Social beliefs and women's role in sanitation decision making in Bihar, India: An exploratory mixed method study.

In low- and middle-income countries, poor autonomy prevents women from making financial decisions, which may impact their access to improved sanitation facilities. Inadequate access to improved sanitation disproportionately affects women's and children's health and wellbeing. Although socio-cultural factors are known contributors to gender inequity, social beliefs that potentially motivate or dissuade women from making sanitation-related household decisions are not well understood. These beliefs may vary across settlement types. To empower more women to make sanitation-related decisions, the relevant socio-cultural norms and underlying social beliefs need to be addressed. In this mixed methods study, we explored women's role in sanitation-related decision making in three settlement types, urban slums, peri-urban, and rural communities in Bihar. Trained qualitative researchers conducted six focus group discussions with women of two age groups: 18-30 years old, and 45-65 years old to understand the norm-focused factors around women's role in getting a toilet for their household. Using insights generated from these group discussions, we developed and conducted a theory-driven survey in 2528 randomly selected participants, to assess the social beliefs regarding women making toilet construction decisions in these communities. Overall, 45% of the respondents reported making joint decisions to build toilets that involved both men and women household members. More women exclusively led this decision-making process in peri-urban (26%) and rural areas (35%) compared to urban slums (12%). Social beliefs that men commonly led household decisions to build toilets were negatively associated with women's participation in decision making in urban slums (adjusted prevalence ratio, aPR: 0.53, 95% CI: 0.42, 0.68). Qualitative insights highlighted normative expectations to take joint decisions with elders, especially in joint family settings. Surrounding norms that limited women's physical mobility and access to peers undermined their confidence in making large financial decisions involved in toilet construction. Women were more likely to be involved in sanitation decisions in peri-urban and rural contexts. Women's involvement in such decisions was perceived as widely acceptable. This highlights the opportunity to increase women's participation in sanitation decision making, particularly in urban contexts. As more women get involved in decisions to build toilets, highlighting this norm may encourage gender-equitable engagement in sanitation-related decisions in low-resource settings.

Aerosol and bioaerosol particle size and dynamics from defective sanitary plumbing systems.

Aerosols are readily transported on airstreams through building sanitary plumbing and sewer systems, and those containing microbial pathogens (known as bioaerosols) are recognized as contributors to infection spread within buildings. When a defect occurs in the sanitary plumbing system that affects the system integrity, a cross-transmission route is created that can enable the emission of bioaerosols from the system into the building. These emission occurrences are characterized as short-burst events (typically <1 min in duration) which make them difficult to detect and predict. The characterization of these emission events is the focus of this research. Two methods were used to characterize bioaerosol emission events in a full-scale test rig: (a) an Aerodynamic Particle Sizer (APS) for particle size distribution and concentrations; and (b) a slit-to-agar sampler to enumerate the ingress of a viable tracer microorganism (Pseudomonas putida). The APS data confirmed that most particles (>99.5%) were <5 µm and were therefore considered aerosols. Particles generated within the sanitary plumbing system as a result of a toilet flush leads to emissions into the building during system defect conditions with an equivalence of someone talking loudly for over 6 and a half minutes. There were no particles detected of a size >11 µm anywhere in the system. Particle count was influenced by toilet flush volume, but it was not possible to determine if there was any direct influence from airflow rate since both particle and biological data showed no correlation with upward airflow rates and velocities. Typical emissions resulting from a 6 L toilet flush were in the range of 280-400 particles per second at a concentration of typically 9-12 number per cm3 and a total particle count in the region of 3000 to 4000 particles, whereas the peak emissions from a 1.2 L toilet flush were 60-80 particles per second at a concentration of 2.4-3 number per cm3 and a total particle count in the region of 886 to 1045 particles. The reduction in particles is in direct proportion to the reduction in toilet flush volume. The slit-to-agar sampler was able to provide viable time course CFU data and confirmed the origin of the particles to be the tracer microorganism flushed into the system. The time course data also have characteristics consistent with the unsteady nature of a toilet flush.

Women are more likely to expect social sanctions for open defecation: Evidence from Tamil Nadu India.

Social sanctions can be effective for sustaining beneficial norms by harnessing the power of social pressure and peer monitoring. Yet, field evidence regarding how norms might be linked to perceived risk of sanction is limited. In this study, we focused on communities located in peri-urban areas of Tamil Nadu, India, and examined how people's perceived prevalence of a socially desirable behavior (i.e., toilet use) relates to the perceived risk of sanctions for deviating from this behavior (i.e., open defecation) in the sanitation domain. Cross-sectional data from 2427 participants in 75 communities revealed that the majority (77%, n = 1861) perceived the risk of informal sanctions related to open defecation. Among those, verbal reprimand was the most common (60%), followed by advice (30%) and gossip (7%). Results from multilevel logistic regression indicated that those who believed toilet use was prevalent in their community were more likely to perceive the risk of social sanctions for open defecation. Moderation analysis revealed that this relationship was robust among women, but attenuated among men. Our findings suggest that women are more likely to expect social sanctions if they deviate from what is perceived as the prevalent sanitation behavior (e.g., toilet use) in their community. Open defecation practices are known to cause psychosocial stress among women due to their experiences with sanitation insecurity, which may include fear of disapproval from community members. Our results highlight the need for gendered intervention strategies when sanitation programs leverage social influence for behavior change.

Does sanitation infrastructure in rural areas affect migrant workers' health? Empirical evidence from China.

Health is considered the most important factor for individual well-being and a country's sustainable development. Among the influential factors of population health, sanitary infrastructure, particularly sanitary toilets and innocuous-sanitary toilets, have already attracted attention. In recent years, to improve the overall health status of rural residents, the Chinese government has promoted the "toilet revolution" in rural areas to update and modernize the facilities of toilets. Given that migrant workers contribute significantly to China's economic growth, and that the migrant workers generally lived in rural areas before they moved to urban areas to find jobs, it is of great interest and importance to investigate the impacts of sanitary infrastructure in rural areas on the migrant workers. This study analyzes the spatial characteristic of rural sanitation facilities' implementation and looks for possible correlation between the health status of migrant workers and the implementation of sanitation facilities in their hometowns. Micro-survey data of migrant workers' health status from China Household Income Projects (CHIP) 2013 and macro-data of provincial economic factors are matched to provide a quality analysis. The analysis of the spatial distribution shows that there were significantly large gaps between the prevalence rates of sanitary toilets in provinces. Furthermore, the regression analysis indicates that the implementation of sanitary toilets and innocuous-sanitary toilets exhibits a positive effect on the overall health status of migrant workers, although the effects of the innocuous-sanitary toilets are greater. Moreover, the positive influences of both types of toilets on population health are higher in the provinces with relatively greater annual precipitation and higher average temperature.

Molecular characterization and antimicrobial susceptibility of bacterial isolates present in tap water of public toilets.

BACKGROUND: The present study was carried out to investigate the tap water quality of public toilets in Amritsar, Punjab, India. METHODS: Water samples from the taps of the public toilets were collected in sterile containers and physicochemical and bacteriological analysis was performed using standard methods. Also, genotypic and phenotypic characterization of the bacterial isolates was performed using different biochemical tests and 16S ribosomal RNA analysis. An antibiotic susceptibility test was performed using antibiotics based on their mode of action. A biofilm assay was performed to assess the adhesion potential of the isolates. RESULTS: A total of 25 bacterial isolates were identified from the water samples, including Acinetobacter junii, Acinetobacter pittii, Acinetobacter haemolyticus, Bacillus pumilus, Bacillus megaterium, Bacillus marisflavi, Bacillus flexus, Bacillus oceanisediminis, Pseudomonas otitidis, Pseudomonas sp. RR013, Pseudomonas sp. RR021, Pseudomonas sp. RR022, Escherichia coli and Enterobacter cloacae. The results of the antimicrobial susceptibility test revealed that the antibiotics cefodroxil, aztreonam, nitrofurantoin, cefepime, ceftazidime and amoxyclav were found to be mostly ineffective against various isolates. The biofilm assay revealed the weak, moderate and strong biofilm producers among them. CONCLUSIONS: The tap water in the public toilets was microbially contaminated and needs to be monitored carefully. The antibiotic susceptibility profile showed that of 25 bacterial isolates, 5 were multidrug resistant. Bacterial isolates exhibited strong to weak adhesion potential in the biofilm assay.

Stunting and associated factors among under-five children in Wukro town, Tigray region, Ethiopia: a cross sectional study.

OBJECTIVE: The objective of the study was to assess the prevalence of stunting and associated factors among under-five children of Wukro town, Tigray, Ethiopia, 2017-2018. RESULT: Totally 394 under-five children were participated in this study with a response rate of 98.5%. A total of 222 (56.3%) of respondents were females and 106 (26.95%) were in the age group of 12-23 month. One hundred ninety-eight (50.3%) of the participants were between 2 and 3 in birth order and 194 (49.2%) had 4 to 5 house hold size. The overall prevalence of stunting was 194 (49.2%). Being female and presence of washing facilities nearby latrine were significantly associated with stunting. Under-five female children were 35.4% lower odds of stunting compared to male children (p = .041, OR = .644, and 95% CI (.422, .983)).

Availability of Public Toilets in Parks and Recreational Sites in Selected US Cities.

PURPOSE: The principal aim of this study was to map and describe the availability of parkland public toilets in major US cities per population and area. DESIGN: Observational and descriptive. SUBJECTS AND SETTING: Data were collected from the following cities: Austin, Texas; Minneapolis-St Paul (MSP), Minnesota; Nashville, Tennessee; New York City (NYC), New York; Philadelphia, Pennsylvania; San Francisco, California (SFC); Seattle, Washington; and Tampa, Florida. These cities are located throughout the United States. METHODS: Data from the US Census and cities' parks/recreation departments about publicly owned and operated permanent toilet facilities were analyzed and then mapped using geographic information systems. Toilet density by population and residential area (mi) was calculated, and toilet distribution was visualized. RESULTS: When calculated per 100,000 residents, MSP had the most parkland public toilets with 24; Tampa, Seattle, and Philadelphia had 17 to 22; and Nashville, NYC, and SFC had the fewest, around 7 toilets. Parkland public toilet density per residential area was highest in NYC and Philadelphia (>2/mi), followed by MSP, Seattle, and SFC (1/mi), then Tampa, Austin, and Nashville (<1/mi). The proportion of Census tracts containing parkland public toilets was more than 0.4 in MSP, Seattle, Tampa, and Philadelphia, more than 0.20 in Nashville and Austin, and less than 0.20 in the other cities. Toilet mapping showed fairly even distribution across Census tracts in MSP, Seattle, Tampa, and Philadelphia. CONCLUSIONS: Availability of parkland public toilets was highest in MSP and lowest in SFC. Findings inform WOC nurses for counseling incontinent patients about self-management strategies. Urban planning that provides an adequate number and distribution of parkland public toilets may improve quality of life.

Prospective study of bidet toilet use: Association of abnormal vaginal colonization and preterm birth in high-risk pregnant women.

AIM: This study aimed to evaluate the association of bidet toilet use with abnormal vaginal microbial colonization and preterm birth (PTB) in high-risk pregnancies. METHODS: This is a prospective cohort study of 208 women, who were admitted to a high-risk pregnancy unit, due to preterm labor, preterm premature rupture of the membrane, or short cervical length, in two tertiary hospitals from April 2015 to July 2017. Responses to a questionnaire about using bidet toilet and vaginal culture were obtained upon admission. Maternal baseline characteristics, vaginal culture results, and pregnancy and neonatal outcomes were compared between bidet toilet users and nonusers. RESULTS: Among the 204 subjects, 67 (32.8%) women were identified as bidet toilet users. Overall, bidet toilet use was associated with a higher rate of abnormal vaginal microbial colonization, compared to the nonusers (60.7% vs 44.2%, P = 0.036). Notably, Escherichia coli colonization rate was significantly higher in bidet toilet users than nonusers (13.1% vs 3.3%, P = 0.023). Bidet toilet users had a significantly higher rate of PTB before 37 weeks of gestation, compared to the nonusers (87.3% vs 73.0%, P = 0.040). CONCLUSION: Our study suggests that chronic use of a bidet toilet is associated with a higher rate of abnormal vaginal colonization by Gram-negative bacteria and PTB in high-risk pregnancies.

Can patients manage toileting after reverse total shoulder arthroplasty? A systematic review.

PURPOSE: A major concern for patients undergoing reverse total shoulder arthroplasty (RTSA) is managing toileting after surgery. The goals of this systematic review of RTSA studies were to determine the following: (1) the percentage of patients who can manage toileting, (2) their degree of difficulty with toileting, and (3) the percentage of patients who can manage toileting after bilateral versus unilateral RTSA. METHODS: Medline, EMBASE, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched for studies reporting the ability to manage toileting after RTSA. Six studies with at least 12 months of follow-up were included, yielding 183 patients (105 unilateral RTSA, 78 bilateral RTSA). We pooled patient data and calculated the weighted mean proportion of patients able to manage toileting, those who reported difficulty, and those able to manage toileting after unilateral versus bilateral RTSA. Statistical significance was set at P < 0.05. RESULTS: Most patients (92%; 95% confidence interval, 87-95%) were able to manage toileting after RTSA. Some degree of difficulty with toileting was reported for 20% of all shoulders. Almost all patients with bilateral RTSA were able to manage toileting with at least one arm (weighted mean proportion 97%; 95% confidence interval, 88-99%). There was no significant difference in the proportion of patients able to manage toileting after unilateral versus bilateral RTSA (P = 0.08). Only 3% of all papers published on the clinical results of RTSA by June 2017 reported upon toileting after the procedure. CONCLUSIONS: With the available evidence, most patients were able to manage toileting after RTSA, although one-fifth reported some degree of difficulty. Ability to manage toileting was similar after unilateral versus bilateral RTSA. In the future, this variable should be a standard question after shoulder arthroplasty. LEVEL OF EVIDENCE: IV.

High School Students' Experiences in School Toilets or Restrooms.

Previous research about school toilets is based on studies of children in elementary school. Thus, the aim of this study was to explore the experiences when using the school toilets reported by students aged 16-18 years. Qualitative interviews with 21 students were conducted and analyzed using content analysis. The data revealed that the toilets were considered insecure, dirty, and unpleasant. Additionally, students refrained from drinking during school hours and remained in constant movement or jumped up and down to withhold urine and stool. This was illustrated in the following categories: assessing the toilet environment, coping with the situation, and feeling exposed Hence, there is an urgent need to improve the school toilet environment in order to respect the rights of all students to void or defecate when necessary, a process which will require involvement of students, teachers, and other school staff as well as the School Health Service.