Sanitation in Developing Countries – Understanding User Preferences and Experiences

Zakiya Seymour Laura Kovalchick Lillian Ponitz Joseph Hughes 25 Oct 2011

2011 OU International WaTER Conference

Motivation

Sanitation can improve global health • WASH interventions have the potential to reduce

incidents of water-borne diseases.

Sanitation practices are user-specific • Sanitation interventions are challenged by the need to

incorporate users preferences.

Relevant literature is selective • The specificity of previous work makes it difficult to

generalize the results in a sufficient manner.

Approach

• Explore overall user satisfaction with various sanitation systems • Explore commonalties and variances throughout sanitation user preference

studies • Investigate perceived drivers and deterrents of sanitation usage for adopters

vs. non-adopters

Objectives

Search Methods • Database Search and Bibliography Cross-Check

• Databases: Web of Science, JSTOR, Google Scholar, ProQuest • Criteria:

• Inclusion: Emerging Regions, Peer-Reviewed and Grey Literature, written in English

• Search: user • AND ONE OF: sanitation, toilet, wastewater, latrine • AND ONE OF: preference, behavior, attitude, belief

Open Defecation Bush, Field

Unimproved Sanitation Unhygienic contact

Unimproved Sanitation Shared facilities

Improved Sanitation Hygienic contact

Methodology

Meta(ish) Analysis 49 studies reviewed (13 unusable)* • Regions: Africa, Asia, South America • Setting: Rural, Peri-Urban, Urban • Implementation: Household, Communal • Technology: None/Bucket, Pit Latrine,

Composting/Ecosan Toilet, Ablution Blocks, Toilets Connected to Piped Sewer/Septic Tank * representing 7,583 households

Limitations • Necessary statistical data (T, χ2, σ) is missing/unavailable. • Historical work is not superimposable. • “There is no placebo for a pit latrine.” -- Cairncross

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Walker (2011)

12

Jenkins (2007)

536

Whittington (1993)

300

Whittington (1993)

480

Walker (2011)

11

Whittington (1993)

84

Altaf* (1994)

593

Bolaane (2011a)

207

Bolaane (2011b)

198

Whittington (1993)

300

Roma (2010a)

29

Roma (2010b)

57

Roma (2011)

83

Oswald (2007)

52

Shared Not Shared

Shared Shared Shared Not Shared

No Facilities

Bucket Pit Latrine Water Closet

Ablution Block

Toilets Ecosan * 81.3% of users utilize pit latrines

N

Shared

Type

What percentage of sanitation users are satisfied with their existing technology?

Rural Peri-Urban

Urban

Why are pit latrines undesirable?

Communal Pit Latrines

Household Pit Latrines

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Lack of Cleanliness (smell, flies)

Not Private (visually,

socially or informedly)

Not convenient

or comfortable

Difficult to Maintain

Not Affordable

Queuing Distance from

household

Lack of Cleanliness (smell, flies)

Not Private (visually,

socially or informedly)

Not convenient

or comfortable

Difficult to Maintain

Not Affordable

Distance from

household

What percentage of users indicate cleanliness as a driver for usage?

Rural Peri-Urban Urban

Pit Latrine 13% Pit Latrine

83% Composting/UDDT 27%

Pit Latrine 31% Composting/

UDDT 6% Composting/ UDDT 45%

Various 47% Ablution

Block 53% Ablution Block 33%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Cleanliness

What percentage of users indicate privacy as a driver for usage?

Rural Peri-Urban Urban

Pit Latrine, 3%

Pit Latrine 10%

Pit Latrine 24%

Pit Latrine 33%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Privacy

What percentage of users indicate convenience and comfort as drivers for usage?

Rural Peri-Urban Urban

Pit Latrine 30% Pit Latrine

18% Pit Latrine 39% Pit Latrine

27% Composting/ UDDT

5% Ablution

Block 47% Ablution

Block 56%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Convenience & Comfort

Pit Latrine 27%

Pit Latrine 8%

Toilet + Sewerage 30%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

What deterrents to system usage are perceived by sanitation users?

Personal/Situational - Lack of income/money

Implementation - Environmental

Conditions

Implementation - Lack of

knowledge

•Lack of income/money is not typically given as a reason to not building a sanitation system.

•Lack of knowledge regarding construction, materials suppliers, or reliable information can deter adoption.

•Users are also deterred from sanitation adoption due to matters outside of their control

•Poor terrain •High water table •Lack of space

Pit Latrine 16%

Pit Latrine 24%

Toilet + Sewerage 25%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Pit Latrine 24%

Pit Latrine 45%

Composting/ UDDT 6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Adopters vs. Non-Adopters Adoption vs. Non-Adoption

Jenkins (1999) Hernandez (2009) Santos (2011) Pit Latrine Pit Latrine Toilets + Sewerage

Rural Rural Peri-Urban Benin Ethiopia Brazil

Total Sample Size N = 320 N = 2000 N = 718 Driver

Importance Rating (1- to 4) (Sample Size)

Adopters (22)

Non-Adopters

(298) p-value Adopters Non-

Adopters p-value Adopters

(647)

Non-Adopters

(71) p-value Gain prestige from visitors 4.00 3.96 * * 3.98 3.91 * * * * 3.39 3.53 NSS Feel royal 2.74 2.75 NSS 3.95 3.90 NSS Make my life more modern 3.48 2.93 * * 3.94 3.86 * * * * 3.48 3.71 NSS For health (spontaneous mention) 1.05 1.29 * * * 3.92 3.89 * 3.7 3.71 NSS Make it easier to defecate due to age/sickness 3.05 2.58 * 3.94 3.90 * * 3.64 3.71 NSS

Have more privacy to defecate 3.89 3.65 * * * 3.91 3.90 3.62 3.71 NSS Keep my house/property clean 3.83 3.57 * * 3.97 3.93 * * Make my house more comfortable 3.82 3.47 * * * 3.58 3.71 NSS Avoid risk of smelling/seeing feces in bush 3.94 3.77 * *

Be able to increase my tenants’ rent 1.92 1.11 * * 3.55 3.82 NSS Makes owner popular 3.85 3.76 * * * * Makes family members proud 3.89 3.83 * * Allows women to have more privacy any time of the day 3.96 3.93 * *

Have more privacy for household affairs 3.46 2.97 * *

It is a nuisance to go to the latrine all the time to defecate 1.27 1.36 * *

Save time 3.84 3.51 * * *

NSS Not Statistically Significant * p<0.1 * * p<0.05 * * * p<0.005 * * * * p<0.0005

Relative Importance Scale: 1 = Least Important 4= Most Important

Overall Satisfaction • Stated user satisfaction levels are dependent on sanitation

technology, implementation approach, and sample size.

Generalizability of Drivers and Deterrents • Drivers and deterrents for usage of sanitation systems vary

by technology and geographical setting.

Comparison of Adopters and Non-Adopters • Sanitation usage drivers are perceived by both adopters and

non-adopters with relatively similar levels of importance.

Summary

Conclusion

Access vs. Usage • Access to sanitation systems does not equate to continued sustained

usage.

Rigor in Studies • Use of standardized terminology would assist with inter-study

comparison, JMP monitoring data, national survey data,….

• The provision of relevant statistical data would aid in analyzing significance of results.

Advancement of Subject • Further studies are needed to examine the behavioral patterns of

sanitation adopters vs. non-adopters.

Bibliography

Altaf, M. A., & Hughes, J. A. (1994). Measuring the demand for improved urban sanitation services - results of a contingent valuation study in Ouagadougou, Burkina-Faso. Urban Studies, 31(10), 1763-1776. doi: 10.1080/00420989420081621

Bolaane, B., & Ikgopoleng, H. (2011). Towards improved sanitation: Constraints and opportunities in accessing waterborne sewerage in major villages of Botswana. Habitat International, 35(3), 486-493. doi: 10.1016/j.habitatint.2011.01.001

Clasen, T. F., Bostoen, K., Schmidt, W. P., Boisson, S., Fung, I. C. H., Jenkins, M. W., . . . Cairncross, S. (2010). Interventions to improve disposal of human excreta for preventing diarrhoea. [Review]. Cochrane Database of Systematic Reviews(6), 30. doi: Cd00718010.1002/14651858.CD007180.pub2

Davis, J., White, G., Damodaron, S., & Thorsten, R. (2008). Improving access to water supply and sanitation in urban India: microfinance for water and sanitation infrastructure development. Water Science and Technology, 58(4), 887-891. doi: 10.2166/wst.2008.671

Fe, N. (2010). User Experience and Drivers for Adoption of Ecological Sanitation Toilets in Kisoro and Kabale, Uganda. Master thesis, Department of Global Health and Population, Harvard School of Public Health, Harvard.

Hernandez, O., Dejene, M., & Faris,K. (2009). Potential Motivators behind household toilet adoption: Results from a study in Amhara, Ethiopia. Proceeding from WEDC International Conference.

Jenkins, M. W. (1999). Sanitation promotion in developing countries: Why the latrines of Benin are few and far between. Ph.D. dissertation, Department of Civil and Environmental Engineering, University of California, Davis, California.

Jenkins, M. W., & Cairncross, S. (2010). Modelling latrine diffusion in Benin: towards a community typology of demand for improved sanitation in developing countries. [Article]. Journal of Water and Health, 8(1), 166-183.

Jenkins, M. W., & Curtis, V. (2005). Achieving the 'good life': Why some people want latrines in rural Benin. Social Science & Medicine, 61(11), 2446-2459. doi: 10.1016/j.socscimed.2005.04.036

Jenkins, M. W., & Scott, B. (2007). Behavioral indicators of household decision-making and demand for sanitation and potential gains from social marketing in Ghana. Social Science & Medicine, 64(12), 2427-2442. doi: 10.1016/j.socscimed.2007.03.010

O'Loughlin, R., Fentie, G., Flannery, B., & Emerson, P. M. (2006). Follow-up of a low cost latrine promotion programme in one district of Amhara, Ethiopia: characteristics of early adopters and non-adopters. Tropical Medicine & International Health, 11(9), 1406-1415. doi: 10.1111/j.1365-3156.2006.01689.x

Bibliography

Robinson, B. (2005), Household adoption of ecological sanitation: An assessment of agricultural value and user perspectives in Nyanza Province, Kenya, Master thesis, Department of Urban Studies and Planning and Department of Civil and Environmental Engineering, Massachusetts Institute of Technology.

Roma, E., Buckley, C., Jefferson, B., & Jeffrey, P. (2010). Assessing users' experience of shared sanitation facilities: A case study of community ablution blocks in Durban, South Africa. Water Sa, 36(5), 589-594.

Roma, E., & Jeffrey, P. (2011). Evaluation of community participation in the implementation of community-based sanitation systems: A case study from Indonesia. Water Science and Technology, 62(5), 1028-1036. doi: 10.2166/wst.2010.344

Santos, A. C., Roberts, J. A., Barreto, M. L., & Cairncross, S. (2011). Demand for sanitation in Salvador, Brazil: A hybrid choice approach. Social Science & Medicine, 72(8), 1325-1332. doi: 10.1016/j.socscimed.2011.02.018

Schouten, M. A. C., & Mathenge, R. W. (2010). Communal sanitation alternatives for slums: A case study of Kibera, Kenya. Physics and Chemistry of the Earth, 35(13-14), 815-822. doi: 10.1016/j.pce.2010.07.002

USAID (2009). In-Depth Consumer Assessment Report for Sanitation Marketing Pilot – Tororo District. Accessed from http://pdf.usaid.gov/pdf_docs/PNADW491.pdf

Walker, M. (2011). Water and sanitation in Bunkpurugu, Ghana: an analysis of the current resources and options for community action. Master thesis, Department of Urban and Regional Planning, Virginia Polytechnic Institute and State University.

Water and Environmental Health at London and Loughborough (WELL). 1999. “Measuring the Health Impact of Water and Sanitation.” Technical Brief No. 10.

Whittington, D., Davis, J., Miarsono, H., & Pollard, R. (2000). Designing a "neighborhood deal" for urban sewers: A case study of Semarang, Indonesia. Journal of Planning Education and Research, 19(3), 297-308. doi: 10.1177/0739456x0001900309

Whittington, D., Lauria, D. T., Choe, K., Hughes, J. A., Swarna, V., & Wright, A. M. (1993). Household sanitation in Kumasi, Ghana - A description of current practices, attitudes, and perceptions. World Development, 21(5), 733-748. doi: 10.1016/0305-750x(93)90030-d

Thank you.

Zakiya Seymour PhD Student Department of Civil and Environmental Engineering Georgia Institute of Technology zakiya.seymour@gatech.edu

Identifying User Preferences

Prestige

- Identification with higher social status

- Express new experience and new lifestyle

- Elevate intergenerational family status

- Doesn't have to share toilet (avoid conflicts with neighbors)

- Self-esteem

Well Being

- Health benefits

- Safety

- Convenience and comforts

- Cleanliness (smell, flies)

- Privacy (visual, social, or informational)

Personal/Situational Characteristics

- Ease of restricted mobility (sick, elderly)

- Financial Considerations (incomes increases, working hours increase)

- Efficiency Considerations (time saved)

Design

- Ease of use

- Use of by-product

- Better than alternative

- Durability

- Functionality (proper excreta disposal)

Implementation

- Availability of construction materials

- Distance from household

- Knowledge of usage (training)

Adopters vs. Non-Adopters

Adoption vs. Non-Adoption

Jenkins (1999) Hernandez (2009) Santos (2011) Pit Latrine Pit Latrine Toilets + Sewerage

Rural Rural Peri-Urban Benin Ethiopia Brazil

Importance Rating (1 to 4) Africa Africa South America

Driver Adopters Non-

Adopters p-value Adopters Non-

Adopters p-value Adopters Non-

Adopters p-value Gain prestige from visitors 4.00 3.96 ** 3.98 3.91 **** 3.39 3.53 Feel royal 2.74 2.75 3.95 3.90 **** 3.43 3.53 Make my life more modern 3.48 2.93 ** 3.94 3.86 **** 3.48 3.71 For health (spontaneous mention) 1.05 1.29 *** 3.92 3.89 * 3.7 3.71 Make it easier to defecate due to age/sickness 3.05 2.58 * 3.94 3.90 ** 3.64 3.71 Have more privacy to defecate 3.89 3.65 *** 3.91 3.90 3.62 3.71 Keep my house/property clean 3.83 3.57 ** 3.97 3.93 ** Make my house more comfortable 3.82 3.47 *** 3.58 3.71 Avoid risk of smelling/seeing faeces in bush 3.94 3.77 ** Be able to increase my tenants’ rent 1.92 1.11 ** 3.55 3.82 Makes owner popular 3.85 3.76 **** Makes family members proud 3.89 3.83 ** Allows women to have more privacy any time of the day 3.96 3.93 ** Have more privacy for household affairs 3.46 2.97 ** It is a nuisance to go to the latrine all the time to defecate 1.27 1.36 ** Save time 3.84 3.51 ***

* p<0.1 ** p<0.05 *** p<0.005 **** p<0.0005

Relative Importance Scale: 1 = Least Important 4= Most Important

Well Being Drivers – Cleanliness and Health Benefits

Jenkins (2005) Hernandez (2009)

USAID (2009) Fe (2010)

Roma (2011)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Well-being: Health Benefits

Jenkins (2005)

O'Loughlin (2006)

Robinson (2005)

USAID (2009)

Fe (2010)

Fe (2010)

Schouten (2010)

Roma (2010)

Roma (2010)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Well-being: Cleanliness •The impact of cleanliness ranges across geographical setting and technology.

•Health benefits appears to dichotomous.

Well Being Drivers – Safety and Convenience & Comfort

Jenkins (2005)

O'Loughlin (2006)

Hernandez (2009)

USAID (2009)

Schouten (2010)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Well-being: Safety

Jenkins (2005) O'Loughlin (2006)

Hernandez (2009) USAID (2009)

Fe (2010) Roma (2010)

Roma (2010)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Well-being: Convenience & Comfort

•Safety does matter, but its importance may be skewed due to availability of other alternatives.

•Convenience and comfort appear to be important drivers depending on geographic setting.

Where Does that Leave Us…

Still questions remain regarding this disconnect and its manifestation in increasing sanitation usage

What are the drivers and deterrents, as viewed by users, to sanitation system use?

Can these drivers and deterrents assist in predicting usage? Are users are satisfied with their sanitation technology?

There appears to be an absence of user preference integration into sanitation systems, representing a true disconnect between the design of appropriate sanitation technology and the implementation of acceptable and affordable technology.

Where Does that Leave Us…

Still questions remain regarding this disconnect and its manifestation in increasing sanitation usage

What are the drivers and deterrents, as viewed by users, to sanitation system use?

Can these drivers and deterrents assist in predicting usage? Are users are satisfied with their sanitation technology?

There appears to be an absence of user preference integration into sanitation systems, representing a true disconnect between the design of appropriate sanitation technology and the implementation of acceptable and affordable technology.

Drivers by Sanitation Type and Geographic Setting Peri-Urban Setting

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Schouten (2010) - Kenya Roma (2010) - South Africa Roma (2010) - South Africa

Toilets Ablution Block

Connected to Piped Sewer System

Well-being - Safety Well-being - Convenience and comfort Well-being - Cleanliness (smell, flies) Design - Better than other alternative Design - Durability Design-separate bath from toilet Personal/Household Situational - Financial Considerations (income increases, working hours increases) (affordability) Implementation-Responsive management

•In peri-urban settings, convenience and durability matter most users.

Prestige

Implementation

Personal /

Situational

Well-Being

Indentifying User Preferences

Measurements

Well Being Drivers – Privacy

Hernandez (2009)

Jenkins (2005)

O'Loughlin (2006)

USAID (2009)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Well-being: Privacy

Diffusion of Innovation

Measurements

Approach and Objectives

Integrated method to examine

• both the user experiences and the impact that various contextual variables have on sanitation preferences and behaviors.

Detailed studies focused on

• specific geographical region

• particular type of sanitation technology

• particular implementation approach

This Approach Historical Approaches

Investigate perceived drivers and deterrents of sanitation Examine characteristics of adopters vs. non-adopters Explore overall satisfaction with sanitation systems

Objectives

Approach and Objectives (2/2)

Difficulties in Increasing Sanitation Coverage in Emerging Nations

“

The minimal or lack of user participation has been identified as a key

barrier towards increasing sanitation access. [Paul 1958, McPherson and McGarry 1987, UN 2010].

What We Know… (2/2)

“Conventional” developed world sanitation approaches are often unsustainable in developing nations.

Little social acceptance is needed when conventional approaches are designed and implemented; thus, there little no need for higher socio-economic classes to be active participants in their sanitation decision-making process [Patterson et al. 2007].

Abandoned Wastewater Facility in Kyrgyzstan, Central Asia

Photo Credit: http://www.sowacon.co.jp/index10f.htm

What We Know… (1/2)

Challenges Exist in Defining “Sanitation”

Several working definitions exist…

An improved sanitation facility is a system that “hygienically separates human excreta from human contact.”

[Joint Monitoring Programme (JMP) 2003]

Basic sanitation the lowest-cost option for securing sustainable access to safe, hygienic, and convenient facilities and services for excreta and sullage disposal that provide privacy and dignity while ensuring a clean and healthful living environment both at home and in the neighborhood of users.

[UN Millennium Project Task Force on Water & Sanitation 2005]

Indentifying User

Preferences

Prestige - Identification with higher social status - Express new experience and new lifestyle - Elevate intergenerational family status - Doesn't have to share toilet (avoid

conflicts with neighbors) - Self-esteem

Well Being - Health benefits - Safety - Convenience and comforts - Cleanliness (smell, flies) -Privacy (visual, social, or informational)

Design - Ease of use - Use of by-product - Better than alternative - Durability - Functionality (proper excreta disposal)

Personal/Situational Characteristics - Ease of restricted mobility (sick, elderly) - Financial Considerations (incomes increases, working hours increase) - Efficiency Considerations (time saved)

Implementation - Availability of construction materials -Distance from household -Knowledge of usage (training)

Motivation

Impact of Sanitation on Global Health • WASH interventions have the potential to reduce

incidences of water-borne diseases.

• While several factors can impact increasing sanitation coverage, the overall objective is to improve overall global health.

• Yet, the health impact of these initiatives can only be sustained through the continued use by their users.

Motivation

Sanitation Practices are User-Specific

• Sanitation interventions are challenged by the need to incorporate users preferences.

• Understanding motivation for sanitation usage is complex.

• Affordability, Safety, Convenience, Comfort, Cleanliness…

Motivation

Sanitation Practices are User-Specific

• Sanitation interventions are challenged by the need to incorporate users preferences.

• Understanding motivation for sanitation usage is complex.

• Affordability, Safety, Convenience, Comfort, Cleanliness…

Motivation

Sanitation Practices are User-Specific

• As previous work examining various user perceptions for sanitation systems often focus on specific contexts, it can be difficult to synthesize the results.

• Geographical Settings, Types of Sanitation Technology, Implementation Approaches

Well Being Drivers – Safety and Convenience & Comfort

Jenkins (2005)

O'Loughlin (2006)

Hernandez (2009)

USAID (2009)

Schouten (2010)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Well-being: Safety

Jenkins (2005) O'Loughlin (2006)

Hernandez (2009) USAID (2009)

Fe (2010) Roma (2010)

Roma (2010)

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Well-being: Convenience & Comfort

•Safety does matter, but its importance may be skewed due to availability of other alternatives.

•Convenience and comfort appear to be important drivers depending on geographic setting.

Investigate Perceived Drivers and Deterrents of Sanitation Drivers by Sanitation Type and Location: Rural Setting

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jenkins (2005) - Benin

Hernandez (2009) - Ethopia

USAID (2009) - Uganda

Robinson (2005) - Kenya

Fe (2010) - Uganda

Fe (2010) - Uganda

Pit Latrine Composting Toilet/EcoSan

Perc

etag

e of

Res

pond

ers

Prestige Well-being Design Personal/Household Situational Implementation

•While well-being and prestige are consistently linked as drivers to pit latrine usage, design and implementation of sanitation system rank higher for ecosan users.