Framework for selection and use of appropriate rural sanitation technologies in low-income settingsINGS

Abstract

Access to safely managed sanitation remains low in rural communities of low- and middle-income countries. Inappropriate technology options, lack of community participation and not fully considering social factors in the local context result in failure of sanitation interventions. Demand-driven approaches considering alternatives in the local context are perceived to improve access to sanitation services. A comprehensive procedure is needed to aid the selection of appropriate options. The impact of sanitation interventions on health outcomes were investigated by a systematic review of randomised controlled trials (RCTs) from 2000 to 2019 based on the PRISMA checklist. 15 of the 746 records from six electronic databases were included. Results indicated that RCTs that showed significant positive impact were: 1/10 for prevalence of disease, 2/8 for child growth and 3/9 for infestation of parasites. Findings were suggestive and inconclusive prompting the need for further trials. The strengths and limitations of available frameworks (2000 - 2019) to select appropriate technologies (ASTs) for rural communities in low- and middle-income settings (LMISs) were critically reviewed. Findings from 12 of the 953 included records that were assessed on 22 criteria indicated that frameworks did not fully address criteria on sanitation demand and behaviour, framework limitations, and flexibility, among others. These shortcomings are used to inform future framework development. A mixed method research design was used to understand how households in a rural district of Zimbabwe adapted their sanitation needs to the Blair ventilated improved pit (BVIP) latrine. A questionnaire survey (790 households) and six focus group discussions (FGDs) were used in a rural district of Zimbabwe to understand how households which could not afford a standard household Blair ventilated improved pit (BVIP) latrine design met their sanitation needs. Households constructed incomplete or poor quality BVIP latrines, considered alternatives, shared latrines or practised open defaecation. Alternative options are needed with government support. Drivers and barriers to sustained use of the BVIP latrine, and how rural households adapt it to climate change were studied among 238 households with BVIP latrines in a rural district of Zimbabwe. Drivers for sustained latrine use were technological, social and public health factors. Barriers included latrine design (e.g., distance from the home or poorly/incomplete construction) and social (e.g., presence of extended family, bad smell and security) factors. Adaptation of the BVIP latrine to effects of climate change were odour and erosion control, adding wood ash, alternative options, and constructing raised and conventional designs. Alternative options are needed for equity and universal access. An integrated multi-criteria decision analysis (MCDA) framework was developed based on the nine steps of the simple multi-attribute rating technique (SMART). Data from literature reviews and household surveys were used. Stakeholders participated in evaluating and weighting criteria, scoring alternatives and validating the procedure. A ranking of alternatives based on total utility values indicated that the urine diverting dry latrine had the highest value (72.54) followed by the BVIP latrine (67.10). The framework was verified to follow a laid down methodology, considered robust based on criteria changes and reasonable based on expert opinion.