Caregiver social support and child toilet training in rural Odisha, India: What types of support facilitate training and how?

Studies show positive impacts of social support on childcare practices, but there is limited research on child toilet training. Social support with toilet training may be especially important for rural Indian caregivers as this is a new childcare practice for many and mothers face an already demanding workload. The aim of this study was to examine the role of social support in toilet training using mediation and conditional process analyses. We surveyed 570 caregivers of children <5 years old living in rural Odisha, India. We found certain types of support aid toilet training through three mechanisms: directly, by improving self-efficacy, and by buffering against stress. Informational and instrumental support had a positive direct effect on toilet training while emotional support had no effect. Instrumental support also aided toilet training indirectly through bolstering a caregiver's perceived self-efficacy. These effects of instrumental support were not moderated by the caregiver's support network size. Additionally, we found perceived stress had a negative indirect effect on caregivers' toilet training efforts through diminishing self-efficacy, but this effect was buffered (i.e. moderated) by social support. These findings offer useful programmatic insights and expand the evidence-base on how social support functions to another childcare practice and cultural context

Child feces management practices and fecal contamination: A cross-sectional study in rural Odisha, India.

Safe child feces management (CFM) is likely critical for reducing exposure to fecal pathogens in and around the home, but the effectiveness of different CFM practices in reducing fecal contamination is not well understood. We conducted a cross-sectional study of households with children <6 years in rural Odisha, India, using household surveys (188 households), environmental sample analysis (373 samples for 80 child defecation events), and unstructured observation (33 households) to characterize practices and measure fecal contamination resulting from CFM-related practices, including defecation, feces handling and disposal, defecation area or tool cleaning, anal cleansing, and handwashing. For environmental sampling, we developed a sampling strategy that involved collecting samples at the time and place of child defecation to capture activity-level fecal contamination for CFM practices. Defecating on the floor or ground, which was practiced by 63.7% of children <6 years, was found to increase E. coli contamination on finished floors (p < 0.001) or earthen ground surfaces (p = 0.008) after feces were removed, even if paper was laid down prior to defecation. Use of unsafe tools (e.g., paper, plastic bag, straw/hay) to pick up child feces increased E. coli contamination on caregiver hands after feces handling (p < 0.0001), whereas the use of safe tools (e.g., potty, hoe, scoop) did not increase hand contamination. Points of contamination from cleaning CFM hardware and anal cleansing were also identified. The most common disposal location for feces of children <6 years was to throw feces into an open field (41.6%), with only 32.3% disposed in a latrine. Several households owned scoops or potties, but use was low and we identified shortcomings of these CFM tools and proposed alternative interventions that may be more effective. Overall, our results demonstrate the need for CFM interventions that move beyond focusing solely on feces disposal to address CFM as a holistic set of practices

Water, Sanitation, and Hygiene Practices and Challenges during the COVID-19 Pandemic: A Cross-Sectional Study in Rural Odisha, India.

Water, sanitation, and hygiene (WASH) practices emerged as a critical component to controlling and preventing the spread of the COVID-19 pandemic. We conducted 131 semistructured phone interviews with households in rural Odisha, India, to understand behavior changes made in WASH practices as a result of the pandemic and challenges that would prevent best practices. Interviews were conducted from May through July 2020 with 73 heads of household, 37 caregivers of children < 5 years old, and 21 members of village water and sanitation committees in villages with community-level piped water and high levels of latrine ownership. The majority of respondents (86%, N = 104) reported a change in their handwashing practice due to COVID-19, typically describing an increase in handwashing frequency, more thorough washing method, and/or use of soap. These improved handwashing practices remained in place a few months after the pandemic began and were often described as a new consistent practice after additional daily actions (such as returning home), suggesting new habit formation. Few participants (13%) reported barriers to handwashing. Some respondents also detailed improvements in other WASH behaviors, including village-level cleaning of water tanks and/or treatment of piped water (48% of villages), household water treatment and storage (17% of respondents), and household cleaning (41% of respondents). However, there was minimal change in latrine use and child feces management practices as a result of the pandemic. We provide detailed thematic summaries of qualitative responses to allow for richer insights into these WASH behavior changes during the pandemic. The results also highlight the importance of ensuring communities have adequate WASH infrastructure to enable the practice of safe behaviors and strengthen resilience during a large-scale health crisis

A cluster-randomized multi-level intervention to increase latrine use and safe disposal of child feces in rural Odisha, India: the Sundara Grama research protocol.

BACKGROUND: Despite health benefits of sanitation, an estimated 12% of the global population practices open defecation, including an estimated 50% of the population of India. Current estimates, however, do not include households that own toilets but do not use them, suggesting that the actual number of people defecating in the open is underestimated. This protocol describes a cluster randomized controlled trial to evaluate an intervention specifically designed to increase latrine use, including the safe disposal of child feces, in rural Odisha, India. METHODS: The trial engages 66 villages in Puri district, 33 randomly allocated to receive the intervention and 33 to serve as controls. The primary outcome is latrine use and is recorded at baseline and endline for all members of all households that own latrines in all trial vilalges. Additional data on determinants of latrine use and safe child feces disposal are also collected to assess change based on the intervetntion. A process evaluation assesses the delivery of the intervention and qualiative research takes place in non-trial villages as well as post-endline in trial villages to help explain trial findings. DISCUSSION: This is one of four trials taking place simultaneously in rural India with latrine use as the primary outcome. All four studies use the same outcome to gerenate comparable data across sites that can serve the government of India. The trial in Odisha is unique in that it collects latrine use data from all potential users in all households that own latrines, enabling a thorough view of the sanitation situation and factors that influence use at the community level. That latrine use is collected via self-report is a limitation, however any bias in reporting should be the same across villages and not impact the overall assessment of intervention impact. TRIAL REGISTRATION: This trial is registered at clinicaltrials.gov: NCT03274245

SUMO-Targeted Ubiquitin Ligases (STUbLs) Reduce the Toxicity and Abnormal Transcriptional Activity Associated With a Mutant, Aggregation-Prone Fragment of Huntingtin

Cell viability and gene expression profiles are altered in cellular models of neurodegenerative disorders such as Huntington\u27s Disease (HD). Using the yeast model system, we show that the SUMO-targeted ubiquitin ligase (STUbL) Slx5 reduces the toxicity and abnormal transcriptional activity associated with a mutant, aggregation-prone fragment of huntingtin (Htt), the causative agent of HD. We demonstrate that expression of an aggregation-prone Htt construct with 103 glutamine residues (103Q), but not the non-expanded form (25Q), results in severe growth defects in slx5Delta and slx8Delta cells. Since Slx5 is a nuclear protein and because Htt expression affects gene transcription, we assessed the effect of STUbLs on the transcriptional properties of aggregation-prone Htt. Expression of Htt 25Q and 55Q fused to the Gal4 activation domain (AD) resulted in reporter gene auto-activation. Remarkably, the auto-activation of Htt constructs was abolished by expression of Slx5 fused to the Gal4 DNA-binding domain (BD-Slx5). In support of these observations, RNF4, the human ortholog of Slx5, curbs the aberrant transcriptional activity of aggregation-prone Htt in yeast and a variety of cultured human cell lines. Functionally, we find that an extra copy of SLX5 specifically reduces Htt aggregates in the cytosol as well as chromatin-associated Htt aggregates in the nucleus. Finally, using RNA sequencing, we identified and confirmed specific targets of Htt\u27s transcriptional activity that are modulated by Slx5. In summary, this study of STUbLs uncovers a conserved pathway that counteracts the accumulation of aggregating, transcriptionally active Htt (and possibly other poly-glutamine expanded proteins) on chromatin in both yeast and in mammalian cells

A qualitative assessment of mothers' perceptions and behaviors in response to an intervention designed to encourage safe child feces management practices in rural Odisha, India

Abstract Child feces are not always safely disposed of into a latrine, potentially contributing to fecal exposure in the household environment. In India, safe disposal of child feces is a relatively uncommon practice despite gains in latrine coverage. This study took place after the delivery of a behavior change intervention that also included the provision of potties and scoops. The aims of this research were to (1) describe current child feces management (CFM) practices, (2) explore perceptions and behaviors of mothers who participated in intervention activities, and (3) assess the spillover of intervention activities in neighboring villages. Twenty-four in-depth interviews and four focus group discussions were conducted across six villages, three of which received the intervention. Using thematic analysis, we explored caregivers' descriptions of the different strategies to manage their child's feces. The study found (i) women's access to and perception of the intervention informed their knowledge, attitudes, perceived risk, and behaviors related to CFM, (ii) most women positively perceived the messages of the intervention with varying use of the tools provided for feces disposal, and (iii) there was no spillover in the neighboring villages. Our findings underscore that CFM practices must be addressed to reduce fecal contamination of the environment

Collective Efficacy: Development and Validation of a Measurement Scale for Use in Public Health and Development Programmes.

Impact evaluations of water, sanitation, and hygiene interventions have demonstrated lower than expected health gains, in some cases due to low uptake and sustained adoption of interventions at a community level. These findings represent common challenges for public health and development programmes relying on collective action. One possible explanation may be low collective efficacy (CE)-perceptions regarding a group's ability to execute actions related to a common goal. The purpose of this study was to develop and validate a metric to assess factors related to CE. We conducted this research within a cluster-randomised sanitation and hygiene trial in Amhara, Ethiopia. Exploratory and confirmatory factor analyses were carried out to examine underlying structures of CE for men and women in rural Ethiopia. We produced three CE scales: one each for men and women that allow for examinations of gender-specific mechanisms through which CE operates, and one 26-item CE scale that can be used across genders. All scales demonstrated high construct validity. CE factor scores were significantly higher for men than women, even among household-level male-female dyads. These CE scales will allow implementers to better design and target community-level interventions, and examine the role of CE in the effectiveness of community-based programming

The impact of sanitation on infectious disease and nutritional status: A systematic review and meta-analysis.

BACKGROUND: Sanitation aims to sequester human feces and prevent exposure to fecal pathogens. More than 2.4 billion people worldwide lack access to improved sanitation facilities and almost one billion practice open defecation. We undertook systematic reviews and meta-analyses to compile the most recent evidence on the impact of sanitation on diarrhea, soil-transmitted helminth (STH) infections, trachoma, schistosomiasis, and nutritional status assessed using anthropometry. METHODS AND FINDINGS: We updated previously published reviews by following their search strategy and eligibility criteria. We searched from the previous review's end date to December 31, 2015. We conducted meta-analyses to estimate pooled measures of effect using random-effects models and conducted subgroup analyses to assess impact of different levels of sanitation services and to explore sources of heterogeneity. We assessed risk of bias and quality of the evidence from intervention studies using the Liverpool Quality Appraisal Tool (LQAT) and Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach, respectively. A total of 171 studies met the review's inclusion criteria, including 64 studies not included in the previous reviews. Overall, the evidence suggests that sanitation is protective against diarrhea, active trachoma, some STH infections, schistosomiasis, and height-for-age, with no protective effect for other anthropometric outcomes. The evidence was generally of poor quality, heterogeneity was high, and GRADE scores ranged from very low to high. CONCLUSIONS: This review confirms positive impacts of sanitation on aspects of health. Evidence gaps remain and point to the need for research that rigorously describes sanitation implementation and type of sanitation interventions

Effect of a low-cost, behaviour-change intervention on latrine use and safe disposal of child faeces in rural Odisha, India: a cluster-randomised controlled trial.

BACKGROUND: Uptake of Government-promoted sanitation remains a challenge in India. We aimed to investigate a low-cost, theory-driven, behavioural intervention designed to increase latrine use and safe disposal of child faeces in India. METHODS: We did a cluster-randomised controlled trial between Jan 30, 2018, and Feb 18, 2019, in 66 rural villages in Puri, Odisha, India. Villages were eligible if not adjacent to another included village and not designated by the Government to be open-defecation free. All latrine-owning households in selected villages were eligible. We assigned 33 villages to the intervention via stratified randomisation. The intervention was required to meet a limit of US$20 per household and included a folk performance, transect walk, community meeting, recognition banners, community wall painting, mothers' meetings, household visits, and latrine repairs. Control villages received no intervention. Neither participants nor field assessors were masked to study group assignment. We estimated intervention effects on reported latrine use and safe disposal of child faeces 4 months after completion of the intervention delivery using a difference-in-differences analysis and stratified results by sex. This study is registered at ClinicalTrials.gov, NCT03274245. FINDINGS: We enrolled 3723 households (1807 [48·5%] in the intervention group and 1916 [51·5%] in the control group). Analysis included 14 181 individuals (6921 [48·8%] in the intervention group and 7260 [51·2%] in the control group). We found an increase of 6·4 percentage points (95% CI 2·0-10·7) in latrine use and an increase of 15·2 percentage points (7·9-22·5) in safe disposal of child faeces. No adverse events were reported. INTERPRETATION: A low-cost behavioural intervention achieved modest increases in latrine use and marked increases in safe disposal of child faeces in the short term but was unlikely to reduce exposure to faecal pathogens to a level necessary to achieve health gains. FUNDING: The Bill & Melinda Gates Foundation and International Initiative for Impact Evaluation

Assessing the impact of sanitation on indicators of fecal exposure along principal transmission pathways: A systematic review.

OBJECTIVE: Fecal-oral transmission of enteric and other pathogens due to poor sanitation is a major cause of morbidity and mortality, especially in low- or middle-income settings. Few studies have investigated the impact of sanitation on indicators of transmission, a prerequisite to achieving health gains. This review attempts to summarize the literature to date. METHODS: We searched leading databases to identify studies that address the effect of sanitation on various transmission pathways including fecal pathogens or indicator bacteria in drinking water, hand contamination, sentinel toys, food, household and latrine surfaces and soil, as well as flies and observations of human feces. This also included studies that assessed the impact of fecal contamination of water supplies based on distance from sanitation facilities. We identified 29 studies that met the review's eligibility criteria. RESULTS AND CONCLUSION: Overall, the studies found little to no effect from sanitation interventions on these transmission pathways. There was no evidence of effects on water quality (source or household), hand or sentinel toy contamination, food contamination, or contamination of surfaces or soil. There is some evidence that sanitation was associated with reductions in flies and a small effect on observations of feces (Risk Difference -0.03, 95%CI -0.06 to 0.01). Studies show an inverse relationship between the distance of a water supply from a latrine and level of fecal contamination of such water supply. Future evaluations of sanitation interventions should include assessments of effects along transmission pathways in order to better understand the circumstances under which interventions may be effective at preventing disease