Below are a few key points from the guidelines on behaviour change (see Chapter 5):

• Governments are the critical stakeholder in the coordination and integration of sanitation behaviour change activities and they should provide leadership and adequate funding.
• All sanitation interventions should include a robust sanitation promotion/behaviour change programme (including monitoring and evaluation), with all stakeholders and participants aligned around the same set of objectives and strategies.
• To influence behaviour and design successful promotion activities it is important to understand the existing sanitation behaviours and the determinants of those behaviours, noting that specific population groups will have different sanitation needs, opportunities for change and barriers to improvement.
• Behaviour change interventions are most successful when they target the determinants of behaviours; a range of models and frameworks exist to aid understanding and target behavioural drivers and should be drawn upon in the intervention design process.
• Careful consideration should be given to the intervention delivery model (stand-alone behaviour change versus integrated approaches; focused versus comprehensive strategies); for a strategy to be successful it needs to impact on uptake, adherence and long-term practice/use of the safe behaviour.
• Behaviour change programming needs adequate and dedicated resources.

You will also find a large table (Table 5.1) summarizing different approaches and factors to consider for implementation:

Dear Alice,

Thanks for your questions. As you said, sanitation and hygiene behaviour change typically involves multiple stakeholders, not only ministry of health, so coordination and clear definition of roles and responsibilities are essential alongside related budget allocations. The guidelines do not suggest that behaviour change interventions should necessarily be implemented by health authorities. For example, in schools, budget and responsibility for implementation may come under ministry of education. However, health authorities need sufficient financial and human resources to provide guidance and oversight to ensure behaviour change approaches are suitable for a given context, as far as possible evidence based, and coherent between different players, strategies and programmes.

Would other forum members like to share their experiences on this?

Kind regards,
Sophie

Hi Elisabeth and Kelly,

Thanks for your comments. It’s true, the topic on shared sanitation has been discussed at length. I guess one important point here is the distinction between normative and monitoring definitions. The guidelines include a normative basis to support development of country norms and standards and JMP reports progress based on agreed upon indicators that can be feasibly measured. While both definitions align, the guidelines allow for more nuances. The guidelines recognize that in many situations it is not possible for every household to have their own toilets, so shared or public toilets can be promoted as an interim solution. However, those toilets have to meet high quality standards for accessibility, safety, affordability through adequate management and maintenance (see Chapter 3 ).

Below is the evidence to support the recommendations on shared sanitation (including some of your papers, Kelly):

Sharing a sanitation facility with more than one household is associated with increased risk of adverse health outcomes compared to private household facilities, including increased odds of moderate to severe diarrhoea in children <5 years (Heijnen et al 2014, Baker 2016). However, the additional risk associated with latrine sharing between several households may be attributed to differences in user demographics, access, type of facilities and cleanliness.

Public and shared sanitation in urban settlements has been linked to stress from lack of cleanliness, anxiety and withholding relief due to long lines, women’s and girls’ fear of harassment from men and boys, and lack of privacy or safety (Sclar 2018).

Homeless, itinerant and slum dweller populations are forced to openly defecate when public facilities are broken, unclean, too far away or have long queues preventing individuals from working or attending to childcare. This highlights the need for a shared sanitation policy that addresses maintenance, accessibility, cleanliness and provision of water and hand washing facilities (Heijnen et al., 2015; Rheinländer 2015; Alam et al., 2017).

Shared sanitation can represent an important advantage over open defecation or unsafe sanitation when individual household facilities are not yet in place or are infeasible (Heijnen et al., 2014, 2015).

Kind regards,
Sophie

Hi Elizabeth,

In addition to keeping latrines clean (which is mostly about protecting older children and adult users), shared latrines must also prevent open feces disposal to protect health from household and public conditions beyond the latrine. Households using public latrines were more likely to dispose of child feces in the open or to have someone in the household practicing open defecation than households using compound shared toilets in urban Ghana (Ritter et al. Within-Compound Versus Public Latrine Access and Child Feces Disposal Practices in Low-Income Neighborhoods of Accra, Ghana) and in urban India (Heijnen et al. Neighbour-shared versus communal latrines in urban slums: a cross-sectional study in Orissa, India exploring household demographics, accessibility, privacy, use and cleanliness). In the Global Enteric Multi-center Study (unpublished manuscript), more numbers of households sharing was associated with less use of latrines for child feces at half of the study sites.

Although evidence (including my own studies) suggests children in households with limited sanitation are more likely to have diarrhea than children in households with private sanitation, I'd like to see indicators that distinguish between households sharing geographically/socially-connected latrines versus those sharing public latrines. I believe sub-categories of limited sanitation could improve measurement of progress in safe feces disposal. The gap to doing this is understanding whether global indicators for defining safe and unsafe limited sanitation could be reduced to who you share with versus a need for more complex measures of social capital among sharers related to both feces disposal and latrine hygiene maintenance. If we can get better global data about latrine use by type of limited sanitation, then we can more rigorously ask the question as to what level of safe sharing offers health benefits.

Kelly

Dear Sophie and Kate,

thank you so much for the opportunity to discuss with you points of question regarding the new WHO guidelines.
The GIZ global programme Sanitation for Millions is currently rethinking behaviour change approaches towards safe sanitation and hygiene in schools, mosques and health care facilities (in Uganda, Pakistan and Jordan).
In my view, the sustainability of behaviour change measures in public institutions can only be ensured if the required responsibilities and budget lines are determined and accepted by the respective stakeholders.
In the WHO guidelines Chapter 5, it says that governments are the critical stakeholders in the coordination and integration of behaviour change initiatives.
I find this statement quite interesting and would like to discuss the issue of responsabilities with you: Have you experienced different levels of responsiveness amongst governmental health authorities in coordinating and budgeting for hygiene behaviour change interventions in public institutions in different country contexts?

Looking forward to your replies!
Best regards, Alice

Dear Sophie and Kate,

Thanks a lot of setting up this thematic discussion. I think it is very timely and will encourage us all to dig deeper into those new guidelines and to learn a lot together!

I am just a little bit worried that there might be too many topics crammed into this one thread. I don't even know where to start. E.g. you have asked these three questions which are all huge:

- What are the key ingredients of good sanitation behaviour change interventions?
- How can demand and supply be addressed concurrently to result in sustained adoption of safe sanitation facilities?
- Shared sanitation: the guidelines recognize that shared sanitation can be promoted as an interim solution. How does this link with SDG 6.2 monitoring targets?

I just wonder if we need to break the threads down into more manageable bite size pieces?

About the behaviour change interventions we have had previous discussions here: forum.susana.org/71-behaviour-change-and-user-psychology-issues (maybe someone could distill out of there what the recurring themes are and what we think is particularly important?).

About the shared sanitation and whether it should count towards SDG 6.2 or not, this is also a huge topic. We have discussed it in various threads on the forum but I have now merged them together into one so that it's easier to find the discussions again:
forum.susana.org/182-sustainable-develop...y-managed-sanitation
Should shared sanitation be included in the SDG 6.2 monitoring for safely managed sanitation?

A recent article on this topic is this one from last year:
Title: Limited services? The role of shared sanitation in the 2030 Agenda for Sustainable Development
Authors: Barbara Evans, Andrés Hueso, Richard Johnston, Guy Norman, Eddy Pérez, Tom Slaymaker, Sophie Trémolet
forum.susana.org/182-sustainable-develop...ged-sanitation#23416

While talking about health, this thread was also important:
forum.susana.org/170-shared-toilets-comm...young-children#17919
Review on shared sanitation - Global Enteric Multicenter Study (GEMS) - Sanitation and Hygiene-Specific Risk Factors for Moderate-to-Severe Diarrhea in Young Children

I am just bringing up these previous discussion threads to enrich the conversation and to ensure we build on previous people's thought processes.

What stuck for me is a comment by Mughal: So, the bottom line is: if the shared sanitation is opted, then frequent cleaning is the key to their success. (forum.susana.org/182-sustainable-develop...ged-sanitation#23015)

This hints at the topic operation and maintenance which is so often neglected in our desire to build, build, build more toilets... (but this might be the topic for another thread).

Regards,
Elisabeth

All of the recommendations in the guidelines include terms that are unpacked in more detail elsewhere in the document. Here’s a couple:

The human right to water and sanitation

Box 1.2 (on page 3) describes the human right to sanitation including:
• The human rights principles: 1) Non-discrimination and equality: 2) Participation 3) The right to information: 4) Accountability 5) Sustainability, and
• The normative of the human right to sanitation defined by: 1) Availability 2) Accessibility 3) Quality 4)Affordability 5) Acceptability

Humans right definitions are also incorporated in Chapter 3 under the definitions of safe management at the toilet step 3.2.2 under additional features page 33.

Demand and supply of sanitation facilities and services

• Demand side – take a look at chapter 5 on behavior change. Section 5.4.1 and Table 5.1 compares common behavior change approaches. Section 5.4.2 describes how to design, adapt and deliver a quality behaviors change intervention
• Supply side - Chapter 3.2 and 3.3 describe the minimum level of safe toilet and safe containment storage/treatment to be achieved for entire communities. Chapter 4.8 and 4.9 discusses developing sanitation services and business models and fostering the sanitation services market.

In this e-discussion, we would like to dive deeper into recommendation 1 of the guidelines:

Recommendation 1: Ensure universal access and use of toilets that safely contain excreta
1.a) Universal access to toilets that safely contain excreta and elimination of open defecation should be prioritized by governments, ensuring that progress is equitable and in line with the principles of the human right to water and sanitation.
1.b) Demand and supply of sanitation facilities and services should be addressed concurrently to ensure toilet adoption and sustained use and enable scale.
1.c) Sanitation interventions should ensure coverage of entire communities with safe toilets that, as a minimum, safely contain excreta, and address technological and behavioural barriers to use.
1.d) Shared and public toilet facilities that safely contain excreta can be promoted for households as an incremental step when individual household facilities are not feasible.
1.e) Everyone in schools, health care facilities, workplaces and public places should have access to a safe toilet that, as a minimum requirement, safely contains excreta.

A few points and questions for discussion:

Access and use by the entire community: without community level coverage with sanitation, those using safe toilets remain at risk from unsafe sanitation systems and practices by other households, communities and institution.
What does the evidence say about this?
What are the key ingredients of good sanitation behaviour change interventions?
How can demand and supply be addressed concurrently to result in sustained adoption of safe sanitation facilities?

Shared sanitation: the guidelines recognize that shared sanitation can be promoted as an interim solution. How does this link with SDG 6.2 monitoring targets?

Looking forward to your comments!