On diarrhoea in adolescents and school toilets: Insights from an Indian village school study

BShyama_2015_p2y Shyama V. Ramani, UNU-MERIT, ramani@merit.unu.edu

For Citation: SITE4Society Brief No. 1-2018
Related to SDG Goals and Indian National Programmes: #SDG3 (Good Health and Well Being)  #SDG4 (Quality Education) #SDG5 (Gender Equality) #SDG6 (Water and Sanitation) #SBM (Swachh Bharat Abhiyan) #NHM (National Health Mission)  #SSA (Sarva Shiksha Abhiyan)
SITE focus: Governance and usage of sanitation infrastructure in schools;
Country Focus: India; 
Sub-Disciplines: Development Economics
Based on: Shyama V. Ramani, Timothée Frühauf and Arijita Dutta, On diarrhoea in adolescents and school toilets: Insights from an Indian village school study, Journal of Development Studies, 1-16 (2017).
Caveat: Please note that our academic works are based on a detailed study of a niche context constrained by the limitations of time and resources. Thus, our policy inferences, which have been extrapolated from such studies should be considered as indicators to be re-confirmed in every new context considered for application.

Context: Diarrhoeal mortality began to rapidly decline across the age pyramid in the 1980s, but slowed down after the start of the new millennium. Consequently, diarrhoeal diseases remain one of the most deadly preventable killers throughout the age pyramid. Their incidence can be decreased by blocking the infection route through the installation and use of toilets and improved hygienic practices. Globally, children older than 5 years, adolescents, and adults experience more than 2.8 billion episodes of diarrhoea per year, 200 million of which occur among 5-15 year olds. Their morbidity and economic costs are also still high: repetitive diarrhoeal episodes during childhood and adolescence lower fitness and decrease adult productivity. To date, no studies have identified the specific morbidity consequences of diarrhoea among adolescents, but it can be postulated based on other episodic chronic diseases, that school absenteeism, degree of achievement and eventually human capital are all negatively affected by diarrhoea in adolescence.


At the national and international level, the SWACHH Bharat Abhiyan programme and SDG 6 not only aim to ensure availability and sustainable management of water and sanitation for all, but also aspire to eliminate open defecation or OD, including by school going children. The reduction of OD will depend, in part, on their impact on adolescents, who are the natural change makers of the future. As they acquire a sense of their identity, adolescents become citizens with agent-specific psychosocial and behavioural routines. They must be nudged towards the use of toilets and the rejection of OD as a norm.

Research Questions:Is access to sanitation at home and at school, a determinant of diarrhoeal incidence among adolescents? Is the impact of access to sanitation, gender discriminatory among adolescents?

Motivation for Research Questions: Behavioural change in adolescents requires an understanding of the current sanitation practices of school going adolescents in order to develop effective adolescent-tailored interventions that take into account the specificities of the problem. For instance, the lack of school toilets has a gender discriminatory impact on school retention during adolescence. Girls require toilets for more than defecation; they also have particular sanitation needs when menstruating and the ability of girls to attend school is restricted, when they lack access to an appropriate sanitation facility during menstruation. The increased enrolment of pubescent girls in schools has been linked to the construction of sex-specific school toilets. Finally, the installation of toilets in schools is not enough; facilities also need to be safe, maintained and monitored.

Methodology UsedA five-step methodology was used. First, a conceptual framework was formulated from a review of the economics and public health literature on the determinants of diarrhoeal diseases in India and validated through discussions with local medical providers and NGOs. Second, a questionnaire was designed from the framework to collect data on the determinants of diarrhoea. Third, the questionnaire was administered via face-to-face interviews with all the students enrolled in the 9th and 10th grades at St. Sebastian School (Kameshwaram village, Tamil Nadu State). Fourth, data obtained were analysed to model diarrhoeal incidence as a function of explanatory variables through logistic regressions. Results were reported as odds of the occurrence of at least one episode of diarrhoea. Finally, the results were disseminated to the staff of St. Sebastian School and three schools in nearby villages via focus group discussions which provided further validation.

Main findings: Among school going adolescents, toilet usage and the degree of crowding in the adolescent’s household are significantly associated with diarrhoeal episodes.

Having access to toilets at home and school as well as adequate living space at home reduces diarrhoeal incidence.

For students whose households do not own a toilet at home, access to a toilet in school lowers their rate of OD, but is not enough to reduce diarrhoeal incidence.


– if the household owns a toilet then the practice of OD is lower (12.20% for males and 15.79% for females). However, OD is not inexistent even in toilet-owning households.

– adolescents with a toilet at home are less likely to use the school toilet than students without a toilet at home, regardless of gender. Female adolescents are less likely to withhold defection and less likely to practice OD at school regardless of household toilet ownership status

– female adolescents have a higher propensity to use toilets than males.

-the probability of having diarrhoea is lowest for adolescents who practice a mix of OD and toilet usage rather than always either ‘OD’ or ‘use of toilet’.

Policy Recommendations:  

First and foremost, sanitation workers in rural schools have to be paid much more as nobody wants to do this job. There is an institutional vacuum, namely a lack of agencies or individuals willing to maintain public toilets in rural India, because of the negative social stigmas attached.

Second most important recommendation is that unless safe gendered spaces are ensured in rural India for simple social interaction, for example, for just chatting in privacy, OD will remain an excuse to seek the same. Girls especially need spaces to chat without being under the eagle eye of elders and they are willing to take the risk of OD to obtain privacy.

Third, schools have to ensure or be provided funds to pay sanitation workers. School authorities are under great pressure to ensure performance of students in board exams and hence investment on cleanliness of school toilets or payments to sanitation workers is largely neglected.

Finally, while the provision of usable and clean toilets is the central key to the containment of diarrhoeal diseases, simply installing toilets in schools would be a myopic strategy. Installation must be preceded by reflection on maintenance and behavioural change.

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