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During the early stages of the global COVID-19 pandemic, governments searched for effective means to rapidly disseminate information about how to prevent the disease and care for sick household members. In June 2020, the government of Kenya considered sending text messages, a behavioral nudging approach, to inform and persuade the public to practice home-based care for those who were infected. We conducted a randomized evaluation of simple informational messages compared to messages targeting personal and social benefits for those receiving the messages. We hypothesized that those that received messages tailored around social or personal benefit would be more likely to undertake the promoted behaviors of isolating if infected with COVID-19 and intending to care for an infected family member. While fear and perceptions of stigma were widespread, more than two-thirds of respondents in the control condition expressed an intention to care for an infected family member at home. Despite greater recall of the personal benefit message, which used reciprocity as its key behavioral lever, intentions to provide care at home and perceptions of stigma did not differ across study groups. Rather, capabilities such as wealth and having sufficient room at home were the key determinants. While text messages as behavioral nudges may be useful for some behaviors, policymakers should consider a broader range of tools for behaviors that are influenced by people’s capabilities, since even low-cost interventions may crowd out the time and energy needed for other responses during an emergency.

Handwashing with soap is an important preventive health behavior, and yet promoting this behavior has proven challenging. We report the results of a program that trained teachers to deliver a handwashing with soap behavior change program to children in primary schools in Bihar, India. Ten intervention schools selected along with ten nearby control schools, and intervention schools received the \"School of Five\" program promoting handwashing with soap using interactive stories, games, and songs, behavioral diaries to encourage habit formation, and public commitment. Households with children aged 8-13 attending the nearby school were enrolled in the study. Handwashing with soap was measured using sticker diaries before eating and after defecation 4 weeks after the intervention was completed. Children in the treatment reported 15.1% more handwashing with soap on key occasions (35.2%) than those in the control group (20.1%) (RR: 1.77, CI: (1.22, 2.58), p = .003). There was no evidence that handwashing with soap after defecation was higher in the treatment group than the control group (RR: 1.18, CI: (0.88, 1.57), p = .265), but there was strong evidence that handwashing with soap was greater in the treatment than in the control before eating (RR: 2.68, 95% CI: (1.43, 5.03), p = .002). Rates of handwashing increased both at home (RR: 1.63, CI: 1.14, 2.32), p = .007) and at school (RR: 4.76, 95% CI: (1.65, 17.9), p = .004), though the impact on handwashing with soap at key occasions in schools was much higher than at home. Promoting handwashing with soap through teachers in schools may be an effective way to achieve behavior change at scale.

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.

IntroductionThere have long been critiques of colonial legacies influencing global health. With growing public awareness of unjust systems in recent years, a new wave of calls for antiracist and decolonisation initiatives has emerged within the sector. This study examined research inequities in the water, sanitation and hygiene (WASH) sector, centring the perspectives of researchers from low-income and middle-income countries (LMICs), to identify barriers faced by WASH researchers in order to support more equitable changes in this subsector of global health.MethodsNineteen semistructured interviews were conducted with researchers of different backgrounds regarding nationality, gender and research experience. Researchers from eight countries were asked about their experiences and direct observations of discrimination across various stages of the research process. Five interviews were conducted with key WASH research funders to assess perceptions of obstacles faced by LMIC researchers, successes achieved and challenges faced by these organisations when working towards more equitable research processes within the WASH sector.ResultsThe results were analysed using an emergent framework that categorised experiences based on power differentials and abuse of power; structural barriers due to organisational policies; institutional and individual indifference; othering speech, action and practices; and context-specific discrimination. The social-ecological model was combined with this framework to identify the types of actors and the level of co-ordination needed to address these issues. Researchers who worked in both LMICs and high-income countries at different career stages were particularly aware of discrimination. Ensuring pro-equity authorship and funding practices were identified as two significant actions to catalyse change within the sector.ConclusionSector-wide efforts must centre LMIC voices when identifying research questions, conducting research, and in dissemination. Individuals, organisations and the entire WASH sector must examine how they participate in upholding inequitable systems of power to begin to dismantle the system through the intentional yielding of power and resources.

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.

Despite clear evidence of the adverse health impacts of unsafe child feces disposal (CFD), there is little evidence of the effectiveness of interventions targeting the improvement of unsafe CFD practices in the Asia-Pacific region. A systematic review of the literature was conducted to identify and evaluate the quality of both behavior change and hardware interventions targeting the improvement of CFD practices in this region. A total of 695 articles were screened, and 15 studies were included. The combined hardware and behavior change interventions reported the highest rates of safe CFD (SCFD) post-intervention; however, these interventions were of lower quality. Four interventions focused specifically on improving SCFD practices, while the remaining seven studies evaluated the impacts of large-scale interventions, such as India's MANTRA and Total Sanitation Campaign programs, on unsafe CFD practices. Large-scale programs and hardware interventions are important for providing communities with the infrastructure necessary to improve unsafe CFD practices, but such interventions may be improved by the addition of a behavioral change component. With little evidence available on the effectiveness of behavioral interventions on reducing unsafe CFD in the Asia-Pacific region, future work should focus on how behavior change models combined with hardware interventions impact unsafe CFD.

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.

Significant investment is needed to improve peri-urban sanitation. Consumer willingness to pay may bridge some of this gap. While contingent valuation has been frequently used to assess this demand, there are few comparative studies to validate this method for water and sanitation. We use contingent valuation to estimate demand for flushing toilets, solid doors, and inside and outside locks on doors and compare this with results from hedonic pricing and discrete choice experiments. We collected data for a randomized, controlled trial in peri-urban Lusaka, Zambia in 2017. Tenants were randomly allocated to discrete choice experiments (n = 432) or contingent valuation (n = 458). Estimates using contingent valuation were lower than discrete choice experiments for solid doors (US $2.6 vs. US$ 3.4), higher for flushing toilets ( $3.4 vs. $ 2.2), and were of the opposite sign for inside and outside locks ( $1.6 vs. $− 1.1). Hedonic pricing aligned more closely to discrete choice experiments for flushing toilets ( $1.7) and locks (−$ 0.9), suggesting significant and inconsistent bias in contingent valuation estimates. While these results provide strong evidence of consumer willingness to pay for sanitation, researchers and policymakers should carefully consider demand assessment methods due to the inconsistent, but often inflated bias of contingent valuation.

Nairobi’s urban slums are ill equipped to prevent spread of the novel coronavirus disease (COVID-19) due to high population density, multigenerational families in poorly ventilated informal housing, and poor sanitation. Physical distancing policies, curfews, and a citywide lockdown were implemented in March and April 2020 resulting in sharp decreases in movement across the city. However, most people cannot afford to stay home completely (e.g., leaving daily to fetch water). If still employed, they may need to travel longer distances for work, potentially exposing them COVID-19 or contributing to its spread. We conducted a household survey across five urban slums to describe factors associated with mobility in the previous 24 h. A total of 1695 adults were interviewed, 63% female. Of these, most reported neighborhood mobility within their informal settlement (54%), 19% stayed home completely, and 27% reported long-distance mobility outside their informal settlement, mainly for work. In adjusted multinomial regression models, women were 58% more likely than men to stay home (relative risk ratio (RRR): 1.58, 95% confidence interval (CI): 1.16, 2.14) and women were 60% less likely than men to report citywide mobility (RRR: 0.40; 95% CI 0.31, 0.52). Individuals in the wealthiest quintile, particularly younger women, were most likely to not leave home at all. Those who reported citywide travel were less likely to have lost employment (RRR: 0.49; 95% CI 0.38, 0.65) and were less likely to avoid public transportation (RRR: 0.30; 95% CI 0.23, 0.39). Employment and job hunting were the main reasons for traveling outside of the slum; less than 20% report other reasons. Our findings suggest that slum residents who retain their employment are traveling larger distances across Nairobi, using public transportation, and are more likely to be male; this travel may put them at higher risk of COVID-19 infection but is necessary to maintain income. Steps to protect workers from COVID-19 both in the workplace and while in transit (including masks, hand sanitizer stations, and reduced capacity on public transportation) are critical as economic insecurity in the city increases due to COVID-19 mitigation measures. Workers must be able to commute and maintain employment to not be driven further into poverty. Additionally, to protect the majority of individuals who are only travelling locally within their settlement, mitigation measures such as making masks and handwashing stations accessible within informal settlements must also be implemented, with special attention to the burden placed on women.

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.