Toilet V.A.L.U.E.E Campaign

Valuing And Learning to Use Equipment Effectively

2015 Global Health Case Competition UAB Sparkman Center for Global Health

Archana Naik, Lakendra Mosley, Sarah Simpson, Sunil Gaikwad, and Yingxue Wang

A STINKY SITUATION

• PROBLEM DEFINITION • KEY TERMS

• OPEN DEFECATION• STUNTING

THE ROTTEN TRUTH

• FACTS RELATED TO ISSUE • GLOBAL BURDEN • EFFECTS IN INDIA

• HEALTH EFFECTS OF OPEN DEFECATION

LINK: STUNTING AND OPEN DEFECATION

• HUMAN HEIGHT • CORRELATE OF HEALTH AND PREDICTOR

OF ECONOMIC PRODUCTIVITY

• ASIAN ENIGMA

• PROBLEM REGARDLESS OF SOCIOECONOMIC STATUS

• FOOD IS AVAILABLE

PREVALENCE OF STUNTING IN CHILDREN UNDER 5 YEARS OF AGE

TARGET AREA

• UTTAR PRADESH (UP)• BACKGROUND INFORMATION

• INTERVENTION AREA:• HAMIRPUR DISTRICT • 5 VILLAGES

• SARILLA, KHARELA, MUSKARA,

• JALALPUR, BENWAR

• REPRESENTATIVE POPULATION

WASTED RESOURCESWHAT HAS BEEN DONE?

• CURRENT INTERVENTIONS • TCS• PROJECT MARYAADA• UNICEF

• OUTCOMES

INEFFECTIVE APPROACHES

WHY ARE CURRENT PROGRAMS FAILING?

• BELIEFS

• PERCEPTIONS

• EXISTING LATRINES ARE UNCLEAN

CULTURAL ROLE IN CHANGE

• VALUE VS. PRACTICE

• BEHAVIORAL CHANGE • INSTILL NEW VALUES• ESTABLISH NEW PRACTICES

TOILET VALUEE CAMPAIGN (VALUING AND LEARNING TO USE EQUIPMENT EFFECTIVELY)

• BASELINE DATA COLLECTION • EDUCATION/AWARENESS PROJECTS • IMPROVED SANITATION• EVALUATE & SPREAD THE CHANGEMISSION:

INSTILL NEW VALUES TO ELICIT A BEHAVIORAL CHANGE

ESTABLISHING PRE-INTERVENTION BASELINES

• INTERVIEW VILLAGERS• SOIL AND WATER QUALITY TESTING• HEALTH SCREENING – CHILDREN • EVALUATION OF THE CURRENT TSC OUTREACH PROGRAM • EVALUATION OF LOCAL GOVERNMENT

EDUCATION MATTERS

• TARGET POPULATIONS: • WOMEN • CHILDREN • COMMUNITY

“without education, they’ll make little difference”

-Ministry of Drinking water and sanitation

EDUCATION FOR WOMEN

• WORKSHOPS• FAMILY INVOLVEMENT • INFORMATIVE

EDUCATING THE CHILDREN

• HEALTH BENEFITS• PROPER HAND WASHING TECH• HEALTHY COMPETITION

ACT LOCALLY, BE GLOBAL

• PRIDE• ECONOMIC DEVELOPMENT• PUBLIZE

SAMPLE EDUCATION MATERIAL

WHISTLE BLOWERS:

• PROGRAM OUTLINE• TARGET GROUP • OBJECTIVE

• CULTURAL RELEVANCE • BEHAVIORAL THEORY

HAND-WASHING CAMPAIGN

• DEMONSTRATE HAND SANITIZATION TECHNIQUES • PROVIDE ANTISEPTIC SOAP

MEDIA CAMPAIGN

• BILLBOARDS, FLYERS• WALL PAINTING• STREET PLAYS• RADIO TIE UP WITH RADIO MIRCHI• TIE UP WITH LOCAL NEWSPAPER- SOCIAL MEDIA NETWORKING AND BRANDING

INCENTIVES• MELA – EVERY YEAR ODF BEST VILLAGE

• 1ST MELA CHIEF GUEST VIDYA BALAN (FAMOUS BOLLYWOOD ACTRESS, AND TSC BRAND AMBASSADOR)

• NIRMAL GRAM PURASKAR• GLOBAL BRANDING• PRIDE• ODOR FREE VILLAGE• REDUCED MORBIDITY AND MORTALITY FROM DIARRHEAL DISEASES• IMPROVED NUTRITIONAL STATUS, HEIGHT IN CHILDREN

INCENTIVEMELA (VILLAGE FAIR) – EVERY YEAR THE BEST VILLAGE

• 1ST MELA CHIEF GUEST VIDYA BALAN (FAMOUS ACTRESS)

Pre Intervention • Community

survey• Environmental

evaluation• Health ScreeningsEvaluate local governments Train Educators

Implement Education

Weekly women workshop

Monthly essay/ painting competition

Set up billboards and wall paintings

Disseminate outreach materials

Build in-home toilets Whistle program Monthly women

workshop Incentive: 1st MELA (village fair) – 1 year

Community feedback

Bi-Yearly evaluations

Height , malnutrition, and usage of toilets

MELA at the end of 1st , 2nd and 3rd year

EVALUATION OF SANITATION • BASELINE ESTABLISHED IN INTERVENTION SURVEY

• REEVALUATE ENVIRONMENT EVERY 6 MONTHS• CONDITION OF LATRINES, CLEANLINESS OF VILLAGE, SOIL AND WATER

TESTS, ATTITUDE TOWARDS CHANGE

• REEVALUATE HEALTH OUTCOMES OF CHILDREN • HEIGHT AND NUTRITIONAL STATUS • 1 YEAR MARK AND THEN EVERY 6 MONTHS

• STUDY DESIGN• LONGITUDINAL STUDY • NORMALIZING FOR THE AGE

BUDGET

COMPLIANCE AND SUSTAINABILITY

• APPEAL TO VALUES • BEHAVIORAL INTERVENTION • CONVENIENCE• SENSE OF BELONGING• ASSURES SAFETY• TRANSLATE THE RESULTS OF EVALUATION TO PUBLIC• EVIDENT HEALTH BENEFIT• COMMUNITY PRIDE• POTENTIAL FOR ECONOMIC DEVELOPMENT

SUMMARY• BASELINE DATA COLLECTION • EDUCATION AND AWARENESS CAMPAIGN • EMPOWERMENT PROJECTS• REEVALUATE HEALTH OUTCOMES• PROGRAM EVALUATION • SPREAD THE GOOD WORD

REFERENCES1. UNICEF. 2009. TRACKING PROGRESS ON CHILD AND MATERNAL NUTRITION: A SURVIVAL AND DEVELOPMENT PRIORITY. RETRIEVED NOVEMBER 13, 2014 FROM: HTTP://WWW.UNICEF.ORG/PUBLICATIONS/FILES/TRACKING_PROGRESS_ON_CHILD_AND_MATERNAL_NUTRITION_EN_110309.PDF

2. BADHAM J, SWEET L. 2010. STUNTING: AN OVERVIEW. SIGHT AND LIFE. RETRIEVED ON NOVEMBER 13, 2014 FROM: HTTP://WWW.SIGHTANDLIFE.ORG/FILEADMIN/DATA/PUBLICATIONS/STUNTING/STUNTING_AN_OVERVIEW.PDF

3. BRENNAN L, MCDONALD J, SHLOMOWITZ R. 2004. INFANT FEEDING PRACTICES AND CHRONIC CHILD MALNUTRITION IN THE INDIAN STATES OF KARNATAKA AND UTTAR PRADESH. ECON HUM BIOL, 2(1), 139-158.

4. ECONOMIST. 2014. THE FINAL FRONTIER. THE ECONOMIST ASIA. RETRIEVED NOVEMBER 13, 2014 FROM: HTTP://WWW.ECONOMIST.COM/NEWS/ASIA/21607837-FIXING-DREADFUL-SANITATION-INDIA-REQUIRES-NOT-JUST-BUILDING-LAVATORIES-ALSO-CHANGING

5. COFFEY D, GUPTA A, HATHI P, KHURANA N, SPEARS D, SRIVASTAV N, VYAS S. 2014. REVEALED PREFERENCE FOR OPEN DEFECATION: EVIDENCE FROM A NEW SURVEY IN RURAL NORTH INDIA. SQUAT WORKING PAPER NO. 1-26.

6. BISWAS S. 2012. IS INDIA’S LACK OF TOILETS A CULTURAL PROBLEM? BBC NEWS INDIA. RETRIEVED NOVEMBER 13, 2014 FROM: HTTP://WWW.BBC.COM/NEWS/WORLD-ASIA-INDIA-17377895

7. MINISTRY OF STATISTICS AND PROGRAMME IMPLEMENTATION (GOVERNMENT OF INDIA). MILLENNIUM DEVELOPMENT GOALS INDIA COUNTRY REPORT 2011. RETRIEVED SEP 29, 2014 FROM: HTTP://WWW.UNDP.ORG/CONTENT/DAM/UNDP/LIBRARY/MDG/ENGLISH/MDG%20COUNTRY%20REPORTS/INDIA/MDG_INDIA_2011.PDF

8. WHO. 2014. GLOBAL DATABASE ON CHILD GROWTH AND MALNUTRITION. RETRIEVED NOVEMBER 13, 2014 FROM: HTTP://WWW.WHO.INT/NUTGROWTHDB/ABOUT/INTRODUCTION/EN/INDEX2.HTML

9. HARRIS, G. 2014. POOR SANITATION IN INDIA MAY AFFLICT WELL-FED CHILDREN WITH MALNUTRITION. THE NEW YORK TIMES. RETRIEVED NOVEMBER 13, 2014 FROM: HTTP://WWW.NYTIMES.COM/2014/07/15/WORLD/ASIA/POOR-SANITATION-IN-INDIA-MAY-AFFLICT-WELL-FED-CHILDREN-WITH-MALNUTRITION.HTML

REFERENCES (CONTINUED) 10. FINK G, GÜNTER I, HILL K. 2011. THE EFFECT OF WATER AND SANITATION ON CHILD HEALTH: EVIDENCE FROM THE DEMOGRAPHIC AND HEALTH SURVEYS 1986-2007. INTERNATIONAL JOURNAL OF EPIDEMIOLOGY. 40, 1196-1204.

11. CHAMBERS R, VON MEDEAZZA R. 2013: SANITATION AND STUNTING IN INDIA: UNDERNUTRITION’S BLIND SPOT. ECONOMIC & POLITICAL WEEKLY. 48(25), 15-17.

12. SPEARS D. 2013. HOW MUCH INTERNATIONAL VARIATION IN CHILD HEIGHT CAN SANITATION EXPLAIN? WORKING PAPER – RESEARCH PROGRAMS IN DEVELOPMENT STUDIES FROM PINCETON UNIVERSITY. RETRIEVED NOVEMBER HTTP://WWW.PRINCETON.EDU/RPDS/PAPERS/SPEARS_HEIGHT_AND_SANITATION.PDF.PDF

13. SPEARS D, GHOST A, CUMMING O. 2013. OPEN DEFECATION AND CHILDHOOD STUNTING IN INDIA: AN ECOLOGICAL ANALYSIS OF NEW DATA FROM 112 DISTRICTS. PLOS ONE. 8(9)

14. UNITED NATIONS DEPARTMENT OF ECONOMICS AND SOCIAL AFFAIRS (UNDESA). 2014. ACCESS TO SANITATION. RETRIEVED NOVEMBER 13, 2014 FROM: HTTP://WWW.UN.ORG/WATERFORLIFEDECADE/SANITATION.SHTML

15. WHO/UNICEF JOINT MONITORING PROGRAMME (JMP) FOR WATER SUPPLY AND SANITATION. PROGRESS ON DRINKING WATER AND SANITATION: 2014 UPDATE. RETRIEVED SEP 30, 2014 FROM: HTTP://WWW.WSSINFO.ORG/FILEADMIN/USER_UPLOAD/RESOURCES/JMP_REPORT_2014_WEBENG.PDF

16. KUMAR GP. 2014. TOTAL SANITATION: WHY TOILETS ALONG CANNOT STOP OPEN DEFECATION. FIRST POST INDIA. RETRIEVED NOVEMBER 13, 2014 FROM: HTTP://WWW.FIRSTPOST.COM/INDIA/TOTAL-SANITATION-WHY-TOILETS-ALONE-CANNOT-STOP-OPEN-DEFECATION-1650563.HTML

17. MEHROTRA K. 2014. INDIA’S TOILET RACE FAILING AS VILLAGES DON’T USE THEM. BLOOMBERG. RETRIEVED NOVEMBER 13, 2014 FROM: HTTP://WWW.BLOOMBERG.COM/NEWS/2014-08-03/INDIA-S-TOILET-RACE-FAILING-AS-VILLAGES-DON-T-USE-THEM.HTML

18. PUROHIT P. 2012. SANITATION IN INDIA. MAHATMA GANDHI CENTRE FOR SANTIATION. RETRIEVED NOVEMBER 13, 2014: HTTP://WWW.SLIDESHARE.NET/PUROHIT1323/SANITATION-IN-INDIA-12066973

19. PATIL SR, ARNOLD BF, SALVATORE AL, BRICENO B, GANGULY S, COLFORD JR JM, GERTLER PJ. 2014. THE EFFECT OF INDIA'S TOTAL SANITATION CAMPAIGN ON DEFECATION BEHAVIORS AND CHILD HEALTH IN RURAL MADHYA PRADESH: A CLUSTER RANDOMIZED CONTROLLED TRIAL. PLOS MEDICINE. DOI: 10.1371/JOURNAL.PMED.1001709

THANK YOU

QUESTIONS

?

NOT A GENETIC OR GEOGRAPHIC ARTIFACT

• CHILD HEIGHT IS STRONGLY ASSOCIATED WITH THE AVERAGE NUMBER OF PEOPLE PER SQUARE KILOMETER IN A COUNTRY WHO PRACTICE OPEN DEFECATION

• THE PRACTICE OF OD IS INVERSELY PROPORTIONAL TO HEIGHT.

• X-AXIS: LOG OF PEOPLE WHO DEFECATE OPENLY.

• Y-AXIS: DIFFERENCE FROM MEAN HEIGHT NORMALIZED AS PER SD

GAINING GOVERNMENT SUPPORT

• FAMILIARIZE OUR TEAM WITH THE CONTEMPORARY GOVERNMENT POLICIES

• CONSTITUTE A BLUEPRINT THAT ALIGN WITH GOVERNMENT POLICIES

• INVOLVE THE LOK SABHA (LOWER HOUSE OF PARLIAMENT) REPRESENTATIVES

BUDGETITEM REQUEST FUND  0-6 MONTHS 6-12 MONTHS 1-3 YEARSPre intervention survey $2,000.00    Screening/Testing $3,000.00 $3,000.00 $9,000.00 Height/nutrition investment $20,000.00 $10,000.00 $30,000.00 Training for education $10,000.00    Hands sannitation      Electronic media $500,000.00    Central reposition $15,000.00 $10,000.00 $25,000.00 Street Play $50,000.00    T-shirts $10,000.00 $5,000.00 $5,000.00 Education material $200,000.00 $100,000.00 $60,000.00 Wall Painting / Bill board $15,000.00    Whistle Program   $2,000.00  Village fair (Mela) $15,000.00 $15,000.00 $30,000.00 Evaluation survey     $8,000.00 Personnel $60,000.00 $60,000.00 $180,000.00 Cell phone $4,000.00 $2,000.00 $4,000.00 Transportation $20,000.00 $15,000.00 $15,000.00 Electricity $2,000.00 $2,000.00 $6,000.00 Office material $2,000.00 $1,500.00 $1,500.00 Miscellaneous $50,000.00 $50,000.00 $100,000.00 Total $978,000.00 $275,500.00 $473,500.00

$2,000.00 $15,000.00 $60,000.00 $10,000.00

$0.00 $500,000.00

$50,000.00 $50,000.00 $20,000.00

$360,000.00 $15,000.00

$2,000.00 $60,000.00

$8,000.00 $300,000.00

$10,000.00 $50,000.00 $10,000.00

$5,000.00 $200,000.00

$1,727,000.00

PRE INTERVENTION SURVEY• IDENTIFICATION OF THE FAMILY AND FAMILY MEMBER• NUMBER OF KIDS UNDER 5 AT HOME.• DO YOU HAVE A TOILET AT HOME?• DO YOU USE A LATRINE?• WHERE DO YOU DEFECATE? • DO YOU LIKE YOUR WAY OF DEFECATING?• WHY DO YOU LIKE/PREFER OD?• IN CASE OF OD, WOULD YOU AVERSE FROM OD IF THERE WAS A

TOILET ATTACHED TO YOUR HOME?• DO YOU KNOW THAT OD IS HARMFUL TO YOU, YOUR FAMILY AND

COMMUNITY’S HEALTH?

TESTS FOR EVALUATION• ANTHROPOMETRY• HEIGHT AND WEIGHT• HEAD AND CHEST CIRCUMFERENCE• SKIN ELASTICITY• COMPLETE BLOOD COUNT• TESTS FOR SPECIFIC MINERALS, AND VITAMIN DEFICIENCY• SERUM TOTAL PROTEIN, BLOOD ALBUMIN AND LIPIDS• FREE FOR UNDER 5 YRS CHILDREN AT COMMUNITY HEALTH CENTERS .• CHILD STOOL PARASITOLOGY• RANDOM SUBSAMPLE OF 1,150 HOUSEHOLDS & COLLECTED STOOL SPECIMEN FROM A CHILD <5 YRS IN THE HOUSEHOLD.

ALL STOOL SAMPLES WERE PRESERVED IN 10% FORMALIN AND ANALYZED AT THE NATIONAL INSTITUTE FOR CHOLERA AND ENTERIC DISEASES IN UP.

• TEST THE SAMPLES FOR SOIL TRANSMITTED HELMINTHES (ASCARIS LUMBRICOIDES, TRICHURIS TRICHIURA, ANCYLOSTOMA DUODENALE, AND NECATOR AMERICANUS) AND TAPEWORM HELMINTHES (HYMENOLEPIS NANA, TAENIA SP., DIPHYLLOBOTHRIUM LATUM).

• A SEPARATE ALIQUOT WAS ANALYZED TO TEST FOR PROTOZOAN INFECTIONS.