Contextual and psychological factors influencing open defecation free status: an exploratory qualitative study in rural South Western Uganda
Globally, about 0.9 billion people still practice open defecation. Although there has been decrease in proportions of the population practicing open defecation in many regions of the world, the number of open defecators increased in sub-Saharan African countries by 16 million to 220 million . Studies reveal that although governments have been spending on increasing latrine coverage for decades, rural open defecation remains high [2, 3]. More so research has also demonstrated that construction of more latrines does not result in reduction of oral-fecal diseases among children. However, open defecation-free status reduces such illnesses leading to improved child health . For example, Abebe and Tucho  further established that the prevalence of diarrhea was much less in open defecation free (ODF) villages compared OD villages.
In a multi country study about ODF sustainability in four countries in Africa which included Uganda, a criteria for household-level ODF status certification was agreed upon. It required a household to have: no human feces in the vicinity, a latrine with a superstructure; with either a water seal for the water born systems or a latrine cover as a means of keeping flies from the pit, a hand washing facility with water and soap or ash, and evidence that a latrine and the hand washing facility were being used (e.g. latrine and handwashing facilities have a walkway path well-trodden on) . Researchers in this study established that 8 % of households having a functioning latrine had visible signs of faeces around the house. Households with latrines having hand washing facilities with water and soap or ash, were 25% and those observed with lids covering the latrine drop hole were 19%. When all the five ODF status criteria were applied, the overall rate of households with ODF status across the study was 8% .
In Uganda, sanitation is still a challenge with 22.9% of the population practicing open defecation . Also, 64% do not practice adequate hand washing (washing hands with water and soap) in the rural areas . In addition, among 2/3 of the Districts in Uganda that receive the District Sanitation and Hygiene Conditional Grant annually from the government of Uganda, 63% of the villages in these districts have not attained the Defecation Free-ODF by 2019 [6, 7]. Rubaya and Buhara subcounties in Kabale District in South Western Uganda rank the lowest in sanitation status in Kabale district . According to Ndorwa West Health Sub District annual health status report, 2018, 35% of the households in Rubaya subcounty did not have latrines and only 3 villages have received the Community Led Total Sanitation (CLTS) intervention of which 2 villages were declared Open defecation free.
Researchers have established that when households or communities are not living in an ODF environment, there are consequences for child mortality and development . It’s under estimated that 2 million children die annually due to poor water, sanitation and hygiene diseases . Mara  emphasized that seeking interventions to address OD should remain core to researchers and implementor. This is because OD has adverse health effects such as excreta-related infections and infestations which mostly affect the poor. More so, OD has been associated to psychosocial stress in women, stunting and missed school days among children as well as environmental pollution, income and productive time loss [12,13,14].
World Health Organization  argues that, considering the global agenda of eliminating OD practice by 2030 on the basis of the previous reduction rates, this goal remains ambitious. Mara  similarly, in his review paper concluded that elimination of OD by 2030 would not be realized. Unfortunately, while most of the regions registered significant OD reduction, 39 countries in sub-Saharan Africa had a 49 million population increase of open defecators during the millennial Development Goals (MDGs) period . Although this was solely attributed to the population increase, there is a need to further explore other underlying factors to this negative trend. Abubakar  states that future research should focus on national level factors influencing OD if reduction and elimination of OD is to be accelerated in sub-Saharan Africa.
Odo and Mekonnen  established some of the factors that are associated with households that have handwashing facilities. These include; a better household wealth status, education status of the household head, having a radio and an improved latrine facility. In the same study, the authors concluded that if effective measures to increase handwashing are to be put in place, there is a need to understand contextual barriers such as existing policies, psychosocial factors and traditional norms. There are several contextual and behavioral factors that influence ODF status components with in different communities. These factors include structural, socio cultural, unpleasantness of the toilet, socio economic, locational, demographic and household characteristics factors [17, 19, 20]. Lopez, Berrocal  identified that social norms are important determinants for latrine use. Similarly, in a systematic review and meta-analysis study, privacy, better maintenance, cleanliness, facility type, accessibility, and newer latrines factors were commonly associated to higher latrine use, while poorer sanitation environment were associated to lower use .
To investigate contextual and psychological factors influencing open defecation free status, we adopted the combination of the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) model and the theory of triadic influence which elaborates social, physical and personal factors. The behavior change method was developed for evaluating behavior change interventions. The approach focuses at changing behavior factors of a given behavior in a population. This RANAS model framework combines behavior change theories of health action process approach and the theory of planned behavior . The model is categorized among the psychological sanitation promotion approaches and focuses on development of interventions based on information about the population’s psychological determinants that are influencing a given behavior. Based on this information collected during the baseline phase, appropriate Behavior Change Techniques (BCTs) that target the identified factors are used in the intervention phase .
Therefore, the aim of this study is to investigate contextual and psychological factors influencing the ODF status using the RANAS model in order to gain an extended understanding of the perceived factors influencing ODF status in Rubaya and Bubara subcounties in Kabale.