Successful open defecation-free intervention in low- and middle-income countries: a qualitative synthesis systematic review protocol

Abstract

Introduction

The results of open defecation-free (ODF) programmes vary greatly, especially in low- and middle-income countries (LMICs). This study will systematically investigate available qualitative research to identify the elements contributing to open defecation programmes’ effectiveness in various situations across LMICs. Furthermore, this review seeks to identify gaps in the available literature and areas that require additional investigation and action.

Methods and analysis

Inclusion criteria were developed considering issues related to open defecation in LMICs, sanitation interventions and behavioural change. Research examining sanitation interventions in schools, shelters, disability communities and virtual communities was excluded, as the review focused exclusively on community-based interventions. Studies published in English and Indonesian were included without limitation of the initial year until 31 January 2025. Systematic research will be carried out using ScienceDirect, PubMed, ProQuest and Scopus databases. Information from grey literature, including conference proceedings and reports from relevant organisations, will be systematically searched using Google Scholar and the websites of leading institutions, such as the WHO, UNICEF and WaterAid. This systematic review did not impose any restrictions on the place and date of publication. Two reviewers followed Joanna Briggs Institute guidelines in selecting studies, conducting critical appraisal using confidential tools and extracting data using a structured approach. Data synthesis will be performed using meta-aggregate methods to identify the themes. A ConQual Summary will be used to assess confidence in the findings.

Ethics and dissemination

The findings of the systematic review will be disseminated through a publication in a peer-reviewed journal and presented at a relevant conference. Since the data used will not contain individual patient information, ethical approval is unnecessary.

PROSPERO registration number

CRD42023408851.

Correspondence to Dr Fatwa Sari Tetra Dewi; [email protected]

STRENGTHS AND LIMITATIONS OF THIS STUDY

• The strengths of this study include providing a qualitative overview of effective sanitation interventions with the use of Joanna Briggs Institute (JBI) meta-aggregation methods to enhance the validity of qualitative data synthesis, a rigorous study selection process guided by clear inclusion criteria based on JBI guidelines, independent data screening and synthesis by researchers, and the application of ConQual to assess findings.

• The research is subject to certain limitations, such as the absence of detailed quotations in some studies, the occasional difficulty in obtaining additional information from original authors, and the possibility of variations in qualitative approaches impacting the consistency of the research results synthesis.

Introduction

Open Defecation (OD) is a significant issue in developing countries, with an estimated 494 million people practicing it worldwide.¹ Eliminating OD in low- and middle-income countries (LMICs) is challenging and frequently results in illnesses including cholera and diarrhoea.^{2 3} The persistence of OD is strongly impacted by household economic situations, cultural norms and habits.^4–6 Limited evidence suggests that the frequency of OD is higher in coastal and riverine locations where people dwell⁷ because many individuals prefer to defecate straight in the water, which is more pleasant.⁸

The issue of OD is inextricably linked with a shortage of clean water.⁹ When insufficient clean water is available, people struggle to practice good hygiene and sanitation. Living circumstances and budgetary constraints are the primary impediments to providing appropriate water and sanitation services.¹⁰ The OD problem affects not only just rural groups but also suburban and urban regions, particularly slum neighbourhoods.¹¹ Ownership of latrines is a key driver of OD behaviours in urban communities.¹²

Several measures have been taken to address this issue, including implementing Community-Led Total Sanitation (CLTS). The CLTS concept, initially developed by Kamal Kar in Bangladesh in 2000, has been implemented extensively primarily due to its alignment with the health decentralisation paradigm, which prioritises community engagement.¹³ CLTS initiative has significantly expanded in the last 20 years, especially in LMICs. Rural areas have mainly adopted it to enhance sanitation.¹⁴ Scientific evidence has significantly contributed to the dissemination of CLTS. A recent research study investigated the efficacy of CLTS interventions, which have demonstrated notable outcomes in modifying behaviour and expanding latrine coverage.¹⁵

In Indonesia, CLTS is referred to as Community-Based Total Sanitation (CBTS), known locally as Sanitasi Total Berbasis Masyarakat. The CBTS programme is initiated by health workers who serve as facilitators, aiming to alter individual behaviours by addressing the community’s emotions, mindsets and practices.¹⁶ Uniquely, the outcomes of CBTS and CLTS programmes are often not sustainable, as impoverished households tend to revert to open defecation after a certain period following the intervention.¹⁷

Interventions carried out in urban areas state that the success of the OD-free programme requires residents’ active participation and the government’s responsibility as a public administrator.¹⁸ A systematic review of sanitation interventions showed that more than existing interventions are needed to increase community latrine ownership and behaviours. The systematic review identified 24 studies demonstrating that increased usage of sanitation facilities is often correlated with improved maintenance, accessibility, privacy, cleanliness, facility type, newer latrines and enhanced hygiene access. Conversely, decreased usage is associated with poorer sanitation conditions. These findings underscore the need for further research to explore how sanitation interventions influence OD.¹⁵

A preliminary search of PROSPERO, the Cochrane Database of Systematic Reviews and Joanna Briggs Institute (JBI) Evidence Synthesis revealed no current or ongoing systematic reviews on this topic, highlighting a gap in the existing literature. This study, prompted by the variability in the effectiveness of interventions in reducing OD, aims to systematically review qualitative syntheses of successful OD interventions in LMICs. The review will examine factors contributing to the success of these interventions to identify best practices and effective strategies for reducing OD in LMICs. By addressing gaps in the literature on sanitation interventions, this review seeks to inform the development of suitable interventions and enhance future public health outcomes especially in LMICs.

Methods and analysis

The planned systematic review will adhere to the JBI methodology for evaluating qualitative data.¹⁹ The review protocol has been registered with PROSPERO under registration number CRD42023408851. Any deviations from the original protocol will be recorded and justified in the appropriate methods section. This research aims to explore the experiences of LMICs with interventions aimed at achieving an OD-free status and to identify factors that contribute to the success or failure of these interventions. This review primarily relies on reports from relevant organisations as its main source of information.

Eligibility criteria

The eligibility criteria and review questions were based on the Sample, Phenomenon of Interest, Design, Evaluation, Research type (SPIDER) guidelines,¹⁷ and the criteria for this systematic review were implemented as outlined in table 1.

Table 1

Application of SPIDER for determining eligibility criteria in this study

SPIDER criterion	Application of SPIDER in the current study
Sample	The articles may feature individuals or community members, such as community leaders, local officials or sanitation workers, who are engaged in ODF initiatives in LMICs.
Phenomena of interest	Sanitation interventions were implemented to tackle the issue of ODF status. These interventions mainly involved the participation of the community and its leaders, focusing on the behavioural changes resulting from such initiatives. This review assessed the effectiveness, challenges and outcomes of these sanitation interventions in achieving ODF status, as well as the process of community behaviour change. This review did not examine sanitation interventions in schools, shelters, communities for people with disabilities or virtual communities.
Design	The current review will incorporate studies employing qualitative research methods. The aim is to capture the participants' experiences and perspectives within the context of the research question. Interpretive studies that draw on the experiences of specific populations will be considered, and critical studies exploring relevant themes will also be included. Mixed methods studies will be included if qualitative findings are reported separately.
Evaluation	Selected articles for screening will undergo critical appraisal in accordance with JBI guidelines, and the synthesised data will be evaluated using the ConQual Approach.22 The study’s main goal is to describe how LMICs have gone about putting interventions into practice to become ODF countries. Articles that fulfil the requirements for inclusion provide a thorough justification of why the intervention implemented overall is persuasive and point out the key elements that have contributed to its success.
Research Type	Qualitative research.

JBI, Joanna Briggs Institute; LMICs, low- and middle-income countries; ODF, open defecation-free; SPIDER, Sample, Phenomenon of Interest, Design, Evaluation, Research.

This systematic review, adhering to the SPIDER criteria, aims to address two key questions: (1) What is the empirical evidence on the measures implemented by low- and middle-income countries (LMICs) to achieve open defecation-free (ODF) status? (2) Which factors influenced these interventions? The evaluation omitted studies that investigated sanitation interventions conducted in schools, shelters, disability communities and virtual communities. This decision was made because the focus of the research was entirely on interventions performed within the community. This systematic review did not include studies that relied on secondary data.

Information sources

A literature search will be done through the PubMed, ScienceDirect, ProQuest and Scopus databases. Conference proceedings and reports from relevant agencies will be explored through the official websites of organisations such as the WHO, UNICEF and WaterAid. Unpublished material and grey literature will be examined using Google Scholar. A potential material search via Google Scholar was carried out using the exact keywords as other database literature searches, focusing on the first 300 articles according to the guidelines of Haddaway et al.²⁰

Search strategy

Two researchers will autonomously do literature searches and article culling using specified keywords. The technique of conducting the literature search was carried out in accordance with the Peer Review of Electronic Search Strategies (PRESS) principles to guarantee its accuracy. The PRESS checklist form consists of the following components: (1) the translation of research questions, (2) the use of Boolean and proximity operators, (3) the use of subject headings, (4) the inclusion of free text, (5) the consideration of spelling, grammar and line numbers and (6) the identification of research restrictions. To identify relevant studies for this systematic review, the following Medical Subject Headings (MeSH) terms and keywords were used is provided in box 1. These terms were combined using “OR” within categories and “AND” between categories to refine the search and ensure comprehensive coverage of relevant literature (a thorough search technique). The MeSH term and search query were used.

Box 1

Keywords and MeSH terms used to identify relevant data

Terms and combinations used in the MeSH/search:

• Open defecation

• Latrine Use

• Latrine Coverage

• Sanitary Latrine

• Toilet Facility

• Sanitation (Mesh term)

• From numbers 1 to 6, use “OR” (title/abstract)

• Community-Led Total Sanitation

• Sanitation Intervention

• Latrine Subsidy Intervention

• Behavior Change Communication

• WASH Intervention

• Community Empowerment

• RANAS

• From numbers 8 to 14, use “OR” (title/abstract)

• Hygiene Behavior

• Water, Sanitation, and Hygiene related to behavior

• Behavior Modification

• WASH behavior

• Defecation Behavior

• Sanitation Behavior

• Sanitation Practice

• From number 16 to 22, use “or.”

• 7 AND, 15 AND 23

A literature search in the ScienceDirect database follows the guidelines with a maximum of 8 Boolean connectors in one search. Boolean connectors used in ScienceDirect database include: (“open defecation” or “sanitation”) AND (“sanitation intervention” OR “Community Led Total Sanitation” OR “community empowerment” OR “Behavior Change Communication” OR RANAS) AND behavior change. In the ProQuest database, literature searches are carried out by entering keywords such as PubMed literature searches and searches in the Summary section.

A literature search in the Scopus database was conducted by entering all relevant keywords, similar to the method used in PubMed. Keywords were connected using the AND operator, and any two-word keyword was enclosed in quotation marks. The grey literature search in Google Scholar used simple keywords such as (“Open defecation” OR “Sanitation behavior”) and included terms like WHO, UNICEF or WaterAid to refine the results. Alternatively, searches using only the essential keywords were conducted .

Selection process

The first phase, the literature search, will be conducted using PubMed, followed by a literature search in additional databases based on the criteria and restrictions that apply to each database. Following a comprehensive literature search across all databases, the articles were uploaded to Rayyan management software for processing. A duplication check was then conducted to identify any redundant entries. Once duplicates were removed, the primary author, along with other independent researchers, screened the abstracts based on the pre-defined inclusion and exclusion criteria.

Second, a thorough full-text review of potentially relevant articles will be performed to determine their eligibility for inclusion based on established criteria. Predetermined inclusion and exclusion criteria will guide the selection of studies to ensure alignment with the research objectives. Two reviewers will independently evaluate the titles and abstracts to decide on their inclusion or exclusion. Relevant research will next be thoroughly evaluated by reviewing the entire text. If the complete text does not fit the inclusion criteria, it will be excluded, with details given in the systematic review. Multiple screening and extraction techniques were used to ensure the accuracy of the literature search results. In the event of any inconsistencies between the two reviewers, they will be handled through conversations and a third reviewer.

All studies published in English and Indonesian that meet the inclusion criteria will be included in this systematic review. This review does not set a starting year limit for research publication as long as the database can retrieve articles and consists of all relevant studies available until 31 January 2025.

Critical appraisal

Two reviewers will evaluate the methodological quality of the qualifying studies using the JBI Critical Appraisal Checklist for Qualitative Studies,²¹ evaluating philosophical perspective, research methodology, research questions, data collection and representation methods, result interpretation, researcher culture, quotations and ethical aspects (further details are provided in online supplemental file 1). Authors of the papers will actively pursue any necessary missing or extra data to provide clarification. Any discrepancies will be resolved through dialogue with a third reviewer. The results of the critical evaluation will be presented in both narrative and tabular form. Irrespective of the quality of the methodology used, all studies shall undergo data extraction and synthesis, if feasible. The critical appraisal findings will be integrated into the review by collecting and synthesising data from all research, regardless of methodological quality.

Data extraction

The data extraction tools were adapted according to the JBI guidelines, including study identity and findings.¹⁹ Based on JBI guidelines, the study description attached includes the following: methodology, method, phenomena of interest, setting, geographical, cultural, participants, data analysis and conclusion (further details are provided in online supplemental file 2). The findings will be extracted using JBI guidelines by grouping themes and subthemes to answer the research objectives, such as types of interventions, descriptions of the sanitation intervention, factors contributing to the success of ODF and the intervention results before and after implementation. Quotations or illustrations will be included to support the grouping of themes in the extracted data.

The credibility of each discovery was evaluated and classified as firm, credible or unsupported. If essential, the authors of the articles will be contacted to obtain any missing or supplementary information. Within 2 weeks, if the researcher does not get answers to the data needed, the articles included in this research will only be reported in the PRISMA chart but not in the systematic review analysis the researcher is conducting. Articles that meet the inclusion criteria but are not accompanied by supporting data will be reported as unsupported.

Every study that is included will undergo data extraction, along with associated visuals, and a plausibility rating will be awarded to each finding. The process of developing categories for the results required meticulous and repetitive analysis of the obtained data. Furthermore, one or more synthesis findings will be expressed as indicator statements.²¹

Any disagreements among the reviewers will be resolved by open discourse or, if required, with the assistance of a third reviewer. Where necessary, the authors of the publications will be contacted to get any missing or supplemental information.

Data synthesis

Whenever feasible, qualitative research findings shall be combined using JBI SUMARI and reliable meta-aggregation.²¹ The phases of data synthesis using a meta-aggregation technique included initially choosing all studies with graphics and narratives contained in the article, guided by the inclusion criteria established by the JBI guidelines, which served as the primary framework for our qualitative research. Categories were developed for each finding with at least two findings per category, followed by synthesising themes from at least two categories. Each finding was categorised by consensus among the researchers involved in the systematic review.

This technique combines or integrates information to generate statements that represent the consolidated outcomes. The findings were compiled and classified according to their semantic similarity. These categories are subsequently combined to yield comprehensive conclusions that form the basis for evidence-based practice. If it is not possible to gather the text together, the results will be presented in a storytelling style. Text collecting in qualitative research is contingent on the data being exact and well-organised to facilitate effective data synthesis. Only the articles that were included in the synthesis were clear and trustworthy.

Quality assessment

The ConQual methodology will be employed to analyse the definitive integrated findings, guaranteeing assurance in the outcome of the qualitative research synthesis. The acquired data is presented as a Summary of Findings.²² The Summary of Findings will encompass essential review elements and comprehensively explain the ConQual score’s calculation process. ConQual scoring is carried out by assessing the dependability and credibility of the findings. The assessment for dependability includes an evaluation of five questions covering: alignment of the research methodology with the aims and methods of data collection, adequacy of data representation and analysis, the researcher’s cultural or theoretical position and recognition of the researcher’s influence on the research results. If all four to five question items are affirmed, the study achieves a higher rating for dependability; otherwise, the score is lower.

The credibility score is carried out by assessing the presence of evidence or quotations in the findings. The evaluation will include the title, population, pertinent phenomena and context-specific details. Each synthesis finding from the study will be presented alongside the associated research type, dependability, believability scores and total ConQual rating.

Patient and public involvement

No patient and public were involved in the design, conduct and reporting of this study.

Ethics and dissemination

Ethics approval is unnecessary in this study. The full reports of this systematic review will be submitted to a peer-reviewed journal and shared during relevant conference presentations.

The authors acknowledge Malahayati University and Gadjah Mada University for permitting the conduct of this research and gratitude to The Center for Education Financial Services (PUSLAPDIK), the Ministry of Education, Culture, Research, and Technology, the Republic of Indonesia, and the Indonesia Endowment Funds for Education (LPDP), under reference number: 202209092201, for funding support.

Ethics statements

Patient consent for publication

Not applicable.

Footnote

Contributors VY is responsible for the overall content and is the guarantor. VY assumed the responsibility of planning and composing the systematic review procedure in the capacity of the first author. FMK participated in developing the search technique and criteria for determining which items to include or exclude. DD contributed to the development of the data extraction plan. FSTD contributed to the formulation of the methodology and research framework. II assisted in the evaluation and examination of the protocol design. All authors provided essential feedback and actively contributed to developing the research, analysis and article.

Funding The Center for Education Financial Services (PUSLAPDIK), the Ministry of Education, Culture, Research, and Technology, the Republic of Indonesia, and the Indonesia Endowment Funds for Education (LPDP) supplied the funding for this study. Reference number funding: 202209092201.

Competing interests None declared.

Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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