The Evolving Landscape of Water, Sanitation, and Hygiene (WaSH) Interventions
Despite decades of investment and effort, water, sanitation, and hygiene (WaSH) interventions in low- and middle-income countries have often failed to deliver expected health benefits. While WaSH interventions have demonstrated positive impacts in small-scale pilot studies, adapting and scaling these evidence-based interventions in ways that maintain effectiveness has proven challenging.
One key factor contributing to this challenge is the ability to effectively adapt WaSH interventions to diverse contexts. Adaptation is common in WaSH programs, but it often occurs in an unsystematic way, leading to poor outcomes. Existing models and frameworks from the broader field of implementation science offer valuable guidance for systematizing the adaptation process, but these tools were primarily developed for healthcare interventions. The unique characteristics of WaSH interventions, which are often implemented outside traditional health system channels, warrant a tailored approach.
This article presents a model for systematically adapting WaSH interventions to facilitate implementation while preserving effectiveness. Drawing on both adaptation literature and case studies of WaSH adaptation, this model provides a comprehensive framework for stakeholders to navigate the key steps of the adaptation process. Additionally, we compile a suite of practical tools that can support data collection and decision-making throughout each phase of adaptation.
By applying this targeted, evidence-based approach to WaSH adaptation, stakeholders can improve the effectiveness, sustainability, and scalability of vital water, sanitation, and hygiene interventions – particularly in the face of growing climate change impacts.
Understanding the Role of Adaptation in WaSH Interventions
Water, sanitation, and hygiene (WaSH) interventions are critical for promoting public health, supporting sustainable livelihoods, and driving economic development. However, the performance of WaSH programs has often fallen short of expected outcomes. A key contributor to this underperformance is the challenge of adapting evidence-based WaSH interventions to diverse contexts while retaining their original effectiveness.
Adaptation is the process of modifying an intervention to improve its fit with a new context, often in response to emerging needs or unexpected implementation challenges. WaSH programs frequently require adaptation, as practitioners work to tailor interventions to local cultural norms, infrastructure capabilities, regulatory environments, and other contextual factors. However, these adaptations are often made in an ad hoc, unsystematic manner, leading to suboptimal outcomes.
In contrast, a systematic approach to adaptation can help preserve the core functions – the underlying mechanisms that drive an intervention’s effectiveness – while modifying the specific forms or activities used to deliver those functions. This balance of preserving core functions while adapting forms is essential for ensuring that adaptations enhance, rather than undermine, an intervention’s impact.
The field of implementation science has developed a variety of models and frameworks to guide systematic adaptation. These tools offer valuable guidance, but they were primarily developed for healthcare interventions. The unique characteristics of WaSH programs, which often involve diverse stakeholders beyond the health sector and are implemented outside traditional health system channels, require a tailored adaptation approach.
A Model for Systematic WaSH Adaptation
To address this gap, we have developed a model specifically designed to support the systematic adaptation of WaSH interventions. This model, grounded in both adaptation literature and case studies of WaSH adaptation, outlines five key phases and the corresponding steps stakeholders should take to effectively adapt WaSH programs.
Phase 1: Intervention Selection
In this initial phase, stakeholders assess the target population’s needs and the broader context to identify appropriate interventions to address those needs. Stakeholders then evaluate the core functions and adaptability of potential interventions, selecting the one that is best suited for adaptation and implementation in the target context.
Phase 2: Assessment
Next, stakeholders determine the purpose and specific needs for adaptation. If adapting an existing intervention, this phase focuses on identifying mismatches between the intervention and the target context. If adapting to improve performance of an existing intervention, the assessment centers on identifying gaps between current and desired outcomes.
Phase 3: Preparation
In the preparation phase, stakeholders develop an adaptation plan and assemble an adapted intervention package. This includes modifying intervention activities, creating an implementation plan, designing an evaluation framework, and preparing training materials. Stakeholders also build support for the adapted intervention among key stakeholders and recruit and train implementers.
Phase 4: Implementation
During implementation, stakeholders pilot test the adapted intervention, assessing outcomes such as acceptability, feasibility, and potential unintended consequences. If pilot testing reveals substantial deficiencies, stakeholders may need to return to earlier steps to refine the adaptation. If the pilot is successful, the adapted intervention is then implemented at scale.
Phase 5: Sustainment
In the final phase, stakeholders evaluate the adapted intervention’s performance according to the evaluation plan developed in the preparation phase. Assuming satisfactory results, they work to systematize and sustain the adapted intervention through scaling up and integrating it into organizational structures and implementation systems.
Throughout this model, stakeholders engage in iterative cycles of assessment, preparation, and implementation. This cyclical approach allows for continuous improvement, enabling stakeholders to rapidly identify and address emerging needs or challenges.
Importantly, the model also emphasizes the need to identify, engage, and build consensus among the diverse set of stakeholders involved in WaSH programs, which can include government agencies, non-governmental organizations, private sector actors, and community members. Aligning the priorities and capabilities of this broad group is crucial for successful adaptation.
Practical Tools to Support Systematic WaSH Adaptation
To complement the adaptation model, we have compiled a suite of practical tools that can aid stakeholders in collecting data and making informed decisions throughout the adaptation process. These tools fall into four broad categories:
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Assessing Context and Conditions: Tools like stakeholder mapping, bottleneck analysis, and contextual assessment frameworks can help stakeholders understand the target population’s needs, existing resources, and potential barriers to successful implementation.
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Understanding Core Functions and Selecting Adaptations: Approaches such as intervention mapping, core function analysis, and multi-criteria decision analysis support stakeholders in identifying an intervention’s core mechanisms, assessing its adaptability, and selecting appropriate adaptations.
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Describing Adaptations and Implementation Processes: Tools like adaptation logs, implementation fidelity checklists, and process evaluation frameworks enable stakeholders to systematically document the adaptation and implementation, facilitating analysis of barriers, facilitators, and outcomes.
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Evaluating Adaptations and Implementation: Evaluation frameworks, such as the RE-AIM model, can guide stakeholders in designing robust evaluation plans to assess the adapted intervention’s performance and guide decisions about scale-up and sustainability.
By leveraging these practical, evidence-based tools, WaSH stakeholders can navigate the adaptation process more systematically, improving the effectiveness, sustainability, and scalability of their programs.
Contextual Considerations for WaSH Adaptation
While the adaptation model presented here is broadly applicable, WaSH interventions pose several unique contextual factors that warrant particular attention:
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Complexity of WaSH Interventions: Many WaSH interventions have both a “hardware” component (e.g., infrastructure, technology) and a “software” component (e.g., behavior change, capacity building). Adapting these interdependent elements requires a holistic, systems-level approach.
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Fragmentation of WaSH Stakeholders: Responsibilities for WaSH implementation, financing, monitoring, and regulation are often divided across multiple government agencies, non-governmental organizations, and private sector actors. Coordinating adaptation efforts among this diverse group can be challenging.
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Unclear Core Functions: Many existing WaSH interventions lack well-defined core functions, making it difficult to distinguish which elements should be preserved during adaptation. Investing time to clearly articulate core functions is crucial.
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Diverse Implementers and Beneficiaries: WaSH programs often rely on community volunteers, decentralized implementers, and direct beneficiary participation, rather than trained health professionals. Adaptation must consider the needs and capabilities of these varied stakeholders.
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Aiming for Universal Coverage: Many WaSH programs target entire communities to achieve “herd protection” benefits. Ensuring that adapted interventions are inclusive and accessible to all members of the community is essential.
By incorporating these contextual factors into the adaptation process, WaSH stakeholders can design and implement more effective, sustainable, and equitable interventions – particularly as they work to address the growing challenges posed by climate change.
Conclusion: Embracing Systematic Adaptation for Resilient WaSH Systems
The ability to systematically adapt evidence-based interventions is crucial for improving the performance and impact of water, sanitation, and hygiene programs. Yet existing adaptation frameworks have largely overlooked the unique characteristics of the WaSH sector.
This article presents a tailored model and accompanying tools to guide WaSH stakeholders through the key steps of the adaptation process. By embracing a systematic, evidence-based approach to adaptation, practitioners can enhance the effectiveness, sustainability, and scalability of their programs – ultimately contributing to more resilient water, sanitation, and hygiene systems that can withstand the growing challenges posed by climate change.
Applying this systematic adaptation framework can help WaSH programs overcome common challenges, such as poor retention of intended health benefits, lack of alignment among diverse stakeholders, and difficulties scaling successful pilots. Most importantly, it empowers practitioners to preserve the core functions that drive positive impact, while adapting intervention forms to better fit local contexts.
As the global community works to achieve universal access to safe water, sanitation, and hygiene, the ability to systematically adapt interventions will be essential. By drawing on the rich body of adaptation literature and the practical lessons from WaSH case studies, stakeholders can unlock the full potential of these vital health and development interventions – building more resilient, equitable, and sustainable WaSH systems for all.
