Association between community toilet deprivation and depression among older adults in India: a multilevel analysis of the Longitudinal Aging Study in India from 2017-2018

Community context is an important determinant of health for older and aging adults. However, much of the research examining these associations has focused on Western contexts. Features and attributes of communities in low- and middle-income countries that might also shape health outcomes among older adults are less understood. This cross-sectional study examines community-level toilet coverage in India as a possible determinant of depression among adults over 45. We applied a multilevel modeling approach to the Longitudinal and Aging Study in India data from 2017 to assess the relationship between the community-level proportion of individuals living in no-toilet households and four commonly used markers of depressive symptoms and probable major depression. Overall, we found that an increase in the proportion of individuals living in no-toilet households within communities is associated with a greater risk of depressive symptoms. For example, people living in communities with the lowest quintile of toilet coverage had a higher risk of experiencing depressive symptoms (OR 1.38, 95% CI 1.08 to 1.76) compared to those living in communities with the highest quintile of toilet coverage. We found the same pattern for measures of probable major depression, too. Our study shows that community-level toilet coverage is an important determinant of depressive symptoms and probable major depression among older and aging women and men in India. Place-based stigma, community-wide shame, and a disorder-generating environment might be possible pathways contributing to this association.