The Environmental Health Group (EHG) is the focus for the School’s work on WASH and health.
Founded as part of the Ross Institute for Tropical Health, the EHG has had a succession of eminent leaders from Prof David Bradley to Sir Richard Feachem and Prof Sandy Cairncross. For over three decades, the EHG has produced world-class research in the area of WASH and health, driving science, as well as policy and practice.
While many research centres look at environmental health interventions from the perspective of a single discipline; the EHG is unique in its combination of engineering with epidemiology, biology, the social sciences and economics. Its members have unusually extensive experience of the implementation and management of environmental health interventions in developing countries enabling them to bridge between research and policy.
In recent years, the EHG has won a succession of large research grants, published a number of important papers and books, and influenced changes in public and private sector policy.
Modules led by EHG staff
Water, Sanitation and Hygiene and Health (module code 3434)
Our flagship MSc module course "WASH & Health" provides students with training to support a future career in WASH-related public health programming, research, or evaluation through lectures, practicals, site visits and seminars with guest lecturers.
Water, Sanitation and Hygiene (module code IDM215)
The aim of this module is to enable students to understand the principles and practices that underlie water, sanitation and hygiene (WASH) interventions, in order to maximise health and social benefits. The module aims to empower students to contribute to discussions with other professionals regarding health impacts, technology choice and policy aspects of water supply, excreta disposal and other environmental interventions affecting health in low and middle-income countries. Find out more information on credits, assessment and application.
Designing Disease Control Programmes in Developing Countries (module code 3457)
This module equips students to design disease control programmes through lectures, group work and presentations. Students choose a challenging real-life scenario and design a programme that could be applied in the field. Topics change year on year but have included cholera, sexually transmitted diseases, disability, mental health, malnutrition, neglected tropical diseases and menstrual hygiene.
EHG staff also teach on:
- Global Disability and Health
- The Diploma of Tropical Medicine and Hygiene course
- The Tropical Medicine and International Health course
- What have we learned about promoting latrine use? (August 2019)
- Using behavioural science to promote latrine use in India: Kavita Chauhan (August 2019)
- #102 Valerie Curtis: Disgust and Hygiene Behavior (November 2018)
- WASH Futures 2018 Conference Keynote Presentation 4: Val Curtis (March 2018)
- Katie Greenland receives first ever Atlas trophy (January 2018)
- Toilet Board Coalition Meet the Members: Val Curtis of the LSHTM (August 2017)
- Katie Greenland (LSHTM): Formative research for behaviour change strategies (January 2017)
- Katie Greenland ISNTD Interview (November 2016)
- Delivering impact and behaviour change – the challenge of explosive urbanisation (November 2015)
- India WASH Summit: Oliver Cumming (March 2015)
- Behaviour centred design webinar (November 2014)
- Bonn WASH Nut – Introduction (Oliver Cumming) (December 2013)
- Soap Video (September 2013)
- SuperMum Film - Full Length - Promotes hand washing with soap (September 2013)
- Val Curtis - the evolution of disgust (September 2013)
- Global handwashing day: Faecal bacteria found on mobile phones (May 2013)
- 2010 Donaghue Conference - Keynote Speaker Val Curtis (May 2013)
- WASH 2011 Conference Keynote Val Curtis Part 1 of 2 (May 2013)
- WASH 2011 Conference Keynote Val Curtis Part 2 of 2 (May 2013)
- Ghana Handwashing Promotion Advertisement (May 2013)
- Can vaccination be used as an entry point for hygiene promotion? (January 2013)
- Investigating the Psychological Determinants of Habit Formation (January 2013)
- Is diarrhoea mainly water borne or water washed? (January 2013)
- Val Curtis, Disgustologist (September 2012)
- WASH and Undernutrition Oliver Cumming World Water Week 2012 Stockholm (September 2012)
Title: Puberty health interventions to improve menstrual health and School attendance among Gambian adolescents (MEGAMBO)
Type of project: Hygiene
Principal investigator: Belen Torondel
Other LSHTM collaborators: Vishna Shah, Wolf Schmidt, Val Curtis, Andrew Prentice
Funder: MRC / DFID / NIHR
Country: The Gambia
Poor menstrual hygiene management (MHM) among adolescent girls
has been associated with school absenteeism and other health outcomes. Globally, girls have developed their own personal strategies to cope with menstruation. These vary greatly from country to country, individuals’ personal preferences, available resources, local traditions and cultural beliefs, and knowledge or education. Some of the menstrual practices have been associated with different health outcomes (urogenital infections).
Across the globe, menstruation and its management also have important social and cultural implications which may in turn impact on girls’ lives. Absence from school has been of particular interest to international organisations and research bodies working in this area, such as WaterAid, Unicef, the Water Research Commission and Plan International.
Challenges girls face when attending school when menstruating include: feelings of embarrassment when menstruating, fear of leaking menstrual blood or of teasing from boys, lack of adequate absorbent materials and lack of privacy and access to appropriate water and sanitation facilities at school. These factors can lead girls to be absent from school during menstruation. A literature review we conducted in 2013 found there was good evidence that educational interventions can improve menstrual hygiene practices and reduce social restrictions, but there was no quantitative evidence that improvements in menstrual knowledge and management methods reduce school absenteeism and urogenital infections.
A study we are conducting among Gambian schoolgirls shows that students (boys and girls) had poor knowledge about menstruation. We also observed that lack of knowledge of menstruation led to embarrassment and fear of teasing, and this, together with pain and lack of effective materials and WASH facilities for MHM led to school girls’ absenteeism.
Our study showed that there is an unmet need from girls, boys and parents for interventions to enable girls to better manage both the psychosocial aspects of menstruation (anxiety and distress) and the physical aspects (management of use of appropriate materials to eliminate leakage of menstrual blood and hygienic habits practices). One workshop with different stakeholders (parents, teachers, students, clinicians, education regional officers and NGOs) was held in Keneba in May 2017 in order to present the initial findings, discuss the problems and find possible solutions. After the workshop we all decided to create a pack of four interventions that could be included in programmes already existing in these communities: a mothers’ club which will work with mothers to inform them about puberty, menstruation and absorbent and hygienic practices; peer education camps, which will involve girls and boys in schools to discuss puberty and menstrual management issues; community meetings around puberty films; and WASH improvements.
The aim of our study is to test, refine and adapt the intervention packages suggested in the first study and to conduct a school-randomised controlled trial to evaluate the effect and cost-effectiveness of an intervention to improve MH among girls to reduce school absenteeism in girls. The study is structured in two phases:
- Phase 1 – Pilot study: To finalise the design and pilot the intervention package
- Phase 2 – Evaluation of the intervention: To conduct a cluster randomised trial to evaluate the impact of our MHM intervention on school attendance
Shah, V, Nabwera, HM, Sosseh, F, Jallow, Y, Comma, E, Keita, O and Torondel, B. 2019. A rite of passage: a mixed methodology study about knowledge, perceptions and practices of menstrual hygiene management in rural Gambia. BMC public health, 19(1), p.277.
Title: Creating Demand for Peri-Urban Sanitation
Type of project: Sanitation / Behaviour Change
Principal investigator: Robert Aunger
Other LSHTM collaborators: James B. Tidwell, Val Curtis
Funder: Funded by the UK Department for International Development through the SHARE Research Programme
Poor health and economic outcomes caused by a lack of adequate peri-urban sanitation are a growing global problem due to rapid urbanization in lower- and middle-income countries. Reaching the Sustainable Development Goal (SDG) for sanitation (6.2) of "Access to safely managed sanitation for all" will require addressing this difficult challenge, as many existing toilets are not of sufficient quality to be connected to any sewerage lines constructed through planned infrastructure improvement initiatives. Few sanitation quality improvement interventions have been tested in peri-urban settings, where high population density and the high prevalence of landlord-tenant-shared on-site sanitation present a very different behavior change challenge to the rural setting. Previous trials in such settings have provided subsidies, worked to improve community-level infrastructure, or have targeted only improved cleaning behaviors. The SanDem trial was designed to test the hypothesis that the quality of shared sanitation, both its cleanliness and structural quality, could be improved by the use of a behavior change intervention motivating landlords to improve the toilets used by their tenants.
The intervention was developed using the Behaviour Centred Design approach through formative research, creative intervention development, and delivery and testing of the intervention. The resulting "Bauleni Secret" intervention consisted of a series of group meetings for landlords designed to motivate sanitation quality improvement as a way to build wealth and reduce conflict among tenants. The four primary outcomes to be evaluated were the presence of:
- A rotational cleaning system for the toilet (to improve hygiene)
- A solid door on the toilet used by tenants with an inside lock (for privacy)
- A lock on the outside of the solid door of the toilet (to limit access by outsiders)
- A seal between fecal containment and the environment (to reduce smell and contamination)
The SanDem project began by developing and validating an outcome measure able to capture the overall quality of on-site sanitation, the "Peri-Urban Healthy Toilet Index". It then quantified tenant willingness to pay for this improved sanitation quality, which accounted for 18% of rent and implied that any landlord with three or more tenant households sharing a single toilet should improve it to the highest possible level of quality. Finally, the positive results from the trial demonstrate that it is possible to improve the structural quality and cleanliness of shared sanitation by targeting landlords with a scalable, theory-driven behaviour change intervention without subsidy or provision of the relevant infrastructure. Future work will investigate the magnitude of change possible in the longer-term and in other contexts from such an approach, as well as investigate whether resolving other challenges such as a lack of access to credit could lead to an even larger effect.
Tidwell J, Chipungu J, Bosomprah S, Aunger R, Curtis V, Chilengi R: Effect of a behavior change intervention to improve peri-urban sanitation quality in Lusaka, Zambia: a randomized controlled trial. Lancet Planetary Health (2019).
Tidwell J, Terris-Prestholt F, Quaife M, Aunger R: Understanding the economic case for consumer-driven sanitation quality improvement using stated and revealed preference methods in peri-urban Lusaka, Zambia. Social Science & Medicine (2019).
Chipungu J, Tidwell J, Chilengi R, Curtis V, Aunger R: The Social Dynamics Around Shared Sanitation in an Informal Settlement of Lusaka, Zambia. Journal of Water, Sanitation, and Hygiene for Development (2018).
Tidwell J, Chipungu J, Chilengi R, Aunger R: Theory-driven formative research on sanitation improvement among landlords and tenants in Lusaka, Zambia. International Journal of Environmental Health Research (2018).
Tidwell J, Chipungu J, Chilengi R, Aunger R: Assessing Peri-Urban Sanitation Quality Using a Theoretically-Derived Composite Measure in Lusaka, Zambia. Journal of Water, Sanitation, and Hygiene for Development (2018).
Tidwell J, Chipungu J, Chilengi R, Aunger R: Using a Theory-Driven Creative Process to Design a Peri-Urban On-Site Sanitation Quality Improvement Intervention. BMC Public Health (2019).
Title: Urban Infant Foodscape
Type of project: Food / Hygiene / Health Impact
Principal investigator: Oliver Cumming
Other LSHTM collaborators: Julie Watson
Funder: BMGF and UK DFID
Countries: Kenya and Mozambique
There is strong evidence to suggest that food systems in low and middle-income countries (LMIC) carry substantial health risks due to the microbial contamination of foods. The majority of the global foodborne disease (FBD) burden is attributable to gastro-enteric infections associated with diarrhoea and most of this burden is borne by young children in LMIC, for whom the consequences can be dire in terms of repeated bouts of illness and the longer-term impacts on growth and development. Despite this, we lack evidence to guide the design and implementation of comprehensive strategies to mitigate the risks to child health and development posed by contaminated food in low-income, high-burden settings and populations.
The Urban Infant Foodscape (UIF) study is a collaborative project with the National Institute of Health (INS; Instituto Nacional de Saúde - Centro de Investigação e Treino em Saúde da Polana Caniço (INS-CISPOC)) in Mozambique, and the International Livestock Research Institute (ILRI) in Kenya. UIF is a food safety study focusing on a population where the FBD burden is highest – young children in low-income communities, and where effective strategies may bring the greatest gains. The study is currently running in parallel in two informal urban neighbourhoods within two low-income countries – Kenya (Dagoretti, Nairobi) and Mozambique (Polana-Caniço, Maputo) - and aims to describe the burden and diversity of pathogen detection among young children and child foods in these communities, and to determine the risk factors associated with this in order to inform the design of an effective FBD intervention.
In Phase One of the study, the FBD burden, the microbial contamination of food, and associated risk factors will be explored across three domains of the food system: the domestic environment - where most of the child’s food is prepared, cooked, served, and then potentially stored, reheated and reserved; the local marketplace - where household food is purchased as either raw ingredients or prepared foods; and the production/supply chain by which food arrives at the market place. Clinical and environmental samples will be tested for the presence of gastro-enteric pathogens, and observations of food preparation and handling conducted, along with qualitative interviews, to enable a comprehensive analysis of risks and critical control points. Findings in Phase One will be used in Phase Two to design a locally appropriate food safety intervention that will be iteratively tested and refined over a six-month period.
Title: TISA Trial: A Cluster Randomized Controlled Trial for the Effect of Combining Household Water Treatment and Hygiene Promotion with Standard Outpatient Treatment of Severe Acute Malnutrition on Recovery Rates, in Northern Senegal
Type of project: Water / Hygiene / Health Impact
Principal investigator: Oliver Cumming
Other LSHTM collaborators: Karin Gallandat, Sonal Shah, Lynn Grignard
Funder: US Office of Foreign Disaster Assistance (OFDA)
Global estimates suggest that 17 million children suffer from severe acute malnutrition (SAM). If untreated, this condition increases a child’s susceptibility to infectious disease and risk of mortality. In outpatient treatment programmes (OTP), SAM cases without complications remain in the household environment, thus potentially exposed to risks of infection, and reported recovery rates vary widely. The provision of a water, sanitation and hygiene (WASH) package to support SAM recovery by preventing infections is part of the integrated WASH and nutrition strategy that has been promoted by various actors in the Sahel region in recent years but effectiveness, cost-effectiveness, and acceptability of such an approach have not so far been rigorously evaluated.
The TISA trial aims to evaluate a simple WASH kit coupled with SAM treatment in terms of effectiveness (based on SAM recovery rates, other relevant health outcomes, enteropathogens carriage, and drinking water quality), cost-effectiveness, and acceptability. The prevalence of enteropathogens and antimicrobial resistance will also be assessed.
TISA is a cluster Randomized Control Trial, randomized by health facility. Eighty-six SAM treatment centres will be divided equally between control and intervention groups. The control group will receive standard SAM OTP and the intervention group will receive standard SAM OTP plus a WASH kit consisting of a single-action household water treatment product (Aquatabs), a safe water storage container, soap, and hygiene promotion. Approximately 2,000 uncomplicated SAM cases aged 6-59 months will be enrolled upon admission to OTP over 12 months across two departments (Podor and Linguère) in Northern Senegal.
The TISA trial will measure the impact of a simple, scalable WASH kit on SAM recovery, enteropathogens carriage and microbiological water quality. Process and cost-effectiveness evaluations will assess acceptability, operationalisation and economic implications of the WASH kit in the Senegalese context. The study will also provide an opportunity to investigate antimicrobial resistance exposures. Results are expected to help support health authorities in decision-making to adapt SAM OTP protocols and integrate WASH in nutrition management in Senegal and potentially in the wider Sahel region.
Title: Impact evaluation of water supply improvements on cholera in Uvira, DRC
Type of project: Water / Health Impact
Principal investigator: Oliver Cumming
Other LSHTM collaborators: Karin Gallandat
Funder: Agence Français de Développement (AFD), Fondation Veolia
Country: Democratic Republic of the Congo
Cholera remains a public health threat in regions without adequate water, sanitation, and hygiene access, with an estimated 2.9 million cases and 95,000 deaths occurring annually in endemic countries. Uvira is a city of approximately 233,000 inhabitants located on the shore of Lake Tanganyika, in the Democratic Republic of the Congo (DRC), within a “cholera hotspot”. Cholera has been reported in the area since the 1970s and decades of protracted conflict combined with limited public health infrastructure have hampered control efforts.
The aim of this ongoing study is to document the impacts of improvements in the water supply infrastructure on cholera and diarrhoeal disease incidence.
An ongoing stepped-wedge cluster randomised controlled trial (SWcRCT) is designed to evaluate the impact of these water supply improvements which include:
- installation of 36 km of new pipes to strengthen and expand the water supply network
- provision of approx. 1,000 new household connections and 115 new community taps;
- replacement of 14 km of existing pipes and approx. 2,000 household connections
- construction of a new 2,000 m3 reservoir
Neighbourhoods constitute study clusters and were randomised so that household and community taps are put into service at a specific time in each neighbourhood. The study team at the cholera treatment centre (CTC) records all admitted cases and confirmation of each case accepting to participate in the study is performed with rapid detection kits. The trial is registered at clinicaltrials.gov.
Findings to date and implications
This research is ongoing but the study has produced two sets of results so far. Firstly, a time series regression analysis has shown that water supply interruptions are associated with increased incidence of suspected cholera cases, suggesting that improvements in water services could help reduce the cholera burden in Uvira. Secondly, a case confirmation study found that approximately 40% of Cholera Treatment Centre (CTC) admissions tested positive for cholera using a rapid diagnostic test (RDT). The ongoing impact evaluation will inform future cholera control and prevention strategies based on improvements in infrastructure in endemic settings.
A. Jeandron, J. Mufitini Saidi, A. Kapama, M. Burhole, F. Birembano, T. Vandevelde, A. Gasparrini, B. Armstrong, S. Cairncross, J.H.J. Ensink. 2015. Water Supply Interruptions and Suspected Cholera Incidence: A Time-Series Regression in the Democratic Republic of the Congo. PLoS Med 12 (10) e1001893. DOI: 10.1371/journal.pmed.1001893
A. Jeandron, O. Cumming, B. Bashige Rumedeka, J. Mufitini Saidi, S. Cousens. 2018. Confirmation of cholera by rapid diagnostic test amongst patients admitted to the cholera treatment centre in Uvira, Democratic Republic of the Congo. PLoS ONE 13 (8) e201306. DOI: 10.1371/journal.pone.0201306
Title: Surprise Soaps
Type of project: Hygiene and Behaviour Change
Principal investigator: Oliver Cumming, Co-PI Julie Watson
Other LSHTM collaborators: Robert Dreibelbis
Funder: Humanitarian Innovation Fund
Children in emergency populations are particularly vulnerable to diseases such as diarrhoea and acute respiratory infections. In emergencies, these diseases account for 30% of child mortality. Handwashing with soap (HWWS) can greatly reduce transmission but handwashing rates are low and, thus far, handwashing promotion has lacked effectiveness. Traditional handwashing interventions have been school-focused, resource-intensive, and reliant on health-based messaging, yet research suggests that health is a poor motivator of behaviour change. Low cost, rapidly deployable, and effective interventions reaching children both in and out-of-school are needed.
In 2018, we designed and tested, for the first time in an emergency setting - an IDP camp in Iraq - a novel soap designed to motivate children’s handwashing through play and curiosity. Toys were embedded inside of transparent soap and delivered to children in short, fun household sessions which avoided using any health-based messaging. The hypothesis was simple: children would wash their hands more often to reach the toy inside.
We tested this intervention in a controlled proof-of-concept study; out of five total blocks within the camp, one was assigned to intervention and one to control and 40 households from each assigned block were then randomly selected for participation. HWWS at key occasions was measured at baseline and four weeks after intervention delivery. Children in the intervention households received the toy soap intervention and the control group received plain soap in a standard, health-based, household session.
At the 4-week follow-up we found that children in the intervention group were 4 times more likely to HWWS after key occasions than expected in the counterfactual (if there had been no intervention), based on comparison to the control group (adjusted RR = 3.94, 95% CI 1.59-9.79). These positive results suggest that this rapidly deployable intervention can improve child handwashing behaviour in a humanitarian emergency and may be a valuable tool for use in disease control.
Watson J, Dreibelbis R, Aunger R, Deola C, King K, Long S, Chase RP, Cumming O. 2018. Child's play: Harnessing play and curiosity motives to improve child handwashing in a humanitarian setting. International journal of hygiene and environmental health. DOI:10.1016/j.ijheh.2018.09.002