Introduction

Every year 525,000 children die due to diarrhea out of the 1.7 billion cases of childhood diarrhea worldwide [1]. Poor sanitation is responsible for 10% of the global disease burden, causing diarrheal diseases, neglected tropical diseases, acute respiratory diseases and malnutrition among children [2].

Basic sanitation facilities are accessible to only 68% of the global population [3]. Among 2.3 billion people who lack access to toilets or latrines, 892 million still defecate in the open places [3]. Higher under-five mortality and malnutrition rates are reported in countries which have higher proportions of people practicing open field defecation [3]. Open defecation is also associated with violence against women in the low middle-income countries (LMIC) [4] including rape among women and girls [5].

The United Nations calls for eliminating open defecation by 2025 [6]. Open defecation has been incorporated in the Sustainable Development Goals (SDG) in target 6.2 aiming to “achieve access to adequate and equitable sanitation and hygiene for all and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations by 2030” [7]. There are different approaches to increase the construction of latrines and promote its use around the world. ‘Sanitation marketing’, involves interventions on raising awareness and motivating the households to adopt and use latrines [8]. Community-led total sanitation (CLTS) approach mobilizes the whole community to gain a social status of “open defecation–free” community [9,10]. ‘Community health clubs’ raises awareness through health debates in the communities [11], and ‘Sanitation as a business’ approach mobilizes the local private sector in latrine building and maintenance [12]. School Led Total Sanitation (SLTS) focuses on motivating the communities and students towards behavioral transformation and latrine promotion, building upon the enhanced partnership of school, local level organizations and the community [13].

Among the world’s population who practice open defecation, more than two-thirds (558 million) live in the rural areas of South Asia. With continuous efforts, the proportion of people practicing open defecation in South Asia dropped from 65% in 1990 to 34% in 2018 [14]. Despite the efforts through different approaches, attaining and sustaining the ‘open defecation free’ status has been possible only in less than half of the places globally [15]. The available quantitative data on open defecation provides limited information regarding the motivations for open defecation [14,15]. A qualitative study from Zambia suggests that the preference for defecation practice of either using a latrine or going for open defecation may have deep-rooted cultural influences [16].

Methods

Participant selection

We used a maximum variation sampling method to recruit the participants who practiced open defecation into the study. With preliminary characteristics of gender and presence of latrine at home, a brainstorming was conducted with community volunteers to generate a list of people who practiced open defecation [31]. Public announcement for recruitment was not suggested appropriate by the volunteers. The list was further added with more volunteers upon through recommendation of people by the initial respondents. Based on the list, the respondents were recruited taking into consideration other characteristics in Table 1. We recruited participants until we reached a point where the participant response did not yield any new information. This resulted in a total of 20 respondents, who participated in in-depth interviews (IDI) and 15 respondents participating in two focus group discussions (FGD). All the potential participants were approached including all who agreed to participate in this study.

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Table 1. Socio-demographic characteristics of the respondents.

https://doi.org/10.1371/journal.pone.0219246.t001

Data analysis

The descriptive analysis of the socio-demographic characteristics of the respondents was done as illustrated in Table 1. A framework method [33] of content analysis and systematically organized the research data was used. The steps included transcription, familiarization with the interview, coding, developing a working analytical framework, applying the analytical framework, charting the data into the framework matrix and interpretation of the data. All four interviewers were involved in the transcription of the recorded audio. The session transcripts were translated into English before performing analysis line by line. Preliminary codes were assigned to the available data and using the codes common themes were searched. The research team finalized the themes after review of the preliminary themes forming the analytical framework. During the reporting of findings, the exact translation of the quotes from the participants was used. To ensure the consistency of the data and the findings, two authors were involved in data analysis and reporting. The quoted verbatim was accompanied by the interpretation of the findings in sentences. The interpretation and analysis of the data were completed in a closed group workshop in presence of all members of the team, where the excel sheet containing the coded data was presented on screen and input was received from all the members. The working analytical framework was then finalized and presented as a summary of the motivators for open defecation as presented in Table 2.

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Table 2. Summary of the motivators for open defecation.

https://doi.org/10.1371/journal.pone.0219246.t002

Results

The respondents of the interviews and the focus group discussions were represented based on gender, education, religion, family size, economic status, having a child under-five at home, ownership of a latrine and status as a head of the household. The characteristics of the respondents can be found in Table 1.

The responses from the IDIs and FGDs were grouped into the three themes as motivations for open defecation by choice, motivations for open defecation by compulsion (issues regarding private latrines) and motivations for open defecation by compulsion (issues regarding public latrines). The motivations for open defecation are summarised in Table 2.

Discussion

Defecation practices are associated with cultural and traditional beliefs [34], therefore exploring the reasons for the ongoing open defecation practices are essential. Understanding the motivations for open defecation may help future sanitation campaigns to help promote latrines at a community level. This study identified the motivators for open defecation by choice or by compulsion. People chose open defecation as a mode of socialization, an activity that gave a sense of autonomy, a habit, and a convenient choice. Religious beliefs and hygiene issues were also cited reasons for choosing open defecation. People were compelled to go for open defecation due to not having a latrine at home or having a latrine structure that was used for alternate purposes (e.g. storing grains). Other reasons compelling open defecation are the fear that latrine would get dirty quicker, the latrine is for used only for guests, or on certain occasions or time of the day; and the existing cultural norms of not sharing latrines between male and female members. People with access to public latrines were still compelled to go out for defecation due to the issues related to long queuing, hygiene issues as the public latrines are usually dirty and the cultural norms of latrine sharing restriction between male and female members of the society. Additionally, females also reported that they did not want to be seen by the male members while queuing in public latrines, which compelled them to go out in the open spaces for defecation. The research highlights a prominent gender component related to the practice of open defecation. The propriety still dictates that women and girls are still not considered of their opinion or needs for sanitary practices. Women and girls are compelled to go for open defecation either due to the absence of a latrine at home or they are not allowed to use the latrine at home as it to be used by the male members of the family. Women and girls also fear harassment or have privacy issues of being seen by the men from the community both during public latrine use and on the way to open defecation.

Concurring with the findings of our study, findings from India show that people who choose open defecation do so because they find open defecation to be more convenient, enjoyable [25] and healthy due to the long walks [35]. Furthermore, the same study from India reports that open defecation provides them with an opportunity for healthy habits of walking and socializing [25]. Open defecation is a good excuse for new brides to go out of the house and socialize with women in Uttar Pradesh, India [5]. It is likely for women and socially vulnerable men [36] to go for defecation in groups which helps them socialize and provides a sense of security from violence [5]. While our study reported a preference to men for using toilets at home while women were compelled to go outside, a study in India reports vice-versa phenomena where men prefer to go out for defecation. Some women consider open defecation as a medium for socialization, while men associate going out for defecation with their masculinity and they prefer that the women, children and the sick to use the toilet at home [5,35]. This clearly calls for researchers and policymakers to consider that open defecation has more personal and cultural aspects to it, which needs serious considerations during sanitation campaigns.

Personal and family/societal beliefs are reported to drive open defecation practices [34]. A report in 2017 presents similar factors as barriers for the use of latrine in Nepal [37]. The participants chose to defecate as far away from their house as possible in this study citing hygiene, religious and spiritual reasons. Some people were highly driven by religious beliefs for their open defecation behavior. However, religion was not mentioned as a reason for motivating open defecation in a similar setting in India [5]. A study from India also suggests people with social norms and beliefs rooted in purity and pollution prefer to defecate far away from home instead of having a latrine nearby their house [38]. A study from rural Odisha, India which has similar socio-cultural context with rural Nepal reports that, the women perceive open defecation as a way of disposing excreta away from home in order to minimize the chances of creating disease breeding places nearby home [27]. This finding is similar to this study where people chose open defecation as a choice to keep the house free from nuisance smell and diseases. In contrast to our study, participants in a Zambia report that using latrine is more hygienic as open defecation provides more opportunities for animals to come in contact with human feces providing an opportunity for disease transmission [16]. The findings from Zambia differ as the Zambian study was conducted in a Tenia endemic area where latrine use was encouraged to prevent Tenia infestation. This shows the need for identifying ways to disseminate health education regarding feco-oral transmission of diseases in rural Nepal to discourage open defecation. Behavior change in people is highly motivated by health concerns as reported for hand washing behaviors in a study in Nepal [39].

Open defecation is practiced as it is perceived more convenient compared to latrine use. Going to any convenient open space far away from home/community is perceived to provide people with a sense of independence, privacy and an opportunity to socialize. This finding is similar to the qualitative study on open defecation in India, where respondents report choosing open defecation places based on the availability of water source for cleaning and bathing after defecation, different areas in different seasons and women choosing far off areas to avoid passing by of a male pedestrian [27]. For women, privacy becomes the most important factor in choosing an open area for defecation.

Not having latrines due to lack of resources as reported in this study concurs with another report from 2017 from Nepal [37]. This is a gap that may be filled sooner with the help of the ongoing campaigns to support communities to build latrines in Nepal. It is not surprising that people with lesser resources would be less willing to build a latrine in their houses [27]. Using the latrine structure for storing grains has been discussed in a report from India as well. The same report mentions that people feel unsafe using latrines as there is a possibility of encountering snakes or spiders inside the latrine [5]. Therefore, campaigns must consider the personal and community motivators for open defecation to design interventions in order to promote the use of these constructed latrines.

Similar to our findings, the studies from rural Ethiopia and Zambia reported participants choosing to defecate in open areas and backyard instead of latrine due to the bad smell coming from the toilet, and also perceive defecating in a latrine as very strange and scary [16,40]. In a previous research in the study area [26], people with dirty latrine refrained from using latrines, which correlates with the current findings that bad smell and hygiene concerns regarding latrines motivate people for open defecation. A report from India strongly argued that interventions to identify and change the sanitary preference of the community along with the construction of latrines may be required to stop the ongoing open defecation [25].

The cultural norms restricting males and females to use the same toilet compel females to look for an alternative defecation places in open areas as reported in this study. This finding is further supported by a study in Nepal with reports of not allowing women to use the toilets used by men, as some communities perceive menstruation as a dirty event. Thereby women are not allowed to use the same toilet as men [37]. While the perceived untouchability during menstruation is being addressed by new laws in Nepal, further campaigns to address this issue in a culturally sensitive manner may be required. The cultural and social norms compelling male and female to use different defecation places was also reported from India [27].

As found in this study, public latrines are considered more inconvenient due to long queues and considered dirty. Women were concerned regarding safety, privacy and unhygienic sanitation in the public facilities. A similar finding was reported from women in Mozambique [41]. Women were not comfortable being seen by male members of the community queuing in public latrines. Open defecation is preferred choice over community/public latrine for women which is also reported from India [42]. Queuing in public latrine has been reported as an opportunity for male members to harass women in the community during the day. The report further elaborates that public latrines are closed at night, thereby open defecation was the only convenient choice [42]. Meanwhile, women in India reported harassment during open defecation including violence. However, the same study has no mention of harassment on women during queuing at the public toilets [5]. This reflects that different practices of defecation bring newer opportunities for harassment towards women and girls. Constructing separate public toilets for men and women may be a feasible option in this regards. However further research may be required to able be to recommend this.

Latrine coverage has increased in Nepal owing to the Government’s commitment to making an 'open defecation free' Nepal. National campaigns along with non-government partners provide support for building latrines in Nepal [21]. Despite this, some households are not able to build the latrine due to the lack of additional funds and spaces around the house. As suggested by the previous report, the government needs to promote self-initiation for latrines construction for improved utilization [26]. Therefore, there is a need for the local government to identify pragmatic interventions to motivate people to self-initiate latrine construction along with behavioral change interventions to address personal and social factors leading to open defecation at the community level.

Conclusions

Open defecation is chosen willingly or by compulsion by people in the communities. Understanding the personal preferences, perceptions, religious beliefs, family/cultural norms, societal practices, and availability of resources may help design better interventions for alleviating the practice of open defecation. There is a need to give careful considerations for understanding the motivations among females for open defecation in order to address open defecation and promote latrine use in a more gender equitable manner.

Supporting information

Acknowledgments

We acknowledge the support received from Ms. Urusha Silwal, Colorado State University, Colorado, USA in the editing process. The authors acknowledge the support received from the BPKIHS and from the residents of Hattimudha for their participation and coordination during data collection.