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Aim: The aim of the current study was to explore the facilitators and barriers to the utilisation of sanitation-related decision-making support tools among environmental health practitioners in Uganda. Subject and methods: A cross-sectional study design, utilizing narratives from 16 key informants in both the public and private sectors was used. Data were collected with the aid of interview guides, audio-recorded, and transcribed verbatim by experienced transcribers. An interviewee transcript review was undertaken to improve the quality of transcriptions, while intercoder reliability was performed to validate the coding process. The coding process was aided by Nvivo version 12.0, following a thematic approach. Results: The sources of information on sanitation-related decision-making support tools included the internet, workshops, communications from agencies such as the World Health Organisation, and the line ministries. The facilitators to utilisation of sanitation related decision-making support tools included awareness, availability of human and financial resources, and the nature of sanitation activities implemented by the practitioner organisations. Conversely, the barriers included inadequate funds, lack of awareness of sanitation-related decision-making support tools, and the nature of activities implemented by the practitioner organisations. Conclusions: There is limited awareness of the sanitation-related decision-making support tools, which in combination with the limited funding and nature of activities implemented by the practitioner organisations, hinders their use. The current study, therefore, highlights the need for stakeholders to invest and undertake capacity building through workshops and other information-sharing platforms such as the internet, as a measure to increase awareness of decision-making tools.

Three water, sanitation and hygiene (WASH) support tools were applied to Kampala city, Uganda, to evaluate areas with the highest health hazard due to poor wastewater and faecal sludge management and to develop interventions to improve sanitation and reduce exposure. The Pathogen Flow and Mapping Tool (PFMT) assessed how different sanitation management interventions influence pathogen emissions to surface water using rotavirus as the indicator pathogen, while the HyCRISTAL health hazard tool evaluated how flooding and drainage infrastructure influence the presence of human excreta in the environment. The SaniPath tool identified common high-risk pathways of exposure to faecal contamination in food, open drains and floodwater. An overlap in high health hazard hotspot areas was identified by the PFMT and the HyCRISTAL tools. Across the city, the most important hazard sources were the indiscriminate disposal of faecal waste into open stormwater drains from onsite sanitation technologies, open defecation and the insufficient treatment of wastewater. The SaniPath tool identified drain water, floodwater, street food and uncooked produce as the dominant faecal exposure pathways for selected parishes in the city, demonstrating the presence of excreta in the environment. Together, the tools provide collective evidence guiding household, community, and city-wide sanitation, hygiene and infrastructure management interventions from a richer assessment than when a single tool is applied. For areas with high spatial risks, those practising open defecation, and for low-lying areas, these interventions include the provision of watertight pit latrines or septic tanks that are safely managed and regularly emptied. Faecal sludge should be emptied before flood events, direct connections of latrines to open storm drains should be prevented, and the safe handling of food and water promoted. The tools enhance decision making for local authorities, and the assessments can be replicated in other cities.