Abstract
BackgroundInconsistent toilet usage is a continuing challenge in India. Despite the impact of social expectations on toilet usage, few programs and studies have developed theoretically grounded norm-centric behavior change interventions to increase toilet use in low-income settings.ObjectiveThe objective of this paper is to detail the rationale and design of an ex ante, parallel cluster-randomized trial evaluating the impact of a demand-side, norm-centric behavior change intervention on exclusive toilet use and maintenance in peri-urban Tamil Nadu, India.MethodsFollowing formative research, we developed an evidence-based norm-centric behavior change intervention called Nam Nalavazhvu (Tamil for “our well-being”). The multilevel intervention aims to improve toilet usage by shifting empirical expectations or beliefs about other relevant people’s sanitation practices. It also provides action-oriented information to aid individuals to set goals and overcome barriers to own, consistently use, and maintain their toilets. This trial includes 76 wards in the Pudukkottai and Karur districts, where half were randomly assigned to receive the intervention and the remaining served as counterfactuals.ResultsWe enrolled wards and conducted a baseline survey among randomly selected individuals in all 76 wards. The 1-year behavior change intervention is currently ongoing. At the endline, we will collect relevant data and compare results between study arms to determine the impacts of the Nam Nalavazhvu intervention on sanitation-related behavioral, health, and well-being outcomes and potential moderators. This study is powered to detect differences in the prevalence of exclusive toilet use between study arms. We are also conducting a process evaluation to understand the extent to which the intervention was implemented as designed, given the special pandemic context.ConclusionsFindings from this trial will inform norm-centric behavior change strategies to improve exclusive toilet usage.Trial RegistrationClinicalTrials.gov NCT04269824; https://www.clinicaltrials.gov/ct2/show/NCT04269824International Registered Report Identifier (IRRID)DERR1-10.2196/24407
Highlights
Study RationaleOpen defecation practices enable environmental contamination and contribute to poor health, well-being, and safety globally [1,2,3]
Recent behavior change interventions designed to promote toilet use in rural India yielded, on average, a 5% increase in reported use amongst toilet owners, which is comparable to results generated by Swachh Bharat Mission (SBM) [9,10,11]
Sustaining exclusive toilet use among all household members is a national priority for the current SBM 2.0, known as the Open Defecation–Free plus scheme [12]
Summary
Study RationaleOpen defecation practices enable environmental contamination and contribute to poor health, well-being, and safety globally [1,2,3]. National sanitation programs, such as the Swachh Bharat Mission (SBM), have significantly increased coverage of private, shared, and public toilets to end persistent open defecation practices in India [4,5]. They have promoted exclusive use or using a toilet every time for defecation. Sustaining exclusive toilet use among all household members is a national priority for the current SBM 2.0, known as the Open Defecation–Free plus scheme [12] This is aligned with the United Nations’ Sustainable Development Goal 6.2, which calls on countries to “achieve access to adequate and equitable sanitation and hygiene for all and end open defecation” by 2030 [13]. Despite the impact of social expectations on toilet usage, few programs and studies have developed theoretically grounded norm-centric behavior change interventions to increase toilet use in low-income settings
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