Sanitation Demand Creation in Peri-Urban Slums of Lusaka, Zambia (SanDem)

This intervention will experimentally test the hypothesis that sanitation can be improved in a peri-urban setting using state-of-the-art behaviour change communications. Formative research indicated that landlords are the effective decision-makers about investments in sanitation on their plots (which can include a number of tenant households as well). Landlords will therefore be the primary targets of the intervention. The study will take the form of a randomized controlled trial of the intervention evaluated at the plot level. The intervention will invite enrolled landlords to a series of meetings in which various mechanisms will be used, each designed to increase their likelihood of improving the toilet(s) on their plot. These meetings will be the main vehicle for a status-building campaign associated with increasing wealth by improving plot sanitation, understanding tenants' implicit demand, understanding the processes by which toilets can be improved, and a competition rewarding landlords that make the greatest improvements to the improvement of their toilet(s). The desired improvements will be measured via multiple primary outcomes that measure aspects of changes to hardware and software components, including indicators of hygienic quality, psychological desirability, accessibility, and ecological sustainability. This is because the investigators argue that, to have a significant impact on population-level diarrheal disease indicators, any sanitation solution must be: effective at reducing exposure to pathogens (i.e., hygienic), desirable (i.e., seen as valuable or humane), and accessible (i.e., no one excluded), so that it can be used by all for a reasonably long time (i.e., sustainable)

A random sample of plots will be selected in Bauleni Compound and invited to participate. Intervention allocation will also be randomized, with approximately equal numbers of plots allocated to the intervention and control arms. Within the chosen plots, resident landlord households will receive the intervention and resident landlord households and one randomly selected tenant household will be chosen for data collection for both intervention and control plots.

The study will be partially single blinded. Participants and investigators cannot be masked to the intervention but outcome assessors will not know where the intervention has taken place and will be given only minimal information to enable assessment of intervention exposure at the end of the survey.

Landlords on selected plots will receive the "Bauleni Secret" intervention. Landlords and selected tenants will be surveyed in baseline/end-line data collection.

The intervention will invite enrolled landlords to a series of meetings in which various mechanisms will be used, each designed to increase their likelihood of improving the toilet(s) on their plot. These meetings will be the main vehicle for a status-building campaign associated with increasing wealth by improving plot sanitation, understanding tenants' implicit demand, understanding the processes by which toilets can be improved, and a competition rewarding landlords that make the greatest improvements to the improvement of their toilet(s).

Landlords report saving money, either individually or by participating in a rotating savings scheme, for toilet improvement

Landlords have either amassed raw materials on the plot (concrete blocks, wood, etc.) for toilet improvement or new construction/upgrading of toilet began (hole dug for new toilet, new slab poured for flushing toilet, etc.)

A theory-based comprehensive index of on-site peri-urban sanitation status including hygienicity, accessibility, desirability, and sustainability of sanitation systems

Landlord reports taking any action directed at establishing a rotational cleaning system (e.g., holding a plot meeting explicitly for this purpose, posting a written rota, or otherwise tangibly indicating rota responsibilities)

Plots will be selected for inclusion in the study based on meeting the inclusion criteria. The intervention will be delivered to the landlord on each plot assigned to the intervention arm. Intervention Inclusion Criteria: Plot located in Bauleni compound Adult landlord (age 18 or higher) resides on plot Intervention Exclusion Criteria: * None Data will be collected from the landlord and one randomly selected tenant from all eligible adult tenants on each plot. Data Collection Inclusion Criteria: * Adult landlord or tenant (age 18 or higher) resides on selected plot most of the time Data Collection Exclusion Criteria: * None

De-identified individual participant data (IPD) will be available with consent from the principal investigators. The study will collect only basic demographic information on individuals along with knowledge/attitudes/preferences data, so there will be little to identify individuals from the shared IPD and little that is very sensitive.

Tidwell JB, Chipungu J, Bosomprah S, Aunger R, Curtis V, Chilengi R. Effect of a behaviour change intervention on the quality of peri-urban sanitation in Lusaka, Zambia: a randomised controlled trial. Lancet Planet Health. 2019 Apr;3(4):e187-e196. doi: 10.1016/S2542-5196(19)30036-1.