Designing context-specific implementation strategies to improve water, sanitation, and hygiene in urban low-income settlements in Nigeria: outcome of stakeholders' collaborative approach.

Background: Urban low-income settlements in Nigeria face significant challenges in accessing Water, Sanitation, and Hygiene (WASH) services, exacerbating health disparities and poverty. Collaborating to design effective and sustainable solutions is crucial for improving WASH outcomes. This study aims to present the process and outcomes of co-designing context-specific implementation strategies of WASH interventions in urban low-income settlements in Anambra State, Nigeria. Methods: The study employed a stakeholder-driven co-design process involving community members, researchers, and policymakers from both health and non-health sectors to develop context-specific implementation strategies for WASH interventions. Four workshops, fifteen in-depth interviews, and one FGD were conducted with these stakeholders. Outputs from the workshops and interviews were analyzed based on the Proctor implementation strategies framework. Results: Seventeen WASH interventions focusing on health education, advocacy, capacity building, and community-led activities were identified. Their key implementation strategies included the definition of each intervention, the actors that will be involved in the implementation, targets, actions, temporality, dose, and the implementation research outcome (IRO) measurements. Prioritization results informed the co-design of implementation strategies of top-prioritized WASH interventions. Stakeholders perceived the developed strategies as highly acceptable, feasible, and relevant to the community's needs. They believed that these would be adopted by end-users and have the potential to make an impact in their community when implemented due to the cultural appropriateness and potential to address specific community challenges. Enablers of the process included strong community participation, inclusion of diverse and experienced stakeholders, and use of local evidence in decision-making. Stakeholder management, including identifying and engaging appropriate individuals, coordinating schedules, and managing time demands, posed significant challenges. Key lessons learned indicate that leveraging informal networks, adapting local evidence approaches, and cultural sensitivity are crucial in designing interventions and navigating success. Conclusions: The study underscores the importance of a collaborative approach in designing effective and sustainable implementation strategies of WASH interventions for urban low-income settlements toward the achievement of SDGs 3 and 6. The findings underscore the need to integrate collaborative and context-specific approaches into WASH policy and programming.