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Achieving universal safely managed sanitation (SMS) is an ambitious long-term goal in resource-limited rural areas. The non-governmental organization, iDE, introduced the alternating dual-pit latrine (ADP), which treats fecal sludge (FS) on-site using storage and lime to increase SMS in rural Cambodia. However, SMS via ADPs requires adherence to recommended practices (e.g., how and when to switch between pits). We surveyed 765 rural households with ADPs across five of 25 Cambodian provinces to understand how real-world household sanitation practices and knowledge affect and are related to adherence to recommended practices at scale. We calculated summary statistics of household survey responses and used regression models of composite indices to describe how households’ practices and attitudes related to ADPs affect adherence to recommended ADP practices. By 24 months after training, three in five households did not recall how long treatment must proceed until emptying can be performed safely. No household waited the recommended two years to empty their pits. While households appreciated the advantages of owning an ADP (e.g., reduced costs and required land area compared to single-pit latrines over time), no household followed recommended treatment practices. This lack of adherence could have health and environmental implications for households using ADPs. Household practices also varied by province, flood proneness, and education level, adding complexity to how to improve adherence; for example, having at least one household member that completed formal education surprisingly reduced compliance with recommended ADP practices. Household behaviors impact the use and maintenance of on-site sanitation systems in rural areas, with proper adherence is necessary to achieve sustained SMS. Increased access to affordable and safe emptying service providers could enable households to manage the pits of their ADPs and dispose of FS in-situ according to treatment duration, while also ensuring that household practices in operating on-site sanitation systems are integrated into the design, installation, and SMS monitoring of such systems.

Access to safe sanitation is a basic requirement for human well-being and is critical for protecting public health and preventing environmental contamination at the community level. The increasing global risk of climate-related disasters exacerbates the likelihood of traditional sanitation solutions failing and exposing communities to harmful pathogens. This risk is ubiquitous in Cambodia's flood-prone Tonle Sap Lake region, which has some of the lowest rates of sanitation coverage in the country. This study sought to design and test a targeted mechanism in the region to deliver sanitation subsidies to households in a vulnerable position due to climate and socioeconomic characteristics. Subsidy eligibility was evaluated using the poverty probability index for Cambodia, with thresholds set according to households' individual and community-level climate vulnerability. In a randomized controlled trial, offering subsidies increased the likelihood of successful sales conversions for climate-resilient latrine products among targeted households by 32 percentage points, indicating effectiveness for increasing market-based sanitation uptake. The research did not find evidence of widespread or sustained market distortion due to the subsidy program.

Achieving safely managed sanitation (SMS) in rural areas has spurred innovation in toilet designs that provide on-site treatment of fecal sludge (FS), including the development of International Development Enterprise (iDE)’s alternating dual-pit latrine upgrade (ADP). ADPs treat FS by inactivating pathogens using storage treatment with lime; however, ADPs’ reduction in pathogenicity (and thus their associated public health benefit) has not yet been described in real-world pits at scale. We thus enumerate the fecal indicator bacteria Escherichia coli (E. coli) and fecal coliforms in 147 pits after two years of storage treatment with lime and compare detected concentrations to relevant standards. E. coli and fecal coliform concentrations indicated a risk to human health in 31% and 42% of sampled pits, respectively. Regression models described relationships between fecal indicator bacteria concentrations and measured factors (e.g., sludge pH, temperature) but did not reveal any meaningful associations. High rates of pit ineligibility also indicate that many ADPs are not operated as recommended. Results indicate a one-in-three chance that a household emptying their own pit would be exposed to health hazards and call into question the effectiveness of the standard two-year storage treatment in real-world applications. To improve rural SMS, various evidence-based recommendations are made.

The connections between WASH and gender equality have been extensively explored and documented using qualitative approaches, but not yet through quantitative means in ways that can strengthen WASH programming. The Water, Sanitation and Hygiene Gender Equality Measure (WASH-GEM) is a novel quantitative multidimensional tool co-produced in partnership between researchers and practitioners. This article explores three dimensions of the WASH-GEM co-production and implementation: (i) the role of partnerships in co-production processes for bringing contextual and practitioner knowledge into measure development; (ii) selected results from the validation pilot in Cambodia and Nepal (n = 3,056) that demonstrate ways in which the measure can inform WASH programming through analysis at different levels and with different co-variants; and (iii) the collaborative process of translating research into programming. The study illustrates that strong partnership and co-production processes were foundational for the development of a conceptually rigorous quantitative measure that has practical relevance. The findings presented in this article have implications for future measure development and WASH programming that aims to influence gender equality in rural communities.

Links between gender equality and water, sanitation, and hygiene (WASH) are well documented in qualitative studies, and emerging literature is recognizing the transformative potential of WASH interventions towards improvements in gender equality, of which empowerment is an important aspect. However, quantitative approaches to measure changing gender equality within WASH programs remain nascent. This study builds on previous work conducted in collaboration with the multi-country Water for Women Fund, establishing the theoretical development of the multi-dimensional WASH-gender equality measure (WASH-GEM) with five domains: resources, agency, critical consciousness, structures, and wellbeing. Starting from a strong conceptual foundation–this article demonstrates the WASH-GEM’s empirical rigor in balance with practical considerations. We present the measure’s staged development; examine its structural validity, internal consistency, and measurement invariance from an empirical basis; providing analysis from concurrent validation studies in Cambodia and Nepal (n = 3056). Twelve of the WASH-GEM’s 15 testable themes demonstrated high internal reliability and nine structural validity. Further refinement is recommended for the remaining four themes. Validation results from Cambodia and Nepal provide evidence of women and men’s differentiated experiences in relation to their WASH access, decision-making and roles, and in their lives more broadly. Results also reinforce the intersectional experiences of inequality and the importance of measurement beyond women’s empowerment. Overall, we provide evaluators and researchers with twelve curated and validated measures to examine changing gender dynamics within WASH-programs. These measures can be used as diagnostic or evaluation tools to support design and implementation of gender-transformative WASH interventions, programs, and policies.