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4 Results for Health Topics

4.2 Water, sanitation and hygiene

4.2.2 Expert interviews

General comments

  • Compared to other humanitarian sectors, WASH is fairly well organised within its sector and the perception is thatthere is strong cooperation and coordination across the various actors (NGOs, extra-governmental, andgovernmental agencies).
  • The WASH sector has a concentration of engineers and non-health professionals, who typically have measuredwater quality outcomes to evaluate interventions. The direct link with health outcomes is currently weak and thereis a lack of guidance regarding how WASH can link with other sectors (notably infectious diseases and nutrition).
  • Uptake is extremely important to characterise; it is not sufficient to report distribution of a given WASH product(e.g., soap) and effect on a health outcome; if studies are not measuring uptake this could leave to severe biases ormisrepresentation of true effect sizes of intervention success.

Study design

  • WASH is typically first or second line response in a disaster, leaving little time to plan how to designmethodologically strong studies (and there is little guidance to do so).
  • The majority of current WASH interventions have been weak in terms of design and evaluation – futureinterventions should be reproducible, rigorous, and have clear objectives.
  • WASH as a sector does not tend to conduct RCTs. Some question whether RCTs are necessary given that manyWASH activities (e.g. hand washing, proper waste disposal) are considered good practice via years of publishedevidence and programmatic experience. Additionally, the use of RCTs to measure the effectiveness of WASHinterventions requiring hardware (e.g., latrines) are logistically and practically problematic in humanitariansettings. However, RCTs would be useful in comparing the effectiveness and cost-effectiveness of different WASHinterventions on health outcomes.
  • Economic studies are also needed because they are currently non-existent in this sector, and experts suggestthere is likely a great difference in cost and benefit of various WASH interventions (e.g. latrine construction vs.soap provision).

Indicators, standards, and guidelines

  • As a sector, WASH follows norms and guidelines – most notably Sphere. However, Sphere’s WASH indicators arenot easy to measure for those practising in the field, which has led to a divergence of indicators, with severalorganisations developing their own.
  • Furthermore, as many WASH professionals have engineering backgrounds, WASH interventions are typicallyevaluated against water quality/treatment indicators (e.g. residual chlorine) because to date WASH actors havemore consensus and acceptance of the robustness of water quality outcomes.
  • There is a belief amongst some WASH professionals that water quality outcomes (with their agreed-uponstandards) are more reliable and therefore a better measure of intervention success than many health outcomes(e.g. self-reported diarrhoea).
  • Future work in this sector must incorporate both public health and measures of use outcomes to provide evidencethat interventions are impacting all routes of disease transmission.

Importance of intersectoral and multidisciplinary research

  • Certain types of WASH responses (e.g. latrine provision) are costly and require massive planning. Given theunstable nature of many crisis-affected environments (e.g. shifting water tables during floods), experts concedethat designing methodologically strong studies is challenging. Still, there is a definite desire to quantify how wellsuch interventions work – both alone and alongside interventions of other sectors (e.g. communicable diseases).
  • In the early 2000s, WASH as a sector realised it could not simply focus on distributing and installing goods (e.g.latrines) without considering cultural, behavioural, and contextual factors. This led to an increasing recognitionthat qualitative and behavioural research is needed to better understand issues such as acceptability and tocreate context-specific approaches.
  • There may be great potential to draw lessons from stable settings and other sectors (e.g. development) wherelonger-term approaches have been implemented and tested.
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