Sanitation in rural communities in Bangladesh.

Sanitation in rural communities in Bangladesh M. Yusuf' & A.M. Zakir Hussain2 Household sanitation in developing countries, especially in the rural areas, is poor. An evaluation of what was achieved in this regard during the 1980-90 decade of safe water supply for all was carried out in the present study. It was observed that even where a safe water supply and sanitary latrines were provided, people did not always use them. While 23% of the studied households had sanitary latrines, children in about 11.5% of these households did not use them and women in about 6% of households did not use them for micturition at night. Not a single house in the study area could fulfil all the criteria of sanitary housing in a strict sense; for example, although 34.5% of the households had tubewells, only 11.5% of them had a satisfactory level of water usage. Since socioeconomic conditions and education influence the level of sanitation, improvements in both are required. Introduction A WHO report (1) has shown that three quarters of the urban population in developing countries have more or less adequate excreta disposal facilities com- pared with only 15% in the rural sector. The data also indicated that sanitary conditions in WHO's South-East Asia region were the worst in the world. The list of housing-related diseases is long (2); the three main areas are diseases related to: - over crowding, e.g., respiratory diseases; - materials used in the building, e.g., allergic and parasitic diseases; - deficiencies in water supply and sanitation, e.g., faeco-oral diseases. These diseases are not only responsible for sickness, low life expectancy, and death but also prevent social and economic progress. Domestic sanitation, an important determinant of health or disease in human populations has been neglected in the developing countries. In Bangladesh, one of the least developed countries in the world, communicable diseases and parasitic infestations are widespread and improvements in sanitation are pos- sible only if adequate information is available, on the basis of which planning and evaluations may be undertaken. The principal aim of this study was to collect data on sanitary conditions in the rural areas of Bangladesh where 85% of the population live." Medical Officer, Upazilla Health Complex, Chouddogram, Comilla, Bangladesh. 2 Associate Professor, Department of Epidemiology, National Ins- titute of Preventive and Social Medicine, Mohakhali, Dhaka 1212, Bangladesh. Requests for reprints should be sent to this author. ' Bangladesh Bureau of Statilsts. Statistical pocketbook, 1989. Dhaka, Ministry of Planning, 1989. Reprint No. 5116 Materials and methods The upazilla (administrative unit with about 250 000 population) of Dhamrai in the Dhaka district, 30 km from Dhaka city and well connected by a trunk road, was chosen as the study area. Two out of the 16 unions (the lowest administrative unit with a popula- tion of about 25 000 each), Dhamrai and Kulla, were selected. Four villages (out of an average of 26) from each union were selected by a random process and all the households in these villages were listed; 25 house- holds from 175 (on average) were selected, again by a simple random process, from each of the 8 villages. The total sample size was therefore 200 households. The estimation of sampling error was not under- taken for several reasons. The selected unions were nearest to the upazilla headquarters and their inhabitants, who were the most educated in the upazilla, represented the best situation among the variables. Since the selected areas were homo- geneous, there was minimum variability and no stratification was attempted during, before or after the sampling. The interview questions and check-lists for observation, which were developed, pretested and finalized, were aimed at the following: cleanliness of the living quarters and courtyards, provision of safe water supply, sanitary latrines, separate kitchen, proper setting of the house, amount of floor space per person, refuse and garbage disposal, and the method of sheltering domestic pets and animals. Data were collected by interviewing the head of each household and by observing the sanitary conditions in the homes and their surroundings. Spontaneous response was advocated and no surrogate respondent was accepted. Operational definitions of the variables were worked out and are given in the Annex. The same person (a physician) interviewed all the respondents to avoid bias. Bulletin of he World Health Organization, U (5): 619-624 (1990) ©) World Health Organization 1990 619 M. Yusuf & A.M. Zakir Hussain Results Income and education. Based on the monthly income/ person, the 200 families were classed as low, middle, and upper, having incomes of <400, 400-1100, and >1100 taka, respectively (taka 32 =US$ 1); 65.5% of the study population belonged to the low income group, while 29.5% belonged to the middle and only 5% to the upper class. Investigation of the level of education showed that 82% of the study population was illiterate, while 13% had primary education, 4% up to secondary level, and only 1% to college level. Sanitary conditlons. The majority of houses (60-85%) were unsatisfactory in their setting, in their window areas and in the amount of floor space/person (Table 1). While nearly half the studied households had a separate kitchen, the majority were unsatisfactory regarding cleanliness (>98%) or were found to have insanitary latrines (> 75%) (Table 1). Children in only 50% of the households with sanitary latrines were using them, in comparison to all the adults. However, about 26% of women in these households did not use the latrines at night for micturition. Although the majority of households (89%) were found to use tubewell water for drinking purposes (the rest used dug-well water), only 34.5% had tube- wells in their household and 65.5% had a tubewell within 400 m of their household; 40% of the house- holds, however, had tubewells sunk within 15 metres of a source of pollution. No household used any boiled, filtered or chemically purified water since the members of these households thought it unnecessary except during an outbreak of diarrhoea or during Table 1: Sanitary condition of the 200 households In the survey Satisfactory Unsatisfactory Variables" No. % No. % Site or setting of the house 39 19.5 161 80.5 Window area 29 14.5 171 85.5 Adequate floor space/ person 76 38.0 124 62.0 Separate kitchen 95 47.5 105 52.5 Clean living quarters and courtyards 34 17.0 166 83.0 Sanitary latrine (water seal+ pit latrines) 46 23.0 154 77.0 Safe water supply and usage 23 11.5 177 88.5 Refuse and garbage disposal 3 1.5 197 98.5 Shelter for domestic pets and animals 0 0 200 100.0 Analysed individually. floods. Few households (11.5%) had a satisfactory level of safe water usage and only 1.5% had satisfac- tory refuse and garbage disposal. Not a single house- hold could be found with a satisfactory place for sheltering domestic pets and animals (Table 1). An analysis of the variables, in combinations of two or more, showed that few households (3-12%) were satisfactory in the following: provision of safe water supply and sanitary latrine; safe water supply, sanitary latrine and a separate kitchen; these three and a proper setting of the house; all these plus adequate floor space/person; and all these plus gen- eral cleanliness of the house (Table 2). While no household was found to be satisfactory in more than seven of the variables, about 10% were satisfactory as regards a safe water supply, presence of sanitary latrine (irrespective of its usage), a separate kitchen, and proper setting of the houses. Table 2: Sanitary condition, In combinations of two or more variables, of the 200 households surveyed Satisfactory Unsatisfactory Variables No. % No. % Safe water supply and sanitary latrine 23 11.5 177 88.5 Safe water supply, sanitary latrine, and separate kitchen 23 11.5 177 88.5 Safe water supply, sanitary latrine, separate kitchen, and proper set ting of the house 19 9.5 181 90.5 Safe water supply, sanitary latrine, separate kitchen, proper setting of the house, and adequate floor space/person 12 6 188 94 Safe water supply, sanitary latrine, separate kitchen, proper setting of the house, adequate floor space/person, and cleanliness 7 3.5 193 96.5 Safe water supply, sanitary latrine, separate kitchen, proper setting of the house, adequate floor space/person, cleanliness, and refuse and garbage disposal 2 1.0 198 99.0 Safe water supply, sanitary latrine, separate kitchen, proper setting of the house, adequate floor space/person, cleanliness, refuse and garbage disposal, and shelter for domestic pets and animals 0 0.0 200 100.0 WHO Bulletin OMS. Vol. 68 1990.620 Sanitation In rural communities In Bangladesh Table 3. Sanitary condition of the 200 households according to their socioeconomic condition (class) and level of education No. of households with satisfactory sanitation for the following variables:" Class and education 1 2 3 4 5 6 7 8 Socioeconomic status: Upper class 4 5 6 6 9 6 1 0 (n= 10) (40)b (50) (60) (60) (90) (60) (10) (0) Middle class 7 32 32 19 31 20 2 0 (n= 59) (11.9) (54.2) (54.2) (32.2) (52.5) (33.9) (3.4) (0) Lower class 12 9 57 14 36 8 0 0 (n= 131) (9.2) (6.9) (43.5) (10.7) (27.5) (6.1) (0) (0) Educational level: Illiterate 11 32 72 28 63 17 0 0 (n= 164) (6.7) (19.5) (43.9) (17.1) (38.4) (10.4) (0) (0) Primary 7 6 16 7 8 12 1 0 (n=26) (26.9) (23.1) (61.5) (26.8) (30.8) (46.2) (3.9) (0) Secondary 3 6 4 2 3 4 1 0 (n=8) (37.5) (75) (50) (25) (37.5) (50) (12.5) (0) Higher secondary 2 2 1 2 2 1 1 0 (n=2) (100) (100) (50) (100) (100) (50) (50) (0) ' Key to variables: 1. Safe water supply; 2. Sanitary latrine; 3. Separate kitchen; 4. Proper setting of the house; 5. Adequate floor space/person; 6. Cleanliness of the house; 7. Refuse and garbage disposal; and 8. Shelter for domestic pets and animals. b Figures in parentheses are percentages. Table 3 presents the number of households with satisfactory sanitation for the eight variables in rela- tion to socioeconomic status and educational level of the occupants. Discussion In developing the questionnaire for this study special care was taken not to put sensitive questions at the start. Some conversation always preceded the inter- view. To avoid between-interviewer bias the same per- son (a physician) interviewed all the respondents. Al- though he was from a different socioeconomic back- ground and from another area of Bangladesh, this should not have biased the collected data because of the homogeneous cultural and religious background. All the data collected through interviews were verified by observation, wherever possible, to pre- clude under- or over-reporting. The possibility of recall bias did not arise because the information collected was cross-sectional in nature. There was no non-response or drop-out bias because of the 100% response rate. Since no surrogate responder was necessary or included, a proxy bias did not arise. Studies or interviews that involve identification, clas- sification or categorization of diseases or reference to certain time periods are fraught with biases, which were avoided in the present study. A WHO/UNICEF study in 1975 showed that only 1.7% of houses in Bangladesh had sanitary lat- rines and only 1.1% of children used them.b This study also showed that latrine sanitation in rural Bangladesh was low but had increased to 23% in 13 years. More and faster improvements are very essen- tial. This study also indicated that, despite the presence of a sanitary latrine in a house, children and sometimes women refrained from using them. This indicates a need for health education. Most households (89%) were found to use tube- well water for drinking and the rest used dug-well water. The above-mentioned WHO/UNICEF study in 1975 showed that 52% of households used tube- well water and 27% used dug-well water for drink- ing; the remainder used surface water (ponds, rivers, etc.) for this purpose. Mujibur Rahman et al. (3) in 1977 obtained similar estimates as that of the WHO/ UNICEF study. In the present study no one was found to use surface water for drinking. This may be due to the health education efforts of the government as well as some nongovernmental organizations in the rural areas and also to the supply of tubewells by the public health engineering department at sub- sidized prices. However, only 11.5% of households used tubewell and dug-well water for cooking and washing of utensils; the rest (88.5%) were using b Skoda, J.D. et al. A survey in rural Bangladesh on diarrhoeal morbidity, water usage and related factors. Unpublished report of UNICEF/WHO, 1977. WHO Bulletin OMS. Vol. 68 1990. 621 M. Yusuf & A.M. Zakir Hussain surface water for these purposes. Thus, the provision of a safe water supply does not necessarily ensure water sanitation. For example, only 7.5% of the household members were found to bathe in tubewell water and 4.0% in dug-well water. All the domestic pets and animals were washed in surface waters which were also used by most household members for bathing, i.e., there was no separate source of water for washing the animals. All the studies on household sanitation in Bang- ladesh have been focused on only water supply and waste disposal. The present study investigated, in addition, other components which are discussed below. The majority of households without a separate, satisfactory kitchen during the survey claimed to have had one previously, but this was destroyed by the floods and cyclone of 1987; owing to the poor socioeconomic situation the respondents could not repair it or erect a new kitchen. A separate kitchen was considered to be satisfactory only if smoke did not pass from it to the living quarters. Although smoke from separate kitchens was never observed to enter the living quarters, not all the kitchens could be considered as clean since garbage and waste water could be found all around the place of cooking. Domestic pets and animals were usually kept outside but within 7.5 m (25 feet) of the living quar- ters. Most respondents had no idea of the possible risks to their health; the main reason for keeping the animals so close was the fear of theft. Very few households provided for the disposal of garbage and refuse in order to prevent pollution of surface water, insect breeding, etc. Clearly there is a role for health education in situations like this. Al- though the socioeconomic situation of the household was a powerful determinant of sanitation, further benefits may be obtained by improving the rate of literacy. In summary, this study has shown that house- hold sanitation, which depends both on education and on socioeconomic situation, is very slowly im- proving in the rural areas of Bangladesh; that mere provision of resources and logistics may not ensure sanitation to the full extent; and that to improve sanitary practices a more acceptable form of com- mode for the children's use is needed, in addition to repeated health education on these matters. R6sum6 Les conditions d'hygl6ne dans les commu- naut6s rurales du Bangladesh L'hygiene domestique comme I'hygiene du milieu sont des questions qui interessent l'OMS, le Pro- gramme des Nations Unies pour l'Environnement et les gouvernements des pays en d6veloppement. C'est I'absence de donnees en provenance de pays en developpement sur nombre de ces problemes qui est a l'origine de la presente etude, pour laquelle des renseignements ont ete recueillis sur les conditions d'hygiene de I'habitat rural au Bangladesh, qui peuvent etre represen- tatives de la situation dans d'autres pays de la region. Aucune habitation n'a ete jugee completement satisfaisante du point du vue de l'hygiene. Les el6ments suivants ont ete examines: implantation de la maison; eclairage et ventilation (fenetres); surface utile par personne; evacuation hygienique des excreta et des ordures; approvisionnement en eau saine; cuisine separee; abris independants pour les animaux domestiques; enfin, proprete des pieces. Les zones choisies pour l'etude se trouvent dans le district de Dacca, mais chaque unite (me- nage) a ete choisie de fa,on aleatoire. La collecte des donnees a ete faite par interrogatoire au moyen de questionnaires et par l'observation des elements figurant sur une liste de controle. Sur les 200 menages etudies, 23% avaient des latrines hygieniques mais il n'y avait que 11,5% des enfants de ces menages qui les utilisaient. Alors que 89% des menages disposaient de puits tubes et en tiraient leur eau de boisson, seuls 6% employaient l'eau de ces puits pour tous les usages. L'eau tiree de puits tubes ou de puits ordinaires etait utilisee pour la cuisine et la vais- selle, ainsi que pour la toilette, par 11,5% des me- nages. II n'y avait que 1,5% des menages qui avaient un endroit reserve aux dechets et ordures, mais la proportion d'habitations jugees satisfaisan- tes du point de vue de la proprete etait tout de meme de 17%. La surface utile par personne etait suffisante dans 38% des habitations mais moins de 20% avaient une ventilation et un eclairage satisfaisants. Tous les menages avaient des eta- bles a vaches a moins de 7,5 metres de leur habitation. Si l'on considere uniquement I'appro- visionnement en eau saine, des latrines hygie- niques, une cuisine separee et une bonne implanta- tion de la maison, on peut qualifier les conditions de satisfaisantes pour environ 10% des menages. Si l'on tient compte des autres variables, alors les conditions peuvent etre qualifiees de partiellement satisfaisantes pour ces memes menages. Etant donne que ce sont la situation socio- economique et le niveau d'instruction qui con- ditionnent l'hygiene domestique, le simple fait de fournir les ressources et les installations neces- WHO Bulletin OMS. Vol. 68 1990.B22 SanitatIon In rural communities In Bangladesh saires risque de ne pas garantir qu'elles soient completement et correctement utilis6es. Une education sanitaire soutenue sur ces questions s'impose donc egalement. References 1. World Health OrganIzatlon. Community water sup- ply and excreta disposal in developing countries: review of progress. World health statistics report, 29(10): 544-603 (1976). 2. Feachem, R.M.C. et al. Water, wastes and health in hot climates. London, ELBS, 1979. 3. Mullbur Rahman, M. et al. A survey of basic health information of rural Bangladesh. Bull. Bangladesh Med. Res. Council, 3(1): 70-76 (1977). Annex Operational definitions Water supply Sanitation of a household's water supply may be regarded as satisfactory if there is a tubewell within 400 metres of the household and the area within 15 metres of the well is free from any source of pollution, and if all the members of the household use this water for drinking and this or other well water for all domestic purposes (cooking, washing utensils and bathing). Bathing in ponds and rivers cannot be safe since all the studied households washed their animals in these places which were usually polluted. Sanitary pond A pond is regarded as satisfactory" if there is a fence around it, if no one is allowed to go into it, and if cattle are not washed there and the aquatic vegeta- tion is periodically removed. Any deviation from this will be regarded as not satisfactory. Separate kitchen Sanitation in this respect is regarded as satisfactory if a dwelling house is provided with a separate kitchen, from which no smoke passes into the living quarters. Shelters for domestic pets and animals It is insanitary to keep domestic pets and animals in the living quarters or within 7.5 m (25 feet) of the living quarters." ' Park, J.E. & Park, K. Environment and health. In: Textbook of preventive and social medicine, 11th ed. Jabalpur, Banarsidas Banot, 1986, pp. 433 457, 469-472. Refuse and garbage disposal Refuse is the unwanted or discarded solid waste material from houses, or from business and agricul- tural premises, arising from man's activities.! Gar- bage is also waste, arising from the preparation, cooking and consumption of food and containing organic matter which ferments on storage.8 Sanitation may be regarded as satisfactory if garbage and refuse are removed from the dwelling at least once daily and disposed of in a sanitary manner, e.g., by digging a manure pit and depositing them there. Setting of houses There should be an open space all around the house. In rural areas it is recommended that the buildings should not exceed one third of the total area for housing. If this limit is exceeded then it will be regarded as unsatisfactory." Proper light and ventilation Proper light means that there must be adequate entrance of light so that one can read or write or do normal work in daytime without any difficulty and without any artificial source of light. Proper ventila- tion means adequate passage of fresh air from the surroundings to the houses, so that one feels comfort- able when the outside air is cool. In rural areas the windows of the houses should be at least 10% of the floor area if they are to be considered as satisfactory.' Floor space The accepted standards for floor space are as fol- lows:' > 10.2 m2 for 2 units 8.4-10.1 m2 for 1.5 units 6.5-8.4 m2 for 1 unit 4.6-6.5 m2 for 0.5 unit <4.6m2 for 0 unit A baby less than 12 months of age is not to be counted; children between 1 and 10 years old are counted as half a unit, and above 10 years as a full unit. Each unit represents one person. Sanitary latrine An open latrine and no fixed place for defecation are regarded as insanitary. Water-seal and pit latrines are sanitary if they are used by all members; non-usage of WHO Bulletin OMS. Vol. 68 1990. 623 M. Yusuf & A.M. Zakir Huatin such latrines indicates the use of an open or unfixed space for defecation in or around the household which might affect others in the family. In this paper, however, satisfactory sanitation in this regard was based on the presence of a sanitary latrine in the household. Cleanliness of living quarters Living quarters and courtyards are regarded as clean and sanitary if refuse is not found in the vicinity and if they are free from too many insects. Household sanitation Sanitation is regarded as satisfactory if all the eight criteria used in the study (cleanliness of the living quarters and courtyard, sanitary latrine, safe water supply, floor space/person, separate kitchen, proper setting of the houses, refuse and garbage disposal, and shelters for domestic pets and animals) are concurrently present in the house up to the satisfac- tory level as defined above. WHO Bulletin OMS. Vol. 68 1990.1|24