Research Investigator Piloting promotion of low cost sanitary hardware for sustainable disposal of child and animal feces in rural Bangladesh Faruqe HUSSAIN Research Investigator Program on Infectious Diseases and Vaccine Sciences ICDDR,B, Bangladesh Welcome to my presentation on the ‘piloting low cost sanitary hardware and the sustainability in rural Bangladesh’

Background Diarrhea kills 1.8 million children <5 every year Human feces, including children’s, are the primary source of diarrhea causing organisms Animal feces, especially chicken droppings and cow dung, also contain diarrhea causing organisms In Bangladesh, children and animals indiscriminately defecate and their feces contaminate the local environment There is lack of sanitary facilities in rural household The majority of mothers dispose of child and animal feces in unsafe ways, which is associated with diarrhea Diarrhoea, is still the biggest childhood killers in the world. Feces, both human and animal, including childrens’, are sources of diarrhea causing organisms. Like many other countries, children <3 defecates indiscriminately and feces contaminates the local environment. Though mothers of young children use local tools to dispose of feces that does not provide safe disposal facilities.

Study objectives Objectives To develop a hygiene intervention to consistently remove child and animal feces from the environment. To assess the feasibility and acceptability of behaviors and enabling hardware to design a larger intervention. Our objectives are: To develop a sanitation and hygiene intervention to consistently and effectively remove child and animal feces from the environment And to assess the feasibility of behaviors and enabling hardware to design a larger intervention.

Trial of improved practices (TIPs)* approach Test hardware or new behavior at small scale for feasibility and acceptability Give the community a voice Help design a larger intervention or program based on the findings TIPs is useful approach to test hardware or new behavior at small scale for feasibility. Community gives a voice and we hear and count them The findings help to design a larger program and intervention * The Manoff Group

TIPs related to child potty and sani-scoop Safety of the physical structure Design functional and acceptable Quick and easy to clean/maintain Sustainability of the hardware Safe disposal in a latrine or pit Research Questions addressed through the trial: We explored questions about whether the hardware was safe If the design of the child potty and sani-scoop was acceptable, feasible, and sustainable? Changes in feces disposal practices.

Methodology Rural setting Study population Timeframe 3 villages/communities (not adjacent) in northeast Bangladesh (37 households) Study population Convenience sample of mothers from rural households with at least one child 7- 36 months of age Timeframe June – July 2010 Kishoreganj Why 7-36 months? There are variations among countries and cultures of when to initiate potty-training Suggested age is 17 – 24 months Earlier initiation has better outcome Difficult to break previous habits when older Most children complete potty-training by 27-36 months

Child defecation pattern/behavior Number of children <3 and domestic animals Existing potty use Feces disposal practices (child & animal) Latrine type and facility Availability and accessibility of water Decided on village and household selection Sanitation assessment Introduced the hardware Captured initial reactions Answered their questions Offered choice of potty model Counted required no. of potties and sani- scoop and different potty models Introductory group discussion Sanitation assessment: Introductory group discussion: To offer people hardware choices and asking them to act as consultants after trying hardware and behaviors out

Assisted mothers to initiate potty-training Instructed about hardware use and maintenance Alerted mothers to possible problems occurring during potty-training Hardware distribution Assisted mothers to initiate potty-training Solved initial problems they faced Explored reasons to like and dislike Identified advantages and disadvantages Made recommendations   Follow up visits Alerted mothers to possible problems occurring during potty-training: fear and constipation Follow up visits to obtain feedback on benefits and challenges

Follow-up visit schedule 1st (1day) Initial feedback after having the hardware Problems Reasons for liking and disliking 2nd (3 days) Beginning of potty training introduction process Feces collection and disposal practices Hardware maintenance 3rd (7 days) At the beginning we were interested to look at the initial problems of using the hardware, the reasons for liking and disliking the hardware. Then we looked at the actual practices with the hardware including perceived barriers and benefits. Lastly we tried to identify any persistent problems need to solve and sought further recommendations 4th (14 days) Perceived barriers and benefits Other challenges Addressed any persistent problems Sought recommendations 5th (30 days)

Main features of potty Shape (animal) Grip Removable pot Rabbit headed Theses are our different potty models. The basic differences are in: Shape (animal or object/furniture) Grip facility Removable pot facility Rabbit headed Duck headed Chair shaped

Sani-scoop Purpose Lifted edges Angle Weight Front age Handle thickness The basic difference between the sani-scoop and traditinal agricultural hoe are: Men’s agricultural hoe Women’s sani-scoop My daughter says, “My father has one scoop (agricultural hoe) and now I have my own (sani) scoop”.

Hardware price Hardware Price (AUD) Chair Rabbit Duck Sani-scoop 3 1.7 1 – 3 Range of price of potty models and sani-scoop (in Australian Dollar) Sani-scoop price varies as we made with ICDDR,B color and logo but the households may not need so.

Data collection tools Semi-structured interviews Observation Morning/first defecation Potty introduction process Sani-scoop use Hardware cleaning and maintenance Group discussion We used semi-structured interviews, observation and group discussions to collect data.

Best potty model: rabbit headed Durable Animal shaped/toy for children Child can hold the ear as grip Mother can add water to removable pot before child defecates Can remove the pot when child uses the potty to sit on or play with Removable pot make it easy to dispose of feces We examined both postive and negative aspects of the three potty models (weight, stability, durability, convenience to use and disposal of feces and maintain the hardware) And the best model the household had selected is the rabbit-headed

We can see pictures of caring of hardware: potty is being dried in the roof of a kitchen and sani-scoop in a bamboo pole.

Barriers to potty use Barriers Solutions Scabies on child’s buttock Initiated potty-training when cured Younger children frightened Parents allowed them to play to make the potty familiar Barriers included mainly on the children’s physical and psychological conditions. Mothers, older siblings, or grandmothers supported them until defecation is complete One or two children fell off

Problems with Sani-scoop Solutions HH head fixed the handle Thinner plate can be used (less expensive) Handle became faulty We found fewer problems with sani-scoop but are managable easily. Household head can fix the handle and thinner plate makes the scoop sharpen and less expensive. Front edge of the plate is thick

Acceptability Potty Sani-scoop Entertaining for children (toy) Easy to grab (thinner handle) Attractive color (red), animal shaped Comfortable bending (45 d. Angle) Smooth surface and finishing Easy to carry to distant (3 edges lifted) Grandmothers, older siblings assist Easy to clean and handle (less weight) Fathers of children encourage to use Male household members fixed sani-scoop Both the hardware were acceptable due to its physical structure, useful function and convenience to use.

Feasibility Mothers agreed to spend time on hardware use and maintenance Removable pot makes it easy to collect and dispose of feces Feces can be carried easily to nearby or distant latrine or pit Potty can be covered and cleaned easily Sani-scoop keep feces stable while carrying to disposal Mothers of young children found the hardware feasible because the hardware enabled them to collect and dispose of feces conveniently.

Cleaning potty and sani-scoop The most common cleaning place of hardware

Perceived benefits: health related Many households also mentioned the use of the new hardware will help to reduce diarrhea. Open feces attract flies Flies land on feces and then on food Flies transmit diarrheal pathogens/indicator organisms Health related perceived benefits focused on the germ transmission by flies that can be interrupted by using the hardware regularly and consistently.

Perceived benefits: non-health Saved time Reduced workload Easily collect and dispose of feces Cleaning is easier Fewer baths for children No need to search for straw or leaves Mothers can work when child defecates Increased personal hygiene Improved household environment Non-health related perceived benefits were prominent among the mothers. The major benefits were the hardware saved time as they don’t need to search for straws or leaves and can continue their work when child defecates. Easy collection, dispose of feces and cleaning hardware reduced their workload. As children’s feces are not scattered when they defecate in potty, they have less chance to soil them and have less chance to find animal feces as mothers scoop feces from courtyard. Regular use of hardware make the courtyard free from feces, foul smell or flies. Children do not soil themselves with feces Children have less chance to find animal feces to put in mouth Courtyard is free from feces No smell or flies

Behavior change Previous Changed/new Children defecated indiscriminately Defecate in designated place (potty) Collected feces with straws and leaves Collect feces using the hardware Mothers disposed of feces in unsafe ways Dispose of feces mostly in latrine and specific pit Community allowed children’s open defecation Community and neighbor appreciate and encourage potty and sani-scoop use We found some changes in behaviors of both children and their mothers and community view. Children defecation pattern have been changed, they now defecate in potty (a designated place). Mothers do not use straws or leave to collect feces and do not dispose of feces by throwing bushes or nearby places. Community and neighbors now appreciate and encourage the use of hardware as they found the consequences positive.

Sustainability over 30 days The perceived health and non-health related benefits motivate mothers of young children to use the hardware: Mothers are willing to keep using both types of hardware Enhances disgust feeling No feces in household and neighbor appreciate Children develop ‘good’ habits Build new social norms Decrease diarrhea Mothers are willing to keep using both types of hardware Fathers also encourage its use Other family members, including me assist to clean feces and maintain hardware carefully Sani-scoop is considered as ‘women’s tool’ contrasting men’s ‘agricultural hoe’ sani-scoop is also useful for other purposes (clean vomit, debris) Men also maintain it when broken

Conclusions Caregivers found sanitary hardware acceptable, feasible and beneficial for children and household Non-health benefits of hardware use can be used to promote sustainable behavior, alongside health related benefits that people mentioned. Size is a remaining challenge Potty and sani-scoop found acceptable, feasible and beneficial for children and households. Highlighting non-health benefits could be useful to promote sustainable behavior change. And lastly we found, the size of potty is still remaining challenge because of the unique size (the model we provided)

International collaborators Acknowledgement Community people Children, their parents and other family members ICDDR,B research team Zahidur Rahman; Tania Naushin; Mamtaj Rima; Nasrin Akter; Mahfuzur Rahman; Shahinoor Akter; Samir Ghosh International collaborators Peter J. Winch Elli Leontsini Leanne Unicomb Dorothy Southern Stephen P. Luby Gates Foundation We acknowledge a great many people who supported us to conduct the trial in different stages.