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Processes and challenges of community mobilisation for latrine promotion under Nirmal Bharat Abhiyan in rural Odisha, India.

ABSTRACT: Despite efforts to eradicate it, open defecation remains widely practiced in India, especially in rural areas. Between 2013 and 2014, 50 villages in one district of Odisha, India, received a sanitation programme under the Nirmal Bharat Abhiyan (NBA - "Clean India Campaign"), the successor of India's Total Sanitation Campaign. This paper documents the strategies and processes of NBA community mobilisation for latrine promotion in these villages and assesses the strengths and limitations of the mobilisation activities.NBA's community mobilisation activities were observed and assessed against the programme's theory of change in 10 randomly selected programme villages from start to finish. Additional data was collected through review of documents, individual interviews (n = 80) and focus group discussions (n = 26) with staff of the implementing NGOs and community members.Our study revealed the lack of a consistent implementation strategy, lack of capacities and facilitation skills of NGO staff to implement sanitation programmes, political interference, challenges in accessing government financial incentives for latrine construction, and lack of clarity on the roles and responsibilities among government and NGO staff, leading to failure in translating government policies into sustainable actions. Social divisions and village dynamics related to gender and caste further constrained the effectiveness of mobilisation activities. Meetings were often dominated by male members of upper caste households, and excluded low caste community members and views of women. Community discussions revolved largely around the government's cash incentive for latrines. Activities aimed at creating demand for sanitation and use of latrines often resonated poorly with community members. An assessment by the implementers, 1 year after community mobilisation found 19% of households had a completed latrine across the 50 villages, a marginal increase of 7 percentage points over baseline.In this setting, the Government of India's NBA programme to increase rural sanitation coverage and use is hampered by political, programmatic, logistical and socio-structural constraints. Sanitation demand generation was difficult for local implementing NGOs as village populations had lost trust in organisations due to previous indications of fraud. Agencies or organisations implementing sanitation campaigns and conducting sanitation promotions need to enhance their staff's knowledge and build capacity in order to address important social heterogeneity within villages. This trial's registration number is NCT01214785 (October 4, 2010).

SUBMITTER: Routray P

PROVIDER: S-EPMC5434619 | biostudies-literature | 2017 May

REPOSITORIES: biostudies-literature

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Processes and challenges of community mobilisation for latrine promotion under Nirmal Bharat Abhiyan in rural Odisha, India.

Routray Parimita P Torondel Belen B Jenkins Marion W MW Clasen Thomas T Schmidt Wolf-Peter WP

BMC public health 20170516 1

<h4>Background</h4>Despite efforts to eradicate it, open defecation remains widely practiced in India, especially in rural areas. Between 2013 and 2014, 50 villages in one district of Odisha, India, received a sanitation programme under the Nirmal Bharat Abhiyan (NBA - "Clean India Campaign"), the successor of India's Total Sanitation Campaign. This paper documents the strategies and processes of NBA community mobilisation for latrine promotion in these villages and assesses the strengths and li ...[more]

PMID: 28511653

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Project description: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 (>3years) 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 48h. 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.

Project description:Child feces are an important source of fecal exposure in household environments. Typically, one of two behaviors is necessary to mitigate this risk: either caregivers dispose of their children's feces into a latrine or children learn how to use a latrine. Although past studies have examined factors associated with these two behaviors collectively (i.e. "safe disposal"), there is a need to separately analyze these distinctive practices to better inform programming. This study aims to quantitatively examine contextual and psychosocial factors influencing caregiver safe disposal and, separately, child latrine training. We surveyed 791 primary female caregivers, who reported on 906 children <5 years old, across 74 villages in rural Odisha, India. At their last defecation event, 38% of children used the latrine and another 10% had their feces safely disposed of into the latrine. Since caregiver safe disposal was rare, we instead assessed safe disposal intention. We used linear regression and multilevel mixed effects models to examine contextual and psychosocial factors. For contextual factors, we found caregivers had stronger safe disposal intention when they came from wealthier households and had greater informational support, but weaker intention when their latrine was near the household. Caregivers more intensely practiced latrine training with their child when they themselves used the latrine for defecation, the latrine was fully intact, and they had greater instrumental support. For psychosocial factors, caregivers had stronger safe disposal intention when their households expected them to practice safe disposal, they felt strongly committed to the behavior, and had a plan for what to do when faced with a water shortage. Caregivers more intensely taught their child how to use the latrine when they believed their child was at risk of becoming sick if they practiced open defecation (OD); viewed child OD as unbeneficial; liked teaching their child; personally felt it was important for the child's father to help; felt confident in their ability to teach their child; and had greater action control over their training practice. Interestingly, caregivers put less effort into latrine training when they felt more concerned for their child's safety when the child defecated outside. These findings underscore the critical need to separately assess unique child feces management (CFM) practices and also provide a road map for practitioners on the types of behavior change strategies to consider in their CFM programming.

Project description:BACKGROUND:While women and girls face special risks from lack of access to sanitation facilities, their ability to participate and influence household-level sanitation is not well understood. This paper examines the association between women's decision-making autonomy and latrine construction in rural areas of Odisha, India. METHODS:We conducted a mixed-method study among rural households in Puri district. This included a cross sectional survey among 475 randomly selected households. These were classified as either having a functional latrine, a non-functional latrine or no latrine at all. We also conducted 17 in-depth interviews and 9 focus group discussions among household members of these three categories of households. RESULTS:Decisions on the construction of household level sanitation facilities were made exclusively by the male head in 80% of households; in 11% the decision was made by men who consulted or otherwise involved women. In only 9% of households the decision was made by women. Households where women were more involved in general decision making processes were no more likely to build a latrine, compared to households where they were excluded from decisions. Qualitative research revealed that women's non-involvement in sanitation decision making is attributed to their low socio-economic status and inability to influence the household's financial decisions. Female heads lacked confidence to take decisions independently, and were dependent on their spouse or other male family members for most decisions. The study revealed the existence of power hierarchies and dynamics within households, which constrained female's participation in decision-making processes regarding sanitation. CONCLUSIONS:Though governments and implementers emphasize women's involvement in sanitation programmes, socio-cultural factors and community and household level dynamics often prevent women from participating in sanitation-related decisions. Measures are needed for strengthening sanitation policies and effective implementation of programmes to address gender power relations and familial relationships that influence latrine adoption and use.

Project description:BackgroundThe Indian Swachh Bharat Mission (SBM) was launched in 2014 with the goal to make India open defecation (OD) free by October 2019. Although it is known that the ambitious goal was not achieved, the nature of the sanitation change brought about by the SBM in different parts of India is poorly understood. One reason is a dearth of case studies that would shed light on the performance of the SBM simultaneously across its different domains. This article provides an example of such study. Employing a Process, Outcomes, Context approach, the objective is to understand the process and outcomes of the SBM-induced sanitation change in a specific context of rural Jharkhand.MethodsThe study utilizes data collected through field research conducted in the rural areas of Ranchi district, Jharkhand, a state in east-central India. This data was obtained via repeated cross-sectional household surveys conducted at the beginning and at the end of the SBM, supplemented by key informant interviews with SBM stakeholders.FindingsWe identified political support of SBM implementation and its acceptance amongst the population. Female community workers became key agents of SBM implementation at local level. The SBM increased toilet coverage in the study area from 15% to 85% and lowered the OD rate from 93% to 26%. It substantially reduced structural inequalities in access to toilets, furthered social sanitation norms, improved some of the attitudes towards toilet use, but impacted less on hygiene and sanitation knowledge. The implementation mainly concentrated on the construction of subsidized toilets but less on improving public understanding of safe sanitation practices.ConclusionsAlthough the SBM reduced sanitation inequalities in access to toilets in the study area, the behaviour change component was underplayed, focusing more on spreading normative sanitation messages and less on public education. Sustainability of the observed sanitation change remains a key question for the future. This article calls for more systematic production of geographically situated knowledge on the performance of sanitation interventions.

Project description:IntroductionIndia's Pradhan Mantri Jan Arogya Yojana (PM-JAY) is the world's largest health assurance scheme providing health cover of 500,000 INR (about USD 6,800) per family per year. It provides financial support for secondary and tertiary care hospitalization expenses to about 500 million of India's poorest households through various insurance models with care delivered by public and private empanelled providers. This study undertook to describe the provider empanelment of PM-JAY, a key element of its functioning and determinant of its impact.MethodsWe carried out secondary analysis of cross-sectional administrative program data publicly available in PM-JAY portal for 30 Indian states and 06 UTs. We analysed the state wise distribution, type and sector of empanelled hospitals and services offered through PM-JAY scheme across all the states and UTs.ResultsWe found that out of the total facilities empanelled (N = 20,257) under the scheme in 2020, more than half (N = 11,367, 56%) were in the public sector, while 8,157 (40%) facilities were private for profit, and 733 (4%) were private not for profit entities. State wise distribution of hospitals showed that five states (Karnataka (N = 2,996, 14.9%), Gujarat (N = 2,672, 13.3%), Uttar Pradesh (N = 2,627, 13%), Tamil Nadu (N = 2315, 11.5%) and Rajasthan (N = 2,093 facilities, 10.4%) contributed to more than 60% of empanelled PMJAY facilities: We also observed that 40% of facilities were offering between two and five specialties while 14% of empanelled hospitals provided 21-24 specialties.ConclusionA majority of the hospital empanelled under the scheme are in states with previous experience of implementing publicly funded health insurance schemes, with the exception of Uttar Pradesh. Reasons underlying these patterns of empanelment as well as the impact of empanelment on service access, utilisation, population health and financial risk protection warrant further study. While the inclusion and regulation of the private sector is a goal that may be served by empanelment, the role of public sector remains critical, particularly in underserved areas of India.

Project description:Safe child feces management (CFM) is likely critical for reducing exposure to fecal pathogens in and around the home, but the effectiveness of different CFM practices in reducing fecal contamination is not well understood. We conducted a cross-sectional study of households with children <6 years in rural Odisha, India, using household surveys (188 households), environmental sample analysis (373 samples for 80 child defecation events), and unstructured observation (33 households) to characterize practices and measure fecal contamination resulting from CFM-related practices, including defecation, feces handling and disposal, defecation area or tool cleaning, anal cleansing, and handwashing. For environmental sampling, we developed a sampling strategy that involved collecting samples at the time and place of child defecation to capture activity-level fecal contamination for CFM practices. Defecating on the floor or ground, which was practiced by 63.7% of children <6 years, was found to increase E. coli contamination on finished floors (p < 0.001) or earthen ground surfaces (p = 0.008) after feces were removed, even if paper was laid down prior to defecation. Use of unsafe tools (e.g., paper, plastic bag, straw/hay) to pick up child feces increased E. coli contamination on caregiver hands after feces handling (p < 0.0001), whereas the use of safe tools (e.g., potty, hoe, scoop) did not increase hand contamination. Points of contamination from cleaning CFM hardware and anal cleansing were also identified. The most common disposal location for feces of children <6 years was to throw feces into an open field (41.6%), with only 32.3% disposed in a latrine. Several households owned scoops or potties, but use was low and we identified shortcomings of these CFM tools and proposed alternative interventions that may be more effective. Overall, our results demonstrate the need for CFM interventions that move beyond focusing solely on feces disposal to address CFM as a holistic set of practices.

Project description:Emerging qualitative research suggests women's sanitation experiences may impact mental health. However, specific associations remain unclear. We aimed to determine if sanitation access and sanitation experiences were associated with mental health among women in rural Odisha, India. Using a cross-sectional design, we evaluated the association between sanitation access and sanitation experiences and selected mental health outcomes. Data were collected from 1347 randomly selected women across four life course stages in 60 rural communities (December 2014-February 2015). Our four primary outcomes included: mental well-being, and symptoms of anxiety, depression, and distress. The primary exposures were (1) access to a functional latrine within the household compound and (2) sanitation insecurity (SI), evaluated using a seven domain measure assessing women's negative sanitation experiences and concerns. We used hierarchical linear modeling to determine associations between the exposures and mental health outcomes, adjusting for covariates (life stage, poverty, current health status, social support). Mean well-being scores were moderate and mean anxiety, depression, and distress scores were above a threshold indicating the potential presence of any of the three conditions. Access to a functional household latrine was associated with higher well-being scores, but not with anxiety, depression or distress. Women's SI domains were associated with all four outcomes: four domains were significantly associated with lower well-being scores, two were significantly associated with higher anxiety scores, three were significantly associated with higher depression scores, and three were significantly associated with higher distress scores, all independent of functional household latrine access. Women in rural Odisha, India may suffer assaults to their well-being and have higher symptoms of anxiety, depression, and distress when urinating and defecating, even if they have an available facility. These findings suggest that sanitation-related interventions should consider how to accommodate women's experiences beyond excreta management to comprehensively impact health.

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Processes and challenges of community mobilisation for latrine promotion under Nirmal Bharat Abhiyan in rural Odisha, India.

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Processes and challenges of community mobilisation for latrine promotion under Nirmal Bharat Abhiyan in rural Odisha, India.

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