Of late, there have been plenty of discussions around the topic of sanitation, which have focussed on building toilets on a massive scale. These are in the aftermath of the new and recently released Millennium Development Goals Report 2014 by the United Nations that shows that India has the world's largest population that defecates out in the open, with it being as high as 66% in rural India [1].
This, despite efforts to achieve universal sanitation coverage since 1986 through constructing toilets under government schemes such as the Central Rural Sanitation Programme, the Total Sanitation Campaign (TSC), and the Nirmal Bharat Abhiyan. However, most of the toilets remain unused [5]. The new NDA government has now launched Swacch Bharat Abhiyan to deal with this problem [12].
But is it enough to just build toilets?
What influences toilet use?
More than the number of toilets, it is the importance of user-friendly designs based on ecological and geographical considerations, quality of construction, periodic maintenance, infrastructure, sewage management systems and availability of water, which have been found to be crucial factors influencing the use of toilets in rural India. But that's not all.
A study conducted by the Research Institute for Compassionate Economics, Uttar Pradesh, from rural households in Bihar, Madhya Pradesh, Uttar Pradesh, Haryana and Rajasthan has made some very surprising and embarrassing revelations. It has found that although 40 percent of the households in these states have a functional toilet, at least one member from the household chooses to defecate out in the open [3, 6].
So why do people with a functional toilet at home still defecate out in the open?
This question, which has left a number of policy makers, planners, researchers and scientists perplexed, finds its answer in experiences gained from certain states in the country.
Behavioural change is key: Findings from qualitative and quantitative studies
Experiences from Sikkim, Haryana and Jharkhand in India and countries such as Bangladesh and Sri Lanka have shown that models of intervention focusing on behavioural changes have been more successful as compared to the supply-based, large scale, target-oriented interventions based on subsidised toilet building [5]. In contrast, recent experiences from Odisha have concluded that exclusive focus on toilet building and toilet numbers did not lead to positive health outcomes as the interventions did not help in changing open defecation and sanitation behaviour of the people [7].
Social dynamics and community must be factored: Findings from qualitative studies
Social norms and expectations have been found to be very important determinants of toilet use among people [8]. These include rules of behaviour that are considered acceptable in a group or society. These aren't formal and many are learned informally whie interacting with others and are passed on from one generation to the next [11]. Qualitative studies have found that:
- Latrines, a luxury: Open defecation is a socially accepted norm and latrines are considered luxury items or expensive assets. Latrine building decisions are rooted in motivations such as prestige and have little to do with concerns regarding health. Thus households that build their own latrines are the ones that come from a higher socio-economic status, are better educated or have a greater awareness of the benefits of latrines. They are likely to build latrines that are more expensive and those that match their preferences [3,4,9].
- Inexpensive localised latrines ignored: Concepts of purity and pollution hinder the use of inexpensive locally suitable latrine models. Household-built latrines are preferred and used as compared to government-built latrines as the latter's pits are smaller making it necessary for latrine pit emptying that people do not prefer due to concepts of purity and pollution. This also hinders the use of inexpensive locally suitable latrine models with more people preferring expensive toilet options [4].
- Age and gender dynamics: Open defecation behaviour is found to vary by age and gender. Villagers prefer open defecation as it allows them to chat together or because it is a time-honoured custom in their community. Open defecation is found to be correlated to age and gender with older men and women more likely to use a latrine while middle aged earning men of the house preferring open defecation. Among men and women, men have been found to show more preference for open defecation as compared to women who are more concerned with privacy issues [3,4,9].
Want change? Understand the importance of social networks!
- Individuals are more likely to own latrines if their social contacts own latrines. This relationship is stronger among those of the same caste, the same education, and those with stronger social ties [9].
- People who are more important or central in the community are most likely to own latrines as they have better exposure to the outside world and it is more likely for their social contacts to build toilets because of social pressures and expectations.
- However, those people who remain at the periphery or those who belong to marginalised communities are many a times not a part of the social networks and are the ones that do not have latrines. Among these individuals, studies show that the correlation between adoption of latrines through social contacts is strongest when the opportunity arises [9].
Latrine building efforts by the government through subsidies have been unsuccessful as they have been unable to address deeper social forces such as caste-based social divides that influence the adoption of toilets. [9]. The studies discussed have added a new dimension to intervention efforts directed at sanitation and have revealed the intricacies in decision making patterns at the community level that influence not only taking up, but the using of of toilets. The studies show that:
- Intervention efforts should be directed at communities, and not individuals.
- Caste and class differences do influence people’s decisions to adopt new norms. Many a time, it is important to target individuals at the periphery who, being deprived and marginalised, are at times faster in adopting toilet use due to being influenced by social contacts [9].
- Latrine building needs to be an accepted norm within a community rather than a matter of individual preference. For this, norms already prevalent in the community need to be overcome through extensive health education and communication, involving the community and through gradually introducing new norms [9].
This is a gradual process, though. As new norms begin to become entrenched in a community, there comes a tipping point, or a point at which a high enough proportion of the population has adopted the new process, after which it spreads rapidly and gradually uproots the earlier norm [9].
Interventions directed at sanitation must take into consideration the complex social processes that influence toilet acceptance in a community and move away from the blanket, supply-based target-oriented strategies that yield no results in the long run. Experience has shown that localised, community-based efforts that involve and take into consideration all sections of the community, bring about a gradual change in the health behaviour of people through convincing of the community and aiding them to make their own decisions.
Lead image source: Sourabh Phadke in CONRADIN, K., KROPAC, M., SPUHLER, D. (Eds.) (2010): The SSWM Toolbox. Basel: seecon international gmbh. URL: http://www.sswm.info
References
1. United Nations (2014) The Millenium Development Goals Report. Downloaded from the site on the 12th of September 2014.
2. Brocklehurst, Clarissa (2014) Scaling up rural sanitation in India. PLOS Medicine, 11(8). Downloaded from the website on 12th September 2014
3. Diane Coffey, Aashish Gupta, Payal Hathi, Nidhi Khurana, Dean Spears, Nikhil Srivastav, and Sangita Vyas (2014) Sanitation quality, use, access and trends. SQUAT Working paper No 1. Downloaded from the website: on the 10th of September 2014
4. Diane Coffey, Aashish Gupta, Payal Hathi, Nidhi Khurana, Dean Spears, Nikhil Srivastav, and Sangita Vyas (2014) Revealed preference for open defecation: Evidence from a new survey in rural north India. Economic and Political Weekly, Vol XLIX, (38). (Copy accessed from the author).
5. Jeetendra, Gupta, Alok, Bera, Sayantan (2014) Mission possible. Down To Earth. Downloaded from the site on the 11th of September 2014.
6. Pandey, Kundan (2014) Despite having toilets at home, many in rural India choose to defecate in open. Down To Earth. Downloaded from the website on the 11th of September 2014.
7. Clasen, Thomas et al (2014) Effectiveness of a rural sanitation programme on diarrhoea, soil transmitted helminth infection and child malnutrition in Odisha, India: A cluster randomised trial. The Lancet, Downloaded from the site on the 24th of September 2014.
8. O'Reilly Kathleen, Louis Elizabeth (2014) The toilet tripod: Understanding successful sanitation in rural India. Health and Place 29 (2014) 43-51. Downloaded from the site on the 11th of September 2014
9. Shakya, Holly B., Christakis, Nicholas A., Fowler, James H. (2014) Social network predictors of latrine ownership. Social Science and Medicine xxx (2014) 1-10. (Copy accessed from the author).
10. Shakya, Holly B., Christakis, Nicholas A., Fowler, James H. (2014) Association Between Social Network Communities and Health Behavior: An Observational Sociocentric Network Study of Latrine Ownership in Rural India. American Journal of Public Health, 104(5). (Copy accessed from the author).
11. Sociology guide (2014) Social norms. Downloaded from the website on the 11th of October 2014.
12. Mukane Pratik (2014) Swachh Bharat Abhiyan: Clean India is responsibility of all 1.25 billion Indians, says PM Narendra Modi. DNA. Downloaded from the website on the 11th of October 2014.