Cleaning Bharat (India): A Scoping Review of Perceptions Regarding How Swachh Bharat Can Continue to Improve Hygiene Across the Nation

Abstract

The spread of diarrheal disease is a major public health problem, and a lack of proper sanitation is an important contributor to this. In 2014, the Swachh Bharat Mission (SBM) was initiated by the Government of Bharat (India) to improve sanitation across the entirety of the country. SBM has received worldwide praise for its success, and it is now being expanded further. For the purposes of guiding the ongoing implementation of SBM and determining where it has or has not been successful, the objective of this scoping review was to determine the perceptions, knowledge, and attitudes of individuals regarding SBM. After screening 5454 research articles across seven databases, nine total articles were eligible for inclusion in this review. In spite of the reduced number of selected studies, numerous key themes emerged: Many chose to greatly praise SBM for its past successes; individuals felt that mass media should continue to be used to raise awareness; mindsets and a lack of awareness continue to serve as barriers to change; addressing inadequate waste disposal and waste segregation should be a very high priority to ensure cleanliness in Bharat. The findings of this review can guide policymakers, government workers, non-governmental organizations, and researchers in ensuring the continual development of SBM in its second phase and beyond the successful achievement of its aims, though the inherently limited generalizability of the qualitative studies included in this scoping review should also be recognized. Further research that is both qualitative and quantitative in nature is needed to develop a deeper understanding of the perceptions regarding SBM and the ways in which the ongoing program can be improved.

1. Introduction

1.1. Impacts and Scale of Poor Sanitation

Diarrheal disease is a major cause of death worldwide [1]. According to the World Health Organization (WHO), it is the cause of approximately 400,000 child deaths and is the third leading cause of death among children who are less than the age of five years old [2]. Worldwide, the lack of adequate sanitation is a major contributor to the transmission of diarrheal diseases, such as cholera, dysentery, typhoid, polio, and various protozoa and intestinal worm infections [2]. In addition, the lack of adequate sanitation has been described as an exacerbator of other major public health problems, such as antimicrobial resistance, and childhood stunting [2]. This is of salience for the country of Bharat (India), which, according to 2021 data, has rates of childhood stunting as high as 35.5% for children under the age of five [3]. It is estimated that approximately 1.5 billion individuals of the world’s population currently live in settings where they do not have access to basic forms of sanitation such as latrines and toilets [2].

1.2. Initiation of Swachh Bharat Mission

For decades, Bharat has been a nation for which a lack of access to adequate sanitation for the populace has been an enormous problem. To address this, in 2014, the national government initiated a nationwide campaign to address the issue of the lack of sanitation; this campaign was named Swachh Bharat Mission (SBM) (also referred to as Swachh Bharat, Swachh Bharat Abhiyan, Clean India, and Clean India Campaign). SBM has been described as the largest sanitation initiative in the world and has the ambitious goal of ensuring that Bharat will be free of open defecation by October 2019 [4]. The initiative has involved collaboration across governments at the state and central levels, with support being provided by other partners. While the development of toilets and latrines was among the utmost priorities of SBM, other important aspects of this initiative have included creating social and behavioral change campaigns, disseminating communication and education materials, providing messaging through media sources (such as social media), and ensuring that there are role models, peer monitoring, and support at the community level [5].

1.3. Benefits of Swachh Bharat Mission

The reported successes of SBM have been substantial; the mission has been noted to have helped approximately 100 million rural households gain access to toilets, which translates to 500 million residents across approximately 630,000 villages in the nation [5]. This has all led to major economic, environmental, and health benefits across the nation of Bharat.

Regarding financial benefits, it is estimated that the economic savings of SBM have amounted to approximately INR 4.9 trillion (approximately USD 76 billion) [6]. Every level of society has experienced this economic benefit, with financial returns on household spending over a decade being estimated at 1.7 times the cost, returns to society on overall spending over a decade being 4.3 times the cost, the poorest in society having a financial return of 2.6 times the cost, and the societal benefit being 5.7 times the cost [7]. A differing analysis showed that the maximum economic benefits, compared to other groups, occurred among the poorest members of society [8].

The full extent of the health benefits of SBM is not yet fully known—however, predictions by the WHO in 2018 indicated that as many as 300,000 deaths may have been averted from causes such as diarrhea and protein-energy malnutrition; in addition, it was predicted that 14 million disability-adjusted life years (DALYs) have been estimated to avoided and that the overall incidence of diarrheal diseases is estimated to have declined substantially [9]. Aside from existing predictions, there is also existing evidence demonstrating the health benefits of SBM. It has been shown that the annual number of acute diarrheal disease outbreaks has steadily declined since the initiation of SBM [10], including those among young children [11], and SBM’s successes have also led to overall improvements in hospital function, with gains in parameters such as infection control, support services, and hygiene promotion [12]. Based on the successes that SBM has shown overall, numerous other nations, such as Nigeria, Indonesia, and Ethiopia, have been influenced to develop ongoing policies with the usage of SBM as a guide [5].

1.4. Next Phase of Swachh Bharat Mission

With the high levels of success that are seen with SBM, the national government of Bharat has begun the second phase of SBM, which commenced in 2019 [13] and is projected to continue until at least 2025. This second phase entails ensuring that areas that have obtained Open-Defecation-Free (ODF) status not only maintain this status but also implement management systems for solid and liquid waste [14]. This includes ensuring improvements in waste disposal for biodegradable wastes, including wastes from human, food, agricultural, and cattle sources [15]. In addition, there is a goal to improve practices in adequately disposing of non-biodegradable wastes such as e-waste, metals, and plastics. Lastly, raising awareness and managing menstrual waste are priorities for the new phase [15]. Therefore, the overall aim of this mission is to provide a shifted focus toward also ensuring that waste is adequately disposed of, thereby better ensuring that the sanitation and overall cleanliness of the nation improve.

1.5. Persisting Issues and Challenges

In spite of the considerable successes that have been shown and demonstrated with SBM thus far, a number of significant barriers to progress have persisted, which have impaired progress. While access to sanitary infrastructure (such as toilets and latrines) has greatly improved in the country, across a number of studies, it has been described that individual attitudes toward cleanliness and the willingness to use toilets/latrines remain a challenge [16,17,18]. A number of other constraints and barriers (resulting in open defecation and improper waste disposal) have also been identified in previous studies, and these include financial problems, a lack of adequate water supply, the mistrust of the government, cultural beliefs, personal preferences, and a lack of overall awareness [16,17]. As a result, all of Bharat is not yet ODF. Furthermore, these problems run the risk of negatively impacting the long-term impacts of the second phase of SBM.

1.6. Improving Implementation of Swachh Bharat Mission

Despite all the progress made with SBM thus far, there is a clear need for further efforts and adjustments to be made in order to realize the ambitious goal of the nation being ODF. Furthermore, clearer guidance is needed to ensure the smooth development and progress of SBM Phase II.

To guide and improve Swachh Bharat for the present and future and to help create policies that will have a persisting influence in the upcoming years and decades, it is critical that the lived experiences of the people of Bharat are considered by policymakers and those who seek to contribute to SBM’s implementation. However, qualitative research that has been conducted regarding individual perceptions, attitudes, and knowledge regarding SBM has yet to be adequately synthesized. These insights, when properly considered and accounted for, may provide valuable insights as to how SBM can be more effectively implemented so that its overall gains can be attained.

1.7. Research Aim

In consideration of the gaps in understanding regarding the lived experiences and feedback with respect to SBM, the goal of this work is to provide a scoping review of qualitative studies that analyze the knowledge, attitudes, and perceptions of SBM in order to provide recommendations as to how SBM can be improved in achieving its short- and long-term aims.

2. Materials and Methods

2.1. Search Terms

This scoping review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines [18]. This scoping review followed the requirements for this type of review methodology, and the completed PRISMA-ScR checklist is shown in Supplementary Table S1. This review was not previously registered.

For this review, systematic searches were conducted in a number of databases in order to retrieve as many relevant articles as possible. Search terms were intended to be as broad as possible, with the following terms being used across differing databases: (“swachh bharat” OR “clean india”) AND (“qualitative” OR “mixed-methods”). These searches—which were all completed on 19 February 2024—were conducted in a total of seven different databases: Google Scholar, OVID Medline, Scopus, Web of Science, EBSCO Academic Search Complete, Embase, and APA PsycInfo. The citation searches of reference lists for the searched papers were also inspected to find any additional, potentially relevant articles.

2.2. Criteria for Inclusion

The following were the inclusion criteria of this review: (1) findings must be from 2014 (this being the year during which SBM was initiated) to 2024 (the period in which searches were conducted); (2) must either be a qualitative study or a mixed-method study with a qualitative component; (3) must include qualitative data pertaining to SBM that encompass at least one of the following: knowledge, attitudes, and/or perspectives; and (4) must be full-text, peer-reviewed research that has been published. Studies were not eligible for inclusion if they were not original research (such as reviews, commentaries, or editorials) and if they were conference abstracts/presentations.

2.3. Screening Process

After searches were conducted and articles were retrieved from the seven databases, the screening for studies began. The screening process for this review began with the removal of duplicate articles retrieved across searches. Once the duplicates were removed, the studies were screened by title and abstract to determine their relevance for this review (with irrelevant studies being removed). Once this was completed, studies were screened next via the entirety of their texts to determine their overall relevance for this review. Once this was completed, the screening process for this review was completed. A PRISMA diagram was included, as modified as per Page et al. [19].

2.4. Extraction of Data

Data were consistently extracted for the studies that were deemed to be worthy of inclusion in this review. To provide an overall understanding of each study and its context, data on the study characteristics were first extracted. The following data on the study characteristics were extracted: authors and year, source of data (for example, interviews), study objectives, study setting/sample size, and data analyses that were conducted in the study. Next, the key findings of studies pertaining to SBM were extracted from the included studies. These findings were summarized for each study. It is noteworthy that these summaries of key findings were focused on the findings related to SBM, as a number of studies in this review included data that did not directly or indirectly pertain to SBM.

2.5. Synthesis and Presentation of Data

The data pertaining to study characteristics were presented in tabular format. The patterns and differences were noted in the text via a narrative synthesis. Similarly, key findings pertaining to SBM were also presented in a tabular format. Again, patterns and differences were denoted in the text, along with the themes of the findings being discussed in further detail. After this was completed, a summary table was presented to describe the most relevant aspects of this review as per the findings of past studies and the implications of these findings for policymakers, those working on the ground, and those who will be conducting future research on the topic of SBM.

3. Results

3.1. Selection of Articles

The searches produced a total of 5454 articles. The following total results were found from each respective database:

• Google Scholar: 3329 results.
• OVID Medline: 1889 results.
• Scopus: 217 results.
• EBSCO Academic Search Complete: 10 results.
• Web of Science: 4 results.
• PsycINFO: 2 results.
• Embase: 2 results.
• Citation search of reference lists: 1 result.

Of the 5454 results, 1076 duplicates were identified and removed. Therefore, a total of 4378 results were screened via their title and abstract. Of these, 4278 were deemed to be ineligible for inclusion in the review. In total, 100 studies had the entirety of their text analyzed. Of these 100 studies, 9 studies [20,21,22,23,24,25,26,27,28] were ultimately determined to be eligible for inclusion in this review. The reasons for the exclusion of articles were as follows: did not include qualitative data pertaining to SBM (60 articles), had the wrong study design (21 results), the full text was not available (9 results), and they were only conference presentations/abstracts (3 results). A full depiction of the screening process [19] is shown in Figure 1.

3.2. Study Characteristics

The characteristics of all nine studies included in this review are shown in

Table 1. Characteristics of the studies included in this review.

Authors (Year)	Source of Data	Objectives	Study Setting and Sample Size	Data Analyses	Study Limitations
Nath, Yadav, and Kumari (2018) [20]	Student essays	Objectives were two-fold: (1) to determine perceptions of components of cleanliness for Swachh Bharat Abhiyaan; (2) to determine perceptions of how students can contribute toward cleanliness.	Medical undergraduates at a medical college in Northern Bharat. Sample size = 100.	Essays were analysed, with students being contacted to clarify ambiguous responses. Deductive coding, with overlapping codes extracted. Four themes were generated: (1) cleanliness practices, (2) behavioral change communication, (3) behavioral change interventions, and (4) behavior change legislations.	Unspecified.
Curtis (2019) [21]	Structured interviews	To describe how the successes of Swachh Bharat Mission in rural Bharat from the perspective of government workers in order to provide guidance for other nations wishing to emulate these successes.	Across four states, Swachh Bharat Mission government workers at the district, state, and national levels. Sample size = 17.	Framework analyses conducted with the following steps: (1) familiarization, (2) identification of a thematic framework, (3) indexing, (4) charting, and (5) interpretation and mapping. Drawing upon the theory of change perspective of behavior-centred design.	Courtesy bias where there was a nearly completely positive response provided by interviewees. Need to study representatives from other states. Study focus was solely on sanitation in rural households across Bharat, with no focus on urban settings.
Datta et al. (2020) [22]	Cross-sectional survey and focus group discussions	Objectives were twofold: (1) to determine knowledge and practices relating to hygiene, sanitation, and solid waste disposal among individuals residing in Agartala city; (2) to analyse factors impacting knowledge and practices.	For qualitative component: Three focus group discussions carried out in urban populations in Agartala Municipal Corporation in Tripura. Sample size = 24.	Pre-selected questions used for focus groups, with an experienced facilitator guiding discussions. Transcripts written and thereafter classified under codes/criteria and then presented in tabular format.	Unspecified.
Paul et al. (2021) [23]	Focus groups and cross-sectional survey	Four primary objectives for this study: (1) Provide health-related awareness education. (2) Assess community attitudes toward types of health education. (3) Provide service relating to waste management to community members. (4) Assess skills of medical students in conducting qualitative research.	For qualitative component: 10 focus groups which included individuals of different ages across groups (from 13–19 to 65–72 years). Sample size = 77. Two medical students led each focus group. Occurred in a Bucho kalan village of Nathana block of Bathina district in Southern Punjab in June 2019 for six days.	For qualitative component: Focus groups focused on Swachh Bharat and its associated activities. Areas of discussion were for the following themes: (1) waste management, (2) Swachh Bharat and its related activities, and (3) community knowledge regarding hygiene and sanitation.	Unspecified.
Jack, Anantharaman, and Browne (2022) [24]	Semi-structured interviews and small group interviews	To determine relations between infrastructure access, social mobility, and usage of resources and cleanliness in Mysore.	Adults interviewed in Mysore regarding cleanliness, with both semi-structured interviews (25) and small group interviews (4). Sample size = 28. Mean age: 37 (range: 21–73).	Four key themes were identified and expanded upon based on the findings of interviews. These were as follows: (1) cleanliness infrastructure, (2) reinforcement of existing hierarchies, (3) positive perceptions of cleanliness, and (4) difficulties of marginalized groups.	Unspecified.
Khandare and Salve (2022) [25]	In-depth interviews and cross-sectional survey	To utilize Critical Caste Theory to determine vulnerabilities of municipality workers in Mumbai relating to disposal of waste.	For qualitative component: Interviewing workers who have had more than 5 years of experience as waste loaders and street sweepers at the municipal corporation of Mumbai, as well as key informants in waste management operations. Sample size = 22.	Critical Caste Theory was utilized to guide analyses of interviews; findings were broken down into themes: risk of ghettoization and determinants of health such as substance use, morbidity, and causes of death. Also focused on Swachh Bharat Mission, indebtedness, and voices for freedom.	Study utilized a cross-sectional design. Results may be seasonal variations that were not accounted for in this study.
Sahoo et al. (2022) [26]	Focus group discussions and interviews	This study aimed to explore community members’ attitudes, capabilities, and opportunities in segregating household waste.	This study involved conducting 10 focus group discussions with inhabitants of Ujjain Municipal Corporation in Madhya Pradesh. Six focus groups with slum dwellers. Four with non-slum dwellers. There were also eight individual interviews to complement focus groups. Sample size = 78. Mean age = 41 years. There were 35 individuals from slums and 43 from non-slums (47 females and 31 males).	Focus group discussions featured the following content: (1) existing practice on household waste sorting and segregation, (2) opportunities, (3) abilities, and (4) motivation. MOAB theory and framework used to propose behavioral changes.	Unspecified.
Dhami et al. (2020) [27]	Structured interviews	To understand the attitudes and motivations of Gandhinagar residents of the SBA and to determine key elements for the future of cleanliness drives regarding perceptions and attitudes.	Sample size = 1000. In total, there were 512 males and 394 females (out of which 94 did not respond to certain sections) across a variety of ages, genders, family types, and educational qualifications. All above 13 years old and residing in Gandhinagar, Gujarat.	Answers were divided into three categories of perception: enthusiastic acceptance, acceptance with reservation, and complete rejection. Afterwards, an analysis group was determined to formulate agreed-upon conclusions.	Does not account for religious perceptions that greatly influence overall views within India. Study is limited to one city where SBA is nation-wide
Jain et al. (2020) [28]	Semi-structured interviews and focus group discussions	To evaluate perspectives on open defecation and latrine use, and the social, economical and political for these perspectives in rural Bihar to ultimately design better sanitation systems.	Sample size = 21. Semi-structured interviews with seven men and six women with variations in age (excluding minors under 18), gender, caste, household latrine ownership, occupation, and education. Also, two focused group discussions were carried out with four men each, and for this group, there were demographic variations but homogeneity with regard to caste, gender, and occupation. All were from rural Bihar.	Interviews were digitally recorded, translated and transcribed to English with two translators. Themes were identified and organized from the data used to develop codes, which were then discussed among researchers in order to refine the codes and group them into broader thematic categories via the qualitative data analysis software ATLAS.ti (version 8.3.1), with researchers then coming together again to ensure intercoder reliability.	Sample size was a small number of participants within one district in a low-income state, which was not representative of all of India with its cultural, social, economic, and political diversity. Therefore, authors were unable to make generalizable conclusions or provide policy recommendations. Study did not explore whether SBA-G successfully inspired positive change with respect to sanitation. Study did not include focus groups with women.

. The studies were conducted between 2018 and 2022. The most common sources of data for included studies were interviews (five studies) and focus group discussions (three studies), with one study utilizing text for analyses (specifically student essays). The study objectives tended to vary across studies; the most common research aims were a focus on the aspects of “cleanliness”, analyses of the attitudes about the effectiveness of waste disposal, and a specific gauge of the perceptions of the successes and shortcomings of SBM. The study sample sizes ranged from 17 to 1000. The populations under study were medical undergraduates in Northern Bharat (100 individuals); government workers at the local, state, and national levels in four different states (17 individuals); urban populations in Tripura (24 individuals); those in a rural village of Southern Punjab (77 individuals); adults residing in Mysore (28 individuals); adults residing in rural Bihar (21 individuals); those residing in Gandhinagar (1000 individuals); waste loaders and street workers, along with informants in waste operations (22 individuals); and slum and non-slum dwellers in Ujjain Municipal Corporation in Madhya Pradesh (78 individuals). While most studies did not specify weaknesses/limitations, four studies that did specify their limitations and denoted the following issues: a lack of representativeness across states, not accounting for religious influence, a focus solely on specific factors (such as sanitation), only having discussions with populations at a single point in time, and not being able to account for seasonal variation in conditions.

3.3. Key Findings Pertaining to SBM

The findings of the study are shown in

Table 2. Key findings across the studies included in this review.

Authors (Year)	Study Population and Sample Size	Summary of Key Findings Regarding Attitudes, Knowledge, and Perceptions of the Swachh Bharat Mission
Nath, Yadav, and Kumari (2018) [20]	100 medical undergraduates at a Medical College in Northern Bharat.	Participants specified that initiatives should begin at the ground level, which is at home; community involvement is necessary for change. More societal focus should be on respecting laborers in cleaning garbage, but everyone should be involved in such efforts. Emphasis should also be placed on ensuring that waste goes into dustbins and reducing the usage of plastic. There is a need to create awareness among both kids and youth regarding cleaning Bharat, and this can be carried out with advertisements, movies, and school workshops and competitions to increase engagement. Can have special days/weekends/times of the month focused on this (e.g., first working day of each month and government holidays; focus on cleaning on government holidays). Other initiatives/efforts that should occur on a larger scale and that are related to ongoing efforts: tree planting, education for the community (such as using mass media sources), discouragement of open defecation, reforming syllabi in teaching institutions, having more awareness campaigns, ensuring the availability of alternative and efficient energy sources, increasing the availability of sanitation and waste disposal efforts, cleaning rivers and riverbeds, carrying out collaboration across industries (such as health, education, and irrigation departments), and ensuring the development of clearer legislation to ensure and improve cleanliness.
Curtis (2019) [21]	17 Government workers involved in the Swachh Bharat Mission working at the district, state, and national level.	Overwhelmingly positive responses for the outcomes and overall aims of the Swachh Bharat Mission. Stated that there were massive efforts by political leaders, which paid off greatly. Many stating that the successes of this initiative were extraordinary, with changes occurring in significant ways in the following domains: breaking administrative norms; involvement of mass media; disrupting undesirable social norms; on-the-ground work by government workers; utilization of technology; rapid action by bureaucrats; provision of appropriate support to those who want to make a difference; psychological changes with the mission’s success, motivating workers; and successfully changing peoples’ behaviors and ongoing efforts to build on successes.
Datta et al. (2020) [22]	For qualitative component: 24 individuals living in urban Agartala Municipal Corporation in Tripura. All participants were males from different households.	Many individuals seem to be informed about the Swachh Bharat Mission, with information sources primarily being from television; other sources include newspapers and mobile phones. Individuals felt that Swachh Bharat can have an important role in making localities garbage-free, preventing the indiscriminate disposal of waste, and preventing the transmission of diarrheal disease (such as those from flies and mosquitoes). Areas of major concern continue to be the presence of garbage in public areas, public toilets remaining unclean, infrequent and unpredictable collection of household waste by those in the municipality, and the presence of clogged drains within municipalities. Participants stated that the indiscriminate throwing of garbage in market areas is rare since the initiation of Swachh Bharat and that drains in localities are cleaned much more frequently. Many felt that individual actions will have an important role in improving cleanliness and maintaining the successes of Swachh Bharat, and individuals are responsible for ensuring that they need to not throw garbage on ground areas and should not utilize drains and latrines for waste disposal.
Paul et al. (2021) [23]	77 individuals in 10 focus groups, which included individuals of different ages across groups (from 13–19 to 65–72 years).	Participants feel that, despite Swachh Bharat, waste disposal is inadequate. Cow dung is piling up in front of houses, kitchen water flows into roads, and plastic waste is inappropriately being disposed of in areas with drains. It was felt that too heavy of a focus was placed on the development of toilets, with minimal focus on waste disposal and drainage. Overall, individuals felt that the following factors contributed to a lack of adequate waste disposal: lack of commitment politically, ignorance of community regarding proper waste disposal, minimal involvement of females, and high costs of disposing waste. Increasing the awareness of waste management of all members of the communities is required; individuals need to demand adequate waste disposal practices from their politicians, and individuals need to be made aware of the methods of disposal, such as vermicomposting for cow dung and kitchen waste carried out by health workers and government workers.
Jack, Anantharaman, and Browne (2022) [24]	28 adults interviewed in Mysore regarding cleanliness, with both semi-structured interviews (25) and small group interviews (4). Mean age: 37 (range: 21–73).	Several respondents exhibited positive optimism regarding Swachh Bharat, feeling that the usage of advertisements in newspapers, radio stations, and railway stations has become a part of people’s memories. Respondents felt that this has resulted in individuals littering less, and therefore, they felt that Swachh Bharat has been a success in this regard. Individuals generally felt that public places were not clean, and a lack of education and awareness or just carrying out the wrong action was a reason for this. Some individuals expressed frustration regarding this.
Khandare and Salve (2022) [25]	22 adult workers interviewed who have had more than 5 years of experience as waste loaders and street sweepers at the municipal corporation of Mumbai, as well as key informants in waste management operations.	Swachh Bharat has been successful in increasing the awareness and consciousness of individuals regarding the need for cleanliness in society. However, it appears that vulnerable individuals (specifically, Safai Karamcharis) who work in waste cleaning continue to be stigmatized and excluded socially. It was reported by at least one participant that the circumstances for vulnerable individuals who clean waste have not changed since the initiation of Swachh Bharat. Safai Kamacharis are still stigmatized, barred from settings such as hotels, taunted and abused, and even assaulted. Despite Swachh Bharat, the occupation continues to not be respected.
Sahoo et al. (2022) [26]	78 individuals who were participants in 10 focus group discussions, and eight individual interviews to complement focus groups. Mean age = 41 years. In total, 35 individuals from slums and 43 from non-slums (47 females and 31 males).	Prior to the initiation of Swachh Bharat, few households were aware of waste segregation. Even those who were aware of it were not carrying it out anywhere near the level as after Swachh Bharat’s initiation. Since the initiation of Swachh Bharat, waste segregation has greatly improved, along with the overall cleanliness in communities. The attitudes and feelings of self-efficacy have seen gradual improvements. Individuals felt that, particularly for children, color-coded containers for separating waste were very helpful. Prior to the Swachh Bharat’s initiation, the color coding of containers occurred—but infrequently. It is now being applied much more, but there remains a clear need for an increase in color coding. Supervisors of waste collection inform community members how to segregate waste, but more of this is needed. Therefore, an emphasis is placed on needing to educate individuals more about waste segregation. This could occur with the use of television and other media sources. Children are learning about waste disposal from television sources. Some in slums felt that they should be better incentivized for separating wastes, whereas those not in slums more commonly felt that it was a civic duty to segregate waste. Incentives can be financial but can also comprise other means such as a certificate of appreciation. Others also felt that incentives could be a starting point for keeping areas clean. Some indication that cleanliness and waste segregation are becoming a social norm, and camera use should be initiated to ensure that people are properly segregating waste. Many waste disposal facilities tended not to operate on Sundays and holidays, which led to the build-up of waste, and this led to improper waste disposal in numerous areas. Due to a lack of garbage vans/collectors coming to households, some disposed of waste via improper methods, such as burning, dumping in sewers, and throwing out waste in the open. Some also felt that the proper disposal of waste was financially burdensome for reasons such as purchasing dustbins.
Dhami et al. (2020) [27]	1000 residents of Gandhinagar, Gujarat, with a variety of ages, genders, family types, and educational qualifications.	The majority of interviewees exhibited the enthusiastic acceptance of SBA’s promotional activities, political affiliations, and environmental impact and the peoples’ perception of the overall personal and societal change regarding this initiative. Regarding political affiliations, subjects assumed that SBA was a strategy to gain votes. With some, the involvement of any government official was viewed with great suspicion for clandestine activities or party propaganda. Others who expressed mixed scepticism were participants who were not too trusting but not entirely sceptical. Some were also completely trusting of the actions of the government. With respect to environmental impacts, celebrity involvement promoting SBA as an environmental concern was an underhanded attempt to gain improved public relations. There were mixed opinions regarding the environmental impacts, with some believing that visible and swift progress has been made, others believing in slow progress, and some stating no progress has been made in environmental cleanliness. For the promotional activities of the government, a positive response was illustrated when clear and active efforts were taken toward mobilizing masses as opposed to promoting hidden agendas for questionable reasons. With respect to personal and societal choices and changes, the most commonly emerging view was the substantial effort made toward realizing the aims and objectives of SBA. Some had a neutral opinion, and some also thought that there was a lack of effort, with no tangible results from the communal results of the SBA initiative. A large proportion of those who expressed that there were strong positive impacts on personal and societal choices were youth members; this can be attributed to their own contributions through the utilization of spreading SBA information through social media.
Jain et al. (2020) [28]	21 citizens of rural Bihar consisting of 7 men and 6 women with variations in age, gender, caste, household latrine ownership, occupation, and education. Eight men with demographic variations who exhibited homogeneity with regard to caste, gender, and occupation.	The latrine construction subsidy of INR 12,000 is too little for the construction and ongoing maintenance of adequately sided latrines. Frustration toward SBA and the government was expressed in terms of not understanding the financial concerns of people when forced to promote cleanliness with no money and the lack of proper waste management carried out by the government. SBA-G incentive delivery methods were not practical, with construction first needed before payment; however, poor people were unable to provide upfront costs. Fears of corruption in not receiving the full subsidy. Uncertain of how subsidy payments are managed, with some thinking that 95% of the ward needs latrines before payment is given. Some believe that payments will take up to five years. Distrust toward the government, influencing the perceptions of SBA-G. In reference to previous development initiatives, some believed that development was prioritized in urban centres first and that governments were less willing to help rural areas. Anger and resentment toward the government influenced their willingness and ability to trust SBA-G.

. The studies tend to show notable variations in terms of the public perceptions of SBM. These key findings can be broken down into five main themes: (1) successes of SBM; (2) the role of media; (3) awareness, mindsets, and education; (4) waste disposal issues; and (5) general/other SBM issues.

• Successes of SBM

In a study evaluating the attitudes of government workers who are involved in SBM at different levels, Nath et al. found that there are overwhelmingly positive attitudes toward SBM among the participants [20]. The respondents in this study described the work of SBM as extraordinary, and its successes are far beyond expectations. Successes were named relative to a wide array of parameters, including (but not limited to) the following: changing social norms regarding cleanliness; motivating workers; utilization of technology; effectively breaking the barriers of large administrations; effective usage of media sources; rapid action by bureaucrats when required; creating psychological changes; and continuing more efforts to build on successes [20]. In a different study by Jack et al., many had a positive attitude toward SBM, and they felt that aspects of this program have entered into the minds and consciousness of citizens [24]. Individuals felt that this translated into reduced littering, highlighting the success of the efforts of SBM. A similar finding was described in a study by Khandare et al., where it was demonstrated that SBM was successful in increasing the awareness of the need to remain as clean as possible [25]. In a study by Datta et al., it was noted by a number of participants that, with the implementation of Swachh Bharat, the disposal of garbage in market areas became rare and that drains in areas were being cleaned much more frequently [22]. The participants in the study by Sahoo et al., which includes slum dwellers and non-slum dwellers, stated that SBM had a highly impactful role in increasing overall cleanliness and waste segregation in the areas that they reside in [26]. Dhami et al. noted that the majority of the perceived success of SBM was from youth members, and this was attributed to their own contributions to SBM via promotional activities on social media [27].

• The role of media

It was generally agreed upon by participants across studies that SBM was effective in utilizing major media sources in order to raise awareness about its overall goals and the importance of maintaining cleanliness. The study on government workers by Nath et al. found that one important reason for SBM’s overall success was attributed to the extent to which media were used for messaging purposes [20]. Participants from Datta et al. described that much of the knowledge that they have previously attained regarding SBM has come primarily from television (and secondarily, from newspapers, and mobile phones) [22]. Similarly, in a study by Jack et al., it was stated that the usage of advertisements for SBM in newspapers, radio stations, and railway stations has been integral in increasing people’s awareness [24]. Recognizing the importance of media sources, participants in Curtis’s study describe that the ongoing usage of media, which may need to be scaled up for certain aspects of cleanliness promotion, is important in order for SBM to have continual success [21]. Many participants in Sahoo et al. emphasized that television sources were of the utmost importance for raising awareness across all age groups [26]. However, Dhami et al. noted that participants found celebrity involvement in promoting SBM as an environmental concern to be an underhanded attempt to gain improved public relations [27].

• Awareness, mindset, and education

It was commonly stated among participants in a number of studies that more initiatives and efforts need to be made to increase awareness among individuals, to ensure the proper education of individuals, and to change existing mindsets that deter cleanliness efforts in communities [21,22,23,24,25,27]. In Curtis’s study, in which medical undergraduates were asked about their opinions on how overall cleanliness can be improved in society, participants indicated a need to raise awareness, particularly among youth and children, and this could happen by increasing engagement through education, competition opportunities, and movies [21]. The participants in this study indicated that this should be supplemented with education for communities and reforming the syllabi in educational institutions. Paul et al. stated that efforts will need to be made to address attitudes and actions in communities, such as the disposal of waste in ground areas and the disposal of waste in latrines/toilets [23]. The study also emphasized that raising awareness of waste management is critical and that individuals in communities need to be guided by health and government workers [23]. Some individuals in the study by Jack et al. stated that the lack of education and awareness was the prime reason public places were not being cleaned, and this was a source of frustration for some [24].

• Waste disposal issues

An issue that was described by participants across studies was the lack of action taken toward waste disposal, and the need for change in this domain was expressed. Medical students in the study by Curtis emphasized that the proper disposal of waste across Bharat needs to be an area of focus [21]. Datta et al. highlight that individuals in the urban parts of Tripura described waste disposal issues that should be prioritized, including the following: garbage in public areas, public toilets continually remaining unclean, infrequent/unpredictable collection and disposal of household waste, clogged drains within the municipalities, and drains/latrines being used by others for waste disposal [22]. These same individuals felt that SBM can have an important role in both preventing the indiscriminate disposal of waste and in ensuring that localities remain free of garbage. Participants in the study by Paul et al. similarly felt that SBM had too heavy of an emphasis on toilet development and an inadequate focus on drainage and waste disposal [23]. They also denoted that individual factors contribute to inadequate waste disposal, along with a lack of political commitment, the ignorance of the community regarding waste disposal, minimal options for females to be involved, and the high financial costs of disposing waste. They felt that a part of SBM should be dedicated to educating individuals about how to dispose of waste and how to carry out different forms of waste disposal, such as vermicomposting for kitchen waste and cow dung. Moreover, they described ongoing issues, such as cow dung piling into houses, kitchen water with waste going into roads, and plastic being inappropriately disposed of, often ending up in drains.

Sahoo et al. discuss the issues of a lack of proper waste segregation and disposal in detail [26]. While they state that waste segregation and the awareness of its importance have increased greatly since the initiation of SBM, these waste issues are nonetheless severely lacking. There is a need for more waste collection supervisors to instruct community members on how to adequately segregate waste. Others stated that incentives should be provided to individuals for segregating waste, and these incentives do not necessarily have to be financial (for example, a certificate of appreciation). Some felt that community surveillance, through camera monitoring, could be a useful way to ensure that more individuals segregate waste and dispose of it properly. An issue that was also brought up by participants in this study was that waste disposal teams and facilities tended not to come at certain times and dates, such as weekends and holidays, which led to an accumulation of waste issues; these issues, which occur due to a build-up of waste, include the burning of waste, the dumping of waste in sewers, and throwing waste in the open. Individuals also stated that purchasing appropriate dustbins was difficult for some as it was a financial burden that they had to take on by themselves. Jain et al. demonstrated that the financial burden of SBM was echoed by the residents of rural Bihar, who found that the construction subsidy of INR 12,000 was inadequate for the construction and maintenance of latrines, and they were unclear as to how subsidy payments would be managed, with some fearing government corruption [28].

• General/other SBM issues

Other issues were described by participants in these studies. Jain et al. noted anger and resentment toward the government with respect to trusting the SBM as they perceived the government to prioritize urban centers first and were less willing to help rural areas [28]. Participants from Khandare et al. stated that they continually faced stigmatization and social exclusion due to their roles as waste loaders and street sweepers. Some even described being banned from certain hotels and even taunted, abused, and assaulted by individuals for their roles [25]. They hence stated that SBM has been unsuccessful in changing stigmatization and social exclusion and that they continue not to be respected. The study by Curtis states that SBM should not be focusing solely on toilet development (and waste disposal) in realizing the goal of ensuring cleanliness in society. Instead, there is a need to make additional changes, such as changing educational systems to emphasize the following: cleanliness; cleaning rivers and riverbeds; creating stronger collaborations across various domains and spheres, such as public health, irrigation, finance, and education departments; and creating clearer and firmer legislation that can lead to improvements in the environment and create upsurges in cleanliness as a priority overall [21].

4. Discussion

In this review, it was demonstrated that, while there are notable variations in the perceptions and thoughts regarding SBM for individuals across the nation, there are also clear parallels and notable themes that emerged. Overall, it appears that many agree that the SBM has been highly successful with respect to numerous parameters. Specifically, the mission was highly effective in working in an efficient manner that was not restricted by slow-moving bureaucracy, and this was facilitated by the collaboration of government workers across differing areas. There were major successes in creating the needed sanitation infrastructure, and this was translated to success in improving sanitation and improving individual and community awareness regarding the need to maintain cleanliness. There was heavy praise for SBM’s usage of mass media sources to disseminate messages regarding cleanliness. For the ongoing implementation and enactment of SBM, these successes need to be recognized and continually built upon to ensure that the successful aspects of SBM will continue to have a positive influence in the future.

In spite of the successes, there are a clear number of areas in which SBM needs to also be expanded upon and revised for continual implementation. While media sources have been highly successful, the use of media sources to present the messages of SBM should be utilized to a higher degree, especially as SBM continues to build upon its existing goals (such as the goals of Phase II of SBM). This should focus on all aspects of populations, including children, and should involve a diverse array of media sources. While television has been shown to be the most effective and is hence a media source that should be heavily relied upon, other media sources, such as radio stations, social media, and phone messaging, should be utilized at large scales.

One of the biggest barriers to the success of SBM, whether it be in regard to open defecation or a lack of proper waste disposal or waste segregation, is the lack of awareness of individuals. As already stated, SBM’s usage of educational and informative resources has been highly effective in creating behavioral changes, but this needs to be scaled up; more focus should be placed on areas where awareness remains minimal, such as those relating to waste and the types of waste. This should entail the usage of media outlets to disseminate further information about the importance of SBM to the public, and whenever possible, health promotion activities that can provide education on the importance of proper waste disposal should be carried out, which can have significant impacts.

It has also been emphasized that individual mindsets may also serve as an important barrier to cleanliness measures across Bharat. Changing these mindsets will likely be difficult, and more research is needed as to how mindsets regarding sanitation and waste can effectively be changed among individuals. However, education will also clearly have an important role in creating these changes. Community collaboration and the encouragement of others to take proper actions can be valuable facilitators of change and should occur nationwide; government workers on the ground can be powerful agents of change across rural and urban settings and in slum and non-slum settings. The usage of incentives (which can also reward positive behaviors without necessarily providing financial prizes), and potentially even forms of punishments, may warrant effective means of creating change, but research is needed on the impacts of these measures. However, they may be worthy of consideration if they can create change at a low cost.

An important area in which SBM has not yet been adequately successful, but could be in the future, is waste management and waste segregation. Participants across numerous studies have made it clear that this is a top priority for them. Therefore, it is highly clear that political commitment should be reserved for improving waste disposal across all parts of the country. This should involve a multi-level approach, similarly to those that were already taken in the first phase of SBM. Developing such comprehensive systems has maximized health promotion in other health contexts [29], and as the past success of SBM has already shown, there is potential for both substantial and rapid success in improving waste disposal if resources are properly allocated for this task in the second phase of SBM. Clear methods by which SBM can have positive impacts on waste disposal are to have significantly more awareness campaigns; provide communities and individuals with informative educational sessions on how to dispose of and segregate waste; provide access to required dustbins at low costs or no costs to individuals; and ensure that waste disposal facilities are provided and that waste is regularly disposed of in communities by government waste workers. Alongside this, it is critical to ensure that workers involved in the disposal of waste are respected as much as possible and that efforts are made to ensure that they are not stigmatized or discriminated against in society; ideally, measures will be taken to change the community’s attitudes so that these workers receive more overall respect from community members. It is also critical to ensure that SBM is implemented equitably across rural and urban locations across India and that rural locations have adequate financial support in constructing and maintaining latrines and waste disposal safely.

A summary of key findings of this review, as well as implications for future policy development and the ongoing implementation of SBM, is shown in

Table 3. Summary of key findings and recommendations for the continual implementation of SBM.

Key Finding	Implications for Policy
Since 2014, many perceive SBM to be highly successful—particularly with respect to high efficiency and collaboration across different spheres, improving sanitation, improving attitudes and awareness, and in the usage of mass media sources.	There is a clear need to recognize that many actions taken relative to SBM have been highly successful, and these successes should be built upon and be used as a source of guidance.
Participants feel that in order for the awareness of SBM’s aims to continue to be a part of the public’s consciousness, there needs to be even more usage of major media sources.	Usage of mass media sources, particularly television, needs to be expanded and further utilized to realize additional longer-term goals of SBM—such as those pertaining to waste management.
Mindsets that are not focused toward maintaining cleanliness and a lack of awareness regarding why and how cleanliness can be maintained are major barriers.	Awareness campaigns and educational campaigns, whether they are in rural or urban settings and in slum or non-slum settings, need to be implemented and enacted on a very large scale for SBM to be successful. Incentives and even forms of punishment may be considered as additional options when educational/awareness efforts do not suffice, but more research is needed on how to best create change.
A clear problem expressed by many individuals is the lack of proper waste disposal and waste segregation.	Scaling up of waste disposal, along with increasing the awareness of the importance of this, should become an important priority of SBM nationwide. The government should provide access to the required dustbins at low cost or no cost to individuals and ensure that waste disposal facilities are provided and that waste is regularly disposed of in communities by government waste workers. Efforts need to be made to stop stigmatization and discrimination against those who work in waste management and disposal.

. Overall, to summarize this study, the findings indicate numerous implications for policies. First, there is a need to use the past success of SBM as a source of guidance for the future. Secondly, the usage of mass media sources will be vital in the continual expansion of policies with SBM. Third, awareness and education campaigns can have a vital role in increasing public awareness. Lastly, major efforts and resources should be allocated toward adequate waste disposal; this should encompass all forms of waste, and we should also work toward improving services relating to recycling, composting, and ensuring the availability of waste bins. These efforts need to be as diverse and inclusive as possible to most effectively support the large population of Bharat.

The findings and implications of this review need to be considered alongside the limitations. While diverse perspectives from individuals across Bharat were considered in the studies in this review, the extent to which these findings are representative of the views of people across the nation is not clear. Due to factors relating to selection and/or desirability bias, it is plausible that a number of individuals with alternative views may not have chosen to participate in these studies, and this may have skewed the overall findings. We recommend that future reviews also focus on other data pertaining to SBM, such as health outcomes and factors relating to hygiene, in order to ensure that more high-quality studies are included from diverse areas across the nation. Furthermore, this review was limited to an analysis of only nine studies. It is possible that this review may have missed some relevant studies due to our inclusion/exclusion criteria (requiring studies to specifically demonstrate qualitative analyses of knowledge, attitudes, and/or perspectives). However, as per the PRISMA guidelines, two independent reviewers carefully and thoroughly screened all 5454 articles to ensure that as many relevant articles were included. Again, it is possible that, with more studies of differing sample populations, the findings may vary. Another limitation of this review is that all of the studies only included perceptions and perspectives at a single time point. It is plausible that individuals’ views may change over time, and they may be different depending on the time of year. However, this was not adequately accounted for in this review. A third potential limitation of this review was that the studies may have provided pre-formed questions (in focus group discussions and/or interviews) to participants that may not have allowed participants to freely express the extent of their opinions regarding SBM and its successes/shortcomings. Regardless of these limitations, this review provides an important evidence base for policymakers, government workers, non-governmental organizations, and researchers in better understanding the domains in which SBM has and has not been successful, and these findings can have an important role in guiding how SBM can be further developed in a way that expediently improves cleanliness across Bharat.

5. Conclusions

In this review, it was shown that SBM is seen in a highly favorable manner across segments of the population across Bharat—particularly in being able to achieve its goals of raising awareness, overcoming potential institutional barriers, and creating the needed infrastructure. However, along with these observations, this review also highlighted the areas for improvement with respect to the ongoing development of SBM; specifically, there is a need to continually use media sources, raise more awareness about issues relating to cleanliness, change mindsets, and invest significantly more resources in ensuring that waste disposal and waste segregation occurs consistently and smoothly across the nation. These findings need to be considered alongside the inherent limitations of entirely qualitative findings, a lack of representation of populations from all parts of the country, and a relatively low number of participants in some studies. Additional research—both qualitative and quantitative—is required to better understand the perceptions regarding SBM and the ways in which SBM can continually be improved during the implementation process. In summary, SBM has shown massive successes in the past, and if strategies are adequately adopted based on existing evidence, then this success can continue to occur in ongoing years and potentially decades.