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 Table of Contents  
Year : 2022  |  Volume : 66  |  Issue : 4  |  Page : 427-433  

Promotion of toilet construction and usage in rural Tamil Nadu: A mixed-methods evaluation study

1 Senior Resident, Department of Community Medicine, Vinayaka Mission's Medical College and Hospital, Karaikal, Tamil Nadu, India
2 Professor, Department of Community Medicine, Panimalar Medical College Hospital and Research Institute, Chennai, Tamil Nadu, India
3 Head, Department of Extension Programmes, Professor in Community Medicine and Medical Education, Pramukhswami Medical College, Karamsad, Gujarat, India

Date of Submission26-Aug-2021
Date of Decision30-Oct-2021
Date of Acceptance05-Nov-2021
Date of Web Publication31-Dec-2022

Correspondence Address:
S Nancy
Department of Community Medicine, Vinayaka Mission's Medical College and Hospital, Karaikal - 609 609
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijph.ijph_1707_21

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Background: Open defecation is the leading cause for malnutrition and diarrhoeal deaths in low- and middle-income countries. The negative public health impacts of open defecation could be neutralized by toilet usage. However, the usage of improved sanitation facilities is unsatisfactory in rural India. Objectives: The study was carried out to find the psycho-social barriers among households for not having toilets and for not using the owned toilets and to develop and find out the effect of Behaviour Change Communication (BCC) strategy on toilet construction and usage. Methods: A community-based Embedded Experimental Mixed Methods study was undertaken in the four field practice villages of Urban Health Training Centre, Villupuram. For baseline and end-line surveys, 422 independent sample households who were not having or not using the toilets were selected by Simple Random Sampling. After IEC clearance, interviews and direct observation of the toilets were undertaken. Context-specific multi-faceted BCC strategy was employed through community participation. The data were analyzed in SPSS software. Chi-square test was used to determine the significance of difference and effect size was calculated to estimate the size of the difference between the baseline and end-line data. Results: Toilet ownership and utilization improved by 21.3% and 23.3% points, respectively. There was a significant reduction in households' perceived psychosocial barriers in toilet adoption. Conclusion: Our intervention demonstrated considerable improvements in both toilet construction and usage surpassing the psycho-social barriers. Future sanitation promotion interventions should focus more on community participation and the key messages should be reinforced multiple times using different channels.

Keywords: Behavior change communication, community participation, construction, toilet, usage

How to cite this article:
Nancy S, Elayaperumal S, Dongre AR. Promotion of toilet construction and usage in rural Tamil Nadu: A mixed-methods evaluation study. Indian J Public Health 2022;66:427-33

How to cite this URL:
Nancy S, Elayaperumal S, Dongre AR. Promotion of toilet construction and usage in rural Tamil Nadu: A mixed-methods evaluation study. Indian J Public Health [serial online] 2022 [cited 2023 Feb 1];66:427-33. Available from:

   Introduction Top

Open Defecation (OD) which is “the disposal of human feces in the fields, forests, bushes, open bodies of water, beaches and other open spaces (pp: 1)”[1] is a well-established traditional practice ingrained from childhood and spread across generations. It is the leading cause for neglected tropical diseases like intestinal worms, schistosomiasis, and trachoma which in turn plays a key role in malnutrition and diarrhoeal deaths in low- and middle-income countries.[2] Despite the negative consequences, 892 million people around the world practice OD.[3] On the other hand, improved sanitation not only bestows health benefits but also maintains water hygiene and provides renewable sources of nutrients from fecal waste.[4] In addition, toilet usage upholds the dignity and status of adolescent girls and women.[4] Hence, the promotion of basic sanitation is one of the key elements of Primary Health Care (PHC).[5] However, in India and Tamil Nadu, only half of the households have access to improved sanitation facilities.[6]

Despite political commitment and provision of subsidies for toilet construction through Total Sanitation Campaign (TSC)[7] and Swachh Bharat Mission (SBM),[8] the improvements in toilet adoption were minimal owing to the lack of community participation and intersectoral coordination.[9] Besides, the levels of toilet utilization were lower than the levels of toilet ownership[10] indicating a dire need to understand the psycho-social facilitators and barriers in toilet utilization. Consequently, this study was planned to find the psycho-social barriers among households for not having toilets and for not using the owned toilets and to develop and find out the effect of Behaviour Change Communication (BCC) strategy on toilet construction and usage.

   Materials and Methods Top

Study setting

The current study was executed in the four field practice villages of Urban Health Training Centre (UHTC), Villupuram, namely, Ayyur Agaram, Pidagam, Kappur, and Anangoor. UHTC caters to the needs of the villagers using community-based PHC services for the past 7 years. In rural areas of Villupuram, more than 50% of households were not using improved sanitation facilities.[6]

Study duration

The study was conducted for 18 months (July 2018 to January 2020).

Study participants

The study included households who lacked a toilet and who did not use the owned toilets. Even if one person in the house was not using a toilet, that household was included in the study.

Study design

It was a community-based Embedded Experimental Mixed Methods study design.[11] The qualitative component (free listing) was sequenced before the main quantitative phase (before and after design) and another qualitative component (Key Informants Interview [KII]) was sequenced after the quantitative phase. Additional qualitative component (KII) was embedded within the main quantitative phase [Visual Diagram 1].

Phase I: (Qual)

Free listing[12] was employed to explore the psycho-social facilitators and barriers in toilet ownership and utilization. About 42 households were selected purposively till the point of saturation. After obtaining verbal consent, a trained Principle Investigator (PI) conducted the free listing exercise addressing the cultural domain. Visual Anthropac software (Analytic Technologies, Inc; Lexington, USA) and scree plot was used to derive the salient items for questionnaire development. The psychological factors were “individual-level processes and meanings that influence mental status (pp: 1).”[13] Socio-cultural factors included “belief and value systems, attitudes, acculturation levels, socialization goals and practices, communication styles, interpersonal relations and experiences, problem solving and stress coping strategies (pp: 2).”[14] While, the structural factors were concerned to “a larger macro-level environment which encompasses leadership, systems, resources and services, policies, guidance and protocols, media and technologies (pp: 1).”[15]

Phase II: (QUAN [qual])

Baseline survey: (QUAN – before and after design)

Sample size and sampling

To begin with, a sampling frame was developed by paying house-to-house visits in all the four study villages with a team consisting of the PI, interns, and medical social workers. The sampling frame consisted of 905 households who had the toilets but did not use it and those who did not have the toilets at the first place.

Considering 50% of the households were not using improved sanitation facilities[6] and 10% improvement in toilet usage after the intervention, a sample of 388 was calculated using Open_Epi software (version 3.01) with 95% confidence interval [CI] and 80% power. Assuming nonresponse in 30–35 houses, the final sample size was 422 households. Then, the households were selected from the sampling frame by Simple Random Sampling without replacement using computer-generated random numbers. From the selected house, the female head of the family was interviewed with the assumption that she would know the reasons for the behavior of her family members.

Tool for data collection

The questionnaire comprised of the sociodemographic profile, details regarding the toilet facility, and usage. The checklist for assessing the toilet infrastructure by direct observation was based on the SBM-Gramin questionnaire[16] and Water Sanitation and Hygiene guidelines.[17] The psycho-social facilitators and barriers in toilet construction and usage were evolved from the free listing findings. The comprehension, acceptability, and language validation were assessed by pretesting the questionnaire with 45 households in Thennamadevi, a field practice village similar to our study villages.

Data collection

After initial rapport development, the survey was conducted in the morning hours and at least three visits were made to increase the coverage. An independent faculty and a medical social worker accompanied the PI. After obtaining informed consent from the respondents, the PI collected the data using a pretested structured questionnaire. Direct observations of the toilets were made to confirm the self-reported toilet ownership as well to observe the toilet infrastructure. The interview and observation lasted for about 10–15 min in each house.

Development of intervention framework: (qual)

In addition to the baseline survey, eight KII (two from each village) were conducted. The informants were purposively selected and their diversity was ensured. The local Panchayat members (n = 2), school teachers (n = 2), Auxiliary Nurse Midwife (n = 1), Anganwadi worker (n = 1) and service providers in SBM (n = 2) were selected. The baseline survey results were shared with the key informants and stakeholders to obtain their solutions/suggestions to improve the toilet construction and utilization. After obtaining informed consent, the PI carried out a semi-structured interview using an interview guide. The interviews were audio-recorded and debriefed at the end. The audio recordings were transcribed in English and thematic analysis was done manually. The key informants' solutions/suggestions were used to plan a context-specific BCC strategy.

Intervention framework

The BCC strategy in this study was based on diffusion of innovation theory[18] to identify the bottlenecks in the program implementation and behavioral issues in the local community and involve the community in making a change in the positive direction. Based on the key informants' solutions/suggestions, context-specific BCC strategies were developed and implemented at the community, group, and household levels for 6 months.

The interventions done at the community level, group level, and household level are described below

Community level

Community-level sensitization activities were conducted to raise mass awareness about the menace of OD. As a first step, we conducted rallies and organized role-plays and folk dances in Grama Sabhas. Besides, sanitation campaigns were conducted in each village in coordination with the key community members and service providers in SBM. The sanitation campaign clarified the doubts of the people regarding the infrastructure and maintenance of the government-subsidized toilets and also served as a platform to apply for the government schemes.

Group level

Group level activities were carried out to facilitate in-depth discussion on the messages derived at the mass level. To engage community participation,[7] we trained the existing community-based groups such as school children and teachers, youth club members, self-help group women, and frontline health workers like Anganwadi and sub-center staffs in mobilization activities. Storytelling activities (narrative communication), drawing competitions, special camps, group discussions, and WhatsApp group messaging were used to sensitize and train the existing community-based groups.

Household level

Household-level activities were undertaken to facilitate one-to-one personalized communication with households who were not having/not using the toilets. In each study village, we distributed brochures to about 15%–20% of target households to address the perceived risks, benefits, and barriers (Health Belief Model)[18] in adopting toilets with the help of volunteers from the youth clubs. The brochure was based on the slogans collected from the key community members and it depicted the harmful effects of OD and the common myths hindering toilet usage. During house-to-house visits, we identified and discussed with the positive deviants[19] who were consistently using toilets despite certain misconceptions prevailing in their community.

Endline survey: (QUAN)

After the intervention, another sample of 422 households was selected from the same sampling frame using the same sampling technique. After obtaining informed consent from the respondents, the same PI undertook the survey using the same questionnaire and direct observation of the toilets was also done.

Data analysis

The data were entered in Epi_Info software (Centre for Disease Control and Prevention; Atlanta, Georgia, US) and analyzed in Statistical Package for the Social Sciences SPSS 24 software (SPSS Inc., Chicago, Illinois, USA). Categorical variables were expressed as frequencies and percentages. The significance of the difference between the baseline and end-line data was determined using Pearsons' Chi-square test. In a 2 × 2 contingency table, if the expected value in any cell was <5, then Fishers' exact test was applied. Effect size (Cramers' V) was calculated to estimate the size of the difference in the toilet ownership and utilization between the baseline and end-line data.

Phase III: (qual)

In addition to the endline survey, eight KII (two from each village) was conducted by the PI to obtain feedback about the intervention. Local Panchayat member (n = 1), school teachers (n = 2), Auxiliary Nurse Midwife (n = 1), Anganwadi workers (n = 2), self-help group leader (n = 1), and service provider in SBM (n = 1) were selected purposively. After obtaining informed consent, semi-structured interviews were conducted. The interviews were note taken and thematic analysis was done.

Ethical issues

We obtained approval from the Research Committee and Institutional Ethics Committee (SMVMCH-EC approval number: 40/2018), Puducherry.

   Results Top

Sociodemographic characteristics of the households before and after intervention

In the present study, about 422 female head of the family were interviewed in the baseline survey and another 422 female head of the family were interviewed in the endline survey. Majority of 382 (90.5%) respondents before the survey and 375 (88.9%) respondents after survey were <60 years old. Nearly half 198 (46.9%) and 183 (43.4%) head of the family were unskilled workers before and after intervention respectively. In the baseline survey, 138 (32.7%) and in the endline survey, 130 (30.8%) head of the family were uneducated. Majority of the households, 417 (98.8%) before the survey and 418 (99.1%) after the survey practiced Hinduism. Almost 299 (70.8%) households preintervention and 290 (68.7%) households postintervention belonged to scheduled castes. About 299 (70.8%) households before intervention and 289 (68.5%) households after intervention hailed from a nuclear family. About 258 (61.1%) households in the baseline survey and 263 (62.3%) households in the endline survey were above the poverty line. There was no statistically significant difference in the households' sociodemographic characteristics in the before and after intervention study sample.

Proportion of toilet ownership and utilization before and after intervention

Before the intervention, about 141 (33.4%; 95% CI; 28.9%–38.1%) households had a toilet, and 33 (23.4%; 95% CI; 16.7%–31.3%) households used the owned toilet. After intervention, almost 231 (54.7%; 95% CI; 49.8%–59.6%) households owned a toilet and 108 (46.8%; 95% CI; 40.2%–53.4%) households used the owned toilet. Notably, 21.3% (95% CI; 14.7%–27.7%) increase in toilet ownership and 23.3% (95% CI; 13.4%–32.3%) increase in toilet usage after intervention was statistically significant (P = 0.001). The effect size (Cramers' V) was 0.21 for toilet ownership and 0.23 for toilet usage which implies a small magnitude of difference.

[Table 1] shows that almost 151 (53.7%) households before intervention and in comparison 72 (37.7%) households after intervention faced problems in availing a government subsidized toilet (x2 = 11.71; df = 1; P = 0.001). Notably, space availability for OD facilitated toilet nonconstruction in eight (2.8%) households in the baseline survey and no household in the endline survey (x2 = 5.43; df = 1; P = 0.020).
Table 1: Status of households' self-reported reasons for not having a toilet before and after intervention (multiple options)

Click here to view

[Table 2] depicts that lack of awareness and exposure hampered toilet usage in eight (7.4%) households before intervention and one (0.8%) household after intervention (x2 = 6.66; df = 1; P = 0.010). About 33 (30.5%) toilets before intervention and 23 (18.7%) toilets after intervention were used for other purposes (x2 = 4.38; df = 1; P = 0.036). Nearly 19 (17.6%) respondents before intervention and in contrast only 10 (8.1%) respondents after intervention reported that toilet usage quickly fills up the pit (x2 = 4.67; df = 1; P = 0.031).
Table 2: Status of households' self-reported reasons for not using the owned toilet before and after intervention (multiple options)

Click here to view

[Table 3] portrays the key informants' solutions/suggestions for the promotion of toilet construction and usage in the study villages. Similar codes were merged to form categories and each category was summarized under three major themes such as psychological barriers, sociocultural barriers, and structural barriers. Key informants' direct quotations (verbatim) were given in italics.
Table 3: Solutions obtained from key informant interview to improve toilet construction and usage in the study villages (n=8)

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   Discussion Top

The present study demonstrated significant improvements of about 21% in toilet ownership and 23% in toilet utilization. A significant reduction in the households who had problems in availing government-subsidized toilets. After the intervention, space availability for OD ceased to be a reason for toilet nonconstruction. In addition, the households who voiced out reasons for toilet nonutilization such as unawareness, toilets used for other purposes, and quick filling of toilet pits were considerably lower in the endline survey.

After 6 months of intervention, there was a considerable increase in the proportion of households owning and using toilets. Notably, studies in India which employed centrally-sponsored TSC interventions[10],[20],[21] and studies outside India which incorporated Nongovernmental Organization-based Community-Led Total Sanitation (CLTS) approaches[22],[23],[24],[25] demonstrated similar outcomes. However, in TSC interventions, levels of toilet utilization were lower than the levels of toilet coverage indicating a need to accelerate community mobilization.[10] While CLTS interventions which used participatory approaches in the absence of subsidies/provisions showed only a minimal improvement in toilet construction in resource-poor settings where building materials were not locally available.[9]

The intervention efficiently addressed the problems in availing government subsidies for toilet construction. Households' unawareness and service providers' nonresponse declined after the intervention. As proposed in KII, the sanitation campaign helped the people to interact with the stakeholders and also provided them an opportunity to apply for government subsidies. Similary, in a community-based randomized trial in Orissa, Village Water and Sanitation Committee (VWSC) consisting of the stakeholders and key community members solved the issues related to government-subsidized toilets.[20]

As a result of our intervention, there was a substantial decline in the structural factors influencing toilet nonconstruction such as space availability for OD. Our community-level sensitization activities helped to change the households' attitude and they considered that toilet possessed various health benefits and it was not just an alternative to OD. Similar to our study findings, in Orissa, an impact evaluation of TSC program which exhibited more thrust on school sanitation along with financial assistance marginally reduced the structural reasons given for toilet nonpossession such as availability of free space for OD.[26]

After intervention, unawareness ceased to be a reason for toilet nonutilization. As suggested in KII, the community-level sensitization activities by the school children and adolescents were used to create awareness about toilet usage. Similarly, a community-based intervention study in Andhra Pradesh created awareness about toilet usage through sensitization activities in the schools and Anganwadis.[27]

Distinctively, a considerable reduction was observed in other purposes of using toilets after the intervention. Interestingly, in many parts of India, concrete toilets without water supplies were converted to storerooms and a place for staking firewoods.[26],[28] The key community members' efforts in solving the issues related to damaged toilets along with sensitization activities assisted in changing the villagers' behavior.

Our intervention reduced the proportion of toilet owners who stated that toilet nonusage was on account of quick filling of toilet pits. The sanitation campaign implemented in coordination with the stakeholders imparted adequate knowledge about the composting nature of the Governments' twin pit toilet. Further, a few villagers who used the wastes from their toilets as manure for their crops (positive deviants) shared their experience in the sanitation campaign. Similarly, a randomized trial in Orissa improved awareness about the infrastructure of toilet pits through mobilization activities by the VWSC.[20]

This community-based intervention study successfully addressed the issue of lack of toilet facility and negligence in toilet usage. Mixed methods were adopted to improve the validity of the questionnaire and outcomes. Besides, before and after study design was feasible to evaluate the effectiveness of our short-term intervention. Nonresponse rate was minimal owing to good rapport development through our existing community-based services in the study villages. Errors due to self-reported toilet ownership were minimized by triangulation in data collection. As the surveys were undertaken by the PI in the supervision of an independent faculty, interviewers' bias was minimal. Nevertheless, being uncontrolled before and after study, biases that were connected with extraneous events such as SBM were unavoidable. Social desirability bias in the self-reported toilet usage would occur despite having a good rapport with the villagers. On account of feasibility, as we relied on the female head of the family for obtaining information regarding the toilet usage of other family members, misclassification bias might occur. Unlike other sanitation intervention studies, the present study did not emphasize on the health outcomes related to toilet usage.

   Conclusion and Recommendations Top

Overall, our context-specific BCC strategy employing a battery of theories at various levels demonstrated considerable improvements in both toilet ownership and utilization surpassing the psycho-social barriers. Future sanitation promotion interventions should emphasize more on the acceptability of the toilets through the participation of all community members and key messages must be reiterated multiple times using different activities. To accelerate the mobilization activities, the frontline health workers involved in SBM and the existing community-based groups should be offered training and monitored periodically. Besides, the sanitation promotion interventions should involve stakeholders, key community members, and positive deviants in the planning and implementation phase.


We acknowledge Dr. Vinayagamoorthy V, Assistant Professor, Department of Community and Family Medicine, All India Institute of Medical Sciences, Deoghar, Jharkhand for lending technical support with his colossal knowledge in the field of Epidemiology and Biostatistics. We express our gratitude to Medical Social Workers, Auxiliary Nurse Midwives, Medical Interns, Nursing College Students, key persons in the villages, and Block Development Officers for rendering their valuable support and cooperation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Agarwal V, Chakraborty I, Banerjee S. Nurturing the rural sanitation in India. Sci Technol Dev 2020;9:130-6.  Back to cited text no. 28


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