Anyone who has watched the film ‘Slumdog Millionaire’ will undoubtedly remember a scene in the movie where the main character jumps from an elevated latrine into the filthy water below in a desperate attempt to see his favourite Bollywood movie star. Most of us cringed in horror or disgust during the sequence. Were liberties taken for the sake of art? It seems not.

A massive 70% of Indians living in villages – equitable to some 550 million people – defecate in the open. It is estimated that even 13% of urban households do so. The situation is reportedly so bad that open defecation is more common in India than in that are poorer countries such as Bangladesh, Kenya, Democratic Republic of Congo, Malawi, Burundi and Rwanda.

However new research has concluded that building toilets may not be enough to end open defecation in India.

A team of researchers asked people in 3 235 rural households in five north Indian states where they defecate and their attitudes towards it. Some 40% of Indians live in these states: Bihar, Madhya Pradesh, Rajasthan and Uttar Pradesh. They also account for 45% of households without a toilet. A third of all people worldwide who defecate in the open – live in these five states.

Incredibly, the study reveals that people in households with working toilets continue to defecate in the open and that toilets provided by the government are especially unlikely to be used.

“In short,” the study reveals, “we find that many people have a revealed preference for open defecating such that merely providing latrine access without promoting latrine use is unlikely to importantly reduce open defecation.”

Why do so many Indians still prefer not to use toilets even when they are available?

The survey found a revealed of replies: Most respondents said they found it “pleasurable, comfortable, or convenient”. Others said it “provides them an opportunity to take a morning walk, see their fields and take in the fresh air”. Others regarded open defecation as “part of a wholesome, healthy virtuous life”.

India, researchers say, “needs a massive campaign to change sanitation preferences” and promote toilets by linking sanitation behaviour with health. One of the ways it can be done is by raising an army of sanitation workers and campaigners in the villages to spread the message.