Determinants of Willingness to Pay for Fecal Sludge Management Services and Knowledge Gaps: A Scoping Review.

Achieving universal access to safely managed sanitation services is one of the Sustainable Development Goal 6 targets (SDG6.2). The cost and availability of services to ensure the safe management of on-site sanitation, such as pit latrines and septic tanks, can be major barriers for poor households. Particularly, fecal sludge emptying services have become increasingly important due to the growing urban population. This review aims to scope the literature on stated and revealed willingness to pay (WTP) for emptying on-site sanitation systems and to identify determinants of WTP and gaps in knowledge. We performed electronic searches of six databases. After deduplication, 1846 records were identified, of which 14 were included in the review. In these studies, we identified 26 distinct scenarios that reported mean or median WTP values for emptying services and their market price (i.e., price at which the services were provided). Among the 26 scenarios, 77% (n = 20) reported that WTP was lower than the market price. We identified 20 statistically significant determinants of WTP, which can be leveraged when developing or improving manual and mechanical emptying services to attract more customers. Future research should consider services that adopt flexible pricing or mobile money payment and optimize their emptying operations to increase WTP. Validating the effectiveness of such services in solving the WTP-market price imbalance is a significant knowledge gap.

Household-level water, sanitation and hygiene factors and interventions and the prevention of relapse after severe acute malnutrition recovery: A systematic review.

Severe acute malnutrition (SAM) is the most serious form of acute malnutrition and is associated with high mortality risk among children under 5. While the Community-based Management of Acute Malnutrition (CMAM) approach, recommended for treating cases of uncomplicated SAM, has increased treatment coverage and recovery outcomes, high relapse rates have been reported. Several risk factors for SAM relapse, such as insufficient food intake and high infectious disease burden in the community, have been identified. However, the role of household water, sanitation and hygiene (WASH) conditions remains unclear. This systematic review: (1) assesses the effectiveness of WASH interventions on preventing SAM relapse and (2) identifies WASH-related conditions associated with relapse to SAM among children aged 6-59 months discharged as recovered following SAM CMAM treatment. We performed electronic searches of six databases to identify relevant studies published between 1 January 2000 and 6 November 2023 and assessed their quality. After deduplication, 10,294 documents were screened by title and abstract, with 13 retrieved for full-text screening. We included three studies ranging from low- to medium-quality. One intervention study found that providing a WASH kit during SAM outpatient treatment did not reduce the risk of relapse to SAM. Two observational studies found inconsistent associations between household WASH conditions-unimproved sanitation and unsafe drinking water-and SAM relapse. Despite the paucity of evidence, the hypothesised causal pathways between WASH conditions and the risk of relapse remain plausible. Further evidence is needed to identify interventions for an integrated postdischarge approach to prevent relapse.

How Much Will Safe Sanitation for all Cost? Evidence from Five Cities.

Global sustainable development goals call for universal access to safely managed sanitation by 2030. Here, we demonstrate methods to estimate the financial requirements for meeting this commitment in urban settings of low-income countries. Our methods considered two financial requirements: (i) the subsidies needed to bridge the gap between the willingness-to-pay of low-income households and actual market prices of toilets and emptying services and (ii) the amounts needed to expand the municipal waste management infrastructure for unserved populations. We applied our methods in five cities- Kisumu, Malindi, Nakuru in Kenya; Kumasi in Ghana; and Rangpur in Bangladesh and compared three to five sanitation approaches in each city. We collected detailed cost data on the sanitation infrastructure, products, and services from 76 key informants across the five cities, and we surveyed a total of 2381 low-income households to estimate willingness-to-pay. We found that the total financial requirements for achieving universal sanitation in the next 10 years and their breakdown between household subsidies and municipal infrastructure varied greatly between sanitation approaches. Across our study cities, sewerage was the costliest approach (total financial requirements of 16-24 USD/person/year), followed by container-based sanitation (10-17 USD/person/year), onsite sanitation (2-14 USD/person/year), and mini-sewers connecting several toilets to communal septic tanks (3-5 USD/person/year). Further applications of our methods can guide sanitation planning in other cities.

The impact of community based interventions for the prevention and control of soil-transmitted helminths: A systematic review and meta-analysis.

Soil-transmitted helminths (STHs) are among the most common human infections worldwide and a major cause of morbidity. They are caused by different species of parasitic worms and transmitted by eggs released in faeces or when hookworm larvae penetrate the skin. The main control strategy in endemic regions is periodic treatment with deworming medication. In the last 10 years, there has been a scale-up of prevention and control activities with a focus on community-based interventions (CBIs). This review aims to systematically analyse the impact of CBIs on the prevalence and infection intensity of STHs. A systematic review was published on this topic in 2014, but there have subsequently been several new studies published which are included in this review. Electronic database search of MEDLINE (Ovid), Global Health Online (Ovid), Cochrane Library, Embase (Ovid) and Web of Science was conducted. Titles, abstracts, and full texts were screened by two independent reviewers according to predefined eligibility criteria. Data were extracted and a meta-analysis of included studies was conducted. A total of 11,954 de-duplicated titles were screened, and 33 studies were included in the review. 14 focussed on community-wide treatment, 11 studies investigated school-based interventions, and 3 studies investigating both. Results suggest that CBIs are effective in reducing the prevalence of Hookworm, Trichuris trichiura and Ascaris lumbricoides. School-based treatment and community-wide treatment, as well as annual and semi-annual deworming, all reduce STH prevalence significantly. Mass drug administration was effective in reducing the infection intensity of Hookworm (Mean difference: -211.36 [95% CI: -519.12, 96.39]), Trichuris trichiura (-736.69 [-1349.97, -123.42]) and Ascaris lumbricoides (-2723.34 [-5014.85, -431.84]). The results suggest that CBIs are effective in reducing the prevalence and intensity of STH infections. While most studies delivered preventive chemotherapy (PC), few studies explored the impact of interventions such as water, sanitation, and hygiene (WASH) or health education, which may be essential in preventing reinfection after PC.

Inclusion of persons living with disabilities in a district-wide sanitation programme: A cross-sectional study in rural Malawi.

Community-led total sanitation (CLTS) is embraced as a key strategy to achieve universal sanitation coverage (Sustainable Development Goal 6.2). Although inclusion is identified as a predictor of CLTS success, people living with disabilities are often excluded from community sanitation programmes and there is limited research exploring CLTS participation amongst people living with disabilities. This study aims to explore the extent to which people living with disabilities participated in a CLTS intervention delivered in rural Malawi using standard approaches. This cross-sectional study was conducted in the Chiradzulu district of Malawi. A household questionnaire was administered to collect information about CLTS participation. Multivariable logistic regression was performed to compare participation in different CLTS activities between households with (n = 80) and without a member with a disability (n = 167), and between household members with (n = 55) and without a disability (n = 226). No difference in CLTS participation was observed at the household-level, but there were marked differences in CLTS participation between household members with and without a disability. Household members without a disability felt they could give more input in triggering activities (OR = 3.72, 95%CI 1.18-11.73), and reported higher participation in the transect walk (OR = 4.03, 95%CI 1.45-11.18), community action planning (OR = 2.89, 95%CI 1.36-6.13), and follow-up visits (OR = 3.37, 95%CI 1.78-6.40) compared to household members with disabilities. There was no difference in the likelihood of being invited to triggering (OR = 0.98, 95%CI 0.41-2.36), attending triggering (OR = 2.09, 95%CI 0.98-4.46), or participating in community mapping (OR = 2.38, 95%CI 0.71-7.98) between household members with and without a disability. This study revealed intra-household inequalities in CLTS participation. To improve participation in CLTS interventions, facilitators should be trained on action steps to make CLTS more inclusive. Further research could include an in-depth analysis of predictors of CLTS participation amongst people living with disabilities, including disability types, severity and age.

Recommendations for hand hygiene in community settings: a scoping review of current international guidelines.

BACKGROUND: Hand hygiene is an important measure to prevent disease transmission. OBJECTIVE: To summarise current international guideline recommendations for hand hygiene in community settings and to assess to what extent they are consistent and evidence based. ELIGIBILITY CRITERIA: We included international guidelines with one or more recommendations on hand hygiene in community settings-categorised as domestic, public or institutional-published by international organisations, in English or French, between 1 January 1990 and 15 November 2021. DATA SOURCES: To identify relevant guidelines, we searched the WHO Institutional Repository for Information Sharing Database, Google, websites of international organisations, and contacted expert organisations and individuals. CHARTING METHODS: Recommendations were mapped to four areas related to hand hygiene: (1) effective hand hygiene; (2) minimum requirements; (3) behaviour change and (4) government measures. Recommendations were assessed for consistency, concordance and whether supported by evidence. RESULTS: We identified 51 guidelines containing 923 recommendations published between 1999 and 2021 by multilateral agencies and international non-governmental organisations. Handwashing with soap is consistently recommended as the preferred method for hand hygiene across all community settings. Most guidelines specifically recommend handwashing with plain soap and running water for at least 20 s; single-use paper towels for hand drying; and alcohol-based hand rub (ABHR) as a complement or alternative to handwashing. There are inconsistent and discordant recommendations for water quality for handwashing, affordable and effective alternatives to soap and ABHR, and the design of handwashing stations. There are gaps in recommendations on soap and water quantity, behaviour change approaches and government measures required for effective hand hygiene. Less than 10% of recommendations are supported by any cited evidence. CONCLUSION: While current international guidelines consistently recommend handwashing with soap across community settings, there remain gaps in recommendations where clear evidence-based guidance might support more effective policy and investment.

Will Households Invest in Safe Sanitation? Results from an Experimental Demand Trial in Nakuru, Kenya.

Unsafe sanitation is an increasing public health concern for rapidly expanding cities in low-income countries. Understanding household demand for improved sanitation infrastructure is critical for planning effective sanitation investments. In this study, we compared the stated and revealed willingness to pay (WTP) for high-quality, pour-flush latrines among households in low-income areas in the city of Nakuru, Kenya. We found that stated WTP for high-quality, pour-flush latrines was much lower than market prices: less than 5% of households were willing to pay the full costs, which we estimated between 87,100-82,900 Kenyan Shillings (KES), or 871-829 USD. In addition, we found large discrepancies between stated and revealed WTP. For example, 90% of households stated that they would be willing to pay a discounted amount of 10,000 KES (100 USD) for a high-quality, pour-flush latrine, but only 10% of households redeemed vouchers at this price point (paid via six installment payments). Households reported that financial constraints (i.e., lack of cash, other spending priorities) were the main barriers to voucher redemption, even at highly discounted prices. Our results emphasize the importance of financial interventions that address the sizable gaps between the costs of sanitation products and customer demand among low-income populations.

When pits fill up: Supply and demand for safe pit-emptying services in Kisumu, Kenya.

Improving sanitation conditions in low-income communities is a major challenge for rapidly growing cities of the developing world. The expenses and logistical difficulties of extending sewerage infrastructure have focused increasing attention on the requirements for safe and cost-effective fecal sludge management services. These services, which are primarily provided by the private sector, include the collection and treatment of fecal waste from latrine pits and septic tanks. To determine the degree to which market forces can promote safe fecal sludge removal in low-income neighborhoods of Kisumu, Kenya, we compared household willingness-to-pay for formal pit emptying with the prices charged by service providers. Through surveys of 942 households and a real-money voucher trial with 646 households, we found that stated and revealed demand for formal emptying services were both low, with less than 20% of households willing to pay full market prices. Our results suggest that improving fecal sludge management in these neighborhoods via the private sector will require large subsides, ranging from 55.1-81.4 million KES (551,000-814,000 USD) annually, to address the gap between willingness-to-pay and market prices. Raising and administering subsidies of this scale will require the development of a city-wide sanitation master plan that includes investment, management, and regulatory procedures for fecal sludge management. In the absence of government investment and coordination, it is unlikely that the private sector will address safe sanitation needs in low-income areas of Kisumu.

Are Presence/Absence Microbial Tests Appropriate for Monitoring Large Urban Water Supplies in Sub-Saharan Africa?

Screening for fecal contamination via microbial water quality monitoring is a critical component of safe drinking water provision and public health protection. Achieving adequate levels of microbial water quality testing, however, is a challenge in resource-limited settings. One strategy for addressing this challenge is to improve the efficiency of monitoring programs. In African countries, quantitative microbial testing methods are commonly used to monitor chlorinated piped water systems. However, presence/absence (P/A) tests may provide an appropriate alternative for water supplies that generally show negative fecal contamination results. This study compares 1048 water quality test results for samples collected from five African urban water systems. The operators of the systems conducted parallel tests on the 1048 samples using their standard quantitative methods (e.g., most probable number or membrane filtration) and the Colitag™ method in P/A format. Combined data demonstrates agreement rates of 97.9% (1024/1046) for detecting total coliforms and 97.8% (1025/1048) for detecting E. coli. We conclude that the P/A test offers advantages as a simpler and similarly sensitive measure of potential fecal contamination for large, urban chlorinated water systems. P/A tests may also offer a cost-effective alternative to quantitative methods, as they are quicker to perform and require less laboratory equipment.