The searches conducted in April 2019 identified 3,054 articles. Figure 1 outlines the study selection process. Overall, 56 papers were identified from 25 countries. By synthesising the information in each paper, we identified five mechanisms that explain the outcomes from the studies: accountability, diffusion, market, ownership and shame. Articles had multiple mechanisms. Across the five mechanisms three sets of outcomes were identified:
- Access (to resources and services such as latrines, clean water, and sanitation) at individual or community level,
- Change (to prevent disease, such as reduction in open defection and increase use of handwashing, or reduction in disease levels, or change in health status such as diarrheal rates) at individual or community level,
- Sustainability (of water and sanitation resources or services, including factors that impact on their long-term sustainability, such as technical capacity to repair, operate and maintain a resource or service).
The next section describes each mechanism in detail, followed by a description of each based on individual outcome, and key contextual factors highlighted as identified through the literature review. See Table 1 for a summary.
Accountability is a formal mechanism triggered by rules, procedures and policies to hold committees, communities and households responsible for decisions and actions. It can help ensure that actions and decisions taken are appropriate to promote access, behaviour change and resource sustainability. The three mechanisms identified were access, change and sustainability.
Triggered by internal or external monitoring, accountability may result in improved community access to a resource or service. The focus of such monitoring may be progress towards achieving a goal. The goal may be about access to a service – e.g., to ensure that sanitation facilities are in place (10,22,31,33), that facilities meet the needs of people with disabilities (38), or that water is accessible (39,40). The goal may also be resource preservation (safety and/or accessibility) so that water is available to be accessed as desired – e.g., to check water samples for faecal or arsenic contamination (15,41), or to assess the level of groundwater available for agriculture throughout the year (32). Internal monitoring can be conducted by a chief or village headman (10,22,31), locally trained volunteers (41), community members (32) or by the community’s health or water committee (39–41). External monitoring can be conducted by NGO facilitators (38) or health workers (33,42).
Opportunities and platforms for regular communication and meetings between community members, service users and health or water committees helps build a sense of trust and connection between all parties and helps to hold them accountable (38,41). This is reinforced where community leadership is transparent and has open channels for communicating with community members (10,22,31,40) and the use of technology allows up to date monitoring (31). Accountability is also strengthened where there is a functional, long-standing water or health committee whose members are active, motivated and committed, and have clear roles and responsibilities (39,40). A gender balanced committee opens up the space for accountability, as more opinions and views are considered on what factors are important and need to be considered (39,40,43,44).
Ongoing external monitoring can hold communities accountable for changing their health and sanitation behaviours (35,38,42,45), leading to improved health of children as seen in height and weight changes and diarrhoea occurrence (35). Without ongoing external monitoring, loss of momentum for change can occur, halting behaviour change progress (23). Ongoing monitoring is enabled by regular meetings and sharing of information to enforce behaviour change (25,41). However, limited access to communities due to remote location, violence and large community size and layout are barriers to ongoing external monitoring (35,40). Accountability can also influence behaviour change, when triggered by fines (e.g. money, goat or chicken) imposed as penalty for not conforming to a desired behaviour. For example, penalties can be used to enforce standards for latrines (25), for not constructing a latrine, and for open defection (10). Trust is an essential contextual factor for such penalties – tensions arise when a community does not trust the person or committee collecting the fines and what they will do with the fines (18,25). Trust depends on the person or committee’s record of financial management, and whether they have clear rules about the use of such penalties.
Accountability within community committees can facilitate their continued activities, therefore promoting the sustainability of resources and services for which they are responsible. This requires that committees have internal feedback systems, take minutes and set agendas with written working plans, reflecting high self-organising capabilities, and a sense of obligation among committee members to attend meetings and take action to manage and maintain resources, thus contributing to sustainability of water and sanitation initiatives (17,25,39,41,46,47). Accountability to government entities (e.g., water boards) for reports and abiding by government policies can promote sustainability as it can hold committees and communities responsible for funds to maintain resources and services (15,17,48,49). Communication with the broader community holds committees accountable for their roles and responsibilities in relation to water and sanitation infrastructure in a community (17,49,50). Communication can help enable the diffusion of efforts to change the landscape of governance within local communities and check progress of actions (10,20).
Committee accountability is enabled when committees have clear roles, responsibilities, rules and procedures (which they understand) on responding to system breakdowns, and managing ongoing maintenance and missing parts, with direct implications for the sustainability of water access and WASH infrastructure (21,25,39). Sustainability of resources and services is facilitated by a committee’s ability to make funds available for operational and maintenance costs, and by it having rules and procedures for funds management (e.g., having a well-educated treasurer who manages and collects funds within the community), or by having the community participate actively in monitoring committee finances (15,19,39,47). However, where there are known instances of abuse of funds or poor financial management, community members are less willing to contribute, leading to low sustainability of resources or services (18–20). Committee activity and social participation play key roles in managing maintenance and operation of water and sanitation systems and assist in management of funds ensuring continued service provision (16,43,51,52). This can promote good governance and practice (16). While committee activity and social participation is an enabling factor, this alone is not enough to ensure the sustainability of community water and sanitation infrastructure (53).
Diffusion reflects the spread of an idea or behaviour by “innovators” (i.e. individuals who are the first to develop and try out new ideas) and “early adopters” (i.e. opinion leaders who enjoy leadership roles, and embrace change opportunities) over time through their influence and through communication amongst members of a community (34,54). They spread innovations by using their shared knowledge of the language, social, cultural and religious beliefs and their existing relationships with and within communities (30,31). Innovators and early adopters in a community include teachers (30,55), leaders (10,22,30,31,34,55,56), healthcare workers (30,42,55,57,58), and community committees (21,46,59,60). Diffusion can contribute to the three outcomes - access, change and sustainability.
Access to resources such as latrines (8,11,31,46,56,61,62), water (33,50,60,63,64) and handwashing facilities (62) can be driven by diffusion. When these facilities or the idea of them are new (i.e. when they are “innovations” in a community), the collective action necessary to build and maintain them depends on the extent to which appreciation for their value spreads in the community. Information on community-led initiatives, and on initiatives that reflect the needs of the community take root more readily than initiatives driven from external sources. Information about the need of the resource or service can diffuse more readily where people have similar characteristics such as occupations and religion, have high levels of social connectedness and social cohesion and respect for one another. This means people are more concerned about others, are more likely to cooperate, communicate and work with one another, and agree on community priorities. Thus, it helps to promote change in resource access, as through information spreads by ‘early adopters’ and in the community helps to promote change in resource access as other community members are able to see the benefits (8,46,61).
In such communities, innovators draw on the existing influence of leaders to set new social norms (11,31,56), and early adopters draw on the existing skills within the community to work on a resource or intervention (31,46,50,60). However, to have an impact on access within a community, diffusion does not need to occur across the whole community, it may just occur within sections of the community such as among women and other community groups (11,60).
Diffusion can occur through communication among peers, which leads to shared understanding, therefore reinforcing the adoption of new behaviour at an individual or community level (30,31,46,63). Examples of diffusion influencing behaviour change include reduction of open defecation (10,34,45,48,55,65), water purification (63), disposable of rubbish and care of animals (45), and sanitation and hygiene behaviours (60), which may lead to improved health outcomes such as reduction in diarrhoea rates and waterborne diseases (42,60). Behaviour change is also further enabled by diffusion in communities with high levels of social cohesion and connectedness – by enabling communication among peers, to build and share knowledge (46,62), and as highly regarded leaders influence the spread of new behaviour and create new social norms through their endorsement (11,20,34,55). Higher levels of social cohesion and connectedness in small rural and remote communities can also help sustain long-term behaviour change (e.g., reduction in open defecation) especially where people stick together to create a supportive environment for long lasting change. In these contexts the focus is on behaviour change at the community rather than individual level (45,55).
The sustainability of a water or sanitation resource or service may depend on the extent to which knowledge of its value diffuse and take root in the community, leading to greater understanding of the potential impact of sustaining the resource or service. The level of social cohesion and connectedness in a community in the form of shared norms, trust, a common sense of identity help facilitate spread information on new ideas (30,46,50,56). The perceived need to collectively mobilise resources to address water or sanitation problems is shared by committees and within committees (50,59,63,66,67). Willingness of community members to help one another further allows the diffusion to lead to sustainability of resources such as latrines (8,62) and water access (59,63), through the maintenance of the resources (50). Gender-balanced committees, or the active involvement of women facilitates the spread of ideas within the community, especially about resources such as water systems that women are particularly involved in using and managing daily (20,21,32,39,60).
The market mechanism operates through the dynamic relations between demand and supply which determines the price of a good or service. Price, in turn, determines the extent of demand and quantity of supply of the good or service. The level of demand or supply for a good or service influences the price consumers are willing to pay for it. When a good or service becomes more available (i.e. if supply increases), prices tend to fall, and when the demand for a good or service reduces, prices tend to fall. The same happens if the price of (competing) alternatives to the good or service were to fall. Market failure results when demand and supply are not responsive to each other
Knowledge mediates relations between supply and demand, lack of knowledge results in imbalances between supply and demand. Without knowledge, access to a resource or service may remain low, even when it is available at an affordable price. Hence, to lead to improved use, efforts to increase and improve the quality of supply (e.g. through training to increase the skills of local artisans on well design), require complementary efforts to increase household knowledge (e.g. through social media and public demonstrations) (68). The greater the level of community dependence on a resource (e.g. high levels of need for clean, safe, drinkable water for domestic purposes), the more likely it is that the community will invest in its supply (e.g. by promoting local development of skills required to maintain hardware), thus, helping to maintain or increase access to water (16,41,43,59,60,69).
Varying levels of demand for a resource or service due to seasonality can have an important influence on sustainability(48,49). For example, water kiosk services are viable during the dry season when people are willing to pay for water because of limited rain and access to water. However, market failure of water kiosks occurs (and they become unviable in the long term) due to continued supply during the wet season in settings where there is increased availability of water due to cheaper options linked to rains then becomes unviable in the long term (51). Willingness to pay for a water system (17–19,21,51) and community-based water supply projects (52,53) often determines a systems reliability or sustainability, and this is linked to demand, affordability and financial capacity in a community. Ability to access resources and funding is important when communities lack knowledge and skills, and the ability to pay for such skills lacking (41).
User fees are often imposed when there is limited internal or external financial support, and the resource or service requires ongoing maintenance and operational costs. User fees can also help to regulate demand and promote responsible use of resources, promoting sustainability (41,52). Low levels of willingness to pay (sometimes reflecting low levels of need or capacity to pay) can become a barrier to operation and maintenance and sustainability of the water service and latrine quality (16,21,41,52,69). Where willingness exists in conjunction with inability to access funds and resources access to water and latrines is compromised (21,65). Willingness to pay may also depend on satisfaction with and quality of the service, which in turn depends on how well it is operated or maintained (19).
Ownership can be triggered through community engagement, inclusion, empowerment, and sense of achievement. The basis of the mechanism is that the sense of ownership of a resource or hardware leads to feeling committed to it at a community or individual level. People value the resource as they feel invested and want to protect it, thus promoting access to it, and its sustainability. Access and sustainability are the two primary outcomes associated with the ownership mechanism.
The extent to which community members feel a sense of ownership towards a resource can influence whether they seek external or draw on internal technical and financial support to ensure that the resources (e.g., water and sanitation facilities) are in place (21,41,46,50,55,70). High levels of social cohesion and connectedness is an enabler of efforts to access external funds or mobilise community resources (21,46,50,70). Involvement of a broad range of community members in water and sanitation initiatives can promote a collective sense of ownership, which, in turn, can facilitate social cohesion and connectedness by providing opportunities for a community to share a common goal (8,71,72). By promoting community ownership of a resource, involving community members in capacity building (e.g. in managing the resource) can promote accessibility (31,32,62), and involving women leaders and people with disabilities (e.g., in decision-making) can ensure that access is equitable (30,38,39,49,71).
Communities with higher financial capacity and proximity to latrine products and materials have higher access to latrine (55). The need of the resource can help promote ownership, as the communities have dependency on it and take greater steps to ensure access to resources such as water and latrines (32,73,74). Women communicate with the committees about system breakdowns and without whom, such information sharing that lead to repair may not occur (50). Such active communication reflects ownership and indicate a willingness to work together and build connections within the community which promotes continuous access by facilitating ongoing response to maintenance issues (32,47,59,63).
Ownership is enabled by involving communities in the design, planning and implementation of a hardware, increasing the likelihood that the resource reflects community needs (15,72), the costs are appropriate and affordable (16,69), the community has the appropriate information for operations and maintenance (69,75), and the community is willing and able to commit to bear hardware costs and ongoing operational and maintenance costs (16,19,48,76), thus becoming self-sufficient (16,69,70). In the absence of this, a community may need to rely on external sources for sustainability of resources (18,52,75,76). Ownership is enabled when communities are allowed or granted decision-making authority in operations and have responsibility for maintenance of hardware (18). Taking ownership requires a leader or committee to champion action (17,37,41,70), especially when a committee has to manage the hardware (e.g. in terms of speed and adequacy of repair), and to raise and manage funds necessary to maintain the hardware (e.g., their water system) in the long term (39,41,44,59,64,70). Financial management ability, can be hampered when communities have low budget resources or communities are unable to afford the service and the committee receives limited funds to maintain a water system, impacting the long-term sustainability of the water service (15,41).
The capacity to manage the hardware can promote a sense of ownership (17,21,32,52,72). Therefore, retention of human resources and committee members, can lead to sustainability as knowledge and skills are retained in communities (21,40). Having a broad range of members (including women) on such committees can promote buy-in from the community, and diverse voices in decisions leading to a greater sense of ownership, and desire to maintain the resource (16,25,39,40,50,69). Involvement of women is important as they use water regularly and have a great need for water, and in some cases, their sense of ownership can be sufficiently strong to enable them to independently fund, plan, build and maintain water systems (60), allowing them to gain status, take on leadership roles and support younger women in the community (16,60). Lack of ownership of hardware can occur in communities with low socio-economic status as they may have other priorities, or where the need for the hardware is limited, which in turn limits commitment to its maintenance (17).
The shame mechanism generates outcomes due to efforts to avoid feeling disgust or disappointment in one’s behaviour or performance. Shame can be leveraged as a feature of interventions which seek to reset community norms, so community members view open defecation and not washing hands as disgusting and as harmful to the whole community. Comparison between individuals, between households and between communities, can lead to shame as it brings out elements of competition and can result in shame from the loss. This may manifest by introducing incentives (e.g. in the form of prizes and rewards) to motivate communities to achieve a water or sanitation goal in comparison to one another (10,31,33,35,40,62). Access and behaviour change are the two outcomes associated with the shame mechanism.
Without external support, shame can promote access to and individual/household ownership of latrines (22,31,38,55,57,62,65,77) and handwashing facilities (30,33,62). These outcomes are limited in communities and households with financial and technical challenges (24,35,61,65). Enablers include initiating shame by leaders and people known within the community, which helps the acceptance, monitoring and enforcement of new norms (22,31,55,57,62,77). Smaller homogenous communities with effective leadership, are more likely to achieve universal sanitation coverage because people have closer relationships and are more mindful of the impact of their behaviours on others, therefore change in social norms occur more readily (31).
Social cohesion and connectedness are important enablers of household latrine construction because a level of cooperation and collective action it promotes can help overcome the inequality in resources and skills necessary to build latrines (11,23,30,34,46,56,61). Together they promote friendship and community respect, and an appreciation of social benefit of private goods that may help reduce open defecation (62). Social cohesion and connectedness also enable ‘shame’ to be transmitted throughout a community. However, when communities lack technical or financial capabilities (24,65), access may be compromised by construction of low standard latrines, although when the new social norm is sufficiently established, communities may seek to repair or rebuild such latrines (55,65). The shame of losing in a competition can have a negative effect on the non-winners who may be demotivated as a result (62). Improvements in access to latrines and handwashing facilities (33,62) may occur as a result of the motivation of winning prizes (e.g., motorcycles) or simply the right of a leader to claim they ‘won’ by their community being first to become open defecation free (31,33).
Efforts to avoid shame can result in change in sanitation behaviour (i.e. reduction in open defecation and increase latrine use (10,11,24,30,31,34,35,40,65,68,77)) and an increase in levels of overall hygiene behaviour, including hand washing (24,25) and safe drinking water and storage (24). These changes impact health outcomes such as reduction childhood in diarrheal disease, roundworm infestation and stunting (31,35,61,65,77). Behaviour change is limited where prior beliefs about the negative impact of open defecation are weak (77), where open defecation solves a cultural problem such as men and women not being allowed to share a toilet (10,11), and where there is lack of water for latrine cleaning or hand washing close to latrines (65). Shame is more effective for behaviour change in small, cohesive, and isolated total communities with similar views, as people want to fit in and conform to social norms (68), where effective leadership and community involvement help reinforce change in social norms (10,30,65), and where high social cohesion and connectedness makes people more likely to conform for the benefit of the community (8,61), especially as social pressure mounts and community tolerance for the undesirable behaviour decreases (11,22,61).
Effective leadership is an important enabler of reduced levels of open defecation in communities, as it helps reinforce changes in social norms (10,30,65). High rates of latrine ownership and access, can indicate a chance in social norms and the acceptance of the new behaviour (55). Communities that have a lead role in an intervention, allows them to identify the impacts of their behaviour and helps them understand importance of change in behaviour leading to a paradigm shift to promote sanitation facilities and stop open defecation (65). However, increase in latrine ownership does not always guarantee their sustained use, increase in handwashing or reduction in open defecation (10,24,55,65). Without ongoing support and acknowledgement of change, behaviour change is unlikely to be sustained as there is a tendency for fatigue or loss of motivation within communities (22–24).