Was the intervention implemented as planned? (fidelity, dose delivered)
Average delivery scores were high for household visit activities (general visit: M = 97%; range = 87-100%) (positive deviant visit: M = 96%; range = 78-100%) and mother’s meeting (M = 81%; range = 56-100%), indicating the activities were often conducted as intended (Table 3). Both the palla performance and transect walk had a lower average score of 77% (palla range = 52-100%; transect walk range = 50-91%), while the community meeting had the lowest average score at 60% (range = 40-83%). The activity observation survey data for these three activities showed steps were often followed only ‘somewhat’ in the correct order. For the community meeting, none of the meetings were sex-segregated as intended, few were conducted in a private place, most did not have participants introduce themselves, and three activity steps were rarely completed in full (recognize sanitation challenges, identify positive deviants, and discuss becoming a model village). There was no statistically significant difference in average delivery score between the four implementing teams for any of the activities.
Enumerator-reported quality of the activities, using a 4pt Likert, aligned with the delivery scores with 81% of mother’s meetings, 78% of palla performances, 69% of transect walks, and 64% of community meetings being rated good or very good. Only two transect walks and one mother’s meeting were rated poor.
All 36 community wall paintings included the required components. Lastly, among the 358 households selected to receive latrine repairs and surveyed at endline, 75% reported receiving the repairs.
Who was reached and how were participants recruited? (reach, recruitment)
Reach
Among latrine-owning households in the intervention villages, 93.1% (N = 1956) reported attending at least one activity. Average reach among latrine-owning households was highest for household activities (M = 73%; range = 44-90%) and palla performance (M = 69%; range = 39-87%), moderate for mother’s meeting (M = 47%; 17-81%) and community meeting (M = 43%; 27-67%), and lowest for the transect walk (M = 30%; range = 16-51%) (Table 3). For the community wall painting, on average, only 36% of latrine-owning households reported having seen the map and only 14% reported being able to identify their own household on the map. For latrine-owning household reach, there was a statistically significant difference between the four implementing teams for the household activities (F = 3.48, p = 0.03).
For community-level activities, palla performances reached, on average, almost a quarter (M = 24%; range = 6-50%) of the village population, while far fewer were reached on average for the community meetings (M = 8%; range = 3-17%) and transect walks (M = 5%, range = 1-14%). For village population reach, there was a statistically significant difference between the four implementing teams for the transect walk (F = 3.08, p = 0.04).
The gender and age of those in attendance varied depending on activity. On average, about half of the audience members at the palla performances were women (M = 49% women; range = 27-77%); slightly fewer women on average attended the transect walk (M = 45% women; range = 0-77%), with no women in attendance in two villages; and more women on average attended the community meeting (M = 57% women; range = 7-87%). The community meeting was also attended by more adults on average (M = 81% adults; range = 64-100%) compared to the palla performance (M = 59% adults; range = 31-80%) and transect walk (M = 57% adults; range = 18-100%). Almost a third of transect walks (N = 10) had a majority of boys and girls <18 years old in attendance. For the mother’s meeting, 20% of all participants did not have a household latrine and 41% brought their child.
Recruitment
Several factors were identified that aided activity recruitment, while others hindered recruitment (Table 4).
RWI mobilizers described the ‘pre-intervention visits’, which were designed to build rapport with village stakeholders and plan activity logistics, as a very successful strategy that later aided recruitment of village members to intervention activities. Additionally, mobilizers sometimes received recruitment assistance from village members and stakeholders who would help go door-to-door to invite village members to the activities. Specifically, Anganwadi workers (teachers for government-run preschool centers) often helped with mother’s meeting recruitment.
In contrast, the recruitment strategy used during the transect walk, where mobilizers went around beating a bell early in the morning, sometimes led to confusion and irritation. Some thought the bell was signaling a call to prayer or that someone had died, while others objected to hearing the bell so early in the morning or felt it disturbed their morning routine. RWI mobilizers also explained it was sometimes difficult to convince people to attend activities, especially for the community and mother’s meetings, since an incentive was often expected and not provided. As some community members would tell them, “If there is no eating, there is no meeting.”
What external factors impacted delivery? (context)
Delivery of the Sundara Grama activities was impacted by three contextual factors: stakeholder support, inclement weather, and social dynamics (Table 4).
Village stakeholders positively impacted delivery by providing the RWI mobilizers with additional assistance. According to enumerator observation debriefs, village stakeholders participated in the activities, helped prepare activity locations in advance, and even managed tensions or conflicts that arose during the community meetings, specifically around government latrine subsidies and construction quality. Based on the activity observation survey data, at least one stakeholder provided support in 92% of all activities observed. The most common stakeholders providing support included Ward members (45%), Anganwadi workers (43%), village heads (36%), and ASHA community workers (Accredited Social Health Activist) (30%).
Inclement weather negatively impacted delivery. Rain, and in a few cases severe heat, led to activities starting late, fewer participants being in attendance, participants leaving early, and the need to shift activity locations to seek better shelter. Activity observation survey data showed weather was an issue in 26% of all activities observed.
Social dynamics related to caste, gender, and age also hindered aspects of delivery and reach. According to both implementer IDIs and enumerator observation debriefs, caste divisions affected activities in three villages. In one village, caste divisions compelled RWI mobilizers to organize two separate palla performances and also led to issues organizing the community meeting. In a second village, one caste group was not able to attend the palla because it was held near the village temple from which they were prohibited. In a third village, one caste group refused to attend the transect walk in the presence of another caste group.
In interviews, RWI mobilizers described how younger mothers were sometimes not able to attend the mother’s meeting and that older women from their households would attend in their place. The mother’s meeting activity record data confirmed this observation; 48% of participants across all the meetings were 40 years old or older with 36% older than 45 years, indicating these participants were likely not the mother of the child <6 years old but potentially the grandmother.
What did participants think of the intervention? (satisfaction)
According to both implementer IDIs and enumerator observation debriefs, the palla performances were positively received by village members, but the transect walk and meetings experienced some negative reactions.
Village members enjoyed the palla performances – they laughed at the jokes, “listened mindfully,” praised the performance for bringing awareness to their village, and commented on how it was both educational and entertaining.
The transect walk elicited mixed reactions. It was well received by children in particular and all participants greatly enjoyed the handwashing demonstration at the end of the walk. However, village members often had negative reactions to visiting open defecation (OD) sites in the village and marking feces with colored powder, the main component of the activity. Many village members refused to visit the OD sites, while others expressed anger, irritation, disgust, and shame towards the act. In some cases, the RWI mobilizers were scolded for leading such an activity. Despite negative reactions, RWI mobilizers explained in interviews that a few participants felt the transect walk would positively impact their village.
Both the community and mother’s meetings experienced frequent upsets. Many community meetings were disrupted by participants voicing their frustration at the poor quality of their government-provided latrine or not having received their latrine subsidy; activity observation survey data showed poor latrine construction came up in 75% (N = 27) of the meetings and latrine subsidies came up in 53% (N = 19). In one meeting, participants attempted a ‘mass exit’ over these issues. Poor latrine construction was also mentioned by participants in 33% of the transect walks (N = 12).
In several mother’s meetings, the distribution of potties and scoops caused upsets. RWI mobilizers were trained to provide participants with a potty and scoop at the end of the meeting once all information was covered. Some caregivers who left the meeting early or had not attended at all became upset over not receiving the hardware. Sometimes their husbands came and demanded the hardware.
What was the experience of implementers in delivering the intervention activities?
In interviews, RWI mobilizers provided feedback on aspects of intervention delivery that were successful, such as the pre-intervention visits, palla performances, and household visits, and aspects that were challenging, such as travelling to their assigned villages and being misconstrued as government officials.
Mobilizers explained that the pre-intervention visits were critical to building rapport with village stakeholders from the start and that the palla performance was an ideal introductory activity since it was well received and helped mobilizers continue to build a positive relationship. Mobilizers also viewed the household visits as especially effective as they could directly engage with participants and reach members who were not able to attend the other activities, such as newly-married and younger women.
The biggest challenges mobilizers faced were with travel and the misbelief among community members that they were actually government officials. Mobilizers lived far from their assigned villages and some villages were not easily reached by public transportation, on which female staff in particular relied as they did not own a motorbike like male staff. Many mobilizers described how they were repeatedly misidentified as government officials, with community members believing they had come to cancel ration cards for those who were not using their government latrine. This misbelief and the issues related to latrine construction and subsidies caused many mobilizers to experience verbal attacks during activities, which were sometimes difficult to manage.
Mobilizers offered several recommended changes to the intervention: less repetitive activity messages, less prescriptive activity guides to allow for flexibility in how messages are conveyed, snacks or other incentives at the meetings since it is expected and could make recruitment easier, later starts to activities (not in the early morning) to make logistics easier, and more time for household visits.
Finally, female mobilizers often had challenging experiences when delivering the intervention. These women, many of whom were young and in their first job, reported being catcalled and shamed by community members as their presence defied social norms restricting the mobility of young women. One woman’s father began accompanying her to the villages because he was worried for her safety. Another mobilizer was scolded by her parents for leaving the house so early for work, as it was not socially appropriate. However, these same mobilizers explained that they gained the respect of community members over time and that they had become more confident by the end, no longer shy in front of others and more comfortable with public speaking.
Cost Analysis
Delivery of the Sundara Grama intervention in 33 villages cost a total of 36,171.72 USD, with an average cost of 1,096.11 USD per village (Table 5). Payments to the palla troupes, latrine repair contractors, and wall painting artisans, including cost of materials, accounted for 43.6% of the total delivery cost (average of 477.96 USD per village); RWI staff salaries and transportation stipends accounted for 43.5% (average of 476.58 USD per village); and consumables, such as banners, posters, potties and scoops, accounted for 12.9% (average of 141.58 USD per village). Based on the endline trial survey, 1,956 latrine-owning households reported having attended at least one of the activities, making the cost per latrine-owning household reached 18.49 USD.