Determinants of Latrine Use Behavior: The Psychosocial Proxies of Individual-Level Defecation Practices in Rural Coastal Ecuador

Velma K. Lopez Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan;

Search for other papers by Velma K. Lopez in
Current site
Google Scholar
PubMed
Close
,
Veronica J. Berrocal Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan;

Search for other papers by Veronica J. Berrocal in
Current site
Google Scholar
PubMed
Close
,
Betty Corozo Angulo Universidad Técnica Luis Vargas Torres de Esmeraldas, Esmeraldas, Ecuador;

Search for other papers by Betty Corozo Angulo in
Current site
Google Scholar
PubMed
Close
,
Pavani K. Ram Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, New York;

Search for other papers by Pavani K. Ram in
Current site
Google Scholar
PubMed
Close
,
James Trostle Department of Anthropology, Trinity College, Hartford, Connecticut

Search for other papers by James Trostle in
Current site
Google Scholar
PubMed
Close
, and
Joseph N. S. Eisenberg Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan;

Search for other papers by Joseph N. S. Eisenberg in
Current site
Google Scholar
PubMed
Close
Restricted access

There is increasing appreciation that latrine access does not imply use—many individuals who own latrines do not consistently use them. Little is known, however, about the determinants of latrine use, particularly among those with variable defecation behaviors. Using the integrated behavior model of water, sanitation, and hygiene framework, we sought to characterize determinants of latrine use in rural Ecuador. We interviewed 197 adults living in three communities with a survey consisting of 70 psychosocial defecation-related questions. Questions were excluded from analysis if responses lacked variability or at least 10% of respondents did not provide a definitive answer. All interviewed individuals had access to a privately owned or shared latrine. We then applied adaptive elastic nets (ENET) and supervised principal component analysis (SPCA) to a reduced dataset of 45 questions among 154 individuals with complete data to select determinants that predict self-reported latrine use. Latrine use was common, but not universal, in the sample (76%). The SPCA model identified six determinants and adaptive ENET selected five determinants. Three indicators were represented in both models—latrine users were more likely to report that their latrine is clean enough to use and also more likely to report daily latrine use; while those reporting that elderly men were not latrine users were less likely to use latrines themselves. Our findings suggest that social norms are important predictors of latrine use, whereas knowledge of the health benefits of sanitation may not be as important. These determinants are informative for promotion of latrine adoption.

Author Notes

Address correspondence to Joseph N. S. Eisenberg, Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI 48109. E-mail: jnse@umich.edu

Authors’ addresses: Velma K. Lopez and Joseph N. S. Eisenberg, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, E-mails: lopezvel@umich.edu and jnse@umich.edu. Veronica J. Berrocal, Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, E-mail: berrocal@umich.edu. Betty Corozo Angulo, Universidad Técnica Luis Vargas Torres de Esmeraldas, Esmeraldas, Ecuador, E-mail: bcorozo@yahoo.es. Pavani K. Ram, Department of Epidemiology and Environmental Health, University at Buffalo, Buffalo, NY, E-mail: pkram@buffalo.edu. James Trostle, Department of Anthropology, Trinity College, Hartford, CT, E-mail: james.trostle@trincoll.edu.

  • 1.

    Bhutta ZA, Das JK, Rizvi A, Gaff MF, Walker N, Horton S, Webb P, Lartey A, Black RE, 2013. Maternal and child nutrition 2: evidence-based interventions for improvement of maternal and child nutrition : what can be done and at what cost ? Lancet 6736: 126.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2.

    Del Carmen Casanovas M, Mangasaryan N, Mwadime R, Hajeebhoy N, Aguilar AM, Kopp C, Rico L, Ibiett G, Andia D, Onyango AW, 2013. Multi-sectoral interventions for healthy growth. Matern Child Nutr 9: 4657.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    Humphrey JH, 2009. Child undernutrition, tropical enteropathy, toilets, and handwashing. Lancet 374: 10321035.

  • 4.

    Wolf J et al. 2014. Systematic review: assessing the impact of drinking water and sanitation on diarrhoeal disease in low- and middle-income settings: systematic review and meta-regression. Trop Med Int Heal 19: 928942.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Pan American Health Organization (PAHO), 2016. Environmental Gradients and Health Inequalities in the Americas Sustainable Development and Health Equity. Available at: http://iris.paho.org/xmlui/bitstream/handle/123456789/31404/9789275119136-eng.pdf?sequence=1&isAllowed=y. Accessed November 14, 2017.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    WHO/UNICEF, Joint Monitoring Programme for Water Supply and Sanitation (JMP). Available at: https://washdata.org/. Accessed November 14, 2017.

  • 7.

    Fuller JA, Villamor E, Cevallos W, Trostle J, Eisenberg JN, 2016. I get height with a little help from my friends: herd protection from sanitation on child growth in rural Ecuador. Int J Epidemiol 45: 460469.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Clasen T et al. 2014. Effectiveness of a rural sanitation programme on diarrhoea, soil-transmitted helminth infection, and child malnutrition in Odisha, India: a cluster-randomised trial. Lancet Glob Heal 2: e645e653.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Patil SR, Arnold BF, Salvatore AL, Briceno B, Ganguly S, Colford JM, Gertler PJ, 2015. The effect of India’s total sanitation campaign on defecation behaviors and child health in rural Madhya Pradesh: a cluster randomized controlled trial. PLoS Med 11: e1001709.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Barnard S, Routray P, Majorin F, Peletz R, Boisson S, Sinha A, Clasen T, 2013. Impact of Indian total sanitation campaign on latrine coverage and use: a cross-sectional study in Orissa three years following programme implementation. PLoS One 8: e71438.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11.

    Rotondo LA, Ngondi J, Rodgers AF, King JD, Kamissoko Y, Amadou A, Jip N, Cromwell EA, Emerson PM, 2009. Evaluation of community intervention with pit latrines for trachoma control in Ghana, Mali, Niger and Nigeria. Int Health 1: 154162.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Burke NJ, Joseph G, Pasick RJ, Barker JC, 2009. Theorizing social context: rethinking behavioral theory. Health Educ Behav 36 (Suppl 5): 55S70S.

  • 13.

    Hulland K, Martin N, Dreibelbis R, DeBruicker Valliant J, Winch P, 2015. What Factors Affect Sustained Adoption of Safe Water, Hygiene and Sanitation Technologies? A Systematic Review of Literature. London, United Kingdom: EPPI-Centre, Social Science Research Unit, UCL Institute of Education, University College London.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Routray P, Schmidt W-P, Boisson S, Clasen T, Jenkins MW, 2015. Socio-cultural and behavioural factors constraining latrine adoption in rural coastal Odisha: an exploratory qualitative study. BMC Public Health 15: 880.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Coffey D, Gupta A, Hathi P, Khurana N, Spears D, Srivastav N, Vyas S, 2014. Revealed preference for open defecation. Econ Political Wkly 49: 4355.

  • 16.

    Dreibelbis R, Jenkins M, Chase RP, Torondel B, Routray P, Boisson S, Clasen T, Freeman MC, 2015. Development of a multidimensional scale to assess attitudinal determinants of sanitation uptake and use. Environ Sci Technol 49: 1361313621.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    United Nations Secretary-General, 2017. Progress Towards the Sustainable Development Goals: Rport E/2017/66. Geneva Switzerland: UN Secretary General.

  • 18.

    Eisenberg JNS et al. 2006. Environmental change and infectious disease: how new roads affect the transmission of diarrheal pathogens in rural Ecuador. Proc Natl Acad Sci U S A 103: 1946019465.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Dreibelbis R, Winch PJ, Leontsini E, Hulland KR, Ram PK, Unicomb L, Luby SP, 2013. The integrated behavioural model for water, sanitation, and hygiene: a systematic review of behavioural models and a framework for designing and evaluating behaviour change interventions in infrastructure-restricted settings. BMC Public Health 13: 1015.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Cialdini RB, Reno RR, Kallgren CA, 1990. A focus theory of normative conduct: recycling the concept of norms to reduce littering in public places. J Pers Soc Psychol 58: 10151026.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Tibshirani R, 1996. Regression selection and shrinkage via the Lasso. J R Stat Soc B 58: 267288.

  • 22.

    Bair E, Hastie T, Paul D, Tibshirani R, 2006. Prediction by supervised principal components. J Am Stat Assoc 101: 119137.

  • 23.

    Zou H, Zhang HH, 2009. On the adaptive elastic-net with a diverging number of parameters. Ann Stat 37: 17331751.

  • 24.

    Lockhart R, Taylor J, Tibshirani RJ, Tibshirani R, 2014. A significance test for the lasso. Ann Stat 42: 413468.

  • 25.

    Wallach D, Goffinet B, 1989. Mean squared error of prediction as a criterion for evaluating and comparing system models. Ecol Modell 44: 299306.

  • 26.

    Jenkins MW, Freeman MC, Routray P, 2014. Measuring the safety of excreta disposal behavior in India with the new safe san index: reliability, validity and utility. Int J Environ Res Public Health 11: 83198346.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Aarts H, Verplanken B, Knippenberg A, 1998. Predicting behavior from actions in the past: repeated decision making or a matter of habit? J Appl Soc Psychol 28: 13551374.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    DiMaggio P, 1997. Culture and cognition. Annu Rev Sociol 23: 263287.

  • 29.

    Bayer JB, Campbell SW, Ling R, 2016. Connection cues: activating the norms and habits of social connectedness. Commun Theory 26: 128149.

  • 30.

    Tumwebaze IK, Orach CG, Niwagaba C, Luthi C, Mosler H-J, 2013. Sanitation facilities in Kampala slums, Uganda: users’ satisfaction and determinant factors. Int J Environ Health Res 23: 191204.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Nelson KB, Karver J, Kullman C, Graham JP, 2014. User perceptions of shared sanitation among rural households in Indonesia and Bangladesh. PLoS One 9: 113.

  • 32.

    Garn JV, Sclar GD, Freeman MC, Penakalapati G, Alexander KT, Brooks P, Rehfuess EA, Boisson S, Medlicott KO, Clasen TF, 2016. The impact of sanitation interventions on latrine coverage and latrine use: systematic review and meta analysis. Int J Hyg Environ Health 220: 329340.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Biran A, Jenkins MW, Dabrase P, Bhagwat I, 2011. Patterns and determinants of communal latrine usage in urban poverty pockets in Bhopal, India. Trop Med Int Heal 16: 854862.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Jenkins MW, Curtis V, 2005. Achieving the ‘good life’: why some people want latrines in rural Benin. Soc Sci Med 61: 24462459.

  • 35.

    Roma E, Buckley C, Jefferson B, Jeffrey P, 2010. Assessing users’ experience of shared sanitation facilities: a case study of community ablution blocks in Durban, South Africa. Water SA 36: 589594.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36.

    Kwiringira J, Atekyereza P, Niwagaba C, Günther I, 2014. Descending the sanitation ladder in urban Uganda: evidence from Kampala slums. BMC Public Health 14: 624.

  • 37.

    Aiemjoy K et al. 2017. Is using a latrine “a strange thing to do”? A mixed-methods study of sanitation preference and behaviors in rural Ethiopia. Am J Trop Med Hyg 96: 6573.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    O’Reilly K, Louiss’ E, 2014. The toilet tripod: understanding successful sanitation in rural India. Heal Place 29: 4351.

  • 39.

    Shakya HB, Christakis NA, Fowler JH, 2015. Social network predictors of latrine ownership. Soc Sci Med 125: 129138.

  • 40.

    Bandura A, 1989. Human agency in social cognitive theory. Am Psychol 44: 11751184.

  • 41.

    Simms VM, Makalo P, Bailey RL, Emerson PM, 2005. Sustainability and acceptability of latrine provision in the Gambia. Trans R Soc Trop Med Hyg 99: 631637.

  • 42.

    Whaley L, Webster J, 2011. The effectiveness and sustainability of two demand-driven sanitation and hygiene approaches in Zimbabwe. J Water Sanit Hyg Dev 1: 2036.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43.

    Ajzen I, 1991. The theory of planned behavior. Organ Behav Hum Decis Process 50: 179211.

  • 44.

    Becker MH, Maiman LA, Kirscht JP, Haefner DP, Drachman RH, 1977. The health belief model and prediction of dietary compliance: a field experiment. J Health Soc Behav 18: 348366.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45.

    Fishbein M, Ajzen I, 1975. Belief, Attitude, Intention, and Behavior: An Introduction to Theory and Research. Reading, MA: Addison-Wesley, 118.

  • 46.

    Janz NK, Becker MH, 1984. The health belief model: a decade later. Health Educ Q 11: 147.

  • 47.

    Kar K, Chambers R, 2008. Handbook on Community-Led Total Sanitation, Vol. 44. London, UK: vis Plan, UK. Available at: http://www.communityledtotalsanitation.org/sites/communityledtotalsanitation.org/files/cltshandbook.pdf. Accessed November 14, 2017.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48.

    Aunger R, Curtis V, 2016. Behaviour centred design: towards an applied science of behaviour change. Health Psychol Rev 10: 425446.

  • 49.

    Schwarz N, 2001. Asking questions about behavior: cognition, communication, and questionnaire construction. Am J Eval 22: 127160.

  • 50.

    Tourangeau R, Yan T, 2007. Sensitive questions in surveys. Psychol Bull 133: 859883.

  • 51.

    Hulland KRS, Chase RP, Caruso BA, Swain R, Biswal B, Sahoo KC, Panigrahi P, Dreibelbis R, 2015. Sanitation, stress, and life stage: a systematic data collection study among women in Odisha, India. PLoS One 10: e0141883.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 52.

    Sahoo KC, Hulland KRS, Caruso BA, Swain R, Freeman MC, Panigrahi P, Dreibelbis R, 2015. Sanitation-related psychosocial stress: a grounded theory study of women across the life-course in Odisha, India. Soc Sci Med 139: 8089.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 53.

    Arnold BF, Khush RS, Ramaswamy P, London AG, Rajkumar P, Ramaprabha P, Durairaj N, Hubbard AE, Balakrishnan K, Colford JM, 2010. Causal inference methods to study nonrandomized, preexisting development interventions. Proc Natl Acad Sci U S A 107: 2260522610.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 54.

    Banda K et al. 2007. Water handling, sanitation and defecation practices in rural southern India: a knowledge, attitudes and practices study. Trans R Soc Trop Med Hyg 101: 11241130.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 55.

    Caruso BA, Freeman MC, Garn JV, Dreibelbis R, Saboori S, Muga R, Rheingans R, 2014. Assessing the impact of a school-based latrine cleaning and handwashing program on pupil absence in Nyanza Province, Kenya: a cluster-randomized trial. Trop Med Int Heal 19: 11851197.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 56.

    Sonego IL, Mosler H-J, 2014. Why are some latrines cleaner than others? Determining the factors of habitual cleaning behaviour and latrine cleanliness in rural Burundi. J Water Sanit Hyg Dev 4: 257267.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 57.

    Tumwebaze IK, Mosler H-J, 2015. Effectiveness of group discussions and commitment in improving cleaning behaviour of shared sanitation users in Kampala, Uganda slums. Soc Sci Med 147: 7279.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 58.

    Kwiringira J, Atekyereza P, Niwagaba C, Günther I, 2014. Gender variations in access, choice to use and cleaning of shared latrines; experiences from Kampala slums, Uganda. BMC Public Health 14: 1180.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 59.

    Kwiringira J, Atekyereza P, Niwagaba C, Kabumbuli R, Rwabukwali C, Kulabako R, Günther I, 2016. Seasonal variations and shared latrine cleaning practices in the slums of Kampala city, Uganda. BMC Public Health 16: 361.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 60.

    Mosler H, Sonego IL, 2017. Improved latrine cleanliness through behaviour change and changes in quality of latrine construction: a longitudinal intervention study in rural Burundi. Int J Environ Health Res 27: 355367.

    • PubMed
    • Search Google Scholar
    • Export Citation
Past two years Past Year Past 30 Days
Abstract Views 132 132 23
Full Text Views 743 38 0
PDF Downloads 398 26 0
 
Membership Banner
 
 
 
Affiliate Membership Banner
 
 
Research for Health Information Banner
 
 
CLOCKSS
 
 
 
Society Publishers Coalition Banner
Save