Development of a Behaviour Change Intervention to promote latrine use and reduce open defecation in rural India

doi:10.21203/rs.3.rs-2739118/v1

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Research Article

Development of a Behaviour Change Intervention to promote latrine use and reduce open defecation in rural India

https://doi.org/10.21203/rs.3.rs-2739118/v1

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published 06 Nov, 2023

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Objectives

Conduct a formative research and feasibility evaluation of behavioural intervention designed to improve latrine use in rural India.

Methods

Study conducted in four villages of Rajasthan, where latrine use is low and open defecation may spread disease. To identify the intervention, we conducted a literature review, a survey of 497 households, focus groups in village households (8–10 women and children). We also conducted seven focus groups with 63 women. Based on the survey results, we developed behaviour change intervention utilising on the Capability-Opportunity-Motivation-behaviour model and MINDSPACE framework. One intervention component involves psychological aspects that engage villagers through a pledge; the other component is provision of small incentives to facilitate latrine use. We also examined whether our intervention is feasible and acceptable in our study population. We delivered the 30-day intervention to women in 38 randomly selected households who despite having a functional latrine did not use it. Post-intervention, we obtained feedback from 22 participating households.

Results

Analysis involved thematic analysis, binary logistic regression analysis and feasibility evaluation of the intervention. We found the piloted intervention was feasible and so offer a revised design. Results driving this evaluation include barriers identified, and used to improved intervention design in the current study. Village authority figures influenced behaviours across the villages and so did factors of convenience (β = 5.28, p = 0.00), relief (β = 5.49, p = 0.00), comfort (β = 2.36, p = 0.00), Construction cost (β=-1.98, p = 0.00) and safety (β = 2.93, p = 0.01) were significant concerns associated with latrine use in the context of prevalent OD in the region. The logistic regression baseline model for the dependant variables indicated a significant increase in latrine use. Based on the feasibility study, we refined our intervention in several ways.

Conclusions

Our theory-driven approach improves latrine use in Rajasthan and offers a useful tool to facilitate hygiene behaviour.

Latrine use

open defecation

rural perceptions

behaviour change intervention

The practice of open defecation (OD) is widespread in rural parts of India where latrine use is alarmingly low. Globally, India has the highest number of people defecating in open fields, near waterways and around trenches. This can cause serious disease in society [1, 2] while raising infant mortality and damaging human capital [3, 4]. Villagers experience psychosocial stress due to the risk of physical attacks OD carries. These include rape, molestation, snake and mosquito bites, as well as foot injury, as many villagers have no shoes [5-7]. Latrine use is a safer alternative that improves sanitation conditions and curbs the spread of disease in populations [8]. Causing an estimated 13% mortality rate associated with OD practices.

India’s government launched the Total Sanitation Campaign in 2000, relaunched as Nirmal Bharat Abhiyan in 2012 and as Swachh Bharat Abhiyan in 2014. Its purpose was to improve coverage by building infrastructure (i.e. latrines and access) and providing incentives for the population. Coverage includes households with access to latrines and sewerage [9] and does not necessarily mean increased latrine use by the population. Moreover, reporting the number of latrines installed, notwithstanding their quality, is simpler than recording behaviour of the population that is shown to be highly variable across India [10-12]. In some areas of India, such as rural Kerala, there has been 100% latrine coverage reported. However, at the other end of the spectrum, 48% coverage has been reported from Bihar state of India. Similarly, in rural Odisha, India, despite coverage, fewer than 50% of households with latrines reported using them at all times [1, 13].

Studies highlight dysfunctional infrastructure as a barrier to latrine use [5, 9, 12, 14]. Latrines should work and be well maintained to encourage use [1, 15]. Poorly constructed latrines tend to be lower-quality and less appealing to users. Studies also highlight poor water quality and availability as a barrier. People may avoid latrines that do not provide sufficient water supply and lack septic tanks, where pits are not covered [16]. Other structural features include the presence of a roof and side walls to provide privacy, a drainage system and accessible location of the latrine [17]. Another major factor in latrine uptake is culture [9]. Choosing OD over latrines is a decision influenced by longstanding habits, rituals, caste, lifestyle routines, gender, age and marital status [5] with mortality at above 10% of the population of India. In rural areas of India, upper caste individuals usually have better access to latrine facilities and water, compared to individuals from lower classes. In tandem, individuals and families of lower caste prefer defecating outdoors because it can be more practical and convenient [5, 18].

The implementation of the Total Sanitation Campaign in India also highlighted the importance of caste. An example is the building of school latrines in villages where lower caste students were forced to clean the toilets [9, 19, 20]. Thereby discouraging latrine use because of negative perceptions. It has been noted that if women had decision-making power across households, more latrines would likely be used [21]. Some women eat less so they do not have to go out at night to defecate [22], which has dire effects on their health. Studies also found that men are often not responsive to the challenges women face in practicing OD [23]. In this regard, marital status is also a factor in latrine use and OD. A study reported that in parts of rural India, before agreeing to marry a husband, women showed a strong preference for the ownership of latrines [24].

Education and awareness are other crucial behavioural factors underlying latrine use. A study in rural Timor found that educated individuals were most likely to use latrines [25] because they were aware of the harms of OD and the benefits of latrine use. A study of rural coastal Odisha in India reported that during their formal education, hostel students exposed to latrines were likely to take up the habit. They were also more likely to be high caste individuals with the financial means to obtain formal education [5]. Despite the strength of education, OD may persist because in some cases, it may be deeply embedded as a social practice in rural communities.

In north India’s rural areas, despite access to latrines, some villagers preferred OD because they saw it as more comfortable, pleasurable and convenient [3]. Another reason to explain preferences for OD was found by a study of a village in Nepal where the practice enabled socialization. Friends had used open fields growing up. It was a time in the morning to share stories, neighbourhood gossip and to plan the day [26]. Literature shows that some interventions to improve adherence target infrastructure, some target socio-cultural behaviour and some interventions aim to target a combination of these two factors [5, 9, 11, 26]. A study commissioned by the World Health Organization advocates the need for interventions [9]. Our aim was to develop and conduct a formative evaluation of our intervention to improve latrine use in Udaipur Rajasthan, India. Our study aimed to address three questions.

What are the barriers to latrine use in this part of India?
Can we co-design a theory-driven behavioural intervention and does a preliminary examination show that the intervention is feasible and acceptable?
What solutions could help increase latrine use?

Study Design

The study is organised into stages that involve surveys and focus groups to understand barriers to latrine use. Informed by this understanding the development of theory-informed intervention is presented, further revised through evidence and expert consultation and feedback procedures outlined in this section.

Qualitative and quantitative data was collected to determine reasons for poor latrine use, and inform intervention design choices that make our intervention feasible. A multi-village survey was conducted using tablets, on which surveyors were trained. Quantitative data were collected through software Kobocollect which can be installed in a mobile phone (see appendix 6) Discussions took place in the field around villages, in the event queries were faced by the surveyors in the field, guidance by experts (researchers, Seva Mandir, the village head known as the Sarpanch) was available through discussions around village sites engaging issues on-site.

The four villages - and their adjoining hamlets are located in Udaipur district. It was found that houses were semi-pukka or pukka[1] in the main village. However, most houses in the hamlets were kutcha (composed of materials including structures made of clay, brick, cement, and organic mixtures of stone). 228 out of 497 sample households were below poverty line and 20% of the total sample covered did not have latrines. Despite the fact that nearly 80% households had latrines, the observed latrine use was only 37 %[2].

The quantitative survey covered all individuals across 497 households in total, with 404 households from tribal communities. The qualitative survey included observations, focussed group discussions (FGD) with women and children in groups of eight-10 and in-depth interviews with women. The barriers identified through the qualitative survey were discussed to corroborate findings and new barriers if any, were noted. The FGD elicited responses concerning the notion of small improvements such as buckets, soap and cleaning equipment. The assertion is that adding the provision of items to our intervention would encourage use of toilet by removing barriers. Village leaders including the Sarpanch (i.e. village head) and influencers such as ASHA (accredited social health activist) workers and Anganwadi workers were also consulted to understand their efforts towards ending OD. To further facilitate our understanding data was also collected on landholding patterns, water source and availability and cost-sharing for latrine construction. This provides structural context for our interpretations. Questions were also posed around perceptions of latrine use, reasons for OD preference, perception of extent of latrine use by others in the community (See Appendix 2 and 4, pilot plan and script to shape our intervention).

Theory – This stage identified design and implementation of the pilot intervention in villages located in the Udaipur district of India (villages see table. 2). We chose a behavioural intervention designed based on systematic behaviour change theory. Specifically, the COM-B framework posits that human behaviour is an interacting system, where capability (physical and psychological), opportunity (social and physical) and motivations (automatic and reflective) interact to generate behaviour [27]. The adjusted model provides a frame for our research.

Figure 1

In our adapted model, the behaviour of concern is adherence to latrine use, whilst seeing open defecation as detrimental and indicative of poor hygiene behaviour that spreads disease. Our intervention builds capability of villagers (physical ability through provision of items, see appendix 1 items) and psychological capacity though a pledge of commitment.

Figure 2

Drawing on the MINDSPACE principles of social dynamics, human psychology and behaviour, our underlying assertion relies on automatic behaviour tendencies. These responses are in figure 2 represented as the messenger, incentives, norms, saliency, priming, affect, commitment, Ego – MINDSPACE mechanisms. They underline the COM-B structure, and explain automatic behaviours amenable to intervention conditions with the aim of changing latrine use behaviour, more specifically, the likelihood of significant outcome.

Principles from the MINDSPACE framework identify robust behaviour change mechanisms that predominantly operate through automatic motivational processes. This framing further sharpened our focus [28, 29]. The framework provides guidance on tools to change behaviour within the broader parameters of the COM-B model (refer to appendix 1 commitment explanation).

In this respect, the use of theory was an advantage in conceptualising our approach and integrating understanding of hygiene behaviour and habit formation. Research shows that behaviour change from OD to latrine use bears similarities with ‘treatment adherence’. It was found that the key barriers to treatment adherence were the absence of adequate positive feedback, especially in the initial stages, lack of tangible benefits / rewards for adherence, long term impact of non-adherence and lack of routine. Our solution is a commitment tool, which aimed to facilitate the creation of a new habit.

Inclusion criteria

The sample selected was representative of demographic indicators such as caste, economic status (whether above poverty line (APL) or below poverty line (BPL)) and religious demographics in Udaipur.
Villages where defecation in the open is high and latrine use is low, including villages declared OD-free by the government.
All willing members of the HH (household) will be included.
Kucha and pukka HH.
A working toilet located in the HH

The Socioeconomic Context

The research area is located in Udaipur District of Rajasthan and is largely tribal. The main forms of livelihood in the area include agriculture, farm labour, livestock rearing, dairy, skilled work and private businesses. Levels of access to water vary and while some households have their own water sources through tube-wells or wells, other villagers depend on public sources. Hand pumps are available though they tend to run dry during peak summers. Eco-san, septic tank and twin pit latrines are prevalent in the area. Most of the latrines had been constructed in the last two years (see appendix 5). The SBM was anchored by the Department of Rural Development and Panchayati Raj in the Rajasthan area.

Developing the Variables – We developed independent variables through a series of steps. This involved reviewing the literature, discussions with Seva Mandir representatives trained to collect data, comprehensive observation of on-site infrastructure related to access and ease of use, the use of templates for standardisation of variables and constructing items that collectively represent various aspects of the independent variables we discussed and finalised. The dependent variable is latrine use in this model. The variables represent barriers targeted using the provision of incentives in the intervention design.

During the preparatory phase of the project, members of village panchayat (council) also participated in most discussions. Thus, communities were directly involved in developing the content (questionnaires, measurement tools) of the proposed research.

Data Analysis

Qualitative data analysis involved critical discussions across focus groups, conducted with the various village heads called “the Sarpanch”. Participants include community workers who provided a grounded perspective during discussions. The data from the focus groups was analysed using thematic analysis. Groups consisted of expert academics, who in sessions with practitioners (social workers with NGOs) and Sarpanch’s guidance, identified barriers that seem meaningful and important in the decision to use a latrine.

To quantitatively evaluate barriers to adherence, post intervention implementation, the data was cleaned, reviewed and binary logistic regression is performed on survey data [SPSS 25 v.25] measured by encoding “other than only latrine use” into 0 and “only latrine” into 1 as nominal categories. We selected a range of independent variables pertaining to; household and village infrastructure, financial constraints and social status, logistics and access including convenience, and behavioural responses. Including a range of emotions and perceptions of latrine use (see appendix 3 - list ordinal and nominal variables); tests conducted include omnibus test.

[1] Semi-pukka are households made of a mix between hard durable material, such as cement and less durable materials like clay or bamboo. Pukka houses are made of durable high-grade materials (e.g., stone or cement).

[2] Some contributing factors identified for low latrine use were poor water availability, incomplete construction, complete but poor construction and attitudinal barriers.

What are the barriers to latrine use in this part of India?

We present the results of implementing our intervention through a revised binary logistic regression. These results show whether the intervention worked to identify barriers to latrine use. The discussion section follows with regard to design and theory guiding our intervention design, application and subsequent evaluation for feasibility.

The omnibus test indicates an improved and significant fit of the revised model to data (p=0.000). In the category only latrine use, correctly classified (n=204) and misclassified (n=12). In the category other than only latrine use, correctly classifies (n=174) and misclassifies (n=8). Overall, an accuracy of 95% reported. The logistic regression baseline model for the dependant variables indicated “Only latrine” use likely to be correct 53.3% of the time. Hygiene behaviour that is convenient and provides desired relief is a significant factor associated with the likelihood of latrine use. If latrines are not complete in construction due to costs, then convenience of OD seems attractive to villagers. Survey results show that BPL families are more likely to use a latrine compared with APL families, indicating social status as a significant influence. In terms of infrastructure barriers, the presence of latrine inside the house (latrine location) increased the likelihood of use. Increase in the cost of constructing the latrine and monthly expense per household were both likely to increase use of a latrine. Comfortable latrines increased the likelihood of their use, while villagers who saw latrines as less convenient were less likely to use it.

Table 1 summarizes the logistic regression analysis results showing details for significant independent variables measured in associated with likelihood of latrine use.

Table 1

In terms of social influences, HH without latrines were facing pressure by others in the village to use this new technique. Villagers who perceived that a high proportion of HH use latrines were less likely to use latrines. We also found that villagers who felt happiness, relief and safety when thinking about latrines were more likely to use them.

Despite toilets present in HH, women in the villages found it difficult to haul enough water, a task men will not do. For example, in village C, one woman said that while toilets are convenient and safer, lack of water availability was a key barrier to her latrine use. She said that she practiced OD due to this shortage.

Through fieldwork in the villages, focussed group discussions and commitment engendering visits to HH for interviews, we identified a range of barriers and behaviours. These impeded the use of toilets and provided reasons for the continuing practice of OD. Scarcity of water was a barrier in all four villages. Table 2 summarizes the water-related barriers encountered during the research fieldwork.

Table 2

In relation to the infrastructure issues presented in table 1, some EcoSan toilets were found in the two villages. We also found design flaws and structural deficiencies. In the village, the quality of latrines was especially poor where private contractors had constructed the toilets (appendix 5).

In order to construct toilets, villagers were told to use their own funds, reimbursable at a later date by the government. But many villagers ran out of funds and were left with incomplete latrines. This left them without government reimbursement, obtainable only by completing the construction. Thereby, villagers were placed in a hopeless situation. Also, we found age to be a factor in uptake. Specifically, older villagers found latrine use difficult. Likewise, those with illnesses also struggled.

Discussions revealed that awareness of the benefits of latrine use and the health and hygiene hazards associated with OD was almost non-existent in the villages. Absence of this awareness meant it was easier to prioritise other water-related activities including cooking, drinking and cleaning. There was also lack of awareness about sanitation procedures to do with regular pit emptying. Most villagers had not been educated about hygiene procedures, which may likely become an issue going forward. Literacy across the villages for Rajasthan are reported at 79% male, 52% female and 66% overall, among the lowest in India [30-32]. Other studies reported literacy at 66.1% [33], 62.71% [34] and 67.10%-below the national average of 74.04% [35].

In the villages, we found unused government constructed toilets, which further reflected our concern for low latrine use and the preference for OD by villagers. Informal attempts to raise awareness were found on wall writings across villages, which talked of the need to use latrines (appendix 5). The assertion holding that villagers could read and interpret writings. This highlighted that emotions like shame at not using latrines and participating in OD instead, and fear of the Sarpanch (head of the village), may be associated with higher latrine use and less defecation in the open. Whether the village sarpanch can influence villagers and what qualities as influence, presents area for further inquiry and development research to inform policy level actions.

In brief, our findings were:

(i) Capabilities and Opportunities: 20% of households were still without a latrine. Observed usage was 37% and varied across our four villages (survey answers were matched with observation of whether the latrines look like being used). Only 53% reported that all members of the household used the latrine (35% continued to defecate in the open, and 12% did both). Usage was generally higher among women for reasons including convenience and safety, and amongst wealthier households. Older people who used latrines often did so due to restricted mobility because of age and health conditions. Another barrier related to capability was cleaning: respondents had a limited awareness of how to clean their latrines daily, and an unrealistic idea of the costs involved. Opportunity (i.e., infrastructure) was a key barrier to latrine usage; water (75%), maintenance cost (45%) and pit size (36%) were the most commonly cited concerns.

(ii) Reflective Motivations: The most prominent issue was latrine ‘experience’: 31% believed that the latrine was dirty and unsuitable to be placed within or even near their home; smell was a concern for 29%; and comfort for 15%. Householders also felt that the latrines were a long way from being ‘their’ toilets, indicating a lack of sense of ‘ownership’.

(iii) Automatic Motivations: People were ‘habituated’ to defecating in the open, and considered the idea of using a latrine alien, with some also reporting feelings of claustrophobia and disgust.

Feasibility and acceptability of the intervention

After the formative research, we asked the question “Can we co-design a theory-driven behavioural intervention and does a preliminary examination show that the intervention is feasible and acceptable?” We developed the intervention by reviewing the literature and applying COM-B to address the psychological and practical barriers to latrine use which we found in the formative research. The intervention comprises three elements (see the Appendix).

(i) Capabilities and Opportunities: We discussed with the households their barriers related to psychological and physical capabilities, and physical and social opportunities. We addressed the barriers identified by educating (e.g., explaining how to use and clean the latrine) and correcting false beliefs (e.g., about water supply and costs involved). Such education improves capabilities and also helps people find opportunities to conduct the behaviours [50].

(ii) Reflective Motivations: In order to change the most important self-reported (reflective) reason for not using the latrine – negative experience – households were able to choose improvements to this experience. Each household choose two bespoke ‘small improvements’ from a pre-selected list (e.g., air freshener, light, water tool etc.) to make and install inside their latrine; thereby improving the ‘experience’ of using the latrine and also increasing the sense of ‘ownership’. The second component involves provision of small incentives in terms of tangible materials to promote latrine use based on barriers identified. These include items such as buckets with mugs, soaps, brushes, toilet fresheners, solar lights and windows / ventilation for toilet. The team intends to measure latrine use through a combination of the following methods:

Paint: This will be used around the latrine pit where people put their feet then revisit after regular intervals of 3 months to see how worn it is.
Dipsticks: That fit around toilet pipes which would be used as a measurement tool at the start and end of a definite period (roughly 6 months)
Toilet Soaps / Scrubbing Bubbles: These wear away as people use the toilet, thus reflecting extent of use. A limitation is that soap might be used for general hygiene. Here the commitment and pledge induced volition and will to participate is a biasing factor (see appendix 1).

(iii) Automatic Motivations: The small improvements should also tackle feelings of claustrophobia (e.g., light, window) and disgust (e.g., air freshener, water tool). Specifically, the provision of soap and other hygiene items for instance fundamentally facilitates changing perceptions about difficulty to using latrines. This is encapsulated in variables that are itemised, including convenience, cost, comfort or emotional responses - see table 1. In combination with a pledge based on MINDSPACE principles and treatment adherence tendencies, the intervention furnishes double-sided impact on perception of latrine use and its overall attraction in terms of a family level commitment.

The most important reported automatic motivational barrier was habitual open defecation. Commitments are known to break old habits and initiate new habits [51]. Psychological commitment occurs because we (automatically) seek to be consistent with our public promises to stick to specific goals or plans. Householders were asked to commit by signing a behavioural contract that contains the statement “This household is committed to using our toilet for next 28 days because we care about the health of the children of our village”. The contract was printed on a poster, which will be displayed somewhere prominent in their home to increase its ‘salience’ (we attend to what is novel and seems relevant to us). Four weeks is a sufficient period to develop a new everyday habit [51].

The intervention utilizes several commitment techniques that tap into those psychological processes by also utilizing Messenger, Incentives, and Ego mechanisms of change [28]. The poster also contained a photo of the family in order to increase the salience of the long-term goal – the health of the family. The poster also showed a calendar and provided ‘incentives’ to reinforce the new habit – ‘smiling face’ stickers [52]. Women were instructed to put a sticker on the calendar only after observing everybody in the family using the latrine on each day. In order to enhance the commitment, the poster showed a picture of human eyes which motivates compliance by subconsciously ‘priming’ (activating) ideas about ‘being watched’ [53] (we posted female eyes because the women took on the stewardship of our intervention).

Feasibility Study. As part of the funded formative research, we examined whether our intervention is feasible and acceptable in our study population. We conducted seven focus groups with 63 women and delivered the intervention to women in 38 randomly selected households who despite having a functional latrine did not use it. The intervention was delivered in Hindi, according to a standardised protocol (see English version in the Appendix). Post-intervention, we obtained feedback from 22 participating households. We found that 79% of households chose to make the 30-day commitment to using their latrine. The barriers discussion and selection of small improvement items were the most preferred intervention components.

The sample families were selected through random sampling, where the criteria of selection were non-usage of toilet with a functional toilet available in households. There was great pressure at the time from the government at local level and policy wide level, pressing improvements in latrine use particularly around rural parts of India.

The intervention was undertaken with informed consent, thereby eliciting full cooperation and willing participation. Each household selected has a fully constructed toilet, but are not using it. In each household, once the family was fully-informed about the intervention and consent was obtained, the intervention was implemented. The acceptability and feasibility of the pledge and the poster was discussed. Once the family was fully informed about the nature of the intervention and consent was obtained, the pilot was implemented.

The APEASE Framework– Intervention refinement involved brainstorming, where the (APEASE) Affordability, Practicality, Effectiveness/cost-effectiveness, Acceptability, Side-effects/safety and Equity) criteria guidance was adopted. The intervention design was iteratively reviewed by respondents from the community, and based on their reactions the final components of interventions evolved into a dual-component tool. The intervention tool was finalised under discussion amongst the Seva Mandir and academic experts in the field.

In addition, Seva Mandir builds and nurtures grassroots level institutions called Gram Samuha in the villages it works, which encourages local men and women by inculcating leadership skills amongst them. The executive body of these Gram Samuhas is the Gram Vikas Committee (GVC), in which 50% are women members. During the preparatory phase of the project, the GVCs deliberated over aspects of the proposed research and intervention in their villages. Members of village panchayat (council) also participated in most discussions. Thus, communities were directly involved in developing the content of the proposed research.

Based on this feasibility study, we refined our intervention in several ways. First, we amended the item list by removing unpopular items (e.g., mirror), adding new items (e.g., ventilation and basic repairs), and switching to more sustainable cleaning items. Second, we swapped the village-level commitment to a household-level pledge. Third, we learnt to now conduct the intervention inside rather than away from the latrine. Fourth, we will target our intervention to female householders who are more receptive to using latrines.

A similar household-level activity is reported by the recent Sundara Grama intervention in rural Odisha, India, which involved a household-level pledge, poster and latrine repairs [36]. Compared to this, our study is distinct in two ways. First, our household-level intervention is founded on theory from behaviour science and economics (See figure 1 COM-B Model) with an integrated methodical approach drawing on empirical evidence in stages. This adds to a mass of theorizing steeped in the behavioural science literature.

In general, behavioural change theory based approaches remain scarce in the literature. Our current pilot feasibility study will be followed by a larger project to reduce OD practice, particularly in the context of accelerated transmission of the SARS-CoV-2 virus responsible for the COVID-19 disease and ongoing pandemic.

Amidst growing calls for theory informed interventions, we conducted a formative evaluation of our pilot behaviour change intervention, implemented in the Udaipur district of Rajasthan. This is a largely tribal area of India where latrine use and OD is an ongoing issue, reported 65% use, 37% observed. Over the decades, most interventions designed to improve latrine use have had a modest effect [37]. Drawing on our research in Rajasthan, below we make suggestions by way of improvements to interventions and their chances of success in India’s rural population areas. This addresses the question “what solutions could help increase latrine use?” by way of better interventions that are feasible in light of our trialled study intervention, and the barriers identified.

Our findings provide an improve model to fit the data; with significant results identified (Table 1).The barriers identified and captured by the intervention include safety, relief and convenience related concerns of villagers. Qualitative data showed that the women across the villages did not feel safe for fear of being attacked and so our study found social and house level support for latrine use Gendered roles were pronounced in villages, more so in some than others. Given scarcity of water and poor infrastructure, common across regions and villages of Udaipur, it is the women alone who are responsible for collection of water and cleaning and maintenance of latrines. The very idea that men could contribute to such activities was seen to be unthinkable and women who otherwise may have preferred latrine use over OD seemed to think that the latter added to their burden. Dire conditions were infrastructure related and thus considerable in terms of their permanence. The villager’s emotions, perhaps underlying feelings of safety or lack of it when using latrines remotely, as well as formation of perceptions and attitudes, persist as factors [3-6] that in our study demonstrated a commitment to latrine use. In terms of broader concerns, somewhat about how to conduct study, we found that fear among the villagers was also reflected in the manner in which they interacted with the study team. None of them appeared to be speaking candidly and it was apparent that they were afraid of backlash from the authorities in case they stated anything that was politically incorrect.

Results support the view that there are ongoing infrastructure and resource issues and sociocultural drivers underlying motivations to use latrine use relative to OD [23, 38-43]. In the villages we visited, interventions to change behaviour should work with local government and informal leaders like the Sarpanch. Evidence suggests that the faciliative role of district authorities, local leaders and influencers and representatives, is extremely important [17]. While villagers can be emotionally engaged [43] their behaviour can be episodic and may not last [44] – making behavioural change unsustainable.

We note, to some extent, our findings may not be generalizable in larger populations due to demographic variation, socio-cultural idiosyncrasies and other relevant differences across India. With regard to improving latrine use, we note that challenges exist for similar future interventions that may adopt randomized controlled trials (RCTs) to improve latrine use [39, 45]. First, blinding both participants and investigators can be challenging. Our study design involves prescribed procedures and elements of judgement by investigators. This makes blinding particularly important for potential RCT interventions [45]. Second, with regard to contamination, it is plausible to ask whether participants really pass on the intervention in such a way as to influence behaviour in the control arm [46]. Ideally, interventions should moderate for bias effects in the field, as well as the issue of courtesy bias [1]. The presence of social desirability bias highlights the tendency to record errors given the data collectors or in cases, villagers who desire identity with the intervention, may play along, desiring or reporting what may be ambiguous and compromising reliability. The current study involved training and discussions with stakeholders, yet there remains no failsafe measure. Thirdly, another difficulty arises when scaled-up programs in the field do not deliver the same benefits that were measured in smaller efficacy trials. In addition, there is the risk of imperfect compliance by villagers [47].

We suggest that in measuring the primary outcome of latrine use and OD, behaviour indicating adherence should be captured effectively. We recommend using average latrine use per person within a household. One method of measuring this is to use an electronic occupancy scanner. This draws on the Passive Latrine Use Monitor (PLUM) approach, which has worked in rural India [48]. The technology is accurate, however, a shortcoming recognized by studies is that it does not permit distinction between users and nonusers (visitors) in HH [8]. While the current study is limited to a feasibility project, a future cluster trial would consider contamination as a concern.

In cases where the intracluster correlation is high, a stepped wedge trial would be suitable. A large sample can be obtained and organised on the ground with local government and agencies, like Seva Mandir, which provides NGO frameworks and social capital and reach. The Swachh Bharat Mission was India’s ambitious sanitation campaign to end OD. It ended in 2019 with success in several areas of the nation. In particular, the rural areas of Rajasthan were declared open defecation free (ODF) in March 2018 [29]. The Swachh Survekshan annual cleanliness review initiated by India in 2016 is a countrywide monitoring tool, which reported a marked improvement[2] across regions. In the 2019 report Rajasthan demonstrated a marked improvement, whilst the Udaipur area showed innovation and initiative.

In this area, our study shows that to improve sanitation and hygiene a sustainable strategy includes building toilets that have low water requirement alongside independent surveys to estimate OD levels [49]. Under the Swachh Bharat Mission, no fixed latrine design is mandated. Rather, EcoSan or dry pit structures may suffice given climatic conditions, resource constraints and water dynamics. To monitor ongoing hygiene behaviours, the Swachh Bharat Mission provides inspection and cross-verification at several levels, namely, at block, district, state and national levels.

Our results also emphasize the role of emotions and how these were factors influencing perceptions of use. We encourage the use of theory informed visual cues and physical amenities (see appendix 1 household level posters) that work to nudge behaviour and develop new habits [27-28].

We see theory informed behaviour change interventions as tools for building capacity at village and household levels, to contribute sustainable habits and behaviours across rural households. Our study – in part designed to identify factors to optimize our pilot intervention [43] enabled refinement on several fronts [40, 41]. Firstly, in preliminary stages of identifying the intervention, we amended the item list by removing unpopular items (e.g. mirror) adding new items (e.g. ventilation and basic repairs) and switching to more sustainable cleaning items. This improvement in design was largely a result of the feedback loops built into the intervention development process of doing research. Secondly, we swapped the village-level commitment to a household-level pledge. This change was an improvement resulting from carrying out the present study. Thirdly, we learned to conduct the intervention inside, rather than away from the latrine. That is, the intervention was designed around the availability and accessibility concerns of villagers, rather than a remote poster on the corner of every village alley. Finally, in applying out refined pilot intervention, we will target our intervention to female householders, who are more receptive to using latrines according to current study.

[3]The figures at ULB level are available at Swach Sarvekshan Survey, the World’s Largest Cleanliness Survey. 2019. Available online: http://www.swachhsurvekshan2020.org/Images/SS2019%20Report.pdf (accessed on 27 February 2021).

Further research is needed to reduce OD and its hazards and to encourage latrine use in rural India. The intervention was developed based on views of key stakeholders and was guided by the COM-B model and seemed feasible and acceptable. We plan to build on this further by piloting and evaluating the effectiveness of the intervention in subsequently.

Research ethics approval and consent to participate

This study was approved by the ethics committee of the International Initiative for Impact Evaluation (3ie). All methods were carried out with relevant guidelines and regulation.

"All participants gave informed consent to participate"

Consent for publication

Not Applicable

Availability of data and materials

The data that support the findings of this study are available from [the international Initiative for Impact Evaluation (3ie)] but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of [the international Initiative for Impact Evaluation (3ie)].

"Study participants or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research."

Competing interests

No potential conflict of interest was reported by the authors.

Funding

This work was supported by Vlaev, I., Behavioural Insights Team, Seva Mandir, Sutra Consulting (2016-2017). Applying a behavioural approach to promote the usage and maintenance of latrines in rural Rajasthan. International Initiative for Impact Evaluation (3ie) ($30,000 / £21,000).

Author Contributions:

U.T: “Finalising manuscript”, “Write up”, “Data management”, “Conducting Research”

L.R: “Finalising manuscript”, “Write up”, “Data management”, “Conducting Research”

I.V: “Finalising manuscript”, “Write up”, “Data management”, “Conducting Research”

Acknowledgements

We acknowledge support by the funding body.

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Table 1. Logistic Regression Analysis Result (significant variables) (sample n=398)

Variable	Β	Exp (B)	P
APL/BPL	-.1.58	0.2	0.02
HHE	1.71	5.56	0.05
Latrine Location	1.69	5.46	0.33
Construction Cost	-1.98	0.13	0.00
Comfort	2.36	10.62	0.00
Convenience	5.28	197.31	0.00
Social Pressure	1.67	0.18	0.17
Perception	-0.851	0.42	0.45
Happy	1.5	4.5	0.94
Safety	2.93	18.78	0.01
Relief	5.49	242.8	0.00

Notes: ABL/BPL=Identifies economic status, caste and religious demographic, HHE=Monthly Household expense on latrine, Latrine Location=Position of latrine in Household, Construction Cost=Construction cost of latrine, Comfort=place of defecation family members found most comfortable, Convenient=Find latrine use convenient, Social Pressure=Social pressure to use latrine, Perception= Perception of villagers use of latrines, Happy=Happiness in thinking about latrine, Safety=Feeling safe thinking about latrine. Relief=Feeling relief thinking about latrine. Cut off for Significance p<0.10 - The Omnibus test looking for effects of our independent variables is highly significant at (p<.000). Using the Nagelkerke’s R suggests that the model fits 89.7% to actual results. This explains a high percentage of variation in results. The Hosmer and Lemeshow Test gives a good fit to the data (p=0.89). Correctly classified outcomes of 95% of the cases.

Table 2. Water-related barriers encountered during the research fieldwork

Setting	Barriers (water related)
Village – A	Water scarcity, only women bring water, so less available. Water supply was an issue, only improved in the past year. Water storage was identified as an issue. Insufficient storage.
Village – B	Scarcity of water discouraged latrine use, and led to OD. Only women brought the water and managed latrines. They often could not manage.
Village - C and Hamlet C	The toilet structure impractical for storing water and hard to use. Village well and other water sources dried up due to heat. For some households a toilet in the household was a sign of upward mobility, but this was curtailed by scarce water availability
Village - D and Hamlet D	Sanitation duties including hauling water was too to manage. Hand pumps near households encouraged latrine use of residents.

No competing interests reported.

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Development of a Behaviour Change Intervention to promote latrine use and reduce open defecation in rural India

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