The 5 Star Toilet Campaign is a scientifically designed programme based on the theory and process of the behaviour-centred design (BCD) framework (Aunger and Curtis, 2016). The study assessed how behaviours can be changed by addressing the key drivers of toilet use targeted through this programme.
Over the past four decades, the Indian government has taken several steps to improve toilet coverage. In 2014, the launch of Swachh Bharat Mission (SBM) provided impetus to toilet construction and focus on toilet use increased through communication and behaviour change activities. Almost 3 million toilets have been constructed in Gujarat since 2014. Some of them have been built by households on their own, other households used the government’s subsidy or they were built as part of toilet construction programmes. The quality of toilets built as part of these programmes ranges from satisfactory, to poorly constructed, to dysfunctional. Beneficiary involvement is often limited to signing up and providing labour, while toilet use is often sub-optimal.
Formative research has shown that households who built their own toilets (alone or with the subsidy), were more likely to be committed users. The reason behind the commitment include: aspirations for a better life, social status, pride in owning a toilet, convenience, time saving, scarcity of space for open defecation (OD), the physical difficulty of squatting in the open, OD being perceived as dirty, and privacy. Reasons for OD included: an incomplete or poorly-built toilet; lack of engagement with an alien ‘government toilet’; desire to limit use to prevent pit filling; preference for fresh air; poor initial use experience associated with a bad smell; and, a ‘packed’ feeling, preference for sticking to routine of going to the fields to defecate (particularly among men), limited water supply for flushing, and traditions concerning child faeces disposal.
Does an innovative, theory-based intervention increase toilet use of all members in a household with government or contractor-built toilets in intervention clusters compared to control clusters in Bhavnagar, Gujarat, India?
The overall purpose of our study was to learn how to improve toilet use in rural India. The specific aim of this study was to evaluate the effect of the ‘5 Star Toilet’ campaign on toilet use by all members of a household aged 5 years or older. The intervention aimed to address the complex determinants of low toilet use in rural Gujarat and improve toilet use among all members of a household with government or contractor-built toilets in selected villages of Bhavnagar, Gujarat.
The ‘5 Star Toilet’ intervention was rolled out by our implementation partner Coastal Salinity Prevention Cell from mid-September to December 2018. The intervention was delivered by two teams comprising three trained facilitators per team and locally trained performing artists. The time gap between Day 1 and Day 2 intervention delivery in each cluster was around 4 weeks. This was based on the overall project timeline and intervention schedule. The intervention was delivered in Talaja (21 clusters), Mahuva (19 clusters) and Palitana (7 clusters) blocks of Bhavnagar, Gujarat.
Theory of change
The ‘5 Star Toilet’ campaign used the BCD framework and theory of change to design its intervention (Aunger and Curtis 2016). BCD uses design thinking for the process of designing and testing interventions. BCD addresses both psychological and environmental determinants of behaviour and has a built-in design process suitable for intervention design and delivery.
The ‘5 Star Toilet campaign’s theory of change consisted of different streams of activity.
The overall campaign theme was the ‘world is getting smarter’, and ‘smart people build smart toilets’. A smart toilet was one with 5 Stars/ 5 Star+. The central concept is that ‘smart’ people have modern toilets, which are like ‘5 star’ hotels in being the best quality. This introduces a sense of social competition within a village to have the best toilet, and associates household sanitation with the social status of that household in the community. In this concept, each star stood for an aspect of comfort (light, ventilation, water), aesthetics (paints/ patterns and cleanliness) and ‘+’ stood for inclusivity (support and toilet chair for old, disabled). The intervention components include 5 Star Toilet makeover promotion, addressing pit filling/emptying anxiety (i.e. it takes longer for a pit to fill and the compost does not smell), community motivational events (all the smart people are using toilets because it saves time and effort) and to create new social norms aiming to change the environment of the target population. The campaign aimed to inspire the community and encourage them to revalue their toilets by recognizing that they provide benefits associated with the motives of hoard, create, convenience (comfort) and affiliation, and provide a reward pathway for transitioning to a new toilet use routine.
The intervention was delivered at cluster level to reach households with government or contractor-built toilets. Our assumption was that exposure to this environmental change will influence the psychology of those in the target population -- i.e. all members in a household, especially men, to value their toilets -- and thus modify their government-built toilets by painting the walls and installing features like ventilation, light, toilet chair for elderly or people living with disabilities that enhance the user experience. This was expected to prompt them to improve their existing toilets and change their behaviour from open defecation to using their contractor-built toilets which, in turn, may impact health and well-being in the long term. The households were not provided any materials or money to undertake these changes. The intervention aimed to initiate a cascade of changes by providing activities that are surprising, cause revaluation of the target behaviour and affect the performance of the behaviour in its setting.
The ‘5 Star Toilet’ campaign was a cluster randomised trial conducted in 94 clusters in four blocks (taluks) of Bhavnagar district in Gujarat which aimed to evaluate the effect of this intervention on toilet use behaviours. The baseline survey had included about 10 households per village, which were then excluded from the endline survey. The endline survey enrolled a new set of households from the census data.
The primary unit of analysis for the trial was the household and the outcome of interest was the proportion of households (assessed in n = 30 households per cluster) that report use of toilets by all household members, measured 6 weeks after intervention delivery through self-reported and proxy-reported questionnaire survey and an additional tool masking open defecation questions as a physical activity survey. The end line study consisted of: (1) the physical activity survey administered in 30 households and 2 members per household in 94 clusters, followed by (2) a questionnaire survey to understand toilet use in 30 households in 94 clusters and (3) process data collected from 4 clusters (2 from each study arm) during and after the intervention delivery period to assess implementation of the campaign.
The endline study findings did not show clear evidence for a relevant effect of the intervention on toilet use in the intervention setting. The small increase in toilet use by all household members aged above 5 years was below the anticipated effect size for which the study was powered. We observed a small increase in toilet use of 7.0 percentage points which was attenuated to 5.5% after adjusting for sample population imbalances. The physical activity tool which attempted to measure toilet use less intrusively showed a 4.4 percentage points lower prevalence of toilet use with only a 1.7 perecentage points higher prevalence in the intervention arm. The process evaluation suggested that low exposure of the target population to the intervention may be a possible cause for the results. Only about 10-15 per cent of the intervention households showed evidence of exposure to the intervention. Further analysis revealed that this small exposure was insufficient to change the population’s perceptions around toilet ownership and other relevant sanitation-related factors. Small positive changes in toilet features and proxy markers of current use were observed but statistical support for these small changes was low and could have occurred by chance.
This study presents important lessons for designing programmes related to behaviour change. The intervention was delivered in clusters with already high levels of toilet coverage and use which appears to have reduced the proportion of the population that could have benefitted from the intervention. Thus, the results underscore the need to identify a suitable target population for future interventions aiming at increasing use of existing toilets. From the implementation perspective, this strongly reduces the efficiency of an intervention if it mainly consists of activities performed at the community level. Better targeting of the intervention to households that are not currently using their toilet fully could be key to improving the effectiveness of the campaign and making it more efficient from the cost perspective. Sufficient time and resources for iterative intervention development and pilot testing could help to maximize the potential of this kind of an intervention approach.
The campaign concept and components have been taken up by other important actors in the sector, including the regional government and Tata Trusts. This kind of impact on government and other civil actors may eventually result in the research having real consequences for toilet use in Gujarat and further afield.