Anderson Darcy M, Gupta Ankush Kumar, Birken Sarah A, Sakas Zoe, Freeman Matthew C
The Water Institute, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, Chapel Hill, NC, USA.
Nepal Health Research Council, Ramshah Path, Kathmandu, P.O.Box 7626, Nepal.
Int J Hyg Environ Health. 2022 Mar;240:113919. doi: 10.1016/j.ijheh.2022.113919. Epub 2022 Jan 14.
Adaptations are modifications made to programming to improve effectiveness or contextual fit, and are important for program improvement. However, adaptations can be detrimental if they do not preserve an intervention's underlying theory of change. We present a case study of 45 adaptations made to rural WaSH programming in Nepal, identified through qualitative interviews with implementers conducted in June through August 2019. For each adaptation, we characterized its target outcomes and implementers' motivations for making the adaptation, and we assessed the adaptation's intended and unintended effects on program quality. Participants described adaptations to both interventions (e.g., changes to hygiene promotion messages) and implementation strategies (e.g., sanctions to enforce toilet construction, such as denying work permits to households without a toilet). Adoption was the most common target outcome, specifically increasing toilet construction. Other target outcomes included feasibility of program delivery, acceptability of messages or WaSH products, reach of program activities in the community, and sustainability. Implementers were commonly motivated by intense pressure to meet national open defecation free targets. Most adaptations achieved their target outcomes. However, sanctions adaptations had substantial unintended negative effects. Implementers reported that sanctions were unpopular with communities and had poor sustainability. In contrast, non-sanctions adaptations that targeted outcomes of feasibility, acceptability, and sustainability had few unintended negative consequences. Our findings suggest that adaptations to promote rapid adoption of toilet construction do not consistently achieve sustained behavior change. Furthermore, adaptations to improve feasibility of program delivery or cost and acceptability of WaSH products can indirectly improve adoption even when it is not an explicit target outcome.
适应性调整是对项目进行的修改，以提高其有效性或与情境的契合度，对项目改进很重要。然而，如果适应性调整没有保留干预措施的潜在变革理论，可能会产生不利影响。我们呈现了一个案例研究，该研究涉及2019年6月至8月通过对尼泊尔农村水、卫生和个人卫生（WaSH）项目实施者进行定性访谈所确定的45项适应性调整。对于每一项调整，我们描述了其目标成果以及实施者进行调整的动机，并评估了调整对项目质量的预期和非预期影响。参与者描述了对干预措施（如卫生促进信息的改变）和实施策略（如为强制建造厕所而实施的制裁，如拒绝给没有厕所的家庭发放工作许可证）的调整。采用是最常见的目标成果，特别是增加厕所建造。其他目标成果包括项目交付的可行性、信息或WaSH产品的可接受性、项目活动在社区中的覆盖范围以及可持续性。实施者通常受到实现国家无露天排便目标的巨大压力的驱使。大多数调整实现了其目标成果。然而，制裁性调整产生了重大的非预期负面影响。实施者报告说，制裁不受社区欢迎且可持续性差。相比之下，针对可行性、可接受性和可持续性成果的非制裁性调整几乎没有非预期的负面后果。我们的研究结果表明，为促进厕所建造的快速采用而进行的调整并不能始终实现持续的行为改变。此外，为提高项目交付的可行性或WaSH产品的成本及可接受性而进行的调整，即使采用不是明确的目标成果，也可以间接提高采用率。
