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      Descending the sanitation ladder in urban Uganda: evidence from Kampala Slums


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          While the sanitation ladder is useful in analysing progressive improvements in sanitation, studies in Uganda have not indicated the sanitation barriers faced by the urban poor. There are various challenges in shared latrine use, cleaning and maintenance. Results from Kampala city indicate that, failure to clean and maintain sanitation infrastructure can lead to a reversal of the potential benefits that come with various sanitation facilities.


          A cross sectional qualitative study was conducted between March and May 2013. Data were collected through 18 focus group discussions (FGDs) held separately; one with women, men and youth respectively. We also used pictorial methods; in addition, 16 key informant interviews were conducted. Data were analysed using content thematic approach. Relevant quotations per thematic area were identified and have been used in the presentation of the results.


          Whether a shared sanitation facility was improved or not, it was abandoned once it was not properly used and cleaned. The problem of using shared latrines began with the lack of proper latrine training when people do not know how to squat on the latrine hole. The constrained access and security concerns, obscure paths that were filthy especially at night, lack of light in the latrine cubicle, raised latrines sometimes up to two metres above the ground, coupled with lack of cleaning and emptying the shared facilities only made a bad situation worse. In this way, open defecation gradually substituted use of the available sanitation facilities. This paper argues that, filthy latrines have the same net effect as crude open defection.


          Whereas most sanitation campaigns are geared towards provision of improved sanitation infrastructure, these findings show that mere provision of infrastructure (improved or not) without adequate emphasis on proper use, cleaning and maintenance triggers an involuntary descent off the sanitation ladder. Understanding this reversal movement is critical in sustainable sanitation services and should be a concern for all actors.

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          The Integrated Behavioural Model for Water, Sanitation, and Hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings

          Background Promotion and provision of low-cost technologies that enable improved water, sanitation, and hygiene (WASH) practices are seen as viable solutions for reducing high rates of morbidity and mortality due to enteric illnesses in low-income countries. A number of theoretical models, explanatory frameworks, and decision-making models have emerged which attempt to guide behaviour change interventions related to WASH. The design and evaluation of such interventions would benefit from a synthesis of this body of theory informing WASH behaviour change and maintenance. Methods We completed a systematic review of existing models and frameworks through a search of related articles available in PubMed and in the grey literature. Information on the organization of behavioural determinants was extracted from the references that fulfilled the selection criteria and synthesized. Results from this synthesis were combined with other relevant literature, and from feedback through concurrent formative and pilot research conducted in the context of two cluster-randomized trials on the efficacy of WASH behaviour change interventions to inform the development of a framework to guide the development and evaluation of WASH interventions: the Integrated Behavioural Model for Water, Sanitation, and Hygiene (IBM-WASH). Results We identified 15 WASH-specific theoretical models, behaviour change frameworks, or programmatic models, of which 9 addressed our review questions. Existing models under-represented the potential role of technology in influencing behavioural outcomes, focused on individual-level behavioural determinants, and had largely ignored the role of the physical and natural environment. IBM-WASH attempts to correct this by acknowledging three dimensions (Contextual Factors, Psychosocial Factors, and Technology Factors) that operate on five-levels (structural, community, household, individual, and habitual). Conclusions A number of WASH-specific models and frameworks exist, yet with some limitations. The IBM-WASH model aims to provide both a conceptual and practical tool for improving our understanding and evaluation of the multi-level multi-dimensional factors that influence water, sanitation, and hygiene practices in infrastructure-constrained settings. We outline future applications of our proposed model as well as future research priorities needed to advance our understanding of the sustained adoption of water, sanitation, and hygiene technologies and practices.
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            Urban-rural differentials in child malnutrition: trends and socioeconomic correlates in sub-Saharan Africa.

             Jean Fotso (2007)
            This paper examines levels and trends of urban-rural differentials in child malnutrition, and investigates whether residual differences exist between urban and rural areas, given comparable measures of socioeconomic status (SES) of households and communities. Using data from Demographic and Health Surveys of 15 sub-Saharan African countries, and multilevel modelling, it shows that urban-rural differentials are considerable in all countries, that they have narrowed in most countries due primarily to an increase in urban malnutrition, and have widened in few countries as a result of sharp decline in urban malnutrition. These urban-rural gaps are abolished in almost all countries when SES is controlled. These results suggest that policies and programs contributing to the attainment of the MDGs should pay particular attention to the urban poor.
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              The Commission on Social Determinants of Health: Tackling the Social Roots of Health Inequities

              The goal of the commission, launched in March 2005, is to strengthen health equity by catalysing policy and institutional change to address the social determinants of health.

                Author and article information

                BMC Public Health
                BMC Public Health
                BMC Public Health
                BioMed Central
                19 June 2014
                : 14
                : 624
                [1 ]Department of Sociology and Anthropology, School of Social Sciences, College of Humanities and Social Sciences (CHUSS), Makerere University, P.O. Box 7062, Kampala, Uganda
                [2 ]Department of Sociology, Kyambogo University, P.O. Box 1 Kyambogo, Kampala, Uganda
                [3 ]Department of Civil and Environmental Engineering, College of Engineering, Design Art and Technology (CEDAT), Makerere University, P.O. Box 7062, Kampala, Uganda
                [4 ]Swiss Federal Institute of Technology –Zurich (ETH-Z) and Centre for Development and Cooperation (NADEL), Zürich, Switzerland
                Copyright © 2014 Kwiringira et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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