Sridhar recently has argued that urban poverty is much more difficult to address than rural poverty, and yet research on how to address urban poverty received comparatively much less attention [
16]. We draw on the Integrated Behavioral Model for Water, Sanitation and Hygiene (IBM-WASH) as a framework for identifying lessons learned from development of our intervention for promoting cleanliness of communal toilets that might be applicable to other health problems occurring among urban populations living in poverty [
12].
The first dimension in IBM-WASH is the contextual factors. These need to be taken into account in developing interventions, but are not readily amenable to change. In low-income communities in Dhaka, contextual factors at the community level include insecurity of land tenure, control of land and resources by local landlords and power-brokers (
mastaan), and the limited political power of the urban poor [
17]. More specific to this intervention is the weak and limited disposal system for solid waste, the lack of a sewer system and lack of wastewater treatment facilities. People from these communities dispose household trash directly into surrounding lakes and lowland areas due to lack of services and poverty. The common features of a slum include poor-quality housing, limited educational and social services, and lacking or limited water, sanitation, electrical grid and street network [
18]. Again most of the slums are located near polluted water bodies, swamps, ditches or putrid drains [
18]. A study conducted in Kampala, Uganda has revealed that group discussions are effective in improving the cleaning behavior of shared sanitation users [
19]. In our study, we conducted baseline and final household surveys where we found the intervention households had less likely to have the shared toilet with visible fecesinside the pan than the control households [
20]. Various non-state actors such as landowners and non-governmental organization (NGOs) fill some but far from all of the gaps in regulation and service provision [
17]. There is little hope of better governance in the near term [
17]. In our study we had also demonstrated low-cost water storage and flushing hardware and promotion of toilet maintenance behaviors which we found as reinforcement of improving both hygienic conditions and user satisfaction with shared toilets even in the area which had water scarcity. And we found both the residents and the landlords were pleased with these efforts [
21]. Linking the interest of entrepreneurial Vacutug operators who want to keep their machines from clogging with users of shared toilets who want clean facilities provides an opportunity for sustainable improvement. This project did not attempt to address the ineffective waste disposal system in Dhaka’s urban slums. Funding trash management removal and treatment is necessary for all countries to attain a sanitary living environment. In addition to funding resources, it is important for political leadership to be interested in improving living conditions in these settings. However, political leadership may benefit financially from keeping services at poor levels, as is the case with local leaders (
mastaan) who control power over basic utilities and lands and, in return for controlling these resources, profit from demanding a daily fee from the local businessmen [
17]. Public authorities in charge of water supply through local government bodies exert their political power all the way down to the local level to control these basic resources [
22,
23].
Psychosocial factors are the second dimension in the IBM-WASH framework. Psychosocial factors identified in this study were gender roles, disgust and shame related to waste products, specifically wastes related to menstrual management and understanding the consequences of trash disposal in the toilet. Technology factors are the third dimension in the IBM-WASH framework. In this case, the technology included the design and construction of existing toilets, and the waste bins introduced by the project (Table
3). The project team was able to assemble an intervention package that addressed psychosocial and technology factors, despite the challenging contextual factors that placed constrains on implementation.
Table 3
Implications for design of interventions to promote cleanliness of communal toilets, organized around the three dimensions in the IBM-WASH model
Contextual dimension in the IBM-WASH model |
Contextual-level barriers • Access: Lack of waste disposal options in slums influences improper disposal of waste in toilet pit • Geography and Income: Solid waste management in slums is complicated by geography and cost, and residents may be less willing to pay for what they perceive to be poor service • Unfavorable environment for habit formation: Systems for cooperative toilet maintenance are complicated by resident transience in urban slums | • Low-cost hardware and behavior change interventions can promote appropriate waste disposal practices and facilitate safe fecal sludge removal • Feasible and environmentally sound waste collection systems should be explored • Landlords can be engaged as a more permanent element to enforce toilet maintenance systems; paid cleaners may more reliably maintain hygienic conditions of communal toilets, including emptying of solid waste than resident volunteers |
Psychosocial dimension in the IBM-WASH model |
Psychosocial-level barriers • Privacy: Lack of private space for menstrual management encourages disposal of menstrual hygiene items in toilet pit • Shame & Disgust: Community feels disgust and embarrassment when encountering items used for menstrual management disposed openly • Existing habits: Caregivers are accustomed to collecting and disposing of children’s feces using plastic bags, but disposal of these bags in the toilet pit impairs fecal sludge removal | • Promote disposal of items used for menstrual management in a closed bin • Promote wrapping of used menstrual hygiene items with locally available materials prior to disposal • Child potties may be promoted to ensure safe disposal of children’s feces without impairing fecal sludge emptying |
Psychosocial-level facilitators • Shared Values: Residents had a strong shared value for toilet cleanliness and worked to maintain the good condition and location of waste bins | • In areas where hardware theft is a concern, messages should emphasize toilet cleanliness as a shared value to build collective efficacy to maintain the good condition and location of waste bins |
Technology dimension in the IBM-WASH model |
Technological-level barriers Convenience: Community members disposed of items used for personal hygiene in the toilet pit at the point of use • Strengths and weaknesses of the hardware: Although both bin models were well-accepted, some residents felt reluctant to dispose of waste when they had to touch the bins in order to use them | • Waste bins were conveniently located to facilitate habitual use; • Ease of operation, durability, adequate volume, and attractive color of bins are attributes to consider in selecting waste-disposal facilitating hardware that is well perceived |
Technology: Provision of waste bins
Adult men and women disposed of items used for personal hygiene in the latrine pit at the point of use, which suggests that convenience was a factor contributing to the inappropriate disposal of trash. Our intervention addressed this issue by placing bins inside the toilets and ensuring bin capacity was adequate to accommodate daily trash. Residents remarked that the attractive color of the bin acted as a reminder for use. Color, size, and location should be considered in selecting bins for trash disposal interventions, such that hardware is perceived to be attractive and convenient to use, thereby facilitating habit formation. During feedback on bin design from community residents, finding a convenient way of disposing of child feces remained an important concern.
We promoted use of trash bins – by advertising their use through signage and demonstrations and placing them in convenient locations in the toilets. Future studies may examine the issue of price, and explore a self-sustaining way of paying for the bins and their maintenance. Additionally, future interventions ought to consider the provision of child potties to ensure the convenient disposal of child feces.
Psychosocial factors: Community and household levels
Lack of social cohesion and poor sanitation system governance in urban slums have been identified as the principal barriers to communal toilet maintenance in Dhaka [
2]. One of the strategies that the current intervention employed to increase social cohesion was to place behavior change messages in common visible locations to encourage discussion. Moreover, the strategy involved community stakeholders in the decision making process for bin emptying-- to appoint a paid cleaner or volunteers. This potentially enhanced social cohesion by encouraging dialogue between community participants. A previous study of communal toilet users in Kampala, Uganda found that if people spend time talking to each other about toilets, they were more likely to work together to keep them clean [
24]. In Kampala people who considered keeping the toilet clean to be important were more likely to be involved [
24]. In our study, we illustrated the hazards of disposing of waste in the toilet (i.e. clogs, increased expense to empty) using behavior change materials in order to increase perception of the importance of using the waste bins. Users expressed that they found these materials to be useful and informative. Users had a strong shared value for the hardware and messages. Ensuring a stable context, by guaranteeing that the waste bins are present and functional, is critical to elicit habitual behavior [
25].
This study tested two models of bin maintenance to assess cleanliness and sustainability. In one model the bins were emptied by female volunteers and in the other model someone was paid by the compound members to empty the bins. The toilets with paid bin emptiers remained much cleaner than the toilets maintained by volunteers, which makes toilets with paid bin emptiers a much more potentially sustainable model. In the Indian cities of Pune, Mumbai, Kanpur and Bangalore, community managed toilet blocks demonstrate self-sustainability of community-run pay-to-use toilets constructed by urban organizations. They found it possible to employ someone for full-time to clean toilets, keep water tanks filled and collect a charge from outsiders [
26].
Psychosocial factors: Individual and habitual levels
We addressed individual level psychosocial factors such as limited knowledge, skills and self-efficacy [
27] by posting signs depicting the correct use of the waste bins and by demonstrating and role modeling the recommended behaviors. According to the concept of observational learning, a construct described in Social Cognitive Theory, individuals learn new behaviors by watching others perform them [
28]. The signs related to waste disposal were developed in response to their recommendation to provide instructions on how to dispose waste properly and perceived by residents to be readily understandable.
A need for privacy was a major factor that influenced the disposal of menstrual management waste in toilets. Participants were embarrassed to dispose menstruation products which could be seen, and even spoke of fears that the sight of menstruation products could cause sickness. Such concerns are particularly relevant in Bangladesh, where menstruation is traditionally considered a time when women are “polluted” and therefore should maintain distance from others, in addition to it being an extremely private matter [
29]. Despite the bins having lids, residents and toilet caretakers designated to empty the bins felt uncomfortable when they encountered sensitive items like menstrual rags disposed in the bin. We found that some women wrapped used rags with polythene or paper before disposing in the bin. This practice may be necessary to create an additional layer of privacy for the disposer as well as to prevent disgust for subsequent bin users or the caretakers who empty the bin contents.
Menstrual management was an important component of waste management for this community but is largely neglected by WASH programs in South Asia [
30]. There is a need to develop long-term strategies for improving women’s sanitation options. To address the privacy/shame issues detected in this study, a bin with a flap rather than a lid that cannot be opened except by the disposer to conceal bin contents could be considered.
Each of the pilots took place over the course of one month, which limited our ability to assess the durability of the hardware and behavior over a long period of time. We did not conduct separate meetings with landlords regarding the enforcement of maintenance systems. This addition would be important for developing a robust mechanism for emptying waste bins in case volunteers stopped maintaining them. Additionally, we conducted pilots in only two compounds, which may not be representative of all urban slum sites in Dhaka. A larger trial involving 600 compound is currently being implemented by iccdr,b and WSUP, which will demonstrate whether an intervention package that includes waste bin provision is effective in improving toilet cleanliness and usability.