IMPROVING TOILET USAGE AND HANDWASHING
Sanitation is key to good health – and a critical issue in India, where more than a quarter of the population do not use an indoor toilet. Despite governmental campaigns to build toilets and discourage open defecation, the practice persists. It’s clear that simply providing a service is not sufficient to change people’s behavior.
When we investigated the problem, we found that people were kept from using toilets by a combination of misconceptions, cultural norms, and visceral reactions. They didn’t understand the connection between open defecation and the spread of disease, and saw no reason to be ashamed of a practice
that had been going on for thousands of years. Many people were uncertain how to use an indoor toilet, or worried that it wasn’t safe for children. And disgust at the dirt and smell of uncleaned toilets was a strong deterrent to their use.
With these insights we were able to pilot a range of simple interventions in schools, households, and the wider community, each tailored to a particular set of concerns. It’s a story of how design can encourage behavior change by responding to people’s deep-seated feelings and beliefs.
USAID & Arghyam
In one of the many schoolyards that dot the villages of Davanagere district in Karnataka state, in India, a brick latrine stands abandoned. The paint has chipped off the walls and the handle has rusted. This latrine is one of 90 million across India that were built in 2011 under a project spearheaded by the Ministry of Drinking Water and Sanitation. These toilets, intended to serve about 70% of the country’s households, were part of an effort to improve sanitation and hygiene. Since children who are sick miss school, and a lack of private bathrooms in schools prevents menstruating girls from attending classes, the ultimate goal of the project was to improve education and help alleviate poverty and hunger.
No simple solutions
But the unused schoolyard toilet is emblematic of an ongoing problem. Despite this large-scale government intervention to improve sanitation, more than one-third of India’s rural population continue to defecate in the open, according to the World Health Organization and UNICEF. When flies and other insects transport fecal particles to food and water supplies, children are vulnerable to diarrhea and other diseases that can cause malnutrition, stunted growth, and even starvation. In India, such illnesses are responsible for more child deaths than measles, malaria, and AIDS combined.
Disease caused by poor sanitary habits are responsible for more child deaths than measles, malaria and AIDS combined.
While flush toilets have been around for several centuries, WHO and UNICEF report that 670 million people globally still practice open defecation – around 340 million of them in India, where the practice has long been a normal and even lauded behavior in many communities. It’s not a lack of sewers, pipes, or pit toilets that is responsible for poor sanitary conditions, but rather the beliefs and feelings that hinder people from using them.
In 2013, Arghyam, a non-profit organization, hired Final Mile to investigate the reasons why rural folk don’t use toilets and develop behavioral, economic, and social strategies that might encourage greater use. We began our research in rural areas, where the habit of open defecation seems most ingrained. We interviewed men, women, and children in 17 villages in Davanagere district to understand their behaviors and beliefs around using toilets versus open defecation.
We learned that families that built toilets had often done so through peer pressure – or simply as a way to access government subsidies for the construction. But they often had no intention of using them, and many household toilets simply served as storage rooms. Where they were used, we found that it was typically only by women, who believed that an in-home toilet offered more privacy and safety than the open air. Even so, many women admitted to sometimes defecating outdoors in order to socialize with other women in the community. Men and children, meanwhile, didn’t see privacy and safety as important concerns for themselves, and therefore continued to defecate outdoors. Similarly, when we visited schools to learn about the government-sanctioned toilets, we observed that many went unused or were found not to be functioning for lack of adequate maintenance.
People will accept government subsidies to build a toilet at home – but making use of it is not a priority
Mapping the range of emotional responses to toilets
Having formed an impression of these behaviors and beliefs, we asked ourselves: why, exactly, is there an aversion to using a toilet in many rural communities? It became clear that for local people, toilets have predominantly negative associations. Most rural toilets channel waste into septic tanks, creating foul odors which arouse feelings of disgust in people, particularly when having to clean the toilet. We also noticed that the toilet rooms are generally dark and cramped, making users feel claustrophobic. A great number of villagers expressed anxieties about not knowing how to use a toilet properly, and about young children falling in. People were also worried about how quickly the septic pit would fill up, how to have it cleaned, and what that would cost. Some preferred only to use in an emergency so that it would cost less in the long term.
At the same time, villagers’ knowledge about the health dangers of open defecation was limited or nonexistent. They felt no embarrassment among themselves about defecating in the open, preferring it over using a private toilet precisely because it was an ingrained part of their culture – and indeed a social experience. Together, all these factors spelled a distinct lack of motivation to change bathroom behaviors.
Following our interviews in Davanagere, we did more observational research across 14 villages in northern Karnataka. We then conducted our scenario-based decision-making game, EthnoLab™, with people in six of these villages, as well as children in three schools, working with our implementing partner Parishudh, an initiative of Infosys Foundation. The goal was to map out in greater detail people’s emotions and mental models around toilet use. Analyzing these enabled us to pinpoint three areas where interventions might effectively change people’s behaviors: making toilet use a social norm, reducing concerns about correct toilet use and maintenance, and addressing the poor design of toilets as well as adding utility to the toilet room.
Changing behaviors from within the community
We experimented with several interventions to address the issues we had observed
To affect social norms, we wanted to educate villagers about the health benefits of toilet use over open defecation. But our research suggested that information coming from outsiders would be less effective than dialogue spurred within the community. So our interventions focused on schools, where breaktimes in the school day were now designated as “toilet breaks”. Signs were posted with a cartoon figure of a toilet to direct children to the bathrooms. Storytelling time included topics that touched on toilet use (for example, that Gandhi had installed a toilet at his home). Finally, children’s homework included an assignment to interview 5-10 adults with set questions that would generate conversation about toilet use. In our experiments, these interventions increased toilet use among children, especially boys.
Next, we turned to managing villagers’ concerns about correct toilet use and maintenance. We painted footprints indicating the right direction to sit on the toilet, and printed and distributed simple manuals explaining how they worked. Since many toilet owners expressed worries about emptying the septic pits when they filled up, we provided stickers to put on each toilet door with the number of a dedicated helpline, and information about the frequency and cost of cleaning a filled pit. We found that these interventions helped calm people’s anxieties, but they did not lead to an increase in toilet use, suggesting that while necessary, they may not be sufficient on their own to change people’s behaviors.
Our final set of interventions aimed to make toilets appear more useful and spur individual commitments to using them, in order to outweigh their negative associations. We did this by offering a catalogue of simple items that villagers could purchase for their own toilets to make them more useful and enhance the look and feel of the space, such as vented windows, mirrors, shelves, plants, decorative stickers, and reading material. The catalogues were circulated at a group meeting to stimulate peer pressure to buy something, and we ensured that the items were promptly supplied. We also installed a water tap or bucket outside the toilets to make them more useful. Following these interventions, we observed that toilet use increased, especially among men, who were more likely to have made the decisions about purchasing items and thus felt more invested in them.
Tackling the problem of urban toilet use
The problem of open defecation is not confined to rural communities, but in urban areas it has not been as extensively studied. In 2015, Final Mile undertook the PUSH project (Promote Urban Sanitation Habits), funded by USAID. We conducted research in several slums in the cities of Delhi and Agra, to compare the rural problem with the urban one, and design interventions to increase community toilet usage.
While people in rural communities tend to have individual household toilets, many urban dwellers rely on toilet blocks known as community toilet complexes (CTCs). Our research covered the entire range of CTC stakeholders, from individual users to infrastructure providers, maintenance contractors, and staff, as well as experts in sanitation and urban planning.
We found that many of the factors that deterred villagers from using toilets applied in urban areas as well, such as visual and olfactory disgust, anxiety, and uncertainty. The disgust factors, heightened in community toilets because the space was shared with other people, led users to believe that CTCs increased rather than reduced the likelihood of disease. There were additional issues at play, such as the CTC being located too far from home to be convenient, or uncertainty about how much time it would take to use a toilet in the morning if there were long lines, especially when some of the stalls were too dirty to be usable. For people in a hurry to prepare breakfast, get to work, or go to school, relieving oneself in an open space instead seemed like a more reliable option.
Interventions to make a habit of using the toilet must be practical – but work on an emotional level
We homed in on four areas to influence behaviors around toilet use in an urban context
First, to address people’s feelings of disgust about CTCs, we had toilet attendants provide disinfectant to people to rinse the toilet as they enter – because people are most concerned about it being clean before they use it – and individual soap bars for handwashing afterward.
Second, to increase people’s feeling of control over their time at the CTC, we put up posters asking them to be patient while waiting outside an occupied stall, and installed mirrors on the outside of doors, and radios, to occupy people’s attention while waiting.
To deal with the fear that it’s risky for children to use toilets, we painted footprints on either side of the squat toilet to show them how to correctly position themselves, and we installed a hand pole next to it to help young users keep their balance.
Our final set of interventions aimed to make toilet use more appealing and habitual. The motivational ideas we tested included distributing lottery tickets for small prizes to people after each use, and giving children colorful handstamps to reward them for using the toilet – and signal to their peers that they had done so. The flipside of these positive measures was to put up posters in areas where open defecation was practiced, portraying it as antisocial, to induce feelings of shame and increase social pressure to use toilets instead.
We tested these interventions in eight settlements in Delhi. Some were more successful than others – the disinfectant and soap bars were particularly effective, and children liked the lottery tickets. While it wasn’t clear whether parents were assuaged by the hand poles to help their children, elderly people reported that they found them very helpful.
Our experience showed us how challenging it can be to break a culturally ingrained habit like open defecation. Merely highlighting its negative health consequences is unpersuasive, and embarrassing people into change is difficult when the community feels no inherent sense of shame around the behavior. Instead, we must take seriously the negative associations of using toilets, and mitigate and compensate for them with interventions that address the most powerful emotions and are designed to induce a lasting change in behavior – a new habit. Early signs of success from our interventions make us hopeful that we are on the right path.