SanQoL-5 index

Do I need permission to use the SanQoL-5?

No permission is needed. However, the work is licensed under Creative Commons Attribution-NonCommercial 4.0 International License, which requires you to attribute SanQoL-5 to us – please cite as:

Akter et al. (2025) Validity and reliability of the Sanitation-related Quality of Life index (SanQoL-5) in six countries, Nature Water, doi: 10.1038/s44221-025-00434-7

Please also let us know if you are using SanQoL-5 and if you have feedback.

Can I change, drop, or add questions?

The measure has been validated for these 5 questions, based on iterative refinement in different countries and settings. It is not recommended to change or drop questions, because: (i) the index values will no longer be comparable to other studies; and, (ii) an amended index may no longer be as valid or reliable. If you want to add questions in the same style/format, that is up to you, but they should not be included in the calculation of the index, for the above 2 reasons.

What is the problem SanQoL-5 is trying to address?

Impact evaluations of sanitation programmes have rarely measured quality of life outcomes (e.g. privacy, safety). Before SanQoL-5, some survey questions and scales did exist for measuring aspects of sanitation-related quality of life. However, there was no measure which had been validated across multiple countries and settings, and: (i) had a small enough number of questions for widespread use; (ii) was applicable to the general population. We hope that if more sanitation implementers and researchers use SanQoL-5, it will help identify which types of sanitation investments are most effective and efficient.

What is quality of life?

There are many ways to define quality of life (QoL). The SanQoL-5 was developed based on the capability approach (CA). Developed by Amartya Sen and others, the CA frames QoL as whether people are able to be and do the things in life they value (“capabilities”). If those attributes of “a good life” are actually achieved, they are called “functionings”. WHO defines QoL as an individual’s perception of their position in life (in the context of their culture, value systems, and goals), which is more or less aligned with the CA. Since QoL is subjective, there is no definitive list of attributes of a good life. However, some have characterised objective features of QoL or central capabilities as an aid to thought. What is clear is that QoL is broader than health, with examples of broader QoL dimensions including education and political voice. Sanitation-related quality of life is a subset of overall quality of life, namely the things that people value about sanitation (see definition and diagram on About page).

Does “sanitation experience in the past 30 days” refer to the experience while at home, or their overall experience including other locations (e.g. work, school)?

The SanQoL-5 questions would ideally be answered with respect to all sanitation experiences in the past 30 days, if the participant can easily answer that. In some cases, however, it will be easier for the participant to consider experiences with respect to the sanitation facility/location they usually use. Per the sheet, we recommend including a filter question for sanitation location (“The last time you went to defecate, where did you go?”), primarily for triage of the SanQoL-5 questions for toilet use versus open defecation. However, if the participant struggles to interpret the questions and/or uses multiple toilets/locations, the interviewer can recommend focusing on the sanitation facility/location used at the time of last defecation per the filter question. In studies considering multiple locations (e.g. sanitation experiences at school versus at home) the preamble could be amended, e.g. “…experiences in the past 30 days while at home”

Are there other measures of sanitation-related quality of life?

Yes. Any question which asks a person to scale something subjective about themselves for a sanitation-related experiential outcome can be considered sanitation-related quality of life. That is, if the questions were derived from a process incorporating participants’ values and priorities. Several existing scales and indices include questions which can be considered QoL under the above definition. For example, the MPNS-36 includes a question “When at home, were you worried that someone would see you while you were changing your menstrual materials?”, which can be considered sanitation-related. All MPNS-36 questions measure QoL under the above definition, though not all are sanitation-related. The ARISE family of scales is focused on empowerment but includes questions like “In the past 30 days, I feared I would be physically harmed by someone when I went to a sanitation location when away from home”. This question measures sanitation-related QoL, as do many other ARISE questions. However, some ARISE questions do not measure QoL under the above definition, e.g. about the status of social norms or perceptions of risk for people other than the respondent. These do not measure QoL because they are not asking a person to scale something subjective about themselves.

When should I use SanQoL-5, and when another scale or index?

A strength of SanQoL-5 is that it has only 5 questions taking 1-2 minutes, so is well-suited to applications where questionnaire space is limited. Having few questions can also be a limitation if granularity is required and questionnaire space is available. In such cases, you might include other measures for specific salient issues alongside SanQoL-5. This approach is quite common in health-related QoL studies where a general-purpose short-form index like EQ-5D is included alongside a scale specific to the medical condition being studied.

How does SanQoL-5 relate to general measures of quality of life which are not sanitation-specific?

Since sanitation-related quality of life is a subset of overall quality of life (see About page), one would expect some level of convergence between SanQoL-5 and indices/scales measuring concepts such as life satisfaction and mental wellbeing. For example, in our Mozambique study, there was slight but not excessive correlation (0.24) with the WHO-5 mental wellbeing index. Correlation with more distal outcomes such as life satisfaction might well be lower or inconclusive.

Where do the SanQoL-5 attribute weights come from?

The five attributes should be weighted according to the values of the population in which the measure is being used, or its nearest equivalent. If the attributes were equally weighted then each would be worth 0.2 (since 0.2 * 5 = 1.0). However, if a given population happens to value disgust higher than shame, then the weights should reflect this, e.g. 0.22 for disgust and 0.18 for shame. You can use existing weights we can provide on request, or you can undertaken a weighting exercise in your study (which can take 2-10 minutes depending on methods). We recommend using the weights derived from our recent discrete choice experiment (DCE) in Mozambique (contact us to get them), because DCE is a robust method widely used in health economics for quality of life index valuation.

Where did SanQoL-5 come from?

SanQoL-5 was developed by a team at the London School of Hygiene & Tropical Medicine in the UK and the Instituto Nacional de Saúde in Mozambique. Its development is described in two papers in peer-reviewed journals, firstly covering how we decided what to measure, and secondly how we evaluated the validity and reliability of the SanQoL-5 index. In more detail, the steps were:

• Qualitative study and literature review – we undertook qualitative research in urban Mozambique in 2018, informed by Amartya Sen’s “capability approach” to welfare economics, as well as a literature review. The main output was a conceptual model linking the five attributes, and a definition of sanitation-related quality of life as “the subset of overall QoL which is directly affected by sanitation practices or services”. The attributes (privacy, safety, disgust, shame, and disease) align well with the literature on what people value about sanitation across different countries and settings.
• Consultation and piloting – we developed several possible questions to measure each attribute, and the longlist was reviewed by 14 external experts. We aimed for the questions to be simple to understand and widely usable across different types of settings. We then undertook piloting and cognitive interviewing in Maputo, Mozambique, then identified which questions achieved the best face and content validity.
• Valuation – in health economics, valuation is the process of aggregating responses to multiple questions into a single index score. Weights derive from the relative value that respondents places on the attributes. In the original study we used a ranking exercise, but subsequently we have used a discrete choice experiment to undertake valuation more robustly.
• Validity and reliability – we undertook a survey in urban Mozambique in 2019, and evaluated seven aspects of validity and reliability of the SanQoL-5 questions. The most important was “construct validity”, which we assessed by testing hypotheses about whether variation in answers/scores was associated with variation in toilet characteristics. For example, we assessed whether people using toilets with a robust superstructure and a lock on the door reported higher privacy scores than those using a toilet with a makeshift superstructure and no lock.
• Subsequent refinement – Further work on validity and reliability in 6 countries (Akter et al., 2025) resulted in slight adjustment of the questions to the final versions. .