Toilet construction under the Swachh Bharat Mission and infant mortality in India.

Improvement of water and sanitation conditions may reduce infant mortality, particularly in countries like India where open defecation is highly prevalent. We conducted a quasi-experimental study to investigate the association between the Swachh Bharat Mission (SBM)-a national sanitation program initiated in 2014-and infant (IMR) and under five mortality rates (U5MR) in India. We analyzed data from thirty-five Indian states and 640 districts spanning 10 years (2011-2020), with IMR and U5MR per thousand live births as the outcomes. Our main exposure was the district-level annual percentage of households that received a constructed toilet under SBM. We mapped changes in IMR and U5MR and toilet access at the district level over time. We fit two-way fixed effects regression models controlling for sociodemographic, wealth, and healthcare-related confounders at the district-level to estimate the association between toilets constructed and child mortality. Toilet access and child mortality have a historically robust inverse association in India. Toilets constructed increased dramatically across India following the implementation of SBM in 2014. Results from panel data regression models show that districts with > 30% toilets constructed under SBM corresponds with 5.3 lower IMR (p < 0.05), and 6.8 lower U5MR (p < 0.05). Placebo, falsification tests and robustness checks support our main findings. The post-SBM period in India exhibited accelerated reductions in infant and child mortality compared to the pre-SBM years. Based on our regression estimates, the provision of toilets at-scale may have contributed to averting approximately 60,000-70,000 infant deaths annually. Our findings show that the implementation of transformative sanitation programs can deliver population health benefits in low- and middle-income countries.

Assessment of water, sanitation and hand hygiene practices in rural households of Tamil Nadu: A cross-sectional study.

Context: Water is a basic human right essential to all for sustainable development. Sanitation is one of the determinants of quality of life and the human development index. Drinking unsafe water impairs health through illnesses such as diarrhoea, and untreated excreta contaminates ground waters and surface waters used for drinking, bathing and household purposes. Aims: To assess the existing facilities and practices related to drinking water, sanitation, and hygiene among household members in the rural population of Tamil Nadu and to assess whether accessibility and availability of safe drinking water and adequate sanitation under sustainable development goal 6 is being achieved in the rural population of Tamil Nadu. Methodology: This community-based cross-sectional study was carried out among 200 households in the rural field practice area of the Medical College and Hospital, Thiruvallur district, Tamil Nadu. The participants were interviewed using a predesigned semi-structured questionnaire on their existing water, sanitation, and hand washing facilities and practices. Results: Our study observed that 71.5% of households had piped water supply into their dwellings, 82% were using sanitary latrines and 28% had closed drainage for draining wastewater. Twenty-eight percent were using soap and water for hand-washing before food, and 82.5% were doing hand-washing with soap after using the toilet. In our study, the association between sanitary practices and education, occupation and socioeconomic status was statistically significant. Conclusions: Our study emphasized the need for strengthening health education and behaviour change communication regarding sanitation and hand hygiene practices.

Psychological and socio-cultural factors affecting latrine ownership and usage in rural South India.

The levels of latrine utilization were lower than the levels of latrine ownership in rural areas owing to certain psycho-social barriers hindering latrine construction and consistent utilization. The study was aimed to identify the proportion of latrine construction and usage and to explore the psychological, socio-cultural and structural factors influencing latrine ownership and utilization. A community-based cross-sectional study was carried out at the four villages of Villupuram district for three months. After IEC clearance, information was collected from a representative sample of 422 households. Direct observation of the latrines was employed along with surveys. The data were entered and analysed in MS Excel. Categorical variables were expressed as frequencies and percentages. Further, the reasons were categorized into psychological, socio-cultural and structural factors. About 54.7% households owned a latrine and among them 46.8% were using it. Psycho-social factors such as convenience, habitual nature, privacy and space constraints in open defecation influenced latrine ownership. Fear of snakes and insects, safety and protection, time saving and proper functioning latrines with availability of water facilitated latrine utilization are of concern. A multi-faceted strategy employing context-specific behaviour change communication along with Government's financial support would improve both latrine construction and utilization.

Prevalence and factors associated with unmet need for menstrual hygiene management in six countries in Sub-Saharan Africa: A multilevel analysis.

BACKGROUND: Menstruation is a normal biological process experienced by more than 300 million women globally every day. Women require clean menstrual absorbents that can be changed as often as needed in a private and safe place with proper hygiene and disposal facilities. These needs must be met consistently throughout the duration of the menstrual cycle. Access to menstrual needs is crucial for women's health, wellbeing, and dignity. This study assessed the prevalence and factors associated with unmet need for menstrual hygiene management (MHM) in Ethiopia, Kenya, Uganda, Burkina Faso, Ghana, and Niger. METHODS: We used data from the Performance Monitoring for Action (PMA) 2020 surveys. We defined the unmet need for MHM as the "lackof resources, facilities and supplies for MHM." Sample characteristics were summarised using frequencies and percentages, while prevalence was summarised using proportions and their respective confidence intervals (CI). Factors associated with unmet need for MHM were assessed using multilevel logistic regression models. RESULTS: The study included 18,048 women of reproductive age from the six countries. The prevalence of unmet need for MHM was highest in Burkina Faso (74.8%), followed by Ethiopia (69.9%), Uganda (65.2%), Niger (57.8%), Kenya (53.5%), and lowest in Ghana (34.2%). Unmet need for MHM was consistently higher among uneducated and multiparous women, those who reused MHM materials, practiced open defecation, and lived in rural areas across all six countries. The odds of unmet need for MHM were higher among younger women under 35 years, unmarried women, those with lower education levels, and those from poorer households. Similarly, the reuse of MHM materials, use of shared or non-improved toilet facilities, and open defecation increased the odds of unmet need for MHM. In contrast, the presence of handwashing facilities reduced the odds of unmet need for MHM. CONCLUSION: More than half of the women in five of the six countries have an unmet need for MHM, with significantly higher odds among younger women, those with low wealth status, the unmarried, and those with inadequate access to sanitary facilities. This study highlights the state of period poverty in Sub-Saharan Africa. Efforts to end period poverty should consider MHM needs as an integrated whole, as addressing each need in isolation is insufficient.

Perception and Disposal Practices of Toddler Feces by Mothers in Suburban Area of Kendari, Indonesia.

Unsafe child feces disposal (CFD) is another form of open defecation and can pose a risk of disease in children. More than 30% of Indonesian households practice unsafe CFD, yet, its determinants are unknown. This study aims to identify the contextual and behavioral determinants of CFD through the lens of the Risk, Attitude, Norm, Ability, and Self-regulation (RANAS) framework. The cross-sectional study was conducted in 349 households in the suburbs of Kendari City, Southeast Sulawesi Province, Indonesia, in mid-2023. About 64% of the respondents practiced unsafe CFD. Most respondents used diapers that were immediately thrown into the trash without cleaning (i.e., 60.2%). Logistic regression analysis found two significant contextual factors associated with safe CFD: having received sanitation-related information and toddler age, i.e., children below 5 years old. Perceived severity was the most influential psychological factor behind the CFD practice, followed by knowledge. This study suggests that informing caregivers about the negative health effects of practicing unsafe CFD, especially on their children, can be a positive trigger for them to practice safe CFD. In addition, the promotion of early toilet initiation and recycling programs for used diaper waste should also be conducted to ensure comprehensive CFD management.

Fecal Sludge Management and Sanitation Safety: An Assessment in Addis Ababa, Ethiopia.

Background: Sanitation safety practices and risks associated with fecal sludge management are crucial for public health and the environment. This study assessed sanitation safety practices and risks in Addis Ababa, Ethiopia, at different stages of fecal sludge management. The research aimed to understand the current state of sanitation facilities, practices, and associated risks and identify areas for improvement. Materials and Methods: A mixed methods/approach was employed, utilizing household surveys, risk assessments, and sanitary inspections. A total of 384 study subjects were interviewed using face-to-face interviews and observations. Results: The findings revealed that the majority of households (97.7%) had consistent access to toilets, with flush/pour flush toilets being the most common type (47.4%). Factors such as odors in toilets or septic tanks, open defecation by children, and the use of untreated wastewater for food production were significantly associated with sociodemographic factors. Risk assessments indicated that 67% of households fell into the low-risk category, while 33% were classified as intermediate risk. The study identified non-compliance issues during sanitary inspections at transfer stations (45%), a wastewater treatment and disposal facility (61.5%), and in the management of wastewater and sludge in the sewer line (64%). These findings call for urgent actions to address improper feces disposal, inadequate maintenance of sanitation facilities, and unsafe practices in fecal sludge management. Conclusion: This study identified concerning issues in fecal sludge management, including improper feces disposal, inadequate facility maintenance, and non-compliance with safety standards during emptying, transport, treatment, and disposal. Urgent action is needed to address these risks. Promoting proper disposal techniques, improving facility maintenance, education programs, strengthening regulations, providing training and protective equipment, and investing in enhanced sanitation facilities and wastewater treatment methods are essential for improving sanitation safety practices.

Integrated Eco-Health approach significantly reduces helminth infections in endemic Khong islands with emphasis on Schistosoma mekongi.

BACKGROUND: Helminth infections, including Opisthorchis viverrini, hookworm, and Trichuris trichiura, are prevalent in Khong district, Champasack province, southern Lao People's Democratic Republic (PDR). Schistosomiasis caused by Schistosoma mekongi is of public health concern on the islands of the Khong district. This study aimed to assess the impact of an Eco-Health/One-Health approach in combination with mass drug administration (MDA) to reduce these helminth infections. METHODS: We conducted a community intervention using a stepped-wedge trial approach on two endemic islands (Donsom and Donkhone) of the Khong district, Champasack province, Lao PDR, between April 2012 and March 2013. In each study village, 30-40 households were randomly selected. All members of selected households, who were at home during the study period were invited to participate in the study. A baseline study was conducted to assess helminth infections, knowledge attitudes and practices toward Schistosoma mekongi infection, behavior of open defecation and availability of latrine at home. After the baseline (T0), the Eco-Health/One-Health approach was implemented on Donsom (intervention) and Donkhone island (control). An assessment was conducted in 2014 (T1), one year after the completion of intervention implementation, to assess the short-term impact of the Eco-Health/One-Health approach on helminth infections and compare intervention and control islands. Later in 2015, the Eco-Health/One-Health approach was implemented on control island (Donkhone). After the implementation of intervention, the parasitological assessments were conducted annually in humans in 2015 (T2), in 2016 (T3) and in 2017 (T4), and in dogs in 2017 (T4) to evaluate the long-term impact of the intervention on helminth infections. Frequency was used to describe the prevalence of helminth infections. Logistic regression was applied to associate the KAP (knowledge, attitudes, and practices and open defecation behavior) and the reduction of helminth infections between intervention and control islands. The reduction in prevalence pre- and post-intervention was associated using a McNemar test. A two-independent sample t-test was applied to compare the mean eggs per gram (EPG) of helminth infections between control and intervention islands. A paired t-test test was used to compare the mean EPG of stool samples before (baseline) and after (follow-up) interventions for the two islands separately. A P-value lower than 0.05 was considered statistically significant. RESULTS: Eco-Health/One-Health approach appears to be associated with reduction in prevalence of S. mekongi by 9.0% [odds ratio (OR) = 0.49, P = 0.003] compared to the use of mass drug administration alone (control island). Additionally, this intervention package significantly reduced O. viverrini infection by 20.3% (OR = 1.92, P < 0.001) and hookworm by 17.9% (OR = 0.71, P = 0.045), respectively. Annual parasitological assessments between 2012 and 2017 showed that the Eco-Health/One-Health approach, coupled with MDA, steadily reduced the prevalence of S. mekongi on the intervention island from 29.1% to 1.8% and on the control island from 28.4% to 3.1%, respectively. CONCLUSIONS: The study findings suggest that the Eco-Health/One-Health approach appears to be associated with a significant reduction in prevalence of S. mekongi and helminth co-infections, particularly hookworm and T. trichiura. Therefore, implementing the Eco-Health/One-Health approach in schistosomiasis-endemic areas could accelerate the achievement of national goals for transmission interruption by 2025 and elimination by 2030.

Knowledge, attitudes and practices toward female genital schistosomiasis among community women and healthcare professionals in Kimpese region, Democratic Republic of Congo.

BACKGROUND: Chronic infection with Schistosoma haematobium causes female genital schistosomiasis (FGS), which leads to diverse lesions in the female genital tract and several complications, including infertility and a higher risk for HIV transmission. This study aims to understand the knowledge, attitudes, and practices (KAP) toward FGS and associated factors among women and health professionals in the schistosomiasis endemic focus of Kimpese, western Democratic Republic of Congo (DRC). METHODS: In January 2022, two semi-quantitative questionnaires were administered to 201 randomly selected community women in Kifua II village, and to purposely selected health professionals (20 nurses and 41 doctors) from Kimpese Health Zone. KAP statements were coded using Likert scale, summarized as frequencies and percentages, and assessed for internal reliability using Cronbach's alpha. Associations between the socio-demographic characteristics of respondents and the KAP variables were assessed using Pearson chi-square (χ2) test, Cramer's V (φ) and gamma (γ) coefficients. RESULTS: Overall, respondents had high knowledge of schistosomiasis in general but low FGS-specific knowledge (91% versus 45%). Misconceptions concerned the disease transmission, with 30.3% of women and 25% of the nurses believing that FGS is transmitted by drinking untreated water, while 26.8% of the doctors mentioned sexual contact as a mode of FGS transmission. Negative attitudes included considering FGS not a very serious disease (34.8%), feeling uncomfortable during gynaecological examination (35.3%), difficulties avoiding risky water contact (72.1%) and open defecation/urination (41.3%), not intending to share FGS status with their husbands (38.3%) and loved ones (63.6%), and believing that husbands would leave them if they were infertile (31.8%). Regarding practices, 77.6% of women engaged daily in activities involving contact with water. Practices of health professionals were hampered by the lack of equipment and specialized knowledge for FGS diagnosis with only 57% of healthcare workers having a microscope in their facilities. Women's KAPs varied by age, education, marital status, occupation and monthly income. CONCLUSION: This study highlights insufficient knowledge, existing negative attitudes, at risk practices towards FGS by women, and limitations of FGS management by health professionals. These findings can help for tailored health education and WASH strategies, and call for health professional's capacities reinforcement.

Spatial variation and geographical weighted regression analysis to explore open defecation practice and its determinants among households in Ethiopia.

BACKGROUND: In Ethiopia, recent evidence revealed that over a quarter (27%) of households (HHs) defecated openly in bush or fields, which play a central role as the source of many water-borne infectious diseases, including cholera. Ethiopia is not on the best track to achieve the SDG of being open-defecation-free by 2030. Therefore, this study aimed to explore the spatial variation and geographical inequalities of open defecation (OD) among HHs in Ethiopia. METHODS: This was a country-wide community-based cross-sectional study among a weighted sample of 8663 HHs in Ethiopia. The global spatial autocorrelation was explored using the global Moran's-I, and the local spatial autocorrelation was presented by Anselin Local Moran's-I to evaluate the spatial patterns of OD practice in Ethiopia. Hot spot and cold spot areas of OD were detected using ArcGIS 10.8. The most likely high and low rates of clusters with OD were explored using SaTScan 10.1. Geographical weighted regression analysis (GWR) was fitted to explore the geographically varying coefficients of factors associated with OD. RESULTS: The prevalence of OD in Ethiopia was 27.10% (95% CI: 22.85-31.79). It was clustered across enumeration areas (Global Moran's I = 0.45, Z-score = 9.88, P-value ≤ 0.001). Anselin Local Moran's I analysis showed that there was high-high clustering of OD at Tigray, Afar, Northern Amhara, Somali, and Gambela regions, while low-low clustering of OD was observed at Addis Ababa, Dire-Dawa, Harari, SNNPR, and Southwest Oromia. Hotspot areas of OD were detected in the Tigray, Afar, eastern Amhara, Gambela, and Somali regions. Tigray, Afar, northern Amhara, eastern Oromia, and Somali regions were explored as having high rates of OD. The GWR model explained 75.20% of the geographical variation of OD among HHs in Ethiopia. It revealed that as the coefficients of being rural residents, female HH heads, having no educational attainment, having no radio, and being the poorest HHs increased, the prevalence of OD also increased. CONCLUSION: The prevalence of OD in Ethiopia was higher than the pooled prevalence in sub-Saharan Africa. Tigray, Afar, northern Amhara, eastern Oromia, and Somali regions had high rates of OD. Rural residents, being female HH heads, HHs with no educational attainment, HHs with no radio, and the poorest HHs were spatially varying determinants that affected OD. Therefore, the government of Ethiopia and stakeholders need to design interventions in hot spots and high-risk clusters. The program managers should plan interventions and strategies like encouraging health extension programs, which aid in facilitating basic sanitation facilities in rural areas and the poorest HHs, including female HHs, as well as community mobilization with awareness creation, especially for those who are uneducated and who do not have radios.

Prevalence of Plasmodium and Soil-Transmitted Helminth Coinfection and Associated Factors among Malaria-Suspected Patients Attending Shewa Robit Health Center, North-Central Ethiopia.

Plasmodium and soil-transmitted helminth (STH) coinfection is a major public health problem in developing countries. Its prevalence and associated factors are poorly addressed in the available research. Therefore, this study aimed to assess Plasmodium-STH coinfection prevalence and associated factors among malaria-suspected patients attending Shewa Robit Health Center, north-central Ethiopia. A cross-sectional study was conducted among 379 malaria-suspected patients attending Shewa Robit Health Center from April to May 2023. Stool and blood samples were collected from each participant. Plasmodium and STHs were detected from blood and stool samples by using blood film and the Kato-Katz method, respectively. Data were entered into Epi Info version 7 and analyzed by SPSS version 26. Descriptive statistics were used to compute Plasmodium-STH coinfection. Logistic regression was used to identify associated factors. Variables with a P-value <0.05 were considered statistically significant. Among the study participants, 27.9%, 20.3%, and 13.4% were positive for Plasmodium, STHs, and Plasmodium-STH coinfection, respectively. The prevalence of Plasmodium-Ascaris lumbricoides coinfection was high (7.6%). Unavailability of insecticide-treated bed nets (ITNs), improper use of ITNs, absence of indoor residual spraying, presence of stagnant water, and previous malaria infection were significantly associated (P <0.01) with Plasmodium infection. Being illiterate, using an unimproved latrine, having an untrimmed fingernail, and practicing open defecation were also significantly associated (P <0.03), with STH infection. Being male, illiterate, and living in rural areas were significantly associated (P <0.03) with Plasmodium-STH coinfection. The prevalence of Plasmodium-STH coinfection was high in malaria-endemic areas. Therefore, malaria-suspected cases should be checked for STH infection.

ß-Lactamase and Macrolide Resistance Gene Carriage in Escherichia coli Isolates Among Children Discharged From Inpatient Care in Western Kenya: A Cross-sectional Study.

Background: Antimicrobial resistance (AMR) is a global threat to infectious disease control, particularly among recently hospitalized children. We sought to determine the prevalence and mitigating factors of resistance in enteric Escherichia coli among children discharged from health facilities in western Kenya. Methods: Between June 2016 and November 2019, children aged 1 to 59 months were enrolled at the point of discharge from the hospital. E coli was isolated by microbiological culture from rectal swabs at baseline. ß-Lactamases and macrolide resistance-conferring genes were detected by polymerase chain reaction. A modified Poisson regression model was used to assess the predictors mph(A) and CTX-M-type extended-spectrum ß-lactamase (ESBL). Results: Of the 238 children whose E coli isolates were tested, 91 (38.2%) and 109 (45.8%) had detectable CTX-M-type ESBL and mph(A) genes, respectively. Antibiotic treatment during hospitalization (adjusted prevalence ratio [aPR], 2.47; 95% CI, 1.12-5.43; P = .025), length of hospitalization (aPR, 1.42; 95% CI, 1.00-2.01; P = .052), and the practice of open defecation (aPR, 2.47; 95% CI, 1.40-4.36; P = .002) were independent predictors for CTX-M-type ESBL and mph(A) genes. Pneumococcal vaccination was associated with a 43% lower likelihood of CTX-M-type ESBL (aPR, 0.57; 95% CI, .38-.85; P = .005), while measles vaccination was associated with a 32% lower likelihood of mph(A) genes (aPR, 0.68; 95% CI, .49-.93; P = .017) in E coli isolates. Conclusions: Among children discharged from the hospital, history of vaccination, shorter hospital stay, lack of in-hospital antibiotic exposure, and improved sanitation were associated with a lower likelihood of AMR genes. To mitigate the continued spread of AMR, AMR control programs should consider strategies beyond antimicrobial stewardship, including improvements in sanitation, increased vaccine coverage, and the development of novel vaccines.

Childhood undernutrition mediates the relationship between open defecation with anemia among Ethiopian children: a nationally representative cross-sectional study.

BACKGROUND: Poor sanitation and/or open defecation are a significant public health problem in Ethiopia, where access to improved sanitation facilities is still limited. There is a growing body of literature about the effect of open defecation on children's linear growth failure. However, very few studies about the effects of open defecation on child anemia exist. In this study, we examine whether childhood undernutrition (i.e. stunting, wasting, and underweight) mediates the relationship between open defecation and childhood anemia in children aged 6-59 months in Ethiopia. METHODS: We used pooled Ethiopia Demographic and Health Survey data (2005-2016) comprising 21,918 (weighted data) children aged 6-59 months. Anemia was defined as an altitude-adjusted hemoglobin (Hb) level of less than 11 g/deciliter (g/dl) for children under 5 years. Childhood undernutrition was assessed using height-for-age Z-scores (HAZ), weight-for-age Z-scores (WAZ), and weight-for-height Z-scores (WHZ) for stunting, wasting, and underweight respectively. Mediation effects were calculated using the bootstrap and the indirect effect was considered significant when the 95% bootstrap confidence intervals (95% CI) did not contain zero. Moreover, separate multilevel regression analyses were used to explore the statistical association between open defecation and child anemia, after adjusting for potential confounders. RESULTS: Our analysis revealed that nearly half (49.6%) of children aged 6 to 59 months were anemic, 46.8% were stunted, 9.9% were wasted, and 29.5% were underweight. Additionally, 45.1% of children belonged to households that practiced open defecation (OD). Open defecation was associated with anemia (AOR: 1.28; 95% CI: 1.18-1.39) and it positively predicted anemia with direct effect of ß = 0.233, p < 0.001. Childhood undernutrition showed a partial mediating role in the relationship between OD and anemia. Analyzing the indirect effects, results revealed that child undernutrition significantly mediated the relationship between open defecation and anemia (stunting (ßindirect = 0.014, p < 0.001), wasting (ßindirect = 0.009, p = 0.002), and underweight (ßindirect = 0.012, p < 0.001)). When the mediating role of child undernutrition was accounted for, open defecation had a positive impact on anemia with a total effect of ßtotal = 0.285, p < 0.001. CONCLUSION: Open defecation showed a significant direct effect on anemia. Child undernutrition remarkably mediated the relationship between OD and anemia that further magnified the effect. This finding has an important programmatic implication calling for strengthened, accelerated and large-scale implementation of strategies to end open defecation and achieve universal access to sanitation in Ethiopia.

Water, sanitation and hygiene insecurity predict abscess incidence among people who inject drugs in a binational US-Mexico metropolitan area: A longitudinal cohort study.

INTRODUCTION: People who inject drugs (PWID) are at high risk of developing injection-related infections, including abscesses. Access to water, sanitation, and hygiene (WASH) are key human rights and services; yet these services have been underexplored as predictors of abscesses among PWID. METHODS: Longitudinal analysis was employed among a cohort of PWID to determine if WASH insecurity (lack of access) was associated with abscess incidence in the Tijuana, Mexico and San Diego, United States metropolitan area during 24-months of follow-up survey data from 2020 to 2023. We calculated abscess prevalence at baseline and tracked the incidence of new abscesses among individuals without an abscess during the previous visit. Time dependent Cox regression modeling was employed with variance clustered by participant to characterize the relationship between WASH insecurity and abscess incidence. RESULTS: At baseline, hand hygiene insecurity, bathing insecurity in the previous six months and open defecation in the last week, were reported by 60 %, 54 % and 38 % of participants, respectively; 21 % reported an abscess in the last six months. The incidence of abscesses was 24.4 (95 %CI: 21.1-27.6) per 100 person-years. After adjusting for covariates, the hazard of developing an abscess remained significantly elevated among individuals using non-improved (with risk of contamination) water sources (e.g., surface water) for preparing drugs (adjusted HR [adjHR]: 1.49 [95 %CI: 1.01-2.21], experiencing bathing insecurity (adjHR: 1.59 [95 %CI: 1.12-2.24]) and open defecation (adjHR: 1.65 [95 %CI: 1.16-2.35]). CONCLUSIONS: PWID in the Tijuana-San Diego metropolitan area reported facing high rates of insecurity accessing WASH services. Abscess incidence was higher (four to nine times) than observed rate among PWID cohorts in other settings. Access to continuously available toilet facilities, bathing infrastructure, and safe water sources for preparing drugs for injection could prevent abscesses among PWID. Accessible WASH infrastructure should be ensured among PWID communities and promoted as a key component of harm reduction infrastructure.

Mapping and predicting open defecation in Ethiopia: 2021 PMA-ET study.

INTRODUCTION: There has been extensive research conducted on open defecation in Ethiopia, but a notable gap persists in comprehensively understanding the spatial variation and predictors at the household level. This study utilizes data from the 2021 Performance Monitoring for Action Ethiopia (PMA-ET) to address this gap by identifying hotspots and predictors of open defecation. Employing geographically weighted regression analysis, it goes beyond traditional models to account for spatial heterogeneity, offering a nuanced understanding of geographical variations in open defecation prevalence and its determinants. This research pinpoints hotspot areas and significant predictors, aiding policymakers and practitioners in tailoring interventions effectively. It not only fills the knowledge gap in Ethiopia but also informs global sanitation initiatives. METHODS: The study comprised a total weighted sample of 24,747 household participants. ArcGIS version 10.7 and SaT Scan version 9.6 were used to handle mapping, hotspots, ordinary least squares, Bernoulli model analysis, and Spatial regression. Bernoulli-based model was used to analyze the purely spatial cluster detection of open defecation at the household level in Ethiopia. Ordinary Least Square (OLS) analysis and geographically weighted regression analysis were employed to assess the association between an open defecation and explanatory variables. RESULTS: The spatial distribution of open defecation at the household level exhibited clustering (global Moran's I index value of 4.540385, coupled with a p-value of less than 0.001), with significant hotspots identified in Amhara, Afar, Harari, and parts of Dire Dawa. Spatial analysis using Kuldorff's Scan identified six clusters, with four showing statistical significance (P-value < 0.05) in Amhara, Afar, Harari, Tigray, and southwest Ethiopia. In the geographically weighted regression model, being male [coefficient = 0.87, P-value < 0.05] and having no media exposure (not watching TV or listening to the radio) [coefficient = 0.47, P-value < 0.05] emerged as statistically significant predictors of household-level open defecation in Ethiopia. CONCLUSION: The study revealed that open defecation at the household level in Ethiopia varies across the regions, with significant hotspots identified in Amhara, Afar, Harari, and parts of Dire Dawa. Geographically weighted regression analysis highlights male participants lacking media exposure as substantial predictors of open defecation. Targeted interventions in Ethiopia should improve media exposure among males in hotspot regions, tailored sanitation programs, and region-specific awareness campaigns. Collaboration with local communities is crucial.

Examining toilet use and menstrual hygiene practices among beneficiary households of Swachh Bharat Abhiyaan (Clean India Mission) in rural areas of Mayurbhanj district of Odisha, India.

Background: Basic sanitation and waste management have always remained a central issue in India. The country launched its flagship sanitation program - Swachh Bharat Abhiyan (SBA) (Clean India Mission) in 2014 to abolish open defecation and achieve universal sanitation coverage. Objective: This study aimed to examine barriers to toilet use and women's menstrual hygiene practices in relation to the availability of toilets among rural residents. Materials and Methods: Using a cross-sectional design and multi-stage sampling method, 120 households were selected from rural villages of the Mayurbhanj district of Odisha. Structured questionnaires and direct observation methods were used for data collection. Results: All the houses had SBA latrines, yet 25% population defecated outside. About 40% households reportedly never cleaned their toilets. Most menstruating women (86.2%) preferred to change their menstrual pads/cloths in their bedroom instead of bathrooms. Incomplete construction was reported as the major reason for not using toilets. Large family size and low caste were found to be other predictors of non-use of toilets. Rural women did not use toilets for menstrual purposes as they do not consider these places as clean and safe. Conclusion: This study clearly suggests that constructing toilets without adequate behaviour change interventions would not solve the problem of hygiene and sanitation in India, particularly in rural areas. There must be adequate monitoring of SBA scheme and utilization of funds for toilet usage. Development and implementation of suitable behaviour change strategies for toilet use in rural areas are essential to achieve the goal of open defaecation-free India.

Prevalence of Open Defecation Practice and Associated Factors Among Households in Geshiyaro Project Implementation Sites in Ethiopia: A Cross-Sectional Study.

Background: Open defecation is a significant global challenge, impacting public health, environmental sanitation, and social well-being, especially in low- and middle-income countries like Ethiopia. It is the second-largest cause of disease burden worldwide by facilitating the spread of germs that cause diarrhea diseases. Studies examining open defecation practices are insufficient, especially in areas implementing Ethiopia's Geshiyaro project. Therefore, this study aimed to assess the status of open defecation practice and associated factors in the study area. Method: A community-based cross-sectional study was conducted from June to July 2023. The total number of households included in this study was 7995. A structured questionnaire and observational checklist were used to collect data. Descriptive and multivariate logistic regression analyses were performed using STATA version 16. Results: The study found that 16.5% of households practiced open defecation. The following factors were significantly associated with the occurrence of open defecation: residence (AOR = 1.56, 95% CI: 1.26-1.92), education (AOR = 0.59, 95% CI: 0.49-0.72), age (AOR = 0.53, 95% CI: 0.41-0.69), knowledge on diarrhea prevention (AOR = 1.32, 95% CI: 1.17-1.50), marital status (AOR = 1.61, 95% CI: 1.32-1.97), and awareness creation about WASH services (AOR = 1.96, 95% CI: 1.71-2.25). On the other hand, no significant association was observed between the occurrence of open defecation and the household's income (AOR = 1.07, 95% CI: 0.93-1.23) or the head of household sex (AOR = 0.94, 95% CI: 0.78-1.12). Conclusion: Open defecation remains a critical public health concern in Ethiopia's Geshiyaro project sites. Various factors influencing this practice have been identified. Targeted interventions are needed to enhance access to safe sanitation facilities and promote awareness of WASH services, aligning with SDG 3 target 3, and SDG 6 target 2.

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

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

Deworming and micronutrient status by community open defecation prevalence: An observational study using nationally representative data from India, 2016-2018.

BACKGROUND: Micronutrient deficiencies are widespread in India. Soil-transmitted helminth (STH) infections are acquired by interaction with soil and water contaminated by human feces and lead to blood loss and poor micronutrient absorption. The current recommendation for control of STH-related morbidity is targeted deworming, yet little is known about the effectiveness of deworming on micronutrient status in varying sanitation contexts. Ranging between 1% and 40% prevalence across Indian states, open defecation (OD) remains high despite India's investments at elimination by promoting community-wide sanitation. This variation provides an opportunity to study the relationship between deworming, micronutrient status, and OD at-scale. METHODS AND FINDINGS: Cross-sectional datasets that were representative for India were obtained the Comprehensive National Nutrition Survey in 2016 to 2018 (n = 105,060 individuals aged 1 to 19 years). Consumption of deworming medication was described by age and community OD level. Logistic regression models were used to examine the relationship between deworming, cluster OD, and their interactions, with anemia and micronutrient deficiencies (iron, zinc, vitamin A, folate, and vitamin B12), controlling for age, sex, wealth, diet, and seasonality. These regression models further allowed us to identify a minimum OD rate after which deworming becomes ineffective. In sensitivity analyses, the association between deworming and deficiencies were tested in subsamples of communities classified into 3 OD levels based on statistical tertiles: OD free (0% of households in the community practicing OD), moderate OD (>0% and <30%), or high OD (at least 30%). Average deworming coverage and OD prevalence in the sample were 43.4% [IQR 26.0, 59.0] and 19.1% [IQR 0, 28.5], respectively. Controlling for other determinants of nutritional status, adolescents living in communities with higher OD levels had lower coverage of deworming and higher prevalence of anemia, zinc, vitamin A, and B12 deficiencies. Compared to those who were not dewormed, dewormed children and adolescents had lower odds of anemia (adjusted odds ratio 0.72, (95% CI [0.67, 0.78], p < 0.001) and deficiencies of iron 0.78, (95% CI [0.74, 0.82], p < 0.001) and folate 0.69, (95% CI [0.64,0.74], p<0.001)) in OD free communities. These protective effects remained significant for anemia but diminished for other micronutrient deficiencies in communities with moderate or high OD. Analysis of community OD indicated a threshold range of 30% to 60%, above which targeted deworming was no longer significantly associated with lower anemia, iron, and folate deficiency. The primary limitations of the study included potential for omitted variables bias and inability to capture longitudinal effects. CONCLUSIONS: Moderate to high rates of OD significantly modify the association between deworming and micronutrient status in India. Public health policy could involve sequencing interventions, with focus on improving deworming coverage in communities that have achieved minimum thresholds of OD and re- triggering sanitation interventions in high OD communities prior to deworming days, ensuring high coverage for both. The efficacy of micronutrient supplementation as a complementary strategy to improve nutritional outcomes alongside deworming and OD elimination in this age group needs further study.

Open defecation practice among households with latrines in rural communities of Ararso District, Somali Region, Eastern Ethiopia.

Background: Open defecation contributes to the spread of different feco-oral diseases. Therefore, access to a latrine is strongly recommended, as it considerably reduces the risks. Even though provision of latrine facilities alone does not guarantee the desired health benefits, they should be integrated with behavior change. In Ethiopia, efforts have been made to increase the coverage of latrine facilities. However, evidence on how consistently households use it is limited. Most prior studies focused on latrine utilization among households, and limited evidence is available about open defecation practices among households with latrines and associated factors. Thus, this study is critical for developing effective intervention approaches to prevent open defecation among households with latrines. Objective: The aim of this study was to assess the open defecation practice and associated factors among households with latrines in rural communities of Ararso District, Somali Region, Eastern Ethiopia, 2023. Method: A community-based, cross-sectional study design was employed among households with latrines in the district. A total of 632 households latrines were selected using a systematic sampling technique. Data were collected using a structured questionnaire and an observational checklist. The questionnaire was designed in KoboTool box, Humanitarian Response software, and the data were collected using the Kobo Collect version 2023.2.4 mobile application. The data were downloaded from the server in the Microsoft Excel format for data cleaning before being exported to STATA version 14 for analysis. Bivariate and multivariable analyses were employed to investigate the relationship between outcome and independent variables. Odd ratios with 95% confidence intervals were utilized to assess the association between the outcome and the predictor variables. A P-value of <0.05 was used as the threshold point for statistical significance. Result: In this study, the prevalence of open defecation practice among households with latrines was 32.4% (95% CI: 28.1, 35.9). Sex of the household (AOR = 1.60, 95% CI: 1.06, 2.4), educational status (AOR = 2.40, 95% CI: 1.08, 5.53), family size (AOR = 1.62, 95% CI: 1.22, 2.78), the presence of under-5-year-old children in the house (AOR = 1.84, 95% CI: 1.19, 2.75), the need for latrine maintenance (AOR = 2.37.95% CI: 1.62, 3.48), current status of the latrine (AOR = 2.37, 95% CI: 1.62, 3.48), and latrine cleanness status (being unclean) (AOR = 1.91, 95% CI: 1.29, 2.81) were significantly associated with open defecation practice among households with latrine. Conclusion: The study concluded that open defecation was significantly practiced by households with latrines. This revealed that the presence of a latrine alone was insufficient to considerably reduce open defecation. To alleviate this problem, the government and health workers, in collaboration with the health bureau, should promote frequent sanitation and hygiene education in the communities.