1. 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’

2. 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.

3. 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.

4. 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

5. 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.

6. 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 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 months

7. 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

8. 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

9. 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)

10. 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

11. 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”.

12. 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.

13. 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.

14. 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

15. 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.

16. 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

17. 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

18. 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.

19. 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.

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

21. 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.

22. 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

23. 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.

24. 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

25. 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)

26. 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.