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Sanitation Intervention in Pranti: Is it a Passing Fad or Permanent Behaviour Change?
Ravi Kumar Dhanuka

There is a growing concern worldwide for the need for improved health outcomes through hygienic practices. This is evident in the increased efforts at awareness creation and provision of sanitation facilities by governmental and non-governmental organisations (NGOs). This article examines this growing concern and discusses knowledge, attitudes, and practices (KAP) related to sanitation in Unsar Pranti in Muzaffarpur district, in Bihar. The findings are based on fieldwork done during October–November 2008. An NGO called ADTHI-PLAN has been working on a sanitation project in the village for the past ten years. Hence the study also reflects the impact of an intervention by an external agency.
The villagers had sufficient knowledge of the harmful effects of open defecation and roughly knew of the kinds of diseases caused by human excreta left in the open. Knowledge of how to deal with diarrhoeal diseases, which are closely linked with sanitary and hygienic practices, was generally fair. The villagers also knew that they should cover their food and wash their hands before taking meals and after defecating. The relationship between this knowledge and the person either being educated or who regularly attended the ADTHI-PLAN meetings shows a very high correlation of 0.81. There was little variation in the knowledge level among households across different categories based on social status, income level, etc.
The attitude towards sanitation had been getting positive day by day. All respondents strongly agreed that good sanitation practices had a good impact on health. Availability of toilets was believed to raise one’s social status. No one wanted to marry his or her daughter into a family who lived in a house with no toilet. No one appreciated the practice of going out if a toilet was available in the house: ‘Only shameless people would do that,’ Nazima Khatun said.
The villagers who had domestic toilets were considered to be concerned about health and social status and were seen to have a progressive outlook.
The positive attitude towards sanitation among all the respondents, and awareness of the adverse consequences of open defecation among 67 per cent of the respondents, would prima facie lead one to conclude that the density of toilets in the village is very high, or that it is at least higher than the national average, with a significant percentage of functional toilets. However, the density of toilets in Unsar Pranti is only 37 per cent (less than the national average of 38 per cent). Out of 350 toilets, only 267 toilets are functional. What explains this paradox? The answer to this question requires us to engage with other questions, such as who are the people who use the toilet, how often they use it, and why they use it.
It was difficult, though not impossible, to find all the members of a household using the toilet whenever the need arose. Nevertheless, the frequency of toilet use had been increasing in some of the households. Across the age groups, youths, and across gender, females were the most frequent users. The predominant reasons cited for toilet use were: ‘Using toilets is more hygienic and safe’ and ‘It enhances one’s social status.’
In general, not all members of a household use toilets. In an average-size family of ten, one toilet does not suffice in the morning and leads to overcrowding, delay, and inconvenience. Moreover, many Muslim families prefer separate toilets for males and females. Old people often go out, claiming that they are used to defecating outside and thus indoor toilets do not make much of a difference to them. Fifty-seven per cent of respondents said that it had also been hard for parents to inculcate good sanitation practices in their children. However, members of every respondent household were in the habit of washing hands by ash, soil, or soap after coming out of the latrine.
The next question is why more than one-fourth of the toilets were non-functional. The most important reasons, along with the corresponding percentage of respondents given in brackets, are as follows:
1. Not comfortable with the model (70 per cent)
Out of 350 toilets, approximately 120 were of the eco-san model, built three months ago. The villagers were not very comfortable with the new concept of pouring ash over excreta instead of water. Some owners did not follow the instructions for using this unique model, which had led to the generation of both germs and unpleasant odours. Many were reluctant to use this model because they think that their own toilet might also be affected.
2. Neglect (23 per cent)
The category of respondents who cited or showed evidence of neglect consisted of old people and children. Seventy per cent of the older respondents were not particular about using toilets. It was not that they persisted with their habit of going outdoors, but they did not put much effort into going to a toilet, especially when it was a matter of urination. Part of the reason may also be attributed to the rural lifestyle. Many people leave their homes early in the morning for their farms. Children play naked on the open ground, defecating in any place they wish, being influenced in particular by children who do not have toilets at home and who are thus used to defecating in the open. Female labourers cannot ensure that their children follow hygienic practices as most of the time they are out of the house earning a livelihood.
3. Lack of maintenance (7 per cent) Some village households had built toilets only for their guests. As they themselves did not use the toilets frequently, they had lost the motivation to maintain them. The aforementioned reasons explain why built-in toilets were not being used. But why is the density so low? Why is the desire of villagers to have toilets at home not being manifested in a physical transformation? In spite of considerable awareness, why do poor people not take the initiative to construct toilets? The fieldwork revealed the following major reasons for these state of affairs.
1. Carelessness People knew about the harmful effects of open defecation, but they did not see any immediate repercussions. This time lag between the following of poor sanitation practices and the manifestation of the adverse consequences of this behaviour makes people careless. Here we may offer a simple analogy for understanding this attitude of indifference and complacency. Almost all of us know that smoking is injurious to health, but many of us continue to smoke despite this knowledge.
2. Excessive reliance on external agencies Many poor people did not build toilets because they hoped that an external agency would step in and perform the task for them. One possible reason for this expectation may be that they lacked the expertise to build toilets. Another reason may be lack of funds. The key question, then, is why they did not save money or arrange for funds to construct this facility in their houses.
3. Low priority A simple explanation is that most of the time the poor villagers struggle to provide two square meals a day for their families. Moreover, because they had got on without a toilet for generations, and could still manage without one, sanitation occupied a low position in their list of priorities.
Another factor that should be taken into account is the time when people’s attitude towards sanitation became positive and an examination of how sanitation practices have changed since that point. A timeline analysis showed that toilet availability increased significantly in the period 2000–2008. On further inquiry, ADITHI-PLAN revealed that 175 toilets, that is, half of the number of available toilets, had been built in the past one year. In addition to providing toilets, ADITHI-PLAN had also been holding regular meetings with the villagers to explain the advantages of having this facility at home. This factor is likely to have brought about the positive attitude towards and the widespread knowledge of sanitation that we see today in the village.
This raises other questions. Will this large-scale shift in behaviour be sustainable? Will the toilets that have already been built be maintained without any further interventions? Only the future can tell. Based on my fieldwork and observations, I can only say that once the villagers are sufficiently motivated to use toilets on a regular basis, they will have very little reason for abandoning this habit. Further, a system of social control is emerging in the village. In the village environment, dignity and respect are much sought after, and, as the results of our study show, a significant proportion of people believe that domestic toilets add to their social status. Thus, we can safely hope for the desirable results of sustainable behaviour change and toilet maintenance, at least among some of those who already have this facility. But sanitising the entire village on a permanent basis will remain a major challenge well into the foreseeable future.
The demand for toilets is found to be a function of land availability, income level, and awareness. Those who do not have a toilet cannot build this facility, no matter how much they may desire it, because of lack of space or land. The second important factor is income. For people who struggle to feed themselves, it is very difficult to save money and incur an expenditure of at least Rs. 2,000 to build a toilet. In these cases, they depend on an external agency to fulfil their need. For the rest of the villagers, awareness is the most important demand-driving factor. They will not build a toilet if they do not perceive any benefit from doing so.
An important lesson learnt is that a combination of economic, social, and behaviour change factors affect sanitation behaviour change, and hence working on any one of these factors alone will not work in achieving our goals.
At this point of time, it is difficult to assess the success of the ADITHI-PLAN intervention on all the relevant parameters. The biggest success is that people have started speaking the language of sanitation, but it remains to be seen how much they have internalised it. It is the internalisation of these values that will ensure the desirable result of bringing about and sustaining a long-term change in the attitudes and practices of villagers.