What do we want to know?

This review investigated both initial and sustained adoption of WASH interventions at the individual, household and community levels in low- and middle-income countries. The review questions are:

What are the factors that influence the sustained adoption of clean water and sanitation technologies?

What are the characteristics of interventions intended to improve adoption of clean water and sanitation technologies and how successful are these interventions at fostering both adoption and sustained adoption?

In answering these questions, the review examined the extent to which existing interventions addressed known barriers to and/or leverage known facilitators of the sustained adoption of water and sanitation technologies.

Who wants to know and why?

This review is relevant to development specialists, public health practitioners and environmental engineers. These findings will be relevant to efforts to decrease communicable disease and increase basic access to a safe, healthy living environment.

What did we find?

Following in-depth synthesis of the 44 studies explicitly reporting on sustained adoption, the following trends were found:

• Post-intervention sustainability is often measured by a combination of survey, interview and observation. There is no clear definition for sustained adoption employed in WASH literature, and sustained adoption is measured through self-report, observed practice, functionality and recalled knowledge.
• Behavioural factors that influence sustained adoption:
  • Psychosocial factors: Perceived susceptibility and severity of disease and perceived benefits and barriers are commonly identified as influences on sustained adoption. However, some other factors, such as injunctive and descriptive norms and nurturing, may be more predictive as motivators of continued use over time.
  • Contextual factors: Age and gender are important factors that influence both who is able to practise the behaviour at the household level, and to determine roles in providing water, soap and child care.
  • Technology factors: Cost is an important factor regardless of the technology. Factors like durability, rate of water flow and maintenance are key in ensuring that technologies withstand frequent use over a long period of time.
• Programme characteristics influencing sustained adoption:
  • Communication strategies were the most commonly described. The most influential factors include frequent, personal contact with a health promoter over a period of time. Personal follow-up in conjunction with on-going communication and support through mass media advertisements or group meetings may further contribute to sustained adoption.

How did we get these results?

A search of commercial databases, journals and web resources for peer-reviewed and grey literature looked for articles documenting water, sanitation or hygiene interventions, incorporating behaviour change, uptake or sustainability, in lower- and middle-income countries. Of the 148 papers mapped, 44 articles specifically reporting on long-term use or sustained adoption were selected for in-depth review and further synthesis.

What are the implications?

There is a diversity of interventions and methodologies to promote and evaluate sustained WASH adoption, and inconsistent definitions of sustained behaviour change and inadequate measurement of behavioural outcomes and factors affecting behaviour are common. The scope of WASH programme planning needs to be widened to put in place conditions during the project period that favour sustained use of WASH technologies and sustained adoption of WASH practices after the project ends. More emphasis needs to be placed on defining sustainability and translating this into metrics and programme elements that can be used to implement, evaluate and further the discussion on sustained WASH adoption. Technologies, implementation strategies, funding mechanisms and evaluation designs should also be expanded to better support these definitions. More resources need to be devoted to the evaluation of sustained use and to the development of new methods for such evaluation. Finally, policy planning and funding should emphasise the importance of planning for sustained WASH adoption from the start, and support the right to safe water, hygiene and sanitation for all. There is a need for direction and leadership in guiding the research agenda on sustained adoption of WASH technologies.

This report should be cited as:

Hulland K, Martin N, Dreibelbis R, DeBruicker Valliant J, Winch P (2015) What factors affect sustained adoption of safe water, hygiene and sanitation technologies? A systematic review of literature. London: EPPI Centre, Social Science Research Unit, UCL Institute of Education.

ISBN: 978-1-907345-77-7