A Ward-by-Ward Approach to Eliminating Open Defecation: Experience from Visakhapatnam, India

The Government of India launched the Swachh Bharat Mission (SBM) in 2014 with the ambitious aim to ensure hygiene, waste management and sanitation across the nation by the 150th anniversary of Gandhi's birth in October 2019. This document aims to build on existing knowledge by detailing how the challenge of achieving universal sanitation and Open Defecation Free (ODF) status has been approached by Visakhapatnam in Andhra Pradesh, presenting nine stepping stones which together constitute a pathway towards citywide ODF status

Balancing Financial Viability and User Affordability: An Assessment of Six WASH Service Delivery Models

This Topic Brief presents assessments of the financial performance of six WSUP-supported WASH service delivery models in Bangladesh, Madagascar, Mozambique and Zambia. Each model has been developed in partnership with locally mandated service providers to facilitate sustainable, at-scale improvements to low-income urban populations

Smart meters: innovating to improve water supply in a post-COVID context

In cities across Africa, rapidly expanding low-income communities (LICs) pose unique technical and social challenges to utilities in expanding services – but they also present an opportunity to expand the customer base and generate revenues. COVID-19 is placing huge additional pressures on the financial viability of utilities, exacerbating the need for innovative service delivery models to this segment of the customer base. In the context of short and long-term challenges posed by COVID-19, water utilities must take every measure available to improve the efficiency of operations: service quality and attention to the customer will be even more important; greater control will be required over the distribution network; and billing and revenues will need to be maximized to support the bottom line.Smart Water Meters are a new technology with the potential to assist utilities in this process of transformation. The model offers greater control for the customer, through a flexible prepayment tailored to the spending habits of low-income households; and greater control for the utility, enabling real-time data on water demand across the supply area, and supporting a shift from reactive firefighting to preventative planning. Pilots of the technology to date have produced good results; however, more testing is needed, particularly in LICs. One project expected to inform the evidence base is a pilot of 500 smart meters recently underway in Watamu, in the Kenyan district of Malindi

Bringing toilets back to Kumasi's compound houses: landlord and tenant behaviours and motivators

In the low-income urban communities of Kumasi, Ghana, a large part of the population live in compound housing, where they often share the same living space with more than 20 tenants. Partly resulting from the high prevalence of public toilets in the city, the vast majority of these tenants have no access to ‘inhouse’ sanitation. Led by the Kumasi Metropolitan Assembly, a five-year strategy is being prepared to promote increased adoption, access, usage and maintenance of compound toilets in Kumasi’s lowincome communities. This paper shares the results of a desk and field-based study commissioned to inform the strategy: among the key challenges to be confronted are the clarification of responsibilities between landlords and tenants with regards to financing sanitation improvements, and the need to motivate landlords - at the hub of compound level sanitation governance - to improve the situation for the betterment of their tenants

Feasibility study for supporting medication adherence for adults with cystic fibrosis: mixed-methods process evaluation

Objectives: To undertake a process evaluation of an adherence support intervention for people with cystic fibrosis (PWCF), to assess its feasibility and acceptability. Setting: Two UK cystic fibrosis (CF) units. Participants: Fourteen adult PWCF; three professionals delivering adherence support (‘interventionists’); five multi-disciplinary CF team members. Interventions: Nebuliser with data recording and transfer capability, linked to a software platform, and strategies to support adherence to nebulised treatments facilitated by interventionists over 5 months (± 1 month). Primary and secondary measures: Feasibility and acceptability of the intervention, assessed through semistructured interviews, questionnaires, fidelity assessments and click analytics. Results: Interventionists were complimentary about the intervention and training. Key barriers to intervention feasibility and acceptability were identified. Interventionists had difficulty finding clinic space and time in normal working hours to conduct review visits. As a result, fewer than expected intervention visits were conducted and interviews indicated this may explain low adherence in some intervention arm participants. Adherence levels appeared to be >100% for some patients, due to inaccurate prescription data, particularly in patients with complex treatment regimens. Flatlines in adherence data at the start of the study were linked to device connectivity problems. Content and delivery quality fidelity were 100% and 60%–92%, respectively, indicating that interventionists needed to focus more on intervention ‘active ingredients’ during sessions. Conclusions: The process evaluation led to 14 key changes to intervention procedures to overcome barriers to intervention success. With the identified changes, it is feasible and acceptable to support medication adherence with this intervention. Trial registration number: ISRCTN13076797; Results

Supporting medication adherence for adults with cystic fibrosis:a randomised feasibility study

Background Preventative medication reduces hospitalisations in people with cystic fibrosis (PWCF) but adherence is poor. We assessed the feasibility of a randomised controlled trial of a complex intervention, which combines display of real time adherence data and behaviour change techniques. Methods Design: Pilot, open-label, parallel-group RCT with concurrent semi-structured interviews. Participants: PWCF at two Cystic Fibrosis (CF) units. Eligible: aged 16 or older; on the CF registry. Ineligible: post-lung transplant or on the active list; unable to consent; using dry powder inhalers. Interventions: Central randomisation on a 1:1 allocation to: (1) intervention, linking nebuliser use with data recording and transfer capability to a software platform, and behavioural strategies to support self-management delivered by trained interventionists (n = 32); or, (2) control, typically face-to-face meetings every 3 months with CF team (n = 32). Outcomes: RCT feasibility defined as: recruitment of ≥ 48 participants (75% of target) in four months (pilot primary outcome); valid exacerbation data available for ≥ 85% of those randomised (future RCT primary outcome); change in % medication adherence; FEV1 percent predicted (key secondaries in future RCT); and perceptions of trial procedures, in semi-structured interviews with intervention (n = 14) and control (n = 5) participants, interventionists (n = 3) and CF team members (n = 5). Results The pilot trial recruited to target, randomising 33 to intervention and 31 to control in the four-month period, June–September 2016. At study completion (30th April 2017), 60 (94%; Intervention = 32, Control =28) participants contributed good quality exacerbation data (intervention: 35 exacerbations; control: 25 exacerbation). The mean change in adherence and baseline-adjusted FEV1 percent predicted were higher in the intervention arm by 10% (95% CI: -5.2 to 25.2) and 5% (95% CI -2 to 12%) respectively. Five serious adverse events occurred, none related to the intervention. The mean change in adherence was 10% (95% CI: -5.2 to 25.2), greater in the intervention arm. Interventionists delivered insufficient numbers of review sessions due to concentration on participant recruitment. This left interventionists insufficient time for key intervention procedures. A total of 10 key changes that were made to RCT procedures are summarised. Conclusions With improved research processes and lower monthly participant recruitment targets, a full-scale trial is feasible

Factors That Encourage or Discourage Doctors from Acting in Accordance with Good Practice

Scraggs E, Bereton L, Newbould J, et al. Factors That Encourage or Discourage Doctors from Acting in Accordance with Good Practice. London: General Medical Council; 2012

Strategies to Connect Low-Income Communities with the Proposed Sewerage Network of the Dhaka Sanitation Improvement Project, Bangladesh: A Qualitative Assessment of the Perspectives of Stakeholders

In Bangladesh, approximately 31% of urban residents are living without safely managed sanitation, the majority of whom are slum residents. To improve the situation, Dhaka Water Supply and Sewerage Authority (DWASA) is implementing the Dhaka Sanitation Improvement Project (DSIP), mostly funded by the World Bank. This study assessed the challenges and opportunities of bringing low-income communities (LICs) under a sewerage connection within the proposed sewerage network plan by 2025. We conducted nine key-informant interviews from DWASA and City Corporation, and 23 focus-group discussions with landlords, tenants, and Community Based Organisations (CBOs) from 16 LICs near the proposed catchment area. To achieve connections, LICs would require improved toilet infrastructures and have to be connected to main roads. Construction of large communal septic tanks is also required where individual toilet connections are difficult. To encourage connection in LICs, income-based or area-based subsidies were recommended. For financing maintenance, respondents suggested monthly fee collection for management of the infrastructure by dividing bills equally among sharing households, or by users per household. Participants also suggested the government’s cooperation with development-partners/NGOs to ensure sewerage connection construction, operation, and maintenance and prerequisite policy changes such as assuring land tenure

Landlords/compound managers: change makers to improve and sustain communal latrine use and maintenance

Shared latrines are the most common primary means of sanitation in the high-density slums in Dhaka city where maintaining cleanliness and functionality is difficult. We developed a cleanliness and maintenance intervention package that included behaviour change materials and interpersonal communication sessions with slum residents, landlords/compound managers, waste bin emptiers regarding flushing, latrine waste disposal in waste bins and safe child feces disposal. We evaluated the role of landlord/ compound managers and explored the mechanism by which they contributed to this intervention. We conducted focus group discussions with landlords/compound managers, community health promoters (CHPs) and tenants, group discussions with CHP supervisors and key informant interviews with the staff member of implementing agency. CHPs and their supervisors said landlords/compound managers supported their efforts to implement this intervention. We found landlords/compound managers play a reinforcing role in the intervention