Cluster-randomised trial to test the effect of a behaviour change intervention on toilet use in rural India: results and methodological considerations

Area of Science:

• Public Health Interventions
• Behavioral Science
• Sanitation and Hygiene

Background:

• Debate exists on effective, scalable behavior change interventions for increasing toilet use in low-income settings.
• The '5 Star Toilet' campaign was developed as a novel intervention to promote existing toilet utilization.

Purpose of the Study:

• To test the effect of the '5 Star Toilet' campaign on household toilet use in rural Gujarat, India.
• To assess the scalability and effectiveness of a digitally enabled behavior change campaign for sanitation.

Main Methods:

• A cluster randomized trial involving 94 villages (47 intervention, 47 control) in rural Gujarat.
• The intervention comprised a 2-day digitally enabled campaign promoting toilet upgrading and household use.
• Primary outcome: proportion of households with all members using toilets, measured via masked questionnaires to minimize bias.

Main Results:

• Post-intervention, toilet use was 90.0% in the intervention arm versus 83.8% in the control arm (adjusted difference 5.0%, 95%CI -0.1, 10.1).
• Low exposure to the campaign was observed, with higher toilet use among exposed individuals within the intervention arm.
• Process evaluation indicated insufficient campaign intensity likely limited the intervention's overall impact.

Conclusions:

• Achieving high intervention intensity is challenging in settings with a small proportion of potential beneficiaries.
• Masking questions as a physical activity study may minimize responder bias in sanitation behavior research.
• Avoiding repeated surveys in the same households could further reduce over-reporting of toilet use.