Formative Research to Develop Appropriate Participatory Approaches towards Water, Sanitation, and Hygiene in Rural Areas

"This study was an intensive qualitative research, undertaken with the objective of understanding perceptions, barriers, and motivators for improved sanitation behavior in rural India."

According to these WASH India researchers, most behaviour change communication (BCC) programming in WASH has relied on employing typical market research approach (addressing emotional, psychological, and entertainment based stimuli) in behavior change message development, but such sanitation promotion approaches are "only partially successful in providing short term increases in sanitation coverage and usage..." because they "often fail to address deeper underlying causes of resistance behind people’s reluctance to adopt improved and safe sanitation and hygiene (or even physical barriers like water availability)." 

In this qualitative study, researchers sought answers to the following questions:

1. "Are there barriers to sanitation arising owing to lack of knowledge and ignorance about the benefits of having and using toilets or from deeper level self perception barriers of caste, class and gender?
2. Who among a village habitants are adopting building and using toilets and why? What are the typologies within and across the states studied?
3. At what threshold level are more people willing to adopt or change their behaviors to start building and using toilets?
4. What is the role of BCC messaging and how is it perceived by the people? Why is it not working? What should the BCC messaging be, what it should reinforce and what it should encourage?”

The study, conducted in Gujarat, Telangana, and Jharkhand during July to December 2015, where, in some communities, formerly declared Open Defecation Free area under the Total Sanitation Campaign (TSC), habits of open defecation had re-entered the communities and, in others, there had been little progress. The methodology involved "intensive direct engagement of individuals and group discussions among the core team of three lead researchers and supporting team members." The core team developed interviewing and focus group discussions to investigate deep barriers to engagement in sanitation behaviour among men, women, and adolescents, older people and the handicapped, as well as teachers and panchayat (provincial to village level government) representatives and anganwadi workers. Village information templates informed a pilot research phase for testing methodology and tools. Observations were summarised, key findings were identified, and recommendations were added, reviewed, and finalised. Plans were developed for dissemination workshops.

Key findings include the following:

• 'Convenience' is the major motivating factor for constructing a toilet at home.
• Villagers did not consider negative health dimensions of open defecation as vitally important - likely due to lack of capacity at the Gram Panchayat level - including lack of appropriate language and lack of message targeting for Information, Education, and Communication (IEC). A need to check children's feces was given as a reason given for open defecation training of children by adults.
• Social barriers, such as gender inequality among women, beliefs, technical aspects, and environment, including lack of construction knowledge and inadequate space), access to water, affordability, and lack of information (on self perception of barriers) and economic barriers, distrust of government, exclusion, and lack of "cadre motivators" prevented uptake.

The researchers detailed habits and customs in traditional villages that are associated with open defecation, including routine, removing oneself from the village environment (increasingly more difficult due to population density), and patterns and preferences of companionship. "These patterns indicate that the families within themselves are not comfortable to have open discussion on sanitation and defecating practices which acts as a deterrent in motivating them and encouraging them in decision making towards collective behavioral change of the family."

Families, especially caregivers: cultivate open defecation habits in children after one year of age; rarely report that they do handwashing; and are unsure about encouraging young children to use toilets. Anganwadi health worker staff are more sure of communicating immunisation and hygiene information for breastfeeding mothers than information for mothers handling child defecation. Illness is not attributed to lack of sanitation, but rather lack of nutrition combined with hard work, early marriage, and child birth, etc.

Exposure to toilets has generated a list of complaints about the facilities. Aspirations for a better quality of life do not include toilets. People expressed fear of water contamination from toilets near living quarters. Religion and gender, as well as old age and disability, barriers also exist. Poorly maintained school toilets has negatively affected demand for toilets in the homes of adolescents. Indebtedness of families is a disincentive, though targeted cash incentives can be a facilitating factor.

Messaging issues include: "Mostly the BCC messages on TV or radios are perceived as messages for urban areas that end up portraying a stereotype of rural people where they are depicted as dirty and lacking hygiene consciousness." The disabled, elderly, women, and youth "expressed the need for a campaign and information dissemination in a decentralized (falia/hamlet level) manner, so that they could discuss their issues and ask for suggestions." Capacity building at the village level for the sanitation agenda is lacking. "Lack of understanding and motivation, competing priorities, lack of personnel capacities, challenges of mobilizing the entire village community when it is divided on political party lines, delays in release of funds, slow response from the government officials are some of the key constraints mentioned." Supply side barriers were also discussed.

BCC messaging and awareness was analysed by communities, and they reported that there is a lack of knowledge linking disease transmission with oral fecal transmission. The language used in messaging is not well understood. Interpretation of posters and other images is incomplete, and content is not sensitive to cultural barriers and tribal customs. "Home visits and interpersonal communication is found to be the most preferred form of receiving the key information, but this method is not followed in the current IEC and BCC intervention strategy."

Recommendations related to communication include the following:

• Identify appropriate BCC messages in WASH from the perspective of the recipient or communities
• Contextualise BCC messages for tribal communities that are living in remote rural areas at a subsistence level.
• Increase gender sensitive BCC messaging in WASH to include household cleanliness messaging and messaging breaking gender stereotypes.
• Use appropriate, locally understood language for BCC messaging. 
• Address peoples’ perception of cause of ill health and disease.
• Include messaging on safe disposal of feces.
• Focus on safe handling and disposal of child feces.
• Address financial barriers and perception of financial barriers in toilet construction.
• Address sanitation proprieties for the aged and infirm.
• Develop campaign strategies at the district level and implementation strategies at the block level.