Validity and Reliability of the Sanitation-related Quality of Life Index (sanqol-5) in Six Countries

Abstract

Sustainable Development Goals 6.2 measures sanitation progress by toilet type. However, improving people's subjective sanitation experiences' such as feeling safe, avoiding disgust, maintaining privacy, reducing shame, and perceiving lower disease risks is often overlooked. The SanQoL?5 index aggregates responses to five questions on these themes into a single 0-1 score. We evaluated its validity and reliability by surveying 6,165 individuals in rural and urban settings across six countries (Ethiopia, India, Kenya, Malawi, Mozambique, Zambia). There was strong construct validity: 87% of predicted associations between SanQoL?5 scores and toilet quality met expectations (P<0.05). Cross-cultural comparability was supported: only 9% of comparisons showed meaningful item bias across countries. Item-response theory models confirmed its structure, and convergent, discriminant, and known-groups validity were established. Overall, SanQoL?5 is a robust tool for sanitation impact evaluation, monitoring, needs assessment, and costs benefit analysis.