Bill & Melinda Gates Foundation, International Initiative for Impact Evaluation (3ie), and Department for International Development-backed SHARE Research Consortium at the London School of Hygiene & Tropical Medicine.

BackgroundFaced with a massive shortfall in meeting sanitation targets, some governments have implemented campaigns that use subsidies focused on latrine construction to overcome income constraints and rapidly expand coverage. In settings like rural India where open defecation is common, this may result in sub-optimal compliance (use), thereby continuing to leave the population exposed to human excreta.MethodsWe conducted a cross-sectional study to investigate latrine coverage and use among 20 villages (447 households, 1933 individuals) in Orissa, India where the Government of India’s Total Sanitation Campaign had been implemented at least three years previously. We defined coverage as the proportion of households that had a latrine; for use we identified the proportion of households with at least one reported user and among those, the extent of reported use by each member of the household.ResultsMean latrine coverage among the villages was 72% (compared to <10% in comparable villages in the same district where the Total Sanitation Campaign had not yet been implemented), though three of the villages had less than 50% coverage. Among these households with latrines, more than a third (39%) were not being used by any member of the household. Well over a third (37%) of the members of households with latrines reported never defecating in their latrines. Less than half (47%) of the members of such households reported using their latrines at all times for defecation. Combined with the 28% of households that did not have latrines, it appears that most defecation events in these communities are still practiced in the open.ConclusionA large-scale campaign to implement sanitation has achieved substantial gains in latrine coverage in this population. Nevertheless, gaps in coverage and widespread continuation of open defecation will result in continued exposure to human excreta, reducing the potential for health gains.

IntroductionMonitoring of sanitation programs is often limited to sanitation access and coverage, with little emphasis on use of the facilities despite increasing evidence of widespread non-use.ObjectivesWe assessed patterns and determinants of individual latrine use over 12 months in a low- income rural study population that had recently received latrines as part of the Government of India’s Total Sanitation Campaign (TSC) in coastal Puri district in Odisha, India.Materials and methodsWe surveyed 1938 individuals (>3 years) in 310 rural households with latrines from 25 villages over 12 months. Data collection rounds were timed to correspond with the seasons. The primary outcome was reported use by each member of the household over the prior 48 h. We classified use into three categories—“never”, “sometimes” and “always/usually”. We also assessed consistency of use over six days across the three seasons (dry cold, dry hot, rainy). We explored the association between individual and household-level variables and latrine use in any given season and longitudinally using multinomial logistic regression. We also inquired about reasons for non-use.ResultsOverall, latrine use was poor and inconsistent. The average response probability at any given round of never use was 43.5% (95% CI = 37.9, 49.1), sometimes use was 4.6% (95% CI = 3.8, 5.5), and always/usual use was 51.9% (95% CI = 46.2, 57.5). Only two-thirds of those who reported always/usually using a latrine in round one reported the same for all three rounds. Across all three rounds, the study population was about equally divided among those who reported never using the latrine (30.1%, 95% CI = 23.0, 37.2), sometimes using the latrine (33.2%, 95% CI = 28.3, 38.1) and always/usually using the latrine (36.8%, 95% CI = 31.8, 41.8). The reported likelihood of always/usually versus never using the latrine was significantly greater in the dry cold season (OR = 1.50, 95% CI = 1.18, 1.89, p = 0.001) and in the rainy season (OR = 1.34, 95% CI = 1.07, 1.69, p = 0.012), than in the dry hot season.Across all three seasons, there was increased likelihood of always/usually and sometimes using the latrine versus never using it among females and where latrines had a door and roof. Older age groups, including those aged 41–59 years and 60+ years, and increase in household size were associated with a decreased likelihood of always/usually using the latrine versus never using it. The leading reason for non-use was a preference for open defecation.ConclusionResults highlight the low and inconsistent use of subsidized latrines built under the TSC in rural Odisha. This study identifies individual and household levels factors that may be used to target behavior change campaigns to drive consistent use of sanitation facilities by all.

Although large-scale programs, like India's Total Sanitation Campaign (TSC), have improved latrine coverage in rural settings, evidence suggests that actual use is suboptimal. However, the reliability of methods to assess latrine use is uncertain. We assessed the reliability of reported use, the standard method, by comparing survey-based responses against passive latrine use monitors (PLUMs) through a cross-sectional study among 292 households in 25 villages in rural Odisha, India, which recently received individual household latrines under the TSC. PLUMs were installed for 2 weeks and householders responded to surveys about their latrine use behavior. Reported use was compared with PLUM results using Bland–Altman (BA) plots and concordance statistics. Reported use was higher than corresponding PLUM-recorded events across the range of comparisons. The mean reported “usual” daily events per household (7.09, 95% confidence interval [CI] = 6.51, 7.68) was nearly twice that of the PLUM-recorded daily average (3.62, 95% CI = 3.29, 3.94). There was poor agreement between “usual” daily latrine use and the average daily PLUM-recorded events (ρc = 0.331, 95% CI = 0.242, 0.427). Moderate agreement (ρc = 0.598, 95% CI = 0.497, 0.683) was obtained when comparing daily reported use during the previous 48 hours with the average daily PLUM count. Reported latrine use, though already suggesting suboptimal adoption, likely exaggerates the actual level of uptake of latrines constructed under the program. Where reliance on self-reports is used, survey questions should focus on the 48 hours prior to the date of the survey rather than asking about “usual” latrine use behavior.

This paper advances research on methods used to evaluate sanitation usage and behavior. The research used quantitative and qualitative methods to contribute to new understanding of sanitation practices and meanings in rural India. We estimated latrine usage behavior through ethnographic interviews and sensor monitoring, specifically the latest generation of infrared toilet sensors, Portland State University Passive Latrine Use Monitors (PLUMs). Two hundred and fifty-eight rural households in West Bengal (WB) and Himachal Pradesh, India, participated in the study by allowing PLUMs to be installed in their houses for a minimum of 6 days. Six hundred interviews were taken in these households, and in others, where sensors had not been installed. Ethnographic and observational methods were used to capture the different defecation habits and their meanings in the two study sites. Those data framed the analysis of the PLUM raw data for each location. PLUMs provided reliable, quantitative verification. Interviews elicited unique information and proved essential to understanding and maximizing the PLUM data set. The combined methodological approach produced key findings that latrines in rural WB were used only for defecation, and that low cost, pit latrines were being used sustainably in both study areas.

No abstract

The International Initiative for Impact Evaluation (3ie) is an international grant-making NGO promoting evidence-informed development policies and programmes. We are the global leader in funding, producing and synthesising high-quality evidence of what works, how, why and at what cost. We believe that better and policy-relevant evidence will make development more effective and improve people's lives. 3ie impact evaluations3ie-supported impact evaluations assess the difference a development intervention has made to social and economic outcomes. 3ie is committed to funding rigorous evaluations that include a theory-based design, use the most appropriate mix of methods to capture outcomes and are useful in complex development contexts. About this report3ie accepted the final version of this report, Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection and child malnutrition in India, as partial fulfilment of requirements under grant OW2.063 issued under Open Window 2. The content has been copy-edited and formatted for publication by 3ie. Due to unavoidable constraints at the time of publication, some figures and tables are not optimal. All of the content is the sole responsibility of the authors and does not represent the opinions of 3ie, its donors or its board of commissioners. Any errors and omissions are the sole responsibility of the authors. Any comments or queries should be directed to the corresponding author, Thomas Clasen, thomas.f.clasen@emory.edu Summary BackgroundA third of the 2.5 billion people worldwide without access to improved sanitation live in India, as do two-thirds of the 1.1 billion practising open defecation and a quarter of the 1.5 million who die annually from diarrhoeal diseases. We aimed to assess the effectiveness of a rural sanitation intervention, within the context of the Government of India's Total Sanitation Campaign, to prevent diarrhoea, soil-transmitted helminth infection and child malnutrition. MethodsWe did a cluster-randomised controlled trial between 20 May 2010 and 22 December 2013, in 100 rural villages in Odisha, India. Households within villages were eligible if they had a child younger than four years or a pregnant woman. Villages were randomly assigned (1:1), with a computer-generated sequence, to undergo latrine promotion and construction or to receive no intervention (control). Randomisation was stratified by administrative block to ensure an equal number of intervention and control villages in each block. Masking of participants was not possible because of the nature of the intervention. However, households were not told explicitly that the purpose of enrolment was to study the effect of a trial intervention, and the surveillance team was different from the intervention team. The primary endpoint was seven-day prevalence of reported diarrhoea in children younger than five years. We did intention-to-treat and per-protocol analyses. This trial is registered with ClinicalTrials.gov, no. NCT01214785. FindingsWe randomly assig...

No abstract