Study design and baseline to evaluate water service provision among peri-urban communities in Kasai Oriental, Democratic Republic of the Congo.

We present a study design and baseline results to establish the impact of interventions on peri-urban water access, security and quality in Kasai Oriental province of the Democratic Republic of the Congo. In standard development practice, program performance is tracked via monitoring and evaluation frameworks of varying sophistication and rigor. Monitoring and evaluation, while usually occurring nearly concurrently with program delivery, may or may not measure parameters that can identify performance with respect to the project's overall goals. Impact evaluations, often using tightly controlled trial designs and conducted over years, challenge iterative program evolution. This study will pilot an implementation science impact evaluation approach in the areas immediately surrounding 14 water service providers, at each surveying 100 randomly-selected households and conducting water quality assessments at 25 randomly-selected households and five water points every three months. We present preliminary point-of-collection and point-of-use baseline data. This study is utilizing a variety of short- and medium-term monitoring and impact evaluation methods to provide feedback at multiple points during the intervention. Rapid feedback monitoring will assess the continuity of water services, point-of-consumption and point-of-collection microbial water quality, household water security, household measures of health status, ability and willingness to pay for water and sanitation service provision, and service performance monitoring. Long-term evaluation will focus on the use of qualitative comparative analysis whereby we will investigate the combination of factors that lead to improved water access, security and quality.

Improving the Reliability of Water Service Delivery in Rural Kenya through Professionalized Maintenance: A System Dynamics Perspective.

Reliable water service delivery continues to be a complex global issue that is particularly challenging in rural communities. Despite billions of dollars of infrastructure interventions, sustainable water services remain out of reach for millions of people. Professionalized maintenance services have emerged as a service provision strategy to supplement the community-based rural water management approach. This study applies system dynamics modeling to assess the potential impact of scaling up professionalized maintenance services on piped water systems in Kitui County, Kenya. The study results show that over a 10 year simulation, calibrated with 21 months of empirical data and based on a range of key assumptions, delivery of professionalized maintenance services across the county may increase countywide functionality rates from 54% to over 83%, leading to a 67% increase in water production. Furthermore, the increase in preventive maintenance activities and proactive repairs can lead to less frequent major breakdowns and reduction in county government spending on major repairs by over 60%. However, current service fee income from communities accounts for 8% of the total cost of service, necessitating substantial sustained external financing or government subsidies to be financially viable at scale.

Pathways to consumer demand and payment for professional rural water infrastructure maintenance across low-income contexts.

Systems for regular, preventive maintenance of infrastructure are needed to ensure safe water access globally. Emerging and growing across rural sub-Saharan Africa, professionalized maintenance arrangements feature legal, regulated service providers who maintain infrastructure in exchange for consumer payment through contracts. However, little is understood about the conditions that enable service providers to retain consumer contracts, an important component of their sustainability that indicates consistent demand and payment. This paper uses fuzzy-set Qualitative Comparative Analysis to identify combinations of operational, natural, physical, political, and social conditions enabling high contract retention across 22 implementation cases in Uganda, uncovering 2 pathways to success. In both pathways, consistent expansion by the service provider normalizes concepts such as tariff payment and local government participation increases trust and accountability between the service provider and consumers. The predominant pathway features one additional condition, coordinated sector aid, ensuring consistent implementation and mitigating harmful dependencies. The alternative pathway relies on large user communities and ease of access to those communities to counteract uncoordinated aid. Thus, operational, social, and political conditions may be sufficient to enable high contract retention irrespective of natural and physical conditions. This paper uncovers the combined efforts required of service providers, service authorities, international donors, and local aid actors to ensure the sustainable maintenance of rural water infrastructure for reliable safe water access.

Pathways for collaboratively strengthening water and sanitation systems.

Collaborative approaches are seen as a promising way to strengthen Water, Sanitation, and Hygiene (WASH) service delivery systems when challenges exceed the mandates and capabilities of any single entity. While collaborative approaches are well studied in high-income country contexts, current understanding of their application to international development contexts is limited. This paper uses fuzzy-set Qualitative Comparative Analysis to assess what conditions and pathways drove or impeded progress within eleven collaborative approaches for WASH service delivery in Eastern Africa. Evidence supported three main findings: (1) Government uptake of recommendations is necessary for progress but cannot be guaranteed solely by government participation in the collaboration, (2) different forms of problem identification are possible; problem scopes are often predefined to align with funders and partner government agendas, but flexible scopes that foster collective problem identification can reap benefits, and (3) hub convening power can be critical and convening power can be gained in different ways. Political dynamics, shifting priorities, and turnover undermine collaborative efforts, but collaborative approaches can still make progress in spite of turnover if funds are available for implementation of activities (i.e. in addition to funds for meetings and hub roles) and program implementers either facilitate collective problem identification or establish a hub with convening power. Yet even these tactics are vulnerable to instability, thus in highly unstable contexts, stakeholders and funders should be realistic from the outset about what they may be able to achieve. Building on existing theories of collaborative approaches, this work revealed that there is no single best design for collaborative approaches in WASH, rather, core elements worked together in different ways depending on the context.

Household Preferences for Rural Fecal Sludge Management Services in Cambodia: A Discrete Choice Experiment.

Continued access to sanitation and the improvements to public health that it provides requires safe fecal sludge management (FSM). Trained service providers offer the best path to achieve safe FSM in rural communities, but this service industry is hindered by a lack of understanding household valuation of FSM services in rural Cambodia. Using a discrete choice experiment, we characterize rural households' preferences for four different FSM-service attributes across five provinces. We find that rural households prefer preventing contact with fecal sludge (FS) most among the tested FSM-service attributes, followed by reducing foul odor and producing fertilizer from FS. Reducing time to service delivery was also preferred comparably to producing fertilizer from FS when time to service delivery increased to 4 weeks. Preferences were also analyzed by province, poverty, and education, providing regional and demographic-specific results. Based on the study's results, we recommend that Cambodia's rural sanitation sector develop an FSM-service model that focuses on preventing human contact with FS. Premium levels of service that reduce foul odor and/or provide fertilizer from FS should be offered. Development practitioners should consider the strong preference heterogeneity for FSM-service attributes of households across and within provinces and demographics. These recommendations will provide practical benefits to FSM safety and ultimately improve public health.

System Approaches to Water, Sanitation, and Hygiene: A Systematic Literature Review.

Endemic issues of sustainability in the water, sanitation, and hygiene (WASH) sector have led to the rapid expansion of 'system approaches' for assessing the multitude of interconnected factors that affect WASH outcomes. However, the sector lacks a systematic analysis and characterization of the knowledge base for systems approaches, in particular how and where they are being implemented and what outcomes have resulted from their application. To address this need, we conducted a wide-ranging systematic literature review of systems approaches for WASH across peer-reviewed, grey, and organizational literature. Our results show a myriad of methods, scopes, and applications within the sector, but an inadequate level of information in the literature to evaluate the utility and efficacy of systems approaches for improving WASH service sustainability. Based on this analysis, we propose four recommendations for improving the evidence base including: diversifying methods that explicitly evaluate interconnections between factors within WASH systems; expanding geopolitical applications; improving reporting on resources required to implement given approaches; and enhancing documentation of effects of systems approaches on WASH services. Overall, these findings provide a robust survey of the existing landscape of systems approaches for WASH and propose a path for future research in this emerging field.

Analyzing Sanitation Sustainability Assessment Frameworks for Resource-Limited Communities.

Diverse and numerous sanitation sustainability assessment frameworks have been created to enhance the ability of systems to provide safe sanitation services, especially in resource-limited contexts. However, many go unused while new frameworks are developed and high sanitation system failure rates persist. To better support the sustainable development goal around global sanitation, there is a need to better understand how sanitation sustainability is defined and measured and the potential advantages and disadvantages of existing assessment frameworks. A subset of existing sanitation sustainability assessment frameworks was reviewed after applying each to evaluate multiple successful and failed community sanitation systems in India. Overall, the evaluated frameworks did not share a sanitation sustainability definition or core set of essential indicators. Many indicators lacked clear definitions and guidance on data collection and analysis. When evaluating framework effectiveness, differentiations between successful and failed cases varied greatly between frameworks. Potential improvements include indicator pilot testing to verify measurement feasibility and that they provide expected results; context-specific weightings; and project-specific framework selection. Clarifying and improving sanitation sustainability assessment frameworks could increase their effectiveness and use, leading to better decision-making and improved public and environmental health, economic viability, and sanitation use and acceptance.

Assessing the impact of household participation on satisfaction and safe design in humanitarian shelter projects.

Participation has long been considered important for post-disaster recovery. Establishing what constitutes participation in post-disaster shelter projects, however, has remained elusive, and the links between different types of participation and shelter programme outcomes are not well understood. Furthermore, recent case studies suggest that misguided participation strategies may be to blame for failures. This study analysed 19 shelter projects implemented in the Philippines following Typhoon Haiyan in November 2013 to identify the forms of participation employed. Using fuzzy-set qualitative comparative analysis, it assessed how household participation in the planning, design, and construction phases of shelter reconstruction led to outcomes of household satisfaction and safe shelter design. Participation was operationalised via eight central project tasks, revealing that the involvement of households in the early planning stages of projects and in construction activities were important for satisfaction and design outcomes, whereas engagement during the design phase of projects had little impact on the selected outcomes.

The use of qualitative comparative analysis to identify pathways to successful and failed sanitation systems.

Sanitation systems globally fail at high rates. Researchers and practitioners attribute the causes of both sanitation success and failure to numerous factors that include technical and non-technical issues. A comprehensive understanding of what leads to sanitation failure and how to achieve sanitation success is imperative to prioritize the use of limited resources. To determine which combinations of causal conditions led to successful and failed sanitation systems, we applied fuzzy-set qualitative comparative analysis to 20 cases in Karnataka and Tamil Nadu, India with small-scale sanitation systems. Two pathways led to successful sanitation systems, and four pathways led to failed sanitation systems. All successful systems required Sufficient O&M Funds, a Clear O&M Plan, and Technical Support in addition to either Addressed Sanitation Priorities and Community Participation in Planning or Behavior Change Education and Municipality Involved in Planning. All failed systems had Lack of Municipality in Planning, Unaddressed Sanitation Priorities, and No Technical Support. Most failed systems also had No Clear O&M Plan, Poor Construction Quality, Lack of Community Participation in Planning, and Insufficient O&M Funds. Two failed cases had unique pathways because Government Barriers permanently disrupted use and maintenance. Overall, implementing organizations who initiate sanitation projects in resource-limited communities should ensure that (1) communities have adequate technical and financial resources for maintenance; (2) community and municipality stakeholders are engaged in planning and know their maintenance responsibilities; and (3) appropriate technologies are selected that meet community needs and achieve community buy-in.

Priority Addressment Protocol: Understanding the Ability and Potential of Sanitation Systems to Address Priorities.

Sanitation acceptance is unlikely if user priorities are not addressed. However, sanitation systems are commonly implemented, especially in resource-limited communities, without incorporating local context. Understanding sanitation systems' abilities to address different priorities will further inform technology selection processes. Therefore, a protocol was created to identify priorities and measure how well sanitation systems address them, based upon their importance to a community. This protocol was applied to 20 community-based sanitation systems in India. Overall, 52 sanitation and 40 community priorities were identified; most, along with their relative importance, were case-specific and not yet identified in literature. Existing sanitation systems poorly addressed priorities. Nonfunctional systems addressed the fewest, but, if use and maintenance were improved, they had the potential to address priorities almost as well as functional systems. Resource recovery systems addressed the most priorities, but there was usually minimal benefit to adding all three resources to an existing system; biogas and water had greater potential to address more priorities than compost. This priority addressment protocol can help identify the most appropriate technologies and strategies to improve technology development and success.

Identifying Electronic Health Record Usability And Safety Challenges In Pediatric Settings.

Pediatric populations are uniquely vulnerable to the usability and safety challenges of electronic health records (EHRs), particularly those related to medication, yet little is known about the specific issues contributing to hazards. To understand specific usability issues and medication errors in the care of children, we analyzed 9,000 patient safety reports, made in the period 2012-17, from three different health care institutions that were likely related to EHR use. Of the 9,000 reports, 3,243 (36 percent) had a usability issue that contributed to the medication event, and 609 (18.8 percent) of the 3,243 might have resulted in patient harm. The general pattern of usability challenges and medication errors were the same across the three sites. The most common usability challenges were associated with system feedback and the visual display. The most common medication error was improper dosing.

A Heuristic Evaluation to Assess Use of After Visit Summaries for Supporting Continuity of Care.

BACKGROUND: Outpatient providers often do not receive discharge summaries from acute care providers prior to follow-up visits. These outpatient providers may use the after-visit summaries (AVS) that are given to patients to obtain clinical information. It is unclear how effectively AVS support care coordination between clinicians. OBJECTIVES: Goals for this effort include: (1) developing usability heuristics that may be applied both for assessment and to guide generation of medical documents in general, (2) conducting a heuristic evaluation to assess the use of AVS for communication between clinicians, and (3) providing recommendations for generating AVS that effectively support both patient/caregiver use and care coordination. METHODS: We created a 17-item heuristic evaluation instrument for assessing usability of medical documents. Eight experts used the instrument to assess each of four simulated AVS. The simulations were created using examples from two hospitals and two pediatric patient cases developed by the National Institute of Standards and Technology. RESULTS: Experts identified 224 unique usability problems ranging in severity from mild to catastrophic. Content issues (e.g., missing medical history, marital status of a 2-year-old) were rated as most severe, but widespread formatting and structural problems (e.g., inconsistent indentation, fonts, and headings; confusing ordering of information) were so distracting that they significantly reduced readers' ability to efficiently use the documents. Overall, issues in the AVS from Hospital 2 were more severe than those in the AVS from Hospital 1. CONCLUSION: The new instrument allowed for quick, inexpensive evaluations of AVS. Usability issues such as unnecessary information, poor organization, missing information, and inconsistent formatting make it hard for patients, caregivers, and clinicians to use the AVS. The heuristics in the new instrument may be used as guidance to adapt electronic health record systems so that they generate more useful and usable medical documents.

A usability and safety analysis of electronic health records: a multi-center study.

To characterize the variability in usability and safety of EHRs from two vendors across four healthcare systems (2 Epic and 2 Cerner). Twelve to 15 emergency medicine physicians participated from each site and completed six clinical scenarios. Keystroke, mouse click, and video data were collected. From the six scenarios, two diagnostic imaging, laboratory, and medication tasks were analyzed. There was wide variability in task completion time, clicks, and error rates. For certain tasks, there were an average of a nine-fold difference in time and eight-fold difference in clicks. Error rates varied by task (X-ray 16.7% to 25%, MRI: 0 to 10%, Lactate: 0% to 14.3%, Tylenol: 0 to 30%; Taper: 16.7% to 50%). The variability in time, clicks, and error rates highlights the need for improved implementation optimization. EHR implementation, in addition to vendor design and development, is critical to usable and safe products.

Long-term functionality of rural water services in developing countries: a system dynamics approach to understanding the dynamic interaction of factors.

Research has shown that sustainability of rural water infrastructure in developing countries is largely affected by the dynamic and systemic interactions of technical, social, financial, institutional, and environmental factors that can lead to premature water system failure. This research employs system dynamics modeling, which uses feedback mechanisms to understand how these factors interact dynamically to influence long-term rural water system functionality. To do this, the research first identified and aggregated key factors from the literature, then asked water sector experts to indicate the polarity and strength between factors through Delphi and cross impact survey questionnaires, and finally used system dynamics modeling to identify and prioritize feedback mechanisms. The resulting model identified 101 feedback mechanisms that were dominated primarily by three- and four-factor mechanisms that contained some combination of the factors: Water System Functionality, Community, Financial, Government, Management, and Technology, implying these factors were the most influential on long-term functionality. These feedback mechanisms were then scored and prioritized, with the most dominant feedback mechanism identified as Water System Functionality-Community-Finance-Management. This study showcases a way for practitioners to better understand the complexities inherent in rural water development using expert opinion and indicates the need for future research in rural water service sustainability that investigates the dynamic interaction of factors in different contexts.

The internal social sustainability of sanitation infrastructure.

While the construction of sanitation infrastructure is one of humankind's greatest public health and environmental engineering achievements, its benefits are not yet enjoyed by all. In addition to the billions of people not yet reached by sanitation infrastructure, at least half of systems constructed in developing contexts are abandoned in the years following initial construction. In this research, we target the problem of postconstruction onsite sanitation infrastructure abandonment in rural Guatemala using legitimacy and status theory. Legitimacy and status are established theoretical concepts from organizational theory that reflect cultural alignment and normative support. Crisp set Qualitative Comparative Analysis (csQCA), which uses Boolean algebra to discover combinations of theoretical conditions that produce an outcome of interest, allowed us to describe the various pathways that have caused socially sustainable uptake. We find that three combinations of legitimacy and status theory explain 85% of household cases at a consistency of 0.97. The most practically useful pathway covers 50% of household cases and shows that the combination of consequential legitimacy (a moral understanding of outcomes) and comprehensibility legitimacy (a cognitive model connecting outcomes to processes) is a powerful way to achieve socially sustainable sanitation infrastructure.

A qualitative comparative analysis of well-managed school sanitation in Bangladesh.

BACKGROUND: Continued management of sanitation and hygiene services, post-intervention, is a global challenge, particularly in the school-setting. This situation threatens anticipated impacts of school sanitation and hygiene investments. To improve programming and policies, and increase the effectiveness of limited development resources, we seek to understand how and why some schools have well-managed sanitation post-intervention, while others do not. METHODS: Based on in-depth qualitative data from 16 case schools in Meherpur, Bangladesh, we employ fuzzy-set qualitative comparative analysis to identify the necessary and sufficient conditions, or combinations of conditions (referred to as pathways), that lead to either well-managed or poorly managed school sanitation. We include posited sustainability determinants from the literature and factors that emerged from the cases themselves in the analysis. RESULTS: We identified three distinct pathways sufficient to support well-managed services, providing multiple options for how well-managed school sanitation could be encouraged. Two of these are applicable to both government and non-government schools: (1) quality construction, financial community support and a champion; and (2) quality construction, financial government support, a maintenance plan and school management committee involvement. On-going financial support for operations and maintenance was identified as a necessary condition for continued service management, which was absent from many schools with poorly managed services. However, financial support was insufficient alone and other conditions are needed in conjunction, including quality construction and incentivizing conditions, such as school management committee involvement in sanitation specifically, a sanitation champion, and/or one teacher clearly responsible for toilet maintenance. Surprisingly, the number of students per toilet (ranging from 18-95 students) and toilet age (ranging from 8-32 months) had no significant effect on sanitation conditions. CONCLUSIONS: Findings corroborate those from a similar study in Belize, and comparison suggests the need for financial community support and the possibly tenuous reliance on local champions in the absence of adequate government support for operations and maintenance. Sub-determinants to the necessary conditions are also discussed which have implications for school sanitation in Bangladesh and may have broader relevance for other low-income countries though further research is needed.

Association of ebola virus matrix protein VP40 with microtubules.

Viruses exploit a variety of cellular components to complete their life cycles, and it has become increasingly clear that use of host cell microtubules is a vital part of the infection process for many viruses. A variety of viral proteins have been identified that interact with microtubules, either directly or via a microtubule-associated motor protein. Here, we report that Ebola virus associates with microtubules via the matrix protein VP40. When transfected into mammalian cells, a fraction of VP40 colocalized with microtubule bundles and VP40 coimmunoprecipitated with tubulin. The degree of colocalization and microtubule bundling in cells was markedly intensified by truncation of the C terminus to a length of 317 amino acids. Further truncation to 308 or fewer amino acids abolished the association with microtubules. Both the full-length and the 317-amino-acid truncation mutant stabilized microtubules against depolymerization with nocodazole. Direct physical interaction between purified VP40 and tubulin proteins was demonstrated in vitro. A region of moderate homology to the tubulin binding motif of the microtubule-associated protein MAP2 was identified in VP40. Deleting this region resulted in loss of microtubule stabilization against drug-induced depolymerization. The presence of VP40-associated microtubules in cells continuously treated with nocodazole suggested that VP40 promotes tubulin polymerization. Using an in vitro polymerization assay, we demonstrated that VP40 directly enhances tubulin polymerization without any cellular mediators. These results suggest that microtubules may play an important role in the Ebola virus life cycle and potentially provide a novel target for therapeutic intervention against this highly pathogenic virus.

Lipid raft microdomains: a gateway for compartmentalized trafficking of Ebola and Marburg viruses.

Spatiotemporal aspects of filovirus entry and release are poorly understood. Lipid rafts act as functional platforms for multiple cellular signaling and trafficking processes. Here, we report the compartmentalization of Ebola and Marburg viral proteins within lipid rafts during viral assembly and budding. Filoviruses released from infected cells incorporated raft-associated molecules, suggesting that viral exit occurs at the rafts. Ectopic expression of Ebola matrix protein and glycoprotein supported raft-dependent release of filamentous, virus-like particles (VLPs), strikingly similar to live virus as revealed by electron microscopy. Our findings also revealed that the entry of filoviruses requires functional rafts, identifying rafts as the site of virus attack. The identification of rafts as the gateway for the entry and exit of filoviruses and raft-dependent generation of VLPs have important implications for development of therapeutics and vaccination strategies against infections with Ebola and Marburg viruses.