How important is culture to sanitation uptake, the influence of local values in rural Bali.

Background: Addressing complex sanitation issues requires a comprehensive understanding of all determinants, including local values. These determinants are considered here within an ecological approach that is used to assess sanitation uptake and sustainability. Method: A survey of 202 respondents was conducted in rural Bali, Indonesia. Data was collected on attitudes, beliefs, and practices related to sanitation. Bivariate and multivariate statistical analyses were applied to identify significant factors of sanitation uptake and maintenance. Results: Only 31.2% of respondents reported having a toilet. A majority presented a negative attitude towards open defecation (OD), but they still considered it acceptable. Aside from other well researched factors such as asset ownership (OR 197.5, 95% CI 23-1690), education of family member (OR 3.3, 95% CI 1.2-9.1) and toilet ownership in the neighborhood (OR 10.4, 95% CI 3.2-33.6); cultural beliefs relating to supernatural power (OR 1.5, 95% CI 1-2.3) also had a significant influence on toilet uptake. Other local beliefs that affected sanitation uptake and maintenance were polluting nature of a toilet and the need to regularly purify dwellings. 90.6% of non-owners would give priority to expenses for religious activities over building a toilet and only 31.7% accepted the reuse of treated human waste as agriculture fertilizer. Conclusion: Because of the importance of the local values and their interactions with other factors in rural communities, future programs need to comprehensively assess determinants and take local priorities and needs into account, in order to address sanitation issues.