title: Assessing Latrine Use in Rural India: A Cross-Sectional Study Comparing Reported Use and Passive Latrine Use Monitors.
abstract: Although large-scale programs, like India's Total Sanitation Campaign (TSC), have improved latrine coverage in rural settings, evidence suggests that actual use is suboptimal. However, the reliability of methods to assess latrine use is uncertain. We assessed the reliability of reported use, the standard method, by comparing survey-based responses against passive latrine use monitors (PLUMs) through a cross-sectional study among 292 households in 25 villages in rural Odisha, India, which recently received individual household latrines under the TSC. PLUMs were installed for 2 weeks and householders responded to surveys about their latrine use behavior. Reported use was compared with PLUM results using Bland-Altman (BA) plots and concordance statistics. Reported use was higher than corresponding PLUM-recorded events across the range of comparisons. The mean reported "usual" daily events per household (7.09, 95% confidence interval [CI] = 6.51, 7.68) was nearly twice that of the PLUM-recorded daily average (3.62, 95% CI = 3.29, 3.94). There was poor agreement between "usual" daily latrine use and the average daily PLUM-recorded events (ρc = 0.331, 95% CI = 0.242, 0.427). Moderate agreement (ρc = 0.598, 95% CI = 0.497, 0.683) was obtained when comparing daily reported use during the previous 48 hours with the average daily PLUM count. Reported latrine use, though already suggesting suboptimal adoption, likely exaggerates the actual level of uptake of latrines constructed under the program. Where reliance on self-reports is used, survey questions should focus on the 48 hours prior to the date of the survey rather than asking about "usual" latrine use behavior.
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Antara
authors.initials: A
authors.lastname: Sinha
authors.affiliation: School of Public Health, Oregon Health and Science University, Portland, Oregon.
authors.forename: Corey L
authors.initials: CL
authors.lastname: Nagel
authors.affiliation: The Portland State University SWEETLab, Portland, Oregon.
authors.forename: Evan
authors.initials: E
authors.lastname: Thomas
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Wolf P
authors.initials: WP
authors.lastname: Schmidt
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Belen
authors.initials: B
authors.lastname: Torondel
authors.affiliation: Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Sophie
authors.initials: S
authors.lastname: Boisson
authors.affiliation: Department of Environment Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Clasen
mesh_terms: D000293:Adolescent; D003430:Cross-Sectional Studies; D005191:Family Characteristics; D006801:Humans; D007194:India; D008297:Male; D012424:Rural Population / Q000706:statistics & numerical data*; D011795:Surveys and Questionnaires; D014038:Toilet Facilities / Q000706:statistics & numerical data*