Measuring the safety of excreta disposal behavior in India with the new Safe San Index: reliability, validity and utility

Abstract

Methods to assess household excreta disposal practices are critical for informing public health outcomes of efforts to improve sanitation in developing countries. We present a new metric, the Safe San Index (SSI), to quantify the hygienic safety of a household's defecation and human feces disposal practices in India, where behavioral outcomes from on-going public expenditures to construct household sanitation facilities and eliminate open defecation are poorly measured. We define hygienic safety of feces disposal as capture in a hygienic sanitation facility. The SSI consists of 15 self-report items and two sub-scales, Latrine Use Frequency and Seven-Day Open Defecation Rate. Households are scored on a standardized scale from 0 (no defecation safely captured) to 100 (all defecation safely captured). We present results of a pilot study in Odisha, India to apply the Index to assess excreta disposal behaviors among rural households and evaluate the reliability and validity of the Index for estimating the rate of correct and consistent sanitation facility usage of household with an improved latrine.

Figure 1

Factors that influence latrine use rates and open defecation behavior identified from India and global literature on latrine adoption and use.

Figure 2

Extent of open defecation over the last 7 days (ODR7 score) of members of study households with a functioning latrine (n = 71), classified by LUF score, and plotted against their Safe San Index score (F1 data).

Figure 3

Intra-household and temporal variations in defecation behavior of study households with a functional latrine (n = 71), grouped by their LUF level (F1 data). (a) Frequency of “always use latrine” for each LUF item and average ODR7 score; (b) Portion reporting open defecation on “some”, “most” or “every” day of the last 7 days for each ODR7 item.