Acceptability evaluation of water, sanitation, and hygiene interventions in low resource settings.

Abstract

Billions of people living in low-resource settings lack access to basic water, sanitation, and hygiene (WASH). The implementation of WASH interventions in these settings, especially those facing water insecurity, is a vital component of increasing global WASH access. However, many WASH interventions are not sustained beyond their initial implementation period. It is increasingly recognised that interventions must be acceptable to the target users to increase adoption and sustained use. While the term 'acceptability' has increasingly appeared in WASH literature over the past decade, and acceptability evaluations are common for health interventions more broadly, there is a need for a greater understanding of how acceptability evaluations can be conducted in practice across the WASH sector.

In this thesis, I aimed to contribute to the current understanding of the acceptability of WASH interventions in low-resource settings against a background of water insecurity. I focused on the Pacific Island Countries and Territories (PICTs) as a setting where acceptable and sustainable WASH interventions are required. To address the aim, I conducted a systematic review of how acceptability has been defined and measured in previous WASH studies, revealing inconsistent definition and a lack of theoretical basis, which limited the depth of the evaluations and comparability of the outcomes. I also systematically reviewed climate variability and water-related infectious diseases in the PICTs and narratively reviewed impacts of water insecurity on the identified diseases and found increased incidence following extreme events, highlighting the importance of ongoing WASH development across the PICTs. Building on the outcomes from the systematic reviews, I designed and conducted a mixed-methods acceptability evaluation of a water-saving portable hygiene intervention in three Fijian communities. This included a household survey (n = 207) and a focus group discussion study (n = 22). As part of this evaluation, I developed and applied a novel quantitative evaluation approach, the "acceptability score", based on the theoretical framework of acceptability.

By integrating the outcomes of the systematic reviews and mixed-methods evaluation, I found that acceptability evaluations provide information on appropriate intervention designs, implementation strategies, and the role of local context in acceptance of the intervention. In practice, they require a consistent, pre-specified definition of acceptability and theory-informed data collection instruments. While the quantitative acceptability score data was efficient to collect and offered insight into acceptability at a community level, limitations in the information gained at an individual level favoured a qualitative approach. The field study highlighted some components of acceptability relevant to WASH interventions that are not captured by existing frameworks. Notably, water security and climate events impacted the acceptability of the WASH intervention, indicating these factors should be explicitly considered as part of WASH acceptability evaluations. Further research on the costs and benefits of acceptability evaluation, empirical associations with other implementation outcomes, and development of WASH-specific acceptability theory will contribute to more effective and sustainable WASH interventions. Overall, this thesis makes practical and knowledge contributions that are pertinent for WASH implementers seeking to enhance implementation through acceptability evaluation. Show more