Sewer misconnection: Recommendations for increasing sewer connections in low-income urban communities in Dhaka, Bangladesh.

In Dhaka, Bangladesh, sewer misconnections persist despite sewer infrastructure expansion by the Dhaka Water Supply and Sewerage Authority (DWASA). This mixed-method cross-sectional study aimed to develop targeted, evidence-based interventions to increase sewer connections in urban communities. We surveyed 384 households and conducted 10 in-depth interviews and two focus group discussions across five DWASA zones. Using the Risks, Attitudes, Norms, Abilities, and Self-regulation (RANAS) framework, we identified key psychological factors influencing sewer connection behaviours. Building on these insights, we mapped psychological factors to Behaviour Change Techniques (BCTs) to develop tailored interventions. Households those were not-connected to sewer exhibited significantly lower awareness of sanitation-related health risks, less confidence in navigating connection procedures, and weaker perceptions of the social benefits of sewer linkage. Qualitative findings revealed widespread dissatisfaction with dysfunctional drainage systems, high connection costs, inadequate maintenance support from DWASA, and bureaucratic delays as significant barriers. These results highlight a complex interplay of psychological, financial, and administrative challenges limiting sewer uptake. Based on these insights, we propose a comprehensive intervention package integrating health education to improve risk awareness, community role models to shift social norms, practical technical guidance to simplify connection processes, and income-adjusted financial incentives to ease economic burdens. The study emphasises the urgent need for integrated, multi-sectoral strategies that address behavioural, structural, and economic barriers simultaneously. Implementing these interventions reduces sewer misconnections, an often-overlooked source of environmental contamination and public health risk, and would advance equitable and sustainable sanitation in rapidly urbanising cities like Dhaka.