Water, sanitation, and hygiene practices among population living in slums, Jhansi, Uttar Pradesh, India.
Water- and sanitation-related disease, despite being preventable, remains one of the most significant child health problems worldwide. Poor water and sanitation result in a huge economic burden in terms of health spending, loss of productivity, and labor diversion. 
World Health Organization (WHO) in August 2015, unveiled a global plan to better integrate water, sanitation, and hygiene (WASH) services with four other public health interventions to accelerate progress in eliminating and eradicating neglected tropical diseases (NTDs) by 2020. "Millions suffer from devastating WASH-related NTDs--such as soil-transmitted helminthiasis, guinea-worm disease, trachoma, and schistosomiasis. Access to safe water, managing human excreta, improving hygiene, and enhancing targeted environmental management are the key solutions. Such improvements not only lead to improved health but also reduce poverty. 
A recent report showed that in 2015 more than 660 million people did not have access to improved water sources. The WHO/UNICEF Joint Monitoring Program for Water Supply and Sanitation report also showed that almost 2.5 billion people lacked access to improved sanitation. Open defecation and lack of hygiene are among important risk factors for the transmission of many NTDs. Over half a million lives are lost each year as a result of NTDs. Prioritizing water and sanitation will address the determinants of many NTDs and support WHO's drive for equitable and sustainable universal health coverage. Targeted water and sanitation interventions are expected to bolster ongoing efforts in tackling 16 out of the 17 NTDs, which affect more than 1 billion of the world's poorest and most vulnerable populations mainly in underprivileged areas like slums. [1,3]
Slum population remained deprived, particularly in health, education, and socioeconomic aspects. The census of 2011 recorded 1.3 crore urban slum households and revealed that the problem is growing, as it indicates the percentage of people living in slums in smaller cities with a population of less than a million is rising. 
A significant proportion of deaths can be prevented through safe drinking water, adequate sanitation, hygiene, and immunization, proper infant feeding, and enabling environments.  The WaSH practices in India are well documented and key measures of the Swachh Bharat Abhiyan, government of India, a massive movement that seeks to create a clean India. [6,7]
Jhansi is a historical city famous for Maharani Laxmi Bai, lies in the region of Bundelkhand on the banks of the Pahuj River, in the extreme south of Uttar Pradesh.  It is recently added to the list of upcoming smart city with a total population of 1,998,603, and around 42% of total urban population lives in slums. [4,8]
Due to paucity of studies and policies execution, there is need to assess present WaSH practices. The objectives for conducting this study were to assess WaSH practices and to find out an association between WaSH and NTDs among the population living in slums, Jhansi, Uttar Pradesh.
MATERIALS AND METHODS
This was a cross-sectional community-based study conducted in slums of Jhansi district in Uttar Pradesh from May 2016 to November 2016.
The study was conducted in the city of Jhansi, Uttar Pradesh, in India. There are 54 notified, and three non-notified slums and around 42% of total urban population lives in these slums. Details of the inhabitations of the slum population in and around Jhansi were obtained from the Jhansi Nagar Nigam.
Sampling: Sources of Data and Study Design
Out of total 57 slums, three slums were selected by simple random sampling method and cluster random sampling method was used for selecting the households living in these slums.
The sample size was calculated considering the prevalence of NTDs as 12%.  Assuming an alpha error of 0.05 and relative precision of 25%; the required sample size comes out as 470. Taking the cluster design effect of 1.5, the sample size was 705 and assuming 5% of non-response rate; the sample size was 740. The total households surveyed for the study were 1004, 768 households with at least one reproductive age women (15-49 years) were included in the study. A semi-structured pretested questionnaire was used to collect information from these women. It contained demographic details of the study subjects and WaSH practices. An approval to conduct the study had been taken from Ethical Committee, and verbal consent of respondents was taken for study.
Data was entered into a Microsoft Excel spreadsheet and analyzed with Epi Info version 126.96.36.199. Wherever applicable, proportion, percentage, and mean (standard deviation) were calculated and P > 0.05 taken as significant.
A total of 768 women of reproductive age group (19-49 years) were studied in the study area. 371 (48.31%) women had age between 26 and 35 years followed by 19-25 years (38.28%). Most of them were Hindu (66.93%) and belonged to general category (41.01%). 362 (47%) women were in the upper lower class followed by 192 (25%) in lower socioeconomic class while around 27% were above the upper lower socioeconomic class (according to Modified B. G. Prasad classification). 409 (53.25%) women were housewives and did all routine activity followed by laborer (14.06%) and business of own (12.52%) (Table 1).
Nearly 42% women reported the source of water as public hand pumps followed by piped water supply and they did not take any extra step to make the water safe for drinking. Only 3.55% of women told that they drink RO water. Around 63% of the families reported storing water in a proper way in a utensil, and nearly half of them reported cleaning of the utensils at least once a day (Figures 1 and 2).
Open defecation was still a reported practice in the study area, and 221 (29%) women reported about open defecation. The main places for defecation were open drains, nearby lands and the streets. Among the total women, 485 (63.15%) reported washing their hands after defecation. Nearly, one-third women reported washing their hands before eating and food preparation and out of them 38% using soap for hand washing (Table 2).
Total 199 (25.9%) had suffered with NTDs in past 1 year and primarily seeking care while 54 (7.03%) needed hospitalization. A highly significant association was found with housing condition of kitchen and storage of food. This shows an increase NTDs with unhygienic kitchen and improper storage of food. A significant association was also seen with hand washing habits and place of defecation. Source and storage of drinking water were not found to be statistically significant with NTDs (Table 3).
One of the key measures to prevent NTDs among the population is the use of safe and wholesome drinking water, basic toilets, and proper hygiene practices. Out of the total families, 42% reported the source of water as public hand pumps and doing nothing at home to make the water safe for drinking. Around 63% of the families reported storing water in a proper way in a utensil. Open defecation was still a reported practice in 29% respondents. One-third of respondents reported washing their hands before eating and after defecation and only 37% using soap for hand washing after defecation. A significant association was found between NTDs and condition of kitchen, storage of food, hand washing habits, and place of defecation. Overall, among the participants, there were both lack of adequate hand washing and sanitation practices.
This study revealed that source of water as public hand pumps followed by piped water supply similar to study by Reddy et al.  This was lower as compared to data reported in Census 2011 of Jhansi district households (94.1%).  According to data of the number of households with an improved drinking water source 96.4% in NFHS 4 Uttar Pradesh.  Majority of households did not take any step for making water safe to drink in the study area similar to study by Kuberan et al. (45%).  Around three-fourth did not store water in a proper way in a utensil, and nearly half of them use un-cleaned utensils similar to Reddy et al.  Open defecation was still a reported practice in the study area and 29% women reported about open defecation similar to study of Kuberan et al.  and lower than data of NFHS 4, Uttar Pradesh  and Reddy et al.  In this study only one-third of women washed their hands before eating and food preparation and merely 38% using soap for hand washing after defecation. Our finding was lower as compared to the study of Reddy et al.,  Ray et al.,  and Wilson.  The study shows significant association with hand washing habits and place of defecation. A highly significant association was found with housing condition of kitchen and storage of food. The study revealed that an increase NTDs with unhygienic kitchen and improper storage of food. A significant association was also seen with hand washing habits and place of defecation. According to the WHO, targeted water and sanitation interventions are expected to bolster ongoing efforts in tackling 16 out of the 17 NTDs, which affect more than 1 billion of the world's poorest and most vulnerable populations. Paucity of safe water sources, open defecation and lack of hygiene are also an important risk factor for the transmission of many NTDs. 
This is a community-based study with adequate sample size and findings are generalized to slums population. It is a unique work in the field of WaSH and NTDs in Bundelkhand region. Our study had certain limitations. There is a possibility of recall bias, and for the better understanding of WaSH practices, one needs a qualitative study. The cross-sectional study design limited the temporality of the association between WaSH and NTDs.
WaSH practices are one of the largest causes of morbidity and mortality in children. Overall, among the participants, there were both lack of adequate hand washing and sanitation practices. Gaps in hygiene practices of study households are a matter of public health concern. The present study found a need for improvement in WaSH practices of the people of slum population, especially those related to the use of sanitary latrines, hand washing, and water treatment practices. There is an immense need for sensitization of slum population through health education and promotion to improve the health and environment conditions. A community-based intervention program needs to be carried out to educate the slum people about appropriate water storage and retrieval methods and sanitation and hand washing practices.
Access this article online
Quick Response online
[1.] Available from: https://www.unicef.org/wash/index.html. [Last accessed on 30 Jun 2017].
[2.] Reddy BV, Kusuma YS, Pandav CS, Goswami AK, Krishnan A. Water and sanitation hygiene practices for under-five children among households of sugali tribe of Chittoor district, Andhra Pradesh, India. J Environ Public Health. 2017; 2017:7517414.
[3.] Available from: http://www.who.int/water_sanitation_ health/en. [Last accessed on 02 Jul 2017].
[4.] Available from: http://www.censusindia.gov.in/2011-Common/ CensusData2011/Slums. [Last accessed on 03 Jul 2017].
[5.] Children: Reducing Mortality. May, 2016. Available from: http://www.who.int/mediacentre/factsheets/en. [Last accessed on 03 Jul 2017].
[6.] Rah JH, Cronin AA, Badgaiyan B, Aguayo V, Coates S, Ahmed S. Household sanitation and personal hygiene practices are associated with child stunting in rural India: A cross-sectional analysis of surveys. BMJ Open. 2015; 5(2):e005180.
[7.] Available from: http://www.swachhbharaturban.in/sbm/home/ SBM. [Last accessed on 06 Jul 2017].
[8.] Available from: http://www.smartcities.gov.in/content/.list of proposed city list.pdf.
[9.] Lobo DA, Velayudhan R, Chatterjee P, Kohli H, Hotez PJ. The neglected tropical diseases of India and South Asia: Review of their prevalence, distribution, and control or elimination. PLoS Negl Trop Dis. 2011; 5(10):e1222.
[10.] Available from: http://www.census2011.co.in/census/ district/537-jhansi.html. [Last accessed on 30 Jun 2017].
[11.] National Family Health Survey-4. State Fact Sheet Uttar Pradesh, 2015-2016. Available from: http://www.NFHS/pdf/ NFHS4/UP_FactSheet.pdf. [Last accessed on 06 Jul 2017].
[12.] Kuberan A, Singh A, Kasav JB, Prasad S, Surapaneni KM, Upadhyay V, et al. Water and sanitation hygiene knowledge, attitude, and practices among household members living in rural setting of India. J Nat Sci Biol Med. 2015; 6 Suppl 1:S69-74.
[13.] Ray SK, Zaman FA, Laskar NB. Hand washing practices in two communities of two states of Eastern India: An intervention study. Indian J Public Health. 2010; 54(3):126-30.
[14.] Wilson JM, Chandler GN. Sustained improvements in hygiene behavior amongst village women in Lombok, Indonesia. Trans R Soc Trop Med Hyg. 1993; 87(6):615-6.
How to cite this article: Agarwal R, Tiwari N, Malhotra AK. Water, sanitation, and h ygiene practices among population living in slums, Jhansi, Uttar Pradesh, India. Int J Med Sci Public Health 2017; 6(10):1533-1537.
Source of Support: Nil, Conflict of Interest: None declared.
Renu Agarwal, Nitin Tiwari, Anil Kumar Malhotra
Department of Community Medicine, Maharani Laxmi Bai Medical College, Jhansi,
Uttar Pradesh, India
Correspondence to: Renu Agarwal, E-mail: firstname.lastname@example.org
Received: August 12 2017, Accepted: September 05, 2017
Table 1: Distribution of mothers by sociodemographic determinants Variables Frequency N=768 (%) Age (years) 19-25 294 (38.28) 26-35 371 (48.31) 36-49 103 (13.41) Religion Hindu 514 (66.93) Muslim 209 (27.21) Others 45 (5.86) Category General 315 (41.01) OBC 239 (31.12) SC 196 (25.52) ST 18 (2.34) Socioeconomic status * Upper 8(1.04) Upper middle 76 (9.89) Lower middle 130 (16.94) Upper lower 362 (47.13) Lower 192 (25.00) Occupation Housewife 409 (53.25) Laborer 108 (14.06) Unskilled worker 25 (3.25) Semi-skilled worker 106 (13.80) Skilled worker 24 (3.12) Business 96 (12.52) * Moditled B. G. Prasad classification Table 2: Distribution by place of defecation and hand washing habits Variables Frequency (%) Place of defecation Open 221 (28.78) House latrine 547 (71.22) Hand washing habits After defecation 485 (63.15) Before eating and 272 (35.42) food preparation Both 11 (1.43) Table 3: Association of WaSH with NTDs Variables NTDs in last 1 year [chi square] Yes No d.f. (N=199) (N=569) P value Source of drinking water Hand pump in house 83 194 5.7 3 0.1 Public hand pump 67 231 Piped (Tap water) 41 108 RO water 8 36 Storage of drinking water Stored not properly 86 220 3.01 1 0.2 Stored properly 113 349 Washing hand habits of respondent After defecation 63 146 72.36 2 0.00 * Before eating and 22 246 after defecation Washing intermittently 114 177 Condition of kitchen Clean 59 264 16.97 1 0.00 * Unclean 140 305 Storage of food Stored properly 63 260 11.91 1 0.001 * Not properly 136 309 Place of defecation House latrine 81 179 5.62 1 0.01 * Open field 118 390 [[chi].sup.2]: Chi-square value, d.f.: Degree of freedom, * P<0.05 taken as significant. WaSH: Water, sanitation and hygiene, NTDs: Neglected tropical diseases Figure 1: Source of drinking water in houses Piped 28.01% (Tap water) Hand pump 26.24% in house Public hand 42.20% pump RO water 3.55% Note: Table made from bar graph. Figure 2: Storage of water in house Stored not properly 37.05% Stored properly 62.95% Note: Table made from pie chart.
|Printer friendly Cite/link Email Feedback|
|Title Annotation:||Research Article|
|Author:||Agarwal, Renu; Tiwari, Nitin; Malhotra, Anil Kumar|
|Publication:||International Journal of Medical Science and Public Health|
|Date:||Oct 1, 2017|
|Previous Article:||Carotid artery intimal media thickness and ankle brachial index as predictors for atherosclerosis in pre-diabetic patients.|
|Next Article:||Visual, aural, read/write, and kinesthetic: An assessment of learning styles among undergraduate medical students of M R Medical College, Kalaburagi.|