BackgroundIt is estimated that more than two-thirds of the population in sub-Saharan Africa (SSA) must leave their home to collect water, putting them at risk for a variety of negative health outcomes. There is little research, however, quantifying who is most affected by long water collection times.ObjectivesThis study aims to a) describe gender differences in water collection labor among both adults and children (< 15 years of age) in the households (HHs) that report spending more than 30 minutes collecting water, disaggregated by urban and rural residence; and b) estimate the absolute number of adults and children affected by water collection times greater than 30 minutes in 24 SSA countries.MethodsWe analyzed data from the Demographic Health Survey (DHS) and the Multiple Indicator Cluster Survey (MICS) (2005–2012) to describe water collection labor in 24 SSA countries.ResultsAmong households spending more than 30 minutes collecting water, adult females were the primary collectors of water across all 24 countries, ranging from 46% in Liberia (17,412 HHs) to 90% in Cote d’Ivoire (224,808 HHs). Across all countries, female children were more likely to be responsible for water collection than male children (62% vs. 38%, respectively). Six countries had more than 100,000 households (HHs) where children were reported to be responsible for water collection (greater than 30 minutes): Burundi (181,702 HHs), Cameroon (154,453 HHs), Ethiopia (1,321,424 HHs), Mozambique (129,544 HHs), Niger (171,305 HHs), and Nigeria (1,045,647 HHs).ConclusionIn the 24 SSA countries studied, an estimated 3.36 million children and 13.54 million adult females were responsible for water collection in households with collection times greater than 30 minutes. We suggest that accessibility to water, water collection by children, and gender ratios for water collection, especially when collection times are great, should be considered as key indicators for measuring progress in the water, sanitation and hygiene sector.

Handwashing with soap is recognized as a cost-effective intervention to reduce morbidity and mortality associated with enteric and respiratory infections. This study analyzes rural Indonesian households’ hygiene behaviors and attitudes to examine how motivations for handwashing, locations of handwashing space in the household, and handwashing moments are associated with handwashing with soap as potential determinants of the behavior. The analysis was conducted using results from a UNICEF cross-sectional study of 1700 households in six districts across three provinces of Indonesia. A composite measure of handwashing with soap was developed that included self-reported handwashing, a handwashing demonstration, and observed handwashing materials and location of facilities in the home. Prevalence ratios were calculated to analyze associations between handwashing with soap and hypothesized determinants of the behavior. Our results showed that determinants that had a significant association with handwashing with soap included: (1) a desire to smell nice; (2) interpersonal influences; (3) the presence of handwashing places within 10 paces of the kitchen and the toilet; and (4) key handwashing moments when hands felt dirty, including after eating and after cleaning child stools. This study concludes that handwashing with soap may be more effectively promoted through the use of non-health messages.

Water, sanitation, and hygiene (WaSH) are foundational public health interventions for infectious disease control. Renewed efforts to end open defecation and provide universal access to safe drinking water, sanitation, and hygiene by 2030 are being enacted through the Sustainable Development Goals. However, results from clinical trials 1-3 question the efficacy of conventional rural WaSH approaches in low-income and middle-income countries (LMICs). Randomised trials in Bangladesh, 1 Kenya, 2 and Zimbabwe, 3 which introduced household pit latrines, hand-washing with soap, and point-of-use water chlorination, found no effect on child growth, and two of the three trials found no reductions in diarrhoea in children. We have, therefore, called for transformative WaSH approaches, 4 to more effectively reduce pathogen burden and promote child health and growth in LMICs. However, currently, it remains uncertain what transformative WaSH entails. We hypothesise that exposure to animal faeces is currently an under-recognised threat to human health. Estimates published in 2018 have highlighted the scale of animal faecal hazards, 5 which are not explicitly addressed by conventional WaSH strategies. Globally, 80% of the faecal load is estimated to come from livestock animals, including two-thirds of faeces at the household level. 5 Research addressing the effect of domestic and wild animal faeces on WaSH effectiveness is scarce 6,7 and collaboration between the WaSH, public health, and animal health sectors in LMICs insufficient. 6 As an interdisciplinary group of researchers, policy makers, and practitioners in One Health, epidemiology, veterinary medicine, child health, nutrition, microbiology, geography, social science, WaSH, and animal ecology, we met (on May 22-23, 2019) to focus attention on the neglected burden of domestic and wild animal faecal exposure among rural households in LMICs. We contend that without adding safe management of animal faeces to current programmes focused solely on human waste, rural WaSH programmes will insufficiently reduce faecal exposure from all sources to the extent needed to improve child health. To emphasise this, we propose a paradigm shift in WaSH terminology, by upgrading the