A Systematic Review of Population-Based Studies of Chronic Bowel Symptoms in Cancer Survivors following Pelvic Radiotherapy.

Pelvic radiotherapy can damage surrounding tissue and organs, causing chronic conditions including bowel symptoms. We systematically identified quantitative, population-based studies of patient-reported bowel symptoms following pelvic radiotherapy to synthesize evidence of symptom type, prevalence, and severity. Medline, CINAHL, EMBASE, and PsychINFO were searched from inception to September 2022. Following independent screening of titles, abstracts, and full-texts, population and study characteristics and symptom findings were extracted, and narrative synthesis was conducted. In total, 45 papers (prostate, n = 39; gynecological, n = 6) reporting 19 datasets were included. Studies were methodologically heterogeneous. Most frequently assessed was bowel function ('score', 26 papers, 'bother', 19 papers). Also assessed was urgency, diarrhea, bleeding, incontinence, abdominal pain, painful hemorrhoids, rectal wetness, constipation, mucous discharge, frequency, and gas. Prevalence ranged from 1% (bleeding) to 59% (anal bleeding for >12 months at any time since start of treatment). In total, 10 papers compared radiotherapy with non-cancer comparators and 24 with non-radiotherapy cancer patient groups. Symptom prevalence/severity was greater/worse in radiotherapy groups and symptoms more common/worse post-radiotherapy than pre-diagnosis/treatment. Symptom prevalence varied between studies and symptoms. This review confirms that many people experience chronic bowel symptoms following pelvic radiotherapy. Greater methodological consistency, and investigation of less-well-studied survivor populations, could better inform the provision of services and support.

Formative Research Using Settings and Motives to Explore Child Faeces Disposal and Management in Rural Solomon Islands.

Unsafe child faeces management can lead to adverse health and wellbeing outcomes for children. In Solomon Islands, diarrhoeal disease is a leading cause of under-5 mortality, though there is limited research into CFM practices and promotion of safe behaviours. The formative research applied a Behaviour-Centred Design framework to investigate the habits, motives and settings related to child faeces management in rural Solomon Islands villages. Data were collected through structured recall demonstrations by caregivers (n = 61), household infrastructure observations (n = 57), semi-structured interviews with caregivers (n = 121) and community leaders (n = 30), focus group discussions (n = 26), and three participatory activities with caregivers. The findings identified a range of CFM-related behaviours, some of which would be considered safe and some, such as outside defecation and disposal to a waterway, as unsafe. Convenience is important in shaping CFM practice and may help health benefits to be achieved without women bearing the cost of an increased work burden. Nurture and disgust may provide the basis for behaviour change communication in SI as they have elsewhere. Critically, the participation in and promotion of safe CFM by fathers in households should be promoted, and motivating such behaviours might be achieved through focus on nurture as a motive.

The effect of improving solid waste collection on waste disposal behaviour and exposure to environmental risk factors in urban low-income communities in Pakistan.

OBJECTIVE: To estimate the effect of improving waste collection services on waste disposal behaviour and exposure to environmental risk factors in urban, low-income communities in Pakistan. METHODS: We enrolled six low-income communities in Islamabad (Pakistan), four of which received an intervention consisting of a door-to-door low-cost waste collection service with centralised waste processing and recycling sites. Intervention communities underwent community-level and household-level mobilisation. The effect of the intervention on waste disposal behaviour, exposure to waste and synanthropic fly counts was measured using two cross-sectional surveys in 180 households per community. RESULTS: Intervention communities had less favourable socio-economic indicators and poorer access to waste disposal services at baseline than control communities. Use of any waste collection service increased from 5% to 49% in the intervention communities (difference 44%, 95% CI 41%, 48%), but the increase was largely confined to two communities where post-intervention coverage exceeded 80% and 90%, respectively. An increase in the use of waste collection services was also found in the two control communities (from 21% to 67%, difference 47%, 95% CI 41%, 53%). Fly counts decreased by about 60% in the intervention communities (rate ratio 0.4, 95% CI 0.3, 0.4) but not in the control communities (rate ratio 1.52, 95% CI 1.1, 2.2). The decrease in fly counts was largely confined to the two high-coverage intervention communities. CONCLUSION: Introduction of a low-cost waste collection service has the potential for high uptake in low-income communities and for decreasing the exposure to waste and synanthropic flies at household level. Intervention success was constrained by low uptake in half of the intervention communities.

A cluster-randomised trial to evaluate an intervention to promote handwashing in rural Nigeria.

Handwashing with soap at critical times helps prevent diarrhoeal diseases. Changing handwashing practices through behaviour change communication remains a challenge. This study designed and tested a scalable intervention to promote handwashing with soap. A cluster-randomised, controlled trial compared our intervention against standard practice. Subjects were men, women and children in 14 villages in Cross-River state, Nigeria. The primary outcome was the proportion of observed key events on which hands were washed with soap. Binomial regression analysis calculated prevalence differences between study arms. The intervention had minimal effect on the primary outcome (+2.4%, p = 0.096). The intervention was associated with increased frequency of handwashes without soap before food contact (+13%, p = 0.017). The intervention failed to produce significant changes in handwashing with soap at key times. The low dose delivered (two contact points) may have increased scalability at the cost of effectiveness, particularly in the challenging context of inconvenient water access.

Effects of a social norm-based handwashing intervention including handwashing stations, and a handwashing station-only intervention on handwashing with soap in urban Côte d'Ivoire: a cluster randomised controlled trial.

BACKGROUND: Diarrhoeal diseases are an important cause of mortality in children younger than 5 years in sub-Saharan Africa. We aimed to evaluate the effect of three handwashing interventions on handwashing with soap (HWWS) after toilet use. METHODS: In this cluster randomised trial in Abidjan, Côte d'Ivoire, we randomly assigned communal housing compounds (1:1:1) to receive one of three interventions: a theory of normative social behaviour (TNSB) intervention, including provision of handwashing stations; handwashing stations only; and no intervention. The TNSB intervention was designed to shift the outcome expectation associated with HWWS from health to riddance of faeces-related disgust, and to increase the perceived descriptive norm and perceived handwashing publicness. Participants and fieldworkers were masked to the study objectives. The primary outcome was HWWS after toilet use, assessed at 1 month and 5 months follow-ups. Analysis was by intention to treat. This trial is registered at the Pan African Clinical Trial Registry, PACTR201501000892239. FINDINGS: Between April 10 and May 22, 2014, we identified 92 eligible compounds, of which 75 compounds were included. Follow-up data on HWWS were available for 23 compounds for the TNSB group, 25 compounds for the handwashing station-only group, and 25 compounds for the control group. The study ended in April, 2017. Compared with a frequency of 5% (29 of 604 occasions) in the control group, HWWS after toilet use increased to 9% (49 of 557 occasions; adjusted risk ratio 1·89, 95% CI 1·16-3·08) in the handwashing station-only group, and 24% (143 of 588 occasions; 4·82, 3·06-7·59) in the TNSB group, at the 1-month follow-up. The intervention effect was only sustained in the TNSB group (98 [22%] of 450 compounds; 2·68, 1·65-4·34). INTERPRETATION: A social norm-based handwashing intervention combined with disgust-inducing messages, with provision of handwashing stations, was effective at increasing HWWS after toilet use. The provision of handwashing stations alone had little effect. Future studies should investigate whether the same approach, when delivered via mass media, can have a similar effect to the face-to-face delivery used in this study. FUNDING: None.

The Inclusion of Rights of People with Disabilities and Women and Girls in Water, Sanitation, and Hygiene Policy Documents and Programs of Bangladesh and Cambodia: Content Analysis Using EquiFrame.

People with disabilities and as women and girls face barriers to accessing water, sanitation, and hygiene (WASH) services and facilities that fully meet their needs, especially in low- and middle-income countries. Women and girls with disabilities experience double discrimination. WASH policies should support and uphold the concepts of disability and gender inclusion, and they should also act as a guide to inform WASH programs and service delivery. Using a modified version of the EquiFrame content analysis tool, this study investigated the inclusion of 21 core concepts of human rights of people with disabilities and women and girls in 16 WASH policy documents and seven end-line program reports from Bangladesh and Cambodia. Included documents typically focused on issues of accessibility and neglected wider issues, including empowerment and support for caregivers. The rights of children and women with disabilities were scarcely focused on specifically, despite their individual needs, and there was a disconnect in the translation of certain rights from policy to practice. Qualitative research is needed with stakeholders in Bangladesh and Cambodia to investigate the inclusion and omission of core rights of people with disabilities, and women and girls, as well as the factors contributing to the translation of rights from policy to practice.

Comparison of Face Washing and Face Wiping Methods for Trachoma Control: A Pilot Study.

Eye-to-eye transmission of Chlamydia trachomatis, the causative agent of trachoma, may be plausibly interrupted if faces are kept free of ocular and nasal discharge. Between April and June 2018, 83 children aged 1-9 years with active trachoma were recruited from 62 households and allocated to a face cleaning protocol: face washing with water, face washing with water and soap, or face wiping. Faces were examined for the presence of ocular and nasal discharge, and swabs were taken from faces and hands to test for C. trachomatis at baseline, immediately post protocol, and after 1, 2, and 4 hours (washing protocols). Washing with soap was more effective at removing ocular discharge than either washing with water (89% and 27% of discharge removed, respectively, P = 0.003) or wiping with a hand (42%, P = 0.013). The reduction in prevalence of ocular discharge was sustained for at least four hours. The prevalence of C. trachomatis on face swabs was reduced by all washing protocols. The importance of soap should not be overlooked during facial cleanliness promotion.

Are current approaches for measuring access to clean water and sanitation inclusive of people with disabilities? Comparison of individual- and household-level access between people with and without disabilities in the Tanahun district of Nepal.

BACKGROUND: The critical importance of safe and affordable access to water, sanitation and hygiene (WASH) is highlighted in Goal 6 of the Sustainable Development Goals, which seeks to achieve universal and equitable access for all by 2030. However, people with disabilities-who comprise 15% of the global population-frequently face difficulties meeting their WASH needs. Unmet WASH needs amongst people with disabilities may not be captured through current approaches to tracking progress towards Goal 6, which focus on household- rather than individual-level access. OBJECTIVE: To evaluate access to safe water, sanitation and hygiene (WASH), at the individual- and household-level, amongst people with disabilities in the Tanahun district of Nepal. METHODS: A population-based survey of disability was conducted from August-October 2016 to evaluate access to improved water and sanitation facilities between households with members with disabilities (n = 198) and those without (n = 1,265) in the Tanahun district of Nepal. A nested case-control then compared individual-level access between cases aged 15 and above with disabilities (n = 192) and age-sex-location matched controls without disabilities (n = 189), using the newly developed 21-item "Quality of WASH Access" questionnaire. Multivariate regression was used to compare household- and individual-level indicators between people and households with and without disabilities. In-depth interviews with 18 people with disabilities and their caregivers was conducted to assess the acceptability and appropriateness of the "Quality of WASH Access" questionnaire. FINDINGS: There were no significant differences between households with and without members with disabilities in access to an improved sanitation facility or water source. However, at the individual-level, people with disabilities experienced significantly greater difficulties accessing water, sanitation and hygiene compared to people without disabilities (p<0.001 for all three scores). Amongst people with disabilities, water difficulty scores were associated with having a physical impairment and greater disability severity; sanitation difficulty scores were associated with lower socioeconomic status and physical or self-care limitations; and hygiene difficulty scores were positively associated with self-care limitations and lower socioeconomic status, and inversely associated with hearing impairments. Qualitative research found the "Quality of WASH Access" questionnaire was well understood by participants and captured many of the challenges they faced. Additional challenges not covered by the tool included: (1) time spent on WASH, (2) consistency of access, (3) sufficiency of access, and (4) dignity of access. CONCLUSION: People with disabilities face substantial challenges to meeting their WASH needs, particularly in using services autonomously, consistently, hygienically, with dignity and privacy, and without pain or fear of abuse. These challenges are not captured through household-level data, and so individual-level WASH access are needed to monitor progress towards universal WASH access. The Quality of WASH Access questionnaire may provide a useful data collection tool.

Selecting behaviour change priorities for trachoma 'F' and 'E' interventions: A formative research study in Oromia, Ethiopia.

BACKGROUND: Trachoma is the leading infectious cause of blindness. However, little is known about the behavioural and environmental determinants of transmission of the causative organism, Chlamydia trachomatis. We conducted formative research in a trachoma hyper-endemic area of Ethiopia to explore the behaviours which are likely to contribute to trachoma transmission and map their determinants. METHODOLOGY/PRINCIPAL FINDINGS: Data on water use, hygiene, defecation, and sleeping arrangements were collected from five communities during the dry and rainy seasons in 2016. Data collection involved direct observation in households (n = 20), interviews with caregivers (n = 20) and focus group discussions (n = 11). Although several behaviours that likely contribute to trachoma transmission were identified, no single behaviour stood out as the dominant contributor. Hygiene practices reflected high levels of poverty and water scarcity. Face washing and soap use varied within and between households, and were associated with other factors such as school attendance. Children's faces were rarely wiped to remove nasal or ocular discharge, which was not perceived to be socially undesirable. Bathing and laundry were performed infrequently due to the amount of time and water required. Open defecation was a normative practice, particularly for young children. Latrines, when present, were poorly constructed, maintained and used. Young children and parents slept closely together and shared bedding that was infrequently washed. CONCLUSIONS/SIGNIFICANCE: Existing norms and enabling factors in this context favour the development of interventions to improve facial cleanliness as more feasible than those that reduce unsafe faeces disposal. Interventions to increase the frequency of bathing and laundry may also be infeasible unless water availability within the home is improved.

Lasting results: A qualitative assessment of efforts to make community-led total sanitation more inclusive of the needs of people with disabilities in Rumphi District, Malawi.

BACKGROUND: In low-income countries, like Malawi, approaches aimed at improving access to household sanitation for persons with disabilities have been limited, and often do not include post-intervention process evaluations. 6% of Malawi's population reports defecating outside rather than in a sanitation facility, and 4% of its population live with a disability; these groups of individuals live predominantly in rural areas. OBJECTIVE: This article describes a post-program evaluation of an inclusive Community-Led Total Sanitation program that specifically responds to household-level needs of people with disabilities in Rumphi District, Malawi. METHODS: Data collected from safety and accessibility audits of household latrines used by persons with disabilities and interviews with implementers at 18 months post-intervention were used to determine sustainability. RESULTS: The household latrine audit results show that existing conditions for sanitation access are still not optimal for persons with disabilities and that changes may require more time to be implemented. Some of the training program steps had more lasting impact on the implementers than other steps, such as the squatting exercise. There was limited evidence implementers had made additional changes or innovations or had transferred their knowledge more widely to other implementers. There is also a need to ensure local vernacular is available to mitigate the social stigma associated with people with disabilities. CONCLUSIONS: Implications for future replication show the need to invest in training a wider group of people to assist with implementation and to keep the program simple and focused on more active learning methods to make sustainable behavioral changes.

Effect of Neighborhood Sanitation Coverage on Fecal Contamination of the Household Environment in Rural Bangladesh.

Enteric pathogens can be transmitted within the household and the surrounding neighborhood. The objective of this study was to understand the effect of neighborhood-level sanitation coverage on contamination of the household environment with levels of fecal indicator bacteria in rural Bangladesh. We conducted spot-check observations of sanitation facilities in neighboring households (NHs) within a 20-m radius of target households with children aged 6-24 months. Sanitation facilities were defined as improved (a private pit latrine with a slab or better) or unimproved. Fecal coliforms (FCs) on children's hands and sentinel toy balls were measured and used as indicators of household-level fecal contamination. We visited 1,784 NHs surrounding 428 target households. On average, sentinel toy balls had 2.11(standard deviation [SD] = 1.37) log10 colony-forming units (CFUs) of FCs/toy ball and children's hands had 2.23 (SD = 1.15) log10 CFU of FCs/two hands. Access to 100% private improved sanitation coverage in the neighborhood was associated with a small and statistically insignificant difference in contamination of sentinel toy balls (difference in means = -0.13 log10 CFU/toy ball; 95% confidence intervals [CI]: -0.64, 0.39; P = 0.63) and children's hands (difference in means = -0.11 log10 CFU/two hands; 95% CI: -0.53, 0.32; P = 0.62). Improved sanitation coverage in the neighborhood had limited measurable effect on FCs in the target household environment. Other factors such as access to improved sanitation in the household, absence of cow dung, presence of appropriate water drainage, and optimal handwashing practice may be more important in reducing FCs in the household environment.

Exploring the links between water, sanitation and hygiene and disability; Results from a case-control study in Guatemala.

OBJECTIVE: To assess the Water, Sanitation and Hygiene (WASH) access and appropriateness of people with disabilities compared to those without, in Guatemala. METHODS: A case-control study was conducted, nested within a national survey. The study included 707 people with disabilities, and 465 age- and sex-matched controls without disabilities. Participants reported on WASH access at the household and individual level. A sub-set of 121 cases and 104 controls completed a newly designed, in-depth WASH questionnaire. RESULTS: Households including people with disabilities were more likely to use an improved sanitation facility compared to control households (age-sex-adjusted OR: 1.7, 95% CI 1.3-2.5), but otherwise there were no differences in WASH access at the household level. At the individual level, people with disabilities reported greater difficulties in relation to sanitation (mean score 26.2, SD 26.5) and hygiene access and quality (mean 30.7, SD 24.2) compared to those without disabilities (15.5, 21.7, p<0.001; 22.4, 19.1, p<0.01). There were no differences in different aspects of water collection between people with and without disabilities in this context where over 85% of participants had water piped into their dwelling. Among people with disabilities, older adults were more likely to experience difficulties in hygiene and sanitation than younger people with disabilities. CONCLUSIONS: People with disabilities in Guatemala experience greater difficulties in accessing sanitation facilities and practicing hygienic behaviours than their peers without disabilities. More data collection is needed using detailed tools to detect these differences, highlight which interventions are needed, and to allow assessment of their effectiveness.

Access to water and sanitation among people with disabilities: results from cross-sectional surveys in Bangladesh, Cameroon, India and Malawi.

OBJECTIVES: To assess access to adequate water, sanitation and hygiene (WASH) among people with disabilities at the household and individual level. DESIGN: Cross-sectional surveys. SETTING: Data were included from five district-level or regional-level surveys: two in Bangladesh (Bangladesh-1, Bangladesh-2), and one each in Cameroon, Malawi and India. PARTICIPANTS: 99 252 participants were sampled across the datasets (range: 3567-75 767), including 2494 with disabilities (93-1374). OUTCOME: Prevalence of access to WASH at household and individual level. DATA ANALYSIS: Age/sex disaggregated disability prevalence estimates were calculated accounting for survey design. The Unicef/WHO Joint Monitoring Programme definitions were used to classify facilities as improved/unimproved. Multivariable logistic regression was undertaken to compare between households with/without a person with a disability, and to identify predictors of access among people with disabilities. RESULTS: There were no differences in access to improved sanitation or water sources between households with/without members with disabilities across the datasets. In Bangladesh-2, households including a person with a disability were more likely to share facilities with other households (OR 1.3, 95% CI 1.1 to 1.5). Households with people with disabilities were more likely to spend >30 min (round-trip) collecting drinking water than households without in both Cameroon (OR 1.8, 95% CI 1.0 to 3.4) and India (OR 2.3, 95% CI 1.2 to 4.7). Within households, people with disabilities reported difficulties collecting water themselves (23%-80% unable to) and accessing the same sanitation facilities as other household members, particularly without coming into contact with faeces (up to 47% in Bangladesh-2). These difficulties were most marked for people with more severe impairments. CONCLUSIONS: People with disabilities may not have poorer access to WASH at the household level, but may have poorer quality of access within their households. Further programmatic work is needed to ensure WASH facilities are inclusive of people with disabilities.

A Cross Sectional Study of the Association between Sanitation Type and Fecal Contamination of the Household Environment in Rural Bangladesh.

We conducted a cross sectional study to assess 1) the association between access to basic sanitation and fecal contamination of sentinel toy balls and 2) if other sanitation factors such as shared use and cleanliness are associated with fecal contamination of sentinel toy balls. We assessed sanitation facilities in 454 households with a child aged 6-24 months in rural Bangladesh. We defined "basic" sanitation as access to improved sanitation facilities (pit latrine with a slab or better) not shared with other households. In each household, an identical toy ball was given to the target child. After 24 hours, the balls were rinsed to enumerate fecal coliforms as an indicator of household fecal contamination. Households with basic sanitation had lower fecal coliform contamination than households with no access to basic sanitation (adjusted difference in means: -0.31 log10 colony forming units [CFU]/toy ball; 95% confidence interval [CI]: -0.61, -0.01). Shared sanitation facilities of otherwise improved type were more likely to have visible feces on the latrine slab compared with private facilities. Among households with access to improved sanitation, households with no visible feces on the latrine slab had less toy ball contamination than households with visible feces on the latrine slab (adjusted difference in means: -0.38 log10 CFU/toy ball; 95% CI: -0.77, 0.02). Access to basic sanitation may prevent fecal contamination of the household environment. An Improved sanitation facility used by an individual household may be better in preventing household fecal contamination compared with improved facilities shared with other households.

A Cluster-Randomized Trial to Evaluate the Impact of an Inclusive, Community-Led Total Sanitation Intervention on Sanitation Access for People with Disabilities in Malawi.

Community-led total sanitation (CLTS) is a common method for promoting sanitation in low-income settings. This cluster-randomized trial evaluated an intervention to improve inclusion of people with disability in CLTS through training facilitators. A qualitative study examined intervention acceptability. The trial included 171 people with disabilities (78 control and 93 intervention) living in 15 intervention and 15 control communities. In the intervention arm, respondents were more likely to participate in a community meeting about sanitation (+18.7%, 95% confidence interval [CI]: 3.2, 34.2) and to have been visited to discuss sanitation (+19.7, 95% CI: 0.6, 37.8). More intervention households improved latrine access for the disabled member (+9%, CI: -3.1, 21.0). Inclusive CLTS could improve sanitation access for people with disability but requires support to households beyond that provided in this trial.

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.

A Qualitative Study of Barriers to Accessing Water, Sanitation and Hygiene for Disabled People in Malawi.

Globally, millions of people lack access to improved water, sanitation and hygiene (WASH). Disabled people, disadvantaged both physically and socially, are likely to be among those facing the greatest inequities in WASH access. This study explores the WASH priorities of disabled people and uses the social model of disability and the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework to look at the relationships between impairments, contextual factors and barriers to WASH access. 36 disabled people and 15 carers from urban and rural Malawi were purposively selected through key informants. The study employed a range of qualitative methods including interviews, emotion mapping, free-listing of priorities, ranking, photo voice, observation and WASH demonstrations. A thematic analysis was conducted using nVivo 10. WASH access affected all participants and comprised almost a third of the challenges of daily living identified by disabled people. Participants reported 50 barriers which related to water and sanitation access, personal and hand hygiene, social attitudes and participation in WASH programs. No two individuals reported facing the same set of barriers. This study found that being female, being from an urban area and having limited wealth and education were likely to increase the number and intensity of the barriers faced by an individual. The social model proved useful for classifying the majority of barriers. However, this model was weaker when applied to individuals who were more seriously disabled by their body function. This study found that body function limitations such as incontinence, pain and an inability to communicate WASH needs are in and of themselves significant barriers to adequate WASH access. Understanding these access barriers is important for the WASH sector at a time when there is a global push for equitable access.

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.

Use of Electronic Loggers to Measure Changes in the Rates of Hand Washing with Soap in Low-Income Urban Households in India.

We evaluated the utility of electronic loggers to measure the effects of a simple intervention designed to influence the rates of hand washing with soap within enclosed toilets and bathrooms in low-income urban households in Kerala, India. 58 households were given three items with embedded electronic loggers for a period of 2-5 days. Two logged soaps tracked hand and body washing in the bathroom. The third logged item was a water vessel used for flushing the toilet and for post-defecation anal cleansing; this served as a marker of toilet use. In addition, 28 households in a Soap by toilet arm were given an additional logged soap, to be kept by the toilet, and used for hand washing. Compared with the Soap in bathroom arm, the loggers in the Soap by toilet households recorded 73% greater daily use of soaps designated for hand washing (t(36)=2.92, p<0.01) and 172% greater use within 2 minutes of the use of the water vessel (t(36)=3.51, p = 0.001). We conclude that the loggers were capable of detecting changes in the rates of hand washing with soap and changes in hand washing with soap after use of the toilet. Further adoption of logger technologies would enable more insightful studies of hand washing within urban environments.

Use of behavior change techniques in clean cooking interventions: a review of the evidence and scorecard of effectiveness.

Despite decades of effort, around 2.8 billion people still rely on solid fuels to meet domestic energy needs. There is robust evidence this causes premature death and chronic disease, as well as wider economic, social, and environmental problems. Behavior change interventions are effective to reduce exposure to harm such as household air pollution, including those using health communications approaches. This article reports the findings of a project that reviewed the effectiveness of behavior change approaches in cleaner cooking interventions in resource-poor settings. The authors synthesized evidence of the use of behavior change techniques, along the cleaner cooking value chain, to bring positive health, economic, and environmental impacts. Forty-eight articles met the inclusion criteria, which documented 55 interventions carried out in 20 countries. The groupings of behavior change techniques most frequently used were shaping knowledge (n = 47), rewards and threats (n = 35), social support (n = 35), and comparisons (n = 16). A scorecard of behavior change effectiveness was developed to analyze a selection of case study interventions. Behavior change techniques have been used effectively as part of multilevel programs. Cooking demonstrations, the right product, and understanding of the barriers and benefits along the value chain have all played a role. Often absent are theories and models of behavior change adapted to the target audience and local context. Robust research methods are needed to track and evaluate behavior change and impact, not just technology disseminated. Behavior change approaches could then play a more prominent role as the "special sauce" in cleaner cooking interventions in resource poor settings.