The “5Ds”: Changing attitudes to open defecation in India

Co-author: Dharmendra Singh

In the village of Bharsauta in Uttar Pradesh, India, construction worker Vishwanath lives with his wife, four children and their elderly parents. Three years ago, the government paid to build a toilet in their house. But the job was not done well: the pit was too shallow, it overflows frequently, and the smell makes it suffocating to use. Cleaning the toilet requires carrying water from a community tap. Vishwanath and his family have decided it isn’t worth the hassle. Mostly, they continue to defecate in the open.

Vishwanath’s family is not alone. Research has shown that households which constructed their own toilets, rather than receiving a government subsidy, are more likely to use them. But what are the most effective ways to persuade people to construct their own toilets?

To improve understanding of this question, formative research was undertaken in Uttar Pradesh and neighboring states, including Rajasthan and Bihar.

The research helped behavioral change practitioners to strengthen the “community-led total sanitation” (CLTS) approach. Building on that, a new “5Ds” approach combines behavior change communications theory, research insights and strengths of the CLTS approach into a comprehensive framework for changing norms around open defecation.

The 5 “Ds” are:
1: Depict. Research reveals that many factors motivate people to decide to construct a toilet. For instance, in Bihar, 75% of respondents mentioned inconvenience in the rainy season; in Rajasthan, 69% mentioned security concerns for women and children.

However, the risk of attempting to convey multiple messages is that ultimately, none gets heard. It is more effective to focus on a single, clear message with emotional heft. Research points to self-esteem and the perceived social standing of the family — for example, a prospective son-in-law not wanting to stay in a house without a toilet — as the most promising focus for a message.

The “depict” stage therefore sets out to establish the norm that using a toilet is proof of being cultured and refined. It seeks to change people’s frame of reference: where they currently think of toilets as a government program, and expect subsidies, the messaging portrays it as a matter of evolving community norms and something they should be willing to invest in themselves.

The research identified the best channels through which to deliver messages in the “depict” stage. For example, television reaches 50% of households with toilets in UP and 29% of those without. Outdoor advertising emerged as a potentially particularly effective channel.

2: Divulge. Research shows that people do not construct a toilet because they are not aware of basic information, for example, the link between open defecation and diarrhea. Some have formed a negative opinion of toilets due to low-quality construction during government sanitation campaigns; 69% of those for whom toilets were constructed did not know the appropriate technology.

People often think toilets are much more expensive than they actually are. In UP, estimates ranged from INR 20,000 to 120,000 (around $300 to $1,500). Perceiving toilets as unaffordable, people prioritize other demands on resources, such as sending their children to school or saving for a daughter’s marriage.

The second “D,” divulge, therefore aims to provide practical information and dispel myths, through a combination of print material, audio-video clips and one-to-one or group conversations. Experience shows that these are more effective if messages are packaged as eye-opening revelations with elements of happiness or surprise.

3: Demonstrate. Even better than telling people is showing them what they need to know — the different models of a toilet, how they are constructed and maintained, how the compost looks — and giving them role models who have constructed and use a toilet. Demonstration is typically challenging in behavior change campaigns, but CLTS already achieves this third “D” through various methods, including travelling exhibitions and group discussions.

A common problem with demonstrations is that their impact fades without means of reinforcement. Often, people are initially convinced but lose their motivation. The 5Ds model addresses this problem by continually reinforcing the desire to act on knowledge learned, through social channels including mobisodes on mobile phones and at events that maintain buzz through word-of-mouth.

4: Dissuade. Even when people are aware of health benefits, the tipping point in behavior change comes when sanctions against open defecation are established and enforced by village authorities and local communities.

The “dissuade” stage needs to make open defecators feel that they are being reminded of emerging community norms, rather than bullied into changing behavior that they still see as acceptable. It helps if sanctions are designed with the community’s participation and uniformly imposed, rather than encouraging ad-hoc actions by vigilante groups. Mass media messages and street plays can help reinforce the new norms.

5: Dignify. The final “D” links back to the “depict” stage, rewarding those who have decided to construct a toilet with enhanced social status. One way to “dignify” toilet use is linking the tradition of singing “Sohar” — a song used to mark joyous household events — with toilet construction. Low-cost ways of spreading this tradition include mobile ringtones and WhatsApp audio messages. Even households without a toilet, 91% have a mobile phone.

Other tactics include local authorities giving “clean house” nameplates to be displayed with pride by households with toilets, and holding periodic public events to recognize local champions of ending open defecation.

The 5Ds approach was developed in partnership with the UP government and is currently being deployed in the state. The mobisodes were shown on International Women’s Day at an event in Gandhinagar attended by the Prime Minister and six thousand Sarpanches, or women community leaders. As the experience in UP proceeds, it should generate valuable lessons that could be used to adapt the program in other Indian states.



Editor's note: This research is property of the World Bank and can be used freely as long as the source is acknowledged.