A Qualitative Comparative Analysis of the Drivers of HIV Status Knowledge in Orphans and Vulnerable Children in Mozambique.

In Mozambique, more than a million children are living with HIV or are otherwise vulnerable due to HIV. In response to this crisis, the US President's Emergency Plan for AIDS Relief funds programs that serve orphans and vulnerable children affected by HIV and their families. These programs retain case workers, known as activistas, who provide and refer beneficiaries to services to increase beneficiaries' knowledge of their HIV status and to improve retention in care among those living with HIV. To improve program effectiveness, implementing organizations need to understand how different case management attributes affect beneficiary outcomes. We applied fuzzy-set qualitative comparative analysis (QCA), based on 119 interviews, to identify the combinations of case management attributes that led to (1) increased knowledge of HIV status, and (2) high percentages of beneficiaries with known HIV status. We identified 6 pathways for the first outcome and 5 pathways for the second outcome. Each pathway demonstrates an alternative combination of conditions that positively influences the outcome and is equally sufficient in achieving the outcome. To improve knowledge of HIV status, programs in a similar context as this study may select any of the identified pathways based on their existing resources and work on ensuring the presence of each of the conditions in the pathway. Overall, based on the presence of some of the factors in multiple pathways, we conclude that to improve knowledge of HIV status it is important that programs implement a formal process to assign cases considering case complexity and existing caseload to reduce overwork; provide activistas with external support such as weekly care team meetings, weekly supervisor meetings, and/or low supervision ratios; hire experienced activistas; provide all activistas with follow-up trainings so they have the tools to address challenging cases; expand the financial resources offered to activistas; and reimburse activistas for work-related expenses.

A Qualitative Comparative Analysis of the Drivers of HIV Status Knowledge in Orphans and Vulnerable Children in Mozambique

In Mozambique, more than a million children are living with HIV or are otherwise vulnerable due to HIV. In response to this crisis, the US President's Emergency Plan for AIDS Relief funds programs that serve orphans and vulnerable children affected by HIV and their families. These programs retain case workers, known as activistas, who provide and refer beneficiaries to services to increase beneficiaries' knowledge of their HIV status and to improve retention in care among those living with HIV. To improve program effectiveness, implementing organizations need to understand how different case management attributes affect beneficiary outcomes. We applied fuzzy-set qualitative comparative analysis (QCA), based on 119 interviews, to identify the combinations of case management attributes that led to (1) increased knowledge of HIV status, and (2) high percentages of beneficiaries with known HIV status. We identified 6 pathways for the first outcome and 5 pathways for the second outcome. Each pathway demonstrates an alternative combination of conditions that positively influences the outcome and is equally sufficient in achieving the outcome. To improve knowledge of HIV status, programs in a similar context as this study may select any of the identified pathways based on their existing resources and work on ensuring the presence of each of the conditions in the pathway. Overall, based on the presence of some of the factors in multiple pathways, we conclude that to improve knowledge of HIV status it is important that programs implement a formal process to assign cases considering case complexity and existing caseload to reduce overwork; provide activistas with external support such as weekly care team meetings, weekly supervisor meetings, and/or low supervision ratios; hire experienced activistas; provide all activistas with follow-up trainings so they have the tools to address challenging cases; expand the financial resources offered to activistas; and reimburse activistas for work-related expenses.

Analyzing Sanitation Sustainability Assessment Frameworks for Resource-Limited Communities.

Diverse and numerous sanitation sustainability assessment frameworks have been created to enhance the ability of systems to provide safe sanitation services, especially in resource-limited contexts. However, many go unused while new frameworks are developed and high sanitation system failure rates persist. To better support the sustainable development goal around global sanitation, there is a need to better understand how sanitation sustainability is defined and measured and the potential advantages and disadvantages of existing assessment frameworks. A subset of existing sanitation sustainability assessment frameworks was reviewed after applying each to evaluate multiple successful and failed community sanitation systems in India. Overall, the evaluated frameworks did not share a sanitation sustainability definition or core set of essential indicators. Many indicators lacked clear definitions and guidance on data collection and analysis. When evaluating framework effectiveness, differentiations between successful and failed cases varied greatly between frameworks. Potential improvements include indicator pilot testing to verify measurement feasibility and that they provide expected results; context-specific weightings; and project-specific framework selection. Clarifying and improving sanitation sustainability assessment frameworks could increase their effectiveness and use, leading to better decision-making and improved public and environmental health, economic viability, and sanitation use and acceptance.

The use of qualitative comparative analysis to identify pathways to successful and failed sanitation systems.

Sanitation systems globally fail at high rates. Researchers and practitioners attribute the causes of both sanitation success and failure to numerous factors that include technical and non-technical issues. A comprehensive understanding of what leads to sanitation failure and how to achieve sanitation success is imperative to prioritize the use of limited resources. To determine which combinations of causal conditions led to successful and failed sanitation systems, we applied fuzzy-set qualitative comparative analysis to 20 cases in Karnataka and Tamil Nadu, India with small-scale sanitation systems. Two pathways led to successful sanitation systems, and four pathways led to failed sanitation systems. All successful systems required Sufficient O&M Funds, a Clear O&M Plan, and Technical Support in addition to either Addressed Sanitation Priorities and Community Participation in Planning or Behavior Change Education and Municipality Involved in Planning. All failed systems had Lack of Municipality in Planning, Unaddressed Sanitation Priorities, and No Technical Support. Most failed systems also had No Clear O&M Plan, Poor Construction Quality, Lack of Community Participation in Planning, and Insufficient O&M Funds. Two failed cases had unique pathways because Government Barriers permanently disrupted use and maintenance. Overall, implementing organizations who initiate sanitation projects in resource-limited communities should ensure that (1) communities have adequate technical and financial resources for maintenance; (2) community and municipality stakeholders are engaged in planning and know their maintenance responsibilities; and (3) appropriate technologies are selected that meet community needs and achieve community buy-in.

Priority Addressment Protocol: Understanding the Ability and Potential of Sanitation Systems to Address Priorities.

Sanitation acceptance is unlikely if user priorities are not addressed. However, sanitation systems are commonly implemented, especially in resource-limited communities, without incorporating local context. Understanding sanitation systems' abilities to address different priorities will further inform technology selection processes. Therefore, a protocol was created to identify priorities and measure how well sanitation systems address them, based upon their importance to a community. This protocol was applied to 20 community-based sanitation systems in India. Overall, 52 sanitation and 40 community priorities were identified; most, along with their relative importance, were case-specific and not yet identified in literature. Existing sanitation systems poorly addressed priorities. Nonfunctional systems addressed the fewest, but, if use and maintenance were improved, they had the potential to address priorities almost as well as functional systems. Resource recovery systems addressed the most priorities, but there was usually minimal benefit to adding all three resources to an existing system; biogas and water had greater potential to address more priorities than compost. This priority addressment protocol can help identify the most appropriate technologies and strategies to improve technology development and success.