Understanding context-mechanism-outcome configurations
Access to water and sanitation is fundamental for human health, yet the effectiveness of water, sanitation and hygiene (WASH) interventions in low- and middle-income countries (LMICs) has been mixed. To understand why some WASH interventions succeed while others fail, researchers have emphasized the importance of examining the contexts into which these interventions are introduced.
A recent realist review examined a range of WASH interventions, from hardware (e.g., new latrines, water supply systems) to software (e.g., WASH committees, health promotion programs), to unpack the mechanisms through which community participation influences outcomes. The review identified five key mechanisms:
1. Accountability: Policies and procedures that hold communities and committees responsible for their actions and the outcomes of an intervention.
2. Diffusion: The spread or adoption of a new behavior or idea through communication and influence among community members.
3. Market: The interplay between supply and demand of a WASH service or resource, and how this balance impacts availability and longevity.
4. Ownership: The sense of possession and control over a WASH service or resource, which can promote investment and commitment to its preservation.
5. Shame: A feeling of disgust about one’s behavior or actions that leads to conforming with socially accepted norms.
These mechanisms were enabled or hindered by 19 contextual factors, including community leadership, technical skills, resource access, committee structures, and the level of community participation.
Accountability: Ensuring responsible management
Accountability is more likely to be achieved when the community is easily accessible, there are opportunities to share information, and there is a strong, functional water committee. This can lead to improved availability of WASH resources and services, as well as behavior change and longevity.
Internal monitoring by community members, such as health committees or village headmen, and external monitoring by NGOs or government officials can hold communities accountable for their actions. Opportunities for regular communication and meetings between service users, committees, and external parties build trust and strengthen accountability.
Accountability is also reinforced when committees have clear roles, responsibilities, and management plans that are understood and followed. Consequences, such as fines, for not conforming to desired behaviors can promote accountability, but trust in how these consequences are applied is crucial.
Accountability within committees can also facilitate the longevity of WASH resources and services. Committees with self-organizing capabilities, financial management systems, and communication with the broader community are better able to maintain infrastructure and services over time.
Diffusion: Spreading new ideas and behaviors
Strong social relationships and community cohesion are essential for the wide and sustained adoption of new WASH ideas, behaviors, or technologies. Community “innovators” and “early adopters” who try out and champion new approaches can influence the rest of the community through their existing communication networks.
In communities with high social cohesion, these innovators and early adopters can leverage the respect and acceptance of local leaders to set new social norms. Peer-to-peer communication also helps build and share knowledge, reinforcing the adoption of new behaviors.
Diffusion is particularly important for achieving behavior change, such as reducing open defecation or increasing handwashing. The spread of new behaviors is enabled by communication channels, social support, and the demonstration of health benefits within the community.
Diffusion also plays a role in the longevity of WASH resources and services. If the community sees the value of a new water system or sanitation facility, they are more motivated to work together to maintain it over time.
Market: Balancing supply and demand
The market mechanism explains how the balance between supply and demand of WASH services and resources impacts their availability and longevity. Factors like community knowledge, resource dependency, and affordability can influence this dynamic.
When there is a clear need and willingness to pay for a WASH service or resource, the community is more likely to invest in its long-term maintenance and operation. However, challenges can arise when seasonal fluctuations in demand, such as for water during the dry season, make services unsustainable.
Lack of technical knowledge and financial capacity within the community can also disrupt the balance between supply and demand. Without the skills to operate and maintain WASH infrastructure, or the funds to cover ongoing costs, the supply of services may become unreliable.
Endogenous WASH interventions, initiated by the community itself, are more likely to reflect local needs and priorities compared to exogenous interventions introduced by external agents. This better alignment between supply and demand can promote the availability and longevity of WASH resources and services.
Ownership: Fostering a sense of control
A strong sense of ownership over WASH resources and services is crucial for promoting investment, commitment, and long-term maintenance. Ownership is enhanced when communities are meaningfully involved in the design, planning, and implementation of WASH interventions.
Involving a diverse range of community members, including women and marginalized groups, in decision-making can increase a collective sense of ownership. This sense of control and possession over a resource or service leads to greater efforts to ensure its availability and longevity.
Community ownership is also facilitated when there are opportunities for hands-on capacity building, such as technical training in operations and maintenance. This helps communities develop the knowledge and skills to independently manage WASH infrastructure and services.
The need for a WASH resource can further promote ownership, as communities with a strong dependency on it are more motivated to take steps to ensure its continued availability. Endogenous WASH interventions that emerge from community-identified priorities often foster a greater sense of ownership compared to exogenous initiatives.
Shame: Conforming to social norms
The shame mechanism explains how the fear of social disgrace or disapproval can lead individuals and communities to conform to socially acceptable WASH behaviors, such as proper handwashing or stopping open defecation.
This mechanism is most effective in smaller, cohesive communities where social comparison and the desire to fit in are strong. Shame can be triggered by community leaders or influential members who set new social norms and monitor compliance.
Availability of WASH resources, like latrines and handwashing facilities, as well as behavior change, are the main outcomes associated with the shame mechanism. The threat of social consequences, like fines or public shaming, can motivate people to adopt desired behaviors.
However, the use of shame should be carefully considered, as it can have negative psychological impacts, especially on marginalized groups who may not have the means to comply. Positive reinforcement and acknowledgement of change may be more effective than punitive measures.
Insights for effective community engagement
The insights from this realist review highlight the importance of understanding the contextual factors that enable or hinder the mechanisms of community participation in WASH interventions. Policymakers, program implementers, and institutions should consider the following when designing and implementing community-based WASH projects:
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Assess community dynamics: Evaluate the level of social cohesion, trust, communication channels, and community leadership before introducing an intervention.
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Understand resource access and dependencies: Analyze the community’s technical skills, financial capacity, and reliance on WASH resources to ensure alignment between supply and demand.
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Strengthen committee structures and practices: Ensure water/WASH committees have clear roles, responsibilities, and management plans that are understood and followed by the community.
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Promote diverse community involvement: Engage a range of community members, including women and marginalized groups, in the design, planning, and implementation of WASH interventions.
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Balance accountability and empowerment: Establish policies and procedures to hold communities responsible, while also fostering a sense of ownership and control over WASH resources and services.
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Address social norms carefully: When using shame or social comparison to drive behavior change, consider the potential for negative psychological impacts and explore more positive approaches.
By considering these contextual factors and tailoring WASH interventions accordingly, policymakers and implementers can harness the power of community participation to ensure sustainable access to safe water and improved sanitation in rural India and beyond.
