Testing community-led approaches for scalability: project briefing

Community-Led Total Sanitation is an approach to create community-wide sanitation and hygiene behaviour change. The CLTS approach has been scaled rapidly to over 50 countries, but limited rigorous evidence on cost-effectiveness and scalability has been generated. The Testing CLTS Approaches for Scalability project is a four-year partnership between Plan International and the Water Institute at the University of North Carolina to collect, criticality evaluate, and disseminate practical lessons learned about implementing CLTS at scale. Learnings are based on rigorous applied research from a systematic literature review and a variety of research activities in 12 countries. This briefing shares a summary of the project, the research designs used, and preliminary findings

Moving from rabies research to rabies control: lessons from India

BACKGROUND: Despite the availability of effective interventions and public recognition of the severity of the problem, rabies continues to suffer neglect by programme planners in India and other low and middle income countries. We investigate whether this state of 'policy impasse' is due to, at least in part, the research community not catering to the information needs of the policy makers. METHODS & FINDINGS: Our objective was to review the research output on rabies from India and examine its alignment with national policy priorities. A systematic literature review of all rabies research articles published from India between 2001 and 2011 was conducted. The distribution of conducted research was compared to the findings of an earlier research prioritization exercise. It was found that a total of 93 research articles were published from India since 2001, out of which 61% consisted of laboratory based studies focussing on rabies virus. Animals were the least studied group, comprising only 8% of the research output. One third of the articles were published in three journals focussing on vaccines and infectious disease epidemiology and the top 4 institutions (2 each from the animal and human health sectors) collectively produced 49% of the national research output. Biomedical research related to development of new interventions dominated the total output as opposed to the identified priority domains of socio-politic-economic research, basic epidemiological research and research to improve existing interventions. CONCLUSION: The paper highlights the gaps between rabies research and policy needs, and makes the case for developing a strategic research agenda that focusses on rabies control as an expected outcome

In pursuit of ‘safe’ water: the burden of personal injury from water fetching in 21 low-income and middle income countries

Introduction: Water fetching for household needs can cause injury, but documentation of the burden of harm globally has been limited. We described the frequency, characteristics and correlates of water-fetching injuries in 24 sites in 21 low-income and middle-income countries in Asia, Africa and Latin America and the Caribbean. Methods: In a survey of 6291 randomly selected households, respondents reported whether and how they had experienced water-fetching injuries. Responses were coded for injury type, mechanism, bodily location and physical context. We then identified correlates of injury using a multilevel, mixed-effects logistic regression model. Results: Thirteen per cent of respondents reported at least one water-fetching injury. Of 879 injuries, fractures and dislocations were the most commonly specified type (29.2%), and falls were the most commonly specified mechanism (76.4%). Where specified, 61.1% of injuries occurred to the lower limbs, and dangerous terrain (69.4%) was the most frequently reported context. Significant correlates included being female (OR 1.50, 95% CI 1.15 to 1.96); rural (OR 4.80, 95% CI 2.83 to 8.15) or periurban residence (OR 2.75, 95% CI 1.64 to 4.60); higher household water insecurity scores (1.09, 95% CI 1.07 to 1.10) and reliance on surface water (OR 1.97, 95% CI 1.21 to 3.22) or off-premise water sources that required queueing (OR 1.72, 95% CI 1.19 to 2.49). Conclusion These data suggest that water-fetching injuries are an underappreciated and largely unmeasured public health challenge. We offer guidelines for comprehensive data collection on injuries to better capture the true burden of inadequate water access. Such data can guide the design of interventions to reduce injury risk and promote equitable water access solutions

Community-Led Total Sanitation: A Mixed-Methods Systematic Review of Evidence and Its Quality

Background: Community-led total sanitation (CLTS) is a widely applied rural behavior change approach for ending open defecation. However, evidence of its impact is unclear. Objectives: We conducted a systematic review of journal-published and gray literature to a) assess evidence quality, b) summarize CLTS impacts, and c) identify factors affecting implementation and effectiveness. Methods: Eligible studies were systematically screened and selected for analysis from searches of seven databases and 16 websites. We developed a framework to appraise literature quality. We qualitatively analyzed factors enabling or constraining CLTS, and summarized results from quantitative evaluations. Discussion: We included 200 studies (14 quantitative evaluations, 29 qualitative studies, and 157 case studies). Journal-published literature was generally of higher quality than gray literature. Fourteen quantitative evaluations reported decreases in open defecation, but did not corroborate the widespread claims of open defecation–free (ODF) villages found in case studies. Over one-fourth of the literature overstated conclusions, attributing outcomes and impacts to interventions without an appropriate study design. We identified 43 implementation- and community-related factors reportedly affecting CLTS. This analysis revealed the importance of adaptability, structured posttriggering activities, appropriate community selection, and further research on combining and sequencing CLTS with other interventions. Conclusions: The evidence base on CLTS effectiveness available to practitioners, policy makers, and program managers to inform their actions is weak. Our results highlight the need for more rigorous research on CLTS impacts as well as applied research initiatives that bring researchers and practitioners together to address implementation challenges to improve rural sanitation efforts

Identifying sources, pathways and risk drivers in ecosystems of Japanese Encephalitis in an epidemic-prone north Indian district

Japanese Encephalitis (JE) has caused repeated outbreaks in endemic pockets of India. This study was conducted in Kushinagar, a highly endemic district, to understand the human-animal-ecosystem interactions, and the drivers that influence disease transmission. Utilizing the ecosystems approach, a cross-sectional, descriptive study, employing mixed methods design was employed. Four villages (two with pig-rearing and two without) were randomly selected from a high, a medium and a low burden (based on case counts) block of Kushinagar. Children, pigs and vectors were sampled from these villages. A qualitative arm was incorporated to explain the findings from the quantitative surveys. All human serum samples were screened for JE-specific IgM using MAC ELISA and negative samples for JE RNA by rRT-PCR in peripheral blood mononuclear cells. In pigs, IgG ELISA and rRT-PCR for viral RNA were used. Of the 242 children tested, 24 tested positive by either rRT-PCR or MAC ELISA; in pigs, 38 out of the 51 pigs were positive. Of the known vectors, Culex vishnui was most commonly isolated across all biotopes. Analysis of 15 blood meals revealed human blood in 10 samples. Univariable analysis showed that gender, religion, lack of indoor residual spraying of insecticides in the past year, indoor vector density (all species), and not being vaccinated against JE in children were significantly associated with JE positivity. In multivariate analysis, only male gender remained as a significant risk factor. Based on previous estimates of symptomatic: asymptomatic cases of JE, we estimate that there should have been 618 cases from Kushinagar, although only 139 were reported. Vaccination of children and vector control measures emerged as major control activities; they had very poor coverage in the studied villages. In addition, lack of awareness about the cause of JE, lack of faith in the conventional medical healthcare system and multiple referral levels causing delay in diagnosis and treatment emerged as factors likely to result in adverse clinical outcomes

One Size Does Not Fit All: Analyzing Variations in the Implementation of Community-Led Total Sanitation

An estimated 946 million people in the world practiced open defecation in 2015, 90% of whom lived in rural areas Poor sanitation poses a substantive environmental health and development challenge. Community-led total sanitation (CLTS) has become the predominant behavior change approach to improve sanitation in rural communities in lower income countries. It is acknowledged as flexible and context-specific, but a systematic analysis of its implementation was lacking. The purpose of this dissertation was to study the context and process of CLTS implementation in various settings to identify factors that influence implementation and thereby, outcomes of the intervention. I conducted a systematic literature review of the available evidence on CLTS to document adaptations, effectiveness on sanitation and health outcomes, and quality of evidence. I found that the diffusion of CLTS worldwide was backed by minimal rigorous evidence of its effectiveness. I also found that, although CLTS adaptations had been widely documented by practitioners, no study had characterized adaptations to understand how best to structure programs to improve their effectiveness in various settings. Therefore, I analyzed adaptations through qualitative case studies of CLTS implementation in seven countries. Data collection included interviews with 293 respondents, and 34 community visits. Rather than being a “community-led” approach, I found that CLTS can be categorized into three broad implementation modalities: NGO-led CLTS, government-led CLTS, and mixed leadership of CLTS. I applied an implementation research framework to these case studies to systematically analyze context and process factors that influence CLTS implementation. This framework serves as both a hypothesis generating tool for researchers and a diagnostic tool for practitioners. My work suggests that an honest exploration and understanding of CLTS implementation is vital to identify improvements, to understand the potential of the approach to achieve desired outcomes, and to recognize ways in which it can be implemented to improve rural sanitation in different contexts and settings. By building a stronger evidence base of mixed methods, and offering concrete tools and recommendations for practitioners and policymakers, the aim is to bridge the gaps between academic implementation theory, ambitious policymaking, and dynamic CLTS practice to improve sanitation programs.Doctor of Philosoph

Rabies control initiative in Tamil Nadu, India: a test case for the ‘One Health’ approach

Although India accounts for nearly 50\% of the global rabies mortality, there is no organised national rabies control programme. Rabies control is generally confined to small urban pockets, with minimal intersectoral co-ordination. Tamil Nadu is the first state in India to implement a state-wide, multisectoral rabies control initiative. The CDC Program Evaluation Framework guided the current assessment of this rabies prevention and control initiative in Tamil Nadu. Principle stakeholders were engaged through a series of interviews in order to document policy initiatives, to describe the programme and to understand their various roles. Surveillance data on dog bites were triangulated with vaccine consumption and dog population data to identify trends at the district level in the state. Findings and recommendations were shared at different levels. Rabies control activities in Tamil Nadu were conducted by separate departments linked by similar objectives. In addition to public health surveillance, animal census and implementation of dog licensing rules, other targeted interventions included waste management, animal birth control and anti-rabies vaccination, awareness campaigns, and widespread availability of anti-rabies vaccine at all public health facilities. In conclusion, this assessment suggests that it is possible to implement a successful ‘One Health’ programme in an environment of strong political will, evidence-based policy innovations, clearly defined roles and responsibilities of agencies, co-ordination mechanisms at all levels, and a culture of open information exchange

The deubiquitinases USP33 and USP20 coordinate β2 adrenergic receptor recycling and resensitization

Agonist-induced ubiquitination of the β2 adrenergic receptor (β2AR) functions as an important post-translational modification to sort internalized receptors to the lysosomes for degradation. We now show that this ubiquitination is reversed by two deubiquitinating enzymes, ubiquitin-specific proteases (USPs) 20 and 33, thus, inhibiting lysosomal trafficking when concomitantly promoting receptor recycling from the late-endosomal compartments as well as resensitization of recycled receptors at the cell surface. Dissociation of constitutively bound endogenously expressed USPs 20 and 33 from the β2AR immediately after agonist stimulation and reassociation on prolonged agonist treatment allows receptors to first become ubiquitinated and then deubiquitinated, thus, providing a ‘trip switch' between degradative and recycling pathways at the late-endosomal compartments. Thus, USPs 20 and 33 serve as novel regulators that dictate both post-endocytic sorting as well as the intensity and extent of β2AR signalling from the cell surface

Proportional distribution of rabies research articles in India across research categories.

<p>Proportional distribution of rabies research articles in India across research categories.</p

Rabies research output, categorized by research factorials [<b>12</b>].

<p>Rabies research output, categorized by research factorials <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0001748#pntd.0001748-Hamburg1" target="_blank">[<b>12</b>]</a>.</p