PROTOCOL: Evidence and Gap Map Protocol: Interventions Promoting Safe Water, Sanitation, and Hygiene for Households, Communities, Schools, and Health Facilities in Low‐ and Middle‐income Countries

Campbell Systematic ReviewsVolume 14, Issue 1 p. 1-41 PROTOCOLOpen Access PROTOCOL: Evidence and Gap Map Protocol: Interventions promoting safe water, sanitation, and hygiene for households, communities, schools, and health facilities in low- and middle-income countries Hugh Waddington, Hugh WaddingtonSearch for more papers by this authorHannah Chirgwin, Hannah ChirgwinSearch for more papers by this authorJohn Eyers, John EyersSearch for more papers by this authorYashaswini PrasannaKumar, Yashaswini PrasannaKumarSearch for more papers by this authorDuae Zehra, Duae ZehraSearch for more papers by this authorSandy Cairncross, Sandy CairncrossSearch for more papers by this author Hugh Waddington, Hugh WaddingtonSearch for more papers by this authorHannah Chirgwin, Hannah ChirgwinSearch for more papers by this authorJohn Eyers, John EyersSearch for more papers by this authorYashaswini PrasannaKumar, Yashaswini PrasannaKumarSearch for more papers by this authorDuae Zehra, Duae ZehraSearch for more papers by this authorSandy Cairncross, Sandy CairncrossSearch for more papers by this author First published: 08 October 2018 https://doi.org/10.1002/CL2.199Citations: 4 Linked article: Evidence and gap map report AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Background The problem According to the Joint Monitoring Programme (JMP), an estimated 844 million people do not use improved water sources and 2.3 billion lack access to even a basic sanitation service (WHO/UNICEF JMP, 2017). Worldwide, 892 million people still practice open defecation. Rural, poor and, vulnerable households have particularly limited access to adequate facilities and inequities are often regionally focused. Populations in sub-Saharan Africa and Oceania are lagging behind in access to improved drinking water sources, whilst South Asia and sub-Saharan Africa have the highest concentrations of open defecation. Limited, or no, access to safe facilities for eliminating human waste, gathering clean drinking water, or practicing hygienic washing and food preparation practices exposes individuals to higher-levels of contagious pathogens. There is evidence to suggest that poor water, sanitation, and hygiene (WASH) conditions are associated with high levels of diarrhoeal disease (Clasen et al., 2015; De Buck et al., 2017), respiratory infections (Aiello et al., 2008), parasitic worm (e.g. helminth and schistosome) infections (Ziegelbauer et al., 2012), trachoma (Rabiu et al. 2012), and possibly even tropical enteropathy (Cumming and Cairncross, 2016). Chronic high infection rates are among the leading causes of undernutrition and death in children (Cairncross et al. 2014). Diarrhoeal diseases, in particular, are the second most common cause of death for children under the age of five; diarrhoeal diseases, in particular, are estimated to kill 480,000 children a year (UNICEF, 2018). Beyond the health consequences, poor quality WASH conditions may also lead to long-term adverse social and economic outcomes including diminished educational attainment (Hennegan et al., 2016), due to both children's school enrolment and attendance as well as teacher attendance, and implications for employment, life-time wage earnings and income (Hutton et al., 2007; Turley et al. 2013). Inadequate access affects disadvantaged groups disproportionately, but women and girls are particularly badly affected by the costs of having limited access to WASH facilities. They often carry the majority of the burden associated with collecting water (including time, calories spent, musculoskeletal injuries, risks of assault and attack by humans and wild animals, and road casualties), and can be placed in high-risk situations when using unsafe places to defecate (Cairncross and Valdmanis, 2006; Cairncross et al., 2010; Sorenson et al., 2011; Sahoo et al., 2015). Women and adolescent girls also experience particular hardships where inadequate WASH facilities constrain menstrual hygiene management (Hennegan et al., 2016; Sumpter and Torondel 2013). There may also be adverse maternal and child health implications due to inadequate WASH services in health facilities and other places of newborn delivery (Benova et al., 2014). In 2015, more than 150 world leaders adopted the new 2030 Agenda for Sustainable Development, which sets new goals for 2030 that build upon, and go even further, than the Millennium Development Goals (MDGs). Sustainable Development Goal (SDG) 6 aims to 'ensure the availability and sustainable management of water and sanitation for all' by 2030 (UN Water, 2018). In order to help achieve these universal targets, which includes reaching the most disadvantaged populations, decision makers need access to high quality evidence on what works in WASH promotion in different contexts, and for different groups of people. Both impact evaluations and evidence syntheses can be useful to decision makers. Single impact studies are useful for providing information on how a programme functions in a specific context; for example, the recent WASH-Benefits trials were unable to detect effects of combined or single water, sanitation, or hygiene interventions on child linear growth in Bangladesh and Kenya (Luby et al., 2018; Null et al., 2018). However, there has been criticism of the generalisability of the studies and the interventions provided (Cumming and Curtis, 2018; Coffey and Spears, 2018). On the other hand, high quality systematic reviews critically appraise and corroborate the findings from individual studies, as well as providing a steer to decision makers about which findings are generalisable and which are more context-specific (Waddington et al., 2012). For policymakers, practitioners and commissioners of research to make informed decisions, they need to be able to identify where high quality evidence exists in usable formats, and where more evidence is needed. There are also concerns about approaches used to measure outcomes in WASH sector primary research, such as self- and carer-reporting of diarrhoeal disease (e.g. Schmidt and Cairncross, 2009). These concerns necessitate, firstly, examining the critically appraised evidence (from systematic reviews) and, secondly, evidence on a wide range of behavioural, health and socio-economic outcomes. What remains an issue, therefore, is the extent of evidence on the effectiveness of interventions to improve access to WASH services for households, communities, schools and health facilities on outcomes in the round, and an assessment of what primary and synthesised evidence is still needed across different low- and middle-income countries and regions. Scope of the evidence and gap map Water, sanitation and hygiene (WASH) interventions have two important components to them – the 'what' and the 'how'. The 'what' describes the technology that the participants end up with (for example, a latrine) and the 'how' describes the mechanism of the intervention (for example, whether toilets are provided on a subsidised basis or at full cost with some form of social marketing). Prior to the early-2000s, the focus of the conversation was principally on 'what' works; research was centred on understanding and demonstrating the short and long term consequences of providing a technology. However, over the last 15 years the conversation has increasingly switched from not just what technology to provide but what is the best way to both get it into the community and have it be regularly used. This has seen the rise of behaviour change and systems-based approaches. Due to this changing focus, the principal interventions will be defined by the mechanisms (the 'how'); this means that the evidence gap map will present intervention mechanisms against outcomes. There will then be a filter for the technology provided by the intervention; this will allow for easy comparison of the evidence for different mechanisms of providing, for example, latrines. Mechanisms for providing WASH technologies can be classified into four main groups; direct provision, health messaging, psychosocial 'triggering', and systems-based interventions. The below definitions have been adapted from relevant literature in the field (De Buck et al., 2017 and Poulos et al., 2006): Direct provision mechanisms cover all interventions where hardware (such as a latrine or water purifier) is provided for free and has been chosen by an external authority (such as a non-governmental organization). Health messaging, most often focused on sanitation or hygiene, is typically a directive educational approach designed to help individuals, or communities, improve their health through increasing their knowledge and/or skills. Psychosocial 'triggering' falls into two subcategories of directive and participative approaches. Both subcategories use behavioural factors which have been derived from psychosocial theories (such as emotions, like disgust and the desire to be a good parent, or social pressure) to motivate behaviour change, rather than reason. An example of this approach is community-led total sanitation (CLTS) where the community is encouraged to discuss how they would like sanitation practices to change, identify problem areas (e.g. 'walks of shame'), and use social cohesion and pressure to motivate people to construct latrines and stop practicing open defecation (Kar and Chambers, 2008). Systems-based mechanisms try to change people's behaviour by changing the wider system around them. These approaches include pricing reform, improving operator performance, private sector (PS) and small-scale independent provider (SSIP) participation, and community driven development (CDD). The behavioural change communication (BCC) approaches – health messaging and psychosocial 'triggering' – are often combined with both direct provision and systems-based approaches in an attempt to simultaneously overcome the social and financial barriers to accessing appropriate WASH services. WASH technologies for household and personal consumption can be classified into four main, related, groups: water quantity, water quality, sanitation hardware and sanitation software (hygiene) (Esrey et al., 1991): Water quantity technologies provide a water supply or distribution system. Water may be supplied to communities at source, such as through a public standpipe, or at point-of-use (POU), such as being piped directly to households. Water quality technologies provide the means to protect water from, or treat water to remove, microbial contaminants. Examples of water treatment technologies include filtration, chlorination, flocculation, solar disinfection, boiling, and pasteurising. Water quality improvements are most commonly undertaken in the household, rather than at the source, though this class of interventions also includes treatment at source and provision of containers for safe transportation and storage of water. Sanitation technologies provide means to dispose of excreta (such as faeces), through new or improved latrines or connection of existing latrines to the public sewer. Hygiene technologies consist of hygienic practices, and facilitators of these such as soap, hand sanitisers, and washing stations. Hygiene practices are most often focused on handwashing but can also include food hygiene, such as proper food storage and washing dishes appropriately, as well as wearing appropriate footwear, or menstrual hygiene management. A third important dimension to any intervention is how, or where, participants interact with it in terms of both their social and physical environments. Interventions that seem similar can be very different in nature, and their outcomes not necessarily comparable, due to the space they inhabit. An ecological model can be integrated into the types of technology to reflect where a technology is used. The place of use is important in the WASH sector as it affects the convenience to users, and therefore adoption rates, as well as how the intervention disrupts the causal chain of disease transmission. The four main spaces in which WASH technologies are provided are in the home (for use by an individual household only), in the community (to be shared), at a school, and at a health facility. Multiple mechanisms can be used in one programme; for example, soap could be directly provided with a social marketing campaign on handwashing. Multiple WASH technologies are also often be provided together in programmes where they are combined. A common example is combined water supply and sanitation (WSS) programmes. The quality of water supply, sanitation and hygiene facilities – that is, the extent to which they are likely to provide potable drinking water or safe removal of excrement from the human environment, or enable hygienic hand-washing – is dependent on the type of water or sanitation facility. Table 1 lists types of improved and unimproved water, sanitation and hygiene facilities according to WHO/UNICEF JMP (2017). Table 1. JMP classification of water, sanitation and hygiene facilities Drinking water Sanitation Hygiene Improved facilities Piped supplies: Tap water in the dwelling, yard, or plot Public standposts/pipes Non-piped supplies: Boreholes / tubewells Protected wells and springs Rainwater Packaged water, including bottled water and sachet water Delivered water, including trucks and small carts Improved sources that require less than 30 minutes round-trip to collect are defined as 'basic water'. Improved sources requiring more than 30 minutes are defined 'limited water'. Networked sanitation: Flush and pour flush toilets connected to sewers On-site sanitation: Flush or pour flush toilets connected to septic tanks or pits Pit latrines with slabs Composting toilets, including twin pit latrines and container-based systems Shared facilities of the above types are defined as 'limited sanitation'. Fixed or mobile handwashing facilities with soap and water (defined as 'basic hygiene'): Handwashing facility defined as a sink with tap water, buckets with taps, tippy-taps, and jugs or basins designated for handwashing. Soap includes bar soap, liquid soap, powder detergent, and soapy water. Handwashing facilities without soap and water (e.g. ash, soil, sand or other handwashing agent) are defined as 'limited hygiene' Unimproved facilities Non-piped supplies: Unprotected wells and springs. On-site sanitation or shared facilities of the following types: Pit latrines without slabs Hanging latrines Bucket latrines No facilities Surface water (e.g. drinking water directly from a river, pond, canal or stream) Open defecation (disposal of human faeces in open spaces or with solid waste) No handwashing facility on premises Source: Based on WHO/UNICEF (2017). Conceptual framework of the EGM The conceptual framework links WASH interventions with impacts along the causal chain (Figure 1). Sector interventions – water and sanitation hardware and software provision and interventions in sector governance (e.g. contracting out and subsidies) – are presented to the left of the figure. Impacts on wellbeing – health, education, income and empowerment – are presented on the right. The conceptual framework shows the causal chain through which inputs are turned into final wellbeing impacts, through activities (construction of new facilities or behaviour change campaigns), outputs (better access to and quality of services) and outcomes (behaviour change, better use of those services). Figure 1Open in figure viewerPowerPoint WASH interventions conceptual framework Source: authors based on White and Gunnarson (2008). The links in the chain are not automatic. For example, in the particular case of water quality, faecal contamination of drinking water between source and point-of-use (POU) means that hygienic approaches may be needed to store clean water collected at source, or treat water for contaminants in the household (POU). Better access to water supply (quantity) may improve health by reducing contamination in the environment by enabling better personal hygiene (e.g. handwashing) and environmental hygiene (e.g. safe disposal of faeces). Factors such as environmental faecal contamination may prevent impacts from clean drinking water provision being realised. Sustainability of impacts requires continued (permanent) adoption and acceptance by beneficiaries as well as appropriate solutions to reduce 'slippage' in improved behaviour and financial barriers to uptake and technical solutions to ensure service delivery reliability. Scalability requires that impacts which are demonstrated under 'ideal settings' of trials are achievable in the context of 'real world' programme implementation, where beneficiaries may not constantly be reminded to use technologies appropriately. Why it is important to develop the EGM? Progress towards the Millennium Development Goals (MDGs) was uneven in the sector. The MDG drinking water target to "halve the number without access to safe drinking water (defined as access to water from an improved source within one kilometre of the household)" was declared met in 2012, but of those who did gain improved access to drinking water since 1990, supplies are mainly provided at the community level and are often unreliable (WHO/UNICEF, 2013). The MDG sanitation target to "halve the number without access to sanitation by 2015" was missed (UN, 2015). The Sustainable Development Goals (SDGs) are aspirational, aiming for universal coverage by 2030, and adding targets for hygiene.1 The SDG targets are as follows (WHO/UNICEF JMP, 2017): To provide safe and affordable drinking water for all, measured by population using safely managed drinking water that is an improved drinking water source, located on premises, available when needed and free from contamination (SDG 6.1). To end open defaecation and provide adequate and equitable sanitation for all, measured by population using safely managed sanitation services and a basic handwashing facility with soap and water (SDG 6.2). Safely managed sanitation is defined as an improved facility where excreta is treated and disposed of in situ or off-site. To ensure all men and women have access to basic services, including basic drinking water, sanitation and hygiene (SDG 1.4). In order to move towards these ambitious targets, it is likely that substantial improvements in resource allocation will be needed to promote interventions which are effective in improving behaviours and outcomes in particular contexts. The purpose of this evidence gap map is to assist policy-makers and practitioners in gaining access to evidence on the effectiveness of WASH interventions. In 2014, 3ie produced an evidence gap map (EGM) on the effectiveness of WASH interventions in improving quality of life outcomes. That map includes evidence until February 2014 and only considered quality of life outcomes (health and non-health) as primary outcomes. Behaviour change outcomes were included as secondary outcomes, provided the study also included primary outcomes. In addition, the map excluded interventions in health facilities. This update aims to capture studies conducted since, as well as broadening the included interventions and outcomes to better reflect the state of evidence on WASH in 2018. Existing evidence maps and relevant systematic reviews In 2014, 3ie produced an evidence gap map for household and community interventions for promoting water, sanitation, and hygiene consumption in LMICs.2 The present study is an update of that map. We are updating the searches and the scope of that map to incorporate: 1) behaviour change as a primary outcome; and 2) water, sanitation and hygiene interventions based in health facilities to improve maternal and child health. A large number of impact evaluations and systematic reviews of WASH interventions will be incorporated in the map. For example, Table 2 lists some reviews of interventions for water, sanitation and hygiene promotion in households and communities, many published prior to 2014. Table 2. Systematic reviews of WASH interventions Outcomes Systematic reviews Diarrhea Curtis & Cairncross 2003 Gundry et al. 2004 Fewtrell & Colford 2004 (also published as Fewtrell et al. 2005) Arnold and Colford 2007 Clasen et al. 2007 Ejemot et al. 2008 Waddington et al. 2009 Hunter 2009 Clasen et al. 2010 Cairncross et al. 2010 Norman et al. 2010 Respiratory infections Aiello et al. 2008 Rabie and Curtis 2006 Helminth infections Ziegelbauer et al. 2012 Trachoma Ejere et al. 2012 Arsenic contamination Jones-Hughes et al. 2013 Nutrition Dangour et al. 2013 Education Jasper et al. 2012 Birdthistle et al. 2011 Income Turley et al. 2013 Attitudes and behaviour Null et al. 2012 De Buck et al. 2017 Objectives The overarching aim of the evidence map is to gather and present the rigorous empirical research on the effectiveness of interventions to improve consumption of water, sanitation and hygiene in the household, communities, schools and health facilities. This protocol provides the project plan for an update to the 2014 WASH evidence gap map (EGM) to take stock of the existing evidence, and capture newly published work, on the effects of interventions in these areas. The aim of the EGM is to identify, map, and describe existing evidence on the effects of interventions to improve access to, and quality of, WASH infrastructure, services, and practices in low- and middle-income countries. This update of the original map aims to capture additional studies conducted in the last three years and extend the scope of the EGM, in particular to cover behavioural outcomes and WASH interventions at healthcare facilities. The primary outcomes for this gap map include morbidities (e.g. diarrhoea), mortality, psychosocial health, nutritional status, education, income, and time use. In addition, behavioural outcomes will also be included as primary outcomes, such as water treatment practices, hygiene behaviour, and latrine construction in CLTS. The update of the EGM addresses three objectives: (1) To identify existing evidence from high quality impact evaluations and systematic reviews (SRs), particularly those published since 2014, which can be used to inform policy. (2) To expand the scope of the EGM to better capture WASH behaviour change and programmes implemented at healthcare facilities, with the aim of improving the map's policy relevance. (3) To identify existing gaps in evidence where new primary studies and systematic reviews could add value. The results from this EGM aim to inform the direction of future research surrounding WASH, and discussions based on systematic evidence about which approaches and interventions are most effective in the WASH sector, whether they are used in small scale projects or large scaled-up programmes. Methodology Defining evidence and gap maps Evidence gap maps aim to establish what we know, and do not know, about the effectiveness of interventions in a thematic area (Snilstveit et al., 2016).3 The evidence gap map presented here includes evidence from primary studies and systematic reviews. It provides a graphical display of interventions and outcomes, indicating the density and paucity of available evidence, and gives confidence ratings for systematic reviews. Evidence gap maps articulate absolute gaps, which are filled with new primary studies, and synthesis gaps, which are filled with new systematic reviews and meta-analyses. They are global public goods which attempt to democratise high quality research evidence for policy makers, practitioners, the public and research commissioners. Table 3. Intervention mechanism classifications Mechanism of delivery Sub-categories Interventions Direct provision None The provision of any WASH hardware for free and which has been chosen by an external authority. This includes interventions where soap is handed out, water purifiers given away, or latrines built by external actors. Health messaging None Directive hygiene, and sometimes sanitation, education where participants are provided with new knowledge or skills to improve their health. These information campaigns may be provided by television, radio, or printed media; provided directly to specific households or through sessions at community meetings / schools / etc.; or provided directly to community leaders or health workers. Psychosocial 'triggering' Directive Psychosocial 'triggering' covers campaigns that use emotional and social cues, pressure, or motivation to encourage community members to change behaviours. Directive mechanisms are typically social marketing campaigns, which use commercial marketing techniques to promote the adoption of beneficial behaviours. Participatory Participatory mechanisms are typically a community-based approach and promote behaviour change through consultation with the community, a two-way dialogue, and joint-decision making. Community-led total sanitation (CLTS) is the most common intervention with this mechanism. Systems-based approaches Pricing reform This covers all interventions that aim to change behaviour, such as the use of a technology, through changing the price of the requisite hardware. This includes subsidies and vouchers aimed at consumers. Improving operator performance These interventions improve access to WASH facilities and services by improving the functioning of the current service provider. This includes improving accountability, increasing oversight/regulation, and changing the financing structure. Private sector (PS) and small-scale independent providers (SSIPs) involvement These interventions encourage the private sector, including not for profits, to become the providers of WASH facilities and services on a commercial basis. Community driven development (CDD) CDD is a form of decentralised delivery that focuses on putting the community at the centre of the planning, design, implementation, and operations of their service provider. It typically uses a participatory approach, cost sharing, and often a component of local institutional strengthening. It includes social funds. Multiple mechanisms Direct provision with health messaging These interventions combine the direct provision of hardware with an intensive health messaging campaign. If only a single session is provided to explain the new hardware, this would simply appear under "direct hardware provision". Direct provision with psychosocial 'triggering' These interventions combine the direct provision of hardware with behavioural change communication that uses psychosocial triggers; these can be either participatory or more often directive (e.g. a social a marketing campaign). Systems-based approaches with health messaging These interventions combine systems-based approaches (e.g. subsidies) with health messaging. Systems-based approaches with psychosocial 'triggering' These interventions combine systems-based approaches with behavioural change communication that uses psychosocial triggers. The framework The framework for this evidence map (Appendix A) is based on the previous WASH evidence map framework developed by the authors (see footnote 2). However, the framework was updated based on a review of the academic and policy literature, and in consultation with relevant decision makers and other key stakeholders (see stakeholder engagement below). The included systematic reviews and impact evaluations will be identified through a comprehensive search of published and unpublished literature. It will include both completed and on-going studies to help identify research in development that might help fill existing evidence gaps. The finalised updated evidence map will be structured around a framework of policy relevant WASH mechanisms and outcomes, with a filter for technologies, and will be available online at 3ie's evidence gap map portal.4 Key features include: Table 4. Intervention technology classifications WASH technologies Sub-categories Interventions Water Supply Source New or improved water supply or distribution methods that do not provide the water directly to households. This includes boreholes or standpipes that require travel for water collection. Point of use (POU) New or improved water supply or distribution methods that provide water directly to the household or at a communal point that requires no travel (i.e. in a garden shared by 20 houses). This includes water directly piped to houses or standpipes within the near vicinity. Water Quality Source Supplies for, and information on, wither water treatments to remove microbial contaminants or safe water storage practices at a communal water access point. POU Supplies for, and information on, water treatments to either remove microbial contaminants or safe water storage practices within the household or commune. Sanitation hardware Latrines New or improved hardware for latrines or other means of excreta disposal. Sewer connection / drainage system Connecting existing means of excreta disposal to a sewer or other drainage system. Hygiene Soap or hand sanitiser Soap or similar products (e.g. hand sanitiser) with information on how to properly use them. Other hygiene supplies Toilet paper, sanitary towels, or other hygiene products with