International Journal of Research in Pharmacy and Biosciences Volume 4, Issue 1, January 2017, PP 6-12 ISSN 2394-5885 (Print) & ISSN 2394-5893 (Online)

Study on Knowledge and Practice Regarding Sanitation Application among the Residents of Rangeli Municipality of ,

Sah RB1, Khadgi A2, Jha N3 1Associate Professor, School of Public Health and Community Medicine, BPKIHS, , Nepal 2Junior Resident, School of Public Health and Community Medicine, BPKIHS, Dharan, Nepal 3Professor & Chief, School of Public Health and Community Medicine, BPKIHS, Dharan, Nepal

ABSTRACT Inadequate sanitation has direct effect on health of individual, family, communitiesand nation as a whole. This study was conducted to identify the knowledge and practice regarding sanitation application among the residents of Rangeli Municipality of Morang District and to measure the association between sociodemographic characteristics and disease pattern with sanitation practices of the study population.A Community based cross- sectional study was conducted from 27th November – 10th December 2016 in Rangeli Municipality where 300 households were taken as subjects. Simple random sampling method was applied. Semi-structured questionnaire was used and face to face interview was conducted. Chi-square test was applied to find out the association between sociodemographic characteristics and disease pattern with sanitation practices of the study population.Only 28% of residents were treat water before drinking. Most of the study population (98.7%) had latrines less than 50 feet away from the water source.Majority of respondents dispose of stool of children in toilet (54%) followed by left in open field (27%), Put/ rinsed in drain or ditch (14.3%) and throw with waste materials (4.6%) respectively.Majority of respondents manage solid wastes by burning (68%) followedby preparecompost (27.3%) and bury (4.7%) respectively.Almost58% of the study population had good sanitary conditions. The study population who studied SLC and above(89.9%), business in occupation(74.6%), above the poverty line (78.3%) and the study population who treat diarrhea using modern medicine had significantly more sanitary practices (p<0.05). We conclude that majority of respondents had average knowledge and practice regarding sanitation. Middle age and old age group, high education level, business in occupation, higher economic condition and study population who treat diarrhea using modern medicine was found significantly more sanitation practices. Keywords: Knowledge, Practice, Sanitation, Rangeli Municipality, Morang District

INTRODUCTION Inadequate sanitation has direct effect on health of individual, family, communities and nation as a whole. Simply, having sanitation facilities increases health well-being and economic productivity. Sanitation includes use of latrine, clean surrounding, water treatment, and proper disposal of solid and liquid wastages. Toilet is taken as an essential and basic indicator of health and sanitation worldwide [1]. Proper sanitation is a necessary prerequisite for improvement in general health standards, productivity of labour force and good quality of life [2]. Every 20 seconds, a child around the world dies as a result of poor sanitation [3]. About 80% of all disease of the developing world is related to unsafe water and inadequate sanitation [4].Worldwide, 5.3% of all deaths and 6.8% of all disability are caused by poor sanitation and unsafe water. Nearly two-thirds (67%) of the total population go for open-air defecation and only one-third (33%) having access to a latrine [5]. The lack of access to sanitation in Nepal is striking. A total of 75% of the population is without access to sanitation, one of the highest proportions in Asia. However, the urban sanitation coverage is75% and the rural sanitation coverage is only 20% [6]. Every day, 16 million Nepalese (around 57% of the population) practice open defecation because they have no toilets [7]. Access to sanitary system, garbage disposal and toilets are lowest among the poorest population and is better in the richer quintiles of the population. There is huge gap in access to sanitary facilities between that available to the poorest population and the national average [8]. Therefore, the present study is undertaken to International Journal of Research in Pharmacy and Biosciences V4 ● I1 ● January 2017 6 Sah RB, et al. ”Study on Knowledge and Practice Regarding Sanitation Application among the Residents of Rangeli Municipality of Morang District, Nepal” identify the knowledge and practice regarding sanitation conditions and to find out the association between sociodemographic characteristics and disease pattern with sanitation practices among residents of Rangeli Municipality. METHODS A Community based cross-sectional study was conducted from 27th November – 10th December 2016 in Rangeli Municipality of Morang District of Nepal. Rangeli is located in the eastern geographical region of Nepal. This was a two weeks study to fulfill epidemiological management carried out by students of MBBS 3rd year Batch 2014 of B. P. Koirala Institute of Health Sciences, Dharan, Nepal. This research was based on random selection of the study area Rangeli Municipality. This study considered 64% of world populations have good sanitation practices. It was calculated as 225.3 by using the formula, sample size (n) = 4 pq/L2 [(n=4 x 64 x 36 / (6.4)2 = 225.3] household as sample based on the prevalence of 64%, 95% confidence level and 10% allowable error. Adding of 15% on final sample for non-response, 226 x 15 / 100= 34, then sample size became 226 + 34 = 260 ≈300.The required sample size is 300 household of mixed ages, 18 years and above in Rangeli Municipality of Morang District (Vivas et al., 2010) [9]. The data was collected from 300 households of mixed ages, 18 years and above in Rangeli Municipality. There are 11 wards in Rangeli Municipality. Among 11 wards, 4 wards was randomly selected. The list of households of four selected wards was prepared and equal number of households (75) from each ward was selected on the basis of simple random sampling by lottery method. Each subject was selected till the sample size was fulfilled from the four wards of Rangeli Municipality. Ethical clearance was taken from Undergraduate Medical Research Protocol Review Board (UM- RPRB) of B P Koirala Institute of Health Sciences, Dharan, Nepal. Written permission was taken from each participants of the study. The participants of both sexes, aged 18 years and above, who were willing to participate in the study, those who gave written consent andthose individuals who were available after three visits were included in the study. Three visits means the selected study subject who was not present at the time of the first visit to the respective place, he or she was followed for three attempts so as to include in the study and in the case of unavailability next study subject was taken.Semi-structured questionnaire and an observational checklist were used for data collection and face to face interview was taken. The confidentiality and privacy of the study was maintained; name of the individuals or participating group was not disclose after the study. All interviewed questionnaires were indexed and kept on file. The collected data was entered in Microsoft Excel and converted into SPSS (Statistical Package for Social Science) software package 11.5 version for statistical analysis. Data was analysed to find out percentage and proportion, and Chi- square test was used to measure the association between socio demographic characteristics and disease pattern with sanitation practices of the study population. The confidence level was set at 5% in which probability of occurrence by chance is significant if P< 0.05 with 95% Confidence Interval. RESULTS Table1. Knowledge and practice regarding sanitation (N=300) Characteristics Frequency Percentage Source of drinking water River/Stream 10 3.3 Spring 4 1.3 Well 117 39.0 Tap 28 9.3 hand pump 141 47.0 Time take to reach the source of water Less than 5 min 296 98.7 More than 5 min 4 1.3 Water treat before drinking Yes 84 28.0 No 216 72.0 If water treat then method used for purification (n=84) Boil 47 56.0 Filter 36 42.9

7 International Journal of Research in Pharmacy and Biosciences V4 ● I1 ● January 2017 Sah RB, et al. ”Study on Knowledge and Practice Regarding Sanitation Application among the Residents of Rangeli Municipality of Morang District, Nepal” Disinfection 1 1.2 Store drinking water Covered 173 57.7 Uncovered 127 42.3 Have Latrines Yes 209 69.7 No 91 30.3 If no latrine then where defecate (n=91) Public toilet 5 5.5 River 11 12.1 Open fields 75 82.4 If no latrine then why didn’t construct latrine (n=91) Not necessary 1 1.2 No money 40 43.9 No place 50 54.9 *Important to have Latrines To keep village clean 284 94.7 Free from odour 60 20.0 Safe from diseases 148 49.3 How often clean Latrines? (n=209) Daily 108 51.7 Every alternate day 11 5.3 Twice in a week 22 10.5 Once a week 64 30.6 Once in 15 days 4 1.9 Distance between water source and latrine <50 feet 296 98.7 ≥ 50 feet 4 1.3 Dispose of stool of children Put/ rinsed in drain or ditch 43 14.3 Left in open field 81 27.0 Throw with waste materials 14 4.6 Used toilet 162 54.0 Drainage Adequate 185 61.7 Inadequate 102 34.0 Absent 13 4.3 Animals at home Yes 148 49.3 No 152 50.7 Distance between cattle sheds & dwelling house (n=148) < 25 feet 124 83.8 ≥ 25 feet 24 16.2 Manage liquid wastes Use in kitchen garden 130 43.3 Feed to cattle 62 20.7 Surrounding home 108 36.0 Manage solid wastes Burn 204 68.0 Bury 14 4.7 Prepare compost 82 27.3 Mosquito breeding sites around the house Yes 271 90.3 No 29 9.7 Mosquito prevention Net 284 94.7 Coils 14 4.7 Smoke around house 2 0.7 Total 300 100.0 *Multiple Responses International Journal of Research in Pharmacy and Biosciences V4 ● I1 ● January 2017 8 Sah RB, et al. ”Study on Knowledge and Practice Regarding Sanitation Application among the Residents of Rangeli Municipality of Morang District, Nepal” Table 1 shows only 28% of residents were treat water before drinking. Most of the study population had latrines less than 50 feet away from the water source. Most of the respondents had cattle shed less than 25 feet away from the house. Table2. Sanitation among study population (N=300) Frequency Percent Sanitary 174 58.0% Unsanitary 126 42.0% Table 2 shows 58% of the study population had good sanitary conditions. So the prevalence of sanitation of this study was 58%. Table3. Association between socio demographic characteristics and sanitary practices of study population (N=300) Characteristics Sanitation Total P value Sanitary Unsanitary Age 17-40 years 85(50%) 85(50%) 170 0.006 41-60 years 62(68.9%) 28(31.1%) 90 < 60 years 27(67.5%) 13(32.5%) 40 Sex Male 74(63.8%) 42(36.2%) 116 0.106 Female 100(54.3%) 84(45.7%) 184 Religion Hindu 167(58.2%) 120(41.8%) 287 0.946 Buddhist 1(50%) 1(50%) 2 Muslim 6(54.5%) 5(45.5%) 11 Ethnicity Brahmin/ Chhetri 23(67.6%) 11(32.4%) 34 0.007 Kirati 2(66.7%) 1(33.3%) 3 Janajati 26(86.7%) 4(13.3%) 30 Dalit 1(50%) 1(50%) 2 Terai caste 122(52.8%) 109(47.2%) 231 Education Illiterate 54(41.2%) 77(58.8%) 131 Below SLC 58(58%) 42(42%) 100 <0.001 Above SLC 62(89.9%) 7(10.1%) 69 Occupation Service 8(57.1%) 6(42.9%) 12 Business 50(74.6%) 17(25.4%) 67 0.031 Farmer 20(55.6%) 16(44.4%) 36 Housewife 75(51.0%) 72(49%) 147 Labor 21(58.3%) 15(41.7%) 36 Economic status Below poverty line (<1.25 $) 84(45.4%) 101(54.6%) 185 <0.001 Above poverty line (≥ 1.25 $) 90(78.3%) 25(21.7%) 115 Total 174 (58.0) 126 (42.0) 300 Table 3 shows the study population who studied SLC and above was significantly more sanitary conditions as compared to below SLC and illiterates (p<0.001). The study population which involved in business was significantly more sanitary conditions compared to the population involved in other occupation (p<0.05). Economic status also shows strong significant association with the study population above the poverty line as compared to people of low socioeconomic condition. Table4. Association between disease pattern and sanitary practices of the study population (N=300) Characteristics Sanitation Total P value Sanitary Unsanitary Previous one year any family member suffer from diarrhea Yes 123(57.2%) 92(42.8%) 215 0.659 No 51(60%) 34(40%) 85

9 International Journal of Research in Pharmacy and Biosciences V4 ● I1 ● January 2017 Sah RB, et al. ”Study on Knowledge and Practice Regarding Sanitation Application among the Residents of Rangeli Municipality of Morang District, Nepal” Where to go to treat diarrhea Dhamijhakri 8(61.5%) 5(38.5%) 13 Doctor 166(57.8%) 121(42.2%) 287 0.792 How do you treat diarrhoea yourself Modern medicine 142(55.5%) 114(44.5%) 256 0.032 Traditional healers 12(27.3%) 32(72.7%) 44 Heard about ORS Yes 171(57.8%) 125(42.2%) 296 0.488 No 3(75%) 1(25%) 4 Know the process of preparing ORS Yes 165(57.1%) 124(42.9%) 289 0.103 No 9(81.8%) 2(18.2%) 11 Total 174 (58.0) 126 (42.0) 300 Table 4 shows the study population who treat diarrhea using modern medicine had significantly more sanitary practices as compared to people believe traditional healers (p< 0.05). All other variables were not significantly associated with sanitary condition of the study population. DISCUSSION WHO/UNICEF Joint Monitoring Programme for water supply and sanitation released in 2013, estimates that 36% of the world’s population – 2.5 billion people lack improved sanitation facilities and 768 million people still use unsafe drinking water sources. Poor farmers and wage earners are less productive due to illness, health systems are overwhelmed and national economies suffer [10]. In our study 58% of the population had good sanitary conditions whereas in a similar study done in village of Eastern Nepal, it was found that 90% of the study population had better knowledge regarding sanitation [11]. This may be due to the reason that in our research setting, 82.4% of the study population defecate in open field, 12.1% riverside and 5.5% public toilet. In our study, majority of the study population used hand pump (47%), well (39%), tap (9.3%), river/stream (3.3%) and spring (1.3%) respectively as a water source. The survey done by the CBS– Nepal, 2012 shows 59.3% of the respondents use tap water as the major source of drinking water followed by river/stream (20.3%), tube well (1.7%), and others including spring, pond and well water (18.7%) [12]. So, the survey was found to be different from our study. More researches should be conducted further in the future. In our study, regarding time taken to reach the source of water by the study population, majority of the study population were less than 5 minutes (98.7%). There was a similar study done in India, where majority of the study population (96.7%) had their water source less than 100 ft. from their shelter [13]. This shows that both the study groups had easy accessibility of water source from their shelter. In our study, water treatment was not done by majority of participants (72%) whereas in a similar study done in India, 70% of the study population treated water (boiled or filtered) before drinking [13]. This may be due to the fact that majority of our study population (43%) were illiterate. In our study regarding Latrine facility, 69.7% of the study population had latrines whereas 30.3% had no latrine facilities. Likewise, in a similar study done in Katahari village of Eastern Nepal, 64% of the study population had latrine facility which was similar to that of our study [11]. Another study done in the hilly region of eastern Nepal showed 93% of the study population had latrine facilities which shows that hilly region had better knowledge and practice of latrine than terai region comparatively [14].Likewise, in a study done in a rural village of India, 98% of the study population had latrine facility [13].This may be due to the reason that socio economic status of their study area was comparatively better than that of our study group. In our study regarding distance between water source and latrine, majority of the study population (98.7%) had less than 50 feet whereas in a similar study done in a rural village in India, 64% of the study group had their latrine more than 30 meters away from the water source [13]. This may be due to the reason that about 43% of our study population were illiterate whereas only 6% of their study group were illiterate. In our study, regarding management of liquid waste, majority of the study population(43.3%) managed their liquid waste in kitchen gardens followed by disposal into the surrounding home (36%) and cattle feeding (20.7%). Likewise, in a similar study done in the hilly region of Eastern Nepal,(46%) of the study population managed their liquid waste in kitchen garden followed by

International Journal of Research in Pharmacy and Biosciences V4 ● I1 ● January 2017 10 Sah RB, et al. ”Study on Knowledge and Practice Regarding Sanitation Application among the Residents of Rangeli Municipality of Morang District, Nepal” disposal into the surrounding home (36%) and cattle feeding (15%) [14]. this result was similar to that of our study. In our study regarding solid waste management, majority of participants were burning (68%) followed by preparation of compost (27.3%} and burring (4.7%) the solid wastes among the study population. Likewise, in a similar study done in the hilly region of Eastern Nepal, (30%) used burning, 29% buried and 25% used for preparing compost [14]. This may be because our study area being in terai region has more open spaces for burning the wastes and has no high risks for forest fire spread, but in the hilly region due to lack of open spaces there is high chance of catching forest fire and hence the people burry the solid wastes. In our study, middle age group population was more significantly associated with the sanitary practices than other age groups. (p<0.05). Similar result was seen in the study done by Reshma et al in India [13]. This may be due to the fact that middle age groups are independent as well as have better knowledge regarding sanitation. Similarly janajati had significantly more sanitary practices as compared to other ethnic group in our study whereas similar study done by Sah et al in Dhankuta, it was found that Brahmin/ Chhetri had more association with sanitary conditions [14]. This may be due to the fact that majority of the study population belong to Janjati ethnicity in our study area. In our study regarding education, higher the level of education, better the sanitation was. The study population who studied SLC and above had significantly more sanitary conditions as compared to those who belong to below SLC and illiterates (p<0.001). Similar study done by Sah et al in Eastern Nepal, there was significant association of high level education with sanitation [14].The study done by Reshma et al in India showed housewife by occupation was more significantly associated with sanitation than other occupations (p=0.007) [13]. However, in our study business by occupation was more significantly associated with sanitation in comparison to other occupations (p<0.05). The reason may be due to the fact that businessman can afford better for the sanitary tools. In our study, economic status showed strong association of wealth with sanitation. Similarly, study done by Reshma et al in India also showed significant association with the sanitation practices [13]. The individuals belonging to the above poverty line had better quality of life than those of below poverty line. This result highlights the strong association of wealth with sanitation practices. Several limitations must be considered when interpreting our results. First, participants self-reported behaviors may have resulted in over-reporting of proper sanitation practices. We attempted to mitigate this bias by including objective measures of resident’s sanitation conditions. Data from observations were generally consistent with participant’s self-reported practices. Second, the cross-sectional study design makes determining causality impossible. CONCLUSION The findings of the study showed that majority of respondents had average knowledge and practice regarding sanitation. Very less of residents were treat water before drinking. Most of the study population had latrines less than 50 feet away from the water source. Majority of respondents dispose of stool of children in toilet and in open field. Majority of respondents manage solid wastes by burning followed by preparing compost. Prevalence of sanitary practices of this study was 58%. Middle age and old age group, high education level, business in occupation, higher economic condition and study population who treat diarrhea using modern medicine was found significantly more sanitation practices. ACKNOWLEDGEMENT We would like to thank to School of Public Health and Community Medicine for approval of our research work. We express our sincere thanks to MBBS (2014 Batch) students who helped us during study period. REFERENCES [1] Environmental sanitation guidelines, Rural Village Water Resources Management Project, 2009. [2] Dwivedi P, Sharma AN. A Study on Environmental Sanitation, Sanitary Habits and Personal Hygiene among the Baigas of Samnapur Block of Dindori District, Madhya Pradesh. 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[8] Winrock International, Nepal country environmental analysis: Environmental sector review; revised draft prepared by World Bank [online] 2007 Feb 22 [cited 2007 Aug 7].Available from: URL:http://www.winrock.org.np. [9] Vivas AP, Gelaye B, Abost N, Kumie A, Berhane Y, Williams MA. Knowledge, attitudes and practices (KAP) of hygiene among school children in Angolela, Ethiopia. J prev med hyg 2010; 51: 73-79. [10] Water, sanitation and hygiene [Internet], 2011. Available from: www.unicef.org/wash/. (Accessed on 4 February 2017) [11] Karn RR, Bhandari B, Jha N. A study on personal hygiene and sanitary practices in a rural village ofmornag district of Nepal. Journal of Nobel Medical College2011;1 (2): 39-44. [12] CBS 2012, Environment statistics of Nepal 2008. Available from: http://cbs.gov.np/. (Accessed on 4 February 2017) [13] Reshma, Mamatha, S Pai & Manjula. 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