Table 3 Implications for design of interventions to promote cleanliness of communal toilets, organized around the three dimensions in the IBM-WASH model

Contextual-level barriers

• Access: Lack of waste disposal options in slums influences improper disposal of waste in toilet pit

• Geography and Income: Solid waste management in slums is complicated by geography and cost, and residents may be less willing to pay for what they perceive to be poor service

• Unfavorable environment for habit formation: Systems for cooperative toilet maintenance are complicated by resident transience in urban slums

• Low-cost hardware and behavior change interventions can promote appropriate waste disposal practices and facilitate safe fecal sludge removal

• Feasible and environmentally sound waste collection systems should be explored

• Landlords can be engaged as a more permanent element to enforce toilet maintenance systems; paid cleaners may more reliably maintain hygienic conditions of communal toilets, including emptying of solid waste than resident volunteers

Psychosocial-level barriers

• Privacy: Lack of private space for menstrual management encourages disposal of menstrual hygiene items in toilet pit

• Shame & Disgust: Community feels disgust and embarrassment when encountering items used for menstrual management disposed openly

• Existing habits: Caregivers are accustomed to collecting and disposing of children’s feces using plastic bags, but disposal of these bags in the toilet pit impairs fecal sludge removal

• Promote disposal of items used for menstrual management in a closed bin

• Promote wrapping of used menstrual hygiene items with locally available materials prior to disposal

• Child potties may be promoted to ensure safe disposal of children’s feces without impairing fecal sludge emptying

Psychosocial-level facilitators

• Shared Values: Residents had a strong shared value for toilet cleanliness and worked to maintain the good condition and location of waste bins

• In areas where hardware theft is a concern, messages should emphasize toilet cleanliness as a shared value to build collective efficacy to maintain the good condition and location of waste bins

Technological-level barriers

Convenience: Community members disposed of items used for personal hygiene in the toilet pit at the point of use

• Strengths and weaknesses of the hardware: Although both bin models were well-accepted, some residents felt reluctant to dispose of waste when they had to touch the bins in order to use them

• Waste bins were conveniently located to facilitate habitual use;

• Ease of operation, durability, adequate volume, and attractive color of bins are attributes to consider in selecting waste-disposal facilitating hardware that is well perceived