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- 1. 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
- 2. A STINKY SITUATION • PROBLEM DEFINITION • KEY TERMS • OPEN DEFECATION • STUNTING
- 3. THE ROTTEN TRUTH • FACTS RELATED TO ISSUE • GLOBAL BURDEN • EFFECTS IN INDIA • HEALTH EFFECTS OF OPEN DEFECATION
- 4. 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
- 5. TARGET AREA • UTTAR PRADESH (UP) • BACKGROUND INFORMATION • INTERVENTION AREA: • HAMIRPUR DISTRICT • 5 VILLAGES • SARILLA, KHARELA, MUSKARA, • JALALPUR, BENWAR • REPRESENTATIVE POPULATION
- 6. WASTED RESOURCES WHAT HAS BEEN DONE? • CURRENT INTERVENTIONS • TCS • PROJECT MARYAADA • UNICEF • OUTCOMES
- 7. INEFFECTIVE APPROACHES WHY ARE CURRENT PROGRAMS FAILING? • BELIEFS • PERCEPTIONS • EXISTING LATRINES ARE UNCLEAN
- 8. CULTURAL ROLE IN CHANGE • VALUE VS. PRACTICE • BEHAVIORAL CHANGE • INSTILL NEW VALUES • ESTABLISH NEW PRACTICES
- 9. TOILET VALUEE CAMPAIGN (VALUING AND LEARNING TO USE EQUIPMENT EFFECTIVELY) • BASELINE DATA COLLECTION • EDUCATION/AWARENESS PROJECTS • IMPROVED SANITATION • EVALUATE & SPREAD THE CHANGE MISSION: INSTILL NEW VALUES TO ELICIT A BEHAVIORAL CHANGE
- 10. 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
- 11. EDUCATION MATTERS • TARGET POPULATIONS: • WOMEN • CHILDREN • COMMUNITY “without education, they’ll make little difference” -Ministry of Drinking water and sanitation
- 12. EDUCATION FOR WOMEN • WORKSHOPS • FAMILY INVOLVEMENT • INFORMATIVE
- 13. EDUCATING THE CHILDREN • HEALTH BENEFITS • PROPER HAND WASHING TECH • HEALTHY COMPETITION
- 14. ACT LOCALLY, BE GLOBAL • PRIDE • ECONOMIC DEVELOPMENT • PUBLIZE
- 16. WHISTLE BLOWERS: • PROGRAM OUTLINE • TARGET GROUP • OBJECTIVE • CULTURAL RELEVANCE • BEHAVIORAL THEORY
- 17. HAND-WASHING CAMPAIGN • DEMONSTRATE HAND SANITIZATION TECHNIQUES • PROVIDE ANTISEPTIC SOAP
- 18. MEDIA CAMPAIGN • BILLBOARDS, FLYERS • WALL PAINTING • STREET PLAYS • RADIO TIE UP WITH RADIO MIRCHI • TIE UP WITH LOCAL NEWSPAPER - SOCIAL MEDIA NETWORKING AND BRANDING
- 19. 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
- 20. INCENTIVE MELA (VILLAGE FAIR) – EVERY YEAR THE BEST VILLAGE • 1ST MELA CHIEF GUEST VIDYA BALAN (FAMOUS ACTRESS)
- 21. 0-2 Months • Pre Intervention • Community survey • Environmental evaluation • Health Screenings • Evaluate local 3-5 Months • Implement Education • Weekly women workshop • Monthly essay/ painting competition • Set up billboards and wall paintings 6-12 Months • Build in-home toilets • Whistle program • Monthly women workshop • Incentive: 1st MELA (village fair) – 1 year 1-3 years • Bi-Yearly evaluations • Height , malnutrition, and usage of toilets • MELA at the end of 1st , nd rd
- 22. 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
- 23. BUDGET
- 24. 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
- 25. SUMMARY • BASELINE DATA COLLECTION • EDUCATION AND AWARENESS CAMPAIGN • EMPOWERMENT PROJECTS • REEVALUATE HEALTH OUTCOMES • PROGRAM EVALUATION • SPREAD THE GOOD WORD
- 26. REFERENCES 1. 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
- 27. 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
- 29. 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
- 30. 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
- 31. BUDGET ITEM REQUEST FUND 0-6 MONTHS 6-12 MONTHS 1-3 YEARS Pre 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
- 32. 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?
- 33. 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.
Notas del editor
- 1
- Today we will be addressing the Roles of Open Defecation and Sanitation as a predictor in the stunting of children in Northern India Define OD - is the practice of defecating outside or in public Villagers defecate in open fields, behind bushes, along roadsides often contaminating soil and water sources OD is related to cultural practices or lack of infrastructure Stunting - Related to chronic malnutrition Children appear proportional but are shorter than normal for their age
- Globally 1 billion people worldwide practice OD 162 million children are stunted due to poor sanitation India 638 million of the 1 billion individuals practicing open defecation are in India Highest prevalence of OD in the world accounting (60% of the rate worldwide) Stunting for children under five is 24.4% for moderate stunting and 32.4% or severe stunting Health effects Exposure to fecal bacteria causes chronic illnesses that prevent the body from absorbing nutrients Leading to malnutrition and ultimately stunted growth Other outcomes include increased Morbidity and Mortality Reduced Intellectual Ability Reduce reproductive performance Increased risk for metabolic and cardiovascular disease 99.5% of variation in height among children is explained by OD
- The first 2 years of a child’s life are the most important time long-term health and development. Map: India and countries in Africa exhibit an alarming 40% of stunting in children under 5 yrs. Open defecation has been associated with stunting. Africa which faced drought, civil war, plague, HIV has overall lower rates of stunting as compared to South east Asia. Asian Enigma is an evidence of the association. •Areas where food programs are implemented, the problem of stunting remains high and the lack of sanitation has been identified as a major contributor, highly in common practice of open defecation
- UP: Contributing significantly to open dedication, accounting for 30% being one of the five districts only 18.5% of households in rural areas had access to improved sanitation Worst indicators for improving sanitation measures Hamirpur District – 5 Villages District is more than 75% rural – representative of UP as a whole 5 villages combine have a population of about 50,000 people Geographically ideal – close together, mainly linked by existing roads Sarilla – operation base (centrally located)
- Beliefs ritually impure Perceptions Dark, small, enclosed, dirty, costly Concern about emptying the waste
- Value: Inform people how to perceive events and analyze new information Emotionally react to new situations Practice: Outward representation of underlying beliefs Affirm and reinforce values New Value: Education/Awareness New Practice: Accessibility Modeling
- Healthy Actions Toilet usage – limiting/eliminating OD Hand washing with soap – removal of pathogens after usage Evaluate and Spread the change: Evaluate the results of the intervention, publish them and translate them to the public.
- Interview the residents Door to door approach (5 minutes per household) 20 Questions - Values, barriers, understanding of health impacts Soil and water quality testing Collect samples throughout village Adult work areas, Children play areas, main water source Test for Fecal contamination Establish baseline value for future comparison Health Screening – Children Age: 0-5 Height and Nutritional Status (malnutrition) Deficiencies – vitamins, protein, iron, etc. Screening to take place at local health centers Evaluation of village’s current TSC outreach program Facilities – numbers, location, maintenance/cleanliness establish guideline and rating scale for evaluation Evaluation of local government Understanding the community’s response to changes Culture, religion, values
- Populations receptive to education – willingness to change Women Motherhood/safety of children and family Health care decision-makers Children - Access to education - Value flexibility Quote – in reference to toilets
- Workshops: share, inspire, encourage Health benefits for toilet use/proper usage and cleaning for individual toilet Proper hand washing techniques Family involvement: Health screening for children when bring in for data collection - height, nutritional status - Provide Soap products – low income families Inform: Sanitation reward program (Nirmal Gram Puraskar) Government subsidy for in-home toilets
- Health benefits: Risk of practicing OD Benefits of using toilets Proper hand washing Taught to students Practice Diagrams in school Image to take home and share Healthy Competitions - Painting and Essay Contests – raise awareness
- Pride: Be proud of your village Keep it Clean Healthy competition Potential Economic Development New market opportunities New job opportunities
- School children and women provided whistle Educated to blow their whistle when they see someone OD 12,000 whistles Goal: Empower the community to self-enforce Respect for oneself and their environment Explain cultural element – not offensive in India/accepted Relate to Behavior Theory
- Touched on in education – might need more Details about providing soap??
- Billboards- 10 per village Wall Paintings 10 per village Street Plays- at weekly Bazaar day each week 1 village for 6 months Radio branding during primetime shows Advertisements in Local Newspapers Flyers 100,000 distributed during 3-6 months 25k per month 5k every village FB, Tweeter, Official website to reach people globally
- Village Fair is a favorite event and will again serve the purpose of popularizing our campaign among the community. This Actress is the campaigning ambassador for TSC.
- NEED to go into detail about control group and comparisons ***
- Appeal to current values Family Health (now and next generation) education Behavioral intervention - establish Good Habits Convenience of in-home and owned toilets Encourage participation in subsidy program Sense of Belonging, hence clean People tend to keep their own toilets clean Assures safety Women not wandering alone in early/late Translate the results of evaluation to public Evident health benefit Community PRIDE Economic development – better facilities New markets New jobs
- Data Collection
- Each circle in this graph is a collapsed round of a Demographic and Health Survey, therefore, each represents one country in one year. The size of the circles is proportionate to the population of the country in that year. For example, the three largest circles at the bottom-right of the graph represent India in 1992, 1998, and 2005 – the three years when India had a DHS survey. One striking fact is that India’s circles fall on the trend line. Indian children are very short by international standards, but are exactly as short as widespread open defecation in India predicts.