The importance of community engagement and evidence-based strategies
Water, sanitation, and hygiene (WASH) interventions have long been recognized as critical for improving health outcomes and reducing the burden of neglected tropical diseases like soil-transmitted helminths (STHs). However, implementing effective WASH programs at scale remains a significant challenge, especially in resource-constrained rural settings. A pragmatic, community-centered approach that combines rigorous research with practical strategies for behavior change and service delivery is essential for driving sustainable impact.
The Gambian study described in the BMJ Open article provides valuable insights into the design and implementation of a theory-driven, community-based WASH intervention to improve weaning food hygiene practices and reduce diarrheal disease in young children. By grounding the intervention in established behavior change frameworks and actively engaging local stakeholders, the researchers developed a culturally appropriate program that was well-received by the target communities.
“The intervention strengths include a strong theoretical base and application of appropriate, replicable and transferable tools from two Asian programmes (in Nepal and India). The communities welcomed the use of culturally embedded performing arts, while the involvement of regional public health officers, rather than research staff, provided a pragmatic and potentially scalable intervention.”
The study’s baseline findings confirm the significant burden of diarrheal disease and respiratory illness among young children in the Central River Region of The Gambia, underscoring the need for effective WASH interventions. By establishing representative village and household characteristics, the researchers ensured that the randomized trial would yield robust and generalizable results.
Adapting evidence-based strategies to local contexts
A key aspect of the Gambian study was the intentional adaptation of successful WASH behavior change tools and strategies from previous programs in Nepal and India. This approach allowed the researchers to leverage existing evidence while ensuring cultural relevance and community ownership.
“Stories, songs, posters and animations from previous relevant programmes in India and Nepal were transferable from Asia to our African setting, and the tools were easy to adapt within 6 weeks (including staff training, refining of the material, field testing and piloting).”
The incorporation of traditional Gambian performing arts, such as drumming, singing, and drama, was particularly impactful, as it attracted broad community engagement and helped ingrain the target behaviors within local cultural norms. By training and deploying local public health officers, rather than external researchers, the researchers also ensured that the intervention could be replicated and scaled within the existing health system.
These insights highlight the importance of adapting evidence-based strategies to local contexts, while leveraging existing community assets and resources. Successful WASH programs must strike a balance between scientific rigor and practical, community-driven implementation.
Measuring impact through rigorous evaluation
The Gambian study’s use of a pragmatic, cluster-randomized controlled trial (cRCT) design represents a gold-standard approach for evaluating the impact of WASH interventions. By randomly assigning villages to intervention or control groups, the researchers aimed to minimize the influence of confounding factors and establish causal linkages between the program and desired outcomes.
The baseline data presented in the article provide a robust foundation for the subsequent evaluation, including:
- Representative village and household characteristics
- Prevalence of diarrhea and respiratory illness among young children
- Microbiological contamination of weaning foods and water
Importantly, the researchers sought to measure not only the impact on disease prevalence, but also the intervention’s effects on the microbiological quality of foods and water prepared for children. This holistic approach to outcome assessment is crucial for understanding the mechanisms by which WASH programs can improve health.
“The primary objective of the main cRCT trial is to investigate the effects of a complex public health community intervention that sought to improve mothers’ weaning food hygiene practices. We further sought to investigate the effect of the intervention on the level of microbiological contamination in food and water prepared for the child’s consumption and to establish the prevalence of diarrhoea and respiratory symptoms, and diarrhoea admission, as reported by mothers.”
The use of a pragmatic, community-based approach, coupled with rigorous evaluation, sets this study apart as a model for future WASH research and programming. By prioritizing both scientific rigor and real-world applicability, the researchers have laid the groundwork for interventions that can drive sustainable impact at scale.
Leveraging existing structures and community assets
A key strength of the Gambian study was its intentional integration with existing public health systems and community structures. Rather than relying on external research teams, the intervention was delivered by local public health officers and traditional communicators, ensuring that the program could be readily replicated and scaled within the Gambian context.
“The delivery method is low-cost, replicable and uses existing systems (PHOs, village organisations and TCs), the programme could be scaled up even with relatively limited resources. If combined with related programmes on child nutrition or Community-led Total Sanitation ran by Unicef, NANA or MOH, our intervention, if proven effective, could further strengthen existing health systems with the training and use of non-specialised staff in rural settings.”
The researchers also engaged a range of local stakeholders, including village leaders, cultural groups, and women’s organizations, to foster broad community ownership and support for the program. This approach contrasts with siloed, top-down interventions that often fail to gain traction at the community level.
“The involvement of policy makers, public health managers and funders from the start, as well as local implementing agencies (as part of the Local Scientific Advisory Committee) helped avoid potential bureaucratic or other threats to the programme.”
By harnessing existing community assets and aligning the intervention with local priorities and structures, the Gambian study demonstrates a pragmatic and sustainable model for WASH programming. This community-centered approach is essential for driving long-term behavior change and ensuring the equitable delivery of vital water, sanitation, and hygiene services.
Conclusion: Towards scalable, evidence-based WASH programs
The Gambian study offers valuable lessons for the design and implementation of effective, community-based WASH interventions. By grounding the program in behavior change theory, adapting successful strategies from previous research, and leveraging local stakeholders and resources, the researchers developed a pragmatic, culturally-relevant approach that engaged the entire community.
Importantly, the use of a rigorous cRCT design, coupled with a holistic assessment of outcomes, will provide robust evidence on the intervention’s impacts. This focus on generating high-quality data to inform decision-making is crucial for driving sustainable, evidence-based WASH programming at scale.
As the global community works towards achieving the Sustainable Development Goals for water, sanitation, and hygiene, studies like this one in The Gambia offer a roadmap for practitioners and policymakers. By prioritizing community engagement, cultural relevance, and scientific rigor, we can develop WASH interventions that truly transform lives and build resilient, healthy communities.
