Moving up the sanitation ladder with the help of microfinance in urban Malawi

Abstract We carried out a stated preference survey in Malawi to examine whether access to microfinance for sanitation would significantly increase the proportion of households upgrading to improved pit latrines or alternative improved sanitation technologies (urine diverting dry toilet, fossa alterna, pour flush). We presented a range of sanitation options at local market prices, initially without and then with a real microfinance option, to 1,300 households sampled across 27 low-income urban settlements in the two largest cities, Lilongwe and Blantyre. When we gave respondents a microfinance option, the proportion of households stating an intention to install improved and unimproved pit latrines decreased significantly, while the proportion stating an intention to upgrade to alternative improved sanitation technologies increased significantly. However, households in the lowest wealth quintile were more likely to state a preference for unimproved pit latrines, suggesting that the benefits of microfinance for sanitation may not accrue equally across wealth strata. Organisations seeking to improve access to safely managed sanitation by promoting alternative sanitation technologies would succeed if households have access to affordable alternative sanitation technologies and microfinance for sanitation. However, poorer households would need more affordable improved sanitation technologies, flexible microfinance options and possibly targeted subsidies to gain access to safely managed sanitation.</jats:p

Farmer driven wastewater treatment: a case study from Faisalabad, Pakistan

The use of wastewater in agriculture provides, besides the obvious risks, also benefits to farmers. This paper presents the case of Faisalabad where farmers used untreated wastewater even though effluent from the local waste stabilization ponds was available. Untreated wastewater had a higher nutrient value and lower salinity as compared to effluent from the WSP and its use resulted in a substantially higher farm income. An approach is therefore proposed in which farmers and wastewater managers enter into dialogue to find mutually beneficial solutions to provide wastewater for agriculture whilst minimizing health risks

Evidence on the Effectiveness of Water, Sanitation, and Hygiene (WASH) Interventions on Health Outcomes in Humanitarian Crises: A Systematic Review.

BACKGROUND: Water, sanitation, and hygiene (WASH) interventions are amongst the most crucial in humanitarian crises, although the impact of the different WASH interventions on health outcomes remains unclear. AIM: To examine the quantity and quality of evidence on WASH interventions on health outcomes in humanitarian crises, as well as evaluate current evidence on their effectiveness against health outcomes in these contexts. METHODS: A systematic literature review was conducted of primary and grey quantitative literature on WASH interventions measured against health outcomes in humanitarian crises occurring from 1980-2014. Populations of interest were those in resident in humanitarian settings, with a focus on acute crisis and early recovery stages of humanitarian crises in low and middle-income countries. Interventions of interest were WASH-related, while outcomes of interest were health-related. Study quality was assessed via STROBE/CONSORT criteria. Results were analyzed descriptively, and PRISMA reporting was followed. RESULTS: Of 3963 studies initially retrieved, only 6 published studies measured a statistically significant change in health outcome as a result of a WASH intervention. All 6 studies employed point-of-use (POU) water quality interventions, with 50% using safe water storage (SWS) and 35% using household water treatment (HWT). All 6 studies used self-reported diarrhea outcomes, 2 studies also reported laboratory confirmed outcomes, and 2 studies reported health treatment outcomes (e.g. clinical admissions). 1 study measured WASH intervention success in relation to both health and water quality outcomes; 1 study recorded uptake (use of soap) as well as health outcomes. 2 studies were unblinded randomized-controlled trials, while 4 were uncontrolled longitudinal studies. 2 studies were graded as providing high quality evidence; 3 studies provided moderate and 1 study low quality evidence. CONCLUSION: The current evidence base on the impact of WASH interventions on health outcomes in humanitarian crises is extremely limited, and numerous methodological limitations limit the ability to determine associative, let alone causal, relationships

Sewage disposal in the Musi-River, India: water quality remediation through irrigation infrastructure

The disposal of untreated urban sewage in to open water bodies is common in most developing countries. This poses potential negative consequences to public health and agricultural sustainability. Hyderabad, one of India's largest cities, disposes large amounts of its wastewater untreated into the Musi River, from where it is used, with the aid of irrigation weirs, for agricultural production. This paper presents a 14 month (December 2003 - January 2005) water quality survey which aimed to quantify spatial and temporal changes in key water quality parameters along a 40 km stretch of the Musi River. The survey found that river water quality improved dramatically with distance from the city; from untreated sewage in the city to irrigation water safe for use in agriculture 40 km downstream of the city. This improvement was contributed to by different treatment processes caused or aided by the irrigation weirs placed on the river. © 2009 Springer Science+Business Media B.V

The Impact of Water, Sanitation and Hygiene Interventions to Control Cholera: A Systematic Review.

BACKGROUND AND METHODS: Cholera remains a significant threat to global public health with an estimated 100,000 deaths per year. Water, sanitation and hygiene (WASH) interventions are frequently employed to control outbreaks though evidence regarding their effectiveness is often missing. This paper presents a systematic literature review investigating the function, use and impact of WASH interventions implemented to control cholera. RESULTS: The review yielded eighteen studies and of the five studies reporting on health impact, four reported outcomes associated with water treatment at the point of use, and one with the provision of improved water and sanitation infrastructure. Furthermore, whilst the reporting of function and use of interventions has become more common in recent publications, the quality of studies remains low. The majority of papers (>60%) described water quality interventions, with those at the water source focussing on ineffective chlorination of wells, and the remaining being applied at the point of use. Interventions such as filtration, solar disinfection and distribution of chlorine products were implemented but their limitations regarding the need for adherence and correct use were not fully considered. Hand washing and hygiene interventions address several transmission routes but only 22% of the studies attempted to evaluate them and mainly focussed on improving knowledge and uptake of messages but not necessarily translating this into safer practices. The use and maintenance of safe water storage containers was only evaluated once, under-estimating the considerable potential for contamination between collection and use. This problem was confirmed in another study evaluating methods of container disinfection. One study investigated uptake of household disinfection kits which were accepted by the target population. A single study in an endemic setting compared a combination of interventions to improve water and sanitation infrastructure, and the resulting reductions in cholera incidence. DISCUSSION AND RECOMMENDATIONS: This review highlights a focus on particular routes of transmission, and the limited number of interventions tested during outbreaks. There is a distinct gap in knowledge of which interventions are most appropriate for a given context and as such a clear need for more robust impact studies evaluating a wider array of WASH interventions, in order to ensure effective cholera control and the best use of limited resources

A faecal exposure assessment of farm workers in Accra, Ghana: a cross sectional study.

BACKGROUND: Wastewater use in urban agriculture is common as a result of rapid urbanisation, and increasing competition for good quality water. In order to minimize risks to farmers and consumers of wastewater irrigated produce the World Health Organization (WHO) has developed guidelines for the safe use of wastewater in agriculture. These guidelines are based on a Quantitative Microbial Risk Assessment (QMRA) model, though the reliability of this model has been questioned due to a lack of primary data. This study aimed to assess the ability of the WHO guidelines to protect farmers' health, by identifying and quantifying key exposures associated with the transmission of faecal pathogens in wastewater irrigated agriculture. METHODS: Eighty farmers were observed and interviewed during the dry and wet seasons, and water and soil samples were analysed for the presence of E. coli. STATA 12 was used for descriptive analyses of farmers' exposure and risk practices, and also to determine risk factors for soil and irrigation water contamination, while the WHO QMRA model and @Risk 6 were used to model farmers' infection risk to pathogens. RESULTS: The results showed that although irrigation water was highly contaminated (5.6 Log E. coli/100 ml), exposure to farm soil (2.3 Log E. coli/g) was found to be the key risk pathway due to soil-to-mouth events. During the observations 93 % of farmers worked barefoot, 86 % experienced hand-to-soil contact, while 53 % experienced 'soil'-to-mouth events, while no 'water' to mouth contacts were observed. On average, farmers were found to have 10 hand-to-mouth events per day. From the indicator based QMRA model the estimated norovirus infection risk to farmers was found to be higher than guidelines set by the WHO. CONCLUSIONS: This study found exposure to soil as the critical pathway of pathogen risk in wastewater farmers, and that this risk exceeded recommended health targets. The study recommends the incorporation of hand-to-mouth events, the use of actual pathogen concentrations, and the use of direct exposure frequencies in order to improve the reliability of risk estimates from QMRA models

Risk Perceptions of Wastewater Use for Urban Agriculture in Accra, Ghana.

Poor food hygiene is a significant risk to public health globally, but especially in low and middle-income countries where access to sanitation, and general hygiene remain poor. Food hygiene becomes even more pertinent when untreated, or poorly treated wastewater is used in agriculture. In such circumstances the WHO recommends the adoption of a multiple-barrier approach that prescribes health protective measures at different entry points along the food chain. This study sought to assess the knowledge and awareness of wastewater use for crop production, its related health risks, and adoption of health protective measures by farmers, market salespersons and consumers using questionnaires and focus group discussions. In the period from September 2012 to August 2013, 490 respondents were interviewed during two cropping seasons. The study found that awareness of the source of irrigation water was low among consumers and street food vendors, though higher among market vendors. In contrast, health risk awareness was generally high among salespersons and consumers, but low among farmers. The study found that consumers did not prioritize health indicators when buying produce from vendors but were motivated to buy produce, or prepared food based on taste, friendship, cost, convenience and freshness of produce. Similarly, farmers' awareness of health risk did not influence their adoption of safer farm practices. The study recommends the promotion of interventions that would result in more direct benefits to both producers and vendors, together with hygiene education and enforcement of food safety byelaws in order to influence behaviour change, and increase the uptake of the multiple-barrier approach

A quantitative assessment method for Ascaris eggs on hands.

The importance of hands in the transmission of soil transmitted helminths, especially Ascaris and Trichuris infections, is under-researched. This is partly because of the absence of a reliable method to quantify the number of eggs on hands. Therefore, the aim of this study was to develop a method to assess the number of Ascaris eggs on hands and determine the egg recovery rate of the method. Under laboratory conditions, hands were seeded with a known number of Ascaris eggs, air dried and washed in a plastic bag retaining the washing water, in order to determine recovery rates of eggs for four different detergents (cationic [benzethonium chloride 0.1% and cetylpyridinium chloride CPC 0.1%], anionic [7X 1% - quadrafos, glycol ether, and dioctyl sulfoccinate sodium salt] and non-ionic [Tween80 0.1% -polyethylene glycol sorbitan monooleate]) and two egg detection methods (McMaster technique and FLOTAC). A modified concentration McMaster technique showed the highest egg recovery rate from bags. Two of the four diluted detergents (benzethonium chloride 0.1% and 7X 1%) also showed a higher egg recovery rate and were then compared with de-ionized water for recovery of helminth eggs from hands. The highest recovery rate (95.6%) was achieved with a hand rinse performed with 7X 1%. Washing hands with de-ionized water resulted in an egg recovery rate of 82.7%. This washing method performed with a low concentration of detergent offers potential for quantitative investigation of contamination of hands with Ascaris eggs and of their role in human infection. Follow-up studies are needed that validate the hand washing method under field conditions, e.g. including people of different age, lower levels of contamination and various levels of hand cleanliness

Monitoring the inputs required to extend and sustain hygiene promotion: findings from the GLAAS 2013/2014 survey.

OBJECTIVES: There are significant gaps in information about the inputs required to effectively extend and sustain hygiene promotion activities to improve people's health outcomes through water, sanitation and hygiene (WASH) interventions. We sought to analyse current country and global trends in the use of key inputs required for effective and sustainable implementation of hygiene promotion to help guide hygiene promotion policy and decision-making after 2015. METHODS: Data collected in response to the GLAAS 2013/2014 survey from 93 countries of 94 were included, and responses were analysed for 12 questions assessing the inputs and enabling environment for hygiene promotion under four thematic areas. Data were included and analysed from 20 External Support Agencies (ESA) of 23 collected through self-administered surveys. RESULTS: Firstly, the data showed a large variation in the way in which hygiene promotion is defined and what constitutes key activities in this area. Secondly, challenges to implement hygiene promotion are considerable: include poor implementation of policies and plans, weak coordination mechanisms, human resource limitations and a lack of available hygiene promotion budget data. CONCLUSION: Despite the proven benefits of hand washing with soap, a critical hygiene-related factor in minimising infection, GLAAS 2013/2014 survey data showed that hygiene promotion remains a neglected component of WASH. Additional research to identify the context-specific strategies and inputs required to enhance the effectiveness of hygiene promotion at scale are needed. Improved data collection methods are also necessary to advance the availability and reliability of hygiene-specific information

Wastewater use in India: the impact of irrigation weirs on water quality and farmer health

Water quality in the wastewater polluted Musi River, India was assessed in a 14 month survey, while the impact of exposure to polluted river water was assessed in an epidemiological study. The water quality survey found very high intestinal nematode and BOD concentrations in Musi water in the city of Hyderabad. Water quality improved dramatically downstream of the city as a result of irrigation weirs that were placed on the river and which promoted sedimentation. River water, at two of the selected sample points, was found to be unfit for use in agriculture based on WHO guidelines. Hookworm infection was found to be the main health risk associated with the use of polluted Musi water and a significantly increased risk of infection was found in farmers using untreated wastewater. In the absence of wastewater treatment facilities, regular anthelmintic treatment programs are recommended to protect farmer health