Achievements and challenges of India's sanitation campaign under clean India mission: A commentary

The process, outcomes and context of the sanitation change induced by the Swachh Bharat Mission in rural Jharkhand, India

BACKGROUND

The Indian Swachh Bharat Mission (SBM) was launched in 2014 with the goal to make India open defecation (OD) free by October 2019. Although it is known that the ambitious goal was not achieved, the nature of the sanitation change brought about by the SBM in different parts of India is poorly understood. One reason is a dearth of case studies that would shed light on the performance of the SBM simultaneously across its different domains. This article provides an example of such study. Employing a Process, Outcomes, Context approach, the objective is to understand the process and outcomes of the SBM-induced sanitation change in a specific context of rural Jharkhand.

METHODS

The study utilizes data collected through field research conducted in the rural areas of Ranchi district, Jharkhand, a state in east-central India. This data was obtained via repeated cross-sectional household surveys conducted at the beginning and at the end of the SBM, supplemented by key informant interviews with SBM stakeholders.

FINDINGS

We identified political support of SBM implementation and its acceptance amongst the population. Female community workers became key agents of SBM implementation at local level. The SBM increased toilet coverage in the study area from 15% to 85% and lowered the OD rate from 93% to 26%. It substantially reduced structural inequalities in access to toilets, furthered social sanitation norms, improved some of the attitudes towards toilet use, but impacted less on hygiene and sanitation knowledge. The implementation mainly concentrated on the construction of subsidized toilets but less on improving public understanding of safe sanitation practices.

CONCLUSIONS

Although the SBM reduced sanitation inequalities in access to toilets in the study area, the behaviour change component was underplayed, focusing more on spreading normative sanitation messages and less on public education. Sustainability of the observed sanitation change remains a key question for the future. This article calls for more systematic production of geographically situated knowledge on the performance of sanitation interventions.

Examining toilet use and menstrual hygiene practices among beneficiary households of Swachh Bharat Abhiyaan (Clean India Mission) in rural areas of Mayurbhanj district of Odisha, India

Background

Basic sanitation and waste management have always remained a central issue in India. The country launched its flagship sanitation program - Swachh Bharat Abhiyan (SBA) (Clean India Mission) in 2014 to abolish open defecation and achieve universal sanitation coverage.

Objective

This study aimed to examine barriers to toilet use and women's menstrual hygiene practices in relation to the availability of toilets among rural residents.

Materials and Methods

Using a cross-sectional design and multi-stage sampling method, 120 households were selected from rural villages of the Mayurbhanj district of Odisha. Structured questionnaires and direct observation methods were used for data collection.

Results

All the houses had SBA latrines, yet 25% population defecated outside. About 40% households reportedly never cleaned their toilets. Most menstruating women (86.2%) preferred to change their menstrual pads/cloths in their bedroom instead of bathrooms. Incomplete construction was reported as the major reason for not using toilets. Large family size and low caste were found to be other predictors of non-use of toilets. Rural women did not use toilets for menstrual purposes as they do not consider these places as clean and safe.

Conclusion

This study clearly suggests that constructing toilets without adequate behaviour change interventions would not solve the problem of hygiene and sanitation in India, particularly in rural areas. There must be adequate monitoring of SBA scheme and utilization of funds for toilet usage. Development and implementation of suitable behaviour change strategies for toilet use in rural areas are essential to achieve the goal of open defaecation-free India.

The Use of Sanitary Latrines and the Practice of Open-Air Defecation in a Rural Setup in Perambalur District: A Cross-Sectional Study

Background Public health initiatives aim to decrease infectious diseases by enhancing sanitation, which is their primary goal. The practice of sporadically contaminating the environment with human feces has been around for generations and is embedded in the cultural behavior of villagers in India. This study aimed to estimate the proportion of people with access to latrine facilities and the proportion of people who practice open defecation in the villages of Perambalur, Tamil Nadu. Methodology This community-based, cross-sectional, analytical study was conducted in two rural villages in the Perambalur district for six months. After obtaining approval from the institutional ethics committee, we informed participants about the study's purpose. We conducted the study in selected rural areas and included every single residence in the hamlet, irrespective of whether the residents were permanent or temporary. We did not include families that were not reachable at any point during the survey. A convenient sampling procedure was used to select 330 houses for the study. The lead investigator interviewed one individual from each household, preferably the head of the family. A semi-structured questionnaire was used to collect the pertinent information. All collected data were entered into Microsoft Excel (Microsoft Corp., Redmond, WA, USA), and SPSS software version 21 (IBM Corp., Armonk, NY, USA) was used to analyze the results. Results Only around 3.6% of the study participants lived in kutcha households, and about 99.1% of participants identified as Hindu. The proportion of household latrines used was 64.1% among the study participants. Of them, 52.3% engaged in open defecation. Only 4.7% of participants had access to an underground drainage system. Most participants gained knowledge from medical professionals (84.8%). Social media was the second most used source, accounting for about 60.7% of the total. The most frequent reason given for practicing open-air defecation was the perception that constructing restrooms would be expensive (76.3%), while the second most frequent reason was a lack of land (53.4%). An independent t-test found no statistically significant relationship between the availability of household latrines and the number of girls or boys, age, or family income. Compared to those living in semi-pucca and kutcha households, most participants (77.3%) who lived in pucca houses had household latrines. The chi-square test revealed that this proportional difference was statistically significant (p = 0.0001). Conclusions The study participants used household latrines 64.1% of the time. Of the participants, 52.3% engaged in open defecation. The government's initiative to build toilets has only helped a quarter of the population, which needs to be improved. Only 5% of people living in rural areas have access to an underground drainage system. The results of our study provide a justification for the government program's mandate that healthcare practitioners must deliver health education. Therefore, a personalized approach is required to overcome the behavioral barrier among rural people and achieve behavior change.

Colonization with extended-spectrum beta-lactamase-producing Escherichia coli and traveler's diarrhea attack rates among travelers to India: a systematic review and meta-analysis

Background

India is an attractive destination for travelers. Unfortunately, numerous reports exist on traveler’s diarrhea (TD) and fecal colonization with extended-spectrum beta-lactamase-producing Escherichia coli (ESBL-EC) among international travelers visiting India. Here, we systematically reviewed studies published on the acquisition of ESBL-EC and TD attack rates among international visitors to India.

Methods

Design: Systematic review and meta-analysis.

A systematic search was performed using Google Scholar, PubMed, EMBASE, Web of Science, and gray literature from 2000 to December 2021, for studies containing data for ESBL-EC acquisition or TD experience related to a trip to India. Random effects models were used to compute the prevalence of ESBL-EC acquisition and TD attack.

Results

The literature search yielded a total of 5023 records. Of these, 31 met our inclusion criteria for systematic review and only 17 could be meta-analyzed (9 for TD, and 8 for ESBL-EC). The overall pooled attack rate of TD was 39% (95% confidence interval, CI: 25–53%). In studies where travelers' memory was used to diagnose TD, the pooled attack rate of TD was slightly higher (42%, 95% CI: 21–64%) compared to those where TD was objectively documented (33%, 95% CI: 17–49%). There were significant risks to be colonized with ESBL-EC among the travelers who experienced TD. The pooled rate of ESBL-EC colonization was 72% (CI: 67–78%). Most ESBL-EC produced CTX-M-15 enzyme. Furthermore, most of the travelers who acquired ESBL-EC were from highly industrialized countries recruited from travel clinics: Canada (n = 80), Germany (n = 69), Netherlands (n = 20), Sweden (n = 18), Japan (n = 10), Finland (n = 8), USA (n = 7), Spain (n = 5), and Denmark (n = 3).

Conclusions

TD pooled attack rate and ESBL-EC acquisition among international travelers visiting India were high in this study. However, we cannot make generalizations based upon this TD pooled attack rate for the current situation, due to a lack of current data. Our study highlights that travelers should be advised on TD to ensure that they do not disregard the risk of contracting TD and be better prepared as a result. It also illustrates the importance of international travel in acquiring antibiotic-resistant Escherichia coli.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40794-022-00179-1.