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Open defecation, in short, is the practice of defecating in open spaces or bodies of water (Saleem et al., 2019; Ayalew et al., 2018) and is directly linked to lack of adequate hygiene and sanitation facilities, lack of awareness or education, and poverty. Globally, 2.3 billion people in low and middle-income countries have no access to a latrine and nearly 892 thousand people still practise open defecation (Saleem et al., 2019). Although the problem largely exists in low and middle-income countries, wealthy countries are not completely exempt where it is a particular problem for people who are homeless, as Capone et al.’s (2018) study in Atlanta, Georgia, USA illustrates.

Open defecation is associated with ill-health and lack of privacy and dignity as well as psychosocial distress for women (Saleem et al., 2019). Public-health experts are clear about the negative effects of open defecation which include exposure to pathogens and microbial risks leading to a number of diseases (Capone et al., 2018) including diarrheal disease and associated morbidity and mortality in young children (Ayalew et al., 2018), and bacterial infections (Kumar et al., 2017). In addition to the detrimental physical impact that open defecation has, for women especially, the practice can also increases the likelihood of sexual exploitation (Saleem et al., 2019).

Despite the negative consequences of open defecation some studies show that the practice can continue in some communities even after the construction of functional latrines. For example, in a study in Northern Ethiopia, Ayalew et al. (2018) found that nearly 13% of the respondents still engaged in open defecation. The question is why? A number of factors have been found to be significant in the persistence of open defecation such as social and community norms which normalize the practice (Jenkins and Scott, 2007), negative attitudes towards authority (Water Aid, 2008) and personal preference or choice (Jenkins and Scott, 2007). A study by Connell (2014) found that open defecation was described by some of the participants as ‘the most natural thing’ and others have noted the role of habit where this practice endures in the presence of adequate latrines (Patwa and Pandit, 2018). A participant in a Ghanaian study by Osumanu et al. (2019: 6) explained the continuance of open defecation like this: ‘our forefathers were defecating openly without any toilet facility but lived over 100 years. How can you convince me that open defecation is not good?’ Beliefs are also important. Children are allowed to defecate freely anywhere because their faeces are generally not regarded as ‘harmful’ (Osumanu et al., 2019: 7). This case study illustrates the power and importance of concepts of health and the links between such socio-cultural factors and health outcomes.

See also the website accompanying this book at www.politybooks.com/chs