Demand-based water options for arsenic mitigation: an experience from rural Bangladesh.

A supply of safe drinking water is a recognized global concern. The arsenic contamination of groundwater in Bangladesh and other countries has furthered this concern. Lack of appropriate water options is one of the main barriers to the supply of safe drinking water for 30-60 million people who are exposed to the risk of drinking arsenic-contaminated water in Bangladesh. This paper describes the experience from a water supply programme for arsenic mitigation based on demand and participation of 30,000 rural people in Srinagar, a subdistrict of Bangladesh. About 85% of the 912 tubewell water samples tested had an arsenic content higher than 0.05 mg/l. The project promoted 11 options including groundwater, surface-water and rainwater-harvesting household-based options as well as community managed technologies. Most people, particularly women, wanted piped water, and hand-operated deep tubewells were also requested. Four cluster-based motorized piped water systems, 20 home-based arsenic-removal options (two types) and an arsenic-removal filter plant were installed. The public contributed about 49, 25 and 20% of the installation costs of piped water, home-based options and filter options, respectively, and 100% of all operation and maintenance costs. The household options and filter plant were abandoned within a few weeks. Reportedly, those options required too much attention, discharged small volumes of water at low rates, were difficult to maintain, and discharged poor-quality water. The proportion of families (54%) that drank arsenic-contaminated water during the final survey was significantly lower than in the baseline survey (87%). For arsenic-affected areas, it is recommended that a cluster-based piped water system be given proper consideration when selecting appropriate water options rather than household-based options or the development of new low-cost options.

Handwashing practices and challenges in Bangladesh.

Handwashing is universally promoted in health interventions. Studies in Bangladesh and elsewhere have shown a 14 - 40% reduction of diarrhoeal diseases with handwashing. The perceptions and methods related to washing of hands vary widely in Bangladesh. Socio-economic factors are also associated with methods practised. In general, the effectiveness of handwashing practices is poor. Faecal coliform bacteriological counts were reported to be high for both left and right hands. About 85% of women studied who lived in slums and 41% of rural women washed their hands using only water. However, most women rubbed their hands on the ground, or used soil, and rinsed them with water during post-defecation handwashing. Most women claimed that they could not afford to buy soap. Experimental trials showed that use of soap, ash or soil gave similar results when women washed their hands under the same conditions. The washing of both hands, rubbing of hands, and the amount and quality of rinsing water used were found to be important determinants in the reduction of bacterial counts on hands. Although handwashing messages have been revised by most of the main programmes after these studies, there is scope for further improvement, as well as evaluation of their impact.

Recommendations for water supply in arsenic mitigation: a case study from Bangladesh.

Arsenic problems have been observed in several countries around the world. The challenges of arsenic mitigation are more difficult for developing and poor countries due to resource and other limitations. Bangladesh is experiencing the worst arsenic problem in the world, as about 30 million people are possibly drinking arsenic contaminated water. Lack of knowledge has hampered the mitigation initiatives. This paper presents experience gained during an action research on water supply in arsenic mitigation in rural Singair, Bangladesh. The mitigation has been implemented there through integrated research and development of appropriate water supply options and its use through community participation. Political leaders and women played key roles in the success of the mitigation. More than one option for safe water has been developed and/or identified. The main recommendations include: integration of screening of tubewells and supply of safe water, research on technological and social aspects, community, women and local government participation, education and training of all stakeholders, immediate and appropriate use of the available knowledge, links between intermediate/immediate and long term investment, effective coordination and immediate attention by health, nutrition, agriculture, education, and other programs to this arsenic issue.

Water, sanitation and diarrhoea.

Water, sanitation and health are inseparably linked. Diarrhoea and other water related diseases are the major causes of health problems in developing countries. Although the need for water and sanitation interventions for health promotion has been recognised, these are labeled as costly and are often neglected in the primary healthcare programmes. Lack of proper water and sanitation initiatives based on appropriate techniques, technologies, knowledge and/or implementation methods have hindered the expected achievements through water and sanitation interventions. Since water and sanitation initiatives include both availability of provisions and their effective use (which mean behavioral changes), they are technically and socially challenging. Disasters and emerging water quality problems, such as arsenic in groundwater, have further been complicating this situation. After reviewing relevant articles, several research issues are suggested in the context of developing country perspectives.

Effects of environmental factors on child survival in Bangladesh: a case control study.

The need for further studies on relationships between deaths and environmental variables has been reported in the literature. This case-control study was, therefore, carried out to find out the associations between several social and environmental variables and deaths of children due to infectious diseases such as those leading to diarrhoea, acute respiratory infection, measles and other diseases. Six hundred and twenty-five deaths (cases) and an equal number of matched living children (controls) aged 1-59 months, were studied in rural Matlab. An analysis of crude and adjusted odds ratio showed differential associations. Sources of drinking water, amount of stored water, conditions of latrines, number of persons sleeping with the child and the type of cooking site were statistically significantly associated with deaths due to infectious diseases after controlling for breast feeding, immunization, and the family size. Significant associations were also observed between: (i) the sources of drinking water and deaths due to ARI, and (ii) conditions of latrines and deaths due to diarrhoeal diseases, after controlling for the confounding variables. Several other environmental factors also showed associations with these various death groups, but they were not statistically significant. The size of the samples in death groups (small) and the prevalence of more or less homogeneous environmental health conditions probably diminished the magnitude of the effects. The results of the study reconfirm the importance of environmental health intervention in child survival, irrespective of breast-feeding, immunization, and selected social variables.

PIP: Findings are reported from a case-control study conducted to assess the associations between several social and environmental variables and deaths of children due to infectious diseases, such as those leading to diarrhea, acute respiratory infection (ARI), measles, and other diseases. 625 deaths (cases) and an equal number of matched living children (controls) aged 1-59 months were studied in rural Matlab. Sources of drinking water, the amount of stored water, latrine conditions, the number of persons sleeping with the child, and the type of cooking site were statistically significantly associated with deaths due to infectious diseases after controlling for breast-feeding, immunization, and family size. Significant associations were also observed between sources of drinking water and deaths due to ARI, and conditions of latrines and deaths due to diarrheal diseases, after controlling for confounding variables. No other statistically significant environmental factors were associated with these various death groups. Study results confirm the importance of environmental health interventions in child survival, irrespective of breast-feeding, immunization, and selected social variables.

Water management practices in rural and urban homes: a case study from Bangladesh on ingestion of polluted water.

Although Bangladesh has achieved remarkable success in extending the availability of hand pumped and piped water, unsafe water is still ingested. This brief study attempted to assess water management practices in rural and urban homes in Bangladesh so as to establish the routes by which unsafe water is ingested, to examine methods of collection and storage, and determine why unsafe water sources are used when unsafe supplies are available. Forty-eight rural and forty-five urban slum households were studied. Observations, interviews and water quality investigations were conducted. The results show that the respondents were aware that hand pump/tap water is safe and took care to use these safe sources for drinking purposes. However, they continued to use surface water for non-drinking activities such as bathing, washing and rinsing their mouths. Reasons were given that it was a traditional practice to bathe in surface water and was more enjoyable. One of the reasons given for not using hand pumped water to wash clothing and food was that such groundwater caused staining. Bacteriological results from such ingested water showed the quality, especially in rural areas, to be poor. Results also showed the internal surfaces of the base of storage containers to be heavily contaminated with bacteria. This showed that water that was safe when it was first drawn would became contaminated during storage. This study had a limited scope; much further research is needed to find what determines and how water becomes contaminated in containers. These factors include how to reduce contamination of water, in particular the relationship between growth of bacteria in stored water and the material from which the container is made and how to improve the overall quality of water. On the management side, studies could be conducted as to how to improve people's understanding of the use of water for domestic purposes and its safe management.

Sustainability of a water, sanitation and hygiene education project in rural Bangladesh: a 5-year follow-up.

An integrated water supply, sanitation and hygiene (WSH) education intervention project was run by the International Centre for Diarrhoeal Disease Research, Bangladesh, over the period 1983-87. In the intervention area the project provided handpumps, pit latrines, and hygiene education to about 800 households. The control population did not receive any interventions, but had access to the usual government and private WSH facilities. After 1987 no external support was provided to maintain these provisions. A cross-sectional follow-up survey, which was carried out in 1992, involved about 500 randomly selected households from the intervention and control areas. In 1992 about 82% of the pumps were still in good functional condition and of these, 94% had been functioning well in 1987. Fewer latrines were functional in 1992 (64%) than at the end of 1987 (93%). In the former intervention area about 84% of the adults were using sanitary latrines in 1992 compared with only 7% in the control area. Knowledge related to disease transmission, however, was poor and similar in both areas. People claimed that they used the WSH facilities to improve the quality of their lives. The prevalence of diarrhoeal diseases in the 1992 survey among the control population was about twice that among those in the intervention area.

PIP: This study presents the findings of a 1992 follow-up survey to determine the behavioral and health benefits of the Mirzapur Handpump Project during 1984-92. The project was part of an integrated water supply, sanitation, and hygiene (WSH) education intervention project run by the International Center for Diarrheal Disease Research in Bangladesh. The project was implemented during 1984-87 in five villages in Mirzapur subdistrict among 880 households with 148 improved handpumps, one twin pit latrine for almost every household, and extensive hygiene education. The control area included 750 households with about 42 handpumps. Local women participated in selecting installation sites, maintaining tubewells and latrines, and collecting data. The last program repairs were made in 1987. Findings from the 1992 survey reveal that the percentage of working pumps declined from 100% to 82% during 1987-92. 75% of respondents believed that maintenance was shared by users. The remaining 25% in the intervention area and all in the control area claimed that repair was taken care of by the owners. 84% used tubewell water because of the improved quality. Use of sanitary latrines was the same over time. Use was 83% in the intervention area and only 8% in the control area. There was a decline in the percentage of proper functioning latrines from 98% in 1987 to 64% in 1993. Hygiene practices remained poor in 1993, but still higher than in the control area. Knowledge of the transmission of diarrhea was poor in 1992 and similar in control and intervention areas. Diarrheal morbidity in the previous 24 hours was significantly lower in the intervention area. Findings indicate improvement in health practices but little understanding of WSH practices and improved health. The monitoring measures were useful in determining project sustainability.

Sustainability of a water, sanitation and hygiene education project in rural Bangladesh: a 5-year follow-up

An integrated water supply, sanitation and hygiene (WSH) education intervention project was run by the International Centre for Diarrhoeal Disease Research, Bangladesh, over the period 1983-87. In the intervention area the project provided handpumps, pit latrines, and hygiene education to about 800 households. The control population did not receive any interventions, but had access to the usual government and private WSH facilities. After 1987 no external support was provided to maintain these provisions. A cross-sectional follow-up survey, which was carried out in 1992, involved about 500 randomly selected households from the intervention and control areas. In 1992 about 82% of the pumps were still in good functional condition and of these, 94% had been functioning well in 1987. Fewer latrines were functional in 1992 (64%) than at the end of 1987 (93%). In the former intervention area about 84% of the adults were using sanitary latrines in 1992 compared with only 7% in the control area. Knowledge related to disease transmission, however, was poor and similar in both areas. People claimed that they used the WSH facilities to improve the quality of their lives. The prevalence of diarrhoeal diseases in the 1992 survey among the control population was about twice that among those in the intervention area.

Research methodology for developing efficient handwashing options: an example from Bangladesh.

Handwashing has been universally promoted for health interventions, but it is essential that the factors related to behaviour are understood in order to develop appropriate handwashing messages. We found the study of behaviour complex and had to combine several methods: in-depth interviewing, questionnaire; observational and bacteriological. Here we present our experiences in developing efficient handwashing options for rural Bangladesh. The components of handwashing practices after defecation of 90 rural women were studied (phase 1). During phase 1 an in-depth interview was used to design the observational and questionnaire surveys. Behaviour was observed using a semi-structured record form and the effectiveness of the acts was measured by means of bacteriological tests. A questionnaire survey was undertaken on socioeconomic and water sanitation-related variables since they influence behaviour. Then, to develop efficient handwashing options, an experimental phase (phase 2) tested the bacteriological efficacy of the components found appropriate in phase 1. The effectiveness of the handwashing practices is believed to be poor since the bacteriological counts were found to be high (faecal coliform count of the left hand 1995, and of the right hand 1318 colony forming units/hand). The practice comprised several components: use of an agent, handedness, frequency of rubbing, source and volume of rinsing water, and drying of the hands. Seventy-five per cent of the women reported that they could not afford soap. The experimental trials showed that soap, ash and soil give similar results under similar conditions of handwashing (faecal coliform counts of left hands: 195 (soap), 98 (ash), 129 (soil) and of right: 112 (soap), 54 (ash) and 89 (soil) cfu/hand). The use of multi-method techniques in the study helped to understand and develop efficient handwashing options.

Post-defecation handwashing in Bangladesh: practice and efficiency perspectives.

Inadequate handwashing after defecation and anal cleaning practices in the Indian subcontinent is an important source of faeco-oral transmission of enteric diseases. To better understand the process as traditionally practised, 90 women in semi-rural Bangladesh were observed washing hands after defecation. Several components of handwashing practices were identified: the cleaning agent, using left or both hands; frequency of rubbing hands, type and amount of water used to wash, and the drying of hands on the wearer's clothes. A subsequent experiment was conducted to assess the effect of currently practised handwashing and drying according to standardised procedure on faecal coliform count of hands. As a rubbing agent, soil was commonly used (40%); soap was used by 19% and was reported unaffordable by about 81% of the non-users. Good handwashing behaviour was positively associated with better social and economic indicators including education of the women observed. Both hands were unacceptably contaminated after traditional handwashing (the geometric mean count of left was 1,995 and right hand was 1,318 faecal coliform units/hand). After standardising the observed components of handwashing procedures the use of any rubbing agent, i.e. soil, ash or soap, produced similar acceptable cleaning. Use of a rubbing agent (e.g. soil, ash or soap), more rubbing (i.e. six times), rinsing with safer water (e.g. 2 litres of tubewell water) and drying with a clean cloth or in the air produced acceptable bacteriological results. Components of traditional handwashing practices were defined through careful observation, and experiments on handwashing with standardised components showed that efficient and affordable options for handwashing can be developed; this knowledge should be helpful in disease control programmes.

Women's involvement in a rural Bangladesh water and sanitation project.

Rural women were involved in a water and sanitation project (WSS) in which health impacts were compared between children in two areas: intervention and comparison areas. In intervention area people were provided with handpumps, latrines and hygiene education, whereas, in the comparison area, people did not receive these project inputs. In the intervention area women were directly involved in the site selection of handpumps and latrines, their installation, construction, and maintenance. Observations on women's involvement and their performances in the intervention area are presented. About 89% of the pumps maintained by women (n = 30), and 86% of those maintained by project workers (n = 49) were found to be in good working condition. Women supervised the construction of all 754 latrines, fenced 58% of the projects-supported latrines (n = 268) and emptied the pits of 65% of the 276 filled-up latrines. Socio-cultural factors were not barriers to women's involvement and performance. The findings have policy implications for effective involvement of rural women towards the development of sustainable WSS programs.

A comparison of local handwashing agents in Bangladesh.

The efficacy of handwashing using ash, soap, mud or plain water was tested in a group of 20 women living in a slum of Dhaka in Bangladesh. Each woman was asked to wash her hands using each of the washing agents and the efficacy of handwashing was assessed by comparing estimated faecal coliform counts from post-washing hand samples. Mud and ash were found to be as efficient as soap. Research on appropriate handwashing techniques in the light of the existing practices is suggested.

Reduction in diarrhoeal diseases in children in rural Bangladesh by environmental and behavioural modifications.

The impact of a water, sanitation and hygiene education intervention project on diarrhoeal morbidity in children under 5 years old was evaluated in a rural area of Bangladesh. Data were collected throughout 1984-1987, covering both pre- and post-intervention periods, from an intervention and a control area. The 2 areas were similar with respect to most socio-economic characteristics and baseline levels of diarrhoeal morbidity. The project showed a striking impact on the incidence of all cases of diarrhoea, including dysentery and persistent diarrhoea. By the end of the study period, children in the intervention area were experiencing 25% fewer episodes of diarrhoea than those in the control area. This impact was evident throughout the year, but particularly in the monsoon season, and in all age groups except those less than 6 months old. Within the intervention area, children from households living closer to handpumps or where better sanitation habits were practised experienced lower rates of diarrhoea. These results suggest that an integrated approach to environmental interventions can have a significant impact on diarrhoeal morbidity.

Iron in tubewell water and linear growth in rural Bangladesh.

The growth of 694 children from rural Bangladesh was studied. Children drinking water containing greater than 1 mg iron/l (n = 628) were significantly taller than those drinking less than 1 mg iron/l (n = 66): their mean (SD) height for age Z score was -2.10 (1.34) compared with -2.45 (1.24), p less than 0.05. This suggests that iron deficiency may contribute to growth retardation in poor communities.

Water supply, sanitation and hygiene education: report of a health impact study in Mirzapur, Bangladesh

The UNDP-World Bank Water and Sanitation Program was organized as a joint endeavor of the United Nations Development Programme and the World Bank and has been one of the primary players in worldwide efforts to meet the challenge of providing basic water supply and sanitation services to those most in need in the developing world. Partners in this venture are the developing countries themselves and the multilateral and bilateral agencies that fund the Program's activities. Tle UNDP-World Bank Water and Sanitation Program produces its own publications and also releases vicrks under the auspices of the World Bank. The Program's publications are divided into two series, a Water and Sanitation Program Report series and a Water and Sanitation Discussion Paper series. The Program Report series presents formal discussions of the Program's operations and research activities as well as examinations of relevant projects and trends within the water and sanitation sector. Program Reports are subject to rigorous external review by independent authorities from appropriate fields. The Discussion Paper series is a less formal means of communicating timely and topical observations, findings, and opinions concerning Program activities and sector issues

Lack of impact of a water and sanitation intervention on the nutritional status of children in rural Bangladesh.

The nutritional impact of a water and sanitation intervention in a rural community of Bangladesh, comprising the provision of handpumps, construction of latrines and hygiene education was assessed. During 3 years, the quarterly anthropometric measures of about 200 children aged 12-35 months from the intervention community were compared with those of a similar number of children from a control area. The interventions reduced the incidence of diarrhoea by 25 per cent among the children less than 5 years of age. There was no significant difference in nutritional status, however, between the two groups of children. Moreover, within the intervention area, indicators of water and latrine use were not significantly related to the children's nutritional status. This suggests that either the obtained reduction of diarrhoea was not large enough to have an impact on nutritional status or that diarrhoea is not an important cause of malnutrition in this community.

Persistent diarrhoea in a rural area of Bangladesh: a community-based longitudinal study.

As part of a health impact evaluation of a water supply and sanitation project in a rural area of Bangladesh, diarrhoeal morbidity was recorded in children 0-4 years of age using weekly recall in household interviews, during the period March 1984 to December 1987. During the baseline year, 1984, the incidence rate of all diarrhoea episodes (3.8 episodes per child per year), and those defined as persistent, duration greater than 14 days (0.6 episodes per child per year), showed a similar age distribution, peaking in the 12-23 month age group. Sixteen per cent of all episodes were classified as persistent, and this proportion was greatest in the 0-5 month age group (25%). Children suffering at least one episode of persistent diarrhoea in 1984 also experienced a higher incidence of acute diarrhoea (less than = 14 days duration) than those suffering acute diarrhoea only (4.2 versus 3.7 episodes per child per year). Persistent diarrhoea showed a similar seasonal pattern to that of all episodes. Rates of abdominal pain, isolation of Shigella spp and a diagnosis of dysentery were significantly higher in persistent episodes than in acute episodes. Closer follow-up of children during 1986 and 1987, through the recording of all periods of absence of the child from the home, showed that overall diarrhoea incidence rates were little affected when absence was taken into account, but that the incidence of persistent diarrhoea and the proportion of episodes classified as persistent were significantly reduced. The implications of this methodological problem are discussed.