Partnering with community-based organizations to provide contextualized approaches to WaSH inequities in the United States

Compared with low- and middle-income countries, there is a relative paucity of research on WaSH insecurity in high-income countries (HICs), including the United States (US) (Meehan et al. 2020; Young et al. 2022). While comprehensive data are lacking, recent analyses suggest that at least two million Americans do not have access to basic water, sanitation, and hygiene (WaSH) services (DigDeep & US Water Alliance 2019; EPA n.d.). Challenges related to reliable and affordable access to WaSH services are not spread uniformly throughout the US but rather occur in pockets along lines of race and class, mirroring historical and current patterns of marginalization and disenfranchisement (Allaire et al. 2018; Deitz & Meehan 2019; Meehan et al. 2020; Mueller & Gasteyer 2021; Brown et al. 2023; Scanlon et al. 2023).

Lack of safe water poses risks of developing waterborne diseases or conditions associated with chemical exposure (WHO 2019). Unsafely managed sanitation also increases one's risk of contact with disease-causing pathogens either through direct contact or from consumption of water that has been contaminated (CDC 2022). Practicing hand hygiene at the appropriate times and in the appropriate manner is essential for the prevention of diarrheal and respiratory diseases (Freeman et al. 2014; Ross et al. 2023).

Previous scholarship on addressing WaSH inequities in HICs, including the US, has emphasized the need for greater community involvement in decision-making around WaSH challenges and solutions in their respective communities (Mattos et al. 2021). Partnering with community-based organizations (CBOs) is one promising approach to achieving greater community leadership in the identification of and response to WaSH challenges.

While CBOs have been critical actors in ensuring the economic, social, physical, and emotional well-being of their communities for quite some time, the COVID-19 pandemic and corresponding response thrust the importance of partnering with these organizations further into the mainstream (Roels et al. 2022; Wong et al. 2022). CBOs, especially those led by people with lived experience and an understanding of the communities they serve, are vital to building community agency, fostering collaboration, and ensuring local ownership. Supporting these organizations also contributes to the development of local leaders who are better positioned to navigate complex decision-making affecting their communities. However, as with any partnership, there are power imbalances that must be considered and addressed if the equitable partnership is to take place (Wallerstein et al. 2019; Andress et al. 2020).

Trust-based philanthropy (TBP) is one such approach that seeks to explicitly name and subsequently shift power and decision-making between funders and communities (Trust-Based Philanthropy Project n.d.). The approach includes six practices, including giving multi-year unrestricted funding, doing the homework, simplifying and streamlining paperwork, being transparent and responsive, soliciting and acting on feedback, and offering support beyond the check (Trust-Based Philanthropy Project 2021).

The main objective of this evaluation is to examine the effectiveness of incorporating TBP practices into partnerships with CBOs to address self-identified WaSH challenges in pursuit of building evidence based on what works to address WaSH challenges in the US.

The CDC Foundation launched the ‘Increasing Access to Water, Sanitation, and Hygiene in the United States’ program in early 2023 to support six CBOs' efforts in seven locations to improve awareness of WaSH issues and access to related solutions. The request for proposals outlined that project designs should be responsive to and rooted in community needs and assets and should work toward the overarching project objectives of (1) increased awareness of WaSH challenges and related illnesses, within affected communities, (2) increased access to safe water and wastewater services, and (3) strengthened relationships between health departments, the private sector, and CBOs to address systemic WaSH challenges. The CDC Foundation also identified an additional goal for themselves as part of this programming which was to expand CBO capacity to address WaSH challenges. After a competitive review of proposals submitted in response to a request for proposals, selected organizations were awarded between $90,000 and $139,998 to address self-identified community WaSH challenges over a 12-month project period, awarding a total of $712,056 USD. Beyond providing financial support, the CDC Foundation provided structural support to CBOs by bringing in a monitoring evaluation and learning (MEAL) consultant to support CBOs with data collection methods and tools and provide MEAL instruction, hosting quarterly cohort/technical assistance calls, 2 technical presentations, and 12 slots made available to CBO staff to attend advocacy writing workshops. Topics for TA calls included assistance with WaSH-specific interventions and support for processes like data collection, technology use, and operational support.

The WaSH-related challenges and their corresponding health impacts are highly context-specific, with communities throughout the US experiencing poor WaSH services in many ways (Table 1). As such, CBOs adapted general health education and awareness strategies for their specific communities and WaSH needs. In Adelanto, California, and Jackson, Mississippi, the CBOs provided water pitchers and sink filters, respectively. In Tennessee, the CBO established free hygiene pantries where individuals could receive hygiene supplies in a way that maintained their personal dignity. In the Navajo Nation and West Virginia, homeowners were provided with home tanks, water systems, or connected to local water lines. In the Black Belt region, one CBO trained trusted local allies from within the community called the ‘BBUWP Community Service Corps’ to go door-to-door enrolling new members into the program. Another CBO in the area conducted focus groups among communities in several counties and facilitated introductions to other WaSH programming in the area so that individuals could connect to running water in their homes after years of going without.

Given the general lack of evidence on what works to address WaSH inequities in HICs like the US, the team designed a monitoring, evaluation, and learning strategy intended to generate insights that would be useful to CBOs as they were carrying out their routine programmatic activities (learning for decision-making), contribute to the broader evidence base on best practices for WaSH programming in the US (learning for decision-making), and measure CBOs' perceptions of the support provided by the CDC Foundation as part of this program (learning for accountability) (Trust-Based Philanthropy Project & Center for Evaluation Innovation 2022).

To guide evaluation efforts, the CDC Foundation program team developed a logical framework for WaSH in the US program based on what they believed CBOs could reasonably achieve during a 1-year implementation period and their goals for building CBO capacity for systems change beyond the project period. Program outcomes were intentionally written in a broad manner to encompass the breadth of activities carried out and the corresponding anticipated impacts of these activities (see Table 2).

A mixed-methods evaluation was completed over the course of 6 months and included (1) quarterly reporting of output indicators via an online reporting form, (2) a mixed-methods survey for community members who engaged with their local CBO, and (3) a mixed-methods survey for staff within the partner CBOs.

For ease of evaluation, communications, and reporting, the output indicators from the quarterly reporting were reviewed and grouped into thematic areas. The first thematic area was ‘technical implementation’ which included primary WaSH interventions, like installing plumbing in homes, installing proper onsite wastewater systems, providing access to hygiene materials, and distributing water filters. The second was ‘advocacy’ which was defined as work done to raise awareness of WaSH issues among power players and push for resources and improvements on behalf of the community. Advocacy also included building partnerships and coalitions. The final thematic area was ‘outreach and education’ which included anything relating to community engagement, enrollment in WaSH-related services or programs, or WaSH-specific educational opportunities or events.

Two electronic surveys were then developed, one for CBO staff (n = 12) to answer questions about operational, financial, and other capacity-building support, and one for community members who engaged in some way with respective CBOs (n = 133). The community survey was also available on paper but only in English. The community member survey was cross-sectional but did include questions soliciting knowledge and opinions both pre- and post-engagement with their respective CBO and pre- and post-engagement ‘scores’ using Likert scale questions were compared using the Wilcoxon signed-rank test, with the null hypothesis being that there was no change between pre- and post-intervention responses.

While all seven sites participated in quarterly reporting, only four of seven sites participated in the CBO and community member surveys, as the other sites had separate pre-planned evaluation activities and one of the core principles of this work was to avoid undue burden on partner CBOs. All electronic surveys were developed in Qualtrics, and quantitative data were analyzed in R, Qualtrics, and Excel.

Partner CBOs reported reaching a collective 36,299 people with a primary WaSH intervention. The numbers reported varied by program site due to factors that included the nature and cost of the intervention, from hygiene kits to full installation of home water systems. Summarized site-specific accomplishments across the three thematic areas are described in Table 3. In addition to the activities described for advocacy-based work and outreach and education, most CBOs also carried out social media campaigns aimed at community education, reaching communities with information about available WaSH tools and advocacy. The reach of these activities is difficult to quantify, so they have been omitted from the table but nonetheless played a role in reaching communities and the respective decision-makers. Since the Navajo Nation is a sovereign nation and not under US law, there are certain steps and cultural norms that need to be followed to collect and analyze data. To ensure cultural sensitivity, recognize tribal sovereignty, and respect the relationship between DigDeep and the Navajo Nation, the CDC Foundation excluded the reported data from these totals according to the table footnotes (Carroll et al. 2019; Rhodes et al. 2024).

Outcome 1: Increase awareness of WaSH challenges and related illnesses, particularly among local governments/municipalities and marginalized populations, within affected communities.

Outcome 2: Increase access to safe water and wastewater services (and other hygiene interventions) which will in turn reduce the burden of diseases that results from poor water and wastewater service in marginalized communities.

There was a 41.8% (n = 101) increase in the proportion of respondents who stated they agreed that WaSH can impact health after having interacted with a CBO. However, there was only a 3% increase (n = 101) in the proportion of people who stated they felt they had control over their health after working with a CBO. Other indicators initially included for reporting under this outcome proved difficult to capture. As such, the team relied on output measures such as a number of technical installs including filters or home water systems to gauge success.

Outcome 3: Expand the capacity of CBOs to address WaSH challenges in their respective communities.

Most CBO respondents reported growing in their capacity to conduct program activities across all thematic areas. Among the 12 respondents, there was a 62.5% increase in reported mean ability to conduct advocacy, a 53% increase in reported mean ability to carry out technical activities, and a 47.8% increase in reported mean ability to carry out educational activities after receiving support from the CDC Foundation.

In terms of strengthened relationships, another important indicator of capacity, one CBO shared: ‘The partnerships that are beginning to develop. I really think the people and organizations I have been able to connect with on this project are going to be integral relationships that help everyone in our community move forward and thrive…More and more people are speaking out. Our organization has been invited to speak at several events about water and what we are doing around it. We have also been asked to join a group of orgs to help do a citywide report/analysis of the new water system (director, proposed changes, repairs, and billing.)’

Outcome 4: Strengthen relationships between health department, private sector, and CBOs to address systemic WaSH challenges more effectively.

Outcome 4 was measured by the general partnerships formed and the reported subjective strength of them according to CBOs. Data were not available for indicator 4.3 at the time of evaluation as it was largely unreported. Qualitative responses added color to this, with most focusing on locally led and built partnerships with other nonprofits or CBOs and/or gaining expert technical partners that support local programming, while health department partnerships were not mentioned frequently. However, CBO partners also had concerns about continued implementation beyond the project period, with 25% of CBO respondents indicating that it was either ‘extremely unlikely’ or ‘unlikely’ that they could continue technical implementation, education outreach, or advocacy activities beyond the funding period without additional funding.

In the context of this program, partnering with CBOs contributed to progress in closing WaSH gaps across several communities in the US, and was particularly effective in addressing immediate informational and educational needs as evidenced by the high number of outputs and increases within select program outcome measures. By allowing CBOs to utilize funding to support community-specific approaches, this program demonstrated that flexible approaches could support greater impact. This is illustrated by the range of people reached in Table 3. Furthermore, findings from the evaluation of this work indicate that this programmatic structure is useful for initiating or capitalizing on existing WaSH work, as CBO strengths, including lived experience, community trust, and deep contextual understanding, help increase project impact while expanding capacities in underdeveloped areas.

The structural support provided by the CDC Foundation is important in all program implementation, but even more so in this project in which short-term (1-year) funding was provided to support CBOs working to address complex systemic issues, which cannot be fully addressed during the project period. However, CBO responses indicate that the structural support provided, while useful in bolstering capacity, may not be sufficient to ensure CBOs could engage in larger systems change activities beyond the project period without additional funding.

There are limitations to these findings that also speak to future directions for data collection to expand upon the evidence base of what works to address WaSH issues in high-income settings such as the US.

First, while the evaluation activities presented here were conducted by an evaluation consultant (L.W.), funds were provided by the CDC Foundation (the funder), and as such, there may have been inadvertent pressures to paint program accomplishments in a positive light. Every effort was made to minimize this bias through clear communication with both the evaluation consultant and CBOs. These communications emphasized that MEAL activities were not meant to be punitive or require ‘positive’ answers, but rather that the CDC Foundation team was interested in learning what works and what does not work to address WaSH challenges in the US (learning for decision-making) and to improve their internal systems and processes for how they provide support to CBOs (learning for accountability).

Second, due to the timing of bringing on the evaluation consultant after CBO project activities had already started, the community surveys used to evaluate progress on several outcome indicators required community members to reflect on their knowledge and opinions prior to engaging with the CBO and then on their current knowledge and opinions after having interacted with a CBO. This approach may have introduced recall bias. Future evaluations of similar efforts should strive to establish MEAL activities in advance of project implementation to better capture this information prior to CBO interaction.

In designing this evaluation, one of the complexities of working with multiple projects within a single program was identifying a systematic way to assess program impact. In future iterations of this type of programming and funding, it would be beneficial to evaluate each individual project site separately on their local impact, and over longer periods of time, in addition to the overall program impact.

Findings from informal interviews with CBOs highlighted the lack of either existing capacity or bandwidth to carry out robust data collection. As such, improved data collection through trained enumerators who are onsite and could take on this dedicated role would be ideal, if not critical, to the success of site-specific evaluations, so funders should strongly consider funding training of this type for existing or temporary CBO staff or providing enumerators intendant of CBO staff. Further, some CBOs stated that there was a lack of access to internet-connected devices that could support survey administration for many community members. Given that many CBOs typically work with underserved communities, this is likely to be an issue other CBOs face, and thus, funding should be available for capital technology purchases to assist with survey administration. In addition, given that many residents in rural areas are older, and are uncomfortable using electronic tools, funding, training, and/or staffing provisions should be made where paper-based registrations and data collection must continue so staff can complete common software and data training and perform data entry for improved representative samples and data analysis.

Lastly, as the CDC Foundation did in this project, the provision of a subject matter expert versed in MEAL can be made available to guide strong impact evaluations. It would be unreasonable to expect every CBO to know how to do this or have the time and staff, so it would be of great value to provide this guidance early in the CBO's project design phase to assist them in defining their own measures of success and defining longer-term outcomes in addition to outputs. Doing this early setup program activities that are evidence-based and establish the basis for implementing strong data collection processes from the beginning of program start. This process can also have lasting skills development for CBO staff, thus fostering the potential for additional funding opportunities.

We would like to thank each of our community-based organization (CBO) partners, including Black Belt Unincorporated Wastewater Program and PEER Consultants, Community Resource Center, DigDeep – The Appalachian Water Project, DigDeep – The Navajo Water Project, El Sol Neighborhood Educational Center, People's Advocacy Institute, and West Central Alabama Community Health Improvement League. We are incredibly grateful for the opportunity to come alongside these organizations and learn with them what works to address WaSH inequities in the United States. We also extend a special thank you to Abby Crawford for her support in the development of this manuscript.

Data cannot be made publicly available; readers should contact the corresponding author for details.

The authors declare there is no conflict.