Evaluating the acceptability of water, sanitation and hygiene interventions, with the case of a portable hygiene intervention (The Spatap) in three Fijian communities, a mixed-methods study.

doi:10.21203/rs.3.rs-4704547/v1

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Evaluating the acceptability of water, sanitation and hygiene interventions, with the case of a portable hygiene intervention (The Spatap) in three Fijian communities, a mixed-methods study.

https://doi.org/10.21203/rs.3.rs-4704547/v1

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Background

The implementation of water, sanitation, and hygiene (WASH) interventions in low-resource communities can improve health outcomes. Acceptability evaluations can increase the uptake and sustainability of WASH interventions, but there is limited literature on how to conduct them. We developed a theory-based acceptability evaluation using mixed-methods and applied it to conduct the first acceptability evaluation the Spatap, a portable, water-saving hygiene intervention, in three Fijian communities.

Methods

We conducted a mixed-methods study in three Fijian communities aiming to evaluate the acceptability of the Spatap. We conducted a baseline household survey (n = 207) on WASH access, environmental conditions, and acceptability. We asked seven questions on acceptability aligned with Sekhon et al. (2017)’s Theoretical Framework of Acceptability (TFA) for healthcare interventions component constructs. We calculated a total acceptability score and modelled it against sociodemographic predictors using multiple linear modelling in R. In December 2022, we conducted three focus group discussions (FGD) with community members (n = 22) on experienced acceptability. We inductively and deductively coded transcripts using NVIVO (ver 12) and analysed the data using thematic analysis.

Results

Baseline acceptability scores out of 35 were high (med 29, min 18, Q1: 28, Q3: 35, max 35) and few barriers were reported, indicating the Spatap was initially accepted by the communities. Burden and cost scored lower than the other component constructs. Sociodemographic factors (age, gender, education, employment) did not significantly affect acceptability scores. The Spataps were still in use and acceptable five months later. Overall, convenient location and timesaving promoted acceptance of the Spatap. In some larger households, time spent re-filling the bottle was as a burden, but the costs of larger bottles were prohibitive. Challenging environmental conditions (water insecurity and climate events) promoted acceptance of the Spatap as a water saving device, and it fit with existing adaptations to water insecurity.

Conclusions

The TFA was useful to frame the acceptability evaluation, but qualitative methods are more appropriate than the score-based method. For future Spatap implementations in low-resource communities, the accessibility of bottles, local-language instruction, provision of Spataps per head rather than household and water availability should be considered. Promotion of the convenient location and ease of use for children may increase initial acceptance. Further research on the acceptability of the Spatap in other contexts, and its efficacy to reduce infectious disease is required.

Acceptability

Handwashing

hygiene

WASH

Qualitative

Quantitative

Enabling technology

Pacific Islands

Handwashing with soap and water (hygiene), safe drinking water, and toilet facilities where excreta are separated from human contact (sanitation), are pillars of human health [1]. Despite this, there are billions of people without basic water, sanitation or hygiene (WASH) access, most of whom live in developing countries [2, 3]. In 2019, 1.4 million deaths in developing countries occurred as a direct result of unsafe WASH [4, 5]. Increased WASH access is a priority in the Pacific Island Countries and Territories (PICTs), which have a high-burden of WASH-associated diseases [6, 7]. WASH coverage varies within and between islands in the PICTs, but rural areas and some low-resource coastal communities have the lower levels of access than urban areas [8]. Delivering WASH infrastructure to remote or otherwise isolated communities is costly and a key challenge for WASH improvement in the PICTs [9]. WASH interventions, including the provision of WASH (e.g., latrines, handwashing stations, water sources) and promotion of accompanying behaviours, are vital for achieving universal access, reducing water insecurity, and improving health outcomes in low-resource settings [10–13].

Beliefs, attitudes, perceptions, and cultural norms influence whether people adopt interventions and use them over time, regardless of their effect on health [14–16]. Because of this, the ‘acceptability’ of an intervention to the intended users affects adoption and sustainability [17–19]. Acceptability evaluations are increasingly common across the WASH and broader healthcare sector [16, 18]. However, previous acceptability evaluations have lacked a consistent definition of acceptability and a theoretical underpinning [20]. The local environmental context, including water availability and the frequency of extreme climate events, also affects sustainability of WASH interventions [21, 22]. PICT communities have adapted to water insecurity with modern and traditional approaches which vary between communities [8, 23–25]. However, very few hygiene intervention studies have explicitly considered the impact of these factors on acceptability [26].

We aimed to conduct a theory-based acceptability evaluation of a portable hygiene intervention, the Spatap, in three communities in the PICTs. The Spatap is a portable silicone tap that attaches to bottles of varying sizes to transform them into a handwashing station (Fig. 1). This hygiene intervention is lightweight, easily transported, and does not require connection to mains water, mitigating many of the costs associated with delivering WASH infrastructure to remote or difficult to access communities. The volume of water dispensed from the bottle can also be carefully controlled using the Spatap, so it may save water compared to traditional taps or other portable handwashing solutions. The Spatap has been distributed in many communities throughout the PICTs and Africa, with positive anecdotal feedback. However, there have been no previous acceptability evaluations or household trials to date. We aimed to evaluate the acceptability of the Spatap in three low-resource communities in Fiji and determine which factors, including environmental context, influenced acceptability, prior to further household trials in the PICTs.

Figure 1. Spatap portable tap attached to a bottle. (Reproduced with permission © Spatap).

We conducted a mixed-methods study to evaluate acceptability of the Spatap. At baseline we provided Spataps to three communities and conducted household surveys. Five months later, we returned to the communities and conducted Focus Group Discussions (FGD). We designed the qualitative component of this study in line with the ‘Relevance, Appropriateness, Transparency and Soundness’ qualitative research guidelines [27].

Study setting

We conducted the study in Fiji, one of the PICTs. Forty percent of the Fijian population live in rural or isolated communities which have lower access to basic and improved WASH facilities than their urban counterparts [28]. Fiji has distinctive wet (November to April) and dry (May to October) seasons. Rainfall is distributed across the main island in the wet season and cyclones frequently occur; during the dry season parts of the main island receive very limited rainfall [29]. Water availability in Fiji communities depends on socioeconomic status, geographic location, climate and use practices. We selected three communities located in the Ba district in the North of the Western Division of Viti Levu (Fiji), in consultation with the Fijian Ministry of Health and Medical Services (MOHMS) based on population size (up to 100 households, to distribute 2 Spataps/household), accessibility, and existing WASH access levels (limited) (Fig. 2). The three communities are referred to hereafter as “Dua’, “Rua” and “Tolu” (one, two, three in iTaukei). The Ba district receives very little rainfall in the dry season [29].

Figure 2. Map of Fiji showing location of study communities in Ba Province, North-Western Viti Levu, Fiji's largest island. Inset: location of Ba Province in Viti Levu (Fiji). Created using ArcGIS Online (Baselayer: ESRI 2023).

Baseline recruitment

In June 2022, the study team visited the communities to provide Spataps and information about the study. We obtained permission to enter the communities from the village heads. We then invited all community members to attend a meeting about the Spatap. At the meetings, researchers and health workers demonstrated the Spatap in English and iTaukei. Community heads were then provided with enough Spataps to distribute two per household. Each Spatap was accompanied by written English and pictorial instructions.

Survey

The field team, consisting of three bilingual field assistants trained in community surveys and one researcher, visited every household in the community two to seven days after distribution of the Spataps. Everyone in the household who was eligible at the time of the visit was invited to complete a survey. Community members were eligible to participate in the adult survey if they (i) were aged 18 years or older, (ii) their household received Spataps and (iii) they resided permanently in the community. Community members were eligible to participate in the child survey if they were aged 10 to 17 years. The survey was administered using an electronic device, the surveyor read the questions and responses aloud and the participant selected a response. Open response questions were recorded verbatim in language of response.

Survey content

The adult survey consisted of 39 questions on sociodemographic (age, sex, education level, employment type, household size and composition), WASH access, and acceptability. The 20-question child survey was a simplified version of the adult survey, with sociodemographic, WASH access and acceptability questions.

WASH Access and environmental conditions

WASH access questions were adapted from the Joint Monitoring Programme (JMP) core household WASH questionnaire [30]. The JMP classifies sanitation (open defecation, unimproved, limited, basic, safely managed) and hygiene access (none, limited, basic). We also asked survey respondents to rate satisfaction with their existing facility and whether they considered it close to the toilet. We included additional questions on water insecurity (occurrence, time periods, frequency, adaptations) and climate events (occurrence, frequency, impact on WASH access and adaptations), and potential impacts on WASH (e.g. changes in water quality/availability, infrastructure damage) compiled from climate-resilient WASH frameworks and other published studies [31–33].

Acceptability: Theory and Definition

Most previous acceptability evaluations of WASH lack theoretical grounding [20]. The Theoretical Framework of Acceptability (TFA) was developed by Sekhon and colleagues through extensive review and a combination of inductive and deductive theorising [16]. While this is the first application of the TFA to a WASH intervention since its development that the authors are aware of, it has been successfully applied to assess a variety of health interventions [34–37]. The TFA is comprised of seven component constructs (affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, self-efficacy) that interact to affect overall acceptability [38]. These components as they relate to the Spatap are in Table 1. In this study, we define acceptability following Sekhon’ et al. (2017) as “a multi-faceted construct that reflects the extent to which people delivering or receiving a healthcare intervention consider it to be appropriate, based on anticipated or experienced cognitive and emotional responses to the intervention” to consolidate varying definitions used by previous studies”, which was developed in tandem with the TFA [38]. A consistent, pre-specified definition of acceptability reduces ambiguity and promotes comparability between evaluations [20].

Table 1

Seven component constructs of the Theoretical Framework of Acceptability related to the Spatap hygiene intervention.
Component construct¹	TFA Definition	Spatap context
Affective attitude	How an individual feels about the intervention	Feelings (positive or negative) towards Spatap and willingness to use it instead of existing handwashing facility.
Burden	The perceived amount of effort that is required to participate in the intervention	Amount of effort required to use and maintain the Spatap
Ethicality	Whether the intervention fits with an individual’s value system	Whether hand washing, the purpose of the Spatap, is important to the recipient
Intervention coherence	The extent to which the participant understands the intervention and how it works	Understanding how to assemble, maintain and use the Spatap including bottle selection and placement
Opportunity costs	The extent to which benefits, profits or values must be given up to engage in the intervention	Whether the Spatap costs time or money
Perceived effectiveness	The extent to which the intervention is perceived as likely to achieve its purpose	Whether the Spatap is perceived as useful as a hand washing device
Self-efficacy	The participant’s confidence that they can perform the behaviour(s) required to participate in the intervention	Degree of confidence on assembling and using the Spatap without assistance
¹ Component constructs from Sekhon et al. (2017)

Acceptability Measurement

We developed a quantitative approach, the “acceptability score” to evaluated baseline acceptability. We calculated a total acceptability score for each respondent from the sum of seven Likert questions, each on a five-point scale. The seven questions corresponded to the seven components of the TFA. For example, the “self-efficacy” question was, “how confident are you to use the Spatap without help?”. We scored the response options from 1 (considered completely unacceptable) to 5 (considered completely acceptable). The minimum total acceptability score was 7 (a score of 1 for each of the 7 components) and the maximum was 35 (a score of 5 for each of the 7 components) accordingly (Fig. 3). We categorised total acceptability scores into completely unacceptable (0–7), unacceptable (8–14), moderate (15–21), acceptable (22–28), and completely acceptable (29–35). We also included open response questions on barriers and enablers to acceptance of the Spatap.

Figure 3. Diagram of the makeup of the acceptability score, with survey questions

Survey data processing and analysis

We created tabulated summaries of the baseline survey data and conducted descriptive data analysis in Microsoft Excel (v2212). We conducted all further statistical analysis of the survey data using R Statistical Software (v4.2.1. [39]).

We modelled total acceptability scores as a numeric outcome ranging from 7–35, predictor variables are detailed in Table 2. We fitted a multi-level multiple linear model with all predictor variables using the lme4 R package [40]. However, the estimated random effects variance was zero, and the model did not converge due to the distribution of individuals across the households. We then fitted a single-level multiple linear model and reduced it using forward and backward stepwise selection by p-value < 0.05 and Akaike Information Criterion. The diagnostic plots and R² indicated that models with acceptability score as a continuous outcome did not fit the data well. We transformed the outcome to a binary variable (acceptability score above or below 32) and conducted bivariate analyses using chi-squared tests of the binary outcome against each of the categorical predictor variables. We then fitted a multiple logistic regression model to the binary outcome and predictor variables. However, it was highly unstable (large standard errors). Finally, we ran a sensitivity analysis to determine the effects of analysing independent individuals, one per household. To do this, we randomly selected one participant from each household, reducing the sample size from 166 to 101, and then repeated the steps of the above analyses. Further details of the statistical analysis, including analysis of the child data, are available in Additional File 1: Statistical analysis.

The bilingual field assistant translated open survey responses in iTaukei to English. To analyse the open responses, we then conducted a content analysis using an inductive approach [41] We first searched the answers for common keywords. Then, we summed the number of responses that mentioned each keyword and calculated the percentages of total responses in Microsoft Excel (v2212).

Table 2

Independent and dependent variables from adult survey included in models of acceptability score
Variable	Type	Possible values or levels
Outcome variable
Acceptability score	Numeric discrete	7 (all 1s selected) to 35 (all 5s selected)
Independent variables
# children < 5 in household	Numeric discrete	0+
# persons living in household including respondent	Numeric discrete	1+
Gender	Binary categorical^˄	2: Male, Female
Age	Ordinal categorical	4: 18–24, 25–54, 55–74, 75+
Education	Ordinal categorical	5: None, primary, secondary, above secondary, misclassified
Employment	Nominal categorical	6: None, homemaker, part time, full time, student, self-employed
Hygiene access	Ordinal categorical	3: None, limited, basic
Sanitation access	Ordinal categorical	4: Open, unimproved, limited, basic
Water availability	Ordinal categorical	3: Always available, unavailable some years, unavailable every year
Satisfaction with existing handwashing facility	Ordinal categorical	5: Completely dissatisfied, somewhat dissatisfied, neutral, somewhat satisfied, completely satisfied
Clustering variables
Community	Nominal categorical	3: Dua, Rua, Tolu
Household identity	Nominal categorical	101 households each with individual numeric ID
*no one had improved sanitation with safely removed or treated onsite

^respondents only selected male and female from available options

Focus group conduct

After five months (December 2022), we returned to the communities and conducted one FGD in each. To recruit for the FGD we first contacted the village head, who spread word about the FGD and recruited volunteers. A bilingual moderator and one researcher ran the FGD. Community members were eligible to participate in the FGD if they (i) were aged over 18, (ii) received Spataps five months prior and (iii) provided informed consent. Participants were informed that their involvement in the FGD was voluntary, would not influence whether they could keep the Spatap, that they did not have to provide a positive opinion to receive the incentive ($25FJD local supermarket voucher). During the FGD, the researcher operated the audio recording equipment and the moderator asked ten questions, excluding additional probes, and facilitated discussion. The question guide was developed in English. The bilingual moderator translated the questions into iTaukei. The iTaukei questions were then back translated by another Fijian researcher who had not seen the English version of the questions. Any discrepancies were resolved through discussion between one researcher and the two translators. The content of the questions was guided by the survey outcomes, existing theory and the research aims. The acceptability questions corresponded to the seven components of the TFA. After the FGD, the moderator transcribed all of the audio recordings verbatim in iTaukei. The iTaukei script was then translated into English by the moderator and a second bilingual health worker.

Focus group data analysis

We analysed the FGD data with NVIVO software (Version 12, QSR International, Melbourne, Australia) using a combination of deductive and inductive approaches [42]. We created predefined codes based on the seven acceptability component constructs of the TFA. We also used an inductive approach to identify unexpected themes emerging from the data. One researcher coded each transcript twice at separate time points (2 months apart). A researcher who was not involved in the data collection then coded a 50% sample of the scripts independently. Intracoder and intercoder agreement were both high. We selected quotes for each theme by consideration of the context, frequency, and internal consistency of the quote and whether it was succinct, illustrative, and representative of the patterns in the data [42, 43]. Any contextual clarifications are denoted by square brackets. English grammar was corrected in the translation for clarity but original words and meaning of the quote are retained wherever possible.

A total of 207 people across the three communities completed the baseline survey, including 166 adults and 41 children. Reasons for non-participation were not recorded. However, most who were present at the time of data collection chose to participate.

Sociodemographic characteristics of participants

The age and gender distributions of the adult respondents are available in Table 3. The community sample had larger average household sizes, more children under five at home, and had completed fewer years of formal education than the general Fijian population. Forty-one children completed a survey. The age and gender distribution of the child respondents are in Additional File 2, Table A2-1.

Table 3

Sociodemographic characteristics of adult survey respondents
	Dua n	Rua n	Tolu n	Total N (%)	National %^{^}
Total Sample	111	42	13	166 (100)	NA
Gender
Male	49	19	8	76 (46)	51
Female	62	23	5	90 (54)	49
Age
18–24	15	6	6	27 (16)	8.3*
25–54	75	29	7	111 (67)	40
55–74	17	7	0	24 (15)	12
75+	4	0	0	4 (2)	1.6
Household size
1–2	7	1	1	9 (5)	25
3–4	19	13	0	32 (19)	35
5–6	42	14	2	58 (35)	25
7+	43	14	10	67 (40)	14
Children < 5 in house
No	42	17	9	68 (41)	72
Yes	69	25	4	98 (59)	28
Completed education^±
No formal	1	2	1	4 (5)	3
Primary	17	30	9	56 (67)	98
Secondary	6	8	0	14 (17)	55
Above secondary	10	0	0	10 (12)	11
Misclassified	77	2	3	82 (NA)	NA
Current employment
None	23	9	4	36 (22)	4.5
Student	1	4	1	6 (4)
Self-employed (farmer, fisher)	32	19	7	58 (35)	55
Homemaker	43	10	1	54 (33)	55
Part time	4	0	0	4 (2)	57
Full time	8	0	0	8 (5)	57
All percentages displayed to 2 significant figures

^ Where available, national population statistics from 2017 Population and Housing census [44] and UNICEF Multiple Indicator Cluster Survey 2021 data [45].

*20–24 age group

±Education levels primary or secondary were misclassified before 28/6, % of respondents completed education is out of 84 (84 classified correctly, 82 misclassified)

WASH access

Hygiene

Almost everyone (99%) had somewhere to wash their hands, usually a plastic or metal basin filled form a central tap (Table 4). However, 39% reported that soap or water were not always available to them. Two-thirds (68%) of the adults did not consider their handwashing facility “close” to their toilet. Despite this, 40% were completely satisfied with their existing facility, and fewer than 5% were dissatisfied (somewhat or completely) (Fig. 4). A higher proportion of children compared to adults (83% vs 68%) reported that their handwashing facility was not close to their toilet. A greater proportion of children were dissatisfied with their existing facility (29% children vs 4% adults) (Fig. 4).

Table 4

Hygiene and sanitation access in the study communities
	Children n (%)	Adults n (%)	National %^
Sanitation access
Open defecation		3 (2)	0
Unimproved		14 (8)	2
Limited		23 (14)	98
Basic		126 (76)	98
Type of toilet
Flush toilet (pour flush or flush)		55 (33)	93.9
Pit latrine: slab-platform		90 (54)	2.4
Pit-latrine: no slab/platform		13 (8)	1.2
Hanging latrine		1 (0.6)	0.2
No facility (open defecation)		3 (12)	0
Other		4 (2)	0.2
Hygiene access
No facility	0 (0)	2 (1)	2.0
Limited	16 (39)	64 (39)	8.0
Basic	25 (61)	100 (60)	90.3
Handwashing Facility
Sink/tap inside	3 (7)	27 (16)	91.9
Sink/tap outside	28 (68)	84 (51)	91.9
Moveable object	10 (24)	50 (30)	5.4
None	0 (0)	2 (1)	2.0
Hand sanitizer	0 (0)	2 (1)
Close to toilet*
No	34 (83)	113 (68)
Yes	7 (17)	53 (32)
Satisfaction with current facility^X
Completely dissatisfied	3 (7)	2 (1)
Somewhat dissatisfied	9 (22)	5 (3)
Neutral	4 (10)	55 (33)
Somewhat satisfied	21 (51)	39 (23)
Completely satisfied	4 (10)	65 (39)

^ From Multiple Indicator Cluster Survey 2021 Fiji release [45]

*Close to toilet is a subjective measure of respondent’s perception, it is not based on a distance measurement

% for adults is out of 166 (total adult respondents) and children is out of 41 (total child respondents)

X Children rated satisfaction with their existing facility on a picture-based attitude scale

Figure 4. Bar graph of levels of satisfaction with existing handwashing facility in adults versus children. Children had higher proportion of dissatisfaction with their existing handwashing facility than adults.

Sanitation

Three-quarters of respondents had access to basic sanitation facilities with an “improved” toilet type (as classified by JMP) (Table 4). The proportion of respondents using unimproved sanitation facilities was four-fold that of the general Fijian population (8.4% vs 2%) (Table 4).

Water availability, insecurity, and adaptations

Water is supplied to Dua from a dam, located several kilometres away, connected to the community by pipes. Rua also has a dam connected by pipes, located 30–45 minutes away by foot. Tolu is supplied by a borehole approximately 1km away, which is connected to the settlement by a single pipe. Most people used the same water source for sanitation and hygiene.

Almost everyone (94%) reported that water was less available in some or every year (16.3%) (Table X), key periods of low water availability varied by community (Table 5). Of the 30 participants from Dua who reported they felt at higher risk of illness during certain times of the year, most said December to February (60%), and March to May (40%) were periods of heightened risk (Table 5, Fig. 5). Community members adapted to water availability issues by ‘changing their habits throughout the year’, ‘storing rainwater’, and ‘changing water sources’ (Table 6).

Table 5

Water availability and perceived illness in the participant communities
	Dua n	Rua n	Tolu n	Overall n (%)
Water insecurity
Never	5	1	4	10 (6)
Some years	79	41	9	129 (77.7)
Every year	27	0	0	27 (16.3)
Unavailable months				n (% of 156)^{^}
Dec - Feb	86	0	0	86 (55.1)
Mar - May	79	25	0	104 (66.7)
Jun - Aug	19	27	5	51 (32.7)
Sep - Nov	12	0	0	12 (7.7)
All months	4	0	0	4 (2.7)
Perceived water illness risk
No	79	40	12	131 (79)
Yes	32	2	1	35 (21)
Perceived water illness time of year				n (% of 30)*
Dec - Feb	22	N/A	N/A	22 (73)
Mar- May	13	2	N/A	15 (50)
Jun - Aug	5	2	1	8 (27)
Sep -Nov	2	N/A	N/A	2 (7)

^ The percentage is of the 156 participants who indicated they experienced water insecurity some years or every year

*35 participants responded “yes, there are times of year when I feel at higher risk of perceived illness”, when asked when, 5 said “always”, the months are out of the remaining 30 who selected particular periods of the year

Figure 5. Percentage of respondents months of perceived higher illness risk and months of water insecurity.

Table 6

Community adaptations to water insecurity provided in open response
Adaptation category	Response n (%)*	Response examples
Store water in containers and tanks	104 (67)	“We store water in buckets and drums before the dry season” “Use the stored water in gallons, buckets and bottles” “Tank water is available in case of limited supply” “Use water stored in tanks” “Go to families who have water tanks”
Rainwater catchment	44 (28)	“rainwater catchment”
Change water sources	15 (10)	“Carry water bottles to town to fill and use the creek for bathing and washing instead” “Use the creek for bathing and get drinking and cooking water from the tank” “Use seawater for washroom [toilet] purposes”
Fijian water authority cuts	8 (5)	“Water cuts from the water authority” “Call water authority Fiji to supply water”
Clean the dam	5 (3)	“Clean the dam” ”Just clean the water so the dam flows well again”
Purchase water	3 (2)	“Water is bought from town” “purchase from the shop”
*The % refers to the number of respondents who provided a response that fit this category out of the 157 respondents who answered the question

Climate events

All participants reported experiencing a climate or weather event in the past three years (Table 7). Increased rainfall was most common, followed by drought, cyclones, floods, rise in sea-level, and decreased rainfall. Almost everyone (92.8%) said these events affected their water in some way. The primary impacts were decreased water availability (89.2%), damaged or destroyed WASH facilities (81.3%), or colour/smell changes (60.8%).

Table 7

Climate events experienced by community members and effects on water source
	Dua n	Rua n	Tolu n	Total n (%)
Experienced climate events (past 3 years)*
Increased rainfall	103	41	13	157 (94.6)
Drought	82	40	9	131 (78.9)
Cyclone	74	41	12	127 (76.5)
Flood	92	1	0	93 (56.0)
Sea level rise	84	0	0	84 (50.6)
Decreased rainfall	16	17	5	38 (22.9)
None	0	0	0	0 (0)
Water source affected
No	9	2	0	11 (6.6)
Yes	101	40	13	154 (92.8)
Effect on water source*
Less water available	95	40	13	148 (89.2)
Facilities damaged or destroyed Dam blocked	88 17(10%)	23	7	118 (71.1)
Colour or smell change	74	23	4	101 (60.8)

*Questions on climate events and water sources had set responses with an ‘open’ response option.

Acceptability

Acceptability scores

The median adult acceptability score was 29 out of 35 (min 18, Q1: 28, Q3: 35, max 35). Almost all of the adult total acceptability scores fell into the acceptable (22–28) and completely acceptable (29–35) ranges (Fig. 0–30. Due to enumerator error, only 15 of 41 children responded to the “attitude” construct question, this construct was removed and the total acceptability score for children is out of 30. The median child acceptability score was 25 out of 30 (min 18, Q1: 22, Q3: 30, max 30). No respondents had acceptability scores in the unacceptable ranges (0–14 adults or 0–12 children).

Figure 6. Bar graph of proportion of total acceptability scores for adults and children.

Component constructs

Some component constructs scored more highly than others. Confidence (self-efficacy), ethicality, affective attitude, and perceived effectiveness of the intervention were all scored as ‘completely acceptable’ (5 on the Likert scale) by 84–90% of adults and 73–80% of children (Fig. 7). Most (71%) adults and children (85%) reported they ‘mostly’ or ‘completely’ understood the purpose of Spatap. This finding was supported when 97% of adults correctly selected that the purpose was handwashing. However, 13% of respondents also incorrectly selected that it was for filtering water.

Burden and cost had a higher proportion of low-score responses than the other component constructs. In adults, 62% scored burden and 61% scored cost three or lower (Fig. 7). The median score for burden and costs was three in adults (Additional File 2, Table A2-2). In children, 53% scored burden and 48% scored costs three or lower (Additional File 2, Figure A2-1). The median children’s score for burden was three and four for costs (Additional File 2, Table A2-2).

Figure 7. Acceptability component constructs broken down by percentage of adult responses from 1 (completely unacceptable) through to 5 (completely acceptable).

Summary of statistical analysis of acceptability score and predictor variables

Employment and water availability were significant predictors of acceptability score in all models, including full and reduced models and models with all respondents and only one from each household, with a continuous outcome (Table 8). The coefficients for employment and water availability were negative across all models (Table 8, details in Additional File 1). Compared to those who were unemployed, those with employment had lower acceptability scores. Those who experienced water issues every year had higher acceptability scores than those who always had water available. Satisfaction with existing facility was significant in the continuous models with all individuals and predictors, and the models with the sub-set sample with all and reduced predictors but had mixed coefficients by category (Table 8). Chi-squared tests of acceptability as a binary outcome (score above or below 32) also indicated that these predictors were significantly different between the groups (Additional File 1, Table A13).

Table 8

Summary of models of acceptability score outcomes
Sample	Outcome	Predictors	Adj R²	p-value	Significant predictors*
All (166)	Continuous	All	0.53	< 0.001	-Employ, -Water, +/-Sat
All (166)	Continuous	HHU5, Employ, Water, Sat	0.55	< 0.001	-Employ, -Water
All (166)	Binary	All			Highly unstable (Age)
Subset (101)	Continuous	All	0.58	< 0.001	-Employ, -Water, -/+Sat
Subset (101)	Continuous	HHnum, Employ, Water, Sat	0.62	< 0.001	-Employ, -Water, -/+Sat
Subset (101)	Binary	All			Highly unstable (none)
*Direction of coefficient - = negative, + = positive

Barriers and enablers to use of the Spatap

Respondents cited ease of use (54%), water-saving (42%), and convenience (18%) (including proximity to the toilet) as key enablers to using the Spatap (Additional File 2, Table A2-3). Only a small number of respondents described anticipated barriers at baseline. These included water leaking (< 3%), water availability (< 3%) and potential damage (< 3%). Children cited similar barriers and enablers to adults (Additional File 2, Table A2-4).

Focus Group Discussion Results

We conducted three FGDs with a total of 22 participants (Table 9). The head of the village/community was present in the discussion in Dua and Rua but not in Tolu.

Table 9

Focus group discussion participant demographics
	Dua n (%)	Rua n (%)	Tolu n(%)	Total N (%)
FGD Participants	10	9	3	22
Gender
Female	5 (50)	5 (56)	1 (33)	11 (50)
Male	5 (50)	4 (44)	2 (66)	11 (50)
Age group
18–24	1 (10)	4 (44)	0	5 (23)
25–54	5 (50)	4 (44)	3	12 (55)
55–74	4 (40)	1 (11)	0	5 (23)
75+	0 (0)	0 (0)	0	0
*% percentage of focus group sample for that community

FGD Thematic Analysis

Use of the Spatap

The Spataps were still in use in the communities at follow-up: “we are all still using it”. They were mainly placed near toilets, front doors, or kitchens. No one reported using the Spatap for functions other than handwashing (e.g. bathing). Maintenance of the Spatap primarily fell to adults, particularly mothers: “It is us, the mothers [who are responsible]”. At baseline, respondents noted children's enthusiasm for handwashing (Additional File 2, Table A2-3). During the FGD, all groups affirmed family-wide usage, with children showing special interest in the Spatap: “the kids really like it”.

Acceptability

Affective Attitude and Self-efficacy

Attitudes towards the Spatap were still positive at follow-up: “we all really like it”. This was because the Spatap made life easier, “we just really appreciate it because it has made our work easier”. The participants recommended it to similar communities: “they would like to have it too if they knew about it” and requested it for their neighbours. All three groups said it was easy enough for children to use: “It is easy for [the children] to just open the bung and use it”, including without supervision: “even when we adults are not at home, the kids use it when they return from playing or the washroom”. No one reported issues with using the device.

Burden and Opportunity Costs

Using or maintaining the Spatap was not an extra burden for most people. Conversely, it added convenience by saving time compared to the previous setup: “Before we had to take a long walk to the tap to wash hands, but now it’s just near the washroom, it is easier and convenient”, with minimal maintenance: “It does not take much effort… whenever the bottle is empty, we refill it, and there is a spare bottle ready”. However, some people with larger households found that small bottles were inconvenient because they required frequent refills, “the bottle is very small for the families of five… some people have ten in their families… and it takes time to change it every hour”. While no one mentioned difficulty obtaining reclaimed bottles, one group said the costs of purchasing larger bottles were prohibitive for some families, “There are four litre bottles, but we have to buy them...it’s very expensive.” As part of this discussion of costs, participants in that community requested the provision of bottles: “Can you bring us bottles to use?”.

Intervention Coherence

In line with a high number of correct answers to “What is the Spatap used for?” in the baseline survey, all of the participants understood the function of the Spatap as a portable handwashing device: “Whenever we touch something dirty, we use it”. Most people indicated that they understood which bottles to select and where to place them to avoid leakage, but one person said, “some bottles we use, the water keeps on leaking”.

Perceived Effectiveness and ethicality

We did not emphasise the benefits of handwashing for reducing infectious illness when the Spatap was distributed. However, it was evident that the participants valued handwashing to reduce disease. They perceived Spatap as effective for “minimising the spread of disease”, saying that “there is less spread of diseases from the Spatap”. Some mentioned changes in attitudes towards handwashing due to the Spatap: ‘‘When this device was brought to our community, it has really taught the kids and us adults the importance of our hygiene”. There was little response when we asked if a different hygiene intervention would have been more helpful. An individual replied: “This is the best model”. However, community members also requested water storage tanks.

Water availability and ethicality

The FGD confirmed that water availability was an ongoing issue in the communities, “during the dry season, there is no water”, “this settlement used to run out of water most of the time”. The discussions also confirmed that adaptations include storing water and changing sources to: “the water stored in drums when there is no water”. During the discussion, some said: “it does not waste a lot of water”. The Spatap was integrated into existing adaptations to water insecurity, “it does not disturb us”, but further insights were limited.

We conducted a mixed-methods study in three Fijian communities to determine the acceptability of the Spatap prior to further household trials. Our results indicated the Spatap was accepted by the participant communities initially, and over time. Key influences on acceptability were convenience, potential to improve health, and water availability. Sociodemographic factors did not influence acceptability in this study (by acceptability score), but this outcome is likely due to limitations in the quantitative evaluation approach, not at lack importance of these factors, as the FGD indicated there were differences in use of the Spatap between genders and age groups (e.g., children vs. adults). Key issues were bottle leakage and the burden of refilling small bottles in larger households. This study was the first acceptability evaluation of the Spatap. However, these outcomes may be compared to similar WASH interventions to determine the generalisability of the findings, make changes for further implementations, and provide some recommendations on methods for future acceptability evaluations of WASH interventions.

Acceptability scores were high in adults and children. This may be due in part to “satisficing”, where respondents select the same response option to each question to reduce the mental effort of completing a survey [46]. While face-to-face surveys reduce the amount of satisficing compared to web-based surveys [47], 59 of 166 (36%) of the adult respondents selected the last option (most acceptable) for each of the seven acceptability questions. However, acceptability scores were still high among those who did not select the same response each time, and there was a spread of responses when broken down by component construct. It is unlikely that satisficing is the only reason acceptability scores were high, and the qualitative results support high acceptability.

The potential for Spatap to either increase or reduce daily burden affected acceptability. Burden scored lower than the other component constructs at baseline, indicating it was an initial concern for some community members. WASH interventions implemented in low-resource settings can be ineffective for improving health if they require high levels of effort for adherence [48, 49]. However, the FGD revealed that the Spatap saved time and reduced daily burden for most people due to its convenient location. The importance of conveniently located handwashing facilities has been demonstrated in several other hygiene studies [50-54]. For example, Hulland et al. (2013) observed that the location of a handwashing station was a key influence on acceptance in low-resource communities in Bangladesh [55]. Promoting the portability of the Spatap may enhance acceptability in communities that do not have a handwashing facility located near to the toilet.

A small number of people raised concerns in the FGD that time spent repeatedly re-filling a small bottle was a burden for larger households. A similar issue was seen in Bangladesh, where handwashing stations with small capacity were the least popular [55]. We provided two Spataps per household, which ranged in size from one to 17 people. In future implementations, Spataps should distributed on a ‘per person’ rather than ‘per household’ basis to reduce the refilling time burden. For example, it may have been more appropriate to deliver one Spatap to a two-person household and four Spataps to a 17-person household.

All community members were able to procure bottles for the Spatap, but the costs of larger bottles were prohibitive for some families. The importance of bottle availability and accessibility has been highlighted for other WASH interventions that require reclaimed bottles [52, 56, 57]. For example, soapy water bottles were a feasible handwashing option urban Bangladesh slums, where reclaimed bottles were cheap and readily available, [52]. Conversely, several SODIS and soapy water studies conducted in rural Africa and Asia, found that participants accepted the interventions but had difficulty accessing plastic bottles [58-60]. Bottle availability and accessibility may present a significant barrier for communities that are located far from places where bottles are sold or are isolated for other reasons or have limited financial resources to purchase bottles.

The available bottles must also be the appropriate size and material [61]. Several acceptability studies of SODIS and soapy water bottles found the only bottles available to participants lacked durability [52, 55, 58, 62]. In the present study, some participants had trouble with leaking due to soft bottles. The feasibility of supplying large, sturdy bottles, and the accessibility of replacement bottles must be considered for future implementations. Aside from bottle material, Spataps may leak if they are hung in the sun (due to bottle shrinkage). The pictorial instructions demonstrated how to assemble and hang the Spatap but did not show where it should be hung. The written language may not be accessible to all Spatap users. Future implementations should include simplified written instructions in the local language and pictures demonstrating that the Spatap should be hung in the shade.

While acceptability scores did not vary significantly by age group in children or adults, high acceptability scores and adult reports indicate that children were especially accepting of the new device. During the FGD the adults reported that children were enthusiastic about washing their hands with the Spatap. While this was limited to adult perceptions, similar outcomes have been seen for other mobile hygiene interventions. For example, children across Africa accepted tippy taps because they were “humorous” and easy to use [63]. There is some evidence that children adapt more readily to WASH interventions and their acceptance can either promote or reduce uptake in households and communities [64-66]. For example, some handwashing station designs were deemed unacceptable to families in Bangladesh because children could not easily use them [55]. Children should be included in the promotion of Spatap. More broadly, children’s perspectives should be included in WASH acceptability evaluations wherever feasible.

Age and gender did not affect acceptability in adults, but this finding reflects method and sampling limitations rather than a lack of importance of these factors. Age affects behaviours and interaction with WASH interventions [21]. For example, age-associated conditions like sight loss, weakness, dementia, and incontinence create additional requirements for older people [67]. The survey age categories were not uniformly distributed, and very few of the survey respondents and none of the FGD participants were aged over 75. While this sample reflected the Fijian population distribution, where only 1.6% are over 75, it limited perspectives from older people in the evaluation [68]. The perspectives of older people receive limited attention at a WASH policy level and must be considered in the design and implementation of interventions.

Gender also affects how people interact with WASH [69-72]. Men and women may have different experiences and expectations of interventions based on their household roles [71, 73]. Women are primarily responsible for household chores in iTaukei Fijian communities, especially in rural areas where traditional gender roles persist to a greater extent than in urban areas [74, 75]. The FGD revealed that mothers were primarily responsible for maintaining the Spataps, but further insights were limited. This may be due to the use of open questions and the lack of gender-specific probes like, “Do men and women use the intervention differently?”. The FGDs were also conducted in mixed-gender groups. iTaukei women have permission to share opinions in most public meetings, but they may still be constrained by status hierarchies and social norms [49]. The importance of including women’s perspectives in WASH programming is increasingly acknowledged across the WASH sector [71, 73]. Subsequent assessments of acceptability should, where appropriate, integrate gender-sensitive methods in data collection.

Employment and satisfaction with existing handwashing facility significantly affected acceptability scores. However, this finding has limited meaning when examined in context. For example, those who were unemployed had higher acceptability scores than those who were employed. This difference may have occurred because those without employment are at home and more exposed to the Spatap than those who work externally. However, ‘homemakers’, an employment category, had lower scores than those in the ‘unemployed’ category, indicating the finding has limited application. The level of satisfaction with existing facility significantly affected scores, but the direction of the effect varied across the five satisfaction categories.

Saving water while handwashing was very or extremely important to 90% of the survey respondents. Field studies conducted in water scarce communities in Africa [76-80], Asia [81, 82] and South America [83], all found that handwashing frequency significantly decreases when less water is available. In a Fijian settlement with similar WASH setup to the communities in this study, the belief that handwashing required a lot of water prevented handwashing [84]. In the study communities, water insecurity promoted, rather than reduced, acceptability of the Spatap because it saved water compared to the existing setup. While addressing water availability may be beyond the scope of most hygiene implementations, demonstration of the small quantity of water required for handwashing can be an effective means of promoting handwashing behaviour change [54]. The Spatap also fit with existing adaptations to water insecurity (rainwater storage and changing sources). However, the Spatap may not be accepted by communities who adapt in alternate ways. In some parts of the world, use of alternate products such as soil, ash, and salt to clean hands, or skipping handwashing altogether are common practices [85, 86]. The principle that an intervention must integrate with existing water practices and adaptations to be acceptable, applies for WASH interventions more broadly.

Community members were highly exposed to extreme weather and climate events. This is unsurprising, given that Fiji and the other PICTs have among the highest exposure to extreme events in the world [87, 88]. In many PICTs, extreme climate events exert a high degree of influence on water security [89]. The respondents reported that climate events reduced their water availability, damaged WASH facilities, and altered water quality. While direct measurement of health outcomes was beyond the scope of the current study, periods of water insecurity aligned with periods of increased perception of illness risk. Reduction of water available for hand hygiene is one of the key mechanisms by which climate and weather variability can adversely affect human health [90]. The prospect of Spatap contributing to improved health in these challenging environmental conditions added to its acceptability in the communities. Community members already associated handwashing with reduced health risks and perceived the Spatap as useful for minimising disease. This interplay between water insecurity, perceived health risks, and the option of handwashing with less water using the Spatap added to acceptability.

While the TFA has previously been applied to assess a variety of health and social interventions [34-36, 91], this study was the first application to a WASH intervention. Using the framework allowed us to triangulate the survey and FGD findings by component construct [92] and aided in translating the observed data into applicable evidence [93]. The seven component constructs of the TFA captured a broad suite of factors that influenced acceptability. However, several factors, including environmental conditions (i.e. water availability), whether replacement intervention parts are accessible beyond the implementation period, were not well described by the framework. Availability has influenced acceptability in previous water intervention studies [94]. Future research should develop an acceptability framework that includes domains directly relevant to WASH interventions.

The acceptability score data was efficient to collect and analyse and provided unique insight into acceptability at a community level, which is difficult to capture with qualitative methods that require individuals or small groups to speak on behalf of a community. However, these benefits were countered by limitations of quantitating the outcome, including losses of complexity and potentially misleading assumptions about interpretation. For example, simplification of ‘acceptability’ into a quantifiable outcome provided limited insight into which component constructs were the most important to the participants and how they relate to each other to influence overall acceptability. The qualitative FGD were necessary to contextualise the survey data. Using one question per construct in both the survey and FGD, to reduce burden on the participants, also resulted in some lack of depth. For example, ethicality, described as the “extent to which the intervention is a good fit with an individual’s value system” [16], cannot be understood with a single closed survey question. There was also limited insight into how the participants understood each question, which is important in a cross-cultural study [95]. Using multiple questions per construct may overcome this limitation because it allows for calculation of a measures of correlation between questions ascertaining the same construct [96]. While it was beyond the scope of this study, cognitive testing is another method to validate comprehension of the constructs [96, 97]. Research methods grounded in paradigms that recognise the subjectivity involved are a better aligned to the nature of acceptability, we recommend the use of multiple open questions per construct in future acceptability surveys to better capture acceptability data.

In addition to these methodological limitations, we recruited FGD participants via volunteer convenience sampling. Those who did not accept the Spatap may have chosen not to participate in the FGD, biasing the results towards positive outcomes. Translation also occurred during the research design, data collection and analysis phases, which introduced the potential for misinterpretation [98]. A valid translation must reach semantic and conceptual equivalence, where the words and what they refer to are the same in both versions [99]. Forward and back translation contributes to ensuring translation validity [100]. The survey and FGD questions were translated in this way. However, the FGD transcripts were only forward translated. This may have resulted in some losses of the original meaning or context in the FGD results.

Finally, it is important to note that researcher paradigms influenced the development of the research questions, construction, and interpretation of the data [101]. The primary author is an Australian academic representing a university. The moderator was a Fijian community health worker who was known to the communities and spoke the local iTaukei dialect. The broader study team comprised experts, including academics of mixed backgrounds working at universities in Australia and New Zealand and Fijian MOHMS employees.

Noting some methodological limitations, overall, the results indicate that the Spatap was accepted in the study communities, and we recommend further household trialling in communities with similar levels of WASH access and resources, to determine the impact of the device on handwashing practice and health outcomes. For future implementations, we recommend provision of local-language instructions, distribution on a per person basis and investigation of the feasibility of bottle supply. Promoting the portability of Spatap for convenience, water-saving, and ease of use for children may increase acceptance and sustained use of the device. For other low-resource communities, investigation of local water adaptations, existing handwashing facilities and bottle accessibility are also required. More broadly, we demonstrate a theory-based approach to defining and measuring acceptability and recommend it for further acceptability evaluations of WASH interventions. To continue improve the implementation of WASH interventions, further research on developing WASH-specific acceptability frameworks and forming evidence base for the acceptability of interventions in different contexts is required.

JMP- Joint Monitoring Programme

MOHMS- Ministry of Health and Medical Services

PICTs – Pacific Island Countries and Territories

TFA – Theoretical framework of Acceptability

WHO – World Health Organisation

Ethics approval and consent to participate

The protocol for this research was approved by the ANU Human Research Ethics Committee (ANU HREC) in November 2021 (2021/564) and the Fiji Human Health Research and Ethics Review Committee (FHHRERC) in February 2022 (53/2021).

Permission was sought from the community heads prior to community visits. Written consent was obtained for each participating adult (18+). For children (10-17), parental or guardian consent was obtained in addition to the child’s assent. Verbal and written details about the study were provided to participants in iTaukei and/or English according to preference. All participants were informed of the voluntary nature of participation. They were not required to complete the survey or participate in the focus groups to receive and retain the Spataps. Participants received a voucher to a local supermarket ($25 FJD) for participation in the FGD, they did not have to provide a positive opinion to receive the incentive. All participants were informed of their right to refuse to answer a question or stop at any time and withdraw participation, confidentiality, and anonymity of the information. No personally identifying information was gathered and all data were de-identified prior to analysis. The data were stored in encrypted files.

Consent for publication

Not applicable

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available due to privacy reasons because they contain individual data but are available from the corresponding author on reasonable request.

Competing interests

The Spatap founder, Stuart Mason, provided advice on previous Spatap implementations in the development phase of the project. SM did not have input in acceptability evaluation design, data collection, analysis or interpretation, decision to publish, or preparation of the manuscript.

Funding

This research was funded by a grant from the Australian Centre for Neglected Tropical Diseases. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Authors’ contributions

DG, AL secured the funding for this research. RH developed the research protocol and all authors provided input in its design and methodological development. RH developed the data collection instruments and supervised data collection, analysed and summarised the data, and lead writing of the manuscript. AL, DG, and SH supervised. AR provided statistical expertise and supervised data analysis. All authors contributed to the writing and editing of the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We thank Mr Stuart Mason (Spatap) for his generous advice on previous Spatap implementations. We thank the Fijian Ministry of Health and Medical Services who supported the implementation of this project. We particularly thank the Ba Ministry of Health and Medical Services team including the field assistants Makareta Rokobui, Matelide Letevou, and Vereniki Vatucicilia and Senior Health Inspector Mosese Koroi who partnered with us to engage with the communities, deliver the intervention and conduct the field work. We thank Timothy Harford-Cross (UNICEF) who contributed to the operationalising of the project. Finally, we express our deepest gratitude to the communities who welcomed the intervention and all who participated in the study, Vinaka vaka levu.

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Evaluating the acceptability of water, sanitation and hygiene interventions, with the case of a portable hygiene intervention (The Spatap) in three Fijian communities, a mixed-methods study.

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Abstract

Background

Methods

Results

Conclusions

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Introduction

Methods

Results

Use of the Spatap

Acceptability

Affective Attitude and Self-efficacy

Burden and Opportunity Costs

Intervention Coherence

Perceived Effectiveness and ethicality

Water availability and ethicality

Discussion

Conclusions

Abbreviations

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Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

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Authors’ contributions

Acknowledgements

References

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