We’re a obsessed with user adoption in our Dispensers for Safe Water program. (see this blog post, and this one, and this one). Adoption measures the percentage of people in a community that verifiably use Dispensers for Safe Water to chlorinate their drinking water. It is important because it gives us an accurate picture of how many people are actually benefiting from improved water quality thanks to Dispensers for Safe Water. It is also an extremely important key performance indicator for our carbon sales. Adoption rates of safe water technologies (such as chlorine) are notoriously low, which is why we are extremely proud that our average adoption rate is over 50%, months or even years after installation.
A New Systematic Review of the Evidence
A new review of safe water, hygiene and sanitation research seems just as interested in the question of adoption as we are. What factors affect sustained adoption of safe water, hygiene and sanitation technologies? is a systematic review of the literature completed an in-depth synthesis of 44 published studies explicitly reporting on sustained adoption.
The authors note specifically that “among the exciting advances in water, sanitation, and hygiene (WASH) programmes and policies, sustainability counts as a renewed and crucial area of focus for implementers,scientists, policy makers, and donors alike.” The authors wanted to understand the “barriers and facilitators to sustained adoption and use of water and sanitation technologies.” They asked two questions: What affects whether or not there is sustained adoption of a clean water technology? What interventions or programs currently exist that successfully foster adoption and sustained adoption? This review is substantially larger than previous ones and is very much in line with what we are interested in for sustained use of Dispensers for Safe Water, a point-of-collection service.
A close look at available research supports the evidence that Dispensers for Safe Water is an innovative, effective safe water delivery model that follows best principles to achieving and sustaining high rates of adoption.
What are the Key Takeaways from this Systematic Review?
1. There is no clear definition of “sustained adoption” used from project to project. The authors note that this can make it very difficult to compare water and sanitation projects with each other. At Evidence Action we measure sustained adoption by randomly testing drinking water samples for residual chlorine in a representative sample of households in a given community as long as a dispenser is installed in that community. This is an objective measure and much better than user recall -- there is either residual chlorine in the water or there isn’t.
2. Behavioural factors seem to affect sustained adoption. The researchers note that while fear of contracting diseases is often perceived as a motivator, desires to conform to social norms as well as a desire to nurture (for example, help make children healthier) may also drive sustained adoption. Dispensers of Safe Water is guided by behavioural economics. Dispensers are situated in a public and salient place directly at the water source. When one community member uses the dispensers this signals to other potential users. Elected community health promoters maintain the dispenser so it is regularly full and available. We found that when promoters are seen using dispensers themselves, adoption increases. In Uganda, we recently worked with a human-centered designer to help us better understand our customers. Overwhelming, we heard from customers, especially mothers, that they care deeply about the well-being and health of their families so tapping into a desire to take better care of loved ones is powerful way to increase adoption.
3. Contextual factors, such as age and gender, also seem to influence an individual’s ability to use a safe water technology. We target a wide range of potential users at community sensitization meetings, a standardized meeting that is held for all communities that receive dispensers to inform them of the dispensers and the benefits of using it. Community promoters are both men and women and of varying ages. All of this helps lower contextual barriers and encourages all household to use the dispenser.
4. Regardless of the type of technology, introducing costs for the user is a huge barrier to adoption. We understand this very well based on important work on costs for preventative health products by colleagues at JPAL. This is why the dispenser delivers chlorine at no cost to the user, a model that is sustainable through economies of scale, and financing through donors and carbon credits.
5. The most influential communication strategy is frequent, personal contact with a health promoter. We could not agree more with that finding. Each Dispensers for Safe Water is maintained by a community promoter - an elected representative from the community to encourage dispenser use, refill the chlorine, troubleshoot problems, and contact Evidence Action for repairs. We know that promoters are key to our adoption rates and are testing different ways to provide incentives to them and their important work.
TLDR: The Effectiveness of Dispensers for Safe Water is Supported by a Growing Body of Evidence
This systematic review of the existing literature affirms all of the strategies that Dispensers for Safe Water uses, making the program that now serves over 4 million people, a best in class. We are proud to grow this evidence-based program and encourage additional rigorous research on effective water and sanitation programs.