Translating SHINE : application of community-based participatory research approaches to the cultural adaptation of a school-based water, sanitation, and hygiene intervention

Abstract

Globally, water, sanitation, and hygiene (WASH) is a widespread public health issue because access to safe drinking water, adequate sanitation systems, and hygienic behaviors are fundamental to human health and development. Although studies have demonstrated the association between poor sanitation and hygiene to various diseases; evidence regarding the effectiveness of WASH interventions is still mixed, illustrating challenges with uptake and sustainability. Development of effective WASH interventions is dependent on having a comprehensive understanding of relevant contextual factors and determinants. Therefore, it is crucial that careful consideration of these factors is applied to intervention design, adaptation, and the assessment of outcomes. One approach which encourages local knowledge sharing regarding contextual factors, derives from the application of community-based participatory research (CBPR). Therefore, in WASH health promotion research, CBPR could help nurture and develop a culturally relevant, thus effective WASH intervention. The purpose of this doctoral research was two-fold, first to develop an in-depth understanding of the contextual setting of the rural community of Thirumalaikodi Tamil Nadu, India, in order to contribute to and document the processes of cultural adaptation of an existing intervention using a CBPR approach, and second to contribute to the broader understanding of how health promotion interventions can be adapted and scaled using formative research. Three sub-studies were developed to help fulfill the purpose of the doctoral research (sub-study 1, 2, 3). Sub-studies included arts-based, qualitative, and quantitative approaches (photovoice, interviews, stool diaries, and survey). Students from two schools were purposively selected to participate in each study. These sub-studies contributed to the cultural adaptation of intervention components and curricula, to accommodate context, culture, and input from youth and the wider community. The first sub-study (Book Chapter I and Manuscript II) utilized arts-based research methods to reveal students’ perceptions of the cultural and contextual factors that influence sanitation and hygiene-related behaviors, and how several social determinants play an influential role. Book Chapter I includes a reflective discussion of the use of arts-based methods in research as a means of participant engagement as demonstrated by sub-study 1. In sub-study 2 (Manuscript III), through qualitative narrative interviews, participants revealed how adolescent girls experience menarche and menstruation, how their experiences connect to the sociocultural context; and what strategies they use to manage menstruation. In sub-study 3 (Manuscript IV), data consisted of semi-structured qualitative interviews, stool diaries and an interviewer administered survey completed by adolescent students. In this sub-study participants discussed cultural representations and perceptions of diarrheal illness using the Bristol Stool Form Scale. Research findings presented in this PhD dissertation highlight several important implications for future intervention adaptation and demonstrate the role of formative research and community engagement within the development and adaptation of health promotion interventions. First, norms (social and gender) are a distal influence on health outcomes. Second, cultural and religious attitudes, beliefs, and practices are linked to sanitation and hygiene-related behaviors. Next, menstruation and diarrhea are linked to various forms of stigma and taboos in this sociocultural context. Furthermore, findings indicate that open defecation, which is a common behavioral target for WASH interventions, may be perceived as taboo. Parents play an important role in health communication for participants, indicating that local knowledge is often passed down intergenerationally, which has important implications for several health challenges. Sub-study findings may be used to inform the cultural adaptation of Project SHINE (Sanitation and Hygiene INnovation in Education) among adolescents in India. Additionally, the systematic documentation of the formative research processes employed, builds upon CBPR-oriented adaptation processes as documented in health promotion literature, thus contributing to the knowledgebase of cultural adaptations of WASH health promotion interventions among adolescents in low- and middle-income settings.

Utfordringer knyttet til vann, sanitærforhold og hygiene (WASH) er et globalt folkehelseproblem ettersom rent drikkevann, tilfredsstillende sanitæranlegg og god hygienisk atferd er fundamentale faktorer for god helse og utvikling. Selv om studier effektivt har dokumentert sammenhengene mellom dårlige sanitære forhold og hygiene med forskjellige sykdommer, har de dokumenterte effektene fra WASH-intervensjoner vært blandede, hvilket illustrerer utfordringer med varig atferdsendring og bærekraftighet. Utvikling av effektive WASH-intervensjoner er avhengig av innsikt i relevante kontekstuelle faktorer og hva som påvirker folkehelsen, og det er derfor avgjørende at disse faktorene vektlegges i design, tilpasning, og resultatmåling av intervensjoner. En tilnærming som oppfordrer til lokal kunnskapsdeling om kontekstuelle faktorer, er deltagerorientert aksjonsforskning (communitybased participatory research). I helsefremmende WASH forskning, kan deltakerorientert aksjonsforskning bidra til å utvikle kulturelt relevante og dermed effektive WASH intervensjoner. Formålet med denne avhandlingen var todelt, først å opparbeide en grundig forståelse for kontekstuelle faktorer i lokalsamfunnet Thirumalaikodi Tamil Nadu, India, for å dokumentere en kulturell tilpasning av en eksisterende intervensjon. Dernest var målet å bidra til en bredere forståelse av hvordan helsefremmende intervensjoner kan tilpasses og skaleres ved hjelp av formative research. Tre delstudier ble utviklet for å besvare formålet med avhandlingen (delstudie 1, 2, 3). Delstudiene tok i bruk kunstbaserte, kvalitative og kvantitative metoder (photovoice, intervjuer, dagbøker for avføringsmønstre og spørreundersøkelser). Elever fra to skoler i Vellore-distriktet, Tamil Nadu, India, deltok i studiene. De tre delstudiene bidro til å tilpasse intervensjonens komponenter og pensum til kontekst, kultur og innspill fra elevene og lokalsamfunnet.