DRAFT summary report: Factors affecting sustained sanitation usage
1
What factors affect sustained adoption of
sanitation interventions?
Summary report drawn from systematic review of literature “What factors
affect sustained adoption of clean water and sanitation technologies?”
Summary report written by Kristyna Hulland, Nina Martin, Robert Dreibelbis, Peter Winch (et al)
EPPI-Centre
Social Science Research Unit
Institute of Education
University of London
SUMMARY
REPORT
DRAFT summary report: Factors affecting sustained sanitation usage
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0 Background to the systematic review
0.1 About 3ie
The International Initiative for Impact Evaluation (3ie) works to improve the lives of people in the
developing world by supporting the production and use of evidence on what works, when, why and
for how much. 3ie is a new initiative that responds to demands for better evidence, and will
enhance development effectiveness by promoting better informed policies. 3ie finances highquality impact evaluations and campaign to inform better program and policy design in developing
countries.
3ie Systematic Reviews examine the range of available evidence on development interventions.
3ie is partnering with the Campbell Collaboration (C2) in the production of systematic reviews. All
reviews will be registered with C2, and the protocols and reviews submitted to C2. 3ie’s approach
is also influenced by the theory-based impact evaluation, which stresses the importance of
recognizing how outcomes may vary by context, and using a broader range of evidence to explain
findings.
0.2 Introduction to this summary report
This report summarizes findings related to sanitation from a larger systematic review entitled
“What factors affect sustained adoption of clean water and sanitation technologies?” that will be
publicly available in fall 2014. This summary report is intended for individuals interested in the
sanitation field, and larger WASH programming and policies.
0.3 The state of water, sanitation, and hygiene in the world
According to 2012 estimates, approximately 89% of the global population had access to an improved
water source (1). However, most of the countries in Sub-Saharan Africa are not on track to meet
MDG targets. Only 66% of the world’s population has access to improved sanitation – far below the
MDG Target of 75% by the year 2015.
Water, sanitation and hygiene (WASH) remain central in the post-2015 development agenda. Global
diarrhoea-related mortality in children under five years of age remains a major justification for
investment in WASH interventions, despite recent declines to an estimated 700,000 deaths in 2011
(2). Improvements in water quality, sanitation, and handwashing are associated with 17 – 48%
reductions in the risk of diarrhoea among children under the age of five (3), as well as mitigate the
dangers that inadequate water and sanitation pose for women and girls. WASH interventions are
also crucial to disease control among a variety of emergency and non-emergency situations (4-9). A
number of authors have suggested that access to clean water and sanitation should be considered a
human right (10, 11), independent of the effects of WASH interventions on health, due to the large
influence that clean water and sanitation have on quality of life and human dignity.
0.4 The review questions
To further our understanding of the barriers and facilitators to sustained adoption of water and
sanitation technologies, we conducted a systematic review of studies concerning the adoption and
sustained adoption of water, sanitation, and hygiene interventions at the individual, household, and
community-levels in low- and middle-income countries. We built on previous reviews of
handwashing and point-of-use water treatment, with a comprehensive review that is dramatically
DRAFT summary report: Factors affecting sustained sanitation usage
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larger and broader in scope than previous studies. It is the only review we know of that includes a
range of WASH interventions and factors associated with adoption. The review questions are:
Q1) What are the factors that influence the sustained adoption of clean water and
sanitation technologies?
Q2) What are the characteristics of interventions intended to improve adoption of clean
water and sanitation technologies and how successful are these interventions at fostering
adoption and sustained adoption?
0.5 Key definitions and concepts
WASH interventions typically promote both a technology (hardware) and regular use of the
technology in the correct way (key behaviours). In the larger review, we examine sustained
adoption of WASH behaviours. The principal water, sanitation and hygiene-related behaviours that
we investigate are:



Water: Filtering, boiling, chlorinating, and solar disinfection of drinking water;
Sanitation: Building, using and maintaining latrines and toilets; and
Hygiene: Handwashing with soap at key times – Before eating, before food preparation, and
after visiting the toilet.
In this review we did not assess adoption of WASH behaviours in schools, hospitals, restaurants and
other institutional settings. We examined adoption of WASH behaviours at the household level, and
promotion of these behaviours primarily at the household and community levels. Other factors
influencing sustained adoption, such as the design, durability and continued functioning of various
WASH technologies, are mentioned in this review in the context of how they influence behaviour.
0.6 Sustainability of WASH interventions
Sustainability is a concern across many sectors in global development. For the purposes of this
review, sustained adoption of WASH behaviours means that people continue to practice the
behaviours over the long term, the behaviours become incorporated into their daily routines, and
in many cases the behaviours become habitual and come to be performed sub-consciously with a
high degree of automaticity (12).
0.7 Review Methodology
A detailed protocol describing study activities was written and reviewed by 3ie prior to the start of
the project. Our four-stage review (Table 2, detailed below) proceeded from a broad initial
screening to descriptive mapping of existing literature on the barriers and facilitators to inform
subsequent in-depth syntheses. The Integrated Behavioural Model for Water, Sanitation, and
Hygiene (IBM WASH) framework (13) will be used to categorize results and guide synthesis of
findings.
Stage 1:
Identification and screening
In the first stage of our study, we collected all literature meeting inclusion criteria. Databases
containing peer-reviewed literature, grey literature, and other sources were searched for all
documents (e.g. journal articles, progress reports, and program evaluations) assessing WASH
interventions and behaviour change. Relevant documents were submitted for Stage 2.
Stage 2:
Mapping and keywording
DRAFT summary report: Factors affecting sustained sanitation usage
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An initial descriptive overview of studies identified in Stage 1 was completed. Using a nine-part
coding form, we systematically documented information on study type / methodology, location,
behavioural outcomes of interest, study quality, and study / intervention characteristics.
Stage 3:
Synthesis
Results from Stage 3 were used to inform the third stage of our review. This stage of the project
was iteratively developed using the study protocol as a guide.

Synthesis of individual factors that influence sustained adoption: In-depth review and
syntheses of a sub-set of studies were conducted to understand the barriers and facilitators
to adoption and sustained adoption of clean water and sanitation technologies (Q1 and subquestions). These syntheses draw on factors presented in the IBM-WASH model and include
studies presenting individual factors or “views” on practicing behaviours and/or using WASH
technologies. We employed a framework synthesis approach to identify, categorize and
synthesize evidence.

Synthesis of programmatic characteristics and factors that influence sustainability:
We employed a thematic synthesis to identify characteristics of interventions that
encourage adoption and/or sustained adoption of water and sanitation technologies (Q2).
Stage 4:
Reporting and dissemination
Findings from our review are being made available to interested parties through publication via 3ie,
peer-reviewed literature, and various networking and conference events, as opportunities arise.
DRAFT summary report: Factors affecting sustained sanitation usage
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Results related to sustained use of
sanitation technologies
1.1 Chapter overview
Water, sanitation and hygiene interventions tend to be implemented as a package. These packages
often provide or promote the construction or purchase of a technology (sometimes referred to as
“hardware”) such as a handwashing station with soap, a water filter, or a latrine. These
technologies are important because they facilitate the practice of the behaviour, enabling a
participant to carry out the behaviour multiple times a day as a habit performed throughout their
lives. The use and availability of the technology itself, the knowledge and attitudes of the users,
and the social and environmental context in which the behaviours are practiced are all factors
influencing behaviours. Most of the articles selected for in-depth review in the Behavioural Factors
syntheses are associated with sustained use of a technology or the practice of a specific behaviour.
Another typical component of an intervention package is education or promotion (referred to, by
some, as “software”). The educational component can take many forms from mass media
advertisements to intimate one-on-one discussions between a community health worker and a
mother of young children. The goal of education is to introduce a user to a behaviour and
technology and in most cases to discuss why, when, and how to do the behaviour. The components
of interventions, including types of communication channels employed, duration of the program,
and the intensity of interactions are discussed in the Programme Characteristics Syntheses. In this
section, we also identify programmes that have reported on sustained practice of behaviours after
the conclusion of an intervention.
Here, we will focus specifically on the reported technological and educational aspects of
interventions designed to promote sustained sanitation use. We will also consider program
implementation factors that influence sustainability of sanitation interventions.
1.2 Mapping and description of current studies
Of the 148 studies retrieved for mapping, 64 studies reported on sanitation interventions.
Sanitation technologies include the above ground structures (toilet or concrete slab) and building
where users enter, and other structures below ground or away from the toilet or latrine to receive,
empty and/or treat the waste.
1.2.1 Intervention Design
Reports of sanitation interventions typically incorporate both latrine construction and educational
efforts and hygiene promotion, such as efforts to educate people about the significance of hand
washing with soap. Educational and hygiene promotion efforts are particularly essential prior to
latrine construction. This is primarily because people are unlikely to utilize newly constructed
latrines if they are not properly educated about their benefits and not properly trained on how to
maintain them.
DRAFT summary report: Factors affecting sustained sanitation usage
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1.2.2 Outcomes
Many studies identified in the mapping phase report on construction of latrines, few mention
technology-specific attributes, and few discuss actual use or discontinued use after construction.
Specific technologies are listed in Table 1 in the Annotated Bibliography section.
On the whole, people are more likely to use latrines if they are better constructed and better
maintained. New latrines should be regularly monitored to ensure construction quality and
maintenance. It is also essential to note that people often choose to build latrines because they
enhance their social status. People feel embarrassed when their guests are forced to practice open
defecation. People feel their households gain status if they have latrines and do not practice open
defecation.
1.3 In-depth Review
Studies included in the mapping stage were considered for in-depth review and synthesis. In order
to answer the question about factors that affect sustained adoption of WASH technologies, we
prioritized studies that explicitly address sustained adoption. The inclusion criteria for synthesis
were:



Studies with an explicit goal of evaluating sustained use or program sustainability,
Studies reporting behavioural factors associated with long-term use, and
Studies with a follow-up period of twelve months or greater (studies or programme
evaluations with a follow-up period of less than one year were included if there
was solid methodology for examining sustained adoption).
1.4 Factors Affecting Sustained Use of Sanitation technologies
Of 44 articles concerning sustained use that were identified for in-depth review, 12 articles focused
on sustained sanitation adoption. Here we present motivating factors at three different levels of
influence identified in the IBM WASH model described earlier.
1.4.1 Psychosocial factors
A wide range of psychosocial factors operate at different levels across the studies surveyed. At the
community level, use of community latrines involves psychosocial factors like shared values and
collective efficacy to keep facilitates clean and operational. One study in this synthesis assessed
community ablution blocks (shared, communal latrines that include a wash station). In a series of
case studies conducted in South Africa users of community ablution blocks cited health, comfort, a
cleaner environment, and easy access as benefits to using communal latrines (14). However, the
authors found that over time the perceived health benefits reported by interviewees decreased by
24%, and they suggest this decrease may be attributed to a loss of enthusiasm for the facilities and
decreased motivation to keep the toilets well maintained.
Several of the sanitation articles in this synthesis are reports of total sanitation programs. These
campaigns mobilize communities to commit to building and using latrines, often staging “triggering
events” at the community level to utilize disgust of faeces in the environment as a means of
stigmatizing open defecation. Though implicit in total sanitation, stigma and social mobilization
were not discussed in detail or measured in the articles included in this synthesis. Similarly, it is
interesting to note that disgust was not commonly mentioned in literature on sustained adoption.
At the individual level, sanitation campaigns often leverage factors such as aspirations, social
norms, and outcome expectations to promote latrine use. In a study assessing the postimplementation latrine use in rural Niger, participants discussed perceived advantages such as
privacy, proximity and environmental hygiene as well as disadvantages like odour (15). However,
DRAFT summary report: Factors affecting sustained sanitation usage
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recognition of the benefits of sanitation does not necessarily influence sustained use. Changing
normative behaviour was a key factor reported by Hanchett et al. in encouraging latrine use for
both rich and poor (16). Knowledge of the mode of transmission of diarrhoea (17, 18) and
awareness of other water related diseases was commonly cited (15, 17, 19, 20).
At the habitual level, having consistent, easy access to latrines helps facilitate long-term
behaviour change. However, existing habits like continued preference for open defecation may
inhibit uptake of sanitation facilities (19).
1.4.2 Contextual factors
At the structural and community levels, seasonal changes and infrastructure shape when and how
WASH technologies are adopted. Latrine adoption in Zimbabwe was modified by seasonal work,
because regular access was limited for field labourers (21). Rainy seasons may also increase
likelihood of latrine collapse (22), and are therefore influential in determining long-term viability.
At the individual level, socioeconomic status, age, and gender are important factors in sanitation
adoption. Socioeconomic status (SES) or a similar measure of household wealth is commonly
assessed; higher SES is typically thought to be associated with better access to water, sanitation,
and hygiene. In a study assessing handwashing and sanitation in Kerala, consistent hygiene and
sanitation practice was associated with socioeconomic status of the household (23), as was use of
latrines by men (24).
Age and gender are important factors influencing sustained adoption because these factors often
determine who in the household has the ability to use and interact with the technology. In a study
of latrine provision in the Gambia both of these factors were influential in determining use. Ninetyfour per cent of households restricted young children from using the latrine, and some households
reserved the use of the latrine for the household head and first wife, only men, or only women
(22).
At the habitual level, prior behaviours may have some impact on adoption of new practices: in
one study, adoption of SODIS in Bolivia was associated with latrine ownership (OR: 3.38; 95% CI
1.07-10.7) (25), and generally prior experience with WASH practices of any kind was also associated
with sustained adoption of WASH behaviours.
1.4.3 Technological factors
Cost, durability, feasibility of use, and maintenance required were all mentioned as important
factors to sustained latrine adoption. In low- and middle-income countries, cost of the initial
technology and any associated parts or replacements are of great significance to users: if
technologies are too expensive, no level of psychosocial motivation will be enough for adoption and
sustained use. Appropriate design (e.g. additional features to assist with menstrual management or
child-friendly latrine pans) also influences continued use, as they enable the individual to feasibly
use the latrine on a routine basis.
Community-wide mobilisation and ownership can aid in effecting long-term changes; successful
programs such as Community-led Total Sanitation (CLTS) in part relies on a community to initiate
the introduction of WASH technologies.
1.5 Program characteristics and sustainability of interventions
1.5.1 Measuring sustained sanitation adoption
Latrine use is measured by:

Self-reported latrine use on a household survey;
DRAFT summary report: Factors affecting sustained sanitation usage


8
Self-reported latrine use through pocket voting: Anonymous voting by a person who
reported their personal latrine use by indicating their answer on a piece of paper and
placing it in an envelope;
Spot-check/observation of the presence and condition of latrines. Though presence of a
latrine provides access, it does not necessarily indicate use. Users may discontinue using a
latrine if it is dirty, if it is inaccessible in certain seasons, or where social norms support
practices of open defecation.
Reported latrine use in these studies varies from 47% respondents claiming to use the latrine all of
the time (19), to 93% of adults reporting to “always” use the latrine (15). A few studies included
measures of self-reported latrine ownership.
1.5.2 Designing a sustainable intervention: One-to-one discussion
The most personal and personnel-intensive channel of communication is a one-on-one discussion in
a participant’s household, and is frequently employed. Latrine adoption as part of a trachoma
control program was found by Ross et al to be significantly associated with visits by health
extension workers (p <.00001) compared to non-adopters (20), and participants in Bangladesh
receiving household visits about latrine use were more likely to have an improved or shared latrine
compared to those who did not receive a household visit (16).
1.5.3 Designing a sustainable intervention: Group meetings
Group meetings are another popular strategy for communicating about intervention behaviours. In
this format, a community health worker or volunteer will present to a group of people, often in
women’s groups, to share and discuss information.
Comparing community led total sanitation (CLTS) with community health clubs (CHCs), Whaley &
Webster found that though both approaches encouraged construction of latrines, CHCs were
effective at sustaining change because of face to face interactions (21). Qualitative data also
suggests CHCs may be an appropriate intervention strategy for Zimbabweans because it promotes
positive messaging as opposed to disgust and shame-driven triggers of CLTS.
1.5.4 Designing a sustainable intervention: Duration
Other factors of programs assessed in these studies include measures of program duration. Though
anecdotal evidence suggests that longer interventions favour sustained adoption of behaviours, the
results from studies with specific measures for this factor are inconclusive.
DRAFT summary report: Factors affecting sustained sanitation usage
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2 Annotated bibliography: studies of
sustainable sanitation interventions
This chapter will provide links to relevant tools and studies identified over the course of our review
that can aid in the development of sustainable sanitation interventions. An overview of the 12
studies discussing sustained sanitation adoption that were reviewed in-depth is provided below.
Following the annotated bibliography are tables indicating specific factors and outcomes assessed
in these studies. These tables are meant to guide readers to topic-specific sources of information,
depending on their interests and objectives.
2.1 Annotated bibliography of peer-reviewed literature and reports assessing
sustained adoption of sanitation technologies and programs
1
Barnard, S., Routray, P., Majorin, F., Peletz, R., Boisson, S., Sinha, A., & Clasen, T. (2013).
Impact of Indian Total Sanitation Campaign on Latrine Coverage and Use: A Cross-Sectional
Study in Orissa Three Years following Programme Implementation. PloS one, 8(8), e71438.
Cross-sectional follow-up survey of 20 selected villages, at least three years (3-8 yr
range) after “total sanitation compaign” (TSC) was implemented in Orissa, India.
Provides background info on TSC and implementation strategies. Outcomes assessed
were reported use of latrines, and observed latrine functionality (detailed criteria
specified). Presents both demographics and OR. 47% had functional latrines; latrine
ownership was associated with household construction, and having heard of a
sanitation council member or latrine program. Open defecation was a large reason
for disuse. Some exploration of psychosocial motivators, but in no great detail.
2
Choudhury, N., & Hossain, M. A. (2006). Exploring the Current Status of Sanitary Latrine use
in Shibpur Upazila, Narsingdi District. Bangladesh Rural Advancement Committee, Dhaka,
Bangladesh.
Discusses the “100% Sanitation Program”, specifically assessing impact on BRAC’s
combined sanitation program on changing knowledge and practices, in a district of
Bangladesh. Unclear if participants had previous been exposed to a campaign.
Participants were questioned on use, perceived benefits of latrines, and
barriers/opportunities of a latrine. Definitions of a “sanitary latrine” differed, and
open defecation was a reported issue, as habitual practice was difficult to overcome.
85% owned any form of latrine. Also presents findings from implementing partners,
and recommends strategies for scaling up.
3
Diallo, M. O., Hopkins, D. R., Kane, M. S., Niandou, S., Amadou, A., Kadri, B., Amza, A.,
Emerson, P.M. & Zingeser, J. A. (2007). Household latrine use, maintenance and
acceptability in rural Zinder, Niger. International journal of environmental health research,
17(6), 443-452.
Post-intervention follow-up one year after a subsidized latrine promotion campaign in
rural Niger. Hygiene education and latrine construction had been a part of the
original promotion strategy (detailed information given). 86% of latrines were
fundtional, and 92% of latrine-owning household reported “always” use by adults.
Use of latrines by children is significantly lower. Participants also described
advantages of latrine use and ownership.
DRAFT summary report: Factors affecting sustained sanitation usage
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10
Eder, C., Schooley, J., Fullerton, J., & Murguia, J. (2012). Assessing impact and
sustainability of health, water, and sanitation interventions in Bolivia six years post-project.
Revista Panamericana de Salud Pública, 32(1), 43-48.
Post-intervention assessment of a combined MNCH/nutrition/WASH intervention in
Bolivia six years after intervention completion.
Outcomes assessed included
knowledge and practice of handwashing and hygiene behaviours. Intervention
communities were found to have a high number of households using soap for
handwashing, and to have functioning water supply systems.
5
Hanchett, S., Krieger, L., Kahn, M. H., Kullmann, C., & Ahmed, R. (2011). Long-Term
Sustainability of Improved Sanitation in Rural Bangladesh. World Bank, Washington DC.
Brief report assessing sustainability of Community-Led Total Sanitation (CLTS) in
Bangladesh. Goal: identify enablers and barriers of sustained rural sanitation.
Households of open-defecation free districts were randomly surveyed. 89.5%
households share a safe latrine; 70% households have owned theirs for at least three
years. Enablers of use of safe latrines include: household head is female; previous
exposure to a follow-up program; access to materials or constructors; supportive
social norms. Barriers include: poverty, natural disasters, and lack of local
leadership. Continues to describe recommendations for future programming.
6
Malebo, H.M. MTUMBA Sanitation and Hygiene Participatory Approach in Tanzania. (2012).
Post-intervention evaluation eight years after implementation of Participatory
Hygiene and Sanitation Transformation (PHAST) strategy in Tanzania.
Brief
description of original intervention; outcomes assessed were use of technologies,
sanitation demand, and factors associated with technology use. 90% of households
had pit latrines present, and 10% reported open defecation. Reports on user
preferences for technologies, costs, and reported disease status, but presents a
limited level of detail. Offers recommendations for future programming.
7
Qutub, S. A., Salam, N., Shah, K., & Anjum, D. (2008). Subsidy and sustainability in urban
sanitation: The case of Quetta Katchi Abadis Environment Management Programme.
Waterlines, 27(3), 205-223.
Assessment of the Quetta Katchi Abadis Environment Management Programme
(QKAEMP), a latrine building and hygiene promotion, four years after program
completion. Community mobilization, hygiene promotion, and provision of sanitation
technologies were components of intervention. Presents very detailed information
on QKAEMP program, reported hygiene and sanitation practice, user benefits,
evidence of impact, and limitations/challenges.
8
Roma, E., Buckley, C., Jefferson, B., & Jeffrey, P. (2010). Assessing users’ experience of
shared sanitation facilities: A case study of community ablution blocks in Durban, South
Africa. Water Sa, 36(5).
Assessment users’ experiences of community ablution blocks constructed in informal
settlements in South Africa, from 0-3 years post implementation. Data were
collected via semi-structured interviews, and assessed user satisfaction, payment
mechanisms, training received, and overall views of the sanitation system. Facility
observations were also conducted. About half of all users perceive a health benefit
from community ablution blocks, though lack of cleanliness or affordability
affected acceptance. Proper maintenance and responsibility were also perceived
issues to latrine upkeep.
9
Ross, R. K., King, J. D., Damte, M., Ayalew, F., Gebre, T., Cromwell, E. A., Teferi, T. &
DRAFT summary report: Factors affecting sustained sanitation usage
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Emerson, P. M. (2011). Evaluation of household latrine coverage in Kewot woreda, Ethiopia,
3 years after implementing interventions to control blinding trachoma. International health,
3(4), 251-258.
Explores characteristics of latrine adopters roughly 1 year after a trachoma latrine
project in Ethiopia (implemented 2007-2009); intervention consisted of health
education and latrine construction. Households were interviewed on latrine use and
sanitation beliefs. Observations on latrine status also collected. Coverage was found
to be 52%, and about 30% had handwashing. Also discuss other predictors of use,
ownership habits, and perceptions of latrines. Detailed discussion of behavioural
factors and perceptions contributing to use, and other current programs.
10
Simms, V. M., Makalo, P., Bailey, R. L., & Emerson, P. M. (2005). Sustainability and
acceptability of latrine provision in The Gambia. Transactions of the Royal Society of
Tropical Medicine and Hygiene, 99(8), 631-637.
Follow up study to assess durability and acceptability of latrines 25-47 months after
construction of pit latrines in the Gambia, as part of a trachoma control intervention
(similar to Ross, 2011). Outcomes assessed included observed status/functionality of
latrines, and reported sanitation behaviours by latrine owners. 88% of latrines were
deemed usable; a small percentage were functional but not used. 46% of
households reported open defecation, and children were often prevented from
using latrines. Reports on intended behaviour, but NOT motivators/barriers of use.
Focused largely on latrine construction.
11
Waterkeyn, J., & Cairncross, S. (2005). Creating demand for sanitation and hygiene through
Community Health Clubs: A cost-effective intervention in two districts in Zimbabwe. Social
Science & Medicine, 61(9), 1958-1970.
Assessment roughly one year after intervention of PHAST (Participatory Hygiene and
Sanitation Transformation) in Zimbabwe, specifically the formation of community
health clubs (CHCs), clubs designed to address norms and behaviour of participants
regarding latrine usage. Provides detailed descriptions of intervention, which
covered all three areas of WASH; outcomes measured in this study concerned
sanitation practices, both reported and observed. Second follow-up occurred three
years later. Presents reasons for use and disuse, implementation notes, and
indicators of improved practice.
Also gives lengthy discussion on process
improvements of PHAST, and reflections on implementation of this model, and
recommendations for future activities (specifically replicating PHAST).
12
Whaley L, Webster J. The effectiveness and sustainability of two demand driven sanitation
and hygiene approaches in Zimbabwe. Journal of Water Sanitation and Hygiene for
Development 2011;1(1):20-36.
Follow up studies six months and two years post intervention introduction to assess
sanitation and hygiene practices after exposure to two different promotion strategies
(community groups, and community-led total sanitation) in Zimbabwe. Outcomes
included reported latrine use, presence of a handwashing facility, and presence of
soap. Community health groups were found to be more effective in promoting good
practices and handwashing station ownership. The report continues to discuss
determinants and motivators of behaviour change, such as financial incentive, sense
of belonging, and sense of achievement.
DRAFT summary report: Factors affecting sustained sanitation usage
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2.2 Key factors affecting sustained adoption of sanitation interventions
Table 1 presents frequencies of technologies mentioned in the literature. Tables 2-4 list specific
studies that assess a combination of psychosocial, contextual, and technological factors.
Table 1.
Sanitation technologies reported in the literature
Frequency of Enabling Technology Installed, Distributed, Sold, or Promoted as Part of a
Sanitation Intervention
Materials for latrine construction provided free of charge to community
11
Materials for latrine construction sold to community
18
Community members trained in latrine construction
23
Private company or contractors construct latrines
5
Community constructs their own latrines, in traditional way
11
Other
22
No enabling technology related to sanitation installed, distributed or sold
2
Enabling technology was part of intervention, but no information provided about it
15
Psychosocial Factor
Knowledge of mode of transmission of diarrhoea
Knowledge of other WASH diseases
✓
✓
Whaley, 2011
Devine, 2011
Malebo, 2012
Ross, 2011
Buckley, 2010
Waterkeyn 2005
Kullmann & Ahmed,
2011
Diallo, 2007
Choudhury, 2006
Psychosocial factors represented in the sanitation literature
Barnard, 2013
Table 2.
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Knowledge of toxins (Arsenic, Fluoride, etc.)
Perceived susceptibility
Perceived severity
Perceived benefits
✓
Perceived barriers
Social norms – Descriptive
✓
Social norms – Injunctive
✓
Subjective norms
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Disgust
Self-efficacy
Behavioural cues
Other
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
DRAFT summary report: Factors affecting sustained sanitation usage
Barnard, 2013
✓
Waterkeyn, 2005
✓
Kullmann & Ahmed, 2011
✓
Other contextual
factors
Ethnicity
✓
Simms, 2005
✓
Roma, 2010
✓
Ross, 2011
✓
✓
✓
✓
✓
✓
✓
Qutub, 2008
Whaley, 2011
Religion
✓
Choudhury, 2006
Malebo, 2012
Income generation
activities or work
patterns
Household structure
Level of education of
household members
Contextual factors represented in the sanitation literature
Household
income/wealth
Table 3.
13
✓
✓
✓
✓
✓
DRAFT summary report: Factors affecting sustained sanitation usage
Status for owner to been seen
owning such a technology
✓
Cost
✓
Installation of the technology
✓
Maintenance and/or difficulty
maintaining in working order
✓
Local manufacturing of technology
✓
✓
✓
✓
✓
Ross, 2011
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
Importing or procuring the
technology
✓
Distribution of the technology
Other technology-related factors
Qutub, 2008
Roma, 2010
✓
Malebo, 2012
Simms, 2005
Feasibility of routine/repeated use
of the technology
Kullmann & Ahmed, 2011
✓
Waterkeyn, 2005
✓
Diallo, 2007
Feasibility of using the technology
Choudhury, 2006
Technological Factors
Barnard, 2013
Technology factors represented in the sanitation literature
Eder, 2012
Table 4.
14
✓
✓
DRAFT summary report: Factors affecting sustained sanitation usage
15
3 Conclusion
Effecting sustained adoption of sanitation requires inputs at many levels: proper
infrastructure, a positive contextual environment, and enablers of the behaviour
must all come together to achieve lasting change. Our findings show that use of a
latrine is tied to perceptions of status, cleanliness, and convenience, but that the
maintenance and upkeep of latrines can be a challenge to sustained use. Even in
places where programs experienced success, open defecation remains a continuing
problem.
Much of the current literature assessing sanitation programs falls into one of two
categories: programs focused on the construction of latrines and their reported
use, or those aimed at changing normative behaviour at the community level (i.e.
CLTS). Overall, few studies explored in-depth behavioural enablers and motivators
of sanitation adoption.
These results suggest that future interventions would benefit by reconciling these
two program designs, to create sanitation packages that include both durable,
environmentally appropriate technologies, and a key package of behaviour change
messages and strategies. Additionally, improved metrics to assess actual
sanitation use (beyond the presence or functionality of a latrine) and
motivators/barriers to use should be established to aid in more accurate reporting
and evaluation.
DRAFT summary report: Factors affecting sustained sanitation usage
16
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