Effect of a low-cost, behaviour-change intervention on latrine use and safe disposal of child faeces in rural Odisha, India: a cluster-randomised controlled trial

Systematic re-review of WASH trials to assess women's engagement in intervention delivery and research activities

Water, sanitation and hygiene (WASH) interventions significantly reduce health risks in low- and middle-income countries. Many rely on women, but the extent of women's engagement remains undocumented. Here we conducted a re-review of papers from two systematic reviews that assessed the effectiveness of water, sanitation and/or handwashing with soap interventions on diarrhoeal disease and acute respiratory infections to assess women's roles in WASH research and intervention activities. A total of 133 studies were included. Among studies that specified gender, women were the most sought-after group for engagement in research (n = 91/132; 68.9%) and intervention (n = 49/120; 40.8%) activities. Reporting time burden for research (n = 1; 1%) and intervention activities (n = 3; 2.5%) was rare. All interventions were classified as gender unequal (36.7%) or gender unaware (63.3%) according to the World Health Organization Gender Responsiveness Assessment Scale, indicating exploitative engagement. Women play a critical but instrumentalized role in WASH, and both research and interventions need to change to enable, and not hinder, gender equality.

Effect of a behavior change and hardware intervention on safe child feces management practices in rural Odisha, India: a cluster-randomized controlled trial

BACKGROUND

Poor child feces management contributes to enteropathogen exposure and, consequently, is associated with diarrheal disease and negative impacts on child growth. Despite high latrine coverage, only 37% of Indian households safely dispose of their child's feces into a latrine or have the child use the latrine, with the lowest rate in the state of Odisha at 12%. We evaluated a behavior change and hardware intervention designed to improve caregiver safe disposal of child feces and child latrine use.

METHODS

We conducted a cluster-randomized controlled trial among 74 villages in rural Odisha, India. Eligible villages previously participated in a water and sanitation infrastructure program. Following a baseline survey, half the villages were assigned to intervention and half to control. Caregivers of children < 5 years old from households with a latrine were eligible to participate. The intervention included five behavior change activities. Hardware was provided at the first activity, based on child age, to aid safe disposal and latrine training (wash basin and bucket with lid for children < 7 months old; latrine training mat platform with removable tray for children 7 to 48 months old). The primary outcome was caregiver reported 'safe disposal' as defined by the WHO/UNICEF Joint Monitoring Programme (JMP) which encompasses two behaviors: caregiver disposal of child's feces into a latrine and child latrine use. Safe disposal was measured four to six months after intervention delivery (endline).

RESULTS

Endline analysis included 665 intervention caregivers (840 children) and 634 control caregivers (785 children). Prevalence of JMP-defined safe disposal was 1.16 times greater in the intervention arm compared to control (77.7% vs. 65.9%; prevalence ratio [PR] 1.16, 95% CI 1.04-1.29), with higher prevalence of caregiver safe disposal (18.6% vs. 13.6%; PR 1.46, 95% CI 1.12-1.92) but no significant difference in child latrine use (59.0% vs. 52.2%; PR 1.06, 95% CI 0.95-1.18). When restricted to children < 3 years old, JMP-defined safe disposal was 1.42 times greater (67.5% vs. 46.7%; PR 1.42 95% CI 1.21-1.67) with higher prevalence of both caregiver safe disposal (34.6% vs. 25.7%; PR 1.44, 95% CI 1.11-1.86) and child latrine use (32.9% vs. 20.9%; PR 1.41, 95% CI 1.08-1.83).

CONCLUSIONS

The intervention increased JMP-defined safe disposal, with substantial improvements in both caregiver safe disposal and child latrine use among children < 3 years old. While future research is needed to demonstrate sustainability of these effects, our results suggest a potentially scalable intervention for improving child feces disposal and reducing disease.

TRIAL REGISTRATION

This trial was retrospectively registered at ISRCTN15831099 on 18/02/2020, which was approximately two months after the first participant was recruited for the baseline survey on 02/12/2019.

Social competition drives collective action to reduce informal waste burning in Uganda

Improving urban air quality is a pressing challenge in the Global South. A key source of air pollution is the informal burning of household waste. Reducing informal burning requires governments to develop formal systems for waste disposal and for residents to adopt new disposal behaviors. Using a randomized experiment, we show that social competitions between pairs of neighborhoods in Nansana municipality, Uganda, galvanized leadership and inspired collective action to reduce informal burning. All 44 neighborhoods in the study received a public health campaign, while 22 treated neighborhoods were paired and competed to reduce waste burning over an 8-mo period. Treated neighborhoods showed a 24 percent reduction (95% CI: 11 to 35 percent) in waste burning relative to control neighborhoods at the end of the competition period. There is no evidence that treated neighborhoods experienced a rebound in waste burning several months after the competitions. Community leaders reported greater effort in coordinating residents and more pride in their neighborhood when assigned to the competition treatment. These results suggest that creating focal points for leadership and collective action can be an effective and low-cost strategy to address policy problems that require broad participation and costly behavior change.

The process, outcomes and context of the sanitation change induced by the Swachh Bharat Mission in rural Jharkhand, India

BACKGROUND

The Indian Swachh Bharat Mission (SBM) was launched in 2014 with the goal to make India open defecation (OD) free by October 2019. Although it is known that the ambitious goal was not achieved, the nature of the sanitation change brought about by the SBM in different parts of India is poorly understood. One reason is a dearth of case studies that would shed light on the performance of the SBM simultaneously across its different domains. This article provides an example of such study. Employing a Process, Outcomes, Context approach, the objective is to understand the process and outcomes of the SBM-induced sanitation change in a specific context of rural Jharkhand.

METHODS

The study utilizes data collected through field research conducted in the rural areas of Ranchi district, Jharkhand, a state in east-central India. This data was obtained via repeated cross-sectional household surveys conducted at the beginning and at the end of the SBM, supplemented by key informant interviews with SBM stakeholders.

FINDINGS

We identified political support of SBM implementation and its acceptance amongst the population. Female community workers became key agents of SBM implementation at local level. The SBM increased toilet coverage in the study area from 15% to 85% and lowered the OD rate from 93% to 26%. It substantially reduced structural inequalities in access to toilets, furthered social sanitation norms, improved some of the attitudes towards toilet use, but impacted less on hygiene and sanitation knowledge. The implementation mainly concentrated on the construction of subsidized toilets but less on improving public understanding of safe sanitation practices.

CONCLUSIONS

Although the SBM reduced sanitation inequalities in access to toilets in the study area, the behaviour change component was underplayed, focusing more on spreading normative sanitation messages and less on public education. Sustainability of the observed sanitation change remains a key question for the future. This article calls for more systematic production of geographically situated knowledge on the performance of sanitation interventions.

Decomposing rural-urban gap in unsafe disposal practice of child stool in India using nationwide sample survey data

A significant rural-urban disparity in unsafe child stool disposal practices exists in India, yet existing research falls short in identifying the contributing factors to this gap. This study addresses the research gap by contextualizing the rural-urban divide in unsafe child stool disposal using data from the fifth round of the National Family Health Survey (NFHS-5, 2019-21). In particular, the study examines the prevalence and predictors of unsafe disposal practices, exploring associated contributing factors to this gap. The study involves a sample of 78,074 women aged 15-49 with a living child under 2 years, without any missing data related to the study interest. Employing descriptive statistics, the Pearson chi-square test, multilevel logistic regression, and the Fairlie decomposition model, the research aims to fulfill its objectives. The rural-urban gap in unsafe child stool disposal practices among the study participants was 22.3 percentage points (pp), with a more pronounced gap among the Scheduled Tribes (ST). Notably, the gap was particularly wide in Madhya Pradesh (33.9 pp), Telangana (27.5 pp), Gujarat (26.1 pp), and Rajasthan (25.8 pp). Predictors such as mother's education, mass media exposure, household wealth quintile, and sanitation facilities proved significant irrespective of residence. However, religion, social group, and water facility on household premises emerged as significant factors in rural areas only. The study identified that 67% of the explained gap in unsafe child stool disposal practices was attributed to the rural-urban difference in household wealth. Other noteworthy contributors were 'household sanitation facility' (21.3%), 'mother's education level' (3.9%), and 'water facility on household premises' (3.9%). These findings underscore the need for population and area-specific policy interventions, especially for individuals from socio-economically disadvantaged backgrounds, those with lower education levels, and limited exposure to mass media, particularly in states with a high prevalence of unsafe disposal practices. Such interventions are crucial to mitigating the existing rural-urban gap in unsafe child stool disposal practices.

Exploring drivers of unsafe disposal of child stool in India using hierarchical regression model

BACKGROUND

Disposal of children's stools is often neglected in Indian sanitation programs, putting them at higher risk of diseases transmitted through the fecal-oral route. Therefore, the current study aims to identify the socioeconomic and demographic factors associated with the unsafe disposal of child stool in India and to estimate the geographical variation in unsafe disposal.

METHODS

The study used 78,074 births under two years from the fifth round of the National Family Health Survey (2019-21). Descriptive statistics, bivariate analysis with the chi-square test, and a four-level hierarchical logistic regression model were applied to accomplish the study objectives.

RESULTS

Findings revealed a 61.3% prevalence of unsafe stool disposal nationwide, significantly varying between rural (45%) and urban (67%) areas. Multilevel logistic regression highlighted that mother's education, wealth quintile, and sanitation facility were significant predictors of unsafe disposal of child stools. Random intercept statistics revealed a substantial geographical unit-level variance in unsafe stool practice in India.

CONCLUSION

The study emphasizes the widespread unsafe disposal of child stool among Indian mothers with young children below two years, and the study underscores a range of contributing factors, including education, media exposure, prosperity, water availability, and sanitation. It also accentuates the significance of the geographical variance in the unsafe disposal of child stool in India, particularly at the household level, followed by the community level. Hence, the findings underscore the importance of focused interventions, including targeted household-level poverty alleviation programs, initiatives to enhance sanitation and water facilities, and community-level public health awareness programs.

Examining toilet use and menstrual hygiene practices among beneficiary households of Swachh Bharat Abhiyaan (Clean India Mission) in rural areas of Mayurbhanj district of Odisha, India

Background

Basic sanitation and waste management have always remained a central issue in India. The country launched its flagship sanitation program - Swachh Bharat Abhiyan (SBA) (Clean India Mission) in 2014 to abolish open defecation and achieve universal sanitation coverage.

Objective

This study aimed to examine barriers to toilet use and women's menstrual hygiene practices in relation to the availability of toilets among rural residents.

Materials and Methods

Using a cross-sectional design and multi-stage sampling method, 120 households were selected from rural villages of the Mayurbhanj district of Odisha. Structured questionnaires and direct observation methods were used for data collection.

Results

All the houses had SBA latrines, yet 25% population defecated outside. About 40% households reportedly never cleaned their toilets. Most menstruating women (86.2%) preferred to change their menstrual pads/cloths in their bedroom instead of bathrooms. Incomplete construction was reported as the major reason for not using toilets. Large family size and low caste were found to be other predictors of non-use of toilets. Rural women did not use toilets for menstrual purposes as they do not consider these places as clean and safe.

Conclusion

This study clearly suggests that constructing toilets without adequate behaviour change interventions would not solve the problem of hygiene and sanitation in India, particularly in rural areas. There must be adequate monitoring of SBA scheme and utilization of funds for toilet usage. Development and implementation of suitable behaviour change strategies for toilet use in rural areas are essential to achieve the goal of open defaecation-free India.

Effect of Positive Deviance Approach on Promotion of Safe Disposal of Child's Feces in Rural Tamil Nadu: A Community-Based Quasi-Experimental Study

Introduction

Safe disposal of feces is ensured when it is deposited into a toilet, whereas unsafe disposal of child's feces plays a crucial role in disease transmission and environmental pollution. These areas are overlooked by many sanitation promotion interventions.

Objective

To determine the effect of positive deviance (PD) approach on safe disposal of child's feces among households who owned a toilet.

Materials and Methods

A community-based quasi-experimental study was conducted in the four field practice villages of the Urban Health Training Center, Villupuram, for 18 months. Households who owned a toilet and had a child less than 5 years old were included. After IEC clearance, information was collected from a representative sample of 100 households before intervention and another 100 households after intervention. PD approach was applied for 6 months to promote safe disposal practices in the study villages. Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software (version 24). The Chi-square test was used to determine the significance of difference between baseline and endline data. The effect size was calculated to estimate the magnitude of difference between baseline and endline data.

Results

Before intervention, only 3% of households disposed the feces into a toilet, while after intervention, almost 38% of households disposed in the toilet (χ2 = 37.39; df = 1; P = 0.001). The effect size (Cramer's V) was found to be 0.43.

Conclusion

PD approach demonstrated considerable improvements in safe disposal of child's feces in rural settings. Further, to sustain the behavior change, frequent reinforcement of key messages at frequent intervals needs to be emphasized.

BabyWASH and diarrhea prevention practices following multimedia educational intervention in hard-to-reach areas of the Afar and Somali regions of Ethiopia: a mixed-method endline evaluation

BACKGROUND

Water, sanitation, and hygiene (WASH) interventions, which are specifically targeted towards young children-known as "BabyWASH"-reduce exposure to environmental contamination and prevent microbial burden in their play and feeding environments. The purpose of this endline study was to evaluate the effectiveness and potential sustainability of a multimedia educational intervention in influencing key BabyWASH and diarrhea prevention practices in four hard-to-reach woredas (i.e. administrative districts) of the Afar and Somali regions of Ethiopia.

METHODS

A mixed-method, comparative cross-sectional study was conducted, which included 457 household surveys, 16 key informant interviews, and 8 focus group discussions. The multimedia educational intervention comprised: broadcasting radio talk shows and radio spot messages, capacity-building training for community health workers and community leaders, community mobilization campaigns, and the distribution of promotional print media materials. Propensity score matching analysis was used to estimate the effect of the multimedia educational intervention on key BabyWASH and diarrhea prevention attitudes and practices, which was then triangulated with qualitative findings.

RESULTS

The multimedia intervention had a significant positive impact on good BabyWASH and diarrhea prevention practices, including appropriate practices of child feces disposal (t-test = 5.17; p < 0.001), handwashing with soap or ash (t-test = 8.85; p < 0.001), maintaining separate playgrounds for young children (t-test = 2.83; p < 0.001), washing of child's body, hands, and faces (t-test = 15.78; p < 0.001), and food hygiene practices (t-test = 2.74; p < 0.05). The findings of the qualitative assessment also revealed that the multimedia intervention packages and the approaches used were successful in influencing key BabyWASH and diarrhea prevention behaviors in the intervention implementation woredas. In addition, providing capacity building training to local actors and community leaders and recording radio talk shows and sharing them with community members were recognized as effective intervention implementation strategies.

CONCLUSION

The endline evaluation found that the multimedia educational intervention improved awareness, perception, and practice of BabyWASH and diarrhea prevention behaviors in intervention woredas compared to control woredas. Sanitation and hygiene promotion interventions in pastoralist settings can be effective when using locally and contextually appropriate intervention strategies. However, considerations for integrating both behavioral and structural components in WASH interventions is essential.