cp_2016_ITD_PhD_Sinha_A.pdf - Sinha A(2017 Assessing latrine use in low-income countries a field study in rural India PhD thesis London School of

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Unformatted text preview: Sinha, A (2017) Assessing latrine use in low-income countries: a field study in rural India. PhD thesis, London School of Hygiene & Tropical Medicine. DOI: Downloaded from: DOI: 10.17037/PUBS.03449896 Usage Guidelines Please refer to usage guidelines at or alternatively contact [email protected] Available under license: ASSESSING LATRINE USE IN LOW-INCOME COUNTRIES: A FIELD STUDY IN RURAL INDIA ANTARA SINHA Thesis submitted in accordance with the requirements for the degree of Doctor of Philosophy of the University of London September 2016 Department of Disease Control Faculty of Infectious and Tropical Diseases LONDON SCHOOL OF HYGIENE & TROPICAL MEDICINE Funded by the Bill & Melinda Gates Foundation Gates Award OPP1008048 Ref. PF818 Research group affiliation(s): Not applicable 1 Statement of Own Work I, Antara Sinha, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. Antara Sinha Date: 15 September 2016 2 Acknowledgements I would like to thank my supervisor, Tom Clasen, who has been a great guide and a constant source of support through all these years. I am grateful to my advisors, WolfPeter Schmidt, for his guidance on study design and statistical analyses; and to Sophie Boisson and Belen Torondel for providing invaluable input and support from the early days of this research. I am also grateful to my advisory panel members: Jeroen Ensink and Mimi Jenkins. Thanks to Joanna Schellenberg, Kathy Baisley and Daniel Chandramohan for their helpful suggestions at the upgrading stage. I am grateful to Evan Thomas, Portland State University, for developing a version of the PLUM that I used in the field and for doing so on very short notice. Many thanks to Corey Nagel, Oregon Health & Science University, for his guidance and collaboration for the statistical analyses of this research. Thanks to Shoumyakant Joshi and Baby Nayak for their energy and diligence while working with me in the field. Thanks, also, to the larger sanitation study team and management in Bhubaneswar, Odisha. I am most grateful to the people of Puri who participated in this research. Finally, I would like to thank my family and friends for their encouragement. 3 Abstract Sanitation programme monitoring is often limited to latrine access and coverage, with little emphasis on use of the facilities. This may be partially explained by the challenges associated with measuring individual and household latrine use. The conventional methods used each have their limitations. The overall goal of this research was to improve the methods for assessing latrine use in low-income countries and enhance our understanding of the patterns and determinants of latrine use in rural India. The evidence from a cross-sectional study to compare reported latrine use with a technology based measure, Passive Latrine Use Monitors, indicated that reported latrine use, though already suggesting low adoption, likely exaggerates the actual level of uptake of government constructed latrines in rural Odisha, India. Moderate agreement was obtained when comparing daily reported use during the previous 48 hours with the average daily PLUM count. Thus, if self-report measures are used, survey questions should focus on the 48 hours prior to the date of the survey rather than asking about “usual” latrine use behavior. The study also assessed patterns and determinants of individual latrine use over 12 months in the study population. Based on a prior 48 hour recall measure of reported use, we classified use into three categories—“never”, “sometimes” and “always/usually”. We also assessed consistency of latrine use across the dry cold, dry hot and rainy seasons. Overall, we found that latrine use was poor. There was significant seasonal variation in use. There was increased reported likelihood of consistently using the latrine among females and where latrines had a door and roof. Older age groups and an increase in household size were associated with a decreased reported likelihood of consistently always/usually using the latrine versus never using it. The leading reported reason for non-use of latrines was a preference for open defecation. 4 Table of Contents STATEMENT OF OWN WORK 2 ACKNOWLEDGEMENT 3 ABSTRACT 4 TABLE OF CONTENTS 5 LIST OF FIGURES 9 LIST OF TABLES 12 LIST OF ABREVIATIONS 13 1 THESIS FRAMEWORK 15 2 INTRODUCTION 17 2.1 Sanitation: Definition and scope 2.2 Global sanitation targets and coverage rates, and progress monitoring 2.2.1 The issue of open defecation: global and regional trends (1990-2015) 2.2.2 The Millennium Development Goals sanitation target 2.2.3 Global and regional sanitation coverage and trends 2.2.4 Monitoring progress on sanitation: from access to use of sanitation facilities 2.3 Benefits of improving sanitation 2.3.1 Sanitation and health 2.3.2 Wider benefits of sanitation 2.4 Government of India sanitation programmes 2.4.1 The Total Sanitation Campaign: India 2.4.2 Moving beyond the TSC: Nirmal Bharat Abhiyan (NBA) and Swachh Bharat Mission 2.5 Summary 17 18 19 22 25 27 34 35 37 38 38 42 3 45 LITERATURE REVIEW 3.1 Introduction 3.2 The issues of latrine access, coverage and use indicators in sanitation monitoring and measurement 3.2.1 Reviewing the Indian Total Sanitation Campaign 3.2.2 Examples from other countries 3.3 Challenges in measuring latrine use 3.4 Household latrine use and health outcomes 3.5 Determinants of latrine use 5 43 45 46 46 57 59 75 83 3.6 Summary and way forward 89 4 RESEARCH GOALS AND OBJECTIVES 90 5 PILOTING AND RESEARCH METHODS 92 5.1 Methods for assessing latrine use – an overview 5.2 Methods of latrine use assessment: Reported use, latrine spot-checks, latrine construction and functionality indicators 5.2.1 Reported use 5.2.2 Latrine spot-checks 5.2.3 Latrine construction and functionality indicators 5.3 Instrumented monitoring: Passive Latrine Use Monitoring (PLUM) 5.3.1 The PLUM device hardware 5.3.1.1 The “second generation” (2G) PLUM 5.3.1.2 The “third generation” (3G) PLUM 5.3.1.3 The Sweet Sense (SS) PLUM 5.3.2 PLUM output and signal interpretation 5.3.2.1 The 2G and 3G PLUM 5.3.2.2 The Sweet Sense PLUM 5.4 Pilot testing 5.4.1 Phase 1 preparation and pilot testing (August 2011 to February 2012): 3G PLUM and other methods to assess latrine use 5.4.1.1 Training of enumerators 5.4.1.2 Testing of the 3G PLUM 5.4.1.2.1 Pilot testing of 3G PLUM: Round 1 5.4.1.2.2 Pilot testing of 3G PLUM: Round 2 5.4.1.3 Piloting of additional methods of latrine use assessment: reported use, latrine spot-checks, latrine construction and functional indicators of use 5.4.1.4 Estimation of a defecation frequency standard for the (rural) study population 5.4.2 Phase 2 pilot testing (June 2012 to September 2012): SweetSense (SS) PLUM and finalisation of additional methods to assess latrine use 5.4.2.1 Testing of the SS PLUM 5.4.2.1.1 Pilot testing: Round 1 (June 2012) 5.4.2.1.2 Pilot testing: Round 2 (July - August 2012) 5.4.2.2 Testing and finalisation of additional methods to assess latrine use 92 93 6 136 METHODS TO ASSESS LATRINE USE 6.1 Study context: The Sanitation Trial 6.2 Assessing latrine use in the context of the Sanitation Trial 6.2.1 Study design 6.3 Sample size 6.3.1 Sampling strategy 6 93 94 95 96 96 97 99 101 103 103 105 107 108 109 110 111 112 119 127 130 130 130 134 135 136 142 142 144 144 6.3.2 Sample size estimation 6.4 Participant eligibility, enrolment and randomisation 6.5 Field methods 6.6 Outcome assessment 6.7 Data management and analysis 6.8 Ethics 145 150 151 155 159 162 7 ASSESSING LATRINE USE IN RURAL INDIA: A CROSS-SECTIONAL STUDY COMPARING REPORTED USE AND PASSIVE LATRINE USE MONITORS 7.1 Abstract 7.2 Introduction 7.3 Materials and methods 7.3.1 Study context 7.3.2 Village and household selection 7.3.3 Surveys to assess latrine use 7.3.4 Passive Latrine Use Monitor 7.3.5 Household follow-up procedure 7.3.6 Data analysis 7.3.7 Ethics 7.4 Results 7.4.1 Assessing agreement using BA plots 7.4.2 Concordance correlation coefficient 7.5 Discussion 7.6 References: Chapter 7 163 8 192 ASSESSING PATTERNS AND DETERMINANTS OF LATRINE USE IN RURAL SETTINGS: A LONGITUDINAL STUDY IN ODISHA, INDIA 8.1 Abstract 8.2 Introduction 8.3 Materials and methods 8.3.1 Study context 8.3.2 Study design 8.3.3 Village and household selection 8.3.4 Measuring use 8.3.5 Predictor variables 8.3.6 Data analysis 8.3.7 Ethics 8.4 Results 8.4.1 Sampled population 8.4.2 Patterns of latrine use 8.4.3 Determinants of latrine use 8.4.3.1 Determinants of latrine use in any given season 8.4.3.2 Determinants of consistent latrine use (across all three seasons) 8.4.4 Reported reasons for non-use of latrines 8.5 Discussion 8.6 Conclusions 7 165 165 167 167 168 168 169 169 171 174 174 175 176 177 187 194 195 198 198 198 199 199 201 203 204 204 204 205 206 206 208 209 210 214 8.7 Acknowledgements 8.8 Financial Support 8.9 Disclosures 8.10 References: Chapter 8 215 215 215 222 9 227 SUMMARY, REFLECTIONS AND WAY FORWARD 9.1 Summary 9.1.1 Cross-sectional study comparing reported use and Passive Latrine Use Monitors 9.1.2 Longitudinal study to assess patterns and determinants of latrine use 9.1.3 Implications 9.2 Reflections 9.2.1 Cross-sectional study comparing reported use and Passive Latrine Use Monitors 9.2.2 Longitudinal study to assess patterns and determinants of latrine use 9.3 Way forward 227 228 229 231 232 232 233 235 REFERENCES 238 APPENDIX 253 APPENDIX 1: LATRINE USE ASSESSMENT SURVEY APPENDIX 2: PUBLICATION - COMBINING SENSOR MONITORING AND ETHNOGRAPHY TO EVALUATE HOUSEHOLD LATRINE USAGE IN RURAL INDIA APPENDIX 3: PUBLICATION - EFFECTIVENESS OF A RURAL SANITATION PROGRAMME ON DIARRHOEA, SOIL TRANSMITTED HELMINTH INFECTION, AND CHILD MALNUTRITION IN ODISHA, INDIA: A CLUSTER-RANDOMISED TRIAL APPENDIX 4: PUBLICATION - IMPACT OF INDIAN TOTAL SANITATION CAMPAIGN ON LATRINE COVERAGE AND USE: A CROSS-SECTIONAL STUDY IN ORISSA THREE YEARS FOLLOWING PROGRAMME IMPLEMENTATION APPENDIX 5: 3G PLUM INSTRUCTION MANUAL, UCB 8 List of Figures Figure 2-1: Reduction in the proportion of population practicing open defecation, from 1990 to 2015 (%) Figure 2-2: Top 10 countries with the highest numbers of people (in millions) practicing open defecation Figure 2-3: Population practicing open defecation in rural and urban areas, 2015 Figure 2-4: The sanitation ladder - WHO-UNICEF Joint Monitoring Programme Figure 2-5: Proportion of population using improved sanitation facilities in 2015 Figure 2-6: Sanitation coverage trends (%) by MDG regions, 1990-2015 Figure 2-7: Progress towards the MDG sanitation target, 2012 – 69 countries were not on track Figure 2-8: Timeline of international targets and actions related to drinking water and sanitation Figure 2-9: F-diagram showing routes for faecal-oral transmission Figure 2-10: Sate-wise percentage share of households with no latrine facilities in India in 2001 and 2011 as per Census of India Figure 3-1: District scores on individual service delivery processes (grouped thematically) in the Indian TSC. Figure 5-1: The viewing range of the PLUM sensor Figure 5-2: Inside view of the 2G PLUM device and an example of how it is installed in a latrine Figure 5-3: The internal fitting of the 3G PLUM. The yellow outline shows the main board; the blue outline shows the secondary sensor board; the red outline shows the PIR sensor (covered with a domed “Fresnel” lens for protection and optical filtering) Figure 5-4: The PLUM mounting side – the red outline shows the power toggle switch; the blue outlines show the four ‘feet’ for mounting the PLUM Figure 5.5: PLUM lid – the red outline shows the screen cover for the sensor Figure 5-6: The SweetSense (SS) PLUM - an external and internal view of the final version used in the study 9 Figure 5-7: Bland Altman plot of the difference against the average to compare the 2G PLUM and the SweetSense PLUM methods of measurement Figure 5-8: Structured observations (Obs) versus SweetSense PLUMs (SS) recorded latrine use Figure 5-9: Timeline of pilot studies undertaken between August 2011 and September 2012 Figure 5-10: 3G PLUM installation protocol Figure 5-11: Variation between 30 ISHHs of mean PLUM-based latrine events per person per HH per day as recorded by the 3G PLUM Figure 5-12: An example showing the pattern of PLUM-based latrine event recordings by hour, using a 24 hour clock, for a given household over the observation period Figure 5-13: An example showing the pattern of PLUM-based latrine event recordings by hour, using a 24 hour clock, for a given household over the observation period Figure 5-14: The first version of the SweetSense PLUM (June 2012) – the internal fitting and the encasing Figure 5-15: The door switch installed in latrines during the Phase 2 pilot testing in Bhoigun, rural Odisha, in June 2012. Figure 6-1: A map depicting seven Blocks in rural Puri district, Odisha, India, from which 100 study villages were selected for inclusion in the Sanitation Trial. Figure 6-2: WaterAid India’s criteria for a completely constructed and functional latrine - brick structure (3. 6 ft. width, 4 ft. length and 5 ft. height); door; single pit and chamber connection for second pit, ring pit with cover plate (WaterAid India, 2010) Figure 6-3: Number of measurement days per household versus sample size per group of households for comparison. Figure 7-1: Mean latrine events and 95% confidence interval for households (N = 292) for reported latrine use and corresponding PLUM-recorded latrine use for varying time. Figure 7-2: Bland–Altman plots comparing (A) reported “usual” daily latrine use with average daily PLUM-recorded latrine events, (B) average of reported use on days 13 and 14 with average daily PLUM-recorded events during the total observation period. Figure 7-3: Scatterplots of (A) reported “usual” daily latrine use and average daily PLUMrecorded latrine events, (B) average of reported use on days 13 and 14 and average daily PLUM-recorded events during the total observation period. Supplemental Figure 7-4: Bland–Altman plots comparing (A) reported use on day 13 with PLUM-recorded events on day 13, (B) reported use on day 14 with PLUM-recorded events on day 14. 10 Supplemental Figure 7-5: Scatterplots of (A) reported use on day 13 and PLUM-recorded events on day 13, (B) reported use on day 14 and PLUM-recorded events on day 14. Figure 8-1: Reported reasons for non-use of latrines among latrine owning households in sample (N=266). 11 List of Tables Table 2-1: Improved and un-improved sanitation facilities – JMP definitions Table 2-2: Changes in global sanitation monitoring undertaken by the WHO and JMP Table 3-1: Results from the Planning Commission (GoI) evaluation study on non-use of toilets among households that have toilets Table 3-2: An overview of measures to assess WASH behaviour Table 3-3: Summary of studies on household latrine use and health outcomes Table 3-4: Individual sanitation practices affect the entire community Table 5-1: Data from 30 intervention surveillance households where the 3G PLUM was installed during Round 2 of the pilot testing (December 2011 - February 2012) Table 5-2: Pilot test results of the survey-based measures of latrine use – latrine construction and functionality, latrine spot-check and reported latrine use (December 2011-February 2012) Table 5-3: Reported usual frequency of defecation events, regardless of site, gender and age, in a sample of 1576 individuals. Table 5-4: Mean defecation frequency/person/day by age groups (N=1574). Table 6-2: Sample size calculation parameters using intra-class correlation Table 6-3: Outcome measures for each objective in the study Table 7-1: Questions and methods used for assessing reported use of latrines and the corresponding PLUM-recorded estimation approaches for four comparison categories Table 8-1: Baseline characteristics of the study households and latrines Table 8-2: Model showing the effect of individual and household-level predictors on individual latrine use based on prior 48 hours recall (in any given season or round) Table 8-3: Model showing the effect of individual and household-level predictors on consistent individual latrine use (across all three seasons or rounds) 12 List of Abbreviations 1G PLUM 2G PLUM 3G PLUM APL BPL CCC CLTS CRT DDWS DHS GoI GP GPS GSM HH ICC ID IEC IHHL INR ISHH JMP KAP LSHTM LUF MDGs MICS MoDWS NBA NGO NGP NSSO OD ODF OWG PIR PLUM PSU (USA) First Generation Passive Latrine Use Monitoring Second Generation Passive Latrine Use Monitoring Third Generation Passive Latrine Use Monitoring Above Poverty Line Below Poverty Line Concordance Correlation Coefficient Community-led Total Sanitation Cluster Randomised Trial Department of Drinking Water and Sanitation Demographic and Health Surveys Government of India Gram Panchayat Global Positioning System Global System for Mobile Communication Household Intra-class Correlation Coefficient Identification Information, Education and Communication Individual Household Latrine Indian Rupee Intervention Surveillance Household Joint Monitoring Programme Knowledge, Attitudes, Practices London School of Hygiene and Tropical Medicine Latrine Use Frequency Millennium Development Goals Multiple Indicator Cluster Surveys Union Ministry of Drinking Water and Sanitation Nirmal Bharat Abhiyan Non-Governmental Organisation Nirmal Gram Puraskar National Sample Survey Office Open Defecation Open Defecation Free Open Working Group on Sustainable Development Goals Passive Infrared Passive Latrine Use Monitoring Portland State University (United States of America) 13 SDA SDGs SES SQUAT survey SS PLUM SUMs SWEETLab TSC UCB UCB-TAMS UK UN UNICEF USAID VIP VWSC WASH WB WHO WSP XIMB Sustainable Development Agenda Sustainable Development Goals Socio-Economic Status Sanitation, Quality, Use, Access and Trends survey SweetSense Passive Latrine Use Monitoring Stove Use Monitors Sanitation, Water, Environment and Energy Technologies Laboratory Total Sanitation Campaign University of California, Berkeley University of California, Berkeley Time-Activity Monitoring System United Kingdom United Nations United Nations International Children’s Emergency Fund United States’ Agency for International Development Ventilated Improved Pit (latrine) Village Water and Sanitation Committee Water, Sanitation and Hygiene World Bank World Health Organization Water and Sanitation Program Xavier Institute of Management Bhubaneswar 14 1 Thesis framework This thesis describes research to evaluate methods for assessing latrine use in lowincome countries and to describe patterns and determinants of latrine use among households that received latrines under the Government of India’s Total Sanitation Campaign in rural India. This work was initiated in 2011 in the context of a cluster randomised controlled field trial (the ‘Sanitation Trial’) in rural Puri district, Odisha (India). Though there is evidence that latrine coverage is not translating into use, further research is required to improve the methods for assessing latrine use in low income countries and to enhance our understanding of the patterns and determinants of latrine use. Chapters 1 – 3 of this thesis provide a context for the research. Chapter 2 is an introduction that provides the rationale for the research and background on the evolving definitions of sanitation, the issue of open defecation, international sanitation targets, monitoring mechanisms and challenges, the benefits of sanitation and finally an overview of the government’s sanitation programme in India. Chapter 3 summarises the relevant literature on latrine access, coverage and use indicators in sanitation progress monitoring and measurement; the challenges in measuring latrine use; the determinants of use to understand why latrines are used or not used; and the association between latrine use and health outcomes. Chapter 4 consists of the research aim...
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