Globally, the use of untreated, often diluted, or partly treated wastewater in agriculture covers about 30 million ha, far exceeding the area under the planned use of well-treated (reclaimed) wastewater which has been estimated in this paper at around 1.0 million ha. This gap has likely increased over the last decade despite significant investments in treatment capacities, due to the even larger increases in population, water consumption, and wastewater generation. To minimize the human health risks from unsafe wastewater irrigation, the WHO’s related 2006 guidelines suggest a broader concept than the previous (1989) edition by emphasizing, especially for low-income countries, the importance of risk-reducing practices from ‘farm to fork’. This shift from relying on technical solutions to facilitating and monitoring human behaviour change is, however, challenging. Another challenge concerns local capacities for quantitative risk assessment and the determination of a risk reduction target. Being aware of these challenges, the WHO has invested in a sanitation safety planning manual which has helped to operationalize the rather academic 2006 guidelines, but without addressing key questions, e.g., on how to trigger, support, and sustain the expected behaviour change, as training alone is unlikely to increase the adoption of health-related practices. This review summarizes the perceived challenges and suggests several considerations for further editions or national adaptations of the WHO guidelines.

In low- and middle-income countries, inadequate sanitation results in faecal contamination of the water used by urban farmers for irrigation. Consumers of raw contaminated vegetables run the risk of developing diarrhoeal diseases and helminth infections, which are a leading cause of under-five mortality and impact the well-being and productivity of millions of adults. This review identifies the evidence base for assessing which factors determine the success and/or failure of interventions that aim to manage the risk of faecal contamination in the urban irrigated vegetable value chain. We carried out a systematic search of the literature from the perspective of the COM-B behaviour framework (Capability + Opportunity + Motivation = Behaviour). Our results reveal that most interventions address stakeholders’ opportunity or capability to adopt safe practices without adequately considering their motivation. Interventions often focus on one sector rather than on the whole value chain (sanitation, agriculture, trade, consumption). To effectively change hygiene and food safety practices in the urban irrigated vegetable value chain, stakeholders’ intrinsic motivations need to be identified. Where WHO's multi-barrier approach is the best option, we recommend building on local multistakeholder platforms and adopting a behaviour change framework to support the largely technical change from farm to fork.

The faecal contamination of irrigation water threatens public health. Although safe practices can mitigate hygiene and food safety risks along the urban irrigated vegetable value chain, their adoption remains limited. A behaviour framework was combined with a participatory approach to explore how institutions influence stakeholders’ capability, opportunity and motivation to adopt safe practices in Accra, Ghana. After extensive preparation, a dialogue engaged stakeholders and institutions in identifying the actors and interactions influencing stakeholder practices. We found that institutional dynamics and misaligned priorities hinder stakeholders’ opportunity and motivation to adopt safe practices, while their capability (education and skills) is not actively hindered. Knowledge gaps created by top-down approaches and sectoral silos were bridged by engaging participants in conducting the behavioural diagnosis. This shared understanding highlights the need to integrate and harmonise policies, regulations and service provision across water, sanitation, agriculture and health sectors, enabling participants to co-design arrangements that make safe practices easier to adopt.

The faecal contamination of irrigation water threatens public health. Although safe practices can mitigate hygiene and food safety risks along the urban irrigated vegetable value chain, their adoption remains limited. A behaviour framework was combined with a participatory approach to explore how institutions influence stakeholders’ capability, opportunity and motivation to adopt safe practices in Accra, Ghana. After extensive preparation, a dialogue engaged stakeholders and institutions in identifying the actors and interactions influencing stakeholder practices. We found that institutional dynamics and misaligned priorities hinder stakeholders’ opportunity and motivation to adopt safe practices, while their capability (education and skills) is not actively hindered. Knowledge gaps created by top-down approaches and sectoral silos were bridged by engaging participants in conducting the behavioural diagnosis. This shared understanding highlights the need to integrate and harmonise policies, regulations and service provision across water, sanitation, agriculture and health sectors, enabling participants to co-design arrangements that make safe practices easier to adopt.

Background: In Accra, Ghana, street food vendors soak leafy greens and other salad vegetables, eaten raw, in a basin of water to which they add salt, with the expectation that this will remove germs. While this method has long been the best available option, salt is less effective than other disinfectants. Potassium permanganate is one such disinfectant commonly used in French-speaking West Africa and other Low- and Middle-Income Countries, but its use to sanitise vegetables is virtually unknown in Ghana. This article aims to identify the factors that would induce street food vendors to use potassium permanganate instead of salt. Methods: Using the Risk-Attitude-Norms-Abilities-Self regulation (RANAS) behaviour change approach, an exploratory sequential mixed-methods design consisting of formative interviews (N=20) and a quantitative survey of street food vendors (N=251) was conducted in 10 neighbourhoods of Accra to investigate which psychosocial factors best predict the adoption of potassium permanganate. An ordinal logistic regression analysis then determined the factors that are the most significant predictors of vendors’ commitment to using potassium permanganate. Results: The interviews and survey showed that street food vendors are aware of the health risks associated with food contaminated with germs and prioritise hygiene. However, limited and sometimes inaccurate knowledge hinders their motivation to adopt safer practices. Our study revealed that personal norms, confidence in resuming the practice after an interruption, and others’ approval (injunctive norms) are significant predictors of street vendors’ commitment to using potassium permanganate. Our findings also suggest that education, training and financial (dis-)incentives are insufficient on their own to motivate the adoption of this safe practice. Conclusions: Our results suggest that public authorities seeking to promote the use of potassium permanganate to sanitise vegetables eaten raw should integrate behaviour change strategies that leverage these predictors to enhance adoption. The article demonstrates the value of the RANAS approach for addressing food safety behaviours across urban vegetable value chains in low- and middle-income countries globally, aligning with WHO recommendations that emphasise socio-cultural dimensions alongside technical measures.