Hrev_master Healthcare in Low-resource Settings 2025; volume 13:13381 Social support to eradicate open defecation: raise awareness and promote healthy behavior Muhammad Ikhtiar, Nur Ulmy Mahmud, Andi Asrina, Andi Arysta, Putri Khairunnisa Public Health Faculty, Muslim University of Indonesia, Kota Makassar, Sulawesi Selatan, Indonesia Abstract Indonesia has achieved a 100% Open Defecation-Free (ODF) status; however, a significant portion of the population still prac- tices open defecation, particularly in proximity to rivers, swamps, and coastal areas. This study aimed to analyze the role of social support in the context of efforts to halt open defecation. This study employed quantitative methodology with a cross-sectional study design. The research was conducted in the catchment area of the Manggarabombang community health center in Takalar Regency. Data were analyzed using both univariate and bivariate tech- niques, and results were presented through narrations, distribution tables, and graphs. The study population comprised 178 house- holds, with sampling conducted using the Slovin formula to obtain a sample size of 123 households. The results of the statistical tests using the chi-square method revealed a p-value of 0.000, indicat- ing a significant relationship between social support and open defecation behavior. This highlights the important roles played by health workers, community leaders, and religious leaders. The findings of the study suggest that emotional and social support, as well as exposure to information about the health risks associated with open defecation, encourage individuals to adopt healthy prac- tices in their environment. With increased knowledge and aware- ness of the importance of personal health, individuals are more likely to commit to long-term open defecation-free behaviors. Introduction Globally, over 1.5 million people still lack access to basic san- itation services, such as private toilets and latrines. Furthermore, 419 million people continue to defecate in unprotected locations, including street gutters, vacant lots, and open water.1 Sanitation- related issues have become a global concern, including in Indonesia, which has set the goal of achieving 0% open defeca- tion and 15% access to safe sanitation by 2024.2-4 The Community-Based Total Sanitation Profile up to 2021 indicates that Indonesia’s population of 288.22 million people still includes 32.77 million individuals engaged in open defecation practices.5,6 The Indonesian government has implemented a series of ini- tiatives with the objective of sustaining a decline in the preva- lence of open defecation on an annual basis. It is expected that open defecation will be eliminated by 2025, while complete access to improved sanitation is projected to be attained by 2027.7,8 Despite the limitations of the data, it would appear that access to safe sanitation has remained constant at 7% over the past five years, which suggests that there is still much work to be done by all parties.2,9 It remains challenging to alter long-estab- lished habits and practices regarding latrine use, particularly in coastal areas, due to deeply entrenched cultural norms and behav- iors. Furthermore, some households possess latrines but refrain from utilizing them despite convenient access to water due to the unfitness or unsanitary nature of the latrines.10,11 As reported by the Ministry of Health of the Republic of Indonesia in 2022, the prevalence of open defecation in Indonesia has declined over time, with an estimated 5.69% of the population engaging in this practice.2 This is inextricably linked to the numer- ous initiatives implemented by the government with the objective of eradicating open defecation, including the provision of latrines and the implementation of awareness-raising campaigns. Despite various efforts, many communities, especially in coastal areas, are reluctant to change their practices regarding open defecation. Government collaboration typically aims to educate these commu- nities to prevent this issue. While positive knowledge and attitudes Correspondence: Muhammad Ikhtiar, Public Health Faculty, Muslim University of Indonesia, Kota Makassar, Sulawesi Selatan, Indonesia. E-mail: Muhammad.ikhtiar@umi.ac.id Tel.: +62.853.4372.3079. Key words: social support; ODF; healthy behavior; cross-sectional study. Conflict of interest: the authors declare that they have no competing interests, and all authors confirm accuracy. Ethics approval and consent to participate: not applicable. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Funding: this study was financially supported by the Ministry of Education, Culture, Research and Technology of the Republic of Indonesia. Acknowledgments: we would like to express our gratitude to the Ministry of Education, Culture, Research and Technology of the Republic of Indonesia for providing financial support for this research project in 2024. We would also like to acknowledge the Muslim University of Indonesia for their continued encouragement and assis- tance in advancing our knowledge, as well as the Government of Takalar Regency, South Sulawesi, for allowing us to conduct our research in their region. Finally, we would like to thank all those who have contributed to this research project in any way. Received: 13 November 2024. Accepted: 11 December 2024. Early access: 11 February 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13:13381 doi:10.4081/hls.2025.13381 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13:13381] [page 111] exist, many still engage in open defecation, highlighting the need for a community-based approach that includes social support. Unhealthy behaviors are often deeply rooted and unconscious, making social support essential, particularly in environments lack- ing strong social norms and encouragement for proper latrine use and maintenance.12,13 It is anticipated that the assistance of local residents, particu- larly community leaders, will facilitate the government’s efforts to establish a healthy environment. The findings indicate that a sig- nificant number of residents continue to engage in open defecation due to a lack of social support from community leaders. Furthermore, there is a lack of social disapproval or warnings from the surrounding community when someone is caught engaging in open defecation. While many residents are aware that open defeca- tion is unhealthy, this awareness is often disregarded if it is not accompanied by community involvement and commitment to achieving open defecation-free status.14,15 Open defecation prac- tices are prevalent across Indonesia, particularly in coastal areas, including South Sulawesi. The province of South Sulawesi has reported and declared that the year 2023 was 100% Open Defecation-Free (ODF), although the Central Statistics Agency (BPS) has indicated that there were still 2.26% of households engaging in open defecation. This repre- sents a decrease from the 3.69% of households engaged in open defecation in 2022.16,17 The government has invested significant resources to achieve the goal of zero open defecation, a target that was met in Takalar District by 2023. However, obtaining a 100% ODF status has not completely eliminated open defecation prac- tices among residents in riverine and coastal areas of Takalar. Despite the local health workers’ efforts in triggering and monitor- ing activities, instances of open defecation continue to occur in rivers, gardens, and other open spaces. A dataset from the Takalar District Health Office in 2022 indicated that 120 households in the Bontomanai village area of the Mangarabombang Community Health Centre still practiced open defecation due to a lack of access to latrines. In the following year, the number of latrine own- ers increased due to a local government assistance program for latrines.18 The provision of triggering and latrine assistance has been car- ried out in stages. However, it has been observed that a portion of the population has not been able to access this assistance due to a lack of financial resources. Some community members do not pri- oritize latrines and even construct homes without bathroom or toi- let facilities. It is, therefore, evident that a robust commitment and motivation from the community, coupled with the provision of social support, is essential to encourage individuals to adopt healthier behaviors. Article Table 2. Distribution of respondents' answers regarding community support to stop open defecation. Number Statement Yes No n % n % 1 Health workers are engaged in providing counseling services related to latrine ownership and use. 113 92.0 10 8.0 2 Health workers recommend that family members utilize the toilet at home, as long as it is available. 116 94.4 7 5.6 3 Health professionals elucidate the health risks associated with the lack of access to adequate sanitation facilities. 118 96.0 5 4.0 4 In the preceding 12-month period, health workers have conducted home surveys. 121 98.4 2 1.6 5 In order to facilitate the utilization of latrines, village officials, community leaders and religious leaders collaborate with household heads to ensure their participation. 120 97.6 3 2.4 6 A program of empowerment has been developed by village officials, community leaders, and religious leaders to encourage the use of latrines. 119 97.4 4 3.2 7 The village head, community leaders, and religious leaders are involved in providing advice and guidance on the construction of healthy latrines. 107 87.2 16 12.8 8 Village officials, community leaders, and religious leaders have provided assistance to facilitate the use and utilization of latrines. 122 99.2 1 0.8 9 Family members encourage the use of the latrine. 119 97.4 4 3.2 10 Local people view the use of latrines positively. 122 99.2 1 0.8 11 In the event of open defecation, neighbours are quick to express their disapproval. 102 83.2 21 16.8 Table 1. Respondents’ characteristics. Characteristics n % Age <20 years 3 2.4 20-29 years 26 21.1 30-39 years 25 20.4 40-49 years 35 28.5 >55 years 34 27.6 Gender Male 54 36.4 Female 69 63.6 Education Elementary school 57 46.4 Senior high school 26 21.1 High school 23 18.7 Not working 17 13.8 Occupation Trader/self-employed 14 11.3 Farmer/fisherman 38 30.9 Laborer 8 6.5 Not working 29 23.6 Housewife 34 27.7 Income of head of family >Rp.3.643.321,- / month 0 0 0.05), indicating a statistically significant relationship between the role of health workers and open defecation behavior in the Mangarabombang Puskesmas area, Takalar Regency. The influence of health workers and community leaders on changing open defecation habits depends on several factors. Firstly, community members need access to information and sup- port from health workers and leaders, as well as consequences for not adhering to open defecation practices. Secondly, it is essential for the community to be committed to using latrines. When both of these conditions are met, they can serve as powerful catalysts for behavioral change.35,36 Households that have never received educa- tion from health workers are 5.037 times more likely to continue open defecation practice compared to those who have been educat- ed by health workers.37,38 Raising public awareness about recom- mended practices, such as ensuring cleanliness and proper sanita- tion, is essential for maintaining a healthy environment and improving the overall health of the community. Conclusions The research findings suggest that social support from health workers, religious leaders, and community leaders plays a crucial role in adopting healthy behaviors. Exposure to information and emotional encouragement from individuals who have stopped open defecation serves as a significant motivator for others to pro- tect their environment. 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