title: Impact of Indian Total Sanitation Campaign on latrine coverage and use: a cross-sectional study in Orissa three years following programme implementation.
abstract: BACKGROUND
  Faced with a massive shortfall in meeting sanitation targets, some governments have implemented campaigns that use subsidies focused on latrine construction to overcome income constraints and rapidly expand coverage. In settings like rural India where open defecation is common, this may result in sub-optimal compliance (use), thereby continuing to leave the population exposed to human excreta.
  
  
  METHODS
  We conducted a cross-sectional study to investigate latrine coverage and use among 20 villages (447 households, 1933 individuals) in Orissa, India where the Government of India's Total Sanitation Campaign had been implemented at least three years previously. We defined coverage as the proportion of households that had a latrine; for use we identified the proportion of households with at least one reported user and among those, the extent of reported use by each member of the household.
  
  
  RESULTS
  Mean latrine coverage among the villages was 72% (compared to <10% in comparable villages in the same district where the Total Sanitation Campaign had not yet been implemented), though three of the villages had less than 50% coverage. Among these households with latrines, more than a third (39%) were not being used by any member of the household. Well over a third (37%) of the members of households with latrines reported never defecating in their latrines. Less than half (47%) of the members of such households reported using their latrines at all times for defecation. Combined with the 28% of households that did not have latrines, it appears that most defecation events in these communities are still practiced in the open.
  
  
  CONCLUSIONS
  A large-scale campaign to implement sanitation has achieved substantial gains in latrine coverage in this population. Nevertheless, gaps in coverage and widespread continuation of open defecation will result in continued exposure to human excreta, reducing the potential for health gains.
authors.affiliation: Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Sharmani
authors.initials: S
authors.lastname: Barnard
authors.forename: Parimita
authors.initials: P
authors.lastname: Routray
authors.forename: Fiona
authors.initials: F
authors.lastname: Majorin
authors.forename: Rachel
authors.initials: R
authors.lastname: Peletz
authors.forename: Sophie
authors.initials: S
authors.lastname: Boisson
authors.forename: Antara
authors.initials: A
authors.lastname: Sinha
authors.forename: Thomas
authors.initials: T
authors.lastname: Clasen
mesh_terms: D001290:Attitude; D003430:Cross-Sectional Studies; D004777:Environment; D005191:Family Characteristics; D005260:Female; D006293:Health Promotion / Q000379:methods*; D006801:Humans; D007194:India; D008297:Male; D015999:Multivariate Analysis; D011634:Public Health / Q000379:methods*; D012111:Residence Characteristics; D012424:Rural Population; D012499:Sanitation / Q000379:methods*; D011795:Surveys and Questionnaires; D014038:Toilet Facilities