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Household-specific feedback on the microbiological safety of drinking water may result in changes to water management practices that reduce exposure risks. We conducted a randomized, controlled trial in India to determine if information on household drinking water quality could change behavior and improve microbiological quality as indicated by Escherichia coli counts. We randomly assigned 589 participating households to one of three arms: (1) a messaging-only arm receiving messaging on safe water management ( n = 237); (2) a standard testing arm receiving the same messaging plus laboratory E. coli testing results specific to that household's drinking water ( n = 173); and (3) a test kit arm receiving messaging plus low-cost E. coli tests that could be used at the household's discretion ( n = 179). Self-reported water treatment increased significantly in both the standard testing arm and the test kit arm between baseline and follow-up one month later. Mean log 10 E. coli counts per 100 mL in household stored drinking water increased in the messaging-only arm from 1.42 to 1.87, while decreasing in the standard testing arm (1.38 to 0.89, 65% relative reduction) and the test kit arm (1.08 to 0.65, 76% relative reduction). Findings indicate that household-specific water quality information can improve both behaviors and drinking water quality.

Objectives: To identify cross-national trends in factors associated with women's sanitation use in sub-Saharan Africa., Methods: Using data from Demographic and Health Surveys conducted in 14 SSA countries between 2008 and 2014, we modelled women's sanitation use in relation to various individual- and neighbourhood-level factors., Results: Substantial variation exists between countries in the strength and direction of factors associated with sanitation use. Particularly significant associations across the region included access to different water sources, years of education, family size, age, living in a female-headed household, being married and wealth. Neighbourhood-level poverty, ethnic diversity and urbanisation were important factors in a majority of countries., Conclusions: International development goals for sanitation are frequently framed in terms of availability, implicitly suggesting that if facilities are accessible, they will be used. A more nuanced view that takes into account not only the existence of facilities but also the factors influencing their use is needed to understand the dynamics of women's sanitation use in the region. Policies focused on availability may not yield the desired public health benefits from improved sanitation in sub-Saharan Africa. Context-relevant factors must be addressed concurrently to achieve sanitation development goals., (© 2017 John Wiley & Sons Ltd.)

Inadequate hand hygiene is estimated to result in nearly 300,000 deaths annually, with the majority of deaths being among children younger than 5 years. In an effort to promote handwashing with soap and water treatment behaviors among highly susceptible household members of cholera patients, we recently developed the Cholera-Hospital-Based Intervention-for-7-Days (CHoBI7); chobi means picture in Bengali. This 1-week handwashing with soap and water treatment intervention is delivered by a promoter in the hospital and the home to cholera patients and their household members. In our randomized controlled trial of this intervention, we observed a significant reduction in symptomatic cholera infections during the 1-week intervention period compared to the control arm and sustained high uptake of observed handwashing with soap behaviors up to 12 months postintervention. The aim of the present study was to assess the underlying mechanism of change that led to the high handwashing with soap behavior observed among participants who received the CHoBI7 intervention. Handwashing with soap was measured using 5-hour structured observation, and psychosocial factors were assessed using a structured questionnaire among 170 intervention and 174 control household members enrolled in the CHoBI7 trial. To investigate potential mediators of the CHoBI7 intervention effect, mediation models were performed. Response efficacy was found to mediate the intervention's effect on habit formation for handwashing with soap at the 1-week follow-up, and disgust, convenience, and cholera awareness were mediators of habit maintenance at the 6- to 12-month follow-up. These results support the use of theory-driven approaches for the development and implementation of handwashing with soap interventions.

While sanitation interventions have focused primarily on child health, women's unique health risks from inadequate sanitation are gaining recognition as a priority issue. This study examines the range of sanitation-related psychosocial stressors during routine sanitation practices in Odisha, India. Between August 2013 and March 2014, we conducted in-depth interviews with 56 women in four life stages: adolescent, newly married, pregnant and established adult women in three settings: urban slums, rural villages and indigenous villages. Using a grounded theory approach, the study team transcribed, translated, coded and discussed interviews using detailed analytic memos to identify and characterize stressors at each life stage and study site. We found that sanitation practices encompassed more than defecation and urination and included carrying water, washing, bathing, menstrual management, and changing clothes. During the course of these activities, women encountered three broad types of stressors-environmental, social, and sexual-the intensity of which were modified by the woman's life stage, living environment, and access to sanitation facilities. Environmental barriers, social factors and fears of sexual violence all contributed to sanitation-related psychosocial stress. Though women responded with small changes to sanitation practices, they were unable to significantly modify their circumstances, notably by achieving adequate privacy for sanitation-related behaviors. A better understanding of the range of causes of stress and adaptive behaviors is needed to inform context-specific, gender-sensitive sanitation interventions., (Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.)