Use of the County Health Rankings by Local Health Departments in Florida, 2010 - 2011

This paper describes how local health departments (LHDs) in Florida used the County Health Rankings over the first two years of their release (2010 – 2011). We surveyed LHD leadership to describe if, how and to what extent the Rankings were used by Florida’s 67 LHDs to improve the health of their communities and describe changes in use from the 2010 to the 2011 release. Our results indicate substantial use of the Rankings by Florida’s LHDs, particularly as applied to community health assessments, staff education, as a starting point for examining other indicators and databases, and in grant applications. From 2010 to 2011, we found significant increases in LHD use of the Rankings to build broad multisectoral community involvement in the solution of community health problems. However, media engagement with the Rankings appears to have decreased with time. A primary implication for public health practice is the apparent utility of the Rankings as a tool for community organizing around public health issues and communicating the multifactorial nature of health

Assessing peri-urban sanitation quality using a theoretically derived composite measure in Lusaka, Zambia

Abstract Despite ongoing debates about what constitutes adequate sanitation, there is a lack of sanitation quality measures that are theoretically grounded in ways that allow empirical comparisons of quality across different types of sanitation. The Healthy Sanitation Framework (HSF) was developed to capture universal aspects of sanitation quality from a public health perspective. From this, the Peri-Urban Healthy Toilet Index (PUHTI) was created for measuring on-site, peri-urban sanitation quality. This PUHTI score was used to assess sanitation quality in a peri-urban area in Lusaka, Zambia. The HSF identified five categories for capturing sanitation quality: hygiene, use, sustainability, desirability, and accessibility. A composite index derived from these categories had high reliability and plausible validity, despite barriers to rigorously evaluating validity. Applying the PUHTI tool showed that while 87% of toilets were classified as ‘improved, but shared,’ there were frequent concerns about doors that could not be locked, dirty user interfaces, unhygienic containment, limited emptyability, and lack of handwashing facilities. The HSF allows granular measures of sanitation quality to be developed in any setting using a reproducible and theoretically grounded process. However, lack of a unified basis on which to compare different types of sanitation overall or evidence to compare within narrower categories currently limits comparisons across types of sanitation.</jats:p

Integrating face washing into a school-based, handwashing behavior change program to prevent trachoma in Turkana, Kenya

Trachoma is the leading infectious cause of blindness, and facial cleanliness is associated with reduced odds of trachomatous inflammation and Chlamydia trachomatis infection, but there is little evidence of how to drive this behavior change at scale. We report the results of a program integrating face washing into a school-based handwashing promotion program in Turkana County, Kenya. Children aged 5-15 years participated in an intervention delivered to schools in two phases, along with a third phase receiving the intervention after the evaluation, which served as a control. The primary outcome was the number of face washing events that took place when handwashing occurred, which was measured by a 3-hour structured observation at all 67 schools, and a total of 3,871 handwashing events were observed. Differences in observed in face washing behavior between each phase and the control schools were calculated using logbinomial regression with clustering at the school level, whereas survey responses on knowledge of trachoma transmission and prevention were compared using χ2tests adjusted for clustering at the school level. Face washing during handwashing events was higher in schools after 12 months (59.3%) and 20 months (44.2%) than in control schools (18.7%, P < 0.001). Trachoma knowledge was higher in schools evaluated after 12 months (80%) and 20 months (70%) than in control schools (42%, P < 0.001), and knowledge of some of key preventive behaviors was higher in intervention schools. Integrating face washing messages into school-based handwashing promotion programs increased face washing, which may help to prevent trachoma when combined with other interventions

Understanding demand for higher quality sanitation in peri-urban Lusaka, Zambia through stated and revealed preference analysis.

Poor peri-urban sanitation is a significant public health problem, likely to become more important as the world rapidly urbanizes. However, little is known about the role of consumer demand in increasing peri-urban sanitation quality, especially for tenants using shared sanitation as only their rental choices can be observed in the market. We analyzed data on existing housing markets collected between 9 Jun and 6 Jul 2017 using the Hedonic Pricing Method (HPM) to capture the percentage of rent attributable to sanitation quality (n = 933). We also conducted discrete choice experiments (DCEs) to obtain willingness to pay (WTP) estimates for specific sanitation components (n = 1087), and explored the implications by estimating the proportion of plots for which improved sanitation quality would generate a higher return on investment for landlords than building a place for an additional tenant to live. The HPM attributed 18% of rental prices to sanitation (∼US$8.10 per month), but parameters for several components were poorly specified due to collinearity and low overall prevalence of some products. DCEs revealed that tenants were willing to pay$2.20 more rent per month for flushing toilets on plots with running water and $3.39 more per month for solid toilet doors, though they were willing to pay little for simple hole covers and had negative WTP for adding locks to doors (-$1.04). Solid doors and flushing toilets had higher rent increase to cost ratios than other ways landlords commonly invested in their plots, especially as the number of tenant households on a plot increased. DCEs yielded estimates generally consistent with and better specified than HPM and may be useful to estimate demand in other settings. Interventions leveraging landlords' profit motives could lead to significant improvements in peri-urban sanitation quality, reduced diarrheal disease transmission, and increased well-being without subsidies or infrastructure investments by government or NGOs

Using a theory-driven creative process to design a peri-urban on-site sanitation quality improvement intervention.

BACKGROUND: Behavior change interventions have been developed by drawing from many different theories using design processes of varying specificity. We describe the development of a behavior change intervention to improve on-site peri-urban sanitation quality in Lusaka, Zambia using the Behavior Centered Design (BCD) framework to explain the results of the process applied to improving the quality of shared peri-urban sanitation and compare them to similar interventions. METHODS: We used the BCD behavioral determinants model to synthesize the data from our literature review and formative research. Then, we partnered with creative professionals using a design process to develop a theory-driven on-site peri-urban sanitation intervention. Particular attention was paid to the implications of using BCD for intervention development on improving its effectiveness, increasing the contributions to knowledge for other behaviors and settings, and advancing the discipline of applied behavioral science. RESULTS: Based on findings from a literature review and formative research, we designed an intervention to encourage landlords to improve their toilets by making them more accessible, desirable, hygienic, and sustainable. The intervention involved landlords meeting in facilitated groups every 2 weeks with individual follow-up after each meeting. The meetings presented surprising "hidden camera"-style videos to reveal tenants' perspectives, used participatory activities to help landlords reevaluate the benefits they would derive from improving sanitation on their plots, and provided practical guidance and mechanisms to facilitate the performance of construction and cleaning behaviors. CONCLUSIONS: Using the BCD framework provided an easy-to-follow intervention design process. The resulting intervention is highly creative and multi-faceted, with each element having a theoretical role in an explicit theory of change. The development of this theory-driven intervention advances applied behavioral science by facilitating evaluation of each of the behavior change techniques and the overall delivery mechanism hypothesized to change the target behaviors. This informs the adaptation of these findings to improving on-site sanitation in other settings and the iterative development of the BCD model, which can be used to more effectively change other behaviors

Theory-driven formative research on on-site, shared sanitation quality improvement among landlords and tenants in peri-urban Lusaka, Zambia.

Rapid, unplanned urbanization in low-income countries is leading to increasing problems of dealing with human waste. On-site sanitation systems are often rudimentary, unhygienic, and poorly maintained. In-depth, on-site interactive interviews were conducted with 33 landlords and 33 tenants in a neighborhood in peri-urban Lusaka to understand on-site, shared sanitation quality improvement behaviors and preferences. Respondents were asked about housing characteristics, toilet histories, and financial decision-making. Improved, shared toilets were common (79%), but many were of low quality and poorly cleaned. Poor coordination among tenants, barriers to communication between landlords and tenants, and landlords viewing sanitation as a required basic service to provide instead of something for which tenants will pay more rent all limit the quality of sanitation in this setting. Landlord-directed interventions targeting non-health motivations for sanitation improvement and introducing effective cleaning systems may increase peri-urban sanitation quality

The social dynamics around shared sanitation in an informal settlement of Lusaka, Zambia

Abstract This study explored the social dynamics affecting collective management of shared sanitation in the Bauleni compound of Lusaka, Zambia. In-depth interviews were conducted with landlords (n = 33) and tenants (n = 33). Elinor Ostrom's eight design principles for the management of common-pool resources was used as a framework to analyse the data. Social capital within plots was also assessed. Pit latrines were predominantly shared by landlords and tenants on residential plots. However, unwelcome non-plot members also used the latrines due to a lack of physical boundaries. Not all plot members fulfilled their cleaning responsibilities equally, thereby compromising the intended benefits for those conforming. Landlords typically decided on latrine improvements independent of tenants. Latrines were not systematically monitored or maintained, but punishment for non-conformers was proportionate to the level of infraction. There was no system in place for conflict resolution, nor local organizations to regulate the management of sanitation. Lastly, there were few enterprises associated with peri-urban sanitation. Social capital was moderately high, and tenants were willing to invest money into improving sanitation. The social dynamics illuminated here provide an important basis for the development of a behavioural intervention targeted towards improving urban sanitation.</jats:p

Evaluation of user experiences for the Clean Team Ghana container-based sanitation service in Kumasi, Ghana

Abstract: There are few affordable and acceptable sanitation solutions for dense, low-income urban settlements. Though container-based toilets are a safely managed sanitation solution, little is known about user experiences to inform how such a solution should be viewed by governments. We conducted a before and after enrolment study of objective and subjective measures of sanitation quality due to the Clean Team Ghana (CTG) container-based toilet service in Kumasi, Ghana from June to December 2019. We collected data immediately prior to installation and 10 weeks afterwards for 292 customers. Most of them initially used public toilets with good structural quality, but sometimes these toilets had poor hygiene, lacked handwashing facilities, and required a 14.3-min mean time to use. We found that CTG delivered a high-quality service that positively impacted the quality of life of customers, saved them money, reduced gender gaps in the quality of life, and addressed the needs of those with physical disabilities. Problems with the CTG service, such as leaking, filling, smelling, or not being replaced as scheduled, were reported by fewer than 10% of customers. This evaluation supports the growing body of evidence that container-based sanitation provides a service valued by users in dense urban settlements

Effect of a behaviour change intervention on the quality of peri-urban sanitation in Lusaka, Zambia: a randomised controlled trial.

BACKGROUND: Poor sanitation in peri-urban areas is a growing public health problem. We tested a scalable, demand-side behaviour change intervention to motivate landlords to improve the quality of shared toilets within their plots. METHODS: We did a residential plot-randomised controlled trial in a peri-urban community in Lusaka, Zambia. We enrolled adult resident landlords on plots where at least one tenant lived. We allocated landlords 1:1 to intervention and control arms on the basis of a random number sequence. The intervention was developed using the Behaviour Centred Design approach and consisted of a series of group meetings designed to motivate sanitation quality improvement as a way to build wealth and reduce on-plot conflict; no subsidies or materials were provided. The control group received no intervention. The four primary outcomes were having a rotational cleaning system in place (to improve hygiene); having a solid door on the toilet used by tenants with an inside lock (for privacy); having an outside lock (for security); and having a sealed toilet (to reduce smell and contamination). We measured outcomes 1 month before the start of the intervention and 4 months after the end of the intervention. Data collectors measuring outcomes were blinded to group assignment. We analysed outcomes by intention to treat, including all landlords with study-end results. Because the outcomes were assumed to not be independent, we used a family-wise error rate of 0·05 to calculate an adjusted significance level of 0·0253. This study was registered with ClinicalTrials.gov, number NCT03174015. FINDINGS: Between June 9 and July 6, 2017, 1085 landlords were enrolled and randomly assigned to the intervention (n=543) or the control group (n=542). The intervention was delivered from Aug 1, 2017, and evaluated from Feb 15 to March 5, 2018. Analysis was based on the 474 intervention and 454 control landlords surveyed at study end. The intervention was associated with improvements in the prevalence of cleaning rotas (relative risk 1·16, 95% CI 1·05-1·30; p=0·0011), inside locks (1·34, 1·10-1·64; p=0·00081), outside locks (1·27, 1·06-1·52; p=0·0028), and toilets with simple covers or water seals (1·25, 1·04-1·50; p=0·0063). INTERPRETATION: It is possible to improve the structural quality and cleanliness of shared sanitation by targeting landlords with a scalable, theory-driven behaviour change intervention without subsidy or provision of the relevant infrastructure. FUNDING: Sanitation and Hygiene Applied Research for Equity

Where Shared Sanitation is the Only Immediate Option: A Research Agenda for Shared Sanitation in Densely Populated Low-Income Urban Settings.

Shared sanitation is not currently accepted within the international normative definitions of "basic" or "safely managed" sanitation. We argue that pro-poor government strategies and investment plans must include high-quality shared sanitation as an intermediate step in some densely populated urban areas. User experience must be considered in establishing the definition of high quality. We call for additional research on effective interventions to reach these quality standards and for the development of rigorous measures applicable to global monitoring