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Water, Sanitation, and Hygiene (WASH) for Child Health: Evidence from Large Household Surveys in Indonesia and Sub-Saharan Africa Open Access

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Background: Water, sanitation, and hygiene (WASH) are essential components of basic human necessities. The overall purpose of this dissertation was to inform where and how future WASH interventions could be conducted by analyzing household-level data from Indonesia and Sub-Saharan African countries.Methods: The dissertation research adopted a three-paper model and conducted cross-sectional data analyses. The first study explored the potential determinants of handwashing with soap in Indonesia by using UNICEF Indonesia’s knowledge, attitude, and practice (KAP) household survey. A composite measure was used to estimate the overall prevalence of handwashing with soap. The second study constructed a handwashing ladder and estimated its association with child diarrhea by using the recent Demographic and Health Survey in 25 countries in Sub-Saharan Africa (SSA). The third study developed a WASH Resource Index (WRI) by using the Uganda Demographic and Health Survey 2011 and examined the geographical distribution of high-risk WASH behaviors at the cluster level: drinking surface water without water treatment at point of use, open defecation, lack of a handwashing place for the household, and water collection time greater than 30 minutes. The association between the index and child diarrhea at the household level was also examined. Results: The first study identified four potential determinants of handwashing with soap including: a desire to smell nice, interpersonal influences, the presence of handwashing places within 10 paces of the kitchen and the toilet, and key handwashing moments including after eating and after cleaning child stools. The second study revealed that availability of water and soap at a handwashing place for the household was associated with both increased and decreased prevalence ratios: 0.89 (95% CI 0.79–0.99) in Chad, 0.82 (0.69–0.97) in Mauritania, 1.30 (1.02–1.66) in Burkina Faso, and 1.67 (1.20–2.33) in Ghana. In other countries, availability of handwashing resources at a handwashing place was not significantly associated with child diarrhea. The third study suggested that high-risk WASH practices and child diarrhea were clustered in different geographical areas at the cluster level. At the household level, being in higher WASH quintiles was found to be associated with a lower prevalence of child diarrhea than that of the lowest WASH quintile.Discussion: The use of non-health messages may effectively promote handwashing with soap in Indonesia. A composite measure of handwashing with soap, reflecting self-reporting, availability of handwashing materials, and handwashing demonstration, may produce a more accurate estimate of the overall levels of handwashing behaviors. Availability of water and soap at a handwashing place for the household remains an important facilitating factor for handwashing practices in SSA. A unique context of each country needs to be considered for promoting handwashing practices more effectively. High-risk WASH practices, particularly lack of a handwashing place and water collection time of greater than 30 minutes, were highly prevalent in Uganda. While promoting handwashing practices and access to drinking water, it is vital to address geographical disparities within each country to target the most vulnerable populations for greater investments.

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