Community perceptions of a multi-level behavior change sanitation intervention in Odisha, India: a qualitative study Open Access

De Shay, Renee (Spring 2019)

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BACKGROUND: India has a long history of government programs to fight open defecation which have mainly focused on latrine construction to increase latrine use uptake. Odisha has one of the lowest rates of individual household latrine coverage in India and research has shown that households owning latrines do not necessarily use them. Cost-effective and culturally appropriate interventions targeting behavioral barriers are necessary to bridge the gap between latrine ownership and use. Understanding how communities perceive behavior change interventions is needed to optimize effectiveness.


OBJECTIVE: This qualitative study broadly examined general perceptions of how communities view sanitation interventions in Odisha, and specifically investigated community perceptions and spillover of Sundara Grama, a multi-level behavior change intervention in Odisha, India which aimed to increase latrine use.


METHODS: Sixteen sex-segregated focus group discussions, eight with women (n=72) and eight with men (n=80), were held in six rural villages. Three villages received the intervention, and three did not. General perceptions of sanitation interventions were assessed in all six villages, perceptions of Sundara Grama were assessed in the three villages that received the intervention, and spillover was evaluated in two villages that did not receive the intervention but were in close proximity to those that did. Data were analyzed using thematic analysis.


RESULTS: Sundara Grama was largely well-received, but not all experienced the intervention as intended. Some lower caste women were missed during recruitment. Unclear messaging led to misunderstandings of the purpose of the transect walk, and may have led villagers to punish open defecators. Internal conflicts and divisions made it difficult for communities to work toward a common sanitation goal. However, the intervention may have boosted community self-efficacy toward cleanliness, though not necessarily latrine usage. Communities were already familiar with sanitation messaging but were often reluctant to encourage members to use a latrine because they could not provide latrines and they considered sanitation a personal decision. Instead, participants expected outsiders to initiate and support sanitation efforts. Intervention spillover into control villages depended on the relations between the villages.


CONCLUSIONS: Post-intervention qualitative work in communities can bring insight to the intervention delivery and explain endline results. Implementers of community interventions in Odisha should consider the different groups, and divisions in a village, and target those most likely to be excluded, such as women and lower castes. Future sanitation interventions aimed at producing collective action should first assess underlying social divisions and cultural norms about sanitation. By including activities to strengthen collective efficacy, communities may become more empowered to act. In a similar way, integrating relationship-building activities and encouraging inter-village cooperation should increase spillover to nearby villages.

Table of Contents

Chapter I: Introduction and Study Purpose 1

Background on open defecation1

Sanitation in India 1

Table 1.1. Sanitation programs sponsored by the Government of India 2

The Sundara Grama intervention 4

Purpose of this qualitative study 5

Table 1.2 Research questions for intervention villages 6

Table 1.3 Research questions for control villages 7

Chapter II: Review of the Literature 8

The problem of open defecation 8

Figure 2.1 Map of Odisha 11

Efforts to end open defecation in India 11

Barriers to end open defecation in India 16

The Sundara Grama intervention 21

Table 2.1 Description of Sundara Grama Activities 22

Table 2.2 Levels of behavioral control in BCD and Sundara Grama activities 25

Table 2.3 Sundara Grama activities and the COM-B System 27

Chapter III: Student Contribution 38

Journal Choice 38

Overview of the Sundara Grama intervention 38

Role of student project within Sundara Grama 39

Student contribution to thesis 40

Methods 40

Table 3.1 Focus group participants by village and sex 42

Table 3.2 Demographics of focus group participants 44

Chapter IV: Manuscript 48

Introduction 48

Materials and Methods 50

Results 52

Discussion 56

Conclusions 59

Table A1 Description of Sundara Grama activities 60

Table A2 Focus participants by village and sex 61

Table A3 Demographics of focus group participants 61

Chapter V: Public Health Implications 65

Implications for intervention activities 65

Implications for community interventions 66

Spillover 70

Future research questions 71

Appendices 74

Appendix A: Definition of terms 74

Appendix B: IRB Approval for parent study 76

Appendix C: Oral consent for focus group participants 77

Appendix D: FGD demographic survey 79

Appendix E: Intervention FGD Guide 81

Appendix F: Control FGD Guide 84

Appendix G: Codebook 88

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