Clinical trial NCT04526171: Vaparshun Improving Toilet Use in Rural India
Official title: Vaparshun Improving Toilet Use in Rural India (The 5 Star Toilet Campaign)
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Behavior
Keywords: sanitation
toilet
behavior
evaluation
Lead sponsor: Public Health Foundation of India
Sponsor class: OTHER
Collaborators: name: London School of Hygiene and Tropical Medicine
First posted: 2020-08-25
Enrollment: 2483
Sex: ALL
Minimum age (years): 18
Maximum age (years): 65
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: yes
Allocation: RANDOMIZED
Intervention model: PARALLEL
Intervention model description: The study was a cluster-randomised trial with 47 intervention and 47 control clusters, with a baseline and an endline survey conducted in the district of Bhavnagar, Gujarat, India. Briefly, 94 villages were randomised to intervention or control groups. We carried out a household census and from this we selected 10 households with a functional 'government' toilet for a baseline and 30 for follow up at endline using random sampling from the census list for each village. Outcomes were measured as the proportion of households where all members were reported to use the toilet and the overall usage of toilets by individuals, employing a standard questionnaire.
Primary purpose: OTHER

Brief summary: Vaparshun intervention aimed to inspire the target audience to use a toilet. It aimed to revalue their toilets by recognizing that they provide benefits associated with the motives of hoard, create, convenience (comfort) and affiliation, and provide a reward pathway for transitioning to a new toilet use routine.

Detailed description: Our intervention consists of four different streams of activity. The outcome is that family members and men improve and use their contractor-built toilets. The activities are listed below.

1. Create Motive:

   Toilet Makeover: Conduct a lottery and perform makeovers of select government built toilets in the village, with the involvement of the community. Demonstrate improvements in comfort (light, space, ventilation, latrine chair/handle) and aesthetics (stencil painting of door and walls).

   Challenge/Opportunity: Many of the 'contractor' toilets are built with low engagement from family members and are uncomfortable to use. People are left with toilets they are not proud of or engaged with.

   Insight (from 'makeover' trial): If families invest in creating an attractive toilet they are be more likely adopt and use them.

   Inputs: Materials for the physical and aesthetic improvement of a toilet, manuals for conducting the community event.

   Outputs: Greater engagement with, and pride in, the toilet after makeover; others in the village inspired to conduct their own makeover. Those who use the upgraded toilet find it a more comfortable experience than they had expected causing reinforcement learning.
2. Hoard motive:

   Pit Emptying Demo and Pit Filling Estimation Demo" A community event-based discussion of the 'real' aspects related to pit filling/emptying designed to graphically overcome their perceptual barriers (e.g., squeezing a watermelon to show how little material there is in faeces).

   Challenge/Opportunity: People over-estimate the speed at which a pit fills and are uncertain about the emptying process. Therefore they hoard the 'limited' pit space by using the toilet only partially.

   Insight from FR: There are gaps between perception and reality which can be addressed. For example; water doesn't stay in the pit but seeps into the soil, faeces are composed mainly of water, decomposition reduces volume, compost doesn't smell and twin pits can be used interchangeably forever.

   Inputs: Films and 'emo-demos' (emotional demonstrations). Outputs: Participants are less anxious about pit filling and emptying.
3. Affiliation/convenience motives:

   Community Motivational Events: Small and large community events such as street plays, films, posters and pledging activities to bring alive convenience/comfort motives by amplifying problems associated with OD and rewards of using toilets; use of affiliation through testimonials films, posters, village maps, etc.

   Challenge/Opportunity: Even if the barriers around pits and toilet comfort are addressed, it may still not be enough to motivate men with entrenched habits of OD to start using toilets.

   Insights: Convenience/comfort can be a powerful drive for toilet usage. Those who use toilets in the village (women, children and elderly) find it is much more convenient and therefore do not return to OD. However, men who are non-users may not have experienced this and need to be convinced. Affiliation can be another strong drive for toilet usage. It is possible to exploit the emerging norms of toilet use and encourage men 'not to be left behind'.

   Inputs: Scripts, props, invitations, loud hailers, audio-visual equipment, etc. Outputs: Men use toilets because they 'get' how convenient they are, and so as not to be 'left behind'.
4. Transition to a new toilet use This would include testimonial videos of toilet users and toilet board of household members who improved their toilets. Providing certificate to households who improved their toilets.

Challenge/Opportunity: Those who use toilets for a specific period tend to stick with the habit; however, some people, especially men, do not try out the toilet or find the first experience unpleasant.

Insight: Reward the use of toilets for a specific period so new habits can form.

Inputs: Stimuli and nudges. Outputs: The entire family, especially men, form the habit of using a toilet.

In addition, village authorities will also be recruited to support delivery of the intervention.

Eligibility criteria: Inclusion Criteria:

- Households with a functional government or contractor built toilet.

Exclusion Criteria:

* Households with self built toilet.

Primary outcomes:
measure: Proportion of households where all members above the age of 5 years were reported to use the toilet the last time they defecated.
timeFrame: A gap of 6 weeks was maintained between campaign roll out and endline data collection
Secondary outcomes:
measure: Exposure to the intervention
timeFrame: Six weeks post intervention delivery
measure: Perceptions related to toilet use
timeFrame: Six weeks post intervention delivery
Other outcomes:
Locations:
city: Gandhinagar
country: India
facility: Indian Institute of Public Health/ Public Health Foundation of India
state: Gujarat
Study officials:
affiliation: IIPHG
name: Deepak o Saxena, PhD
role: PRINCIPAL_INVESTIGATOR
References:
citation: Schmidt WP, Chauhan K, Bhavsar P, Yasobant S, Patwardhan V, Aunger R, Mavalankar D, Saxena D, Curtis V. Cluster-randomised trial to test the effect of a behaviour change intervention on toilet use in rural India: results and methodological considerations. BMC Public Health. 2020 Sep 11;20(1):1389. doi: 10.1186/s12889-020-09501-y.