Analysis of latrine fecal odor release pattern and the deodorization with composited microbial agent.

As an important source of malodor, the odor gases emitted from public toilet significantly interfered the air quality of living surroundings, resulting in environmental problem which received little attention before. Thus, this paper explored the odor release pattern of latrine feces and deodorization effect with composited microbial agent in Chengdu, China. The odor release rules were investigated in sealed installations with a working volume of 9 L for 20 days. The odor units (OU), ammonia (NH3), hydrogen sulfide (H2S) and total volatile organic compounds (TVOC) were selected to assess the release of malodorous gases under different temperature and humidity, while the highest malodor release was observed under 45℃, with OU and TVOC concentration was 643.91 ± 2.49 and 7767.33 ± 33.50 mg/m3, respectively. Microbes with deodorization ability were screened and mixed into an agent, which composited of Bacillus amyloliquefaciens, Lactobacillus plantarum, Enterococcus faecalis and Pichia fermentans. The addition of microbial deodorant could significantly suppress the release of malodor gas during a 20-day trial, and the removal efficiency of NH3, H2S, TVOC and OU was 81.50 %, 38.31 %, 64.38 %, and 76.86 %, respectively. The analysis of microbial community structure showed that temperature was the main environmental factor driving the microbial variations in latrine feces, while Firmicutes, Actinobacteria, Proteobacteria and Bacteroidetes were the main bacteria phyla involved in the formation and emission of malodorous gases. However, after adding the deodorant, the abundance of Bacteroidetes, Proteobacteria and Actinobacteria were decreased, while the abundance of Firmicutes was increased. Furthermore, P. fermentans successfully colonized in fecal substrates and became the dominant fungus after deodorization. These results expanded the understanding of the odor release from latrine feces, and the composited microbial deodorant provided a valuable basis to the management of odor pollution.

The Occupational and Environmental Hazards of Uncovered Toilets.

ABSTRACT: Substantial evidence demonstrates that plumes from uncovered toilets potentially expose nurses and other health care workers to aerosols containing infectious agents and hazardous drugs, including antineoplastic drugs. Most hospitals in the United States utilize flushometer-type toilets, which operate under high pressure and do not have a permanently attached closure or lid, which is known to reduce the aerosols generated by flushing. This article aims to raise awareness among nurses of the potential exposure risks associated with toilet plume aerosols, so they can educate other health care workers and take part in initiatives to address these risks.

Excreta flow mapping along the sanitation service chain, a case of Kombolcha town, Ethiopia.

Poor management of fecal sludge (FSM) presents significant risks to public health and the environment. This study employed qualitative and quantitative data collection methods, along with the Shit Flow Diagram (SFD) data analyzing tool to investigate FSM patterns in Kombolcha town, Ethiopia. The findings indicate that 75.7% of housing unites in the town are shared toilets, with multiple households sharing a single facility. The primary toilet technologies used include cistern flush toilets (2.1%), pour/manual flush toilets (19.8%), ventilated improved pit latrines (11.1%), pit latrines with slabs (56.4%), and pit latrines without slabs (10.6%). However, 98.5% of these toilet types had either unlined or only partially lined containments. Furthermore, only 37% of households practice safe pit or sludge tank emptying. As a result, only 17% of fecal sludge goes through the sanitation value chain and is effectively treated, while 39% remains onsite and unemptied, and the remaining 44% is disposed of in a manner that poses risks to the environment and public health. The study highlights the significant public health and environmental risks associated with the high reliance on shared toilets, the prevalence of inadequately lined toilet types, and the low adoption of proper fecal sludge management practices. Addressing these challenges requires the implementation of sanitation bylaws and building code regulations that prioritize hygienic standards and promote improved toilet technologies.

Transmission of Viruses from Restroom Use: A Quantitative Microbial Risk Assessment.

Restroom use has been implicated in a number of viral outbreaks. In this study, we apply quantitative microbial risk assessment to quantify the risk of viral transmission by contaminated restroom fomites. We estimate risk from high-touch fomite surfaces (entrance/exit door, toilet seat) for three viruses of interest (SARS-CoV-2, adenovirus, norovirus) through eight exposure scenarios involving differing user behaviors, and the use of hand sanitizer following each scenario. We assessed the impacts of several sequences of fomite contacts in the restroom, reflecting the variability of human behavior, on infection risks for these viruses. Touching of the toilet seat was assumed to model adjustment of the seat (open vs. closed), a common touch point in single-user restrooms (home, small business, hospital). A Monte Carlo simulation was conducted for each exposure scenario (10,000 simulations each). Norovirus resulted in the highest probability of infection for all exposure scenarios with fomite surfaces. Post-restroom automatic-dispensing hand sanitizer use reduced the probability of infection for each virus by up to 99.75%. Handwashing within the restroom, an important risk-reduction intervention, was not found to be as effective as use of a non-touch hand sanitizer dispenser for reducing risk to near or below 1/1,000,000, a commonly used risk threshold for comparison.

Assessment of sanitation infrastructure resilience to extreme rainfall and flooding: Evidence from an informal settlement in Kenya.

Sanitation infrastructure can fail during heavy rainfall and flooding, allowing the release of fecal waste - and the pathogens it carries - into spaces where people live, work, and play. However, there is a scarcity of reliable frameworks that can effectively assess the resilience of such infrastructure to extreme rainfall and flooding events. The purpose of this study was to develop and apply a novel framework for assessing and ranking the resilience of sanitation infrastructure in informal settlements. A framework for assessing sanitation infrastructure resilience was developed consisting of 19 indicators that were categorized into three domains: physical infrastructure design (8 indicators), operations and management (5 indicators), and environmental factors (6 indicators). The framework was applied to data from 200 shared sanitation facilities in Kibera, Kenya, collected through transect walks, field observations, surveys, and sanitary risk inspections. Results indicate that sanitation infrastructure type impacts resilience. Toilet facilities connected to a piped sewer (r = 1.345, 95% CI: 1.19-1.50) and toilets connected to a septic system (r = 1.014, 95% CI: 0.78-1.25) demonstrated higher levels of resilience compared to latrines (r = 0.663, 95% CI: 0.36-0.97) and hanging toilets (r = 0.014, 95% CI: 0.30-0.33) on a scale ranging from 0 to 4. The key determinants of sanitation infrastructure resilience were physical design, functionality, operational and maintenance routines, and environmental factors. This evidence provides valuable insights for developing standards and guidelines for the design and safe siting of new sanitation infrastructure and encourages investment in sewer and septic systems as superior options for resilient sanitation infrastructure. Additionally, our findings underscore the importance for implementers and communities to prioritize repairing damaged infrastructure, sealing potential discharge points into open drains, and emptying filled containment systems before the onset of the rainy season.

Determinants of Willingness to Pay for Fecal Sludge Management Services and Knowledge Gaps: A Scoping Review.

Achieving universal access to safely managed sanitation services is one of the Sustainable Development Goal 6 targets (SDG6.2). The cost and availability of services to ensure the safe management of on-site sanitation, such as pit latrines and septic tanks, can be major barriers for poor households. Particularly, fecal sludge emptying services have become increasingly important due to the growing urban population. This review aims to scope the literature on stated and revealed willingness to pay (WTP) for emptying on-site sanitation systems and to identify determinants of WTP and gaps in knowledge. We performed electronic searches of six databases. After deduplication, 1846 records were identified, of which 14 were included in the review. In these studies, we identified 26 distinct scenarios that reported mean or median WTP values for emptying services and their market price (i.e., price at which the services were provided). Among the 26 scenarios, 77% (n = 20) reported that WTP was lower than the market price. We identified 20 statistically significant determinants of WTP, which can be leveraged when developing or improving manual and mechanical emptying services to attract more customers. Future research should consider services that adopt flexible pricing or mobile money payment and optimize their emptying operations to increase WTP. Validating the effectiveness of such services in solving the WTP-market price imbalance is a significant knowledge gap.

From the bathroom to a national discussion of LGBTQ+ rights: a case of discrimination in the Philippines.

Despite the Philippines' progress in gender equality, contemporary evidence suggests that Filipinos continue to possess negative attitudes toward lesbian and gay individuals. Likewise, discrimination and violence toward bisexual, transgender, and queer Filipinos have been documented. Despite cases of sexual orientation and gender identity and expression (SOGIE) based discrimination, national-level anti-discrimination legislation remains unpassed in the Senate. This study explores the national discussions on the SOGIE Equality Bill triggered by a bathroom discrimination experienced by a Filipino transgender woman in 2019. Taking cues from Richardson's sexual citizenship framework, we investigate the diverse rights discourses among sectoral groups, such as local lesbian, gay, bisexual, transgender, queer, and other individuals of marginalized sexualities and genders (LGBTQ+) organizations and their allies, high-ranking Filipino politicians, and religious organizations. Analysis of local discourses showed that those supporting the SOGIE Equality Bill leverage identity-based rights discourses, while those opposed primarily navigate these debates using conduct-based rights discourses. Future policy and advocacy work must leverage the insights from these public proceedings to foster LGBTQ + solidarity in their campaigns for LGBTQ + rights in the country. Particularly, future work must (1) locate the middle ground between the LGBTQ + community and opposed legislators; (2) highlight essential values and common issues shared by all Filipinos; (3) surface how privilege can preclude and advance solidarity within the LGBTQ + community; (4) campaign for the passage of local anti-discrimination ordinances; (5) improve the SOGIE-related competencies of policy implementers; and (6) engage in research that explores public discourses and meanings assigned to sexual rights among Filipinos.

The potential risks of Legionella arising from ligature-resistant fixtures.

To provide a safe environment, behavioral health settings must adhere to "ligature-resistant" protocols for patients at risk of harm to themselves or others. However, certain bathroom ligature-resistant fixtures alter environmental controls, such as sinks and showerheads, and increase the risk of water-borne pathogens due to low water output settings, highlighting the importance of an interdisciplinary water management program. We describe how ligature-resistant water fixtures may have been associated with a possible case of hospital-associated Legionellosis.

Selection of appropriate on-site household sanitation options for rural communities of Zimbabwe - case of Mbire district, Zimbabwe.

Selecting an appropriate sanitation option involves multiple stakeholders with often conflicting objectives. A multiple criteria decision analysis (MCDA) framework was developed to inform decision makers on selecting appropriate sanitation options for rural communities. Criteria established from literature were evaluated and weighted on-line by stakeholders. A performance matrix was developed by assigning weights to criteria and scoring alternatives. Selection of alternatives was based on a composite appropriateness index from a rank using the simple multi-attribute ranking technique. The framework was evaluated by verification, validation and sensitivity analysis. Five alternatives were evaluated on 14 decision criteria. The first preferred alternative was the urine diverting dry toilet (72.54) then the Blair ventilated improved pit latrine (67.10). The framework was commented as reasonable and robust. A simple and transparent MCDA framework was developed considering local conditions in a participatory manner to select appropriate alternatives for rural sanitation where a single option is encouraged.

"This is not built for me": A qualitative study of adult-sized changing tables and public restroom accessibility.

BACKGROUND: Adult-sized changing tables allow individuals with disabilities or medical conditions related to toileting to change with or without assistance. These tables are rarely found in public restrooms, and as a result, those who need them are often changed on floors, in vehicles, or are unable to stay in public spaces for more than a few hours. OBJECTIVE: This study aimed to understand how individuals who utilize adult-sized changing tables, or self-advocates, and caregivers for disabled people, access public restrooms and to report recommendations to improve inclusivity of public restrooms. METHODS: We virtually interviewed five self-advocates and sixteen caregivers in February and March 2023. We performed a qualitative analysis of the interview transcripts using MAXQDA 2022. RESULTS: Four major themes arose during interviews: social consequences, health effects, caregiver effects, and inaccessibility of restrooms in the healthcare setting. All caregivers have changed disabled individuals in vehicles, and 11 on public restroom floors, experiencing guilt and stress, and often receiving injuries. Several respondents reported limiting intake of fluids or using suppositories to prevent the need to toilet during unavoidable outings. Respondents most need height adjustable changing tables in healthcare settings, airports, and large recreational facilities. CONCLUSIONS: Without adult-sized changing tables, individuals with disabilities are forced to risk their health and dignity to utilize public spaces.

Occupational groups and lower urinary tract symptoms: A cross-sectional analysis of women in the Boston Area Community Health Study.

OBJECTIVES: The objective of this study is to inform our hypothesis that the workplace toileting environment may impact lower urinary tract symptoms (LUTS); we examined the prevalence of LUTS across occupational groups in the Boston Area Community Health Survey. METHODS: At baseline, women (n = 3205) reported their occupation and frequency of 15 LUTS. Using the US Department of Labor's Standard Occupational Classification (SOC) system, we categorized women into 11 standard occupational groups. Prevalence ratios (PRs) were calculated by log-link generalized linear models, adjusting for age, race, education, fluid intake, and parity. Women classified in Office and Administrative Support were used as the reference group given their potential for fewer workplace toileting restrictions. RESULTS: Of the 3189 women with complete data, 68% of women reported any LUTS, ranging from 57% to 82% across the SOCs. Relative to women in Office and Administrative Support (n = 576), women in Computing, Engineering, and Science (n = 64) were more likely to report any LUTS (PR = 1.2, 95% confidence interval [95% CI]: 1.0-1.4) and urinating again in <2 h (PR = 1.7, 95% CI: 1.4-2.2), and women in Education, Legal, Community Service, Arts, and Media (n = 477), as well as Healthcare Practitioner and Technical Occupations (n = 162), were less likely to report perceived frequent daytime urination (PR = 0.6, 95% CI: 0.5-0.9 and PR = 0.6, 95% CI: 0.4-0.9, respectively). CONCLUSIONS: Our cross-sectional findings suggest that urination frequency varies across understudied occupational groups with various workplace toileting environments. Future studies should examine this relationship prospectively to inform the influence of workplace toileting environments on urination frequency, as well as the development and/or worsening of LUTS.

Designing ergonomic toilets and bathrooms for older adults: A study on anthropometric dimensions and recommendations.

AIMS: This study aimed to evaluate the ergonomic design of toilets and bathroom equipment for older adults using anthropometric measurements. DESIGN: This was a descriptive cross-sectional study. METHODS: Data were collected from 2,721 people aged ≥ 65 years in Turkey. Fourteen anthropometric measurements were evaluated. Body dimension characteristics were described using minimum, maximum, and arithmetic means and standard deviations and the 5th, 25th, 50th, 75th, and 95th percentiles. RESULTS: The measurements showed that companies generally do not design bathroom toilet equipment that is suitable for older adults. CONCLUSION: This study provides advice to designers and manufacturers on how to adapt their products to the bathroom according to users' body characteristics in order to increase person-environment fit for older people.

Rural Sanitation Sustainability Dynamics: Gaining Insight through Participatory and Simulation Modeling.

Improved sanitation provides many benefits to human health and well-being and is integral to achieving Sustainable Development Goal Six. However, many nations, including most of sub-Saharan Africa, are not on track to meeting sanitation targets. Recognizing the inherent complexity of environmental health, we used systems thinking to study sanitation sustainability in Uganda. Our study participants, 37 sanitation actors in three rural districts, were engaged in interviews, group model building workshops, and a survey. The resulting model was parametrized and calibrated using publicly available data and data collected through the Uganda Sanitation for Health Activity. Our simulations revealed slippage from improved sanitation in all study districts, a behavior reflected in real interventions. This implies that systemic changes-changes to the rules and relationships in the system-may be required to improve sanitation outcomes in this context. Adding reinforcing feedback targeting households' perceived value of sanitation yielded promising simulation results. We conclude with the following general recommendations for those designing sanitation policies or interventions: (1) conceptualize sanitation systems in terms of reinforcing and balancing feedback, (2) consider using participatory and simulation modeling to build confidence in these conceptual models, and (3) design many experiments (e.g., simulation scenarios) to test and improve understanding.

Civet latrines in three habitats of a coffee dominated landscape of the Western Ghats biodiversity hotspot.

Civets are frugivorous animals in the Order Carnivora. They are relatively less shy towards people and anthropogenic habitats. It has been reported that the civets' preference of defecating in open sites enable them to be important seed dispersers of degraded forests and urban ecosystems of Asia and Africa. We surveyed for scats of palm civet (Paradoxurus hermaphroditus) in forest fragments of sacred groves (closed), coffee plantations (partly closed) and home gardens (relatively open) during the fruit ripening period of Coffee and Caryota urens - the two preferred fruits of civet - to report the microhabitat characteristics and seed composition of civet latrines. The microhabitat of each scat position - whether on or off the ground and the shade type - was recorded. The scat analysis showed the presence of 4234 seeds belonging to coffee (90.2%), C. urens (9.7%), and an anonymous Rubiacea species (0.10%) in a total of 105 scats collected from coffee plantations (55), home gardens (5), and sacred groves (45). The number of scats sampled from the three habitats was different, but not the number of seeds per scat. Overall, the number of scats increased with the canopy cover, but the trend was different for different habitats. In home garden and coffee plantations, it decreased, but in sacred groves, it increased with the canopy cover. The number of scats sampled above the ground - on tree branches, logs and built-up structures- was more than that was on the ground. The findings contradict the general belief that the civet latrines occur more in open areas than the shaded areas. Because the civet latrines are seen more above ground than on the ground, their efficiency as seed dispersal agent may be examined critically in different contexts.

Evaluation of SaTo pans as a new latrine technology in Kisumu County healthcare facilities, Kenya.

OBJECTIVES: Innovations to improve public sanitation facilities, especially in healthcare facilities (HCFs) in low-income countries, are limited. SaTo pans represent novel, largely untested, modifications to reduce odour and flies and improve acceptability of HCF sanitation facilities. We conducted a pilot project to evaluate acceptability, cleanliness, flies and odour within latrines in 37 HCFs in Kisumu, Kenya, randomised into intervention (SaTo pan modifications) and control arms by sub-county and HCF level. METHODS: At baseline (pre-intervention) and endline (>3 months after completion of SaTo pan installations in latrines in intervention HCFs), we surveyed users, cleaners and in-charges, observed odour and cleanliness, and assessed flies using fly tape. Unadjusted difference-in-difference analysis compared changes from baseline to endline in patient-reported acceptability and observed latrine conditions between intervention and control HCFs. A secondary assessment compared patient-reported acceptability following use of SaTo pan versus non-SaTo pan latrines within intervention HCFs. RESULTS: Patient-reported acceptability of latrines was higher following the intervention (baseline: 87%, endline: 96%, p = 0.05). However, patient-reported acceptability was also high in the control arm (79%, 86%, p = 0.34), and the between-arm difference-in-difference was not significant. Enumerator-observed odour declined in intervention latrines (32%-14%) compared with controls (36%-51%, difference-in-difference ratio: 0.32, 95% confidence interval: 0.12-0.84), but changes in flies, puddling of urine and visible faeces did not differ between arms. In the secondary assessment, fewer intervention than control latrines had patient-reported flies (0% vs. 26%) and odour (18% vs. 50%), and reported satisfaction was greater. Most cleaners reported dropholes and floors were easier to clean in intervention versus controls; limited challenges with water for flushing were reported. CONCLUSIONS: Our results suggest SaTo pans may be acceptable by cleaners and users and reduce odour in HCF sanitation facilities, though challenges exist and further evaluation with larger sample sizes is needed.

Sustainability of facilities built under the Community-Led Total Sanitation (CLTS) implementation: Moving from basic to safe facilities on the sanitation ladder.

In the context of monitoring progress towards SDG target 6.2, a household is counted to have access to sanitation if it uses at least basic sanitation services. Several approaches have been employed to help rural communities to climb up the sanitation ladder such as Community-led Total Sanitation (CLTS), whose primary target is to end open defecation through behavior change. CLTS does not subsidize sanitation facilities, but let households build their own facilities. The types and sustainability of facilities when construction is entrusted to households without guidelines remain understudied. The contribution of CLTS in achieving SDG6.2 also have not been studied. This paper addresses these gaps. Conducted in the province of Sissili in Burkina Faso, our study involved interviewing CLTS implementers, government officials, and community stakeholders. Coupled with household surveys, the data was analyzed using SPSS and Excel software. Findings indicate that CLTS succeeded in motivating households to build latrines hence escalating latrine coverage from 29.51% in 2016 (pre-CLTS) to 90.44% in 2020 (post-CLTS) in the province. However, 97.53% of latrines built were unimproved pit latrines with superstructures and without/with wooden or clay slabs and no roof, of which 19.76% collapsed during the rainy season. During this period, sanitation access rate rose from 11.9% to 17.00%. The study has therefore revealed that CLTS significantly elevates latrine coverage, yet it does not guarantee a proportional rise in sanitation access. This discrepancy results from the type of technologies generated by CLTS, which are not considered in calculating the sanitation access rate due to their unimproved nature. Consequently, further exploration of social approaches is essential, amalgamating technical and engineering aspects. Beyond socio-economic considerations, the sustainability of CLTS and the achievement of access to adequate and safe sanitation also rely on the robustness and resilience of the implemented facilities.

Factors influencing community-led total sanitation (CLTS) implementation abandonment before achieving open defecation-free (ODF) status: case study of the Central-Western region of Burkina Faso.

Access to sanitation has become an important element for improving the health of populations in developing countries. In Burkina Faso, 12% of the population in rural areas has access to latrine and 65% practice open defecation (OD). In a bid to eliminate this unsanitary practice and enhance sanitation access in rural areas, the government embraced community-led total sanitation (CLTS) as a national strategy in 2014. However, more than 6 years later, a notable observation is the high abandonment rate, with only a small fraction of rural communities successfully eradicating OD. Out of the 8892 villages in the country, 3546 underwent a CLTS triggering from 2014 to 2020. Nevertheless, in 787 of these villages, the implementation of the CLTS approach was abandoned, indicating a substantial abandonment rate of 22.19%. Until now, most studies on CLTS have focused on the post-ODF phase, emphasizing the question of the sustainability of the results generated by the approach, as if the process from triggering to obtaining ODF certification was not subject to any problems. However, cases of abandonment of the CLTS process after triggering do exist, although poorly documented in the literature, and there are no studies that clearly assign responsibilities to the actors when CLTS implementation comes to be abandoned. This research aims to bridge these gaps by identifying the root causes of these abandonment cases while delineating the distinct responsibilities associated with these instances. To achieve this, the study was conducted in the Central-Western region of Burkina Faso, where all stakeholders involved in CLTS implementation, including target communities, were identified, their different roles in the process defined, and data collected through household surveys, interviews, and focus groups. The content analysis method was used to analyze the data. The research findings indicate that the abandonment of the CLTS implementation process is due to four categories of factors: sociocultural and economic aspects (39.78%), physical conditions (17.52%), governance aspects (26.28%), and the quality of approach implementation (16.42%). Moreover, these factors highlight a shared accountability for abandonment involving the government, implementing organizations, and target communities. These findings have significant implications for the future design of sanitation programs using the CLTS approach. To mitigate abandonment rates in the CLTS implementation process across rural communities, it is imperative for policymakers to attentively consider these factors and integrate the recommendations delineated in this study.

Influence of social factors on adoption of sanitation practices in rural areas: a mixed methods study in Nzaui, Kenya.

Introduction: provision of adequate sanitation is among the common strategies of preventing sanitation-related diseases. However, provision of sanitation facilities may only be a sustainable solution if the population´s behavior changes and positive perception is embraced. This paper highlights the influence of social factors on adoption of sanitation practices. Methods: convergent mixed methods design was employed. Quantitative data was gathered using structured questionnaires from 100 household heads selected using cluster and simple random techniques. Logistic regression analysis was performed to explore factors that influenced adoption of sanitation practices. Qualitative data was gathered from a purposively selected focus group and analyzed thematically. Results: many (57%) of the participants were males. The average age for participants was 39 years, standard deviation (SD)=0.20. From the multivariable regression analysis with adjusted odds, household heads being aged 18-33 years (OR 1.76, 95% CI: 0.62-3.02, p=0.015) and safety of latrines (OR 1.72, 95% CI: 0.70-5.15, p<0.001) was associated with increased open defecation chances; whereas being a female (OR 0.16 95% CI: 0.06-1.81, P=0.01), availability of open spaces near households (OR 0.12, 95% CI: 0.05-1.13, p=0.30), and mason skills (OR 0.29, 95% CI: 0.13-1.65) were associated with reduced likelihood of open defecation practices. Further, being a female (OR 1.06, 95% CI: 0.18-3.16, p=0.043), having knowledge on safe sanitation (OR 1.01, 95% CI: 0.74-3.08, p=0.02), engaging skilled masons for toilet construction (OR 1.299, 95% CI: 1.01-8.95, p=0.005) and financial stability (OR 1.95, 95% CI: 0.98-23.40, P=0.032<0.001) were positively associated with adoption of improved toilets. Conclusion: the sanitation status in the study area was mainly poor due to the influence of multiple factors like gender, absence of toilets, knowledge on safe sanitation, poverty, mason skills and toilet location in relation to safety. The findings showed the need for innovative planning approaches based on the social aspects of communities for progress in sanitation standards in rural areas. Such approaches should adhere to the sanitation hardware versus software components of communities to promote active utilization of the available toilets, construction of improved toilets and reduction of open defecation.

Development of a behaviour change intervention to promote sanitation and latrine use in rural India.

BACKGROUND: Across developing countries poor sanitation is associated with disease often found widespread in rural populations. OBJECTIVES: This objective of this study was to conduct a formative research and feasibility evaluation of the behavioural intervention designed to improve latrine use in rural India. METHODS: Study conducted in four villages of Rajasthan, where latrine use is low and open defecation may spread disease. To identify the intervention a literature review was conducted, a survey of 497 households, and focus groups in village households (8-10 women and children). Seven focus groups with 63 women were conducted. Based on the survey results, the behaviour change intervention is developed utilising the Capability-Opportunity-Motivation-behaviour model and MINDSPACE framework. One intervention component involves psychological aspects that engage villagers through a pledge; the other component is provision of small incentives to facilitate latrine use. Feasibility and acceptability of the intervention was examined in the study population. The 30-day intervention was delivered to women in 38 randomly selected households who despite having a functional latrine did not use it. Thematic analysis, binary logistic regression analysis and feasibility evaluation of the intervention conducted. Post-intervention feedback from 22 participating households was obtained. RESULTS: The piloted intervention was feasible and so a revised design is offered. Results driving this evaluation include barriers identified, and used to improved intervention design in the current study. Village authority figures influenced behaviours across the villages and so did factors of convenience (ß = 5.28, p < 0.01), relief (ß = 5.49, p < 0.01), comfort (ß = 2.36, p < 0.01), Construction cost (ß=-1.98, p < 0.01) and safety (ß = 2.93, p < 0.01) were significant concerns associated with latrine use in the context of prevalent OD in the region. The logistic regression baseline model for the dependant variables indicated a significant increase in latrine use. Based on the feasibility study, the intervention is refined in several ways. CONCLUSIONS: Our theory-driven approach improves latrine use in Rajasthan and offers a useful tool to facilitate hygiene behaviour.