Conclusion
In a randomized controlled trial that provided latrine upgrades along with initial intensive behavior change promotion, high access to hygienic latrines with a functional water seal and well-contained fecal waste was sustained among intervention recipients up to 3.5 years after intervention initiation. Access was high even after behavior change promotion stopped. Our findings from a setting with existing sanitation norms indicate that latrine quality, once established, can be maintained without ongoing promotion activities. Future studies should investigate strategies to achieve and sustain access to and use of latrines that effectively isolate feces from the environment in settings with different baseline sanitation norms. Despite free provision of potties and sani-scoop tools and messages on safe child feces management included in the behavior change promotion program, adoption of these tools remained low among intervention recipients. Studies should investigate barriers to safe child feces management practices and strategies to ensure their sustained adoption, as well as test the effectiveness of child feces management interventions, alone or combined with broader sanitation improvements, in reducing fecal exposures.