Users of a container-based sanitation service experience high sanitation-related quality of life: A prospective cohort study in Cap Haitien, Haiti

Abstract

Sanitation users often value improved sanitation interventions for social benefits, such as improved safety and dignity. Some sanitation providers have started using well-being measurements to evaluate service impacts beyond infectious disease outcomes. In particular, the Sanitation Quality of Life (SanQoL) Index explores five attributes associated with sanitation wellbeing: health, disgust, shame, safety, and privacy. In this prospective cohort study we assess changes to sanitation-related quality of life among users of the EkoLakay container-based sanitation (CBS) service operating in northern Haiti. EkoLakay staff surveyed baseline SanQoL among all households who expressed interest in joining the service. For households who proceeded with joining, follow-up visits were conducted >4 weeks after installation to determine endline SanQoL. Between October 2023 and November 2024 EkoLakay gathered complete baseline and endline data from 291 customer households. Each SanQoL response was scored between 0 (worst) and 3 (best). The difference between baseline and endline SanQoL cumulative and attribute-specific scores were calculated for each household and changes were assessed using paired t-tests. Multivariate regression controlling for socio-economic factors were conducted to explore how prior sanitation access is associated with changes to sanitation-related quality of life. On a 15-point scale, the mean difference in cumulative SanQoL score between baseline and endline was 7.88 (95% CI: 7.32-8.45), representing a substantial overall improvement after joining the CBS service. Households who practiced open defecation prior to joining EkoLakay experienced the greatest improvement in SanQoL scores (mean difference 10.22, 95% CI: 9.42-11.03). This research suggests that CBS is associated with substantially higher quality of life of users in northern Haiti, particularly among the most vulnerable who did not previously have access to any sanitation facility. The results also support the use of measurements such as SanQoL, that explore improvements to users’ wellbeing, when evaluating the overall impact of sanitation interventions.