Resolving The Asian Enigma

Sapha

Sara Johnson | Katherine Hymel Sara Liaghati-Mobarhan | Jessica Sidhu 1

2

Even with adequate caloric and nutritional intake, lack of sanitation inhibits growth.

3

Stunting • Low length- or

height-for-age• Consequence of

multiple factors often linked to poverty

• Can lead to developmental problems and is often impossible to correct, but can be prevented

GROWING UP EDUCATION

VICIOUS CYCLEPROFESSIONAL LIFE

4

“India’s stunting problem represents

the

largest loss of human

potential in any country in

history, and it affects 20 times more people

in India alone than H.I.V./AIDS does

around the world.”Ramanan Laxminarayan

Vice president for research and policy at the Public Health Foundation of India

Uttar PradeshRELIGIONS | Hindi,Urdu,Bhojpuri, AwadhiLANGUAGES | Hindi, UrduPOPULATION | 211,797,459

REGIONAL | 75 districts Literacy rate: 70%, below national average of 74%

Key industries: IT, Agro Processing, Tourism, Mineral-based industries and Textiles

UTTAR PRADESH (UP)

5

78% of people in UP practice open defecation (OD)Poor sanitation spreads infectionsRapid escalation with population growth

OPEN DEFECATION IN UP

6

Far from his dwelling let him remove urine (and ordure), far (let him remove) the water used for washing his feet, and far the remnants of food and the water from his bath.

PURITY AND POLLUTION

7

CURRENT STRATEGIES

Total Sanitation Campaign(TSC)/Clean India CampaignChange social norms and reduce OD

Nirmal Gram Puraskar monetary award for “open defecation free” cities

Generational resistanceConstructed latrines in disuse

8

IMPLEMENTATION BARRIERS

Only 26% surveyed gave link between diarrhea and infectious agents

Scientific misconceptionsOD associated with strength, rising early

9

ObjectiveCombat child stunting in rural regions of northern India through assessment of each village’s resources, mobilizing the community through religious figures to educate women and children on minimizing exposure to growth-stunting microbia

10

Intervention overview• Strong community assessment using

“triggering” phases to determine current sanitation infrastructure and practices

• Determination of exposure pathways• Community mobilization with educational

programs/appropriate technologies to minimize exposure to those pathways

11

Initiative timeline

1 . Mar . 2015 1 . Mar . 2016 1 . Mar . 2017 1 . Mar . 2018

1 . Jan . 2016

1 . Apr . 2016

1 . Aug . 2016

1 . Jan . 2017

1 . Mar . 2015

1 . Aug . 2015

1 . Jan . 2018

1 . Jan . 2016

1 . Jan . 2017

1 . Jan . 2018

1 . Jan . 2019

12

Defecation area transect

walk

Community

mapping

Specific questio

ns about

defecation

behaviors

Community assessment

13

Exposure assessment• Exposed groups potentially at riskWho?

• Directly and indirectly exposedHow many?

• Point of exposure in sanitation systemWhere?

• Routes (direct, water/food sources, mosquito breeding)Which?

• Frequency of exposure (daily, weekly)How?

• Likely dose of exposure and typeWhat?14

Exposure pathways

Source: Engineers Without Borders15

Quantitative microbial risk assessment

16

Infrastructure assessment

Access to improved water source?

Yes

Access to latrine?

Yes

Is latrine in use?

No

No

17

INFR

ASTR

UCTU

RESA

NITA

TION

INFRASTRUCTURE

SANITATION

COMMUNITY DEVELOPMENT

COM

MUN

ITY

DEVE

LOPM

ENT

18

INFR

ASTR

UCTU

RESA

NITA

TION

COM

MUN

ITY

DEVE

LOPM

ENT

Community development

19

INFR

ASTR

UCTU

RESA

NITA

TION

COM

MUN

ITY

DEVE

LOPM

ENT

Identify community leaders

• Female empowerment: most direct link to children

• Involve religious leaders• Provide with concrete tools (Facilitator’s

Manual, infrastructure and education guidelines)

20

INFR

ASTR

UCTU

RESA

NITA

TION

COM

MUN

ITY

DEVE

LOPM

ENT

Public health committees

• Host programs for women on basic hygiene science and practices

• Monitor project implementations • Seek input of community with

interventions

21

INFR

ASTR

UCTU

RESA

NITA

TION

COM

MUN

ITY

DEVE

LOPM

ENT

Primary schools

• Introduction of basic hygiene lessons• Interactive demonstrations• Partnerships with pre-existing work:

• Hope for Hapric• UNICEF, TSC• Tippy Tap• Sulabh School Sanitation Club• Swacch Express• Feedback Foundation

22

Primary school interventions

Handwashing with soap at critical times can reduce diarrhea rates by approximately 40%

INFR

ASTR

UCTU

RESA

NITA

TION

COM

MUN

ITY

DEVE

LOPM

ENT

23

INFR

ASTR

UCTU

RESA

NITA

TION

COM

MUN

ITY

DEVE

LOPM

ENT

Partnerships with NGOsSulabh International, Engineers Without Borders

24

INFR

ASTR

UCTU

RESA

NITA

TION

COM

MUN

ITY

DEVE

LOPM

ENT

Bank filtration, managed aquifer recharge Pumps, wells, spring boxes, gravity systems

Rainwater harvesting, micro dams

25

Monitoring and evaluation

• Adapted from Patil et al., 2014; see appendix

• Measured Outcomes (questionnaires, waste disposal classification, testing of drinking water, child anthropometry and specimen testing)

• Frequency: 2 times per year• Award: Monetary incentives for villages

26

Projected community

• Mahoba district • Population: 876,055 • 78.84 % population of Mahoba districts lives in rural areas

of villages• Literacy rate: 65.27%• Total child population (0-6): 128,129

• Four villages of focus• Akona• Jaitpur• Rawatpura• Salat

27

Hypothetical assessment

• Highest risk exposure pathway: ingestion of excreta (fecal to hand to mouth)

• Latrines built by government but not in use

• Access to food and water

28

INFR

ASTR

UCTU

RESA

NITA

TION

INFRASTRUCTURE

SANITATION

COMMUNITY DEVELOPMENT

COM

MUN

ITY

DEVE

LOPM

ENT

29

INFR

ASTR

UCTU

RESA

NITA

TION

COM

MUN

ITY

DEVE

LOPM

ENT

Not a major concern according to assessmentLatrines in disuse

30

Primary school interventions Projected diarrhea reduction rates by approximately 40%

INFR

ASTR

UCTU

RESA

NITA

TION

COM

MUN

ITY

DEVE

LOPM

ENT

Tippy taps constructed at schools and near identified areas for open defecation 31

INFR

ASTR

UCTU

RESA

NITA

TION

COM

MUN

ITY

DEVE

LOPM

ENT

Community development

• Public health committee established• Handwashing demonstration with women

and school children

32

Partnership with candidates during election seasonExpansion of program into other districtsInvolve university students

FUTURE PLANS33

SUSTAINABILITY

Cultural awarenessAvoidance of proprietary breakdownsCommunity members fuel the movement

34

Budget

35

ReferencesBadham J, Sweet L. (2010). Stunting: an Overview. Sight and Life. Retrieved on February 3, 2015 from: http://www.sightandlife.org/fileadmin/data/Publications/Stunting/Stunting_An_O verview.pdf Banda, K., Sarkar, R., Gopal, S., Govindarajan, J., Harijan, B., Jeyakumar, M., … Balraj, V. (2007). Water handling, sanitation and defecation practices in rural southern India: A knowledge, attitudes and practices study. Transactions of the Royal Society of Tropical Medicine and Hygiene, 101(11), 1124-1130. Coffey, D., Gupta, A., Hathi, P., Khurana, N., Srivastav, N., & Vyas, S. (2014, September 20). Revealed preference for Open Defecation: Evidence from a new survey in rural North India. Economic & Political Weekly, 43-55. Curtis, V., & Cairncross, S. (2003). Effect of washing hands with soap on diarrhea risk in the community: a systematic review. Lancet Infectious Diseases 3, 275–81. Greater Access to Cell Phones Than Toilets in India: UN – United Nations University. (2010, April 14). Retrieved February 7, 2015, from http://unu.edu/media-relations/releases/greater-access-to-cell-phones-than-toilets-in-india.html  Harris, G. (2014). Poor Sanitation in India May Afflict Well-Fed Children with Malnutrition. The New York Times. February 5, 2015 from: http://www.nytimes.com/2014/07/15/world/asia/poor-sanitation-in-india-may- afflict-well-fed-children-with-malnutrition.html Mahoba District : Census 2011 data. (n.d.). Retrieved February 6, 2015, from http://www.census2011.co.in/census/district/540-mahoba.html  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  Quantitative Microbial Risk Assessment (QMRA) Wiki. (n.d.). Retrieved February 6, 2015, from http://qmrawiki.canr.msu.edu/index.php/Quantitative_Microbial_Risk_Assessment_(QMRA)_Wiki  Singh, P., Chavan, P., & Mathur, D. (2013, August 10). Policy Brief for Parliamentarians, Open Defecation: This is also your business! Retrieved February 7, 2015, from http://www.clraindia.org/include/ODpolicybriefFinal.pdf  The Sphere Project (2010). Minimum standards in water supply, sanitation, and hygiene promotion. The Sphere Handbook, 51-102. Retrieved from: http://my.ewb-usa.org/theme/library/myewb-usa/project-resources/technical/SphereHandbook-Chapter2.pdf  Sulabh International Social Service Organisation. (n.d.). Retrieved February 5, 2015, from http://www.sulabhinternational.org/ Tippy Tap. (n.d.). Retrieved February 4, 2015, from http://www.tippytap.org  WaterAid (2011). Technology Notes. Retrieved from: http://my.ewb-usa.org/theme/library/myewb-usa/project-resources/technical/water_aid_technology_notes.pdf  WHO/UNICEF Joint Monitoring Programme (JMP) for Water Supply and Sanitation. Progress on Drinking Water and Sanitation: 2014 Update. Retrieved February 6, 2015 from: http://www.wssinfo.org/fileadmin/user_upload/resources/JMP_report_2014_webE ng.pdf   36

Hope for Hapric

• Campaign within primary schools to promote good facilities, build hygiene behaviors, and educate students interactively on WASH access

• Partnership with Save the Children

Primary schools37

UNICEF’s Child Environment Program

• WASH in school interventions that promote hygiene behaviors

• Supports government TSC and National Rural Drinking Water Programme

Primary schools38

Sulabh School Sanitation Club

• Composed of students, both boys and girls, ranging from 10 to 16 years of age

• Responsible for looking after the school’s water and sanitation facilities, and spreading hygiene messages among their peers.

Primary schools39

NGO: Swacch Express

• Passes through villages in urban and rural villages throughout India (including UP)

• Creates awareness around hygiene and sanitation through interactive videos, flyer distributions, posters, hand-washing sessions and street plays.

Primary schools40

Feedback Foundation (Partnership)

• Community engagement entity that could partner with us to train university students and community leaders/members to do work in schools and communities

• Led a capacity building effort that “Trained the Trainers” of the community-led Total Sanitation Approach in rural areas

Primary schools41