Sanitation-related quality of life

Impact evaluations of sanitation programmes have rarely measured quality of life gains (e.g. privacy, safety and disgust) and economic evaluations not at all. In my PhD research (2017-2020) I developed a five-question measure of ‘sanitation-related quality of life’ to enable measurement and valuation of these outcomes.

Papers on sanitation-related quality of life will be added here as they are published:

1. Qualitative study identifying attributes: Ross et al. (2021). How does sanitation influence people’s quality of life? Qualitative research in low-income areas of Maputo, Mozambique. Social Science & Medicine, 272, 113709. doi:10.1016/j.socscimed.2021.113709

2. Quantitative study investigating validity and reliability of SanQoL measure: Ross et al. (2021). Measuring and valuing broader impacts in public health: Development of a sanitation-related quality of life instrument in Maputo, Mozambique. Health Economics, 1-15. doi:10.1002/hec.4462

3. Impact of an intervention on SanQoL and mental wellbeing: Ross et al. (2022). Impact of a sanitation intervention on quality of life and mental well-being in low-income urban neighbourhoods of Maputo, Mozambique: an observational study. BMJ Open 2022;12:e062517. doi: 10.1136/bmjopen-2022-062517

Further detail and frequently asked questions are provided below.


Recent trials of basic sanitation interventions in low- and middle-income countries have identified little or no health impact, despite improving access to toilets and their quality. However, qualitative studies frequently report that toilet users value broader benefits for privacy, safety and status. Economic evaluations have not included these benefits, in the absence of means to measure them quantitatively, potentially leading to misallocated resources. My PhD research aimed to develop and apply an approach to measuring and valuing quality of life in the economic evaluation of sanitation interventions.


By integrating qualitative and quantitative methods from health economics, my thesis outlined the development and application of a measure of “sanitation-related quality of life” (SanQoL). The thesis found that the benefits of an urban sanitation intervention for toilet users’ quality of life can be quantitatively measured and valued, working alongside the Maputo Sanitation trial in Mozambique. Attributes of the measure were first identified in qualitative research using the capability approach. The validity and reliability of the ensuing SanQoL measure were assessed using psychometric analytic methods. The SanQoL measure captures the degree of achievement of five sanitation-related capabilities: privacy, safety, health, shame and disgust. Rescaling with user-derived weights results in SanQoL index values ranging from zero (no sanitation capability) to one (full sanitation capability).

Can I use SanQoL measures?

If you are interested to use the SanQoL measure, please get in touch with me to discuss options (using email on right of this page). It has already been used in Mozambique, Ghana, Zambia and Ethiopia. A website with guidance documents will be launched in due course. The questions are below. Translations into various languages are available.

Attribute Question Responses
Disgust How often do you feel disgusted when using the toilet? Always
Disease How often do you worry that the toilet spreads diseases?
Privacy How often do you worry about being seen while using the toilet?
Shame How often do you feel ashamed about using the toilet?
Safety How often do you feel unsafe while using the toilet?