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Water, sanitation, and hygiene practices among population living in slums, Jhansi, Uttar Pradesh, India.

INTRODUCTION

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. [1]

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. [3]

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. [4]

A significant proportion of deaths can be prevented through safe drinking water, adequate sanitation, hygiene, and immunization, proper infant feeding, and enabling environments. [5] 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. [8] 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.

Study area

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.

Sample Size

The sample size was calculated considering the prevalence of NTDs as 12%. [9] 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 Analysis

Data was entered into a Microsoft Excel spreadsheet and analyzed with Epi Info version 7.2.0.1. Wherever applicable, proportion, percentage, and mean (standard deviation) were calculated and P > 0.05 taken as significant.

RESULTS

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).

DISCUSSION

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. [2] This was lower as compared to data reported in Census 2011 of Jhansi district households (94.1%). [10] According to data of the number of households with an improved drinking water source 96.4% in NFHS 4 Uttar Pradesh. [11] 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%). [12] 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. [2] 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. [12] and lower than data of NFHS 4, Uttar Pradesh [11] and Reddy et al. [2] 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., [2] Ray et al., [13] and Wilson. [14] 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. [3]

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.

CONCLUSION

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.

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Website: http://www.ijmsph.com

DOI: 10.5455/ijmsph.2017.0824506092017001

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REFERENCES

[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: renu.omer@gmail.com

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.
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Article Details
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Title Annotation:Research Article
Author:Agarwal, Renu; Tiwari, Nitin; Malhotra, Anil Kumar
Publication:International Journal of Medical Science and Public Health
Geographic Code:9INDI
Date:Oct 1, 2017
Words:2587
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