Prevalence of open defecation among households with toilets and associated factors in rural south India: an analytical cross-sectional study

Background: India's National Sanitation Mission aims to end open defecation by changing social norms and behaviours coupled with financial subsidies to build toilets. An earlier evaluation in the rural Dharmapuri district of Tamil Nadu reported poor use of household toilets constructed with government assistance. Our objectives were to estimate the prevalence of adults with a household toilet practicing open defecation and determine the factors associated with it. Methods: We conducted a cross-sectional survey in 251 villages of the Dharmapuri district. We randomly selected households with toilets from the government register. We interviewed one adult member per household. We used multiple Logistic regression to determine factors associated with open defecation. Results: Of the 493 respondents, 270 (54.8% [95% confidence interval 50.2 to 59.2]) practiced open defecation despite having a household toilet. Inadequate design and incompletely constructed toilets, poor accessibility and availability of water, preference for open defecation, personal beliefs, sociocultural behaviours, family dynamics and Lack of recognizing the health benefits of toilet use were significantly associated with open defecation. Exposure to government propaganda promoting safe sanitation practices was associated with toilet use. Conclusions: Open defecation is common despite the presence of household toilets in the Dharmapuri district of Tamil Nadu. Toilet use is influenced by several structural and sociocultural determinants. The mission needs to shift its emphasis from toilet construction to sustainable functioning and use of toilets.