Browsing by Author "Tidwell JB"

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Effect of a behaviour change intervention on the quality of peri-urban sanitation in Lusaka, Zambia: a randomised controlled trial.
(2019-Apr) Tidwell JB; Chipungu J; Bosomprah S; Aunger R; Curtis V; Chilengi R; Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel St, London, UK.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia; Department of Biostatistics, School of Public Health, University of Ghana, Accra, Ghana.; Center for Infectious Disease Research in Zambia, Lusaka, Zambia.; Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel St, London, UK. Electronic address: ben.tidwell@lshtm.ac.uk.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Poor sanitation in peri-urban areas is a growing public health problem. We tested a scalable, demand-side behaviour change intervention to motivate landlords to improve the quality of shared toilets within their plots. METHODS: We did a residential plot-randomised controlled trial in a peri-urban community in Lusaka, Zambia. We enrolled adult resident landlords on plots where at least one tenant lived. We allocated landlords 1:1 to intervention and control arms on the basis of a random number sequence. The intervention was developed using the Behaviour Centred Design approach and consisted of a series of group meetings designed to motivate sanitation quality improvement as a way to build wealth and reduce on-plot conflict; no subsidies or materials were provided. The control group received no intervention. The four primary outcomes were having a rotational cleaning system in place (to improve hygiene); having a solid door on the toilet used by tenants with an inside lock (for privacy); having an outside lock (for security); and having a sealed toilet (to reduce smell and contamination). We measured outcomes 1 month before the start of the intervention and 4 months after the end of the intervention. Data collectors measuring outcomes were blinded to group assignment. We analysed outcomes by intention to treat, including all landlords with study-end results. Because the outcomes were assumed to not be independent, we used a family-wise error rate of 0·05 to calculate an adjusted significance level of 0·0253. This study was registered with ClinicalTrials.gov, number NCT03174015. FINDINGS: Between June 9 and July 6, 2017, 1085 landlords were enrolled and randomly assigned to the intervention (n=543) or the control group (n=542). The intervention was delivered from Aug 1, 2017, and evaluated from Feb 15 to March 5, 2018. Analysis was based on the 474 intervention and 454 control landlords surveyed at study end. The intervention was associated with improvements in the prevalence of cleaning rotas (relative risk 1·16, 95% CI 1·05-1·30; p=0·0011), inside locks (1·34, 1·10-1·64; p=0·00081), outside locks (1·27, 1·06-1·52; p=0·0028), and toilets with simple covers or water seals (1·25, 1·04-1·50; p=0·0063). INTERPRETATION: It is possible to improve the structural quality and cleanliness of shared sanitation by targeting landlords with a scalable, theory-driven behaviour change intervention without subsidy or provision of the relevant infrastructure. FUNDING: Sanitation and Hygiene Applied Research for Equity.
How can global guidelines support sustainable hygiene systems?
(2023-Oct) Esteves Mills J; Thomas A; Abdalla N; El-Alam R; Al-Shabi K; Ashinyo ME; Bangoura FO; Charles K; Chipungu J; Cole AO; Engebretson B; Goyol K; Grasham CF; Grossi V; Hickling S; Kalandarov S; Ababu AK; Kholmuhammad K; Klaesener-Metzner N; Kugedera Z; Kwakye A; Lee-Llacer A; Maani PP; Makhafola B; Mohamed A; Monirul Alam M; Monse B; Northover H; Palomares A; Patabendi N; Paynter N; Prasad-Gautam O; Panthi SR; Rudge L; Saha S; Salaru I; Saltiel G; Sax L; Shahid MA; Gafur MS; Shrestha S; Szeberényi K; Tidwell JB; Trinies V; Yiha O; Ziganshin R; Gordon B; Cumming O; Water, Sanitation, Hygiene and Health Unit, Department of Environment, Climate Change and Health, World Health Organization (WHO), Geneva, Switzerland jestevesmills@gmail.com.; Ministry of Health, Government of Ethiopia, Addis Ababa, Ethiopia.; UNICEF Sri Lanka Country Office, Colombo, Sri Lanka.; University of Oxford, Oxford, UK.; Department of Public Health, Ministry of Health, Funafuti, Tuvalu.; World Vision International, Washington, District of Columbia, USA.; Ministry of Health & Social Protection, Government of Tajikistan, Dushanbe, Tajikistan.; WHO Ethiopia Country Office, Addis Ababa, Ethiopia.; WHO Country Office, Sana'a, Yemen.; Foreign Commonwealth & Development Office, Government of the United Kingdom, London, UK.; UNICEF Regional Office for East and Southern Africa, Nairobi, Kenya.; UNICEF Bangladesh Country Office, Dhaka, Bangladesh.; UNICEF Pakistan Country Office, Lahore, Pakistan.; IRC India, New Delhi, India.; Global Consultant, London, UK.; UNICEF Regional Office for South Asia, Kathmandu, Nepal.; WHO Bangladesh Country Office, Dhaka, Bangladesh.; WHO Iraq Country Office, Baghdad, Iraq.; Ministry of Health, Government of South Africa, Pretoria, South Africa.; UNICEF Nepal Country Office, Lalitpur, Nepal.; London School of Hygiene and Tropical Medicine, London, UK.; Global Handwashing Partnership, Washington, District of Columbia, USA.; Water, Sanitation, Hygiene and Health Unit, Department of Environment, Climate Change and Health, World Health Organization (WHO), Geneva, Switzerland.; World Bank, Washington, District of Columbia, USA.; Health Emergency Interventions, WHO, Geneva, Switzerland.; United Nations Children's Fund (UNICEF), New York, New York, USA.; Environmental Health, World Health Organization, Kathmandu, Nepal.; European Centre for Environment & Health, WHO Regional Office for Europe, Bonn, Germany.; Centre for Infectious Disease Research, Zambia (CIDRZ), Lusaka, Zambia.; WHO Regional Office for the Eastern Mediterranean, Amman, Jordan.; WaterAid, London, UK.; WHO Country Office, Conakry, Guinea.; Department of Public Health Engineering, Government of Bangladesh, Dhaka, Bangladesh.; National Center for Public Health, Government of Hungary, Budapest, Hungary.; WHO Tajikistan Country Office, Dushanbe, Tajikistan.; WHO Ghana Country Office, Accra, Ghana.; UNICEF Tajikistan Country Office, Dushanbe, Tajikistan.; UNICEF Ethiopia Country Office, Addis Ababa, Ethiopia.; National Agency for Public Health, Government of the Republic of Moldova, Chisinau, Moldova (the Republic of).; Centers for Disease Control and Prevention, Atlanta, Georgia, USA.; German Agency for International Cooperation, Bonn, Germany.; Department of Health, Government of the Philippines, Manila, Philippines.; Department of Quality Assurance, Ghana Health Service, Accra, Ghana.
Theory-driven formative research on on-site, shared sanitation quality improvement among landlords and tenants in peri-urban Lusaka, Zambia.
(2019-Jun) Tidwell JB; Chipungu J; Chilengi R; Curtis V; Aunger R; a Department of Disease Control , London School of Hygiene & Tropical Medicine , London , UK.; b Center for Infectious Disease Research in Zambia , Lusaka , Zambia.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
Rapid, unplanned urbanization in low-income countries is leading to increasing problems of dealing with human waste. On-site sanitation systems are often rudimentary, unhygienic, and poorly maintained. In-depth, on-site interactive interviews were conducted with 33 landlords and 33 tenants in a neighborhood in peri-urban Lusaka to understand on-site, shared sanitation quality improvement behaviors and preferences. Respondents were asked about housing characteristics, toilet histories, and financial decision-making. Improved, shared toilets were common (79%), but many were of low quality and poorly cleaned. Poor coordination among tenants, barriers to communication between landlords and tenants, and landlords viewing sanitation as a required basic service to provide instead of something for which tenants will pay more rent all limit the quality of sanitation in this setting. Landlord-directed interventions targeting non-health motivations for sanitation improvement and introducing effective cleaning systems may increase peri-urban sanitation quality.
Using a theory-driven creative process to design a peri-urban on-site sanitation quality improvement intervention.
(2019-May-14) Tidwell JB; Chipungu J; Chilengi R; Curtis V; Aunger R; Center for Infectious Disease Research in Zambia, Plot 34620, Alick Nkhata Road, Lusaka, Zambia.; London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK.; London School of Hygiene & Tropical Medicine, Keppel St, London, WC1E 7HT, UK. ben_tidwell@hks.harvard.edu.; CIDRZ; Centre for Infectious Disease Research in Zambia (CIDRZ)
BACKGROUND: Behavior change interventions have been developed by drawing from many different theories using design processes of varying specificity. We describe the development of a behavior change intervention to improve on-site peri-urban sanitation quality in Lusaka, Zambia using the Behavior Centered Design (BCD) framework to explain the results of the process applied to improving the quality of shared peri-urban sanitation and compare them to similar interventions. METHODS: We used the BCD behavioral determinants model to synthesize the data from our literature review and formative research. Then, we partnered with creative professionals using a design process to develop a theory-driven on-site peri-urban sanitation intervention. Particular attention was paid to the implications of using BCD for intervention development on improving its effectiveness, increasing the contributions to knowledge for other behaviors and settings, and advancing the discipline of applied behavioral science. RESULTS: Based on findings from a literature review and formative research, we designed an intervention to encourage landlords to improve their toilets by making them more accessible, desirable, hygienic, and sustainable. The intervention involved landlords meeting in facilitated groups every 2 weeks with individual follow-up after each meeting. The meetings presented surprising "hidden camera"-style videos to reveal tenants' perspectives, used participatory activities to help landlords reevaluate the benefits they would derive from improving sanitation on their plots, and provided practical guidance and mechanisms to facilitate the performance of construction and cleaning behaviors. CONCLUSIONS: Using the BCD framework provided an easy-to-follow intervention design process. The resulting intervention is highly creative and multi-faceted, with each element having a theoretical role in an explicit theory of change. The development of this theory-driven intervention advances applied behavioral science by facilitating evaluation of each of the behavior change techniques and the overall delivery mechanism hypothesized to change the target behaviors. This informs the adaptation of these findings to improving on-site sanitation in other settings and the iterative development of the BCD model, which can be used to more effectively change other behaviors.