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Factors Associated with Use of Improved Water Sources and Sanitation Among Rural Primary Schoolchildren in Pursat Province, Cambodia

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Factors Associated with Use of Improved Water Sources and Sanitation Among Rural Primary Schoolchildren in Pursat Province, Cambodia SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH FACTORS ASSOCIATED WITH USE OF IMPROVED WATER SOURCES AND SANITATION AMONG RURAL PRIMARY SCHOOLCHILDREN IN PURSAT PROVINCE, CAMBODIA Wee Liang En1 and Goh Lee Gan2 1Yong Loo Lin School of Medicine, 2Division of Family Medicine, Department of Medicine, National University Hospital, National University Health System, Singapore Abstract. Access to improved water supplies and sanitation generally reduces childhood diarrhea incidence. Using a cross-sectional stratified cluster sampling design, interviews were conducted among grade 4-6 primary schoolchildren from 10 primary schools in highland and lowland districts of Pursat Province, Cambodia, in both June (rainy season) and December (dry season) 2009 to deter- mine the demographics and water sources/sanitation used. Parents also recorded any incidents of diarrhea in their children over those months. We explored the sociodemographic factors associated with use of improved water sources/sanita- tion, using mixed effect modelling. Participation was 84.7% (1,101/1,300). About half exclusively used improved water sources but less than 25% had access to improved sanitation during both seasons. Adjusting for clustering within house- holds and within individuals over time, exclusive use of improved water sources and sanitation were associated with the following: dry season, more permanent housing type, family size < 8 members, and higher levels of education. Exclu- sive use of improved sanitation was associated with good hygiene practices and exclusive use of improved water sources was associated with male gender. Ac- cess to improved water sources and sanitation among rural Cambodian primary schoolchildren can be improved, particularly in those with lower socio-economic status. Programs to promote use of improved water sources/sanitation need to target less educated parents. Keywords: water source, sanitation, schoolchildren, Cambodia INTRODUCTION of developing countries (Sunoto, 1982). Many interventions can reduce diarrhea Diarrheal diseases cause significant incidence, including improving water mortality and morbidity among children quality and sanitation facilities (Esrey et al, 1991). Water quality can be addressed Correspondence: Wee Liang En, Block MD3, at many levels, including at the source, #03-20, 16 Medical Drive, Department of Epidemiology and Public Health, Yong Loo storage and point-of-use; it can also be Lin School of Medicine, National University of improved through investment in infra- Singapore, National University Health System, structure or catalysing behavioral change. Singapore 117597. Infrastructure improvement tends to be Tel: +65 96777651; Fax: +65 67791489 more cost-effective in areas where access E-mail: [email protected] to improved water sources and sanitation 1022 Vol 42 No. 4 July 2011 USE OF IMPROVED WATER SOURCES AMONG RURAL CAMBODIAN SCHOOLCHILDREN remains low (Haller et al, 2007). Pursat Province (Ministry of Planning, Reduced access in childhood to im- 2007). However, the factors associated proved water sources and proper sanita- with use of improved water sources and tion can lead to poor nutritional status sanitation are unknown, making it diffi- and impaired growth (Esrey et al, 1988; cult to define a target group for potential Checkley et al, 2004). One of the targets intervention. It is therefore of interest to of the Millennium Development Goals investigate the factors influencing use of is to halve, by 2015, the proportion of improved sanitation and water sources people without sustainable access to in this country; especially in rural areas safe drinking water and basic sanitation; where interventions to increase use can though improvements have been made for potentially yield significant dividends ensuring better access to improved water and improve child health. Here we present sources, progress towards basic sanita- the results of such a study done in June tion is unfortunately insufficient (WHO/ and December 2009 among rural primary UNICEF, 2010a). Improved water sources school-going children in Pursat Province, have been shown to be associated with Cambodia. Pursat is one of Cambodia’s decreased childhood diarrhea (Plate et al, twenty-four provinces; predominantly 2004), perhaps because of decreased fecal rural and incorporating both highland contamination (Kravitz et al, 1999). Simi- and lake basin regions, it is a microcosm larly, improved sanitation can likewise of Cambodia proper. be linked with decreased risk of diarrhea (Cairncross et al, 2010), and reduced diar- MATERIALS AND METHODS rhea mortality in children (Burnstrom et al, 2005). Improvements are most marked This study was carried out in Pursat when access to improved sanitation and Province, Cambodia, using a cross-sec- water sources are combined (Gasana et al, tional, stratified cluster sampling design. 2002). In developing countries with low Pursat Province is Cambodia’s 4th largest levels of access to these improvements, province and is organised into six dis- encouraging increased use of improved tricts: one urban (Sampov Meas), one re- water sources and sanitation has the po- mote and relatively underpopulated dis- tential to reduce diarrhea morbidity and trict (Veal Veng), and four rural districts, improve pediatric health. one highland (Phnom Kravanh), and three Cambodia is a developing Southeast lowland districts in the Tonle Sap lake Asian country with low levels of access basin (Bakan, Kandieng and Krakor). We to improved water sources and sanita- excluded urban and remote districts from tion, particularly in rural areas. In 2008, our study. The total schoolgoing popula- 46% of the rural population had access tion in the rural districts of Pursat Prov- to improved water sources; while only ince was 56,921; 19.5% (11,117/56,921) of 18% of the rural population had access which stay in highland districts (Ministry to improved sanitation (WHO/UNICEF, of Education, Youth and Sport, 2008). We 2010b). This is in contrast to urbanized chose only children in grades 4-6 due to areas of the country where more than 90% improve communication and reliability of residents in Phnom Penh (the capital) of data. Of the three districts, we chose have access to potable drinking water, Bakan District as the most representative compared to less than 12% in largely rural of the lowland population, given that a Vol 42 No. 4 July 2011 1023 SOUTHEAST ASIAN J TROP MED PUBLIC HEALTH majority of the population stayed in this surface water sources, like springs, rivers district. There were 63 primary schools and ponds, were considered unimproved; in Bakan District (lowland) and 35 in pour-flush and simple-pit latrines were Phnom Kravanh (highland) enrolled in considered “improved sanitation”, while grades 4-6. The total population enrolled public and open latrines were considered in grades 4-6 in these schools was 12,546. unimproved. Due to the difficulty of cal- An updated list of all 98 primary schools culating rural incomes, we used housing was used as the sampling frame; schools type as a proxy for socio-economic status. were stratified proportionately accord- Those staying in more temporary housing ing to highland/lowland distribution. (eg, thatched roof instead of zinc roof, Ten schools were randomly selected, wooden walls instead of brick/concrete) consisting of 7 lowland and 3 highland were classified as having a lower socio- schools, with a total enrolment of 1,300 economic status. students and a range of 120-140 students Statistical analysis per school. All eligible students in each Children were chategorize as exclu- school were surveyed. sive or non-exclusive users of improved We collected demographic informa- water sources/improved sanitation. tion and descriptions of water sources/ Descriptive statistics were computed sanitation through interviews with the for the general population. McNemar’s students’ parents, using self-reported chi-square test was used to determine questionnaires and the help of trained significant differences in usage of vari- Khmer translators and picture aids. Par- ous water sources and sanitation between ents recorded a 1-month history of diar- the rainy and dry seasons. To control for rhea symptoms among the schoolchildren, clustering within households and within after the definition of diarrhea was com- individuals over time, we used mixed ef- municated to them. Data was collected on fect models to determine the independent two occasions; once in the rainy season predictors of exclusive use of improved (June 2009) and once in the dry season water sources and improved sanitation; (December 2009). Ethical approval was as well as independent predictors of diar- obtained from the National University rhea incidence. We used an unstructured of Singapore Institutional Review Board, model based on the results of likelihood and permission to conduct the study was ratio testing. The random effects were obtained from local school authorities; households and individuals. The statis- informed consent was obtained from both tical Package for Social Sciences (SPSS, parents and children, and participation Version 17.0, Chicaco) and STATA Data was fully voluntary. Analysis and Statistical Software, version Definitions 11.0 were used; statistical significance was set at the conventional p<0.05. Diarrhea was defined as ≥ 3 loose stools during the previous 24 hours. Using RESULTS the 2000 WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanita- A majority of the study population tion classification, tube wells, dug
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