Scaling the sanitation ladder decreases exposure to various illnesses including diarrheal disease, soil-transmitted helminths and trachoma. In rural Zambia, community-led total sanitation (CLTS) has been deployed to help Zambians scale the sanitation ladder. Analysis of monthly routine surveillance data of village-level sanitation coverage of 13,688 villages shows that villages moved up the sanitation ladder following CLTS intervention with more than one third of villages achieving 100% coverage of adequate sanitation. Villages also moved down the sanitation ladder – approximately half of those achieving 100% coverage of adequate sanitation also dropped from that coverage at some point during monitoring. Larger villages were less likely to achieve 100% coverage, and more likely to drop if they did achieve 100% coverage. Drops were more likely to occur during the wet season. Of those villages dropping from 100% coverage, more than half rebounded to 100% coverage. The adequate latrine components most likely to drop off from 100% coverage were handwashing stations and lids to cover holes, both key components in preventing disease transmission. These results have implications for water, sanitation and hygiene (WASH) programming – sustained support may be required to ensure villages move up the sanitation ladder and stay there.
Behavioral economics hold great promise in changing patterns of behavior that influence human health. Handwashing with soap is one such behavior that is important in reducing exposure to pathogens, and in school-age children, handwashing helps reduce absenteeism through the prevention of respiratory and diarrheal diseases. However, the gap between knowledge on the importance of handwashing and actual handwashing practice, especially with soap, persists. Many traditional behavior change communication approaches have failed in achieving and sustaining improved handwashing practices. Cognitive psychology research on habits as well as nudge theory, a component of behavioral economics predicated on the idea of making a behavior as easy as possible to do, suggests that introducing a disruptive cue into the environment may be able to interrupt current habitual neurological patterns to effect and then sustain behavior change. We used a participatory process to identify and introduce a locally appropriate disruptive cue to improve handwashing behavior in schools in Zambia. We then utilized a school-randomized controlled trial to test the soap-on-a-rope in 50 government schools in Namwala District of Southern Province. Two outcomes were considered among school children; washing hands with water and using soap while washing hands. Following the intervention, soap use was more likely in intervention schools than control schools [Odds ratio = 7.23, 95% confidence interval = (1.76–29.71)], though both intervention and control schools saw an increase in handwashing without soap. This low-cost intervention could be scaled throughout Zambia and may work well in other countries of similar circumstances.
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