Saxton, Ronald

Public Health



Bangladesh - Qualitative and quantitative research to support a cluster-randomized trial of mass media behaviour change messaging to improve communal toilets in Dhaka, Bangladesh

The majority of urban poor households in Dhaka only have access to communal toilets which contribute to poor community-level sanitary conditions. Mass media behaviour change communication messages cannot directly resolve this situation because of many underlying factors including lack of financial resources to purchase a better option, high cost of land making space for toilets expensive, weak public institutions, and a pervasive informal local political system. Previous work however suggests that mass media alone can bring behaviour change under certain circumstances. The central question for this research project is: Can a strategically designed creative mass media campaign deliver messages that shift the current equilibrium of unhygienic shared sanitation facilities that contaminate the environment in low-income communities of Dhaka?

Global Health Mentor: Peter Winch, MD
Director, Social and Behavioral Interventions Program

            Through my field placement, I had the opportunity to gain firsthand experience in the conduct of formative research. As a research intern with the International Centre for Diarrhoeal Disease in Dhaka, Bangladesh (icddr,b), I collaborated with an international team of researchers in designing and evaluating a sanitation behavior change intervention. Our program is currently being implemented in 1,200 shared toilet facilities in Dhaka. Our intervention intends to promote cleanliness and functionality of shared toilet facilities in urban slum communities struggling with low water resources, such that residents perceive communal sanitation to be both acceptable and valuable, and sustained adoption of this health technology is encouraged.

              Specifically, I drafted qualitative interview and focus group discussion guides to collect information on slum residents’ perceptions of toilet quality and cleanliness, and barriers to communal toilet use. These formative data were used to develop the specific content and key behavioral strategies we would promote to improve community maintenance of shared toilets. Each intervention strategy was piloted on a small scale to ensure feasibility and provide an opportunity for further troubleshooting. Using these formative results and drawing on other examples from the literature on communal toilet cleanliness, I designed quantitative survey instruments to measure communal toilet users’ satisfaction with and access to communal toilets, material and psychosocial barriers to toilet maintenance, and perceived behavioral control and cleaning intentions for shared facilities. Additionally, I helped create a direct observation instrument to assess cleanliness and functionality of communal toilets. Both measures were piloted and revised based on feedback from field research assistants. I drafted observation, photo-coding procedures for ensuring inter-rater reliability, as these instruments are currently being deployed at baseline and endline to assess the impacts of our intervention.

             This placement was a productive and rewarding experience. The WASH research group at icddr,b is an excellent team of researchers. Future students considering a placement at icddr,b can expect to participate in program design, implementation and evaluation, as well as the opportunity to contribute to multiple publishable manuscripts. I recommend that students stake out a research sub-project of their own early on, because the requests and opportunities for assistance on multiple projects can become overwhelming. Students with limited Bangla language skills should also be realistic about how they can be most useful to their project team, and might expect much of their work to occur in an office. The majority—99.21%, I did the math—of my work time was spent working on a computer to conduct literature reviews, draft manuscripts, prepare presentations of research findings, perform qualitative and quantitative analyses and draft intervention materials and procedures. That said, the office environment is comfortable, the food is delicious and there are tea breaks twice a day. Outside of work, Dhaka is an intense and active place to live. If in Dhaka during late November, be sure to attend the Bengal Foundation Classical Music Festival, a free, five-day concert, and purportedly the largest music festival in Asia.


Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...

September 2019



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