This mixed method impact evaluation assessed the effectiveness of sanitation programming on women’s psychosocial stress in two districts of rural Bihar. However, the evaluation could not be completed as per the original study design. Due to tensions between community members and the survey team, the endline survey had to be called off (see methodology section for details). It therefore draws on quantitative baseline findings, as well as qualitative data collected at baseline and endline.
The study was carried out in two districts in rural Bihar – Gopalganj and Paschim Champaran. The government has made increasing sanitation access and use a national priority, most notably through the Swachh Bharat Mission (Clean India Mission) - a national programme to eliminate open defecation in India by October 2019.
Research questions for the proposed evaluation were:
- What is the effect of the Global Sanitation Fund (GSF)-supported intervention on sanitation-related psychosocial stress, generalised psychosocial stress, perceived quality of life, hair cortisol and urogenital health among women between the ages of 14 and 60?
- What is the effect of the GSF-supported intervention on sanitation adoption (e.g. sanitation access and exclusive use) among individuals and households receiving the GSF intervention?
- What are individual and community experiences with sanitation, intervention participation, and latrine construction and adoption?
The original mixed-method impact evaluation design changed due to parallel sanitation activities in control areas. The new evaluation design was around a treatment and dosage model measured differentially across project areas. However, tensions between the endline survey team and village members on the issue of hair sample collection resulted in the survey team being detained by local law enforcement. Matters became highly politicised among local officials. As a result, the endline survey and quantitative analysis had to be terminated. This study therefore uses data from the baseline survey, baseline and endline ethnography, along with a range of key informant interviews with village and district-level stakeholders.
The study showed that when the GSF-supported intervention was successful, it had an impact on sanitation coverage and use and women’s psychosocial stress. In general, women reported that an individual household latrine reduced environmental, social and sexual violence stressors. This is in-line with baseline quantitative findings which saw 48 per cent lower sanitation-related psychosocial stress scores among women with access to a sanitation facility. Some gendered stressors are not relieved by access to sanitation and will likely require addressing gender-related social norms. The dominance of household-led construction over contractor-led construction in many villages also opened new areas of stress for women.
Reducing psychosocial stressors – particularly environmental and social stressors – were often the main reasons cited for building individual household latrines. These findings contradict other studies in India that suggest preferences for open defecation among women in rural areas and disgust related to individual household latrines. Women in the study areas reported the benefits and quality of life improvements they had experienced after building a household latrine. This may reflect societal changes in attitudes towards defecation and toilets in recent years, with the increase in attention given to sanitation at the national level.
Despite improvements among some households, consistent and uncoordinated implementation has limited progress on sanitation adoption and use. While greater gains were realised in villages where contractors managed village-wide construction, this was pursued at the expense of women’s sanitation preferences. Facilities were built to specification but did not include additional amenities that women preferred. Further, contractor-led construction presented opportunities for corruption and exploitation of Swachh Bharat Mission systems. Models that bring together the best of both approaches – such as ensuring contractors provide households with a range of sanitation options – could accelerate progress and ensure consistent use; although necessary oversight and monitoring would be needed.