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We conducted a controlled before-and-after trial to evaluate the impact of an onsite urban sanitation intervention on the prevalence of enteric infection, soil transmitted helminth re-infection, and diarrhea among children in Maputo, Mozambique. A non-governmental organization replaced existing poor-quality latrines with pour-flush toilets with septic tanks serving household clusters. We enrolled children aged 1–48 months at baseline and measured outcomes before and 12 and 24 months after the intervention, with concurrent measurement among children in a comparable control arm. Despite nearly exclusive use, we found no evidence that intervention affected the prevalence of any measured outcome after 12 or 24 months of exposure. Among children born into study sites after intervention, we observed a reduced prevalence of Trichuris and Shigella infection relative to the same age group at baseline (<2 years old). Protection from birth may be important to reduce exposure to and infection with enteric pathogens in this setting.

Over one billion people gained access to piped water between 2000 and 2015. Piped water access in sub-Saharan Africa (SSA), however, is the lowest of all SDG regions and is declining: in 2017, only 56% of the urban population in SSA had access to piped water in their homes, down from 65% in 2000. Increasing water access via private connections is difficult for many of utility providers in SSA, and unconnected households may also choose not to connect to the water utility network because of low-quality utility service, high water charges and high connection fees. This paper focuses on understanding the impact of the pro-poor water reforms implemented between 2010 and 2019 in the Greater Maputo Area (GMA), Mozambique; specifically, it attempts to understand how households were able to obtain piped water access through a water connection campaign, a reduction of the connection fee, and the option of paying in instalments. We use data collected in 2010 and 2012 – before and after these policy changes were introduced – from 1300 households in 6 poor neighbourhoods in peri-urban Maputo. This paper also investigates the broader sectoral impacts of these policies over time from the water utility’s perspective, using data from sector reports and interviews with key informants that were conducted by one of the authors in 2019. We found that between 2009 and 2017, the number of domestic private connections more than doubled in the GMA. Both the utility connection campaign and the reduction in connection fees facilitated water access for low-income households – although the poorest households were still unable to access piped water in the studied neighbourhoods – and for a few households, access was made possible by the option of paying the connection fee in instalments. Such rapid increases in the number of connections had two important implications for the water sector: first, as the number of private connections increased, the quality of service decreased significantly; second, the increase in domestic connections among largely low-income and relatively low-consuming customers resulted in major financial challenges for the system. These results are in line with those of other authors who argue that social and financial goals cannot be achieved in tandem; they also support findings in the existing literature on the limited ability of tariffs to deliver subsidies to the poor.

Community-led Total Sanitation (CLTS) is a popular intervention for eliminating open defecation in rural communities. Previous research has explored the contextual and programmatic factors that influence CLTS performance. Less is known about the community-level conditions that sustain latrine coverage and use. We hypothesized three categories of community conditions underlying CLTS sustainability: (i) engagement of community leaders, (ii) follow-up intensity, and (iii) support to poor households. We evaluated these among communities in Cambodia and Ghana, and applied fuzzy-set Qualitative Comparative Analysis (fsQCA) to identify combinations of conditions that influenced current latrine coverage and consistent latrine use. In Cambodia, latrine coverage was highest in communities with active commune-level leaders rather than traditional leaders, and with leaders who used casual approaches for promoting latrine construction. Latrine use in Cambodia was less consistent among communities with intense commune engagement, higher pressure from traditional leaders, high follow-up and high financial support. In Ghana, by contrast, active leaders, high follow-up, high pro-poor support, and continued activities post-implementation promoted latrine coverage and consistent use. The different responses to CLTS programming emphasize that rural communities do not have homogenous reactions to CLTS. Accounting for community perceptions and context when designing community-led interventions can foster long-term sustainability beyond short-term achievement.

Over the last 50 years, a combination of factors has driven sanitation improvements in rural areas of low-income and emerging economies in Asia. While open defecation remains an important challenge in many countries, Cambodia has rapidly increased rural sanitation coverage in the last 20 years. Using data collected via 92 interviews and seven focus group discussions, this qualitative study analysed the macro-level, community, and individual factors that motivated rural households to invest in high-quality latrines in seven villages in Cambodia that achieved and sustained open defecation free status with at least 85% latrine coverage. Local demand for adoption of high quality latrine was stimulated by a number of factors which include: a) NGO-led interventions that included behaviour change communication, sanitation marketing, and community-led total sanitation, all magnified by the strong support of local leaders at the village and commune levels; b) an increased proportion of rural households engaging in factory work, with access to raising wages, higher disposable incomes, and remittances; and c) subsidies and microcredit. Furthermore, migrants not only transferred financial resources to their home villages, but also transferred a set of ideas, norms, expectations, information, and behaviors back to their communities that reflect the migrants’ new ways of life, and economic possibilities. We provide evidence that new habits among factory workers, and ownership and display of new technologies and consumer commodities as symbols of modern success and social status facilitated high-quality latrine adoption. Peer-to-peer pressure at the village level, and among adult children commuting to factories or visiting their rural hometown ensured widespread adoption.

Access to safe sanitation in low-income, informal settlements of Sub-Saharan Africa has not significantly improved since 1990. The combination of a high faecal-related disease burden and inadequate infrastructure suggests that investment in expanding sanitation access in densely populated urban slums can yield important public health gains. No rigorous, controlled intervention studies have evaluated the health effects of decentralised (non-sewerage) sanitation in an informal urban setting, despite the role that such technologies will likely play in scaling up access. We have designed a controlled, before-and-after (CBA) trial to estimate the health impacts of an urban sanitation intervention in informal neighbourhoods of Maputo, Mozambique, including an assessment of whether exposures and health outcomes vary by localised population density. The intervention consists of private pour-flush latrines (to septic tank) shared by multiple households in compounds or household clusters. We will measure objective health outcomes in approximately 760 children (380 children with household access to interventions, 380 matched controls using existing shared private latrines in poor sanitary conditions), at 2 time points: immediately before the intervention and at follow-up after 12 months. The primary outcome is combined prevalence of selected enteric infections among children under 5 years of age. Secondary outcome measures include soil-transmitted helminth (STH) reinfection in children following baseline deworming and prevalence of reported diarrhoeal disease. We will use exposure assessment, faecal source tracking, and microbial transmission modelling to examine whether and how routes of exposure for diarrhoeagenic pathogens and STHs change following introduction of effective sanitation. Study protocols have been reviewed and approved by human subjects review boards at the London School of Hygiene and Tropical Medicine, the Georgia Institute of Technology, the University of North Carolina at Chapel Hill, and the Ministry of Health, Republic of Mozambique. NCT02362932.

About 20% of the urban population in sub-Saharan Africa relies on resellers of utility water for their water supply, yet the practice has received little attention either in the academic literature or in sector policy. This study uses primary data collected from more than 200 resellers in Maputo, Mozambique, through in-person surveys, participant observation and focus group discussions. Despite the widely held assumption that all small-scale water providers are profit-maximizing entrepreneurs, this study suggests that this model does not characterize resale behavior in Maputo. Instead, three non-mutually exclusive motivations provide more persuasive explanations for why households resell utility water: (1) earning cash to meet daily subsistence needs; (2) obtaining a form of informal social insurance to deal with future needs; and (3) solidifying embeddedness in social relationships by satisfying the social norms of their communities. These findings suggest that programs and policies typically designed for small-scale providers may be inappropriate for water resellers.

In sub-Saharan Africa only 35% of the urban population has access to a piped water connection on their premises. The majority of households obtain water from public standpipes or from neighbors who are connected to the municipal network. Water resale is often prohibited, however, because of concerns about affordability and risks to public health. Using data collected from 1,377 households in Maputo, Mozambique, we compare the microbiological quality, as well as the time and money costs of water supply from individual house connections, public standpipes, and water obtained from neighbors. Households with their own water connections have better service across virtually all indicators measured, and express greater satisfaction with their service, as compared with those using other water sources. Households purchasing water from their neighbors pay lower time and money costs per liter of water, on average, as compared with those using standpipes. Resale competes favorably with standpipes along a number of service quality dimensions; however, after controlling for water supply characteristics, households purchasing water from neighbors are significantly less likely to be satisfied with their water service as compared with those using standpipes.

In Sub-Saharan Africa (SSA), two in three urban households do not have access to a piped water connection in their premises. These households rely on shared point sources, as well as services provided by small-scale private operators such as cart vendors, tanker trucks, and neighbors connected to the municipal network who resell water. This dissertation contributes to the limited literature on water supply services available to low-income urban populations, by assessing service characteristics and preferences for water service improvements among households without individual connections; comparing across different source options service attributes typically measured in the water sector, including time and money costs, service quality and users' satisfaction; exploring the characteristics of households who resell water and their motivations for doing so. This dissertation focuses on the case of Maputo, Mozambique.Chapter 2 found that felt needs and preferences among peri-urban households in Maputo are more heterogeneous than characterized in the literature, even when households have similar socio-economic and demographic characteristics. Overall, time and money costs of supply drive respondent preferences to a greater extent than any other attributes.Chapter 3 found that households purchasing water from their neighbors pay lower time and money costs per liter of water, on average, and report a higher likelihood of obtaining credit from their supplier, as compared to those using standpipes. No significant difference in the quantity of water obtained from these two water sources was observed, nor were there any significant differences in water quality at source between neighbor's taps and standpipes. Standpipes outperform resale with respect to both the number of hours of service per day and the predictability of supply. Although resale competes favorably with standpipes along a number of service quality dimensions, after controlling for water supply characteristics, households purchasing water from neighbors are significantly less likely to be satisfied with their water services as compared to those using standpipes.Chapter 4 found that most water resellers in Maputo do not behave as entrepreneurs, nor are they motivated by profits when performing their activities. Three non-mutually exclusive explanations of why households engaged in water resale were presented. The first explanation is that households perform their resale activities to obtain cash to buy daily food items, such as bread and vegetables. A second explanation is that resellers engage in resale to \"buy\" informal social insurance and protect themselves in case of future need, either because they anticipate needing the help of their neighbors or fear social isolation. A third motivation for households to engage in resale is linked to their embeddedness in dense networks of social relations in which helping neighbors is a social norm.

Background There is a scarcity of randomized and high-quality studies to aid clinicians in management and treatment of Wilson disease (WD). Even amongst society practice guidelines in North America and Europe, diagnosis and management of WD varies. The aim of this study is to elucidate WD diagnosis and treatment patterns by conducting a survey of clinicians in California and comparing the results to clinicians in Italy as a representation of European practices. Methods We developed a 51-item survey assessing WD diagnostics, therapeutics, and disease monitoring. The survey was distributed through email to 1330 California gastroenterologists, hepatologists, and movement neurologists and to multiple Italian academic medical centers. Results Thirty-two providers in California completed the survey encompassing a total of 236 patients. Twenty-three providers in Italy with a total of 390 patients in their care responded. About half of California providers perform a full neurologic evaluation before initiating therapy in patients with predominantly hepatic presentation while 71% of Italian providers perform one. In patients with predominantly hepatic presentation, 47.4% of California providers use trientine as initial therapy, 26.3% use d-penicillamine, and 10.5% use combination therapy with chelators and zinc. No one reported using zinc monotherapy as initial treatment. Italian providers report using d-penicillamine as initial therapy in 85% of cases, followed by zinc salt (10%), and none uses trientine. WD patients on combination therapy with chelators and zinc are followed by 34% of California respondents and 32% of Italian respondents. In patients with predominantly neurologic manifestations, initial therapy choices are variable with 38.9% of California providers using d-penicillamine, 16.7% using zinc salts, 11.1% using trientine, and 22% using other therapies. 55% of Italian providers use d-penicillamine, 20% combination chelator and zinc, 15%, trientine and 10% zinc salts. Changing from initial therapy to maintenance therapy in both surveys occur after stabilization of clinical presentation, liver function tests, and 24-hour urinary copper in 72% and 86% of California and Italian providers respectively. Conclusions Our findings highlight the significant variability in initial therapies for WD amongst California and European/Italian providers. Despite the wide use of combination therapy of chelators and zinc, its needs further exploration.