Title: Implementation and adaptation in rural water, sanitation, and hygiene programs
Abstract: Safe water, sanitation, and hygiene (WaSH) have a variety of health and development benefits, such as reducing enteric infections and promoting safety and dignity during bathing and defecation. However, challenges implementing and sustaining WaSH intervention sare a substantial barrier to realizing benefits, leading to calls for research to better understand implementation challenges. Implementation science is a discipline that seeks to understand and promote uptake of interventions into routine practice and to understand implementation processes, barriers, and facilitators.
The goal of this dissertation is to understand the successes and challenges of delivering and sustaining rural WaSH programs, using implementation science.
- Chapter 1 presents a literature review to provide context and position the contribution of this dissertation.
- Chapters 2 and 3 present case studies of rural WaSH programs in Nepal, using data from qualitative interviews with implementers.
- Chapter 2 assesses adaptation as one aspect of implementation,examining the adaptations made to rural WaSH programming, their effects on program outcomes, and implementers’ motivations for adaptation.
- Chapter 3 examines differences in implementation approaches, successes, challenges, and support systems between men and women implementers, and the effects of these factors on WaSH programs.
- Chapter 4 derives a model to guide WaSH practitioners through systematic adaptation of WaSH interventions, based on adaptation literature in WaSH and implementation science.
- Chapter 5 presents a joint discussion and conclusion.
I found that implementation approaches commonly targeted adoption as the primary outcome, which was typically inadequate for achieving long-term health and development goals. Implementation approaches that leveraged social capital and targeted a wider range of outcomes beyond just adoption (e.g., acceptability, sustainability) had better success. Women were particularly effective at leveraging social capital. External policies and incentives, particularly national WaSH targets, strongly influenced adaptation and implementation approaches. Systematic decision making, collaborations, and knowledge sharing between diverse stakeholders from government, development organizations, and civil society organizations led to adaptations and implementation approaches with more positive outcomes. Application theoretical tools from implementation science in this dissertation allowed for richer, more nuanced descriptions, analysis, and understanding of implementation processes and the factors that influenced them.
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