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Objectives: To investigate differences in reported open defecation between a question about latrine use or open defecation for every household member and a household-level question., Setting: Rural India is home to most of the world's open defecation. India's Demographic and Health Survey (DHS) 2015-2016 estimates that 54% of households in rural India defecate in the open. This measure is based on a question asking about the behaviour of all household members in one question. Yet, studies in rural India find substantial open defecation among individuals living in households with latrines, suggesting that household-level questions underestimate true open defecation., Participants: In 2018, we randomly assigned latrine-owning households in rural parts of four Indian states to receive one of two survey modules measuring sanitation behaviour. 1215 households were asked about latrine use or open defecation individually for every household member. 1216 households were asked the household-level question used in India's DHS: what type of facility do members of the household usually use?, Results: We compare reported open defecation between households asked the individual-level questions and those asked the household-level question. Using two methods for comparing open defecation by question type, the individual-level question found 20-21 (95% CI 16 to 25 for both estimates) percentage points more open defecation than the household-level question, among all households, and 28-29 (95% CI 22 to 35 for both estimates) percentage points more open defecation among households that received assistance to construct their latrines., Conclusions: We provide the first evidence that individual-level questions find more open defecation than household-level questions. Because reducing open defecation in India is essential to meeting the Sustainable Development Goals, and exposure to open defecation has consequences for child mortality and development, it is essential to accurately monitor its progress., Trial Registration Number: Registry for International Development Impact Evaluations (5b55458ca54d1)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Poor sanitation remains a major public health concern linked to several important health outcomes; emerging evidence indicates a link to childhood stunting. In India over half of the population defecates in the open; the prevalence of stunting remains very high. Recently published data on levels of stunting in 112 districts of India provide an opportunity to explore the relationship between levels of open defecation and stunting within this population. We conducted an ecological regression analysis to assess the association between the prevalence of open defecation and stunting after adjustment for potential confounding factors. Data from the 2011 HUNGaMA survey was used for the outcome of interest, stunting; data from the 2011 Indian Census for the same districts was used for the exposure of interest, open defecation. After adjustment for various potential confounding factors--including socio-economic status, maternal education and calorie availability--a 10 percent increase in open defecation was associated with a 0.7 percentage point increase in both stunting and severe stunting. Differences in open defecation can statistically account for 35 to 55 percent of the average difference in stunting between districts identified as low-performing and high-performing in the HUNGaMA data. In addition, using a Monte Carlo simulation, we explored the effect on statistical power of the common practice of dichotomizing continuous height data into binary stunting indicators. Our simulation showed that dichotomization of height sacrifices statistical power, suggesting that our estimate of the association between open defecation and stunting may be a lower bound. Whilst our analysis is ecological and therefore vulnerable to residual confounding, these findings use the most recently collected large-scale data from India to add to a growing body of suggestive evidence for an effect of poor sanitation on human growth. New intervention studies, currently underway, may shed more light on this important issue.

The UN Sustainable Development Goals call for the elimination of open defecation by 2030. Assessing global progress will require learning from India's sanitation efforts because of its ambitious program of high-profile behavior change messaging to tackle open defecation, and because open defecation is widespread in India. In 2014, the Prime Minister announced a policy called the Swachh Bharat Mission (SBM), which aimed to eliminate open defecation by 2019. However, the 2015-16 National Family Health Survey -4 found that about 55% of rural and 11% of urban Indian households lack a toilet or latrine. To assess the extent of public awareness of the SBM, we use a mobile phone survey to ask about people's knowledge of the existence and purpose of the SBM. We report representative estimates of awareness of the SBM among adults in Delhi (2016), Uttar Pradesh (2016), Mumbai (2016-17), Rajasthan (2016-17), Bihar (2018), Jharkhand (2018), and Maharashtra (2018). While much of the SBM's activities took place in its last two years, we find that, at the time of the survey, no more than one-third of adults in any state are aware that the SBM intends to promote toilet and latrine use. Awareness was particularly low in Uttar Pradesh, where one in eight people who defecates in the open worldwide lives. While the SBM was very active in constructing latrines, the lack of awareness we find suggests that the SBM was less successful in raising the awareness required for large-scale behavior change in promoting latrine use. [ABSTRACT FROM AUTHOR]

Exposure to open defecation has serious consequences for child mortality, health, and human capital development. South Asia has the highest rates of open defecation worldwide, and although the incidence declines as household income rises, differences across South Asian countries are not explained by differences in per capita income. The rate of open defecation in sub-national regions of Bangladesh, India and Nepal is highly correlated with the fraction of the population that identifies as Hindu, in part because certain rituals of purity and pollution discourage having latrines in close proximity to one's home. Almost all open defecation occurs in rural areas, and this paper estimates how much the rate could be reduced if rural households in regions that have a higher fraction of Hindus, where open defecation is still common, altered their behaviour to reflect that of non-Hindu households in regions that are predominantly non-Hindu, where the rate of open defecation is much lower. Using nonparametric reweighting methods, this paper projects that rural open defecation in Bangladesh, India, and Nepal could be reduced to rates of between 6 and 8 per cent, compared to the prevailing level of 65 per cent. [ABSTRACT FROM AUTHOR]

Open defecation, which is still practiced by about a billion people worldwide, is one of the most compelling examples of how place influences health in developing countries. Efforts by governments and development organizations to address the world's remaining open defecation would be greatly supported by a better understanding of why some people adopt latrines and others do not. We analyze the 2005 and 2012 rounds of the India Human Development Survey (IHDS), a nationally representative panel of households in India, the country which is home to 60% of the people worldwide who defecate in the open. Among rural households that defecated in the open in 2005, we investigate what baseline properties and what changes over time are associated with switching to latrine use between 2005 and 2012. We find that households that are richer or better educated, that have certain demographic properties, or that improved their homes over this period were more likely to switch to using a latrine or toilet. However, each of these effect sizes is small; overall switching to latrine use from open defecation is low; and no ready household-level mechanisms are available for sanitation programs to widely influence these factors. Our research adds to a growing consensus in the literature that the social context should not be overlooked when trying to understand and bring about change in sanitation behavior. [ABSTRACT FROM AUTHOR]

The world's remaining open defecation is increasingly concentrated in rural India. The Indian Government's efforts to reduce open defecation by providing subsidies for latrine construction have been largely unsuccessful in addressing the problem. It is now clear that behaviour change must be the priority if progress on ending open defecation is to be made. While community-led strategies have proven effective in various developing country contexts, there are serious reasons to question whether similar methods can work in rural India. Through both quantitative and qualitative analyses, we find that strict social hierarchies that continue to govern daily interactions in rural life today obstruct the spirit of cooperation upon which such methods rely. Additionally, caste-based notions of purity and pollution make the simple latrines used all over the developing world unattractive to rural Indians. In a context where people identify most closely with their caste and religious groups rather than their geographical villages, our findings suggest that a more nuanced understanding of the idea of 'community' is required. More experimentation, both with community-led and other strategies, is needed in order to effectively move from open defecation to latrine use in rural India. [ABSTRACT FROM AUTHOR]

Even compared with neighbouring countries, latrine use is especially uncommon in India. How might caste – historically associated with sanitation inequality – interact with government sanitation policy? Using data from Rajasthan state, we investigate the effect of caste-based reservations for village chairmen elected in 2005 on the likelihood of winning the government’s Clean Village Prize by mid 2012. This prize is a large cash award for villages in which open defecation has been eliminated; thus it is intended to be a prize for both latrine construction and use. Villages randomly assigned to a Scheduled (low-ranking) Caste chairman are less likely to win the prize. [ABSTRACT FROM PUBLISHER]