Community perceptions of a multi-level behavior change sanitation intervention in Odisha, India: a qualitative study Open Access
De Shay, Renee (Spring 2019)
Abstract
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
About this Master's Thesis
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