| Abstract|| |
Introduction: India is facing a challenge in controlling open-air defecation (OAD). There are various sociocultural and behavioral factors that influenced the practice. Objective: To study the attitude, behavior, and practice associated with OAD among individuals in Samayapuram area, Trichy district, Tamil Nadu. Methodology: This was a qualitative study done during August 2016. The topic guide comprised questions about OAD and latrines. Focus group discussions (FGDs) and in-depth interviews (IDIs) were conducted among various groups and individuals. Results: The study population comprised people of different age groups and gender residing in Samayapuram, Trichy District, Tamil Nadu. Five FGDs were conducted among field workers, adult males, adult females, and school children (both males and females). Ten IDIs were conducted among school children, adults, the elderly, a medical officer, an executive officer, a sanitary inspector, and a sanitary worker. The study showed that people prefer OAD over latrine for the following reasons: economical, habit, comfort, space constraints, opportunity to be combined with walking, smoking and chatting with friends, ventilation, and easy accessibility. They did not prefer community latrines for maintenance constraints such as water scarcity, cleanliness, and distance. Conclusion: The issue of OAD can be addressed only by strong and continuous motivation of individuals and groups. Any intervention to reduce OAD should aim at exploring the unique beliefs, culture, common factors, etc., for it to be effective. The intervention should be highly multidimensional with a special focus on behavior, engineering, and legislation.
Keywords: Beliefs, community latrine, latrine use, open-air defecation, practices
|How to cite this article:|
Britto R, Arputham S C, Monika S, Meena R, Neevetha R, Dheekshana S, Deepa A, Veerakumar A M, George N. Open-air defecation: A qualitative approach. Ann Trop Med Public Health 2018;11:119-24
|How to cite this URL:|
Britto R, Arputham S C, Monika S, Meena R, Neevetha R, Dheekshana S, Deepa A, Veerakumar A M, George N. Open-air defecation: A qualitative approach. Ann Trop Med Public Health [serial online] 2018 [cited 2021 Feb 28];11:119-24. Available from: https://www.atmph.org/text.asp?2018/11/4/119/272559
| Introduction|| |
India is one of the fastest developing nations in terms of technology and industrial growth as per the economic survey on 2016–2017, the Indian Economy should grow by 6.75%–7.5%. As per the Economic Survey 2015–2016, the expenditure by the government (Central and state governments combined) on health as percentage of GDP was 1.3%. According to the Total Sanitation Campaign conducted in 2011, latrine coverage and sanitation performance, the Government of India claimed that coverage was 68%. However, recent census data revealed that real coverage was only 31%. This means that <1 in five toilets were reportedly constructed is in actual place.
Although the country is flourishing in all aspects of health such as health tourism, the primary area of concern which requires immediate reform is open-air defecation (OAD), which has been a challenge over the past few decades in all parts of the country, especially the villages. This problem has caused enormous health and economic consequences to the country. The economic impact of inadequate sanitation is about Rs. 2.4 trillion or 6.4 percent of India's gross domestic product. The progress of the country is both directly and indirectly affected by this behavior. Out of world's estimated 7 billion people, only 4.5 billion people have access to working latrines and about 1 billion people practice OAD. The WHO and UNICEF estimates that there are more than 620 million people practicing OAD in India, that is, over 62% of the world's population who practice OAD. Rest of the world has been steadily improving sanitation and eliminating the practice of OAD, whereas in India, it still remains high.
OAD is the practice of people defecating outside and not into a designated toilet. OAD has dire consequences on both human and the environment. People who defecate in the open in India excrete close to 65,000 tonnes of feces into the environment each day. Although only a part of the population pollutes the environment, even the people who use latrines and practice proper sanitation measures are exposed to the contaminating effects of it. OAD spreads various diarrheal and respiratory diseases, worm infections, causes stunting, and affects the cognitive development. Some of the consequences of this practice is reflected in the recent report of the National Family Health Survey-4, 2015–2016, 35.7% children under 5 years of age are underweight and 38.4% are stunted. India reports the highest number of under-five diarrheal deaths worldwide. The practice of OAD also poses a great risk to the dignity of the people, especially women who are exposed to the danger of physical attacks. Women feel constrained to relieve themselves only under the cover of dark for reasons of privacy to protect their dignity.
Realizing the economic and health impact on the country, the Government of India recognized the need of the people and started providing facilities for community and household latrine constructions. Providing latrine access without promoting latrine usage is unlikely to reduce OAD. Various studies were conducted across the country which concluded that there are significant social, cultural, and behavioral barriers for using latrines. India being a diverse cultural country, this gap between the knowledge and practice of latrine use could be studied better by an exploratory method. Out of 4600 houses in Samayapuram, Trichy District, Tamil Nadu, 3200 houses are provided with latrines while the remaining populations are provided with community latrines. There are around 20 community latrines in Samayapuram. To reveal the behavior and practice associated with the practice of OAD, a qualitative study was conducted in one of the OAD prevalent areas of Samayapuram, Trichy District.
To study the attitude, behavior, and practice associated with OAD among individuals in Samayapuram area, Trichy district, Tamil Nadu.
| Methodology|| |
The study population comprised people of different age groups and gender residing in Samayapuram, Trichy District, South India. It was framed on the basis of a qualitative research model. It was conducted during August 2016. The data collection methods used were focus group discussions (FGDs) and in-depth interviews (IDIs). A focus group is an organized discussion, though structured in a flexible way, of between 6 and 12 participants. It usually lasts 1 or 2 h and provides the opportunity for all the respondents to participate and to give their opinions. The IDI is a qualitative method of analysis, which proceeds as a confidential and secure conversation between an interviewer and a respondent. FGDs and IDIs were conducted using a topic guide [Table 1].
|Table 1: Topic guide for focus group discussions and in-depth interviews|
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Five FGDs were conducted among field workers, adult males, adult females, and school children (both males and females). FGDs with field workers and adults were conducted in an urban health center and FGDs among school children were conducted in Government school, Samayapuram. All the FGDs were conducted in the local language Tamil and written informed consent was obtained before the discussion. Each FGD was recorded electronically and the key points during the interview were noted. Each FGD took an average time of 15 min. A sociogram was plotted to ensure equal participation of interviewees. The focus groups were more or less homogenous, to create a nonthreatening environment so that the participants were free to speak openly and give honest opinions. Participants were encouraged to not only express their own opinions but also to respond to the others comments and questions posed by the moderator.
Ten IDIs were conducted among school children, adults, the elderly, a medical officer, an executive officer, a sanitary inspector, and a sanitary worker. Written informed consent was obtained before each interview and the interview was recorded electronically and key points noted. Each interview took an average time of 10 min. The interviews were mainly focused on open-ended questions and were broadly divided into questions that pertained to the practice of OAD and latrine usage among the study population. All FGDs and IDIs were dually recorded. Handwritten notes also were taken along with audio recording to identify key concerns and themes for categorization. The data were analyzed using a thematic “Framework Approach.” The data obtained were coded and grouped into broad themes and subthemes.
| Results|| |
From the survey conducted in one of the OAD prevalent areas, the data obtained by an inductive approach is categorized into the following framework as represented in [Figure 1].
Majority of the study population had told that the practice of defecating in the open is habitual, more comfortable and could be combined with walking. It has been the preferred practice for emergency usage due to easy accessibility because of inadequate latrine facility. A few of them revealed that people were forced to practice OAD due to economical issues such as latrine construction and maintenance.
A field worker stated that, “People prefer going with company for OAD as it gives a chance for small talks and chatting.”
A male participant stated that, “People who are habituated to smoking as an inducer for defecation can do it in the open air.”
A female elderly participant told that, “It feels oppressed inside a confined latrine but OAD gives free space and ventilation.”
Almost every participant of the interview had put forth that pollution of the environment and the transmissions of contagious diseases were the first disadvantage of OAD.
Some of the school children stated that, “OAD produces fly nuisance in the area leading to the transmission of many foodborne diseases.”
A female child revealed, “We even experienced the unpleasant odor produced by OAD.”
The executive officer and field workers, particularly mentioned that, “OAD is not safe for the people and their safety is not guaranteed, especially among the females who may be physically attacked or harassed.”
Majority of the study population had proposed that the main benefit of using a latrine is that it controls the spread of many diseases.
The sanitary inspector stated that, “It is a way of proper disposal of feces.”
The medical officer stated that, “People feel comfortable if latrines are close to their house.”
Other benefits which stated by the study population were as follows: latrine use is safe and hygienic, it is helpful during emergency-like household latrines, and environmental cleanliness is achieved.
Space constraints for latrine construction, water supply issues, maintenance issues, and economic issues were the main complaints by most of the participants.
A school child mentioned that, “It is dark and sweating inside a latrine.”
A fieldworker stated that, “Many persons are unable to use the latrine at the same time, especially in overcrowded houses and community latrines.”
Other drawbacks stated were being slippery, especially for the elderly and there is always a need to empty septic tanks.
Availability of latrines
Majority of the participants had revealed that more than 50% of houses are provided with latrines and study area being a semi-urban area, the availability of latrines is comparatively high. There are around 20–22 community latrines available in the area, that is, about 1 community latrine for every 200 houses present.
Majority of the people who went for OAD are either below 10 years or above 60 years.
Executive officer and school children had stated that, “Males practice OAD more commonly than females.”
The sanitary inspector mentioned that, “The floating population such as vendors, pilgrims, and beggars defecate more in the open when compared to the normal residents of this study area.”
The most preferred places for OAD are fields, riversides, bushy areas, roadsides, deserted and secluded buildings, bus stands, etc.
“Roadsides are preferred during cultivation season,” said the executive officer. Women preferred deserted and darker areas for OAD due to fear of physical attacks.
Timings preferred by people for OAD were before sunrise and after sunset. They prefer going in the dark for privacy reasons.
Many women preferred to go after completing their household chore and sending their children to school.
Preference for open-air defecation over community latrines
Despite the government and private (pay and use types) community latrines made available for the people, OAD is preferred over these latrines because of the following reasons: water supply issues, maintenance issues, and lack of cleanliness. Some people were hesitant to use latrines used by others.
An elderly female participant said that, “I once developed constipation after using a common latrine.”
Other reasons are community latrines produces unpleasant odor and cleaning was done only fortnightly.
Suggestion of preventive measures
The following preventive measures were suggested by the study population:
Creating more awareness
Majority of the study population were aware of the ill effects of OAD, but the practice is less due to lack of motivation. They suggested that OAD can be prevented only by continued education about the health and economic impact.
The executive officer said that, “OAD is a major and continuing problem in our country in spite of all the sanitary measures provided by the government, it is the social responsibility of each and every citizen of the country to keep his environment clean. This could be achieved only by continued house-to-house education and motivation.” He also proposed that, “Resolutions regarding latrine usage can be taken by school children and in religious places.”
Many have suggested that OAD can be eliminated completely only by penalties and punishments.
“As many countries followed this method to eradicate OAD and achieved the same in a short period if this is followed in our country, it is possible to eliminate the problem,” said the participants.
Some field workers also suggested that latrine usage can be rewarded to encourage the practice.
Most people stated that, “Space constraints are the main problem and some people are forced to defecate in the open, this need should be fulfilled by the government.”
Many suggested constructing more community latrines with proper maintenance, adequate water, and electricity supply.
Some school children came with ideas of changing the wastelands, clearing the bushes, and other deserted places used for OAD into agricultural fields, parks for walking or playing, or even building latrine.
| Discussion|| |
We call a country developed not only on the basis of its industrial, economic, scientific, and cultural advances but also the health and hygiene of its citizens. In that aspect, the developing countries are far behind. For instance, they are still fighting infectious, social, and preventive diseases which developed countries have already overcome. From what we hear and see, it is evident that OAD contributes more to the development of infectious diseases. Although the government is providing financial aid to construct latrines and taking active measures to impart awareness and promote latrine culture, OAD and its ill effects are still prevalent in the rural and suburban parts of India. More than half of the people who defecate in the open are in India. Even the holy places are not exempted. For instance, Samayapuram is a well-known and important pilgrimage center drawing mass number of pilgrims annually is very unclean mostly because of OAD.
In our study, we found many favoring reasons for OAD practice such as the political apathy for not providing latrine facilities, unfinished infrastructure of available latrines, and on the other hand, the social, economic, cultural, and behavioral factors associated with OAD. Even after various studies and the various measures taken by the government like the recent SWACHH BHARAT MISSION to eradicate this perennial problem, the menace is still prevailing in India. We inferred from our study that, though for various reasons they still follow OAD, people seemed to be aware of and accept the benefits of closed latrine and may go for it if they are properly motivated and guided.
The practice of OAD is present not only in India but also other developing and underdeveloped nations of the world. The top 10 countries with high rate of OAD are mostly African, South-Asian and South-American nations. Several studies were done in these countries as a measure to eradicate the problem. One of the studies done in Ghana, Africa where only <10% of the population were using improved sanitary latrines revealed that there are socioeconomic and cultural factors that promote open defecation. Some of the factors were indiscipline, poverty (cannot afford to construct improved facilities because they are poor), laws enjoining landlords to provide sanitation not being enforced, a belief that visiting a public latrine would cause one to be possessed by demons or lose one's magical powers, the notion that OAD fertilizes the soil and is costless and the people wanting to protect their bodies from the bad odor from latrines.
According to the participants in our study, poverty (i.e., the inability to afford a latrine) was not a major problem; rather people practice OAD in Samayapuram due to its advantages such as comfort, easy access for emergency usage, as a place for small talks and chatting with friends, and preferred by some people who are habituated to use smoking as an inducer for defecation.
Another exploratory study done in rural Odisha, India, about the sociocultural factors and behavioral factors constraining latrine adoption revealed that latrine use was neglected mainly due to the unfinished latrines subsidized by the government. Other factors which hindered latrine adoption were habits, socializing, sanitation rituals and daily routines varying with caste, gender, marital status, and lifestyle. It was also observed that some head males had interests in constructing latrines for their daughter-in-laws considering their privacy and security.
Community latrines were neglected mainly due to its maintenance issues. Furthermore, most of the people hesitate to use a community latrine as they do not like using the same facility which is being used by many others. Some of them also revealed that there are inadequate lighting and ventilation inside the latrine. Furthermore, the slippery nature of the latrine was a major concern for the elderly people. People who lived in overcrowded houses felt that single latrine was not adequate for the members which led to OAD.
Another survey was designed named Sanitation, Quality, Use, and Trend to represent open defecation challenge in rural North India about the preferences for OAD, among the states of Bihar, Haryana, Madhya Pradesh, Rajasthan, and Uttar Pradesh. The survey predicted that if the government were to build a latrine for every rural household that lacked one, without changing sanitation preferences, the sample of people in the above states would nevertheless defecate in the open. The respondents of that study had said that defecating in the open provided them with an opportunity to take a morning walk, visit their fields, and take in fresh air; many of them regard open defecation as part of wholesome, healthy, and virtuous life. According to our study, even though the people of Samayapuram find OAD comfortable and convenient, they were well aware of the ill effects of OAD such as spreading diseases and environment pollution. The study population listed out the people who practice open defecation were more commonly children <1 years and elders above 60 years. Other persons who prefer OAD were the floating population such as pilgrims, vendors, and beggars. The most preferred time for OAD was before sunrise and after sunset during the darker hours for privacy. Preferred places for OAD were fields, riversides, bushy areas, roadsides, deserted and secluded buildings, bus stands, etc.
The most common preventive measure suggested by the study population was to conduct house-to-house awareness. Many people suggested legislative measures such as penalties for OAD and rewards for latrine usage. Engineering measures suggested by the participants were to increase the availability of latrines and provide space for construction with proper maintenance of community latrines. Some suggested clearing the OAD areas and converting them into agricultural field, parks, building community latrines or fencing them to avoid using it for OAD. We inferred from this study that by taking into consideration the preferences as mentioned by the people and the preventive measures they have suggested, by giving continuous motivation and education about the benefits of latrine usage and ill effects caused by OAD, and by providing the necessary amenities by the government and NGOs and making sure that it reaches the people, OAD can possibly be eliminated from the area.
| Conclusion|| |
People have different beliefs and different culture. People defecate openly due to lack of motivation affected with various factors. However, these factors are common with geography, socioeconomic status, etc., Any intervention to reduce OAD should aim at exploring those unique beliefs, culture, common factors, etc., for it to be effective. The intervention should be highly multidimensional with a special focus on behavior, engineering, and legislation.
We would recommend the government to undertake legislative measures such as penalties/punishments for defecating in the open and reward incentives for using of latrines. The promotion of Pay and Use type latrines will be appropriate in this area along with proper measures for its maintenance. Furthermore, it will be advisable to clear waste lands used for OAD and making them into religious places, agricultural fields, parks, playing area, and community latrines. Health education and motivation sessions should be conducted from the part of government about the ill effects of OAD and to promote latrine use and maintenance. Existing community latrines have to be properly maintained with natural lighting and enough space and also should make it more approachable with various means. Field-level workers will have to actively engage to motivate the people against OAD and promotion of latrines either in community or their homes.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Rock Britto
Department of Community Medicine, Chennai Medical College Hospital and Research Centre, Irungalur, Trichy - 621 105, Tamil Nadu
Source of Support: None, Conflict of Interest: None