Rural Sanitation Sustainability Dynamics: Gaining Insight through Participatory and Simulation Modeling.

Improved sanitation provides many benefits to human health and well-being and is integral to achieving Sustainable Development Goal Six. However, many nations, including most of sub-Saharan Africa, are not on track to meeting sanitation targets. Recognizing the inherent complexity of environmental health, we used systems thinking to study sanitation sustainability in Uganda. Our study participants, 37 sanitation actors in three rural districts, were engaged in interviews, group model building workshops, and a survey. The resulting model was parametrized and calibrated using publicly available data and data collected through the Uganda Sanitation for Health Activity. Our simulations revealed slippage from improved sanitation in all study districts, a behavior reflected in real interventions. This implies that systemic changes-changes to the rules and relationships in the system-may be required to improve sanitation outcomes in this context. Adding reinforcing feedback targeting households' perceived value of sanitation yielded promising simulation results. We conclude with the following general recommendations for those designing sanitation policies or interventions: (1) conceptualize sanitation systems in terms of reinforcing and balancing feedback, (2) consider using participatory and simulation modeling to build confidence in these conceptual models, and (3) design many experiments (e.g., simulation scenarios) to test and improve understanding.

Promotion of market-based sanitation in Ethiopia: a case study from Wolaita zone.

Ethiopia increased the availability of latrines notably, but the sanitation facilities rarely meet hygienic standards. Therefore, the market-based sanitation (MBS) programme has been implemented across the country for nearly a decade to expand the market and boost the demand for hygienic sanitation products and services. While it does not seem that the MBS would bring any notable change in sanitation conditions so far, its implementation challenges are not adequately understood. To address this gap, this article delves into the grassroots-level implementation of MBS in the Wolaita zone. The study relies on qualitative data gathered through interviews with various stakeholders, examining both demand- and supply-side challenges. Some issues identified were external to MBS implementation, such as high inflation and an unstable political and security situation in Ethiopia. Additionally, the study reveals that more general deficiencies of the Ethiopian health extension program, including the stress and discouragement of local change agents (health extension workers, health development army members) due to workloads and low remuneration, have adversely impacted MBS delivery. The implementation of MBS has also not effectively addressed the affordability of hygienic sanitation products. On the supply side, economic constraints and organizational inefficiencies have hindered the development of the sanitation market, preventing it from reaching a critical mass. Our research suggests that MBS alone will not suffice to improve sanitation in Ethiopia.

Evaluation of SaTo pans as a new latrine technology in Kisumu County healthcare facilities, Kenya.

OBJECTIVES: Innovations to improve public sanitation facilities, especially in healthcare facilities (HCFs) in low-income countries, are limited. SaTo pans represent novel, largely untested, modifications to reduce odour and flies and improve acceptability of HCF sanitation facilities. We conducted a pilot project to evaluate acceptability, cleanliness, flies and odour within latrines in 37 HCFs in Kisumu, Kenya, randomised into intervention (SaTo pan modifications) and control arms by sub-county and HCF level. METHODS: At baseline (pre-intervention) and endline (>3 months after completion of SaTo pan installations in latrines in intervention HCFs), we surveyed users, cleaners and in-charges, observed odour and cleanliness, and assessed flies using fly tape. Unadjusted difference-in-difference analysis compared changes from baseline to endline in patient-reported acceptability and observed latrine conditions between intervention and control HCFs. A secondary assessment compared patient-reported acceptability following use of SaTo pan versus non-SaTo pan latrines within intervention HCFs. RESULTS: Patient-reported acceptability of latrines was higher following the intervention (baseline: 87%, endline: 96%, p = 0.05). However, patient-reported acceptability was also high in the control arm (79%, 86%, p = 0.34), and the between-arm difference-in-difference was not significant. Enumerator-observed odour declined in intervention latrines (32%-14%) compared with controls (36%-51%, difference-in-difference ratio: 0.32, 95% confidence interval: 0.12-0.84), but changes in flies, puddling of urine and visible faeces did not differ between arms. In the secondary assessment, fewer intervention than control latrines had patient-reported flies (0% vs. 26%) and odour (18% vs. 50%), and reported satisfaction was greater. Most cleaners reported dropholes and floors were easier to clean in intervention versus controls; limited challenges with water for flushing were reported. CONCLUSIONS: Our results suggest SaTo pans may be acceptable by cleaners and users and reduce odour in HCF sanitation facilities, though challenges exist and further evaluation with larger sample sizes is needed.

Do Sanitation Marketing Activities Increase Households' Likelihoods of Reaching Improved Sanitation or Involving Women in Decision Making?

Poor sanitation causes 30% of diarrheal deaths globally, and much of the world has struggled to finance top-down interventions. Sanitation marketing is a demand-led approach that uses a mixture of social and commercial marketing methods and direct sales to households. However, little is known about its impacts on household decision making. This mixed-methods study uses data from eight focus groups and 86,666 household surveys from participants in a five-year sanitation marketing program in Uganda. Logistic regression models identified 10 variables predicting attainment of improved (limited or basic) sanitation and four variables predicting female involvement in decision making. Triggering session attendance increased chances of reaching improved sanitation by 15-28%, depending on who attended, and by 19% if the household found the session motivational. Although women were engaged in decision-making conversations, they were not viewed as primary decision makers, even in female-headed households. Women were more likely to become involved in decision making if they had attended triggering sessions with men (+70%) or engaged with sales promoters alone (+74%) or with men (+78%). For both outcomes, joint activity engagement was more effective than male or female engagement alone. This work highlights two sanitation marketing activities as pathways to improving latrine coverage and women's decision-making agency.

Urban Sanitation: New Terminology for Globally Relevant Solutions?

Progress toward Sustainable Development Goals for global access to safe sanitation is lagging significantly. In this Feature, we propose that misleading terminology leads to errors of categorization and hinders progress toward sanitation service provision in urban areas. Binary classifications such as "offsite/onsite" and "sewered/nonsewered" do not capture the need for "transport to treatment" or the complexity of urban sanitation and should be discarded. "Fecal sludge management" is used only in the development context of low- or middle-income countries, implying separate solutions for "poor" or "southern" contexts, which is unhelpful. Terminology alone does not solve problems, but rather than using outdated or "special" terminology, we argue that a robust terminology that is globally relevant across low-, middle-, and upper-income contexts is required to overcome increasingly unhelpful assumptions and stereotypes. The use of accurate, technically robust vocabulary and definitions can improve decisions about management and selection of treatment, promote a circular economy, provide a basis for evidence-based science and technology research, and lead to critical shifts and transformations to set policy goals around truly safely managed sanitation. In this Feature, the three current modes of sanitation are defined, examples of misconceptions based on existing terminology are presented, and a new terminology for collection and conveyance is proposed: (I) fully road transported, (II) source-separated mixed transport, (III) mixed transport, and (IV) fully pipe transported.

Development of a behaviour change intervention to promote sanitation and latrine use in rural India.

BACKGROUND: Across developing countries poor sanitation is associated with disease often found widespread in rural populations. OBJECTIVES: This objective of this study was to conduct a formative research and feasibility evaluation of the behavioural intervention designed to improve latrine use in rural India. METHODS: Study conducted in four villages of Rajasthan, where latrine use is low and open defecation may spread disease. To identify the intervention a literature review was conducted, a survey of 497 households, and focus groups in village households (8-10 women and children). Seven focus groups with 63 women were conducted. Based on the survey results, the behaviour change intervention is developed utilising the Capability-Opportunity-Motivation-behaviour model and MINDSPACE framework. One intervention component involves psychological aspects that engage villagers through a pledge; the other component is provision of small incentives to facilitate latrine use. Feasibility and acceptability of the intervention was examined in the study population. The 30-day intervention was delivered to women in 38 randomly selected households who despite having a functional latrine did not use it. Thematic analysis, binary logistic regression analysis and feasibility evaluation of the intervention conducted. Post-intervention feedback from 22 participating households was obtained. RESULTS: The piloted intervention was feasible and so a revised design is offered. Results driving this evaluation include barriers identified, and used to improved intervention design in the current study. Village authority figures influenced behaviours across the villages and so did factors of convenience (ß = 5.28, p < 0.01), relief (ß = 5.49, p < 0.01), comfort (ß = 2.36, p < 0.01), Construction cost (ß=-1.98, p < 0.01) and safety (ß = 2.93, p < 0.01) were significant concerns associated with latrine use in the context of prevalent OD in the region. The logistic regression baseline model for the dependant variables indicated a significant increase in latrine use. Based on the feasibility study, the intervention is refined in several ways. CONCLUSIONS: Our theory-driven approach improves latrine use in Rajasthan and offers a useful tool to facilitate hygiene behaviour.

The effect of a health extension program on improving water, sanitation, and hygiene practices in rural Ethiopia.

BACKGROUND: To make basic primary health care services accessible, especially to the rural community, the government of Ethiopia launched the Health Extension Program (HEP) in 2004. Most of components of HEP are dedicated to hygiene and sanitation. Few studies have assessed the role of the Health Extension Program in improving water, hygiene, and sanitation (WASH) practices in Ethiopia. This study explored the role of health extension workers (HEWs) in influencing household water treatment practices, latrine ownership, latrine use and ownership, and the use of hand-washing facilities on the incidence of diarrheal diseases among the children under five years of age in rural Ethiopia. METHODS: Using a cross sectional design, we conducted a national assessment that covered all nine regions of Ethiopia. We conducted face-to-face interviews among a sample of 6430 rural households using a structured questionnaire and an observation checklist to collect data from March 2018 to May 2019. Multilevel logistic regressions models were used to determine the relationships between the exposure of households to HEWs and WASH practice outcomes such as the use of water from an improved water source, household water treatment practices, availability of hand-washing and hand-washing with soap and water, availability of latrines, and use of latrines as well as the incidence of diarrheal diseases among children age 5 and younger. Our models were adjusted for covariates and confounders and P-values less than 5% were set to determine statistical significance. RESULTS: We found that 72.7% of rural households had some type of latrine and 27.3% reported practicing open defecation. A total of 71.5% of rural households had access to drinking water from improved water sources, but only 9.4% reported practicing household water treatment. Exposure to HEWs was positively associated with household water treatment practices (AOR: 1.46; 95% CI = 1.01-2.10) and latrine availability (AOR: 1.44; 95% CI = 1.15-1.80). Among the households who were either visited by HEWs at their home or the that visited health posts to meet with the HEWs, being exposed to WASH health education by HEWs was significantly associated with the availability of a hand-washing facility (AOR: 5.14; 95% CI = 4.11-6.42) and latrine availability (AOR: 1.48; 95% CI = 1.10-2.01). However, we did not find a relationship between the incidence of diarrhea among children age 5 and under and exposure to HEWs (AOR: 2.09; 95% CI = 0.73- 6.62). CONCLUSION: Our results show a significant association between exposure to the Health Extension Program/ HEWs and improved household water treatment practices, latrine construction, and the availability of hand-washing facilities in rural Ethiopia, suggesting the need to strengthen efforts to change WASH behavior through the Heath Extension Program. On the other hand, further investigation is needed regarding the spillover effect of latrine use practices and the reduction of the incidence of diarrheal diseases.

Household-level sanitation in Ethiopia and its influencing factors: a systematic review.

BACKGROUND: Within the past two decades, Ethiopia has achieved one of the fastest reductions of open defecation worldwide. This change can be attributed to the implementation of a national sanitation strategy that focused on facilitating community demand for latrine adoption and use of basic self-constructed latrines but less on other preconditions of hygienic sanitation. Recognition of sanitation by policymakers also catalyzed primary research in this area. As such, the synthesis of the available evidence is both warranted and possible. In this article, we thus decided to assess available primary evidence on the household-level sanitation in Ethiopia and its influencing factors. METHODS: We searched primary studies that present findings on the role of factors influencing household-level sanitation outcomes in Ethiopia. We typologically classified sanitation outcomes analyzed in identified literature and computed pooled estimates for the most prevalent ones (measures of latrine availability and use). We characterized thematic types (themes and sub-themes) of influential sanitation drivers and used network analysis to examine the relational patterns between sanitation outcomes and their influencing factors. FINDINGS: We identified 37 studies that met our inclusion criteria-all but one published after 2009. The general latrine coverage pooled across 23 studies was 70% (95% CI: 62-77%), the share of improved latrines pooled across 15 studies was 55% (95% CI: 41-68%), and latrine use pooled across 22 studies was 72% (95% CI: 64-79%). Between-study heterogeneity was high, and no time trends were identified. The identified sanitation outcomes were classified into eight types and factors reported to influence these outcomes were classified into 11 broader themes and 43 more specific sub-themes. Factors around the quality of latrines represented the most frequent sub-theme of consequential drivers. We found that the available research focused predominantly on outcomes concerning the initial adoption and use of basic latrines, emulating the main focus of national sanitation strategy. By contrast, research on drivers of the sustainability of sanitation change and, in particular, on the upgrading of latrines, has been rare despite its urgency. There is a high need to redirect the focus of sanitation research in Ethiopia towards understanding these factors on both the demand and supply side.

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.

India's achievement towards sustainable Development Goal 6 (Ensure availability and sustainable management of water and sanitation for all) in the 2030 Agenda.

BACKGROUND: Clean water and sanitation are global public health issues. Safe drinking water and sanitation are essential, especially for children, to prevent acute and chronic illness death and sustain a healthy life. The UN General Assembly announced the 17 Sustainable Development Goals (SDGs) and 169 targets for the 2030 Agenda on 25 September 2015. SDG 6 is very important because it affects other SDG (1, 2,3,5,11,14 and 15). The present study deals with the national and state-wise analysis of the current status and to access deficiency of India's achievement towards SDG 6 (clean water and sanitation for all) for the 2030 agenda based on targets 6.1, 6.2,6.4,6.6 from 2012 to 2020. MATERIALS AND METHODS: Data of different indicators of SDG 6 are collected from different secondary sources-NSS 69th (2012) and 76th (2018) round; CGWB annual report 2016-2017 and 2018-2019; NARSS (2019-2020); SBM-Grameen (2020). To understand overall achievement towards SDG 6 in the 2030 agenda, the goal score (arithmetic mean of normalised value) has been calculated. MAJOR FINDINGS: According to NSS data, 88.7% of Indian households had enough drinking water from primary drinking water sources throughout the year, while 79.8% of households had access to toilet facilities in 2018. As per the 2019-2021 goal score for States and UTs in rural India based on SDG 6 indicator, SDG 6 achiever States and UTs (100%) are Sikkim, Himachal Pradesh, Andaman and Nicobar Islands. CONCLUSION: Drinking water and sanitation for all ensure a healthy life. It is a matter of concern for the government, policymakers, and people to improve the condition where the goal score and indicator value of SDG 6 are low.

Manual emptying of ventilated improved pit latrines and hygiene challenges - a baseline survey in a peri-urban community in KwaZulu-Natal, South Africa.

The presence of Escherichia coli and Staphylococcus spp. was determined on the skin, personal protective equipment, the municipal vehicle, and various surfaces at ten households in a peri-urban community (KwaZulu-Natal, South Africa) before and after manual emptying of ventilated improved pit latrines. Surface samples (n = 14) were collected using sterile wet wipes, and target bacteria were detected using standard procedures. Additionally, E. coli was enumerated in soil samples from an area of open defecation (log10 3.7 MPN/g) and areas where geophagia occurred (log10 2.7 - log10 3.3 MPN/g), using a most probable number (MPN) method. The detection frequency for the target bacteria on household surfaces (e.g., the walkway between the pit latrine and the municipal vehicle) and on municipal workers' hands (which were frequently contaminated before pit emptying), occasionally increased after the pits were emptied, indicating that manual pit emptying might pose a potential health risk to workers and community members.

Longitudinal Effects of a Sanitation Intervention on Environmental Fecal Contamination in a Cluster-Randomized Controlled Trial in Rural Bangladesh.

Household latrine access generally is not associated with reduced fecal contamination in the environment, but its long-term effectiveness has not been measured. We conducted an environmental assessment nested within the WASH Benefits Bangladesh randomized controlled trial (NCT01590095). We quantified E. coli and fecal coliforms in samples of stored drinking water, child hands, mother hands, soil, and food among a random sample of households from the sanitation and control arms of the trial. Samples were collected during eight quarterly visits approximately 1-3.5 years after intervention initiation. Overall, there were no substantial differences in environmental fecal contamination between households enrolled in the sanitation and control arms. Statistically significant reductions were found in stored water and child hands after pooling across sampling rounds, but the effects were small and not consistent across rounds. In addition, we assessed potential effect modification of intervention effects by follow-up time, season, wealth, community-level latrine density and coverage, population density, and domestic animal ownership. While the intervention had statistically significant effects within some subgroups, there were no consistent patterns of effect modification. Our findings support a growing consensus that on-site latrines are insufficient to prevent fecal contamination in the rural household environment.

The role of emptying services in provision of safely managed sanitation: A classification and quantification of the needs of LMICs.

Classifications for onsite sanitation in terms of facility type (septic tanks, pit latrines) exist, but connecting these facilities to the wider sanitation value chain via improved containment, emptying, and collection has not been well explored. Using existing Joint Monitoring Programme facility classifications and secondary data on piped water access, a Service Typology was developed to classify and quantify the primary emptying service needs of household level onsite sanitation facilities. Facilities in six Sustainable Development Goal (SDG) regions were classified as Emptiable (faecal sludge can be removed either via Mechanized or Non-Mechanized means) or Unemptiable. Of the 722 million household level sanitation facilities assessed in these regions, 32% were found to be emptiable via Mechanized means, 50% via Non-Mechanized means and 18% were found to be Unemptiable pits. The volume (by number of facilities) and density (as a proportion of the full population) of each service type were estimated by SDG region and by country. Results from this study provide background data on the role of emptying sanitation facilities in achieving SDG6, and can be incorporated into investment priorities, policy framing, technology development, infrastructure development, and targeted behaviour change strategies.

Faecal sludge pyrolysis: Understanding the relationships between organic composition and thermal decomposition.

Sludge treatment is an integral part of faecal sludge management in non-sewered sanitation settings. Development of pyrolysis as a suitable sludge treatment method requires thorough knowledge about the properties and thermal decomposition mechanisms of the feedstock. This study aimed to improve the current lack of understanding concerning relevant sludge properties and their influence on the thermal decomposition characteristics. Major organic compounds (hemicellulose, cellulose, lignin, protein, oil and grease, other carbohydrates) were quantified in 30 faecal sludge samples taken from different sanitation technologies, providing the most comprehensive organic faecal sludge data set to date. This information was used to predict the sludge properties crucial to pyrolysis (calorific value, fixed carbon, volatile matter, carbon, hydrogen). Samples were then subjected to thermogravimetric analysis to delineate the influence of organic composition on thermal decomposition. Septic tanks showed lower median fractions of lignin (9.4%dwb) but higher oil and grease (10.7%dwb), compared with ventilated improved pit latrines (17.4%dwb and 4.6%dwb respectively) and urine diverting dry toilets (17.9%dwb and 4.7%dwb respectively). High fixed carbon fractions in lignin (45.1%dwb) and protein (18.8%dwb) suggested their importance for char formation, while oil and grease fully volatilised. For the first time, this study provided mechanistic insights into faecal sludge pyrolysis as a function of temperature and feedstock composition. Classification into the following three phases was proposed: decomposition of hemicellulose, cellulose, other carbohydrates, proteins and, partially, lignin (200-380 °C), continued decomposition of lignin and thermal cracking of oil and grease (380-500 °C) and continued carbonisation (>500 °C). The findings will facilitate the development and optimisation of faecal sludge pyrolysis, emphasising the importance of considering the organic composition of the feedstock.

Effectiveness of community and school-based sanitation interventions in improving latrine coverage: a systematic review and meta-analysis of randomized controlled interventions.

INTRODUCTION: Approximately 1000 children die each year due to preventable water and sanitation-related diarrheal diseases. Six in 10 people lacked access to safely managed sanitation facilities in 2015. Numerous community- and school-based approaches have been implemented to eradicate open defecation practices, promote latrine ownership, improve situation sanitation, and reduce waterborne disease. OBJECTIVE: Given that current evidence for sanitation interventions seem promising, the aim of this study was to systematically summarize existing research on the effectiveness of community- and school-based randomized controlled sanitation intervention in improving (1) free open defecation (safe feces disposal), (2) latrine usage, (3) latrine coverage or access, and (4) improved latrine coverage or access. METHODS: Eight electronic databases were searched: PubMed, Scopus, WHO Global Health Library (GHL), Virtual Health Library (VHL), POPLINE, Web of Science, Cochrane, and Google Scholar up to 26 April 2019. Original randomized clinical trials addressing community-based or school-based intervention that reported feces disposal and latrine coverage were deemed eligible. More than two researchers independently contributed to screening of papers, data extraction, and bias assessment. We conducted a meta-analysis by random-effects model. The risk of bias was assessed by the Cochrane risk of bias tool. RESULTS: Eighteen papers that matched all criteria and 16 studies were included in the final meta-analysis. Compared to the control, the sanitation intervention significantly increased safe feces disposal (OR 2.19, 95% CI 1.51-3.19, p < 0.05, I2 = 97.28), latrine usage (OR 3.72, 95% CI 1.71-8.11, p < 0.05, I2 = 91.52), latrine coverage or access (OR 3.95, 95% CI 2.08-7.50, p < 0.05, I2 = 99.07), and improved latrine coverage or access (OR 3.68, 95% CI 1.52-8.91, p < 0.05, I2 = 99.11). A combination of education and latrine construction was more effective compared to educational intervention alone. CONCLUSION: Our study showed strong evidence for both community- and school-based sanitation interventions as effective for the safe disposal of human excreta. The finding suggests major implications for health policy and design of future intervention in developing countries.

Access and utilization of sanitation facilities in a Rural Area of Haryana, North India.

BACKGROUND: Ensuring universal access to sanitation in households is essential for public health. OBJECTIVES: The objective of the study was to assess the availability of sanitary latrine at the household level and its use at the individual level in a rural area and factors associated with availability and use of sanitary latrine. METHODS: This cross-sectional study was conducted from December, 2016 to January 2017 (mention month and year) at the rural Health and Demographic Surveillance Site, Ballabgarh, in district Faridabad, Haryana, North India. A total of 16,896 households were studied. House-to-house visits were made by trained health workers who conducted interviews regarding availability and pattern of use of sanitary latrine in the household. The health worker also observed the type of sanitation facility, its functional status, availability of water, and hand-washing facility. RESULTS: Individual household latrine (IHL) was present in 87.3% of the households. An improved sanitation facility was available in 84.8% of the households, while 15.2% of the households had unimproved or no sanitation facility. Hand-washing facility along with improved sanitation was present in 70.4% of the households. Nonavailability of latrine among socially disadvantaged communities (scheduled caste households) was significantly higher (19.4%) as compared to other castes (10.4%) (P < 0.001). A significantly higher proportion of households below poverty line (28.9%) lacked IHL as compared to those above the poverty line (11.0%) (P < 0.001). Nearly 11% of the individuals reported open defecation. CONCLUSION: The availability of sanitary latrines in the study area was high. Nonavailability of in-house sanitary latrine was higher among economically poor households and those belonging to socially disadvantaged communities.

Knowing Me, Knowing You: Anal Gland Secretion of European Badgers (Meles meles) Codes for Individuality, Sex and Social Group Membership.

European badgers, Meles meles, are group-living in the UK, and demarcate their ranges with shared latrines. As carnivores, badgers possess paired anal glands, but olfactory information on the content of badger anal gland secretion (AGS) is largely uninvestigated. Here, we examined the volatile organic compounds (VOCs) of AGS samples from 57 free-living badgers using solid-phase microextraction (SPME) and gas chromatography-mass spectrometry. AGS was rich in alkanes (C7-C15, 14.3% of identified compounds), aldehydes (C5-C14, 9.7%), phenols (C6-C15, 9.5%), alcohols (C5-C10, 7.3%), aromatic hydrocarbons (C6-C13, 6.8%), ketones (C6-C13, 6.3%) and carboxylic acids (C3-C12, 5.6%) and contained a variety of esters, sulfurous and nitrogenous compounds, and ethers. The number of VOCs per profile ranged from 20 to 111 (mean = 65.4; ± 22.7 SD), but no compound was unique for any of the biological categories. After normalization of the raw data using Probabilistic Quotient Normalization, we produced a resemblance matrix by calculating the Euclidian distances between all sample pairs. PERMANOVA revealed that AGS composition differs between social groups, and concentration and complexity in terms of number of measurable VOCs varies between seasons and years. AGS VOC profiles encode individual identity, sex and vary with female reproductive state, indicating an important function in intraspecific communication. Because AGS is excreted together with fecal deposits, we conclude that chemical complexity of AGS enables particularly latrine-using species, such as badgers, to advertise more complex individual-specific information than in feces alone.

Latent variable modeling to develop a robust proxy for sensitive behaviors: application to latrine use behavior and its association with sanitation access in a middle-income country.

BACKGROUND: Globally, diarrhea is a leading cause of child morbidity and mortality. Although latrines are integral for reducing enteric pathogen transmission, several studies have shown no evidence that latrine ownership improved child health. There are a number of explanations for these results. One explanation is that latrine access does not equate to latrine use. Latrine use, however, is difficult to accurately ascertain, as defecation behavior is often stigmatized. To address this measurement issue, we measure latrine use as a latent variable, indicated by a suite of psychosocial variables. METHODS: We administered a survey of 16 defecation-related psychosocial questions to 251 individuals living in rural Ecuador. We applied latent class analysis (LCA) to these data to model the probability of latrine use as a latent variable. To account for uncertainty in predicted latent class membership, we used a pseudo-class approach to impute five different probabilities of latrine use for each respondent. Via regression modeling, we tested the association between household sanitation and each imputed latrine use variable. RESULTS: The optimal model presented strong evidence of two latent classes (entropy = 0.86): consistent users (78%) and inconsistent users (22%), predicted by 5 of our 16 psychosocial variables. There was no evidence of an association between the probability of latrine use, predicted from the LCA, and household access to basic sanitation (OR = 1.1, 95% CI = 0.6-2.1). This suggests that home access to a sanitation facility may not ensure the use of the facility for every family member at all times. CONCLUSION: Effective implementation and evaluation of sanitation programs requires accurate measurement of latrine use. Psychosocial variables, such as norms, perceptions, and attitudes may provide robust proxy-measures. Future longitudinal studies will help to strengthen the use of these surrogate measures, as many of these factors may be subject to secular trends. Additionally, subgroup analyses will elucidate how our  proxy indicators of latrine defecation vary by individual-level characteristics.

Discovery of Eurytrema Eggs in Sediment from a Colonial Period Latrine in Taiwan.

In this study we take a closer look at the diseases that afflicted Japanese police officers who were stationed in a remote mountainous region of Taiwan from 1921 to 1944. Samples were taken from the latrine at the Huabanuo police outpost, and analyzed for the eggs of intestinal parasites, using microscopy and ELISA. The eggs of Eurytrema sp., (possibly E. pancreaticum), whipworm and roundworm were shown to be present. True infection with Eurytrema would indicate that the policemen ate uncooked grasshoppers and crickets infected with the parasite. However, false parasitism might also occur if the policemen ate the uncooked intestines of infected cattle, and the Eurytrema eggs passed through the human intestines. These findings provide an insight into the diet and health of the Japanese colonists in Taiwan nearly a century ago.

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.