Effectiveness of a community-based water, sanitation, and hygiene (WASH) intervention in reduction of diarrhoea among under-five children: Evidence from a repeated cross-sectional study (2007-2015) in rural Bangladesh.

Diarrhoea, the most common disease directly related to water, sanitation, and hygiene (WASH), still remains one of the most significant health problems among children under-five worldwide. In this reality, BRAC, the largest NGO in the world initiated a comprehensive WASH intervention in 50 upazilas (sub-districts) of Bangladesh in 2007 which was later scaled up to cover 150 upazilas in two subsequent phases. The intervention period of the programme was 2007-2011. The present study encompassed 30 upazilas of the first phase of intervention. The aim of the study was to investigate the effectiveness of this intervention on reduction of diarrhoea among under-five children, and to identify the factors associated with childhood diarrhoea. A repeated cross-sectional study design was followed, and a population-based survey was carried out on four occasions: baseline (2007), midline (2009), endline (2011), and post-endline (2015) among 4,775 households. This analysis considers only households having at least one under-five children. Absence of handwashing practice with soap after defecation and before eating food, unclean latrine condition, and unsafe disposal of child faeces were identified as significant risk factors associated with under-five diarrhoea from Log-binomial regression. The prevalence of under-five diarrhoea within the past 2 weeks of the survey declined from 13.7% at baseline to 3.6% at end-line (p < 0.001) in the WASH intervention area. However, the progress seemingly stalled after 2011, which may have occurred due to the lack of improvement in unsafe disposal of child faeces and unclean latrine condition after the intervention period. Study findings suggest that, to reduce the prevalence of childhood diarrhoea it is important to promote safe disposal of child faeces, maintaining cleanliness of latrines, and washing hand with soap at critical times, beyond merely increasing the sanitation coverage. Findings also underline the necessity of maintaining a small-scale monitoring component involving local community, such as a WatSan committee (a local committee comprising the user communities for supervising WASH related activities) for periodic monitoring at household level for a certain period after the program intervention works to make the behavioural change more sustainable and to keep the reduction rate of under-five diarrhoeal prevalence steady.

Microbial contamination of drinking water from risky tubewells situated in different hydrological regions of Bangladesh.

This study, conducted in 40 selected upazilas covering four hydrological regions of Bangladesh, aimed at determining the risk of selected shallow tubewells (depth<30m) used for drinking purpose (n=26,229). This was based on WHO's sanitary inspection guidelines and identifying the association of sanitary inspection indicators and risk scores with microbiological contamination of shallow tubewells. The main objective of the study was to observe the seasonal and regional differences of microbial contamination and finally reaching a conclusion about safe distance between tubewells and latrines by comparing the contamination of two tubewell categories (category-1: distance ≤10m from nearest latrine; n=80 and category 2: distances 11-20m from nearest latrine; n=80) in different geographical contexts. About 62% of sampled tubewells were at medium to high risk according to WHO's sanitary inspection guidelines, while the situation was worst in south-west region. Microbiological contamination was significantly higher in sampled category-1 tubewells compared to category-2 tubewells, while the number of contaminated tubewells and level of contamination was higher during wet season. About 21% (CI95=12%-30%), 54% (CI95=43%-65%) and 58% (CI95=46%-69%) of water samples collected from category-1 tubewells were contaminated by E. coli, FC, and TC respectively during the wet season. The number of category-1 tubewells having E.coli was highest in the north-west (n=8) and north-central (n=4) region during wet season and dry season respectively, while the level of E.coli contamination in tubewell water (number of CFU/100ml of sample) was significantly higher in north-central region. However, the south-west region had the highest number of FC contaminated category-1 tubewells (n=16 & n=17; respectively during wet and dry season) and significantly a higher level of TC and FC in sampled Category-1 tubewells than north-west, north-central and south-east region, mainly during wet season. Multivariate regression analysis could identified some sanitary inspection indicators, such as tubewell within <10m of latrine, platform absent/broken, pollution source (i.e. household's waste dumping point/poultry/dairy farm) within 10m of tubewell and unimproved sanitation facility which were significantly associated with presence of microbial contaminants in tubewell water (p<0.01). A tubewell with high risk level was associated with a higher chance of having FC and TC in tubewell water than a tubewell with a medium risk during wet season, but no such conclusion could be drawn in case of E.coli contamination. Construction of pit latrine in areas with high water table should be highly discouraged. Raised sealed pits or flush/pour flash to septic tank could be installed considering sanitary inspection criteria. Water should be treated before drinking.

Transition overtime in household latrine use in rural Bangladesh: a longitudinal cohort study.

BACKGROUND: In a low-income country like Bangladesh, where the poverty rate is higher in rural compared to urban areas, the consistent use of sanitary latrines over time is a challenge. To address this issue, the Water, Sanitation, and Hygiene (WASH) program of the Bangladesh Rural Advancement Committee (BRAC) was devised to improve health of the rural poor through enhanced sanitation services, such as by providing loans or education. Sanitary latrine use in households and changes over time were assessed in this study. METHODS: This was a longitudinal cohort study of the baseline, midline, and end line status of the WASH project. Households assessed in all three rounds of surveys (26,404 in each survey) were included in the analysis. Thirty thousand households from 50 upazilas (sub-districts) were selected in two stages: i) thirty villages were selected from each of the 50 upazilas by cluster sampling, and ii) twenty households were chosen systematically from each selected village. A female member capable of providing household-level information was interviewed from each house using the pre-tested questionnaire. Spot observations of some components were made to assess the quality of sanitary latrine use. The adjusted log-binomial regression was performed and risk ratios with 95% confidence intervals were estimated for sanitary latrine use. Data were analyzed using Statistical Package for the Social Sciences (SPSS) and Stata software. RESULTS: The use of sanitary latrines by households increased significantly from the baseline (31.7%) to midline (41.5%) and end line (57.4%) assessment points. The proportion of physically verified clean latrines increased significantly from 33.4% at baseline to 50.8% at the midline and 53.3% at the end line. Analysis of changes in latrine-use showed that 73.3% of the baseline latrine-using households continued to do so at the end line, while the rest switched to unsanitary practices. Households with better socioeconomic status were more likely to use sanitary latrines. CONCLUSION: There are improvements in ownership and use of sanitary latrines by households over the years in WASH intervention areas. However, switching of some households from sanitary to unsanitary latrines remains a matter of concern regarding sustainability.

Exploring the gap between hand washing knowledge and practices in Bangladesh: a cross-sectional comparative study.

BACKGROUND: Hand washing is considered as one of the most effective hygiene promotion activities for public health in developing countries. This study compared hand washing knowledge and practices in BRAC's water; sanitation and hygiene (WASH) programme areas over time. METHODS: This study is a cross-sectional comparative study between baseline (2006), midline (2009) and end-line (2011) surveys in 50 sub-districts from the first phase of the programme. Thirty thousand households from 50 sub-districts were selected in two steps: i) 30 villages were selected from each sub-district by cluster sampling, and ii) 20 households were chosen systematically from each village. The matched households were considered (26,404 in each survey) for analysis. Data were collected from households through face-to-face interview using a pre-tested questionnaire. Respondents were the adult female members of the same households, who had knowledge of day-to-day household activities related to water, sanitation and hygiene. RESULTS: A gap between perception and practice of proper hand washing practices with soap was identified in the study areas. Hand washing practice with soap before eating was much lower than after defecation. In baseline data, 8% reported to wash their hands with soap which significantly increased to 22% in end line. Hand washing knowledge and practices before cooking food, before serving food and while handling babies is considerably limited than other critical times. A multivariate analysis shows that socio-economic factors including education of household head and respondent, water availability and access to media have strong positive association with hand washing with soap. CONCLUSION: Gap between knowledge and practice still persists in hand washing practices. Long term and extensive initiatives can aware people about the effectiveness of hand washing.