Water, sanitation, and hygiene practices and challenges during the COVID-19 pandemic: a cross-sectional study in rural Odisha, India

Water, sanitation, and hygiene (WASH) practices emerged as a critical component to controlling and preventing the spread of the COVID-19 pandemic. We conducted 131 semi-structured phone interviews with households in rural Odisha, India to understand behavior changes made in WASH practices as a result of the pandemic and challenges that would prevent best practices. Interviews were conducted from May-July 2020 with 73 heads of household, 37 caregivers of children less than five years old, and 21 members of village water and sanitation committees in villages with community-level piped water and high levels of latrine ownership. The majority of respondents (86%, N=104) reported a change in their handwashing practice due to COVID-19 or the related government lockdown, typically describing an increase in handwashing frequency, more thorough washing method, and/or use of soap. These improved handwashing practices remained in place a few months after the pandemic began and were often described as a new consistent practice after additional daily actions (such as returning home), suggesting new habit formation. Few participants (13%) reported barriers to handwashing. Some respondents also detailed improvements in other WASH behaviors including village-level cleaning of water tanks and/or treatment of piped water (48% of villages), household water treatment and storage (17% of respondents), and household cleaning (41% of respondents). However, there was minimal change in latrine use and child feces management practices as a result of the pandemic. We provide detailed thematic summaries of qualitative responses to allow for richer insights into these WASH behavior changes, or lack thereof, during the pandemic. The results also highlight the importance of ensuring communities have adequate WASH infrastructure to enable the practice of safe behaviors and strengthen resilience during a large-scale health crisis.

flushing and subsequently inhaled or leading to contamination of surfaces. 9 Due to the 70 recognized importance of handwashing to reduce transmission, and possible spread via feces, it 71 is clear WASH access and practices are important for reducing the spread of  73 The objective of this research was to understand the WASH-related practices of rural households 74 and communities in Odisha, India in response to the COVID-19 pandemic. We evaluated WASH 75 behavior changes made as a result of COVID-19 and challenges faced that could affect 76 participant's ability to comply with recommended WASH preventative measures. We used a mix 77 of qualitative and quantitative questions in phone interviews to capture participants' experiences 78 at a time when COVID-19 was rapidly spreading throughout Odisha, India. The knowledge from 79 this research can help inform WASH-related guidelines for controlling COVID-19 and improve 80 community resilience to external shocks increasingly faced by marginalized populations. 81 82

Methods 83
Study site and sampling frame 84 We conducted semi-structured phone interviews with head of households (HOH), caregivers of 85 children less than 5 years old, and Village Water and Sanitation Committee (VWSC) members in 86 Ganjam and Gajapati districts of rural Odisha, India. Interviews were completed between May-87 July 2020 when there were lockdowns in both districts, including restrictions on travel and 88 commercial activities which changed over time based on local case counts. 10 During this time, 89 there was also an influx of migrants workers returning to Odisha, which was accompanied by a 90 surge in local COVID-19 cases and Ganjam district becoming a hotspot of cases within Odisha. 11 91 Massive awareness campaigns to educate the public on COVID-19 and encourage preventive 92 soap. The VWSC interview tool also included questions about changes to village piped water 116 distribution services. Lastly, the caregiver interview tool included specific questions on the 117 impact of the pandemic on CFM practices. The phone numbers of HOH and caregiver target respondents were randomly ordered using a 128 computer-generated sequence, and research assistants were instructed to contact respondents in 129 the given random order. VWSC members were selected based on village selection. Further 130 details about respondent selection and calling procedures are reported elsewhere. 11 131 132 Data collection occurred over phone calls. When a respondent answered the phone, the research 133 assistants introduced themselves, briefly explained the purpose of the call, and read a consent 134 form, including consent to audio record the conversation. Once the respondent gave their 135 consent, the research assistant continued with the interview questions. During the interview, the 136 research assistant recorded responses and notes in a Microsoft Word version of the interview 137 All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. During data quality checks, it was realized that one enumerator had sometimes skipped certain 150 survey questions and fabricated some of the data for a portion of their surveys. However, since 151 interviews were audio recorded, the accuracy of the data was ensured by having the study 152 supervisor listen to each of this enumerator's interviews and correct the data accordingly prior to 153 analysis. As a result, sample sizes vary slightly among different questions due to some questions 154 being sometimes skipped. 155 156 Ethics 157 Informed consent was verbally obtained over the phone from all participants before interviews 158 began. At the end of the interview, research assistants read a list of helplines participants could 159 call if they needed assistance and also provided information on COVID-19 preventative 160 Handwashing 179 A large majority of respondents (86%, N=104) reported a change in their handwashing due to 180 COVID-19 or the lockdown. Most described positive changes, such as an increase in the 181 frequency of handwashing, an increase in the use of soap and/or sanitizer, or adopting a more 182 thorough handwashing technique. Several respondents also described that they had started using 183 waterless hand sanitizer for the first time and now use it frequently, particularly when they are 184 outside their home. However, not all respondents had changed to a proper handwashing 185 technique. Some respondents reported only using water to wash their hands, sometimes due to 186 the cost of soap (Table 2). 187

188
When describing their increase in handwashing frequency and soap/sanitizer use, many 189 respondents explained that they were now washing their hands very frequently, with several 190 respondents linking handwashing to new daily activities or discussing that it has become a new 191 habit, whereas they previously only washed before eating or not at all: 192 193 "Earlier, we did not use to wash our hands when we used to come from outside. We used 194 to wash our hands only when needed. Now, when we come back from outside or market, 195 we wash our hands and feet before entering the house. We are washing our hands 5-6 196 times a day. If we have to go to some office, we wash our hands. We are using [waterless 197 All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. "We did not use to wash our hands earlier, but are now washing them with soap and 211 sanitizer. In every 20-30 minutes, we wash. Who used to wash their hands like this 212 earlier, madam? They used to wash, but only before eating." 213 -Female caregiver respondent, 25-29 years old (July 2020) 214 215 Some respondents also explained that they had made changes to their handwashing practices to 216 now wash their hands more thoroughly: 217 218 All rights reserved. No reuse allowed without permission.
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The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10.1101/2021.01.26.21250274 doi: medRxiv preprint "Now, after seeing it from the TV, we are washing our hands very frequently from all the 219 sides in a systematic way; from above, below and between the fingers. Earlier we only 220 used to wash one side of the hand palm and that too, not very frequently." Challenges related to handwashing. Most respondents (87%, N=110) reported no challenges in 237 being able to frequently wash their hands with water and soap. Among the few who experienced 238 challenges (13%, N=17), this mostly related to buying soap (8% of all respondents, N=10) and/or 239 getting water (6% of all respondents, N=8; 3 of these respondents described a challenge with 240 both), with 2 respondents (2%) describing other challenges. The challenge with soap was 241 predominantly cost, with two respondents specifically stating the government had not offered 242 help with buying soap. No one mentioned being unable to find soap at shops. For challenges 243 getting water, this was often due to water scarcity in the summer season or the water source 244 being far away (Table 2). 245 246 All rights reserved. No reuse allowed without permission.
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.   Increased frequency of handwashing: Among respondents who reported a change, the majority said they were washing their hands more frequently now due to COVID-19. Some respondents described washing hands very frequently, such as 20 to 30 times a day or every 30 to 60 minutes. Many explained they are now more conscious or alert about handwashing and are washing their hands as soon as they get home, after each task, or after touching objects outside the home, as well as at key times such as before eating. Some respondents discussed how the pandemic had made handwashing a habit for them. Others specifically said that no one washed their hands before coronavirus and it was a new practice for them.
 Started using any or more soap/sanitizer: Many respondents explained they started using soap or waterless hand sanitizer due to COVID-19 or reported using more soap or water now. Several respondents also elaborated that this is their first time using hand sanitizer and they now keep a bottle with them and use it frequently.
 Started washing hands more thoroughly: Some respondents explained that they now wash their hands more thoroughly. This included washing hands for a longer time and washing specific parts of the hands, such as the fingers and gap between the fingers that they had not previously washed. A few respondents said they had changed their practices after learning about proper handwashing practices from ASHA and Anganwadi workers and one respondent explained he had learned the technique for washing his whole hands from television.
 No change: Among respondents who reported no change in their handwashing practices, many said this was because they had always washed their hands with soap and water often.
 Improper handwashing: Not all respondents had changed to a proper handwashing technique. Some respondents reported only using water to wash their hands. For some, this was due to the cost of soap, although not all respondents explained why they only use water. A few respondents also said they do not wash their hands frequently because they are not used to it or because they only wash their hands when they remember.
Challenges related to handwashing 13% (N=17) of respondents reported challenges to frequently washing their hands with water and soap  Challenge buying soap (8% of all respondents, N=10): The challenge with soap was predominantly cost, with two respondents specifically stating the government had not offered help with buying soap. No one mentioned being unable to find soap at shops.
 Challenge getting water (6% of all respondents, N=8): For challenges with water, respondents described problems discussed in more detail in Table 3 under "Challenges related to household water availability".
 Other challenges (2% of all respondents, N=2): One respondent described how frequent handwashing can negatively impact your skin and another said that it can be challenging to use soap regularly as it is a new practice.

Water access and treatment 249
At the village level, about half of VWSC members (52%, N=11) reported a change to the piped 250 water supply service in their village as a result of COVID-19. Changes included adding 251 bleaching powder to the water tank for water treatment, cleaning the water tank, and/or 252 extending or reducing the hours of water supply (Table 3). At the household level, 84% of 253 respondents (N=101) reported they had not experienced any reduced water availability due to 254 COVID-19 or the lockdown in the past 7 days. Among the few respondents who reported 255 reduced water availability (16%, N=19), many of the problems described were likely unrelated to 256 COVID-19 (Table 3). 257

258
The majority of respondents 83% (N=98) reported no change in their drinking water practices 259 due to COVID-19. Among the respondents who reported a change (17%, N=20), 19 respondents 260 (16% of total respondents) described a change in how they treat their drinking water, and 4 261 respondents (3% of total respondents) described a change in how they store their drinking water 262 (3 of these respondents described a change in both; Table 3). 263 264 All rights reserved. No reuse allowed without permission.
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The copyright holder for this preprint this version posted January 27, 2021. ;  Added bleaching powder to village water tank (33%, N=7): The most common reported change was that bleaching powder had been added to the water tank by the VWSC or government officials, either specifically or more frequently due to COVID-19.
 Cleaned village water tank (24%, N=5): The next most common reported change was the water tank being cleaned by the VWSC or government officials, either specifically or more frequently due to COVID-19. As an example, one VWSC respondent said they used to clean the tank regularly once every two months, but now increased the cleaning frequency to once per month due to COVID-19.
 Change in water supply service hours (14%, N=3): In two villages, the water supply hours were extended due to coronavirus. In one of these villages, the VWSC member said they extended the water supply time each day due to the water needs of people staying at the village quarantine center. In contrast, in another village the water supply hours were reduced due to its village quarantine center using a lot of water.
 No change (48%, N=10): Among the other half of VWSC respondents who reported no change in the piped water supply service due to coronavirus, four explained they already regularly clean the tank and/or put bleaching powder in it, and three explained the water is already supplied throughout the entire day. Four villages also mentioned issues related to water scarcity and the water source for the tank drying up in the summer season.
Changes related to household drinking water practices 17% (N=20) of respondents reported that coronavirus or the lockdown had changed their drinking water practices  Started treating their drinking water (16%, N=19): The following changes in drinking water treatment due to COVID-19 were reported: 16 respondents started to boil their drinking water, 1 started to both filter and boil their water, 1 treated their household water tank with bleaching powder, and 1 treated their water with a tablet that was given to them by an ASHA worker. Several respondents that reported no change in their drinking water practices explained they do not treat their drinking water in any way, although many also reported they have always treated their drinking water, either by boiling, filtering, or using an Aquaguard purifier attached to their tap.
 Changed how they store their drinking water (3%, N=4): Four respondents explained that they either cleaned or changed their drinking water storage container due to coronavirus. Specifically, one respondent said they cleaned their water storage containers now, another said they were using a cleaner vessel, one started storing water in clay pots that were distributed to them, and lastly, one respondent had stopped putting their hands in the water container when getting water out and were instead using a utensil to retrieve the water.
Challenges related to household water availability 16% (N=19) of respondents reported they had experienced reduced water  Reduced water availability due to COVID-19: Only two respondents provided details of water availability problems specifically related to coronavirus. One respondent used to get water from public taps including one at the school, but due to the lockdown they can no longer get water from the school tap, making it more difficult for them to availability in the past 7 days access water. Another respondent explained they are getting less water now because people residing at the village quarantine center are using water, which has led to fewer hours of piped water supply.
 Reduced water availability that may be partially related to COVID-19: Respondents in four different villages described recent problems with piped water availability. Three of these respondents explained that the motor for their village's water tank pump was not functioning and had to be repaired, but it was fixed now. It was not mentioned whether COVID-19 impacted the ability to fix the pump quickly, but it is possible this was a factor. In one village the respondent said the motor was not working for 20 days.
 Reduced water availability not related to COVID-19: Several respondents explained problems with water availability that were not related to COVID-19. At least four respondents described water scarcity being a problem in the summer season, due to water sources drying up, while a couple respondents said the piped water becomes muddy when it rains. Others mentioned general problems with the water supply system, such as difficulty with the water connection, problems due to an old pipeline or changes to the water supply system, not getting regular water, or that water is only supplied for 30 minutes a day.

Sanitation 267
The pandemic and lockdown had no major impact on reported latrine use (Table 4) Respondents were also asked if COVID-19 or the lockdowns had impacted defecation practices 282 within their village. Again, the majority of respondents (77%, N=86) believed there had been no 283 change, 14% (N=16) did not know whether there had been a change, and only 9% (N=10) 284 believed there was more latrine use in their village now. Among those who reported more latrine 285 use and less open defecation in their village now, it was common for respondents to attribute this 286 change to either awareness of coronavirus or because villagers were going out less due to the 287 lockdown: 288 289 All rights reserved. No reuse allowed without permission.
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The copyright holder for this preprint this version posted January 27, 2021. Additionally, although the interview did not include a specific question related to latrine 302 construction, two respondents from households without latrines expressed that COVID-19 or the 303 lockdown had either stopped or made it more difficult for them to construct a household latrine. 304 One respondent described how his family was previously building a latrine, but it had stopped 305 due to COVID-19. Another respondent described how her family wanted to build a latrine but it 306 was now difficult to do so because of the lockdown and low income due to COVID-19. 307 All rights reserved. No reuse allowed without permission.
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The copyright holder for this preprint this version posted January 27, 2021. ; Table 4. Reported changes and challenges in sanitation practices as a result of COVID-19 or lockdowns. 308

Sanitation Practice
Quantitative Results Qualitative Themes and Descriptions Changes related to defecation locations and latrine use 88% (N=100) of respondents reported defecating in the latrine the last time they defecated 3% (N=3) reported a change in their family's defecation practices due to coronavirus or the lockdown 9% (N=10) thought there was more latrine use in their village now  Small change in household latrine use: Among the few respondents who reported a change in latrine use practices, one respondent explained that their grandfather became scared of defecating in the open due to the COVID-19 outbreak and started defecating in the latrine. Two other respondents talked about specifically using phenyl or "medicine" to clean the latrine after defecation due to coronavirus.
 Small increase in village latrine use: When considering defecation practices in their entire village, only 9% (N=10) believed there was more latrine use in their village now. Among those who reported more latrine use in their village, some respondents explained that this change was due to the increased awareness or fear of coronavirus, whereas others said that villagers are going out less now due to the lockdown. More specifically, a VWSC member explained when villagers used to leave the village to go somewhere such as marketplaces, they would defecate in the open due to unavailability of a latrine there. However, since that movement has stopped, that open defecation has also stopped. Among those that reported no change in village defecation practices (77%, N=86), many reported that everyone in the village was already using the latrine before coronavirus. For respondents who said they did not know if there was a change (14%, N=16), these were mostly caregivers who explained that they do not know other villager's defecation practices.
 No change in household latrine use: Among respondents that reported no change in their family's latrine use, most elaborated that all family members always use the latrine (83%, N=91), which was also the case before COVID-19. Some respondents specifically mentioned they have been using the latrine for a long time. Other respondents (10%, N=11) reported that they sometimes open defecate and sometimes use the latrine. Some of these respondents explained that the decision of whether or not to use the latrine was based on time of day (e.g., open defecate in the daytime but use the latrine at night due to snakes), water supply (e.g., go for open defecation when there are problems getting water or water supply has stopped), season (e.g., prefer to use the latrine during rainy season), or condition of the latrine (e.g., do not use latrine when wall or latrine pan are broken). A few respondents (5%, N=6) explained that some family members open defecate while others use the latrine. Out of the four respondents who said they defecated in the open, three did so because they did not have a latrine while one explained this is a habit he cannot change.
Changes related to child feces management (CFM) No caregivers reported a change in CFM practices connected to the pandemic/lockdowns  No change in CFM practice due to COVID-19: Only four caregivers (12%) reported a change in where their child defecates and where they dispose of their child's feces since the start of the pandemic or lockdowns. However, none attributed this change to the pandemic, but rather to their child growing and transitioning to new behaviors: two of the children started walking and hence began learning to use the latrine while the other two children had started their latrine training and then fully transitioned to latrine use. Although there was no change for households interviewed, two caregivers thought that child latrine use must be happening more now in their village as families are doing whatever they can to keep their children healthy and safe from coronavirus.
 Change in childcare and support caregivers receive: About one fourth of caregivers (26%, N=9) described a change in childcare or support with childcare tasks such as CFM. Six caregivers (18%) described being 'more alert' in their childcare, such as paying closer attention to their child's hygiene and ensuring they do not roam outside, two caregivers (6%) received more childcare support now with more family members at home, and one caregiver (3%), in contrast, expressed less support since she could no longer visit relatives.
Over a third of respondents (41%, N=49) reported that COVID-19 or the lockdown changed their 311 household cleaning practices (Table 5). All respondents who reported a change described a 312 positive change, including cleaning the house more frequently since the pandemic started (34% 313 N=40) and either starting to use detergent/disinfectant or using more of it now (13%, N=16): 314 315 "When it comes to cleaning our house, we are doing it more than how we used to do it (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

Quantitative Results Qualitative Themes and Descriptions
Changes related to household cleaning 41% (N=49) reported that coronavirus or the lockdown had changed their household cleaning practices  Cleaning house more frequently: 34% of respondents (N=40) explained that they have started cleaning their house more frequently since the pandemic started. Some specified the change in frequency, such as cleaning once a week to now twice a week or four times a week. Some of these respondents explained that they have 'pucca' (concrete) floors and are washing and/or wiping them more frequently, whereas others have clay or earth floors and have increased the frequency that they sweep or clean the floor by adding a layer of a cow dung/water mixture. When washing floors, many described using water with phenyl, detergent, bleaching powder, or shampoo.
 Use of detergent/disinfectant: 13% of respondents (N=16) said they had either started using or now use more of detergent/disinfectant when cleaning their home due to COVID-19. One respondent elaborated that it is repeatedly said on television that one needs to keep their home clean.
 No change: Among those that reported no change (59%, N=70), some respondents said this was because they have always cleaned their house frequently or properly, or that their house is always clean. One respondent said that they clean their house whenever it is dirty, and another respondent said that they clean it whenever they feel like it. A few respondents expressed that they were not aware that you should clean your house to protect against COVID-19.

Discussion 333
The COVID-19 pandemic led to positive changes in WASH practices in rural Odisha, India. In 334 particular, we found the majority of respondents reported increased frequency and/or improved 335 handwashing practices, an important WASH behavior to reduce the spread of COVID-19. We 336 also found improvements in other WASH behaviors as a result of the pandemic for some villages 337 and respondents, including improved service delivery of village level water supply, increased 338 household water treatment, and improved household cleaning practices. There was minimal 339 change in defecation practices as the vast majority of respondents continued to use their 340 household's latrine. The WASH infrastructure investments in study villages, including village-341 level piped water supply and high household latrine coverage, likely aided in compliance with 342 COVID-19 preventative measures -particularly the ability to wash hands frequently and stay 343 home during strict lockdown periods. These findings can be useful for improving response to 344 COVID-19, understanding the effects of the pandemic on WASH behavior change and habit 345 formation, and building resiliency to be better prepared for future pandemics. 346 347 Participants overwhelmingly reported positive changes in handwashing due to the pandemic 348 (with 86% reporting a change), and few reporting challenges with frequently washing their hands 349 with soap and water. We found an increase in handwashing frequency and thoroughness, as well 350 as the use of soap, which remained in place a few months after the pandemic began and the first 351 lockdown went into effect in India, suggesting a new habit may have formed among adults and 352 children. Many respondents also linked handwashing behavior as a new and consistent practice 353 after additional actions throughout the day (such as returning home), offering further evidence 354 that habit formation was occurring for handwashing, which is an important predictor for 355 All rights reserved. No reuse allowed without permission.
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The copyright holder for this preprint this version posted January 27, 2021. ;https://doi.org/10.1101https://doi.org/10. /2021 achieving sustained handwashing behavior change. 15,16 The longevity of these changes also 356 suggests that improved handwashing habits might remain after the pandemic subsides, which 357 could potentially lead to reduced disease transmission for other respiratory and fecal-oral 358 diseases, as was observed in Mexico after the H1N1 influenza pandemic. 17 Among the few 359 participants that reported barriers to handwashing in our study, this was attributed to the cost of 360 soap (8%) or challenges getting water (6%) that were often due to a problem with the water 361 supply system or water scarcity in the summer season. The proportion of respondents reporting 362 barriers to handwashing was substantially lower than a study among students and slum dwellers 363 in Uganda where 60.1% reported lack of soap, detergents, alcohol-based hand rub, or antiseptic 364 as a barrier to handwashing and 33.9% reported lack of running water as a barrier. 18 These 365 findings illustrate how the provision of soap and reliable water supply are needed to enable 366 individuals to practice the promoted preventative measure of handwashing. This is also in line 367 with common behavior change theories which include the concept of having an enabling 368 physical environment as a requisite for behavioral performance. 19-21 Therefore, the provision or 369 facilitation for accessibility of infrastructure along with mobilization towards proper use may be 370 required to achieve behavior change for many WASH practices and preventative measures. 371

372
Our results related to handwashing as a COVID-19 preventative measure are generally in 373 agreement with other studies. There were high levels of reported handwashing as a preventative 374 measure in online surveys throughout India, 22-26 a phone survey in Tamil Nadu, India, person surveys in Ethiopia 28 and Kenya, 29 all of which found at least 85% of respondents 376 reported handwashing to prevent COVID-19. However, many of these surveys did not specify 377 water source access, the use of soap, or if there was a change in handwashing practices. 378 Additionally, most of the online surveys were in English and required literacy and internet 379 access, which likely skewed the population to wealthier urban respondents not representative of 380 rural villagers. Furthermore, the wording of the survey question could impact response, as seen 381 in our survey where 86% reported that COVID-19 or the lockdown had changed their 382 handwashing practices for the better, compared to 96% who reported that they had washed 383 hands/used hand sanitizer more frequently in the past 7 days as an action to avoid COVID-19. 11 384 This difference is likely due to the more qualitative nature of the former question that prompted 385 respondents to explain changes and give more detailed responses about their handwashing 386 practices. Overall, this study population had high levels of knowledge about the importance of 387 handwashing and other preventative measures to reduce transmission of COVID-19, and 388 reported primarily getting their information about COVID-19 from television news, 389 conversations with a community-level government worker, and/or social media or the internet. 11 390 391 Some households described improvements in other healthful WASH behaviors, such as water 392 treatment and/or household cleaning practices, which could also have beneficial effects on 393 overall disease transmission. Although the majority of households in these villages have 394 functional piped water connected to their households, the supply is intermittent in many cases, 395 often with set daily hours of operation, and many households are still storing water as a result. 30 396 Therefore, point-of-use treatment of water may still be required to ensure safe quality drinking 397 water in many of the villages where regular chlorination is not provided. The reported water 398 treatment and household cleaning behaviors may have been a kind of spillover behavior change 399 effect resulting from other messaging on preventing COVID-19 transmission. In addition, 400 VWSC members in many villages reported that government officials came to clean village water 401 tanks or add bleaching powder to the tank for water treatment, and these actions may have given 402 focus to proper water treatment and encouraged a general message of cleanliness. While these 403 WASH behaviors have not yet been proven to reduce transmission of COVID-19, they could 404 reduce transmission of other diseases such as diarrheal disease. 31 405

406
There was minimal change in defecation location as a result of the lockdowns or COVID-19, 407 with most respondents reporting continued latrine use. This is in line with the results of another 408 study in Tamil Nadu, India, which also found minimal change in defecation practices with 92% 409 of respondents reporting no change since the lockdown and the majority of respondents with a 410 private latrine continuing to use it and only a few (7%) beginning to use their private latrine as a 411 result of the pandemic. 27 Our study area had high levels of latrine coverage and use prior to the 412 pandemic, 30 which may have also contributed to the minimal change observed. Our qualitative 413 findings also suggest little change in the decision-making or motivational factors individuals 414 typically consider when choosing their place of defecation. Many respondents who reported no 415 change described aspects such as time of day, water supply, season, or condition of the latrine as 416 driving their defecation practice, which aligns with factors noted in previous work completed 417 prior to the pandemic in the nearby district of Puri in Odisha. 32 When defecation changes were 418 described by our participants, they were often a result of other factors caused by the lockdown, 419 such as reduced traveling to markets or other public areas that do not have latrines, with few 420 respondents associating defecation practices with COVID-19 risk. Additionally, although there is 421 room for improvement in child feces management practices in this study area, 33 caregivers did 422 not report any changes in these practices as a result of the pandemic. 423 424 All rights reserved. No reuse allowed without permission.
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The copyright holder for this preprint this version posted January 27, 2021. ; their village that had network. Additionally, responses were self-reported. This could introduce 448 reporting bias, as respondents sometimes overreport hygienic behaviors like handwashing due to 449 courtesy bias or social desirability bias. 35-37 Self-reports of increased handwashing also do not 450 measure if handwashing is being performed correctly. While some respondents in our study 451 explained they had learned the correct handwashing technique due to COVID-19 information 452 campaigns and are now washing all parts of their hands, this may not be true of the entire study 453 population. For example, in a study in Nigeria, only 39% of respondents washed all critical parts 454 of their hands correctly when asked to demonstrate handwashing, compared to 90.5% of 455 respondents who reported practicing regular handwashing with soap and water to prevent 456 COVID-19. 38 We tried to reduce reporting bias and capture detailed experiences by including 457 several open-ended questions and asking for follow-up explanations to closed-ended questions. 458 Finally, we targeted respondents who resided in villages that had completed the MANTRA 459 program that installed village-level piped water and created high levels of sanitation access, 30 460 and therefore results related to WASH practices may not be generalizable to other villages with 461 lower levels of water and sanitation access. 462

463
The research revealed rich descriptions of changes in WASH practices among rural villagers in 464 Odisha as a result of the COVID-19 pandemic, including improvements in handwashing 465 practices that were promoted for COVID-19 prevention, as well as improvements in other 466 WASH practices that were not directly promoted such as water treatment and household 467 cleaning. With regards to handwashing, we found an increase in handwashing frequency, 468 thoroughness, and use of soap, and that these practices remained in place a few months after the 469 pandemic began and were often described as a new and consistent practice after additional daily 470 All rights reserved. No reuse allowed without permission.
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The copyright holder for this preprint this version posted January 27, 2021. ; https://doi.org/10. 1101/2021 actions, suggesting new habit formation that could potentially lead to sustained handwashing 471 behavior change. The role of barriers and enabling factors were also described for WASH-related 472 preventive practices, including the provision of soap and a reliable water supply. The results also 473