Characterizing modern bathrooms to support sanitation adoption Open Access

Globally, 14% of the world's population lacks access to improved sanitation, which is defined as a sanitation system, that hygienically separates human waste from human contact (UNICEF & WHO 2021). Without improved sanitation, households are at greater risk of diarrheal diseases, stunting, and reduced overall well-being (Mara et al. 2010; Guerrant et al. 2013; Sahoo et al. 2015; Saleem et al. 2019; WHO 2019). Household ownership of improved sanitation can reduce these risks; however, acceptance varies by context and is not guaranteed, especially if users are not satisfied with the bathroom design and selected sanitation system (Tilley et al. 2014). In this study, we define a sanitation system as the sanitation infrastructure (e.g., pit and septic tank) and slab, in addition to the sitting-style toilet or squat plate. The term bathroom includes all other aspects that respondents associate with the space including the superstructure and fixtures within (e.g., sink).

Reasons for dissatisfaction, and thus the disuse or abandonment of a bathroom, can extend beyond the sanitation system type. For example, multiple studies have noted households being dissatisfied with their current bathroom and thus being motivated to either adapt their current bathroom or construct one that is modern (Jenkins & Curtis 2005; Hernandez et al. 2009; WSP 2009; Routray et al. 2015; Leong 2020). We saw similar trends near Cascas, Peru, where some households described feeling dissatisfied with their current bathroom because it is not modern and aspired for a more modern bathroom. However, despite multiple studies noting the motivation for a modern bathroom, these studies only identified a dichotomous response when households perceived an entire bathroom design to be modern or not (Jenkins & Curtis 2005; Hernandez et al. 2009; Russel et al. 2015; Leong 2020). Additionally, these studies often applied a scholarly understanding and perspective of modern sanitation infrastructure. In contrast, few studies have investigated vernacular definitions of modern and thus have not captured household definitions of modern, specifically what other characteristics, such as materials, and fixtures used are associated with modern.

Recent scholarship by Lawhon et al. (2023) pulled from postcolonial and political-ecological literature to parse out theoretical characteristics of the modern infrastructure. They emphasized that modern is upheld by the belief that ‘nature is separate [from society] and controllable through science’ (p. 190). The authors also emphasized modernity's ties to uniformity and how it is often practiced through the implementation of technocentric solutions for perceived homogenous groups of people. However, as described by these scholars and others (Gambrill et al. 2020; Schrecongost et al. 2020), there is a need to acknowledge the heterogeneity of people and their contexts and implement a mix of infrastructure systems that together meet the varied preferences and needs of people within these groups. While past literature has noted that the desire for a modern bathroom is not inherently universal (Leong 2020), it is still crucial to understand local perceptions of modern to best incorporate preferences for modern into sanitation programming when it is desired.

In summary, there is a limited understanding of vernacular definitions of modern infrastructure; however, a better understanding of modern, especially when it is desired for sanitation solutions, is important. For example, it is unclear whether perceptions of modern are only associated with the sanitation infrastructure or if more is needed to achieve modern. Literature has focused on labeling sanitation infrastructure, like pour flush toilets (del Carmen Morales et al. 2014; Seymour & Hughes 2014; Kabange & Nkansah 2015), and ceramic toilets connected to sewer systems (Lawhon et al. 2022) as modern without first identifying local definitions of modern. While some studies have suggested that modernity may be possible using a mix of sanitation technologies (Letema 2012), literature has stopped short of identifying the specific characteristics beyond the sanitation infrastructure type that are associated with a modern bathroom. Determining characteristics of households perceive as modern will help the Water, Sanitation, and Hygiene (WASH) sector plan for future sanitation programming and implement diverse sanitation solutions that honor people's varied preferences.

One reason that studies have not yet associated characteristics with modern is due to these studies' settings. For example, modern has been cited as a reason for accepting a bathroom design in communities that otherwise lack any other bathroom options (Leong 2020); the lack of variance in bathroom characteristics thus made it difficult to identify and test associations between unique bathroom characteristics and perceptions of modern. An opportunity exists to study communities that self-construct bathrooms because there is wide variation in bathroom design, both in what infrastructure is constructed below-ground (i.e., sanitation infrastructure type) and the above-ground design (i.e., superstructure, materiality, toilet type, fixtures present, etc.). This variation would allow for the identification of characteristics and to test the significance of multiple unique characteristics associated with a modern bathroom. Finally, past literature has demonstrated the utility of capturing stated and revealed preferences when studying sanitation demand and willingness to pay (Goddard et al. 2018; Tidwell et al. 2019; United Nations Children's Fund (UNICEF) & World Health Organization 2021). As we seek to understand local definitions of modern, it is important to capture both participants' stated preferences (definitions) of modern and observed (revealed) designs of perceived modern bathrooms in the participant's current context.

Thus, this study sought to characterize users' perceptions of modern bathrooms by addressing the research question: What combinations of characteristics are most often associated with modern? In doing so, we analyze the characteristics associated with user-identified modern bathrooms. We did this by systematically analyzing the characteristics of households associated with modern from both unimproved and improved sanitation users. An increased understanding of how modern is characterized will help implementers better target and incorporate these preferences into design and support increased adoption and use.

We identified characteristics that households associated with modern across nine communities near Cascas, La Libertad, Peru. These communities were initially identified due to their high variability in bathroom design, where some households self-construct their bathrooms paso-a-paso (step by step) when they can afford to do so. This high variability in bathroom characteristics and perceptions of modern enabled us to determine what characteristics users associated with bathrooms they perceived to be modern and whether an improved sanitation system was included in their definition of modern.

The questionnaire included a section on sanitation access and modern perceptions where participants were asked whether their current bathroom was perceived by others as modern and what characteristics do or do not make their bathroom modern. Questions included both open-ended and closed-ended questions, including Do other people consider your bathroom to be modern? (Yes/No/Don't Know) and What about your bathroom makes it modern? (Open-ended). Based on findings from our pilot survey, we asked participants to describe how others perceive the modernness of their bathroom, as opposed to asking them to directly identify their bathroom as modern, to align with local cultural norms. Specifically, we found that respondents were hesitant to speak critically of something gifted to them or financially supported by others; however, they would report socially defined perceptions of modern by the community. Enumerators also conducted observations, including capturing two photos of each bathroom, which were used to triangulate information on improved status, toilet style, and materiality, as well as identify the presence of fixtures (e.g., sink or shower). The sanitation system type was determined by participant responses where they were asked, ‘What type of bathroom do you have in your home?’, and enumerators completed observations to validate the sanitation system type, including identifying how waste was stored on-site. More information on the survey format, including example questions, can be found in Supplementary Materials, Table S1.

Five enumerators administered the survey orally, in Spanish, to 305 households in nine selected communities near Cascas, La Libertad, Peru from August to September 2021. To qualify the study, each community needed to have at least 25 occupied households, have some households with improved sanitation coverage based upon the 2020 national sanitation coverage data, and have participated in self-construction programming to support bathroom construction. Within each community, households were selected by sampling every other household. To qualify the study, each participant had to have a bathroom on their property and be at least 18 years old. Oral informed consent was obtained from all participants and followed the CU Boulder IRB #21-0030 protocol. All data were collected using mWater, a surveyor app that enumerators can access on-site through a cell phone.

Survey data were analyzed in two phases. Responses were exported from mWater to Microsoft Excel, cleaned, and then imported into NVivo for qualitative analysis in Phase 1 and R for statistical analysis in Phase 2. In Phase 1, two open-ended questions were inductively coded using NVivo to identify the unique characteristics most commonly associated with modern. In Phase 2, data from observations, including the two photos, were used to identify the presence or absence of the top three modern characteristics in each bathroom. These results were then transformed into binary and categorical variables and tested using logistic regression modeling to predict the household's perception of whether their current bathroom was modern. Together, Phase 1 and Phase 2 seek to investigate both stated and revealed preferences for modern as described in preference theory.

In Phase 1, one closed-ended question– ‘Do others think your bathroom is modern?’(yes, no, or don't know) and two open-ended questions – ’What about your bathroom makes it modern?’ and ‘What needs to change to make your bathroom modern?’ – were qualitatively analyzed to characterize how households are defined modern. This included identifying combinations of characteristics that households often associate with a modern bathroom. Responses to the two open-ended questions were inductively coded to identify bathroom characteristics associated with modern. Participant responses often followed a list format such as ‘because it has a toilet bowl, shower, and sink’. After characterizing all responses, the relative frequency of codes across the entire sample and groups of interest (including respondent gender) were analyzed. The co-occurrence of codes was assessed to identify common pairs of characteristics, such as tile and sitting-style toilet, that were cited by participants.

In Phase 2, photos of each participant's bathroom were systematically coded to determine the presence of the top three characteristics identified in Phase 1. Finally, a logistical regression model analysis was conducted to identify whether the presence of these characteristics significantly predicted the bathroom being perceived as modern.

A majority (76%) of households had an improved sanitation infrastructure; however, despite the high prevalence of improved sanitation systems, only 22% of respondents believed that others perceived their bathroom to be modern, and 3% did not know whether their bathroom was modern or not. Supplementary Material, Tables S2–S5 provide an overview of the respondent's sanitation system type and the prevalence of improved sanitation and modern status. Supplementary Material, Table S2 describes participant demographics, Table S3 presents the prevalence of improved sanitation infrastructure and modern status by the community, Table S4 presents the prevalence of improved sanitation infrastructure and modern status by sanitation infrastructure type, and Table S5 describes the prevalence of modern status by unimproved and improved bathrooms. In summary, the 305 respondents (178 male, 127 female) were between 19 and 88 years old (mean 51) and had between 0 and 17 years of education (mean 7.4 years). Of the respondents, 67 stated others perceived their bathroom as modern, 229 stated others did not perceive their bathroom as modern; and 9 did not know.

Across the nine communities, the prevalence of bathrooms perceived as modern in each community ranged from 7 to 50%; improved sanitation systems were higher but ranged from 59 to 90% of sampled households (Supplementary Material, Table S3). Perceived modern bathrooms were present in four of the five captured sanitation system types. There were zero cases of modern bathrooms in households with squatting-style pit latrines.

Overall, 22% of the 305 households stated that others perceive their bathroom as modern, and 75% of households said their bathroom was not perceived as modern. Analysis of open-ended responses on modern resulted in 19 unique bathroom characteristics being identified, which included fixtures, materials, and sanitation system types. Of the 296 respondents that responded yes or no to their bathroom being perceived by others as modern, 33% stated only one characteristic when asked to describe the modernity of their bathroom, and 67% stated at least two characteristics. The three most common characteristics mentioned by households who believed others perceived their bathroom to be modern were sitting-style toilet (88%), shower (54%), and sink (52%); additions stated by households that they would need to add to have a modern bathroom included a sitting-style toilet (32%), changing the system to sewered (28%), a sink (24%), and a shower (23%) (Table 1). An extended list of characteristics mentioned by households can be found in Supplementary Materials, Tables S6 and S7. Across both groups, sink, shower, and sitting-style toilet were often associated with modern.

Furthermore, while sewered systems were mentioned as a reason why a household bathroom was not modern, those that perceived their bathrooms to be modern rarely mentioned the presence of sewered connections or the below-ground infrastructure. Overall, 23% of households in the entire sample mentioned system type when describing modern. Therefore, despite literature discussing modern sanitation interchangeably with a specific sanitation infrastructure type, like a sewer system, in this context, we see fewer households emphasize it in their description of modern.

The most common combination of bathroom characteristics stated by participants included at least one of the following: sitting-style toilet, shower, and sink. Most respondents (67%) stated more than one characteristic when discussing modern. Of the 229 respondents that stated their bathroom was perceived to be not modern, 19% indicated that adding both a sitting-style toilet and a sink would make it modern. Similarly, 48% of respondents that stated their bathroom was perceived as modern noted that the presence of both a shower and a sink made it modern (Table 1). The mention of more than one characteristic suggests that more than one change may be needed to achieve a bathroom perceived as modern.

Phase 2 expanded from characteristics associated with modern to identify the presence of a shower, a sink, and a sitting-style toilet via photographs of household bathroom space. Additionally, the improved status of each household bathroom was determined by triangulating data from participant responses, enumerator observations, and photographs.

To identify whether the presence of characteristics significantly predicted the bathroom to be perceived as modern, we used the binary dependent variable modern, which was determined using the closed-ended survey question ‘Do people consider your bathroom to be modern?’. Participants could choose either ‘yes’, ‘no’, or ‘don't know’. The 3% of respondents that selected ‘don't know’ were combined with the ‘no’ group for analysis. Independent variables included binary variables of bathroom characteristics of shower, sink, and sitting-style toilet, and the categorical variables included the sanitation infrastructure type (sewered, pit latrine, septic tank, and biodigester). The sitting-style toilet was the most prevalent bathroom characteristic, followed by a shower and then a sink. Additional information on these model variables can be found in Supplementary Material, S9.

Across all five sanitation system types, having an improved sanitation system was more common than having a modern bathroom. Importantly, this suggests that having an improved system may not be sufficient for achieving modern. All bathrooms with a squatting-style pit latrine also lacked a sink and a shower. Every household in this group also noted their bathroom was not perceived as modern by others. Focusing on the other four types of sanitation systems, we note that even when the bathrooms have an improved system and a sitting-style toilet, it does not guarantee that the bathroom will be perceived as modern by others (Table 2). This suggests that more than an improved sanitation system and a sitting-style toilet may be needed to achieve modern.

The statistical significance of the three most frequently mentioned characteristics of a modern bathroom and a sanitation system type was tested using multilinear logistic regression analysis. Two logistic regression models were developed (see Table 3) to test the significance of the presence of a shower, a sink, and a sitting-style toilet, and sanitation infrastructure on the bathroom being perceived as modern. Supplementary Material, S9 shows the variables included in the tested models. A sitting-style toilet was not included as a separate variable due to the multicollinearity of the sanitation infrastructure type and the toilet style. Because pit latrines were the most common sanitation infrastructure, they were used as the reference category for which septic tanks, biodigesters, and sewered sanitation systems were compared in the statistical analysis.

In a model where the sanitation system type, the presence of a sink, and the presence of a shower are regressed on modern perception, controlling for random effects due to community, the presence of a sink, and the presence of a shower were significant predictors. Households with a sink were 2.74 times more likely to say that their bathroom was perceived as modern than households without a sink, controlling for the system type and the presence of a shower. Households with a shower were 6.41 times more likely to say their bathroom was perceived as modern than households without a shower, controlling for the sanitation system type and the presence of a sink. Septic tank, biodigester, and sewered system were not significant predictors of modern, when compared to pit latrine, and controlling for the presence of a sink and a shower.

Following these results, the relationship between sinks, showers, and accessories was further tested by a model with only households that had a sitting-style toilet (n = 180). By holding the sitting-style toilet constant across the data subset, we sought to further parse out any effects due to the infrastructure system type and a sink and a shower.

In a model where the sanitation system type, the presence of a sink, and the presence of a shower are regressed on modern perception, the presence of a shower was the only significant predictor. Households with a shower were 3.09 times more likely to say their bathroom was modern than households without a shower, controlling for the system type and the presence of a sink. Sanitation system types (i.e., septic tank, biodigester, and sewer system) remained as a not significant predictor of modern perceptions. Through this analysis, we found that when the bathroom contains a sitting-style toilet, the presence of a sink becomes non-significant, and the shower remains as the only significant predictor of a bathroom being perceived as modern.

We discuss common findings across the phases, including propositions based on the results.

The below ground infrastructure is not commonly associated with a household's perception of modern nor is it a significant predictor of having a bathroom that is perceived by others as modern’

We anticipated that the sanitation system type would be a significant predictor of modern because previous literature has used modern synonymously with sewered or improved sanitation systems. However, when asked to describe what makes their bathroom modern and what characteristics would need to change to make their bathroom modern, 23% of participants mentioned the bathroom's sanitation infrastructure type or the need to pair below-ground sanitation infrastructure with above-ground characteristics to achieve perceptions of modern. This points toward the potential for meeting modern through decentralized sanitation system types.

Bathrooms perceived as modern had improved sanitation systems, but bathrooms with improved sanitation systems were not always perceived as modern

Nearly all unimproved sanitation systems were pit latrines that also lacked a shower, a sink, and a sitting-style toilet (see Supplementary Material, Table S8 for the prevalence of a shower, a sink, and a sitting-style toilet by improved and unimproved infrastructures). Meanwhile, households that perceived their bathroom to be modern always had an improved sanitation system, excluding three households where the sanitation system type could not be determined. However, households with an improved sanitation system did not always perceive their bathroom to be modern (Supplementary Material, Table S5). Therefore, these results suggest that improved sanitation systems are necessary but not sufficient for achieving a modern bathroom, even if the system's improved status was not commonly stated in a participant's definition of modern. Future studies should further test this relationship between improved sanitation access and modern perception to better understand how targeting modern characteristics in implementation practices could lead more households up the sanitation ladder.

A sink, shower, and sitting-style toilet are the three most commonly associated characteristics of a modern bathroom; a sitting-style toilet is necessary for modern

Households commonly associated a sitting-style toilet, a shower, and a sink with modern bathrooms. The three most common pairs of characteristics mentioned by households included two of these three characteristics. In addition, a sitting-style toilet was the most commonly stated modern bathroom characteristic (88% of households with a modern bathroom). Of the 229 households who stated their bathroom was not modern, 32% stated that a sitting-style toilet was needed to make their bathroom modern. All households that lacked a sitting-style toilet identified their bathrooms as not modern and all households that identified their bathrooms as modern had a sitting-style toilet. Yet, a portion of households with sitting-style toilets stated they did not have a modern bathroom. Therefore, we hypothesize that a sitting-style toilet is required but not sufficient for meeting a modern bathroom.

Households also emphasized the presence of a sink and a shower in their definition of modern. This may be due to previous community-wide exposure to bathrooms that compose these three characteristics in urban settings. Furthermore, a sink and a shower may be seen as luxury items due to the area's high water scarcity. Households that stated having a bathroom that was perceived as modern often had only two of these three characteristics (sink, shower, and sitting-style toilet) pointing toward modern being possible without all three characteristics.

This study sought to characterize and define modern sanitation near Cascas, Peru. A household-level survey including pictures was used to identify the presence of characteristics; however, pictures were limited in what they could show. For example, a few households had a sink located outside of their interior bathroom space (on an exterior wall). While some pictures captured this exterior sink, other exterior sinks could have existed but have not been captured in photos. Statistical analyses focused on testing the significance of characteristics that were identified as important for achieving a modern bathroom. However, two variables, sanitation system type and toilet style, could not be separated for analysis due to multicollinearity. Future work should investigate these two variables and test their significance in other contexts to further parse the effect both design elements have on defining modern sanitation.

While this study focused on the sanitation perceptions of sanitation system owners, data collection was limited to areas that were accessible by motorbike and within a day's trip from the enumerator's base location. Therefore, results represent the perspectives of households located only within one part of the rural Peruvian context. While these results do not represent the perspectives of all rural Peruvian households, they may provide valuable insights into the type of characteristics desired in similar contexts.

Finally, the categorization of households based on their modern status (i.e. modern, not modern, and don't know) was determined using a question that captured participants' perceptions of what others think about their bathroom. It is possible that others' perceptions of participant bathrooms differ from those stated by the participant themselves. Future work should identify whether participants themselves believe their bathroom to be modern and from there identify definitions of modern. Furthermore, future work should classify whether households aspire toward these modern bathrooms.

This study sought to identify sanitation design characteristics that are commonly associated with modern bathrooms. We did this by systematically analyzing household definitions of modern in a rural Peruvian context. Using a household-level survey, we developed a method for identifying and characterizing definitions of modern. Modern bathroom characteristics included three characteristics: sitting-style toilet, sink, and shower. Most respondents did not mention the sanitation infrastructure type when discussing modern and it was notably not a significant predictor of a bathroom being perceived as modern in the logistical regression analysis. This suggests that modern may be achievable in the study's context independent of the sanitation system type.

Results from this study can be used by implementers, researchers, and government officials focused on increasing improved sanitation access to adapt the sanitation system designs that they work with. Specifically, our study found that other bathroom characteristics, like a sink and a shower, play a role in the household perception of modern. While it cannot be assumed that all households in a context inherently desire modern, this study suggests that those who desire a modern bathroom may meet this aspiration by having these three identified characteristics. Should implementers or other groups wish to increase the desirability and satisfaction of an improved sanitation system for households that seek modern, they may consider adding one of these fixtures to their proposed bathroom designs.

The authors thank Water for People for their support of the study through providing contextual knowledge, logistics, payment of enumerators, and validation; our enumerators who gathered survey responses and the survey participants for their participation. We also gratefully acknowledge the Graduate Assistantship in Areas of National Need (GAANN) Fellowship (P200A180024) for providing financial support for the first author's graduate studies. Finally, we thank Dr Sherri Cook for her support and advice on study design, data collection, and analysis.

Data cannot be made publicly available; readers should contact the corresponding author for details.

The authors declare there is no conflict.