An evaluation of a multistakeholder initiative on Safe Child Faeces Management (CFM) in rural Odisha shows promising behaviour change evidence among caregivers and infants. The results show a 21% increase in latrine use by children aged 24 to 35 months. Safe disposal of faeces by caregivers increased by 15% for infants aged 12 to 17 months and 29% for infants aged 8 to 11 months.

In June 2019, Gram Vikas and Emory University collaborated to design a behaviour change intervention and hardware to promote safe CFM practices among caregivers and infants. Supported by USAID and Tetra Tech’s WASHPaLS initiative, they implemented the initiative across 37 villages in Odisha’s Ganjam and Gajapati districts. The programme involved five behaviour change activities and designing a new CFM hardware.

The intervention

The behaviour change intervention addressed risks, attitudes, norms, abilities, and self-regulation for mothers and family members to adopt CFM. Simultaneously, through user-centred design sessions, the team engaged mothers and stakeholders to design a new CFM hardware and trained them in its use.

Liby Johson, the Executive Director of Gram Vikas, spoke on the importance of the intervention, “We found that more than 75-80% of the people use toilets in our partner villages. Proper disposal of child faeces has now emerged as an area of concern. We must work on attitudes and behaviours among caregivers and children to ensure improper disposal of child faeces does not create new problems. The work on CFM is a vital aspect of deepening and integrating Gram Vikas’ work in Water, Sanitation and Hygiene to achieve better health and nutrition outcomes.”

The programme built action knowledge on latrine use, safe faeces disposal, and caregivers’ confidence in adopting the behaviour. It helped them to develop strategies to overcome barriers, gave a goal tracker to monitor adherence, and fostered support from fathers and grandparents. Caregiver support group meetings provided social support and encouragement. Public acknowledgement and celebratory gatherings created a positive identity for those who practised safe disposal and nudged the establishment of new norms around child faeces disposal.

Dr.Apurva Ghugey, the intervention lead from Gram Vikas, talks about the programme’s significance for India, “From a cultural perspective, families consider child faeces as harmless. At the same time, it is more harmful because children have underdeveloped immune systems for the first five years of their lives. About 25 million children are born in India every year. We must focus on developing programmes that move beyond infrastructure to address safe sanitation and health outcomes for children of a younger age.”

The evaluation

The team rolled out the evaluation in 37 intervention and 37 control villages between December 2020 to March 2021. The 74 villages in the two districts are Gram Vikas programme villages with a combined water and sanitation programme.

The endline survey reached 662 primary caregivers and 841 children less than five years who received the intervention and 631 caregivers and 785 children in control villages. Overall, the study found a 12% higher safe child faeces disposal and 7% more child latrine use in the intervention villages compared to the control. The evaluation noted substantial improvements among children less than three years. Latrine use among children between 24 to 35 months increased by 21% in intervention villages.

Access to water and sanitation facilities improved the adoption of safe child faeces disposal behaviour among caregivers.

The study noted that most children between three to five years used latrines and identified children below three as the group to focus on for further impact. Gloria Sclar, Research Programme Manager from Emory University, shared her surprise, “We are excited by the dramatic increase of about 20% in caregiver disposal of faeces. The findings reveal that the study made a difference among younger children and facilitated young children’s latrine use.”

Dr.Ghugey emphasised the importance of the study, “Little evidence is available on child faeces disposal or its management in India. We need to demostrate with evidence how we can design, implement and promote safe disposal of faecal waste. It contributes to the ODF plus agenda of the Swachh Bharat Mission aiming for a contamination free surface environment through solid and liquid waste management.”

Bill & Melinda Gates Foundation supported the evaluation.

Evidence uptake workshop

Gram Vikas convened a result-sharing workshop in Bhubaneshwar on 10-11 November 2022, bringing together 77 government officials, institutions, practitioners, policymakers and NGOs to share the results and promote cross learnings. The workshop participants discussed the accomplishments and challenges of the CFM trial’s design and key findings from the process evaluation.

Manoj Kar, Professor of Public Policy and Governance at Xavier Institute of Management (XIM) University and former Public Health Advisor to the National Rural Health Mission shared his optimism about the findings. He said, “The research intervention project has tremendous potential to be scaled up to other districts benefiting households which adopt it and the communities. For this, the many stakeholders should engage with the community intensely and advocate for change. Only then will the community own it.”

Munmun Dasmohapatra, a public health professional and a research team member, commented on the importance of intense community outreach, “Civil society organisations should reach out to the community and explain the dangers of exposure to child faeces. It is necessary to understand community behaviour and help them roll out the project until all the targeted groups attain the behaviour change.”

Dr. Ghugey said the initiative shows an example of bridging the gap between knowledge and action on CFM.

Child Faeces Management is an integral part of Gram Vikas’ work on Sanitation and Health across our partner villages. Our work has led to 1427 villages being Open Defecation Free with functional infrastructure and community monitoring systems for local management. Know more about it here.