PT  - JOURNAL ARTICLE
AU  - Zoe Sakas
AU  - Eberechukwu A. Uwah
AU  - Raj Kumar Bhattrai
AU  - Joshua V. Garn
AU  - Krishna Hari Gc
AU  - Anna Mutta
AU  - Kumbulani Ndlovu
AU  - Fanuel Nyaboro
AU  - Ram Prakash Singh
AU  - Ugyen Rinzin
AU  - Jedidiah S. Snyder
AU  - Kencho Wangdi
AU  - Matthew C. Freeman
TI  - Assessing Sustainability Factors for Rural Household Sanitation Coverage in Bhutan, Kenya, Nepal, and Zambia: A Qualitative Analysis
AID  - 10.9745/GHSP-D-21-00724
DP  - 2022 Dec 21
TA  - Global Health: Science and Practice
PG  - e2100724
VI  - 10
IP  - 6
4099  - http://www.ghspjournal.org/content/10/6/e2100724.short
4100  - http://www.ghspjournal.org/content/10/6/e2100724.full
SO  - GLOB HEALTH SCI PRACT2022 Dec 21; 10
AB  - Key FindingsInnovative construction approaches, local government commitment, and adequate resource allocation can help address geographic and environmental challenges, including soil type and heavy rains that cause low-quality toilets to collapse, that hinder sustainability of household sanitation coverage.Community health worker programs, which represent local capacity for implementing demand generation and behavior change programming, enabled the sustainability of household sanitation coverage improvements through adapting programs based on cultural norms and dynamics. Community health workers were supported by tailored trainings led by SNV and local governments.Key ImplicationsSustainable sanitation coverage requires passionate and innovative local leadership, capacity building and commitment from the local government, adaptive capacity to innovate and respond to challenges, and a strong supply chain system for sufficient resources.Sustainability-focused activities—such as advocating for local government involvement, guiding the local government in resource allocation, supporting reliable monitoring and evidence-based innovation, and agreeing on provision of continuous support with local partners—may extend the longevity of sanitation improvements.Background:Few countries are likely to achieve universal sanitation within the next decade as sustaining household sanitation coverage remains a critical challenge. This study aimed to investigate factors that may have supported or hindered sustainability of sanitation coverage 1–2 years after the completion of an integrated, area-wide sanitation program in 4 countries.Methods:We conducted qualitative analyses to identify factors related to the sustainability of sanitation coverage in Bhutan, Kenya, Nepal, and Zambia, 2 years after completion of the Sustainable Sanitation and Hygiene for All program. From November 2019 to March 2020, we conducted focus group discussions and key informant interviews with community members, project implementers, and decision makers. We triangulated the qualitative findings with data from household surveys to characterize subnational sanitation coverage throughout implementation and 1–2 years after.Results:Our data revealed behavioral, contextual, and service delivery factors that were related to the sustainability of sanitation improvements. Service delivery factors included follow-up hygiene promotion, access to construction materials, local government commitment postimplementation, functioning monitoring systems, private sector uptake of supply chain improvements, and capacity for innovation. Contextual and behavioral factors included poverty, soil type, road networks, social cohesion, desire for improved latrines, maintenance and cleaning, and knowledge of sanitation benefits.Conclusion:The presence or absence of sustainability factors identified through this research may have implications on where certain programmatic approaches will work and where adaptations may be required. By comparing sustainability factors with subnational slippage rates, we were able to illustrate how local service delivery systems may respond to barriers and enablers. Understanding the programmatic and contextual factors that either drive or hinder long-term sanitation coverage may allow for greater program impact through adapting implementation based on existing challenges in service delivery and context.