Cluster-randomised trial to test the effect of a behaviour change intervention on toilet use in rural India: results and methodological considerations

Wolf-Peter Schmidt, Kavita Chauhan, Priya Bhavsar, Sandul Yasobant, Vaibhav Patwardhan, Robert Aunger, Dileep Mavalankar, Deepak Saxena, Val Curtis, Wolf-Peter Schmidt, Kavita Chauhan, Priya Bhavsar, Sandul Yasobant, Vaibhav Patwardhan, Robert Aunger, Dileep Mavalankar, Deepak Saxena, Val Curtis

Abstract

Background: Effective and scalable behaviour change interventions to increase use of existing toilets in low income settings are under debate. We tested the effect of a novel intervention, the '5 Star Toilet' campaign, on toilet use among households owning a toilet in a rural setting in the Indian state of Gujarat.

Methods: The intervention included innovative and digitally enabled campaign components delivered over 2 days, promoting the upgrading of existing toilets to achieve use by all household members. The intervention was tested in a cluster randomised trial in 94 villages (47 intervention and 47 control). The primary outcome was the proportion of households with use of toilets by all household members, measured through self- or proxy-reported toilet use. We applied a separate questionnaire tool that masked open defecation questions as a physical activity study, and excluded households surveyed at baseline from the post-intervention survey. We calculated prevalence differences using linear regression with generalised estimating equations.

Results: The primary study outcome was assessed in 2483 households (1275 intervention and 1208 control). Exposure to the intervention was low. Post-intervention, toilet use was 83.8% in the control and 90.0% in the intervention arm (unadjusted difference + 6.3%, 95%CI 1.1, 11.4, adjusted difference + 5.0%, 95%CI -0.1, 10.1. The physical activity questionnaire was done in 4736 individuals (2483 intervention and 2253 control), and found no evidence for an effect (toilet use 80.7% vs 82.2%, difference + 1.7%, 95%CI -3.2, 6.7). In the intervention arm, toilet use measured with the main questionnaire was higher in those exposed to the campaign compared to the unexposed (+ 7.0%, 95%CI 2.2%, 11.7%), while there was no difference when measured with the physical activity questionnaire (+ 0.9%, 95%CI -3.7%, 5.5%). Process evaluation suggested that insufficient campaign intensity may have contributed to the low impact of the intervention.

Conclusion: The study highlights the challenge in achieving high intervention intensity in settings where the proportion of the total population that are potential beneficiaries is small. Responder bias may be minimised by masking open defecation questions as a physical activity study. Over-reporting of toilet use may be further reduced by avoiding repeated surveys in the same households.

Trial registration: The trial was registered on the RIDIE registry ( RIDIE-STUDY-ID-5b8568ac80c30 , 27-8-2018) and retrospectively on clinicaltrials.gov ( NCT04526171 , 30-8-2020).

Keywords: Behaviour change; Bias; Sanitation.

Conflict of interest statement

None declared.

Figures

Fig. 1
Fig. 1
Study flow diagram
Fig. 2
Fig. 2
BCD concept, from [16]
Fig. 3
Fig. 3
Comparison of effect sizes resulting from the two questionnaire tools used in the study. The left side shows the effect size of the intervention on toilet use vs control (+ 5.0% for the main tool, + 1.7% for the physical activity tool). The right side shows the effect sizes on toilet use among participants exposed to the intervention vs those not exposed in the intervention arm (+ 7.0% for the main tool, + 0.9% for the physical activity tool). P values denote test for interaction
Fig. 4
Fig. 4
Comparison of baseline to endline change in reported toilet use in control arm across all 4 trials participating in the programme, adapted from [20]. The columns for Gujarat describe the findings from the present study

References

    1. Cumming O, Arnold BF, Ban R, Clasen T, Esteves Mills J, Freeman MC, Gordon B, Guiteras R, Howard G, Hunter PR, et al. The implications of three major new trials for the effect of water, sanitation and hygiene on childhood diarrhea and stunting: a consensus statement. BMC Med. 2019;17(1):173. doi: 10.1186/s12916-019-1410-x.
    1. Schmidt WP. Seven trials, seven question marks. Lancet Glob Health. 2015;3(11):e659–e660. doi: 10.1016/S2214-109X(15)00182-5.
    1. Sahoo KC, Hulland KR, Caruso BA, Swain R, Freeman MC, Panigrahi P, Dreibelbis R. Sanitation-related psychosocial stress: a grounded theory study of women across the life-course in Odisha, India. Soc Sci Med. 2015;139:80–89. doi: 10.1016/j.socscimed.2015.06.031.
    1. WHO, UNICEF . Joint Monitoring Programme (JMP) for Water Supply and Sanitation. 2014.
    1. Routray P, Torondel B, Jenkins MW, Clasen T, Schmidt WP. Processes and challenges of community mobilisation for latrine promotion under Nirmal Bharat Abhiyan in rural Odisha, India. BMC Public Health. 2017;17(1):453. doi: 10.1186/s12889-017-4382-9.
    1. Routray P, Schmidt WP, Boisson S, Clasen T, Jenkins MW. Socio-cultural and behavioural factors constraining latrine adoption in rural coastal Odisha: an exploratory qualitative study. BMC Public Health. 2015;15:880. doi: 10.1186/s12889-015-2206-3.
    1. WaterAid India. Feeling the Pulse. A Study of the Total Sanitation Campaign in Five States. New Delhi; 2008.
    1. Sinha A, Nagel CL, Schmidt WP, Torondel B, Boisson S, Routray P, Clasen TF. Assessing patterns and determinants of latrine use in rural settings: a longitudinal study in Odisha, India. Int J Hyg Environ Health. 2017;220(5):906–915. doi: 10.1016/j.ijheh.2017.05.004.
    1. Swachh Bharat Mission (Gramin) Dashboard. Swachh Bharat Mission Portal. . Accessed 10 Sept 2020.
    1. Curtis V. Explaining the outcomes of the 'Clean India' campaign: institutional behaviour and sanitation transformation in India. BMJ Glob Health. 2019;4(5):e001892. doi: 10.1136/bmjgh-2019-001892.
    1. Office N-NSS . SBM status Report. 2016.
    1. institute R . SQUAT survey. 2018.
    1. NARSS . National Annual Rural Sanitation Survey. 2019.
    1. Pattanayak SK, Yang JC, Dickinson KL, Poulos C, Patil SR, Mallick RK, Blitstein JL, Praharaj P. Shame or subsidy revisited: social mobilization for sanitation in Orissa, India. Bull World Health Organ. 2009;87(8):580–587. doi: 10.2471/BLT.08.057422.
    1. Lilje J, Mosler HJ. Effects of a behavior change campaign on household drinking water disinfection in the Lake Chad basin using the RANAS approach. Sci Total Environ. 2018;619-620:1599–1607. doi: 10.1016/j.scitotenv.2017.10.142.
    1. Aunger R, Curtis V. Behaviour Centred design: towards an applied science of behaviour change. Health Psychol Rev. 2016;10(4):425–446. doi: 10.1080/17437199.2016.1219673.
    1. Biran A, Schmidt WP, Varadharajan KS, Rajaraman D, Kumar R, Greenland K, Gopalan B, Aunger R, Curtis V. Effect of a behaviour-change intervention on handwashing with soap in India (SuperAmma): a cluster-randomised trial. Lancet Glob Health. 2014;2(3):e145–e154. doi: 10.1016/S2214-109X(13)70160-8.
    1. Seimetz E, Kumar S, Mosler HJ. Effects of an awareness raising campaign on intention and behavioural determinants for handwashing. Health Educ Res. 2016;31(2):109–120. doi: 10.1093/her/cyw002.
    1. Gautam OP, Schmidt WP, Cairncross S, Cavill S, Curtis V. Trial of a novel intervention to improve multiple food hygiene behaviors in Nepal. Am J Trop Med Hyg. 2017;96(6):1415–1426. doi: 10.4269/ajtmh.16-0526.
    1. The RICE institute: Promoting-latrine-use-in rural-india. .
    1. Chauhan K, Schmidt WP, Aunger R, Gopalan B, Saxena D, Yashobant S, Patwardhan V, Bhavsar P, Mavalankar D, Curtis V. 5 star toilet campaign-improving-toilet-use-rural India. 2019.
    1. Clasen T, Boisson S, Routray P, Torondel B, Bell M, Cumming O, Ensink J, Freeman M, Jenkins M, Odagiri M, et al. Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial. Lancet Glob Health. 2014;2(11):e645–e653. doi: 10.1016/S2214-109X(14)70307-9.
    1. Huda TM, Unicomb L, Johnston RB, Halder AK, Yushuf Sharker MA, Luby SP. Interim evaluation of a large scale sanitation, hygiene and water improvement programme on childhood diarrhea and respiratory disease in rural Bangladesh. Soc Sci Med. 2012;75(4):604–611. doi: 10.1016/j.socscimed.2011.10.042.
    1. Briceno B, Coville A, Gertler P, Martinez S. Are there synergies from combining hygiene and sanitation promotion campaigns: evidence from a large-scale cluster-randomized trial in rural Tanzania. PLoS One. 2017;12(11):e0186228. doi: 10.1371/journal.pone.0186228.
    1. Lewis HE, Greenland K, Curtis V, Schmidt WP. Effect of a school-based hygiene behavior change campaign on Handwashing with soap in Bihar, India: cluster-randomized trial. Am J Trop Med Hyg. 2018;99(4):924–933. doi: 10.4269/ajtmh.18-0187.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi