Assessing high-profile public messaging for sanitation behaviour change: evidence from a mobile phone survey in India
The UN Sustainable Development Goals call for the elimination of open defecation by 2030. Assessing global progress will require learning from India’s sanitation efforts because of its ambitious program of high-profile behavior change messaging to tackle open defecation, and because open defecation is widespread in India. In 2014, the Prime Minister announced a policy called the Swachh Bharat Mission (SBM), which aimed to eliminate open defecation by 2019. However, the 2015–16 National Family Health Survey –4 found that about 55% of rural and 11% of urban Indian households lack a toilet or latrine. To assess the extent of public awareness of the SBM, we use a mobile phone survey to ask about people’s knowledge of the existence and purpose of the SBM. We report representative estimates of awareness of the SBM among adults in Delhi (2016), Uttar Pradesh (2016), Mumbai (2016–17), Rajasthan (2016–17), Bihar (2018), Jharkhand (2018), and Maharashtra (2018). While much of the SBM’s activities took place in its last two years, we find that, at the time of the survey, no more than one-third of adults in any state are aware that the SBM intends to promote toilet and latrine use. Awareness was particularly low in Uttar Pradesh, where one in eight people who defecates in the open worldwide lives. While the SBM was very active in constructing latrines, the lack of awareness we find suggests that the SBM was less successful in raising the awareness required for large-scale behavior change in promoting latrine use.Banerjee, A.V., Duflo, E. and Glennerster, R. (2008) ‘Putting a Band-Aid on a corpse: incentives for nurses in the Indian public health care system’, Journal of the European Economic Association 6(2-3): 487–500 <https://doi.org/10.1162/JEEA.2008.6.2-3.487>.
Boisson, S., Sosai, P., Ray, S., Routray, P., Torondel, B., Schmidt, W.P., Bhanja, B. and Clasen, T. (2014) ‘Promoting latrine construction and use in rural villages practicing open defecation: process evaluation in connection with a randomised controlled trial in Orissa, India’, BMC Research Notes 7(1): 486 <https://doi.org/10.1186/1756-0500-7-486>.
Chaudhury, N., Hammer, J., Kremer, M., Muralidharan, K. and Rogers, F.H. (2006) ‘Missing in action: teacher and health worker absence in developing countries’, The Journal of Economic Perspectives 20(1): 91–116 <https://doi.org/10.1257/089533006776526058>.
Coffey, D. and Spears, D. (2017) Where India Goes: Abandoned Toilets, Stunted Development, and the Costs of Caste, Harper Collins, India.
Coffey, D., Spears, D. and Vyas, S. (2017a) ‘Switching to sanitation: understanding latrine adoption in a representative panel of rural Indian households’, Social Science & Medicine 188(C): 41–50 <https://doi.org/10.1016/j.socscimed.2017.07.001>.
Coffey, D., Gupta, A., Hathi, P., Spears, D., Srivastav, N. and Vyas, S. (2017b) ‘Understanding open defecation in rural India: untouchability, pollution, and latrine pits’, Economic & Political Weekly 52(1): 59–66.
Coffey, D., Hathi, P., Khurana, N. and Thorat, A. (2018) ‘Explicit prejudice: evidence from a new survey’, Economic & Political Weekly 53(1): 46–54.
Cutler, D. and Miller, G. (2005) ‘The role of public health improvements in health advances: the twentieth-century United States’, Demography 42(1): 1–22 <https://doi.org/10.1353/dem.2005.0002>.
Dutta-Bergman, M.J. (2005) ‘Theory and practice in health communication campaigns: a critical interrogation’, Health Communication 18(2): 103–22 <https://doi.org/10.1207/s15327027hc1802_1>.
Esrey, S.A., Potash, J.B., Roberts, L. and Shiff, C. (1991) ‘Effects of improved water supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma’, Bulletin of the World Health Organization 69(5): 609.
Fink, G., Günther, I. and Hill, K. (2011) ‘The effect of water and sanitation on child health: evidence from the demographic and health surveys 1986–2007’, International Journal of Epidemiology 40(5): 1196–204 <https://doi.org/10.1093/ije/dyr102>.
Gupta, A., Khalid, N., Desphande, D., Hathi, P., Kapur, A., Srivastav, N., Vyas, S., Spears, D. and Coffey, D. (2019) Changes in Open Defecation in Rural North India: 2014–2018 [online] IZA Institute of Labor Economics <https://www.iza.org/publications/dp/12065/changes-in-open-defecation-in-rural-north-india-2014-2018> [accessed 8 July 2020].
Hathi, P., Haque, S., Pant, L., Coffey, D. and Spears, D. (2017) ‘Place and child health: the interaction of population density and sanitation in developing countries’, Demography 54(1): 337–60 <https://doi.org/10.1007/s13524-016-0538-y>.
Hathi, P., Khalid, N., Khurana, N., Thorat, A. and Coffey, D. (2020) Mobile Phone Survey Methods for Measuring Social Discrimination [online], research institute for compassionate economics (r.i.c.e.) <https://riceinstitute.org/research/mobile-phone-survey-methods-for-measuring-social-discrimination/> [accessed 13 July 2020].
International Institute for Impact Evaluation (3ie) (2019) Promoting latrine use in rural India evid-ence programme [online] <https://www.3ieimpact.org/our-work/water-sanitation-and-hygiene/promoting-latrine-use-rural-india-evidence-programme> [accessed 8 July 2020].
Kapur, A. and Deshpande, D. (2019) Swachh Bharat Mission – Gramin [online], Accountability Initiative, Budget Brief, 2019–2020 <https://www.cprindia.org/news/budget-briefs-2019-post-interim-budget-analysis> [accessed 8 July 2020].
Kapur, A., Srinivas, V. and Choudhury, P.R. (2016) Swachh Bharat Mission – Gramin [online], Accountability Initiative Budget Brief, 2016–2017 <https://accountabilityindia.in/publication/swachh-bharat-mission-gramin-goi-2016-17/> [accessed 13 July 2020].
Kayser, G., McElroy, S. and Benmarhnia, T. (2019) The role of inadequate water and sanitation on economic and social determinants of child mortality: a global analysis across 43 countries [online] <https://dx.doi.org/10.2139/ssrn.3311853> [accessed 13 July 2020].
Kohut, A., Keeter, S., Doherty, C., Dimock, M. and Christian, L. (2012) Assessing the Representativeness of Public Opinion Surveys, Pew Research Center, Washington, DC.
Ministry of Drinking Water and Sanitation (MoDWS) (2017) Guidelines for the Swachh Bharat Mission (Gramin) [pdf] <http://swachhbharatmission.gov.in/sbmcms/writereaddata/images/pdf/Guidelines/Complete-set-guidelines.pdf> [accessed 8 July 2020].
Ministry of Drinking Water and Sanitation (MoDWS) (2019) National Annual Rural Sanitation Survey, Round 2 (2018-19) National Report [pdf] <https://jalshakti-ddws.gov.in/sites/default/files/National_Report_NARSS_2018_19.pdf> [accessed 8 July 2020].
Ministry of Statistics & Programme Implementation (MoSPI) (2018) Drinking Water, Sanitation, Hygiene, and Housing Condition in India, NSS 76th Round [pdf] <http://mospi.nic.in/sites/default/files/publication_reports/Report_584_final_0.pdf> [accessed 8 July 2020].
Preston, S.H. and Haines, M.R. (2014) Fatal Years: Child Mortality in Late Nineteenth-Century America, Princeton University Press, Princeton, NJ.
Rosenboom, J.W. and Ban, R. (2017) ‘From new evidence to better practice: finding the sanitation sweet spot’, Waterlines 36(4): 267–83 <https://doi.org/10.3362/1756-3488.17-00011>.
Routray, P., Schmidt, W.P., Boisson, S., Clasen, T. and Jenkins, M.W. (2015) ‘Socio-cultural and behavioural factors constraining latrine adoption in rural coastal Odisha: an exploratory qualitative study’, BMC Public Health 15(1): 880 <https://doi.org/10.1186/s12889-015-2206-3>.
Slutkin, G., Okware, S., Naamara, W., Sutherland, D., Flanagan, D., Carael, M., Blas, E., Delay, P. and Tarantola, D. (2006) ‘How Uganda reversed its HIV epidemic’, AIDS and Behavior 10(4): 351–60 <https://doi.org/10.1007/s10461-006-9118-2>.
Swaminathan, S. and Thomas, J. (2007) ‘Saving the next generation: political capacity and infant mortality decline in India’s states’, International Interactions 33(3): 217–42 <https://doi.org/10.1080/03050620701449017>.
Teltumbde, A. (2014) ‘No Swachh Bharat without annihilation of caste’, Economic & Political Weekly 49(45): 11.
WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) (2012) Progress on Drinking Water and Sanitation: Joint Monitoring Programme Update 2012, WHO, Geneva; UNICEF, New York.
World Bank (2003) World Development Report 2004: Making Services Work for Poor People, Oxford University Press for the World Bank, Washington, DC.
World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) (2017) Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG Baselines, WHO, Geneva; UNICEF, New York.
Banerjee, A.V., Duflo, E. and Glennerster, R. (2008) ‘Putting a Band-Aid on a corpse: incentives for nurses in the Indian public health care system’, Journal of the European Economic Association 6(2-3): 487–500 <https://doi.org/10.1162/JEEA.2008.6.2-3.487>.
Boisson, S., Sosai, P., Ray, S., Routray, P., Torondel, B., Schmidt, W.P., Bhanja, B. and Clasen, T. (2014) ‘Promoting latrine construction and use in rural villages practicing open defecation: process evaluation in connection with a randomised controlled trial in Orissa, India’, BMC Research Notes 7(1): 486 <https://doi.org/10.1186/1756-0500-7-486>.
Chaudhury, N., Hammer, J., Kremer, M., Muralidharan, K. and Rogers, F.H. (2006) ‘Missing in action: teacher and health worker absence in developing countries’, The Journal of Economic Perspectives 20(1): 91–116 <https://doi.org/10.1257/089533006776526058>.
Coffey, D. and Spears, D. (2017) Where India Goes: Abandoned Toilets, Stunted Development, and the Costs of Caste, Harper Collins, India.
Coffey, D., Spears, D. and Vyas, S. (2017a) ‘Switching to sanitation: understanding latrine adoption in a representative panel of rural Indian households’, Social Science & Medicine 188(C): 41–50 <https://doi.org/10.1016/j.socscimed.2017.07.001>.
Coffey, D., Gupta, A., Hathi, P., Spears, D., Srivastav, N. and Vyas, S. (2017b) ‘Understanding open defecation in rural India: untouchability, pollution, and latrine pits’, Economic & Political Weekly 52(1): 59–66.
Coffey, D., Hathi, P., Khurana, N. and Thorat, A. (2018) ‘Explicit prejudice: evidence from a new survey’, Economic & Political Weekly 53(1): 46–54.
Cutler, D. and Miller, G. (2005) ‘The role of public health improvements in health advances: the twentieth-century United States’, Demography 42(1): 1–22 <https://doi.org/10.1353/dem.2005.0002>.
Dutta-Bergman, M.J. (2005) ‘Theory and practice in health communication campaigns: a critical interrogation’, Health Communication 18(2): 103–22 <https://doi.org/10.1207/s15327027hc1802_1>.
Esrey, S.A., Potash, J.B., Roberts, L. and Shiff, C. (1991) ‘Effects of improved water supply and sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection, schistosomiasis, and trachoma’, Bulletin of the World Health Organization 69(5): 609.
Fink, G., Günther, I. and Hill, K. (2011) ‘The effect of water and sanitation on child health: evidence from the demographic and health surveys 1986–2007’, International Journal of Epidemiology 40(5): 1196–204 <https://doi.org/10.1093/ije/dyr102>.
Gupta, A., Khalid, N., Desphande, D., Hathi, P., Kapur, A., Srivastav, N., Vyas, S., Spears, D. and Coffey, D. (2019) Changes in Open Defecation in Rural North India: 2014–2018 [online] IZA Institute of Labor Economics <https://www.iza.org/publications/dp/12065/changes-in-open-defecation-in-rural-north-india-2014-2018> [accessed 8 July 2020].
Hathi, P., Haque, S., Pant, L., Coffey, D. and Spears, D. (2017) ‘Place and child health: the interaction of population density and sanitation in developing countries’, Demography 54(1): 337–60 <https://doi.org/10.1007/s13524-016-0538-y>.
Hathi, P., Khalid, N., Khurana, N., Thorat, A. and Coffey, D. (2020) Mobile Phone Survey Methods for Measuring Social Discrimination [online], research institute for compassionate economics (r.i.c.e.) <https://riceinstitute.org/research/mobile-phone-survey-methods-for-measuring-social-discrimination/> [accessed 13 July 2020].
International Institute for Impact Evaluation (3ie) (2019) Promoting latrine use in rural India evid-ence programme [online] <https://www.3ieimpact.org/our-work/water-sanitation-and-hygiene/promoting-latrine-use-rural-india-evidence-programme> [accessed 8 July 2020].
Kapur, A. and Deshpande, D. (2019) Swachh Bharat Mission – Gramin [online], Accountability Initiative, Budget Brief, 2019–2020 <https://www.cprindia.org/news/budget-briefs-2019-post-interim-budget-analysis> [accessed 8 July 2020].
Kapur, A., Srinivas, V. and Choudhury, P.R. (2016) Swachh Bharat Mission – Gramin [online], Accountability Initiative Budget Brief, 2016–2017 <https://accountabilityindia.in/publication/swachh-bharat-mission-gramin-goi-2016-17/> [accessed 13 July 2020].
Kayser, G., McElroy, S. and Benmarhnia, T. (2019) The role of inadequate water and sanitation on economic and social determinants of child mortality: a global analysis across 43 countries [online] <https://dx.doi.org/10.2139/ssrn.3311853> [accessed 13 July 2020].
Kohut, A., Keeter, S., Doherty, C., Dimock, M. and Christian, L. (2012) Assessing the Representativeness of Public Opinion Surveys, Pew Research Center, Washington, DC.
Ministry of Drinking Water and Sanitation (MoDWS) (2017) Guidelines for the Swachh Bharat Mission (Gramin) [pdf] <http://swachhbharatmission.gov.in/sbmcms/writereaddata/images/pdf/Guidelines/Complete-set-guidelines.pdf> [accessed 8 July 2020].
Ministry of Drinking Water and Sanitation (MoDWS) (2019) National Annual Rural Sanitation Survey, Round 2 (2018-19) National Report [pdf] <https://jalshakti-ddws.gov.in/sites/default/files/National_Report_NARSS_2018_19.pdf> [accessed 8 July 2020].
Ministry of Statistics & Programme Implementation (MoSPI) (2018) Drinking Water, Sanitation, Hygiene, and Housing Condition in India, NSS 76th Round [pdf] <http://mospi.nic.in/sites/default/files/publication_reports/Report_584_final_0.pdf> [accessed 8 July 2020].
Preston, S.H. and Haines, M.R. (2014) Fatal Years: Child Mortality in Late Nineteenth-Century America, Princeton University Press, Princeton, NJ.
Rosenboom, J.W. and Ban, R. (2017) ‘From new evidence to better practice: finding the sanitation sweet spot’, Waterlines 36(4): 267–83 <https://doi.org/10.3362/1756-3488.17-00011>.
Routray, P., Schmidt, W.P., Boisson, S., Clasen, T. and Jenkins, M.W. (2015) ‘Socio-cultural and behavioural factors constraining latrine adoption in rural coastal Odisha: an exploratory qualitative study’, BMC Public Health 15(1): 880 <https://doi.org/10.1186/s12889-015-2206-3>.
Slutkin, G., Okware, S., Naamara, W., Sutherland, D., Flanagan, D., Carael, M., Blas, E., Delay, P. and Tarantola, D. (2006) ‘How Uganda reversed its HIV epidemic’, AIDS and Behavior 10(4): 351–60 <https://doi.org/10.1007/s10461-006-9118-2>.
Swaminathan, S. and Thomas, J. (2007) ‘Saving the next generation: political capacity and infant mortality decline in India’s states’, International Interactions 33(3): 217–42 <https://doi.org/10.1080/03050620701449017>.
Teltumbde, A. (2014) ‘No Swachh Bharat without annihilation of caste’, Economic & Political Weekly 49(45): 11.
WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation (JMP) (2012) Progress on Drinking Water and Sanitation: Joint Monitoring Programme Update 2012, WHO, Geneva; UNICEF, New York.
World Bank (2003) World Development Report 2004: Making Services Work for Poor People, Oxford University Press for the World Bank, Washington, DC.
World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) (2017) Progress on Drinking Water, Sanitation and Hygiene: 2017 Update and SDG Baselines, WHO, Geneva; UNICEF, New York.
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