Magister Public Health - MPH / Background and Rationale The World Health Organization (WHO) has shown that the provision of Water Sanitation and Hygiene (WASH) in Health Care Facilities (HCFs) of many low and middle-income countries is poor. This is compounded by the lack of national plans and consolidated data on WASH in HCFs. This study assessed the availability and adequacy of Water Sanitation and Hygiene (WASH) infrastructure in 13 mission hospitals spanning 13 districts in Zambia. The objectives of this study were to identify the different kinds of WASH infrastructure available, and their adequacy, and factors influencing the status of WASH infrastructure and services in the selected hospitals. Methodology This study had a mixed methods design with semi-quantitative, descriptive and qualitative components. Assessments were conducted of the WASH infrastructure on the hospital property, and specifically in the male medical wards and outpatient facilities as two tracer areas, using a WHO checklist adapted and administered by the researcher. Checklist items were assigned scores (0=absent/bad to 2=on target/good) and total WASH scores for each facility compiled. For the qualitative component, individual semi-structured interviews using an interview guide were conducted, also by the researcher, with the facility managers and the head staff of the male medical wards. Results Overall coverage with an improved water source was reasonably good with 11 of the 13 hospitals reporting availability of improved water sources within the facilities. Hand washing basin coverage was similarly good. In contrast, coverage by well-functioning toilets was not as high, with 5 hospitals reporting toilets that were either broken, blocked, or having no running water and no toilet paper. Facility WASH scores varied from 22 (38%) to 57 (97%) out of a possible total of 58 points. Most of the Facility Managers indicated that the hospital WASH infrastructure was old, and with frequent breakdowns. This was worsened by lack of readily available spares and materials for repairing once there was a fault. Conclusion This study reveals an uneven coverage of WASH across facilities and elements, with poor sanitation a challenge across facilities. This is compounded by ongoing challenges in WASH infrastructure maintenance. Moving forward, there is need for government to develop a clear policy on WASH in HCFs. A national plan with resources and a monitoring framework need to be in place for streamlined support and tracking of progress by all stakeholders.

Climate change and increased pressure on water resources through urban and peri-urban population growth present some major uncertainties to the sustainable provision of good quality water, sanitation and hygiene (WASH) services, particularly to small-scale decentralized systems which are considered more vulnerable compared to centralized systems. The concept of “resilience” could be useful when dealing with such uncertainties. It deals with planning for shocks and stressors which could help address long-term water security and sanitation challenges. The aim of this research is to explore the relevance of the concept of resilience in dealing with uncertainties for decentralized WASH systems. Through literature review, interviews (n=22) and group discussions (n=18), the relevance of the 7 resilience principles, developed by SRC, to WASH planning for decentralized systems was explored. WHO community water and sanitation planning guidelines were reviewed to determine how resilience could add useful aspects to management of decentralised WASH systems.  Results showed that the resilience concept is important in planning and management of decentralized WASH systems, since, with the resilience principles as a basis, there is potential to involve different stakeholders to share knowledge, skills and resources across multiple scales. The three resilience principles considered most important from the 7 SRC resilience principles for decentralized WASH were identified as: 1) Broadening participation, 2) Maintenance of diversity and redundancy, and 3) Management of slow changing variables and feedbacks. Other important WASH aspects missing from the resilience principles were: 1) Contextuality, 2) Accountability, 3) Equity and human rights, 4) Monitoring and maintenance, 5) Resource capacity. Two case studies served as examples of how decentralized WASH systems are managed in a high-income country (Värmdö, Sweden) and  a low/middle income country (MSETO, Kenya). In both cases, applied resilience principles were identified together with areas of improvement. With reference to resilience, Värmdö municipality showed strength in the flow of information (connectivity) between actors but lacked integrated WASH planning guidelines and diversity of water supplies. The MSETO project exhibited strength in overlapping responsibilities (polycentric governance) but lacked management of slow changing variables and feedbacks, linked to the lack of adequate re-sources. The analysis of WHO Water Safety Plans and sanitation safety planning guidelines through the resilience framework revealed that the WHO guidelines have a heavy focus on technical aspects and lack an integrated approach involving polycentric governance and complex adaptive system thinking. There is need for the revision of the guide-lines to incorporate community social aspects, strategies of improving water availability and consideration of complex adaptive systems thinking. Municipalities and practitioners are recommended to consider resilience principles as well as the identified missing aspects in WASH planning and interventions. Further research is needed investigating necessary conditions for the application of resilience principles and important trade-offs.

Les Objectifs de Développement Durable visent d'ici 2030 un « accès pour tous à des services d'assainissement et d'hygiène adéquats, en mettant fin à la défécation à l'air libre ». Un service d'assainissement peut-être défini par ses composantes techniques et sociales, et leurs interactions. Dans l'optique de proposer des pistes d'améliorations des services d'assainissement en zone tropicale, les travaux de cette thèse ont porté à la fois sur des infrastructures de traitement et sur l'implication de l'ensemble des acteurs dans la définition du service. L'analyse croisée des contextes des départements d'outre-mer (DOM) français et du Sénégal a permis d'identifier des contraintes qui pèsent sur le secteur de l'assainissement en zone tropicale. Du point de vue des infrastructures de traitement, ces contraintes nous ont amenées à proposer des procédés issus de la famille des Filtres Plantés de Végétaux (FPV) comme solutions à priori pertinentes. Cette thèse présente leurs adaptations à la zone tropicale, en détaillant les choix retenus pour le dimensionnement, la conception des filtres et le choix des végétaux. Une centaine de campagnes de suivi ont été réalisées sur 7 stations pilotes en tailles réelles, à travers les 5 DOM. Les résultats montrent que malgré une plus grande compacité, le dimensionnement proposé permet de conserver des niveaux de traitement au moins comparables à ceux observés en climat tempéré. Compte tenu des contraintes climatiques et organisationnelles en milieu tropical, une analyse de leur résilience à des perturbations et de leur fiabilité de traitement a été réalisée par une étude statistique sur les données produites par l'autosurveillance réglementaire. Elle montre que les FPV sont également plus fiables que les procédés de traitement conventionnel les plus répandus pour les petites collectivités. Ce qui s'explique à la fois par la barrière physique que représente ces procédés de cultures fixées sur support fin ainsi que par des besoins en entretien plus réduits. Le deuxième axe de recherche part du constat d'un manque de concertation entre acteurs au moment de la planification de l'assainissement, étape qui préside à la construction du système d'assainissement. En particulier, les utilisateurs, leurs besoins et leurs contraintes sont très peu et mal pris en compte. La modélisation d'accompagnement pourrait permettre de créer à la fois un support (le modèle) permettant de discuter des choix techniques et de leurs conséquences, ainsi que le cadre dans lequel les différents acteurs pourraient échanger leurs points de vue et trouver un consensus soutenable. Un processus de modélisation d'accompagnement a été conçu et mis en place sur la planification de l'assainissement dans 2 zones (urbaine et rurale) du Sénégal. Il nécessitait, pour proposer des scénarios viables, d'intégrer une part non négligeable de connaissances expertes. Centré sur les populations, ce processus a permis la création d'un premier modèle générique sur l'accès à l'assainissement qui prend la forme d'un jeu de rôle. La pertinence de tels outils dans la caractérisation des besoins des usagers a été évaluée. Par ailleurs, l'attention a été portée sur l'acceptation par les usagers du service proposé et sa traduction en volonté de contribution / Sustainable Develoment Goals aim by 2030, to « achieve access to adequate and equitable sanitation and hygiene for all and end open defecation », by « using safely managed sanitation services ». Sanitation service can be defined by its technical and social components, and their interactions. This thesis focuses on both treatment infrastructures and involvement of all the stakeholders into service definition. Cross analysis of French Overseas Territories (FOT) and Senegal contexts, has identified common constraints that weigh on sanitation sector in tropical areas. From treatment infrastructure point of view, these constraints lead to suggest treatment wetlands systems and particularly French vertical-flow treatment wetland (FS-VFTW) to easier sludge managment, as a relevant solution. Their adaptation for tropical climate is the subjet of the first axis of our work. It aimed at defining their adaptation in terms of design, plant choices and defining the treatment wetlands type to implement according to outlet requirements. A hundred of 24h sampling campains were performed on 7 full scale demonstration plants, accross the 5 FOTs. Results show that despite more compacity, the proposed design allows maintaining performances at least similar to those observed in temperate climate. Due to climatic and organizational constraints inn tropical climate, a statistical analysis has been done to point out the resilience and reliability of the systems based on regulatory selfmonitoring data. It highlights the fact that FS-VFTWs are more reliable than most of the conventional treatment processes when applied for small size communities. Their physical barrier (filter) and their lower maintenance requirement explain this observation. The second axis of our research is based on an observed lack of consultation between stakeholders during the sanitation planning phase, which is responsible for the construction of the sanitation system. In particular, the users, their needs and their constraints are poorly and badly taken into account. Companion modeling approach could create both a support (the model) for discussing technical choices, as well as the framework within which the stakeholders could exchange points of view and find a sustainable consensus. Such a process has been developed and implemented for sanitation planning in 2 areas (urban and rural) of Senegal. Focused on household population, this process has led to create a generic model for sanitation access, embodied as a role playing game, which include a significant part of expert knowledge. The relevance of such tools in the characterization of user needs has been evaluated. In addition, attention was paid to users' acceptance of the proposed service and its translation into a willingness to contribute

Background: Antenatal care (ANC), facility delivery and postnatal care (PNC), are proven to reduce maternal and child mortality and morbidity in high burden settings. However, few rural pregnant women use these services sufficiently and it is essential to identify the barriers. Aim: The aim of this study was to examine barriers, with a focus on water, sanitation and hygiene (WASH), affecting women’s decision to seek care during pregnancy, childbirth and postnatal period in rural Kenya, and to examine if the Afya intervention helped overcome barriers. Methods: A qualitative study was conducted in the Siaya County, Kenya. 25 mothers were selected by using purposive sampling for in-depth interviews and focus group discussions. Assessment of WASH facilities was conducted at 5 healthcare facilities. Data were analysed by content analysis method. The “three delay model” informed the analytic process and discussion. Results: Women delayed seeking or did not attend ANC and PNC or gave birth at home, due to lack of knowledge of benefits of maternal health services and on complications; traditional and religious beliefs; embarrassed over pregnancy; busy with other life activities or of fear of HIV status and hospitals. Gender norms, distance and transport costs were the contributing factor for delaying in reaching the hospital. Unprofessional and inadequate number of staff, lack of equipment and supplies, and the water, sanitation and hygiene quality were factors delaying receiving quality care. The assessment showed on inadequate WASH facilities. Conclusion: Use of antenatal care, delivery and postnatal care in rural western Kenya is influenced by several barriers. The findings suggest a need to increase the knowledge about ANC and PNC, and to lower barriers preventing women from reaching the healthcare facility. There is also a need to improve the WASH facilities and the healthcare personnel’s treatment.

<p>The Lake Bosomtwe impact crater is located in the Ashanti region of Ghana, West Africa. The impact crater diameter from rim to rim is approximately 10.5 km wide with a lake located at the center. Three different districts touch the lake containing 155,000 hectacres of land. There are approximately 7,500 people from 24 villages, and 12 of those villages reside within walking distance of the lake shore. Within the last ten years, the lake has been subjected to overfishing and environmental degradation. The health of the lake has declined due to overfishing and algae blooms caused by improper fertilization rates. Because of these factors, residents of the area have been forced to transition to subsidence farming as their main vocation. According to the Ghana Statistical Service group, 97.6% of the population participates in some form of rural crop farming (Ghana Statistical Service, 2010). Experience with common practices such as crop rotation, fertilizer use, and erosion control is extremely limited. The lake has not been recommended for recreational use due to the excess runoff in the form of agrochemicals, liquid, and organic waste. Caged aquaculture and traditional fishing within Lake Bosomtwe is currently illegal.</p><p><br></p><p>A comprehensive Institutional Review Board (IRB) survey was developed for the six primary research questions to be examined. From these six research questions, 147 specific questions were developed. Three of the 147 questions were to obtain Global Positioning System (GPS) data for community households, pit latrines, and water wells or boreholes. This study sought to interview 10-15 farmers per village, for each of the 12 villages located along the shore of Lake Bosomtwe of their perspective on land use change/cover in the Lake Bosomtwe area, current farming practices, current water sanitation and hygiene practices, and current fishing practices. These surveys were collected in the form of oral responses, for which 118 small-holder farmers were interviewed. Of the participants surveyed, 66% were qualified to answer all questions, and 100% of participants completed the survey.</p><p><br></p><p>Some specific statistical tests were conducted based of market assessment survey. It was determined that no association between gender and level of education existed. Meaning, that female participants interviewed have just as many opportunities as male participants to pursue education beyond Junior High School (JHS). Yield averages between the villages on the north side of the lake with road access and villages on the southern portion of the lake with limited to no road access were determined to be significantly different. It was determined that road access does affect village yield. When comparing average usable yields between villages located on the northern side of the lake with road access or between villages on the southern side of the lake with limited to no road access, these results were not statistically significant. No significant difference in the scores for villages with road access on the northern side of the lake and villages with limited to no road access on the southern side of the lake existed. Therefore, road access does not affect village usable yield. Through statistical analysis an association was determined between people who practice bathing and washing in the lake and those who practice fishing as a form of livelihood.</p><p><br></p><p>Four decision matrices were created to prioritize the following items: Farm Components, technologies to showcase at an appropriate technology center, improved farming practices to showcase through Demonstration Plots, and extension outreach topics. The top three results for the Farm Components were: Appropriate Technology Center (ATC), Demonstration Plots, and a Micro-Credit Union. The top three technologies to showcase as part of the ATC are: PICS Bags, Moisture Meters, and Above-Ground Aquaculture. The three demonstration plots recommended terracing/erosion control, crop rotation, and cover crops. The highest priority extension outreach topics were: basic home/farm finance, improving health through washing stations, and post-harvest loss prevention. The top three priorities of each decision matrix will be the focus of further study, so that these topics can be developed and programs focusing on these needs can be implemented in collaboration with the community partners.</p>

<p>In developing countries water access is not always available. In many locations around the world, people lack sufficient access of water for both drinking and domestic purposes and use unsafe water sources. Particularly in sub-Saharan Africa, women and children walk great distances to obtain access to water. People must have equitable and affordable access to safe and sufficient water that is palatable and in sufficient quantity for both drinking and domestic purposes before any other long-term economic development or social improvement can occur. This research seeks to increase access to subsurface water by improving the driving capabilities of the Well-Driver PUP (Purdue Utility Project) vehicle. The Well-Driver PUP is a low-volume manufactured utility vehicle with a hydraulic post driver mated to it in order to mechanize tube well installation. </p> <p>Worldwide, there are many locations where the water table depth is less than 23 meters, specifically in the 10-20 meters range. These areas include sub-Saharan Africa, the Caribbean, South America, northern India, Asia, and parts of the Asia Pacific Islands. These locations are places where the Well-Driver PUP could potentially be utilized, if sufficient reliability and depth can be demonstrated on a repeatable basis. This would increase the number of locations throughout the world that the vehicle could be used to access ground water for those with limited to no current water access. Ghana is one of the many countries located within sub-Saharan Africa where the Well-Driver PUP could have a positive impact.</p> <p>The author has had significant professional experience working in Ghana on various international development projects related to agriculture, water, sanitation, and hygiene (WASH). She has been part of international development projects in Ghana, Tanzania, and Haiti, with experience working cross-culturally since 2014. She has worked on projects specifically in Ghana for more than 9 years and has been part of more than 32 different water resource projects within the country. Therefore, consideration is specifically given to the appropriateness of the Well-Driver PUP as first piloted in Ghana. For this work, a cost analysis of using the Well-Driver PUP per depth and comparison to current driven wells in Ghana was carried-out. </p> <p>A review of the literature was conducted. Four research questions and experiments were established. Experiment 1 carried-out three different pipe stack numerical loading studies that were simulated in Fusion 360® (Autodesk, San Rafael, CA). Load models were examined of a centered hit, a non-centered hit, and a well point only. It was shown that the average dynamic impact force applied by the driving ram was calculated to be 39 kN. FEA analysis was conducted in Fusion 360®, and it included Von Mises, safety factor, and displacement results. The average dynamic impact force that the Well-Driver PUP applies was less than both the yield stress and ultimate tensile strength of ASTM A53 steel, indicating that no deformation or breakage of the well point should be expected. </p> <p>Experiment 2 included increasing the weight of the driving ram, through the addition of weight plates. A series of wooden fence post installations using these new weight additions was conducted. This experiment allowed for a regression model to be developed predicting the impact of weight added to the driving ram, the drop height of the ram, and the soil moisture content, on the driving depth of the vehicle. The MLR model included the penetration depth (Y), weight added (X₁), drop height (X₂), and soil moisture content (X₃). The model coefficient estimates were determined, and the predictor variables were all found to be significant at p < 0.01.</p> <p>Experiment 3 focused on improved reliability and finding the maximum depth capabilities of the Well-Driver PUP with new weight additions added to the driving ram. Two attempts were made to determine the driving depth capabilities of the vehicle. Both well installations were conducted in Montgomery County Indiana. Water was struck at both locations. At the first location, final well depth was 2.1 m with a 0.76 m of water within the column. The driver encountered a layer of blue-gray clay that it was unable to pass through. </p> <p>A second driving attempt was made to install a deeper well. The final well depth was 5.0 m with 1.67 m of water within the column. At this location, it is believed that a layer of limestone, shale, or siltstone was encountered. Comparing the compressive strength of limestone, sandstone, and shale, the Well-Driver PUP was not capable of driving through such materials. Therefore, at both well locations, the maximum driving depth capabilities of the driver were achieved. At both installation locations, the wells were formally developed. Both sets of water quality samples were submitted to the Montgomery County Health Department and received satisfactory ratings. </p> <p>Experiment 4 resulted in the fabrication and design of a 4” well point. The fabricated well point was installed to create a completed well at a depth of 2.7 m in Linden IN. There was 0.1 m of water within the pipe column. The well was formally developed, and the water quality results received a satisfactory rating. A cost analysis of a 4” well by depth was conducted. The total cost to fabricate one well point totaled $661.42. Of the total cost, 81% of the costs came from the 4” base pipe and the specialty pre-perforated screen used to create the secondary screen. The completion of these experiments provides a better understanding of the driving capabilities of the Well-Driver Pup. Improving the driving depth capabilities of the Well-Driver Pup will help to push this low-cost alternative technology closer to release in the developing world.</p> <p><br></p>