The study assessed whether a multi-level behavioural intervention can increase latrine use and safe disposal of child faeces in rural communities.
Odisha state has one of the lowest rates of sanitation coverage in India. According to the 2015-2016 India National Family Health Survey, coverage was only 23 per cent in rural areas. The sanitation context of rural Puri district, the location of this research, was better than the overall context of the state, with 36.8 per cent of households having an improved sanitation facility.
Findings from this study can inform the government of India’s efforts to be open defecation free by 2 October 2019.
- Is latrine use among people who own a latrine in communities that received the intervention significantly different at endline than among people who own a latrine in communities that did not receive the intervention?
- Is latrine construction by endline, among households that do not own a latrine in communities that received the intervention, significantly different from households that do not own a latrine in communities that did not receive the intervention?
- Are behavioural determinant scores (for social norms, ability, physical opportunity, risk perception, motivation, and self-regulation) significantly different at end line among owners of latrines in intervention villages compared to latrine owners in control villages?
- Are behavioural determinant scores associated with latrine use?
The multi-level intervention included activities at the community level (palla, a traditional folk art performance; transect walk marking faeces in village; community meetings; recognition of positive deviant households with banners; and a public wall painting mapping the latrine using households), household level (individualized visits to reiterate messages and motivate use; latrine repairs as appropriate), and group level (meeting with caregivers of children under age five to encourage safe child faeces disposal).
Theory of change
Informed by formative research and a literature review, we surmised that latrine use would increase by improving the physical environment, specifically by increasing access to functional latrines, by improving the social environment (norms) of latrine use and encouraging rejection of OD, and by targeting key ‘brain’ or psycho-social determinants like personal-level motivators (namely status, justice, comfort, disgust, nurture), ability to practice latrine use and safe feces disposal, risk perceptions associated with OD, and ‘self-regulation’ or ability to sustain the behaviors.
The intervention is expected to have an impact on these behavioural determinants and encourage latrine use. Specifically, the intervention aims to make people aware of risks associated with open defaecation and the health benefits of latrine use; instruct individuals as to how to use latrines and hardware for safe child faeces disposal; shift social norms around latrine use and non-use; motivate latrine use; encourage continued use; and provide facilities (latrine repairs) and hardware (potties, scoops) to enable use and safe disposal by all latrine owners.
This evaluation used a cluster randomisation that included 66 rural villages (33 intervention, 33 control) in Puri District, Odisha. Latrine-use data was collected from all latrine-owning households in each village at baseline and endline. Observations of latrines were conducted to assess their use and functionality. A subset of 20 households in each village received a survey that aimed to assess drivers of latrine use behaviour. Qualitative research was conducted post-endline to help interpret trial findings. Six additional villages (3 received the intervention) were engaged in qualitative research to assess a) village members’ perceptions of the intervention within a few weeks of delivery and b) whether or not non-intervention communities near intervention communities heard any intervention messages (spillover).
This study reports differences in use and uptake by age and sex.
Latrine use increased in both intervention and control communities. The study found an increase in reported latrine use among individuals aged 5 and older in 6.4 per cent in the intervention group at endline after accounting for the increase in latrine use observed in the control group. Latrine use increased among females (aged 5+) by 6.6 per cent in the intervention group at endline and among males (aged 5+) by 6.1 per cent.
The study found an increase in reported safe child faeces disposal of 20.4 per cent in the intervention group at endline, after accounting for the increase in safe disposal of child faeces observed in the control group.
No difference was observed between intervention and control groups in the proportion of households that did not have a latrine at baseline and the proportion that had one at endline. Physical opportunity, ability, and social norms behavioral scores were all significant predictors of latrine use (favorable scores were associated with latrine use). Scores for motivation, risk perception, and self-regulation were not. Scores were similar at baseline and endline for all behavioural determinants.
The intervention had an incremental cost-effectiveness ratio of 47.05 USD per household – that is, a cost of 47.05 USD to improve latrine use of one household that experiences some level of exposure to the intervention.
Implications for implementers
The intervention did not reach all eligible participants. Implementers need to invest time in understanding village dynamics that may influence program delivery to ensure all are able to access and participate in intervention activities.
Implications for policy and practice
The intervention influenced latrine uptake, but efforts are needed to sustain uptake. Latrine use should be viewed as a long-term, continuous investment. In addition to further investment to change behavior of non-latrine users, the government should invest in strategies to enable and motivate continued use.
Implications for further research
Researchers should investigate strategies for maintaining latrine use behaviour, and conduct qualitative research and rigorous process evaluations to gain a rich understanding of how interventions are implemented and perceived, and what opportunities exist for improvement.
CARUSO, B. A., SCLAR, G. D., ROUTRAY, P., MAJORIN, F., NAGEL, C. & CLASEN, T. 2019. A cluster-randomized multi-level intervention to increase latrine use and safe disposal of child feces in rural Odisha, India: the Sundara Grama research protocol. BMC Public Health, 19, 322.