WASH Interventions Research Articles

Improving population health through targeted policies on water sanitation and hygiene: Case study of water, sanitation and hygiene related practices in the Hohoe Municipality, Ghana

Background: Policies that improve the availability of safe drinking water, good hygiene practices and adequate sanitation conditions are considered crucial ingredients to sustain and improve the health of all populations. To attain the United Nations Sustainable Development Goals require concerted efforts globally to improve or health related morbidity outcomes as a result of poor water sources, sanitation and unhygienic conditions.Aim: The study assessed water, sanitation and hygiene related practices among household residents in Hohoe Municipality, Ghana with the aim of mapping out targeted policies required to improve urban population health in Ghana.Setting: Hohoe Municipality, Ghana.Method: A descriptive cross-sectional design was used to collect data among 403 household residents in Hohoe Municipality, Ghana. Participants were selected using multistage sampling technique. Data was collected using self-administered questionnaire, entered, cleaned and analyzed in STATA version 13.1.Findings: About 16.4% of the participants practiced open defecation. Overall, 58% of the 403 household residents had adequate hygiene practice levels. Percentages of participants that had improved, unimproved and piped drinking water sources were 67%, 14% and 19% respectively.Conclusion: Participants generally had a fairly adequate hygiene practice level and access to improved drinking water source. While almost half of the participants did not own or shared a private toilet facility. Our findings underscore the need for WASH interventions including policies to improve upon WASH practices among the households in Hohoe Municipality.

Effects of an Integrated Poultry Value Chain, Nutrition, Gender and Wash Intervention (SELEVER) on Hygiene and Child Morbidity and Anthropometry in Burkina Faso: A Secondary Outcome Analysis of a Cluster Randomized Trial

Effects of an Integrated Poultry Value Chain, Nutrition, Gender and Wash Intervention (SELEVER) on Hygiene and Child Morbidity and Anthropometry in Burkina Faso: A Secondary Outcome Analysis of a Cluster Randomized Trial

Factors associated with prevalence of diarrhea among children under five years of age in Pakistan

ObjectivesThe study aimed to identify the determinants of childhood diarrhea in Pakistan with a specific focus on water, sanitation, hygiene, and mother’s decision-making ability. MethodsThis study is based on nationally representative Demographic and Health Survey of Pakistan. The working sample is 3,067 children. Bi-variate and multi-variate logistic regressions are used to estimate the unadjusted and adjusted odds ratios of the determinants of diarrhea, respectively. ResultsIn bivariate regression, type of water source i.e., tube well/bore has significantly lower odds [OR = 0.85, 95 CI = 0.76–0.96] of diarrhea among children of age less than five years compared to piped water. Although, this variable is not significant in the multivariate model. Though, the variable of toilet type, Flush to Septic Tank, is significant in multivariate analysis with the odds of [OR = 0.77, 0.59–0.99] meaning that odds of household with a flush to septic tank type of toilet observe 23 percent less diarrhea compared to households with piped to sewer type of toilet. Moreover, the presence of a handwashing facility is an insignificant predictor of diarrhea. In a household where a mother does not make health-related decisions, a child is significantly likely to have diarrhea [OR = 1.25, 95% CI = 1.12–1.39]. Although, this association is lost in multivariate regression analysis. ConclusionThe results show that mothers should be empowered to make their health-related decisions, as children of empowered mothers are less susceptible to diarrhea. Similarly, the findings suggest that WASH interventions are likely to work better if they target multiple WASH sectors instead of focusing on one of the components, as children with access to multiple improved WASH components are less likely to get diarrhea as compared to the children who have access to one of them.

Financial, institutional, environmental, technical, and social (FIETS) aspects of water, sanitation, and hygiene conditions in indigenous - rural Indonesia

BackgroundThere is increasing recognition of the complexity underlying WASH conditions in developing countries. This article explores the complexity by assessing the vulnerability of a specific area to poor WASH conditions using a qualitative approach.MethodsWe present our findings for the district of East Sumba in Indonesia. This area is known as one of the poorest regions in Indonesia with inadequate WASH services, indigenous belief that hinder the practice of WASH-related behaviours, and has a high rate of children malnutrition. All the factors that contribute to poor WASH conditions were discussed through the lens of the Financial, Institutional, Environmental, Technological, and Social (FIETS) framework. We then summarised the factors and visualized the “system” using a mind map which shows how factors are interconnected and helps to find the root causes of poor WASH conditions.ResultsThere are three main challenges that inhibit the improvement of WASH conditions in this area: inadequate institutional capacity, water scarcity, and poor socio-economic conditions. We found that a village leader is the most important actor who influences the sustainability of WASH services in this area and healthcare workers are influential WASH promoters. This study also shows how culture shapes people’s daily lives and institution performance, and influences the current WASH conditions in East Sumba. The mind map shows there is an overlap and interconnection between FIEST aspects and WASH conditions in the study area.ConclusionWASH conditions are influenced by many factors and are often interconnected with each other. Understanding this complexity is necessary to improve WASH conditions and sustain adequate WASH services in developing countries. Finally, WASH interventions have to be considerate of the prevailing cultural practices and should involve multidisciplinary stakeholders.

Factors influencing sanitation and hygiene practices among students in a public university in Bangladesh.

IntroductionImproved hygiene and sanitation practices in educational settings are effective for the prevention of infections, controlling the transmission of pathogens, and promoting good health. Bangladesh has made remarkable advances in improving higher education in recent decades. Over a hundred universities were established to expand higher education facilities across the country. Hundreds of thousands of graduate students spend time in university settings during their studies. However, little is known about the sanitation and hygiene practice of the university-going population. This study aims to understand and uncover which factors influence students’ sanitation and hygiene behavior in university settings.MethodsThis study was conducted in a public university named Shahjalal University of Science and Technology located in a divisional city of Bangladesh. Based on the Integrated Behavioral Model for Water, Sanitation, and Hygiene (IBM-WASH), we adopted an exploratory qualitative study design. We developed semi-structured interview guides entailing sanitation and hygiene behavior, access, and practice-related questions and tested their efficacy and clarity before use. We conducted seventeen in-depth interviews (IDIs), and four focus group discussions (FGDs, [6–8 participants per FGD]) with students, and seven key informant interviews (KIIs) with university staff. Thematic analysis was used to analyze the data. Triangulation of methods and participants was performed to achieve data validity.ResultsDespite having reasonable awareness and knowledge, the sanitation and hygiene practices of the students were remarkably low. A broad array of interconnected factors influenced sanitation and hygiene behavior, as well as each other. Individual factors (gender, awareness, perception, and sense of health benefits), contextual factors (lack of cleanliness and maintenance, and the supply of sanitary products), socio-behavioural factors (norms, peer influence), and factors related to university infrastructure (shortage of female toilets, lack of monitoring and supervision of cleaning activities) emerged as the underpinning factors that determined the sanitation and hygiene behavior of the university going-population.ConclusionThe results of this study suggest that despite the rapid expansion of on-campus university education, hygiene practices in public universities are remarkably poor due to a variety of dynamic and interconnected factors situated in different (individual, contextual, socio-phycological) levels. Therefore, multi-level interventions including regular supply of WASH-related materials and agents, promoting low-cost WASH interventions, improving quality cleaning services, close monitoring of cleaning activities, promoting good hygiene behavior at the individual level, and introducing gender-sensitive WASH infrastructure and construction may be beneficial to advance improved sanitation and hygiene practices among university students.

Factors Associated with Stunted Growth in Children Under Five Years in Antananarivo, Madagascar and Bangui, Central African Republic

ObjectivesWith a fourth of all under-five children affected, stunting remains one of the biggest health challenges worldwide. Even though the main underlying factors are known, the exact pathways to stunting varying in affected regions, and interventions thus need to be tailored to the local contexts. This study aimed assessing and comparing factors associated with stunting in two understudied sub-Saharan urban contexts with some of the highest stunting prevalence globally: Bangui, Central African Republic (~ 36%) and Antananarivo, Madagascar (42%).MethodsWe performed a case–control study on 175 + 194 stunted and 237 + 230 non-stunted control children aged 2–5 years and matched for age, gender and district of residency. Factors associated with stunting were identified using a standardized, paper questionnaire delivered by trained interviewers. Statistical analysis was done using logistic regression modelling.ResultsIn both sites, formal maternal education lowered the risk of being stunted and restricted access to soap, suffering of anaemia and low birth weight were associated with higher risk of stunting. Short maternal stature, household head different from parents, diarrhoea and coughing were associated with an increased risk and continuing breastfeeding was associated with a lower risk of stunting in Antananarivo. Previous severe undernutrition and dermatitis/ fungal skin infections were associated with higher and changes in diet during pregnancy with lower risk of stunting in Bangui.ConclusionsOur results suggest maternal education, antenatal care, iron supplementation and simple WASH interventions such as using soap and infection control as general and breastfeeding (Antananarivo) or better nutrition (Bangui) as area-specified interventions.

Biomapping of Microbial Indicators on Beef Subprimals Subjected to Spray or Dry Chilling over Prolonged Refrigerated Storage.

As the global meat market moves to never frozen alternatives, meat processors seek opportunities for increasing the shelf life of fresh meats by combinations of proper cold chain management, barrier technologies, and antimicrobial interventions. The objective of this study was to determine the impact of spray and dry chilling combined with hot water carcass treatments on the levels of microbial indicator organisms during the long-term refrigerated storage of beef cuts. Samples were taken using EZ-Reach™ sponge samplers with 25 mL buffered peptone water over a 100 cm2 area of the striploin. Sample collection was conducted before the hot carcass wash, after wash, and after the 24 h carcass chilling. Chilled striploins were cut into four sections, individually vacuum packaged, and stored to be sampled at 0, 45, 70, and 135 days (n = 200) of refrigerated storage and distribution. Aerobic plate counts, enterobacteria, Escherichia coli, coliforms, and psychrotroph counts were evaluated for each sample. Not enough evidence (p > 0.05) was found indicating the hot water wash intervention reduced bacterial concentration on the carcass surface. E. coli was below detection limits (<0.25 CFU/cm2) in most of the samples taken. No significant difference (p > 0.05) was found between coliform counts throughout the sampling dates. Feed type did not seem to influence the (p > 0.25) microbial load of the treatments. Even though no immediate effect was seen when comparing spray or dry chilling of the samples at day 0, as the product aged, a significantly lower (p < 0.05) concentration of aerobic and psychrotrophic organisms in dry-chilled samples could be observed when compared to their spray-chilled counterparts. Data collected can be used to select alternative chilling systems to maximize shelf life in vacuum packaged beef kept over prolonged storage periods.

PROTOCOL: What is the impact of complex WASH interventions on gender and social equality outcomes in low- and middle-income countries? A mixed-method systematic review protocol.

PROTOCOL: What is the impact of complex WASH interventions on gender and social equality outcomes in low- and middle-income countries? A mixed-method systematic review protocol.

Child Hand Washing Intervention (Age < 5 Years) Against The Risk of Infection in Child Care: Systematic Review

The risk of infection experienced by children (age < 5 years) who do not wash their hands properly becomes a serious threat to the health. Purpose: The study aims to explain handwashing interventions in child care facilities against the risk of infection. A systematic review was obtained from Scopus, PubMed, Science Direct, SAGE and ProQuest database, published between 2010-2020. The study design; Narrative analysis of the study's findings has been conducted. A total of 25 studies covered about comprehensive handwashing interventions (n=18) and behavior (n=7). The average number of participants more than one hundred respondents. Dealing with hand washing is essential in first aid to prevent the risk of infection in children aged < 5 years. Various interventions can have a significant effect on reducing the risk of infection although other interventions provide different successes.

An evaluation of water, sanitation, and hygiene status and household assets and their associations with soil-transmitted helminthiasis and reported diarrhea in Nueva Santa Rosa, Guatemala

Abstract Soil-transmitted helminth (STH) infections and diarrheal illness affect billions of people yearly. We conducted a cross-sectional survey in Nueva Santa Rosa, Guatemala to identify factors associated with STH infections and diarrhea using univariable and multivariable logistic regression models. On multivariable analyses, we found associations between STH infections and two factors: school-aged children (odds ratio (OR) vs. adults: 2.35, 95% CI 1.10–4.99) and household drinking water supply classified as ‘other improved’ (OR vs. ‘improved’: 7.00, CI 1.22–40.14). Finished floors in the household vs. natural floors were highly protective (OR 0.16, CI 0.05–0.50) for STH infection. In crowded households (&amp;gt;2.5 people/bedroom), observing water present at handwashing stations was also protective (OR 0.32, CI 0.11–0.98). When adjusted for drying hands, diarrhea was associated with preschool-age children (OR vs. adults: 3.33, CI 1.83–6.04), spending &amp;gt;10 min per round trip collecting water (OR 1.90, CI 1.02–3.56), and having a handwashing station ≤10 m near a sanitation facility (OR 3.69, CI 1.33–10.21). Our study indicates that familiar WASH interventions, such as increasing drinking water quantity and water at handwashing stations in crowded homes, coupled with a hygiene intervention like finished flooring may hold promise for STH and diarrhea control programs.

Lessons Learnt from financing WASH rehabilitation works in small towns in Zimbabwe

ABSTRACT This paper describes urban WASH interventions (hardware, hygiene promotion, and institutional support) implemented in the Small Towns WASH Programme (STWP) across 14 towns in Zimbabwe with the associated costing. Key lessons in terms of urban WASH rehabilitation include the need for flexible funding and programme approaches accommodate changes during implementation, and that strong programme governance, multi-stakeholder involvement, and integration of hardware and software are required to contribute to benefits beyond infrastructure rehabilitation alone. Critical recommendations for sustaining the rehabilitated infrastructure and institutional strengthening are presented.

Water, sanitation and hygiene coverage and practices of a semi-arid county in the Eastern region of Kenya

Abstract Despite substantial progress in sanitation and hygiene in Kenya, its semi-arid regions still experience poor environmental conditions. Kitui County, a semi-arid region, is characterized by water supply shortages, poor sanitation and poor hygiene coverage. This study covers water, sanitation and hygiene coverage and practices in two subcounties of Kitui County. A cross-sectional survey using mixed methods of data collection was adopted. Seven hundred and fifty-seven households were included and household heads were interviewed. Quantitative data were analyzed using descriptive statistics. Five focused group discussions and key informant interviews were conducted and data analyzed thematically. These revealed that a majority of people obtain their water from rivers (39.9%), with 57.4% walking more than 2 km to water sources. Only 11.9% of all water sources were available throughout the year. A total of 47.4% of people use 13.3 liters/capita/day with an average cost of Ksh. 35 per 20 liter jerry can, which was reported as costly. A total of 43.6% of people felt that the water they collected was not enough to meet their requirements. Filtering was the most common form of water purification, with a majority of people perceiving clear water as safe for drinking. Latrine coverage stood at 56.4% and open defecation at 8.5%. Access to safe and adequate water supply, hygiene and sanitation services to the community continues to be poor and hence WASH interventions need to be scaled up for meeting recommended national standards.

WASH Intervention Effects and Implications in Rural Schools and Communities of Georgia

WASH Intervention Effects and Implications in Rural Schools and Communities of Georgia

The Preventive aspect of Ayurveda in Viral Infection with special reference to COVID-19

In Ayurveda, the management of viral infectious diseases can be either preventive or curative. Prevention is better than cure, while there is no medicine for COVID-19 as of now, it will be good to take preventative measures. In this study for the preventative aspect of Ayurveda in COVID-19, the data has been collected, collated, and reviewed from all available literature related to the topic. It is analyzed that, COVID-19 pandemics can be correlated with janapadadhavnsa roga which are highly communicable diseases described in Ayurveda. It can be correlated as Abhishanga Sannipataj jwara which is of kapha predominance. Ama plays a major role in metabolic disorder patients for invading severe coronavirus disease. Ayurvedic medicines that have Ama pachak and immunity-boosting action play important role in the prevention of COVID-19 infection. Apart from the social distancing and hand washing, local and systemic intervention, Panchakarma therapy and certain use of Rasayana (immunomodulators) have been advocated to prevent the COVID-19.

Assessment of microbial risk during Australian industrial practices for Escherichia coli O157:H7 in fresh cut-cos lettuce: A stochastic quantitative approach

Escherichia coli O157:H7 risk associated with the consumption of fresh cut-cos lettuce during Australian industrial practices was assessed. A probabilistic risk assessment model was developed and implemented in the @Risk software by using the Monte Carlo simulation technique with 1,000,000 iterations. Australian preharvest practices yielded predicted annual mean E. coli O157:H7 levels from 0.2 to −3.4 log CFU/g and prevalence values ranged from 2 to 6.4%. While exclusion of solar radiation from the baseline model yielded a significant increase in concentration of E. coli O157:H7 (−5.2 -log fold), drip irrigation usage, exclusion of manure amended soil and rainfall reduced E. coli O157:H7 levels by 7.4, 6.5, and 4.3-log fold, respectively. The microbial quality of irrigation water and irrigation type both had a significant effect on E. coli O157:H7 concentrations at harvest (p < 0.05). The probability of illness due to consumption of E. coli O157:H7 contaminated fresh cut-cos lettuce when water washing interventions were introduced into the processing module, was reduced by 1.4–2.7-log fold (p < 0.05). This study provides a robust basis for assessment of risk associated with E. coli O157:H7 contamination on fresh cut-cos lettuce for industrial practices and will assist the leafy green industry and food safety authorities in Australia to identify potential risk management strategies.

Modeling the Impact of Population Intervention Strategies on Reducing Health Disparities: Water, Sanitation, and Hygiene Interventions and Childhood Diarrheal Disease in Peru.

Access to safe water and basic sanitation and hygiene facilities (WASH) are important for childhood health globally. However, inequalities in WASH access persist, and local governments need to better understand the potential impact of scaling up WASH services on childhood health. Using 2011 Peru Demographic and Health Survey data as a case study, we applied a modified substitution estimator approach to assess the impact of scaling up access (20-100%) to WASH on diarrhea prevalence among children < 5 years. The modified substitution estimator approach can help identify population subgroups or areas where WASH interventions and sustained implementation could be most beneficial and reduce existing disparities. Using findings from a recent meta-analysis and computing bootstrapped estimates and 95% CIs, we examined inequalities in the effect of WASH on self-reported diarrhea by urbanicity, maternal education level, household wealth, and district of residence. Increasing access (100% change) to improved water sources, sanitation, and hygiene facilities reduced population-level prevalence of childhood diarrhea by 8.2% (95% CI: 4.1, 12.3), 5.5% (95% CI: 0.7, 9.8), and 5.2% (95% CI: 2.2, 8.1), respectively. In stratified analyses, increased access to improved water sources and hygiene facilities was associated with decreased prevalence of diarrhea, with the largest reduction in rural areas and households with lower maternal education and lower wealth. Our findings suggest targeted WASH implementation in Peru is needed in rural areas and among lower socioeconomic-status households. In addition, even low levels of change in overall WASH access may decrease diarrhea prevalence.

English

This study evaluated the health impacts of WASH interventions in 9 intervention communities against 9 control communities in disaster-prone areas in northern Ghana. We extracted community-specific data on patient-reported cases of WASH-related diseases from health facilities in the study areas. Also, we used key informant interviews and household questionnaires to seek information for validation. The impact was measured using the before-after study with concurrent control (BAC) method of Health Impact Evaluation in WASH interventions. The findings indicate a substantial increase in the number of WASH facilities across the intervention communities. However, some respondents complained of access to inadequate quantities and increase downtime of water systems when there is a breakdown. Access to improved sanitation facilities was still a challenge, although a steady increase in the number of household access to latrines was observed. We extracted about 2,315 reported cases of WASH-related diseases, comprising diarrhoea (83%), dysentery (8%), typhoid fever (7%) and intestinal worms (2%). Impacts on diarrhoea prevalence were generally lower than reported figures, and varied across the intervention communities, ranging from 0 to 7% reduction. We recommend that greater attention be given to the sustainability of the intervention to ensure service delivery, rather than as a one-time investment, to achieve more significant impacts. Key words: Disaster-prone communities, WASH, sanitation, public health.

A first nation-wide assessment of soil-transmitted helminthiasis in Fijian primary schools, and factors associated with the infection, using a lymphatic filariasis transmission assessment survey as surveillance platform.

BackgroundSoil-transmitted helminthiasis (STH) is endemic in Fiji but its prevalence is not known and likely to have changed after a decade of mass drug administration (MDA) for lymphatic filariasis (LF). By linking with LF transmission assessment surveys (LF-TAS), we undertook the first nation-wide assessment of STH in Fijian primary schools, as well as an analysis of factors associated with STH infections.Methodology/Principal findingsA cross-sectional assessment for STH was conducted in all four Divisions of Fiji from 2014 to 2015. In the Western, Central, and Northern Divisions, schools were sub-sampled after LF-TAS, while, in the Eastern Division, schools were selected via simple random sampling. For the diagnosis of STH, stool samples were examined by coproscopy with a single Kato-Katz thick smear (KK) and the formol-ether-acetate concentration technique, except for the samples from the Eastern Division where only KK was used. Mean prevalence of any STH among class 1–2 students at the national level was 10.5% (95% CI: 6.9–15.5). Across the three Divisions via LF-TAS, the prevalence levels for ascariasis were 8.7% (95% CI: 4.3–16.6), hookworm 3.9% (95% CI: 2.3–6.6) and trichuriasis 0%. In the Eastern Division, ascariasis prevalence was 13.3% (95% CI: 6.4–25.6), and hookworm 0.7% (95% CI: 0.2–2.5), with one case of trichuriasis. Among class 3–8 students, ascariasis prevalence was lower. Lower risk of any STH was associated with wearing shoes (adjusted OR 0.54, 95% CI: 0.32–0.90) and having piped water from the Fiji Water Authority at home (adjusted OR 0.48, 95% CI: 0.25–0.92).ConclusionsAfter a decade of community-based LF-MDA, STH in school-age children in Fiji is now close to 10%, but localities of endemicity remain. Preventive chemotherapy should be maintained in areas with elevated STH prevalence alongside targeted delivery of integrated WASH interventions. LF-TAS has provided an opportunity to develop future public health surveillance platforms.

Distribution of hygiene kits during a cholera outbreak in Kasa\xef-Oriental, Democratic Republic of Congo: a process evaluation

BackgroundCholera remains a leading cause of infectious disease outbreaks globally, and a major public health threat in complex emergencies. Hygiene kits distributed to cholera case-households have previously shown an effect in reducing cholera incidence and are recommended by Médecins Sans Frontières (MSF) for distribution to admitted patients and accompanying household members upon admission to health care facilities (HCFs).MethodsThis process evaluation documented the implementation, participant response and context of hygiene kit distribution by MSF during a 2018 cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo (DRC). The study population comprised key informant interviews with seven MSF staff, 17 staff from other organisations and a random sample of 27 hygiene kit recipients. Structured observations were conducted of hygiene kit demonstrations and health promotion, and programme reports were analysed to triangulate data.Results and conclusionsBetween Week (W) 28–48 of the 2018 cholera outbreak in Kasaï-Oriental, there were 667 suspected cholera cases with a 5% case fatality rate (CFR). Across seven HCFs supported by MSF, 196 patients were admitted with suspected cholera between W43-W47 and hygiene kit were provided to patients upon admission and health promotion at the HCF was conducted to accompanying household contacts 5–6 times per day. Distribution of hygiene kits was limited and only 52% of admitted suspected cholera cases received a hygiene kit. The delay of the overall response, delayed supply and insufficient quantities of hygiene kits available limited the coverage and utility of the hygiene kits, and may have diminished the effectiveness of the intervention. The integration of a WASH intervention for cholera control at the point of patient admission is a growing trend and promising intervention for case-targeted cholera responses. However, the barriers identified in this study warrant consideration in subsequent cholera responses and further research is required to identify ways to improve implementation and delivery of this intervention.

Are ceramic water filters effective in preventing diarrhoea and acute malnutrition among under-five children in Sudan?

Access to safe drinking-water at home is essential during the outpatient treatment of children with acute malnutrition due to their increased vulnerability to infections and disease. The study aimed to evaluate the effectiveness of ceramic water filters with safe storage in preventing diarrhoea and acute malnutrition among under-five children in Kassala state, Sudan. It was designed as an open-label randomized controlled trial, comparing two study groups. Data was collected through face-to-face interviews and direct observations, then processed and analysed using Epi Info 7.2.0.1. Use of water filters is a potential predictor of number of diarrhoea episodes per child (P < 0.001). The intervention group had a lower diarrhoea occurrence (P < 0.001), better monthly average weight gain (P = 0.012) and average mid-upper arm circumference increase (P = 0.001), and lower prevalence of acute malnutrition at the end of the study (P = 0.001) compared with the control group. Ceramic water filters with safe storage can be effective in preventing diarrhoea and acute malnutrition, and beneficial to children admitted to Community Management of Acute Malnutrition programmes in Kassala state. More research is needed to understand the pathways to achieving these outcomes. Other WASH interventions may be needed to interrupt the primary vectors of diarrhoea disease transmission in this setting.