A socio-ecological perspective of the facilitators and barriers to uptake of water, sanitation and hygiene interventions in a slum setting in Kampala, Uganda: a qualitative study

We explored the facilitators and barriers to uptake of water, sanitation and hygiene (WASH) interventions among slum dwellers in Kampala, Uganda using a socio-ecological perspective. This qualitative exploration used focus group discussions with community members and key informant interviews with community leaders and technocrats to collect data. Among facilitators to uptake of WASH interventions were susceptibility to WASH-related diseases and low WASH knowledge levels at individual level, peer practices at household level, and promotion of WASH at organizational level. At community and public policy levels, community engagement and empowerment, and formation and enforcement of ordinances and bye-laws, respectively, motivated slums dwellers to adopt WASH interventions. Conversely, individual knowledge, beliefs, language, and financial status inhibited individuals from taking up WASH interventions. Negative peer practices and upbringing at peer level; unsupportive environments, and engagement of communities at organizational level; cultural beliefs and lack of space at community level; and unexamplary leaders and political interference barred slum dwellers in Kampala from embracing the WASH interventions. Uptake of WASH interventions in the slum community is influenced by a cascade of facilitators and barriers across the socio-ecological realm. Hence, a multi-faceted approach targeting all stakeholders is required in planning and implementation of WASH interventions. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence (CC BY 4.0), which permits copying, adaptation and redistribution, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/). doi: 10.2166/washdev.2020.124 ://iwaponline.com/washdev/article-pdf/10/2/227/713040/washdev0100227.pdf Charles Ssemugabo (corresponding author) Abdullah Ali Halage Carol Namata David Musoke John C. Ssempebwa Department of Disease control and Environmental Health, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda E-mail: cssemugabo@gmail.com

). Despite the fact that WASH interventions are expected to yield good WASH behaviors and practices (Tannahill ; Wasonga et al. ), some literature has revealed that low knowledge levels on WASH often have no effect on hygiene attitude and practices (Sibiya & Gumbo ).
There are indeed other factors that affect uptake of WASH interventions in Kampala slums. WASH intervention uptake might be due to interrelated multi-level factors including physical (Firdaus ), sociocultural (Wasonga et al. ), economic, and political (Gleaton ) issues. However, there is limited evidence on how these factors interact and affect uptake of WASH interventions in slums. Thus, we used the socio-ecological model (SEM) to explore how and why some communities have adopted the WASH interventions and others have not. The model has five aggregate levels that unpack motivators and barriers to uptake of WASH interventions (McLaroy et al. ). At individual level, the SEM explains the biological and personal experiences that increase the likelihood of uptake of WASH interventions. At household/interpersonal level, SEM examines close relationships that may increase or reduce uptake of WASH interventions. At the third level, SEM focuses on organizations within the community whose efforts support or oppose uptake of WASH interventions. At community level, the model looks at the settings in which WASH behavior and practices occur and identify characteristics that might promote or hinder their uptake.
At policy level, we used the SEM to explore broader societal factors that can create an enabling environment for WASH uptake and vice versa.

Study design
This was a qualitative study that collected data from nine key informant (KIs) and five focus group discussions (FGDs). KIs were deliberately selected based on their expertise and experience while FGD participants were selected based on their WASH behaviors and practices.
KIs included two health workers from Rubaga Division, a local leader and a CHW from each of the six participating zones. The FGD participants were household heads and/or their spouses who were directly affected by WASH challenges. Three FGDs were conducted with females and two with males. Each FGD was composed of seven to twelve participants.

Study setting
This study was conducted in six out of the nine zones of Kasubi slum in Kampala, the capital city of Uganda. A slum is defined as a heavily populated urban formal settlement where inhabitants are characterized by substandard housing and low standards of living (Nolan ). Kasubi Parish comprises mainly informal and substandard housing and a few businesses. We selected Kasubi slum because many interventions have been implemented yet the WASH situation has not greatly improved.

Data collection and guides
KIs were invited to participate in the study by the principal investigator through an invitation letter sent a week before the interview while FGD participants were screened by CHW for eligibility a day prior to the meeting. Prior to the interview and group discussion, the participants were introduced to the purpose of the interview and FGD, respectively. Written informed consent was obtained.
Semi-structured guides developed by the study team were employed to explore facilitators and barriers to uptake of WASH interventions. The guides were translated to the local language (Luganda) and translated back to English for accuracy. The guides were piloted with community members in Mulago Parish, a slum community in Kampala. The

Data management and analysis
The audio recordings were transcribed verbatim and translated to English by two experienced researchers fluent both in English and Luganda. Two people read the transcripts and assigned meaning units to each response which were later combined to form a code book. Data were entered into ATLAS ti software version 7.0 for coding. Analysis was carried out using directed content analysis (Assarroudi et al. ). We used the SEM as a guiding framework to identify recurrent themes and subthemes by categorizing the codes.

Ethics considerations
We obtained ethical approval from the Makerere University School of Public Health Higher Degrees, Research and Ethics Committee (101). The study was also approved by Uganda National Council of Science and Technology (HS 867). Study participants provided written informed consent.

RESULTS
The findings are organized and presented based on the five levels of the socio-ecological model as shown in (Figure 1), with facilitators presented first.

Intrapersonal level
Perceived susceptibility: Fear of disease and the law was identified as a facilitator for uptake of WASH interventions among slum dwellers. Community members observed that during disease outbreaks people adopted WASH interven- 'We are taught how to sort waste into plastics, metallic items, […], and how to use it to make charcoal. We want to keep our homes in a hygienic situation, stay healthy and generate energy resources that can help us.'

Interpersonal level
Neighbor practices: Neighborhood practices such as reuse of solid waste facilitated uptake of WASH interventions. Community members said that they were motivated by their colleagues who used food peelings to make charcoal and to feed animals, as well as cow dung as fertiliser, which inspired them to collect their waste for reuse.  Individual susceptibility to WASH-related diseases and sanitation-related laws and ordinances was a great driver to adoption of appropriate WASH practices in slums.
Indeed, treating diarrheal diseases is quite costly, especially in low-resource settings in Kampala (Hutton & Chase ). It was also revealed that availability and enforcement of laws and regulations facilitates or motivates uptake of WASH interventions in slum communities in Kampala.
The Tannahill model highlights that, in order to ensure health promotion, awareness and availability of interventions must be accompanied with laws or penalties to those who might fail to abide by them (Tannahill ). In fact, laws have also been emphasized as important in building a competent health workforce and ensuring good governance for health (Marks-Sultan et al. ). However, laws that govern WASH are at times weak or poorly enforced and abused by the authorities as highlighted in our findings.
This hinders uptake of interventions, especially in resource-limited settings. Therefore, there is the need to strengthen existing WASH laws and policies and ensure adequate implementation.
This study truly reflects the facilitators and barriers to uptake of WASH interventions given that sufficient time was allowed between the interventions and this assessment.
Thus, we can authoritatively describe uptake of the interventions. However, the study looked at a broad range of WASH interventions, so it is difficult to attribute a specific facilitator or barrier to a specific intervention.

Uptake of WASH interventions in slum communities is
influenced by a cascade of facilitators including individual perceived susceptibility, knowledge and values, peer practices community empowerment and resources, funding and enforcement of bye-laws. Barriers such as community members' knowledge and attitudes, cost of WASH utilities, uncooperative neighbors, lack of space for sanitary facilities, lack of community involvement, and failure to enforce byelaws were also said to affect uptake of WASH interventions as we move from individual to policy/national level. Facilitators and barriers to uptake of WASH interventions are multi-faceted and, as such, require a multi-level and multistakeholder approach in their planning, designing, and implementation in slum communities in Kampala.