Only a third of households surveyed by non-profit WaterAid India in 2016 across nine states and 34 districts had access to toilets, and 64% had at least a family member defecating in the open.

The presence of a toilet alone does not guarantee use; programmes must identify and address the underlying drivers to encourage use,” said Arundati Muralidharan, manager policy (WASH in health & nutrition, and Schools) at WaterAid India. In an email interview with IndiaSpend, she answered questions on the relationship between hygiene and malnutrition and awareness about washing hands across India.

Murlidharan, 37, has 15 years of experience as a public-health practitioner and qualitative researcher with expertise in menstrual health and hygiene management, gender and sanitation, and sexual and reproductive health.

At WaterAid India, she garners evidence to integrate Water And Sanitation Hygiene (WASH) into health interventions and policy initiatives.

Muralidharan has worked with the Public Health Foundation of India, an advocacy, leading research on social determinants of health (specifically gender and WASH). With Society for Nutrition Education and Health Action (an NGO based in Mumbai working on health and sanitation in urban slums), she conducted research and developed an intervention on menstruation and menstrual hygiene management.

She started her public-health career with Population Services International (not-for-profit global health organisation with programmes targeting malaria, child survival, HIV and reproductive health), Mumbai, developing and implementing behaviour change and community-led interventions for HIV/AIDS prevention.

Muralidharan has a doctorate in public health from Boston University and a masters in social work from the Tata Institute of Social Sciences, Mumbai.

Analysing various sanitation programmes over the last 15 years, IndiaSpend found Uttar Pradesh, Bihar, Madhya Pradesh, Odisha and Jharkhand are the worst performing states. Since WaterAid functions in these areas, what, according to you, are the reasons for these particular states performing badly?

The following reasons have been identified for these states to be performing badly:

* low base: when Swacch Bharat Mission (SBM, Clean India Mission) was implemented, these areas were lagging in terms of toilet coverage and usage... and so the story continues;

* poor social infrastructure;

* overall weak governance and implementation mechanisms;

* lack of context-appropriate technologies. Bihar is known to be a flood-prone state but there is hardly any work done on ensuring use of technologies that are flood-resistant ensuring safety of toilet infrastructure and water sources; and

* weak institutional capacity.

One of the biggest challenges related to toilet use is changing mindsets/attitudes towards latrine use. The presence of a toilet alone does not guarantee use, and to encourage use, programmes must identify and address the underlying drivers.

Secondly, latrine use and maintenance is difficult when faced with issues related to water availability and reliability. To help these states perform better, we must go beyond looking at sanitation coverage to unearthing and resolving the reasons for not using toilets.

Improvements in sanitation coverage and toilet use are important for nutrition-related indicators such as stunting. Understanding why states have low coverage and toilet use, and taking steps to ameliorate the situation can contribute to efforts to improve the nutritional status of children in these areas.

WaterAid India’s assessment across nine states in January to April 2016 to assess the status of water, sanitation and hygiene has proposed policy implementation changes.

The study shows that open defecation is still prevalent in many districts. This is related to both: Lack of behaviour change and poor access to functional facilities.

The study also confirms a large gap in terms of hygiene awareness and education. We are far behind the universal standards of hygiene in terms of handwashing with soap. Even in solid and liquid waste management and proper disposal of children’s faeces, we are trailing acceptable levels.

Although SBM addresses most of these aspects to varying degrees, the evidence emerging from the research suggests that its ambitious vision requires further measures in order to be successful. A new social norm needs to be created in which open defecation becomes an unacceptable practice, and environmental cleanliness becomes as important as cleanliness inside the house.

The perception/belief people in rural areas have on sanitation is having a negative impact on latrine usage, as Diane Coffey, co-founder, Research Institute for Compassionate Economics (RICE), and her colleagues have found (and as IndiaSpend reported on August 13, 2017).

Many households prefer not to have latrines within their homes as they are considered polluting. Moreover, perception that latrines with larger pits are much better than soil pits increases the cost of construction of toilets, hence dissuading folks from building toilets.

India has the highest number (48 million) of stunted children in the world, according to WaterAid report, Caught Short. The report also said that open defecation and lack of hygiene is one of the main reasons for stunting. Can you explain this relationship?

Globally, 50% undernutrition is associated with repeated diarrhoea or intestinal worm infections caused by unsafe water, sanitation and hygiene, according to the World Health Organization. Moreover, 88% of cases of diarrhoea are caused by inadequate WASH. A quarter of all cases of stunting are estimated to be directly caused by chronic diarrhoea in the first two years of life.

The faecal-oral route of transmission explains the connection between open defecation and stunting: When people defecate in the open, faecal matter enters the soil and water sources that are used for drinking and household purposes. When children drink water contaminated by faecal matter, when they do not wash their hands after going to the toilet or before eating, and when their caregivers do not wash their hands after defecation, before preparing food, or feeding the child, pathogens enter body, initiating a cycle of illness.

An immediate and common outcome is diarrhoea. Other WASH-related infections include intestinal worm infections or soil-transmitted helminth infections, schistosomiasis, and environmental enteropathy.

Repeated bouts of diarrhoea dramatically deplete the body of essential nutrients required for growth. Soil-transmitted helminth infections make a child susceptible to diarrhoeal episodes, anaemia, and the infection forces the body to compete for important nutrients. Schistosomiasis is transmitted through parasitic worms, schistosomes, that are hosted by aquatic snails that thrive on faecally contaminated water.

Environmental enteropathy--a condition caused by frequent intestinal infections due to chronic exposure to faecal pathogens--changes the lining of the small intestine, compromising its ability to absorb nutrients from the food children eat. These infections prevent a child’s body from absorbing the nutrients to grow and develop--both physically and cognitively--and from using nutrients to fight infections, compromising the child’s immunity. Chronic undernutrition leads to stunting, where children do not develop as they should, physically, cognitively, and socially.

Stunting is irreversible after the age of two, and has long-term consequences. Stunted children’s school performance is poorer than their non-stunted counterparts, and they earn 22% less than their peers in adulthood.

Stunting affects a country’s economy with malnutrition costing 11% of the gross domestic product annually across Asia and Africa.

Sanitation access has improved for households from 29% in 2005-06 to 48% in 2014-15, according to National Family Health Survey-4 (2015-16). Has this led to higher utilisation of sanitation facilities among households?

While the construction of toilets is an important indicator and driver of use, it cannot be considered as the sole driver or indicator of use. The relationship between having a toilet at home and usage is complex, driven by several socio-cultural factors that shape an individual’s perceptions and attitudes towards toilet use.

We also see differences by gender with perhaps more women using a toilet than men. These gender differences are also informed, in part by beliefs around why toilet use may be beneficial to women (e.g., protects their dignity) and not men.

Toilet use is also informed to some extent by people’s perception of the toilet technology. For instance, understanding of how quickly a twin pit may fill up can inform a family’s decision regarding frequency of use. The availability of water to use and clean the toilet also contributes to use as do perceptions of who will clean the toilet and/or empty the pits when full. In sum, the mere presence of a toilet cannot be equated with use.

Water Aid has conducted a study on hand hygiene and its impact on diarrhoeal deaths. Could you elaborate on the findings of the study? Why is there a need to focus on hand hygiene as a measure to curb diarrhea?

Washing hands with soap and water at critical times is important for a child’s health. Hand hygiene is an important primary action to prevent the faecal-oral transmission of diseases. When a caregiver’s hands are contaminated with faecal matter (e.g., as a result of not washing hands properly after defecation or after washing a child’s bottom), faecal pathogens can enter the child’s body when preparing food or feeding a child. This, in turn, can result in diarrhoea.

Frequent episodes of diarrhea can weaken the child and compromise his/her nutritional intake. In critical circumstances, this can result in death. Diarrhoea is the second leading cause of death in children under five years, killing an estimated 321 children every day in 2015, according to the World Health Organization.

Thus, to prevent diarrhea, toilet use is not the only solution. Toilet use must be accompanied by handwashing at critical times (after defecation, after washing a child’s bottom and disposing a child’s faces, before preparing food, before eating, before feeding a child), and safe handling and storage of drinking water.

Respondents were more likely to have washed their hands after defecation (99.3%), and before eating (91.9%) than at other critical times such as before preparing food (50.1%) and during childcare related activities, particularly infant and young child feeding and disposal of child faeces, WaterAid’s assessment of hand hygiene practices in four states has found. The lower proportion reporting handwashing associated with childcare activities may be reflective of the number of respondents who had young children in their households.

Looking specifically at data from respondents who have a child under five years in their family, we found a slightly higher proportion cleaning their hands while engaging in child-care tasks (26.3% washed hands before child feeding, 14.7% before breastfeeding, 16.7% after disposing child faeces, and 18.4% after cleaning a child’s bottom).

Soap was the preferred cleansing agent for activities that involved contact with faecal matter (i.e., defecation, washing a child’s bottom, disposing child faeces). In fact, a greater proportion of respondents cleaned their hands after coming in contact with child faeces than after defecating themselves (though this difference is not significant). For activities that did not involve such contact, between two-fifths and half of the respondents used water alone as well (Figure below).

Source: WaterAid India

How many lives can be saved if the focus on hygiene behaviour is increased, and how?

It is difficult to estimate how many lives can be saved with the inculcation of hygiene behaviour. What we do know is that key hygiene behaviours related to toilet use, hand washing at critical times, safe handling and storage of drinking water, and safe food preparation can all contribute towards efforts to prevent avoidable deaths and diseases among children, especially those under the age of five.

We must engage the range of hygiene behaviours for individuals, families and communities to improve the situation. This way, we can truly contribute towards reductions in child mortality and morbidity.

The govt spent an average of Rs 1.4 crore (per day) on ads for Swachh Bharat in 2016, according to a response--to a right-to-information request--by the ministry of drinking water and sanitation. Do you think the government is doing enough when it comes to focusing on hygiene messaging?

The government is increasingly aware that hygiene behaviour change is an important component of efforts to make India open-defecation free. The approach thus far has been to first ensure that necessary toilet infrastructure is in place, and consequently, much of the messaging has centred on this.

Civil society organisations, research institutions and think tanks have to play a critical role in providing guidance in not only hygiene messaging on toilet use and hand hygiene but also safe handling and storage of drinking water, and food hygiene. There is an opportunity to contribute to the government’s on-going efforts by drawing upon the evidence base to develop strong hygiene messages, identify key audiences and the most effective delivery mechanisms of these hygiene messages for different audiences.

I would also suggest that national campaigns using mass media are important to drive awareness but ground-level mobilisation through institutional empowerment and inter-sectoral action (e.g., leveraging and strengthening the role of Accredited Social Health Activists and anganwadi workers to deliver hygiene messages and to emphasise the link between WASH and health and nutrition) is another critical aspect to be able to drive change.

Most of the efforts today are around construction of toilets. For example, under Swachh Vidyalaya, almost 96% schools have toilets but 28% are dysfunctional. Why is maintenance of toilets not a priority for the government, the NGOs and the end-users?

Operations and maintenance (O&M) has not come to the forefront till now because the focus has largely been on ensuring that the infrastructure is present. Now that many schools have WASH infrastructure, the importance of O&M in sustaining that infrastructure and ensuring sustained use comes up.

In early 2016, WaterAid India undertook an assessment in 453 schools in 34 districts across nine states to take stock of WASH services and infrastructure, understand the functionality and usage and know the status and awareness of hygiene including menstrual hygiene management (MHM).

It was found that in terms of water, hand pumps were the primary source of water in 64% schools (and was also primary drinking water source for 61%), followed by piped water supply in just 20% schools. Almost 10% schools reported water shortage during the summer months and 15% schools reported muddy or unclean water.

In terms of sanitation, the toilet-student ratio was below the Swachh Vidyalaya proposed ideal norm of one toilet unit for 40 students--at one functional toilet for 76 boys and one functional toilet for 66 girls. In 39% schools, toilets were found to be locked. As many as 15% students interviewed reported that they never used the school toilets during school hours with many of these students defecating in the open.

Solid waste management was insufficient in schools with 45% teachers mentioning that garbage was burnt in a field or dump and 32% noting that garbage was thrown outside the school premises.

(Salve is an analyst & Yadavar a principal correspondent with IndiaSpend.)

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