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.

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.