infectious disease transmission and influencers of mental well-being. While WASH is seen as a critical enabler of health, important knowledge gaps related to the content and delivery of effective, holistic WASH programming exist. Corresponding impacts of WASH on mental well-being are also underexplored. There is a need for more robust implementation research that yields information regarding whether and how community-based, demand-side interventions facilitate progressive and sustained adoption of improved sanitation and hygiene behaviors and downstream health impacts. The purpose of this protocol is to detail the rationale and design of a cluster-randomized trial evaluating the impact of a demand-side sanitation and hygiene intervention on sustained behavior change and mental well-being in rural and peri-urban Amhara, Ethiopia. METHODS: Together with partners, we developed a theoretically-informed, evidence-based behavioral intervention called Andilaye. We randomly selected and assigned 50 sub-districts (kebeles) from three purposively selected districts (woredas); half to receive the Andilaye intervention, and half the standard of care sanitation and hygiene programming (i.e., community-led total sanitation and hygiene [CLTSH]). During baseline, midline, and endline, we will collect data on an array of behavioral factors, potential moderators (e.g., water and sanitation insecurity, collective efficacy), and our primary study outcomes: sanitation and hygiene behaviors and mental well-being. We will perform a process evaluation to assess intervention fidelity and related attributes. DISCUSSION: While CLTSH has fostered sanitation and hygiene improvements in Ethiopia, evidence of behavioral slippage, or regression to unimproved practices in communities previously declared open defecation free exists. Other limitations of CLTSH, such as its focus on disgust, poor triggering, and over-saturation of Health Extension Workers have been documented. We employed rigorous formative research and practically applied social and behavioral theory to develop Andilaye, a scalable intervention designed to address these issues and complement existing service delivery within Ethiopia's Health Extension Program. Evidence from this trial may help address knowledge gaps related to scalable alternatives to CLTSH and inform sanitation and hygiene programming and policy in Ethiopia and beyond. TRIAL REGISTRATION: This trial was registered with clinicaltrials.gov ( NCT03075436 ) on March 9, 2017.

A cluster-randomized multi-level intervention to increase latrine use and safe disposal of child feces in rural Odisha, India: the Sundara Grama research protocol.

BACKGROUND: Despite health benefits of sanitation, an estimated 12% of the global population practices open defecation, including an estimated 50% of the population of India. Current estimates, however, do not include households that own toilets but do not use them, suggesting that the actual number of people defecating in the open is underestimated. This protocol describes a cluster randomized controlled trial to evaluate an intervention specifically designed to increase latrine use, including the safe disposal of child feces, in rural Odisha, India. METHODS: The trial engages 66 villages in Puri district, 33 randomly allocated to receive the intervention and 33 to serve as controls. The primary outcome is latrine use and is recorded at baseline and endline for all members of all households that own latrines in all trial vilalges. Additional data on determinants of latrine use and safe child feces disposal are also collected to assess change based on the intervetntion. A process evaluation assesses the delivery of the intervention and qualiative research takes place in non-trial villages as well as post-endline in trial villages to help explain trial findings. DISCUSSION: This is one of four trials taking place simultaneously in rural India with latrine use as the primary outcome. All four studies use the same outcome to gerenate comparable data across sites that can serve the government of India. The trial in Odisha is unique in that it collects latrine use data from all potential users in all households that own latrines, enabling a thorough view of the sanitation situation and factors that influence use at the community level. That latrine use is collected via self-report is a limitation, however any bias in reporting should be the same across villages and not impact the overall assessment of intervention impact. TRIAL REGISTRATION: This trial is registered at clinicaltrials.gov: NCT03274245 .

Impact of a multi-level intervention, Sundara Grama, on latrine use and safe disposal of child faeces in rural Odisha, India

Odisha state has one of the lowest rates of sanitation coverage in India. According to the 2015-2016 India National Family Health Survey, coverage was only 23 per cent in rural areas. The sanitation context of rural Puri district, the location of this research, was better than the overall context of the state, with 36.8 per cent of households having an improved sanitation facility.

Quantifying user preferences for sanitation construction and use: Application of discrete choice experiments in Amhara, Ethiopia.

OBJECTIVE: To quantify stated preferences for latrine use and construction in Amhara, Ethiopia, using Discrete Choice Experiments (DCEs). METHODS: We conducted image-based DCEs to assess preferences for latrine use (stratified by gender) and construction (among men only) in Amhara, Ethiopia. Preference was quantified using a conditional logistic model to estimate utilities and corresponding odds ratios associated with a set of latrine attributes. RESULTS: For latrine use, tin roof, handwashing stations and clean latrines had the highest relative utility coefficients. Tin roof was preferred to no roof for use (Women: OR: 3.68, 95% CI: 3.18-4.25; Men: OR: 3.75, 95% CI: 3.21-4.39) and new latrine construction (5.92, 5.04-6.95). Concrete slabs, a critical aspect of improved sanitation, was not preferred to dirt floors for use (Women: 0.87, 0.75-1.00; Men: 1.03, 0.88-1.20), but was preferred for new construction (1.52, 1.30-1.78). We did not observe any trends in preference for direct (monetary) or indirect cost (labour days), so we were not able to elicit trade-offs between latrine attributes and these costs for the construction of new latrines. CONCLUSION: Our findings suggest similar latrine use preferences between men and women. We found that tin roofs are the most strongly preferred latrine characteristic, but concrete slabs, commonly promoted in sanitation programmes, were not preferred for use. We demonstrate the utility of DCEs to elicit stated preferences for latrine use and construction among community members who have myriad motivations for using and making improvements to their sanitation facilities, including the ease of cleaning and hygiene, durability, or privacy and comfort.

SUMO-Targeted Ubiquitin Ligases (STUbLs) Reduce the Toxicity and Abnormal Transcriptional Activity Associated With a Mutant, Aggregation-Prone Fragment of Huntingtin.

Cell viability and gene expression profiles are altered in cellular models of neurodegenerative disorders such as Huntington's Disease (HD). Using the yeast model system, we show that the SUMO-targeted ubiquitin ligase (STUbL) Slx5 reduces the toxicity and abnormal transcriptional activity associated with a mutant, aggregation-prone fragment of huntingtin (Htt), the causative agent of HD. We demonstrate that expression of an aggregation-prone Htt construct with 103 glutamine residues (103Q), but not the non-expanded form (25Q), results in severe growth defects in slx5Δ and slx8Δ cells. Since Slx5 is a nuclear protein and because Htt expression affects gene transcription, we assessed the effect of STUbLs on the transcriptional properties of aggregation-prone Htt. Expression of Htt 25Q and 55Q fused to the Gal4 activation domain (AD) resulted in reporter gene auto-activation. Remarkably, the auto-activation of Htt constructs was abolished by expression of Slx5 fused to the Gal4 DNA-binding domain (BD-Slx5). In support of these observations, RNF4, the human ortholog of Slx5, curbs the aberrant transcriptional activity of aggregation-prone Htt in yeast and a variety of cultured human cell lines. Functionally, we find that an extra copy of SLX5 specifically reduces Htt aggregates in the cytosol as well as chromatin-associated Htt aggregates in the nucleus. Finally, using RNA sequencing, we identified and confirmed specific targets of Htt's transcriptional activity that are modulated by Slx5. In summary, this study of STUbLs uncovers a conserved pathway that counteracts the accumulation of aggregating, transcriptionally active Htt (and possibly other poly-glutamine expanded proteins) on chromatin in both yeast and in mammalian cells.

Collective Efficacy: Development and Validation of a Measurement Scale for Use in Public Health and Development Programmes.

Impact evaluations of water, sanitation, and hygiene interventions have demonstrated lower than expected health gains, in some cases due to low uptake and sustained adoption of interventions at a community level. These findings represent common challenges for public health and development programmes relying on collective action. One possible explanation may be low collective efficacy (CE)-perceptions regarding a group's ability to execute actions related to a common goal. The purpose of this study was to develop and validate a metric to assess factors related to CE. We conducted this research within a cluster-randomised sanitation and hygiene trial in Amhara, Ethiopia. Exploratory and confirmatory factor analyses were carried out to examine underlying structures of CE for men and women in rural Ethiopia. We produced three CE scales: one each for men and women that allow for examinations of gender-specific mechanisms through which CE operates, and one 26-item CE scale that can be used across genders. All scales demonstrated high construct validity. CE factor scores were significantly higher for men than women, even among household-level male-female dyads. These CE scales will allow implementers to better design and target community-level interventions, and examine the role of CE in the effectiveness of community-based programming.

The impact of sanitation on infectious disease and nutritional status: A systematic review and meta-analysis.

BACKGROUND: Sanitation aims to sequester human feces and prevent exposure to fecal pathogens. More than 2.4 billion people worldwide lack access to improved sanitation facilities and almost one billion practice open defecation. We undertook systematic reviews and meta-analyses to compile the most recent evidence on the impact of sanitation on diarrhea, soil-transmitted helminth (STH) infections, trachoma, schistosomiasis, and nutritional status assessed using anthropometry. METHODS AND FINDINGS: We updated previously published reviews by following their search strategy and eligibility criteria. We searched from the previous review's end date to December 31, 2015. We conducted meta-analyses to estimate pooled measures of effect using random-effects models and conducted subgroup analyses to assess impact of different levels of sanitation services and to explore sources of heterogeneity. We assessed risk of bias and quality of the evidence from intervention studies using the Liverpool Quality Appraisal Tool (LQAT) and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach, respectively. A total of 171 studies met the review's inclusion criteria, including 64 studies not included in the previous reviews. Overall, the evidence suggests that sanitation is protective against diarrhea, active trachoma, some STH infections, schistosomiasis, and height-for-age, with no protective effect for other anthropometric outcomes. The evidence was generally of poor quality, heterogeneity was high, and GRADE scores ranged from very low to high. CONCLUSIONS: This review confirms positive impacts of sanitation on aspects of health. Evidence gaps remain and point to the need for research that rigorously describes sanitation implementation and type of sanitation interventions.

Design and rationale of a matched cohort study to assess the effectiveness of a combined household-level piped water and sanitation intervention in rural Odisha, India.

INTRODUCTION: Government efforts to address massive shortfalls in rural water and sanitation in India have centred on construction of community water sources and toilets for selected households. However, deficiencies with water quality and quantity at the household level and community coverage and actual use of toilets have led Gram Vikas, a local non-governmental organization in Odisha, India, to develop an approach that provides household-level piped water connections contingent on full community-level toilet coverage. METHODS: This matched cohort study was designed to assess the effectiveness of a combined piped water and sanitation intervention. Households with children <5 years in 45 randomly selected intervention villages and 45 matched control villages will be followed over 17 months. The primary outcome is prevalence of diarrhoeal diseases; secondary health outcomes include soil-transmitted helminth infection, nutritional status, seroconversion to enteric pathogens, urogenital infections and environmental enteric dysfunction. In addition, intervention effects on sanitation and water coverage, access and use, environmental fecal contamination, women's empowerment, as well as collective efficacy, and intervention cost and cost-effectiveness will be assessed. ETHICS AND DISSEMINATION: The study protocol has been reviewed and approved by the ethics boards of the London School of Hygiene and Tropical Medicine, UK and KIIT University, Bhubaneswar, India. Findings will be disseminated via peer-reviewed literature and presentation to stakeholders, government officials, implementers and researchers. TRIAL REGISTRATION NUMBER: NCT02441699.

The impact of sanitation interventions on latrine coverage and latrine use: A systematic review and meta-analysis.

BACKGROUND: An estimated 2.4 billion people still lack access to improved sanitation and 946 million still practice open defecation. The World Health Organization (WHO) commissioned this review to assess the impact of sanitation on coverage and use, as part of its effort to develop a set of guidelines on sanitation and health. METHODS AND FINDINGS: We systematically reviewed the literature and used meta-analysis to quantitatively characterize how different sanitation interventions impact latrine coverage and use. We also assessed both qualitative and quantitative studies to understand how different structural and design characteristics of sanitation are associated with individual latrine use. A total of 64 studies met our eligibility criteria. Of 27 intervention studies that reported on household latrine coverage and provided a point estimate with confidence interval, the average increase in coverage was 14% (95% CI: 10%, 19%). The intervention types with the largest absolute increases in coverage included the Indian government's "Total Sanitation Campaign" (27%; 95% CI: 14%, 39%), latrine subsidy/provision interventions (16%; 95% CI: 8%, 24%), latrine subsidy/provision interventions that also incorporated education components (17%; 95% CI: -5%, 38%), sewerage interventions (14%; 95% CI: 1%, 28%), sanitation education interventions (14%; 95% CI: 3%, 26%), and community-led total sanitation interventions (12%; 95% CI: -2%, 27%). Of 10 intervention studies that reported on household latrine use, the average increase was 13% (95% CI: 4%, 21%). The sanitation interventions and contexts in which they were implemented varied, leading to high heterogeneity across studies. We found 24 studies that examined the association between structural and design characteristics of sanitation facilities and facility use. These studies reported that better maintenance, accessibility, privacy, facility type, cleanliness, newer latrines, and better hygiene access were all frequently associated with higher use, whereas poorer sanitation conditions were associated with lower use. CONCLUSIONS: Our results indicate that most sanitation interventions only had a modest impact on increasing latrine coverage and use. A further understanding of how different sanitation characteristics and sanitation interventions impact coverage and use is essential in order to more effectively attain sanitation access for all, eliminate open defecation, and ultimately improve health.