Nossal Institute for Global Health - Theses
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ItemCommunity-led Total Sanitation in Manufahi, Timor-Leste( 2019)Water, sanitation and hygiene (WASH) are important for health and wellbeing. In Timor-Leste, the rates of access to WASH are some of the lowest in the world, particularly in remote areas. The national government’s response to improving sanitation in remote areas is a community-based approach called ‘PAKSI’ (Planu Aksaun Komunidade, Saneamentu no Ijiene) which is also implemented by non-governmental organisations. The research documented in this thesis sought to understand the implementation and outcomes of the PAKSI component of the WaterAid program in Manufahi Municipality, Timor-Leste from 2013 to 2014 as part of the ‘WASH for Worms’ cluster-randomised control trial. PAKSI is based on Community-Led Total Sanitation (CLTS): an approach which aims to inspire rural communities to lead themselves to become open defecation free (ODF) through triggering collective feelings of disgust and shame about open defecation. CLTS is popular; however, there are few rigorous studies about the approach, especially in the context of Timor-Leste. Three studies were conducted as part of this research to better understand PAKSI: the Timor-Leste adaptation of CLTS. The first study compared the official descriptions of PAKSI (and CLTS) to the way it was implemented and described by 19 representatives of the government, WaterAid and intervention communities as well as Dr Kamal Kar and Dr Robert Chambers. The findings suggested that, officially, PAKSI and CLTS are quite similar; however, the implementation of PAKSI in the research sites diverged from these official descriptions in that the approach was more facilitator-led than community-led. The second study used quantitative methods with 65 households to measure the changes in sanitation-related knowledge, attitudes and practices after the WaterAid program. Whilst toilet coverage increased over the course of the study, and open defecation decreased, the proportion of participants who reported feeling disgusted at the sight of faeces in the open did not change. This suggests that a) the WaterAid PAKSI intervention did not trigger feelings of disgust (which is what PAKSI and CLTS are officially purported to do) and b) whilst disgust might be a necessary motivator for becoming ODF, on its own it is insufficient. The third study explored the possible factors influencing whether households become or continue to be ODF, through interviews with 21 participants including community leaders, household representatives and implementing staff. The experiences of participants who had a disability, an age-related impairment or were from female-headed households were sought to be included. Several factors were identified, including competing priorities for finances and other resources, and participants feeling like they were doing what they had been ‘told to do’. The 17 behavioural factors in the RANAS model of behaviour change provided a framework for analysing what motivates people in remote parts of Timor-Leste to change their sanitation behaviour. The findings suggest that motivators other than disgust and embarrassment, such as affordability of toilets and ‘being told what to do’, are relevant. Further research should investigate whether other approaches such as government regulation and strengthened sanitation markets are effective for bringing about ODF communities in Manufahi Municipality, Timor-Leste.
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ItemValidating the UNICEF/Washington Group Child Functioning Module as a method for disaggregating Fiji’s Education Management Information System( 2019)Disability disaggregation of education management information systems (EMIS) is vital to inform policies and resourcing for disability-inclusive education and evaluate progress towards targets. The approach to disaggregation must use a valid and reliable method for identifying children with disabilities. The UNICEF/Washington Group Child Functioning Module (CFM) is recommended by the United Nations for identifying children with disabilities and has been recommended for disaggregating education program data by disability. In the context of an education sector support program in Fiji, this research aimed to validate a method for disaggregating Fiji’s EMIS by disability. A cross-sectional diagnostic accuracy study was undertaken in which teacher and parent CFM responses for 472 primary-aged students were compared to reference standard clinical assessments in five domains: vision, hearing, musculoskeletal, speech and cognition. Receiver operating characteristic curves (depicting the trade-off between sensitivity and specificity) were constructed and optimal cut-off points and inter-rater reliability were assessed. Nested survey data on learning and support needs were analysed to explore whether combining CFM data on activity and participation data with data on environmental factors related to LSN (educational adjustments, assistive technology and personal assistance requirements) more accurately identifies children with disabilities. The study produced a range of novel findings. Diagnostic accuracy of parent observations related to seeing, walking and speaking was stronger than that of teachers, however teacher accuracy was very acceptable. Conversely, for cognitive domains teacher accuracy was far stronger than parents. The CFM domains seeing, hearing, walking and speaking showed “good” to “excellent” accuracy, however remembering and focusing attention showed only “fair” to “poor” accuracy. The domain learning was “good” with teachers as respondents, but only “fair” with parent respondents. As a whole, the CFM had “fair” accuracy (area under the Receiver Operating Characteristic curve: 0.763 parent responses, 0.786 teacher responses). Severe impairments were reported relatively evenly across CFM response categories “some difficulty”, “a lot of difficulty” and “cannot do at all”. If the cut-off level for identifying children with disabilities were “a lot of difficulty”, nearly 40% of children with moderate clinical impairments and 28% of children with severe impairments would miss out on services as they were reported as having “some difficulty”. On the other hand, the rates of false positives would be very high if the cut-off “some difficulty” were used. Combining data from the CFM with LSN data shows potential to increase the accuracy of domain-specific disability identification and, crucially, identification of children with disabilities amongst those reported as having “some difficulty” on the CFM. The CFM alone is not accurate enough for the purpose of disaggregating Fiji’s EMIS by disability. The choice of cut-off level and the mixture of severity of impairments reported across response categories are particular challenges for the CFM. Combining CFM data with data on educational adjustments, assistive technology and personal assistance requirements could improve disability identification accuracy. Follow-up verification visits are required to confirm funding eligibility due to inherent risks of tools based on self-report.