Assessment of Knowledge, Attitude, and Practice of WASH and Nutrition

Research Article

iMedPub Journals British Journal of Research 2020 www.imedpub.com Vol.7 No.2:55 ISSN 2394-3718

DOI: 10.36648/2394-3718.7.2.55 Assessment of Knowledge, Attitude, and Practice of WASH and Nutrition in Emergencies: A Study on a Haor Area of Bangladesh Affected by Floods Md Azizul Haque* and Sourabh Chakraborty

Jodhpur School of Public Health, Maulana Azad University, Jodhpur, Rajasthan, India *Corresponding author: Haque MA, Ph.D. Scholar, School of Public Health, Maulana Azad University, Jodhpur Rajasthan, India, E-mail: [email protected] Received Date: April 24, 2020; Accepted Date: May 02, 2020; Published Date: May 08, 2020 Citation: Haque MA, Chakraborty S (2020) Assessment of Knowledge, Attitude, and Practice of WASH and Nutrition in Emergencies: A Study on a Haor Area of Bangladesh Affected by Floods. Br J Res Vol.7 No.2:55. Keywords: Knowledge; Attitude; Practice; WASH; Abstract Nutrition; Emergencies; Haor area; Bangladesh; Flood

Background: Haor is a bowl-shaped large tectonic depression. It receives surface runoff water by rivers and Introduction canals, and consequently, a Haor becomes a very The World Health Organization [1] estimates that more than extensive water body in the monsoon and dries up mostly in the post-monsoon period. The Haors are considered one billion people are without access to safe and adequate the most productive wetland resources of Bangladesh. drinking water sources. Annually a significant number of illnesses and deaths as a result of waterborne diseases are Objective: The objective of the study was to assess the reported. Diarrhea-related illnesses alone are estimated to Knowledge, Attitude, And Practice (KAP) of WASH and cause two to three million deaths per year; the majority of nutrition in the emergency because of floods in the Haor which are children [2]. Countries and development partners area of Bangladesh. have been working incessantly to ensure access to safe water and sanitation services to people of all socio-economic Methodology: This is a cross-sectional survey of 252 statuses. Being a disaster-prone country, Bangladesh has a households using face-to-face interviews. long history of both natural and human-made disasters and emergencies [3]. Especially, the country is widely known for Result: The found male were 177 (70.2%), Age groups the natural disasters it faces due to its geophysical position [4]. (31-40) 77 (30.6%), marital status married 238 (94.4%), Most of Bangladesh lies in the largest delta in the world, the Occupation farmer 155 (61.5%), Education illiterate 188 Bengal Basin, formed by the Ganges, Brahmaputra, and (74.6%). Most of the respondents (92.1 %, n=232) in the Meghna (GBM) river system. The total area of wetlands in study area get their drinking water from the deep tube Bangladesh is estimated to be 7-8 million hectares or about well. The majority of the respondents (65.5 %, n=165) do 50% of its total land surface [5]. This includes 5.4 million not treat their drinking water. Almost all (98.9%, n=86) the hectares of open and closed lakes on ﬂoodplains that are households that treat their drinking water store it in jars. inundated every year [6]. Wetlands are defined as low-lying Only 1 (1.1%) household was found to store the treated ecosystems where the groundwater table is always at or near drinking water in the pitcher. None of the respondents the surface that also include areas of marsh, fen, bog, (100%, n=252) knew how to prepare oral rehydration floodplain, and shallow coastal areas [7]. The vast coverage of solution. Most of the households (95.2%, n=240) had latrines, whereas 12 households (4.8%) had none. 222 wetlands has both advantages and disadvantages. Wetlands respondents (92.5%) reported that all the members use provide a wide range of economic, social, and ecological the latrines. In 14 households (5.8%), the latrine is used benefits [8]. From the perspective of a developing country, only by a person with a physical challenge. In 4 cases wetlands are an important source of commercial fishing, (1.7%), we found only adult men and women being the agriculture, seasonal livestock grazing, wood collection, and users of the latrine. All the respondents (100%, n=222) ecotourism. However, owing to its physical and hydrological reported that they use the latrine regularly. features, human settlements in and around the wetlands became the hard-to-reach places, and consequently, the least Conclusion: Despite the success in the water and developed areas in the country. Among the identified hard-to- sanitation sector as a result of continuous effort, hard-to- reach places [9], Haor is one of the most important ones reach marginal areas of the countries are still lacking because of its importance both in terms of economic adequate facilities and provision of such supports. productivity and biodiversity. The basin supports a large variety of wetland biodiversity and works as a natural reservoir. A total of 373 haors cover a total of 858,450 hectares

of land [10]. Unfortunately, natural disasters (especially maintained. Before taking any photograph or audio, written monsoon floods and flash floods) frequently make permission was taken from the participants. We adhered to all emergencies in these hard-to-reach areas. One such even set the rules and regulations of the Bangladesh government as the stage for our study. A devastating flash flood broke out in well as Maulana Azad University of Jodhpur, India in all 7 haor districts of Bangladesh in April 2017. Almost 371,381 conducting the research. hectares of Boro rice-the the main crop of this single cropped region-catastrophically got damaged; 90% damage been reported at many places. An estimated 5,081 crore BDT (620 million USD) of damage of rice, fish, fodder occurred [11,12]. Most of the local health services became partially functional or fully closed due to the lack of health practitioners and medicine supply. Pregnant women, lactating mothers, and children were lacking essential maternal and child health support/services. Acute shortage of clean drinking water arose. Most children stopped going to school. Local health services became partially operational but there is a huge lack of health personnel and medicine. Pregnant women, lactating mothers, and children faced a lack of essential maternal and child health support/services [11,12]. The government and development partners may have faced challenges in the rapid provision of water and sanitation support. Understanding the Figure 1: Study area. water and sanitation situation of such a disaster is, thus, necessary. Therefore, the main objective of the study was to assess the Knowledge, Attitude, and Practice (KAP) of WASH Statistical analysis and nutrition in the emergency because of floods in the Haor area of Bangladesh. Descriptive statistics, frequency, percentage, etc. were estimated as appropriate. Binary logistic regressions were Methodology performed to predict the outcome of water treatment, soap use for washing hands, breastfeeding of infants within 1 hour of birth, feeding children aged 6-23 months more than four Study area groups of food, and taking rest my pregnant mothers, from The study was conducted in a northern village of education level, family size and monthly income of the Bangladesh named Jagir Para under the Union named households. All levels of significance were set to =0.05. All Gaokandia under Durgapur Upazila (sub-district) of Netrokona statistical tests were performed using the software package district of Mymensingh division (Figure 1). Durgapur Upazila is IBM SPSS Statistics for Windows, version 24.0 [14]. in Netrokona District with an area of 278.3 sq. km., with a population of around 224,893. It is located between 24°57' Result and 25°12' north latitudes and in between 90°28' and 90°47' east longitudes [13]. It is surrounded by the Meghalaya state Water of India on the north, Kalmakanda Upazila on the east, Dhobaura Upazila on the west, and Netrokona Sadar and Water source: Most of the respondents (92.1%, n=232) in Purbadhala Upazilas on the south. The Garo hills and valleys the study area get their drinking water from the deep tube are in the northern part of the Upazila. Among others, well. The rest of the respondents collect water from dug well indigenous communities such as Garo and Hajongs live in this (6.7%, n=17) or other sources (1.2%, n=3) such as open water Upazila. The rivers passing through the Upazila are Kangsa, bodies. Someshwari, and Old Someshwari. Treatment of water: Majority of the respondents (65.5%, n=165) do not treat their drinking water. A logistic regression Sampling and data collection was performed to ascertain the effects of income, family size Data were collected from a cross-sectional survey of 252 and educational status on the likelihood that participants treat households using face-to-face interviews. We sampled from their water before drinking. The logistic regression model was those households that have at least 1 child. statistically significant, (χ2 (6)=128.9, p<0.001). The model explained 55.3% (Nagelkerke R2) of the variance in treating Ethical consideration water and correctly classified 81.3% of cases. Overall contribution of all the predictors i.e. income (Wald (2)=11.7, The approval letter from the BMRC (Bangladesh Medical p=0.003)), family size (Wald (2)=23.8, p<0.001) and Research Council) as well as from the authority of Maulana educational status (Wald (2)=54.5, p<0.001) were significant. Azad University of Jodhpur, India were taken for the Respondent who had passed Class VIII were 6.6 times conduction of the research. Privacy and confidentiality were (p=0.002) more likely to treat the water than the respondents 2 This article is available from: http://www.imedpub.com/ British Journal of Research 2020 ISSN 2394-3718 Vol.7 No.2:55

with no education. We found the effect of family size on the Alarmingly, 89.7% households (n=226) use only water for practice of treating the drinking water. A family with 3-5 washing their hands. Whereas 1 respondent (0.4%) informed members and a family comprising more than 5 members are of using ash, and 1 respondent (0.4%) informed of using soil 3.5 times (p=0.007) and 117.4 (p<0.001) times, respectively, for washing their hands. Analysis show that about 96.4 % more likely to treat their drinking water than a family people (n=243) wash their hands beside the latrine, whereas comprising 1-3 members. Opposed to our expectation, 3.6% (n=9) of the people use a hand washing station. When increasing income could not cause the increased practice of The sociodemographic characteristics of the study the treatment of drinking water. A family with medium range participants are shown in (Table 1). of income and a high range of income were 15.9 times (p<0.001) and 142.9 times (p<0.001), respectively, less likely to Table 1: Demographic characteristics of the persons in the treat their drinking water. selected study households, late 2018. Water storage: Almost all (98.9%, n=86) the households that treat their drinking water store it in jars. Only 1 (1.1%) Frequency Percentage Variable Category (n) (%) household was found to store the treated drinking water in pitcher. Male 177 70.2 Water serving substrate: People in the study area Gender Female 75 29.8

predominantly use glass (99.2%, n=250) for serving drinking 21-30 52 20.6 water. We found 2 households (0.8%) to use dipper as a substrate for serving water. 31-40 77 30.6 ORS preparation: None of the respondents (100%, n=252) 41-50 47 18.7 knew how to prepare oral rehydration solution. 51-60 50 19.8 Age groups in Latrine and sanitation: Most of the households (95.2%, years 60+ 26 10.3 n=240) had latrines, whereas 12 households (4.8%) had none. 222 respondents (92.5%) reported that all the members use Married 238 94.4 the latrines. In 14 households (5.8%), latrine is used only by Single 1 0.4 person with physical challenge. In 4 cases (1.7%), we found Marital status of the respondents Widow/widower 13 5.2 only adult men and women being the users of the latrine. All the respondents (100%, n=222) reported that they use the Christianity 2 0.8

latrine regularly. In response to whether anyone in the Hinduism 1 0.4 household needs help in using latrine, 154 respondents (64.2%) replied yes, whereas 86 respondents (35.8%) reported Religion Islam 249 98.8 no. People mostly requiring help include person with physical Business 4 1.6 challenge, children, and elderly people. Most of the households (75.8%, n=182) had their children use the latrine, Day labourer 21 8.3 whereas 24.2% households (n=58) didn’t have their children Farmer 155 61.5 use the latrine. Housewife 71 28.2 Waste disposal method: When we asked how do they Occupation Service 1 0.4 dispose of their infants ’ or children ’ faeces, most of the respondents (97.6%, n=244) replied that they cover with the No education 188 74.6

soil and dispose. Only 5 respondents (2%) informed they use Primary 36 14.3 latrine for disposing of their infants’ faeces. In response to how do they manage their day-to-day household waste, 98.8% Education Class VII Pass 28 11.1 (n=245) responded they throw the wastes behind their houses, 1-3 members 55 21.8 whereas 1.2% (n=3) responded that they throw the wastes into the canal. 4-5 members 162 64.3 Hand wash: Most of the respondents (90.5%, n=228) do not Family size >5 members 35 13.9 use soap to wash their hands. We found only 24 respondents Low (BDT 1000-3000) 97 38.5 (9.5%) informing that they use soap for washing their hands. Medium (BDT The logistic regression model with education, family size and 3001-6000) 89 35.3 income being predictors was not statistically significant, 2 High (BDT χ (6)=12.5, p=0.05. Although the model was not conclusively Monthly income 6001-15000) 66 26.2 significant, if we consider it to be significant (with p=0.05), interestingly, income level could predict the practice of hand we asked about hand washing time, almost all the washing with soap. Household with medium and high income respondents (99.2%, n=250) confirmed that their family wash level used soap for hand washing 3 times (p=0.03) and 4.3 the hands all the 5 times (after defecation, after cleaning the times (p=0.03) more than those with low income level. © Copyright iMedPub 3 British Journal of Research 2020 ISSN 2394-3718 Vol.7 No.2:55

bottom of child, before taking food, before the preparation of Respondents having preliminary education were 4.4 times food, and before serving the food). 1 respondent (0.4%) (p=0.006) more likely to have their households let the mothers informed that they wash before serving and eating foods and 1 take rest during pregnancy compared to the illiterate respondent (0.4%) wash after defecation. respondents. Food preparation and hygiene: Most of the respondents (96.4%, n=243) prepare their food for cooking in the house. Discussion This is a common scenario in Bangladesh as the kitchen is inside the house boundary. 1.6% (n=4) of the households The current study found that knowledge and practice of prepare their food nearby dug well, whereas 2% (n=5) use water, sanitation and hygiene are still unsatisfactory. The most other places for preparing their food for cooking. Almost all worrisome of all is the nutritional status of children and the respondents (99.2%, n=250) informed they wash their food pregnant mothers. Ground water remains the major source of preparation surface before starting the food preparation. Only fresh water for the Bangladeshis living in the Haor areas. The 2 respondents (0.8%) do not practice it. For washing the popularity of tube wells stems from its modest cost of preparation place and utensils, most of the households installation and health benefit, i.e., reduced cases of (96.8%, n=244) use only water. Only 1.2% (n=3) use soap and diarrhoeal disease [15]. Majority of households’ not treating 2% (n=5) use ash for the purpose. their drinking water reflects the poor knowledge and practice of the people about the effects of drinking water without the Cooked food hygiene: Satisfactorily, 99.2% (n=250) treatment. Because of the prevalence of the practice of not households wash their raw foods before cooking. Only 0.8% treating the drinking water, various water borne diseases such (n=2) of respondents answered negatively. All the households as diarrhoea, cholera, dysentery, skin diseases, may prevail in (100%, n=252) use pots for storing the cooked food. 94.8% the area [16]. Education being a significant predictor of (n=239) respondents said they store the cooked foods for less treating the drinking water corroborates the well-established than or equal to 6 hours. 4.8% (n=12) households store the fact that education is associated with better health [17]. As food for 8 hours and only 1 household (0.4%) store their expected, education raised awareness among families about cooked for more than 12 hours. All (99.6%, n=251) but 1 treating the water for drinking. Interestingly, although the (n=0.4%) households reheat their cooked food. study population did not have much higher education (class Nutritional status: Among the 252 respondents that have or VIII pass at best), our study found a significant impact of had children, 65 (25.8%) replied that they did not breastfeed literacy, even if it is only of preliminary stage, compared to their infants within 1 hour of birth. However, 160 (63.5%) illiteracy in terms of water hygiene practice. Schooling, both responded that they exclusively breastfed their infants formal and non-formal, could, thus, be a great factor for raising between the age 0-5 months. 82 (32.5%) respondents said that awareness about health and hygiene among the people that they fed their children aged 6-23 months four or more groups are still leaving behind. Why the family size can predict the of foods daily opposed to a large number of respondents likelihood of treating the drinking water is not clear. (67.5%, n=170) that replied to have fed less than 4 groups. Assumedly, increased family size means extra pair of hands in a Only 2% (n=5) women took folic acid during their pregnancy. family, which may increase the opportunity of extra hours of Likewise, only 1.6% (n=4) ate extra food during the pregnancy. household works. Members of a large family, especially 65 respondents (25.8%) said the mother of the households woman, thus, may get extra hours of efforts for treating the took enough rest during the pregnancy. 249 respondents water for her family. Our not finding positive association of (98.8%) informed that the pregnant mother visited doctor only increased income and increased water treatment practice may once during the pregnancy, whereas 3 (1.2%) of them visited 2 have two likely explanations. One reason could be the level of times. Binary logistic regression model for breastfeeding of income not being optimal. Level of income in the study infants within 1 hour was statistically significant (χ2 (6)=16.02, population is very low (38.5% of the sampled household p=0.01). The model explained 9.1% (Negelkerke R2) of the having their monthly income between BDT 1000-3000). Even variance in breastfeeding and correctly classified 75% of cases. though we categorized the levels being low, medium and high, Overall effect of educational status was significant (W(2)=9.6, none of the level is optimal for causing impact in their living p=0.008). People with primary education were 3.1 times standard. Thus, level of income could not reflect any positive (p=0.005) more likely to breastfeed their children than the association. Oppositely, the result showed a negative people with no literacy. Family size (p=0.2) and income association. Another reason could be the association between (p=0.53) did not have any influence. A logistic regression family size and income. In general, although overall income model for predicting whether the children aged 6-23 months rises somewhat with family size, an increase in the number of were fed four or more food groups daily did not find any children appears to reduce the family's standard of living, influence of education, family size or even income (χ2 (6)=8.3, especially in young families with small children [18]. However, p=0.2). A binary logistic regression model could predict this explanation is less likely because our study found a whether the pregnant mother take enough rest (χ2 (6)=27.4, positive association between the water treatment and family p<0.001). The model explained 15.1% (Negelkerke R2) of the size. A main goal of the WHO is that all people, regardless their variance in taking rest during pregnancy and correctly stage of development and their social and economic classified 75% of cases. Interestingly, educational status had conditions, have the right to have access to an adequate significant influence on this practice (W(2)=10.2, p=0.006). supply of safe drinking water,’ where ‘safe’ refers to a water supply that poses no significant health risk. As a result, the 4 This article is available from: http://www.imedpub.com/ British Journal of Research 2020 ISSN 2394-3718 Vol.7 No.2:55

WHO established water quality guidelines for drinking water geographical context and acceptance by the community. Field that included no detectable levels of Escherichia coli or trials by Oxfam GB found that raised pit latrines are more coliform bacteria and arsenic levels at or less than 10 µg/l [19]. appropriate in flood- and cyclone-prone areas in our country But improved water treatment has not been achieved, despite and more widely accepted by the community, than other a concentrated effort to do so over the past decade [2,19,20]. technologies [26]. As our study found that a number of people All the respondents lack knowledge of a very useful and in the households need help for using toilets, adaptive latrines sometimes life-saving method-preparation of ORS. Although should consider the needs of person with physical challenge, Bangladesh achieved a significant success in teaching people children and elderly people, so that they can use the latrines the preparation of ORS through the NGOs [21], result of our independently or at least without any risk. As these groups of current study shows that there are still works to be done, people are more vulnerable to any disaster, planning in any especially in the marginal societies such as Haor areas. One of level should include these groups. Design of toilet may have the main sources of diarrhoeal infection is human excreta [22]. been discouraging some parents let their children use the Therefore, human excreta must be managed as a potentially toilet. Together with children, elderly people and people with dangerous material. The construction of latrines is a relatively physical challenge face similar sort of problem while using simple technology that may be used to control the spread of toilets. As mentioned, design of the toilets, thus consider the infectious diseases [23]. Studies have shown that latrine groups. The associated risk of covering and disposing of the coverage should reach 90% of a population to have an impact faeces of infants/children may not have been adequately on community health [24]. Our study area showed somewhat communicated to the community. Because of cultural attitude satisfactory situation in terms of using latrine. However, a towards children, people may not deem the faeces of children percentage of the households still do not have access to the to be dangerous. A hygiene promotion program can be latrines. A large percentage of children does not use toilet, launched to make the people aware of the danger of such which may easily increase the likelihood of their getting practice. At least, they should be encouraged to bury the infected by diseases. Two simultaneous sanitation programs faeces of infants under the soil further away from the ran in Bangladesh during the 1990s. The first was a national dwellings. Other measures such as provision of potties in the campaign promoted by the Government of Bangladesh (GoB) event of emergency could be a possible solution [27]. This is a and UNICEF [24]. The program organized over 1,000 village complete malpractice and is the reason for unhealthy and sanitation centers throughout the nation where subsidized polluted environment. In Haor areas as these wastes get mixed water-seal latrines were sold. Latrine coverage is estimated to with the water during monsoon, they pollute the water and have increased from below 3% to above 26% since the start of cause various water borne diseases. This attitude of throwing the program more than 18 years ago. The second program wastes haphazardly rather than in definite waste disposal took place at the same time as the national latrine promotion points make the surrounding unhealthy, unhygienic and thus program, but this program used a community-based approach causes serious health hazards during and post emergencies. in sanitation promotion. The International Center for Household solid waste disposal practices are influenced by the Diarrhoeal Disease Research, Bangladesh developed the supply of waste disposal services and other infrastructures; Sanitation and Family Education Project (SAFE) implemented it and where solid waste facilities are readily available, in the primarily agricultural region of southeast Bangladesh households tend to use them in a better way [28]. The practice [25]. A post intervention evaluation found improvements in all of solid waste disposal by households at these destinations is targeted behaviors. Results showed increases in latrine use influenced by factors such as socioeconomic status of the from 36% to 91%, The key elements to success were household, urbanity, supply of waste disposal infrastructure, community participation, participatory extension methods, regulation by the municipality and environmental and health and focusing on a few key behaviors for change [23]. Our study concerns [28,29]. Handwashing with soap prevents diarrhea suggests that promotional activities using participatory and respiratory disease, but it is rarely practiced in high-need approach may increase the practice of using safe latrines. One settings. Households that receive intensive handwashing important drawback in the flooded area could be the promotion report less diarrhea [30]. However, in settings inundation of latrines, which ultimately increase the risk of where diarrhea is an important cause of child mortality, the spread of diseases. Although our study did not focus on the prevalence of handwashing with soap after contact with feces status of the latrines, development partners and government as assessed by structured observation is typically <30% [31]. should come up to find solution to this problem not only by However, as found, the study area lacks usage of soap for promotion, but also with the innovation of adaptive latrines. washing hands. As expected, economic condition is related to Having a latrine reduces the chances of faecal discharge in the use of soap. Affordability becomes an important issue in open places. It is useful for reducing various water and air case of use of soap for washing hands. Development partners borne diseases. Moreover, having a latrine in a household also and government should take the fact into consideration and indicates their increased social status and living condition. The include the provision in the post-emergency programs. combined pit latrine (direct and off-set pit) are well accepted Although most of the respondents found aware of the timing by the haor community. This option also shows the greatest of washing hands, practice of using only water is alarming. The flood resistant latrines in that area [26]. Proper excreta and knowledge about regular hand-washing could be due to the waste management in flood-and cyclone-prone areas of nation-wide hand wash campaign for so many years. However, Bangladesh is a challenge. The appropriateness of latrine the problem remains, as already mentioned, in not using technology depends on soil type, groundwater table, proper washing material. In addition to provisioning of soap, © Copyright iMedPub 5 British Journal of Research 2020 ISSN 2394-3718 Vol.7 No.2:55

development partners may include in their awareness program sold their livestock at a price half the normal price, sold their about the encouraging of at least the alternative of soap such furniture and migrated to other areas searching works. as ash. Although the respondents practice the washing of the food-preparation surface, most use only water for the Acknowledgment purpose, which requires attention. Our study found that the people are aware of washing raw food before cooking. They Author wished to thank his supervisor for valuable also are aware of storing foods appropriately. The most suggestions, which improved the final form of this paper. alarming situation we found in the area is the nutritional status of infants, children and mothers. Breast milk has a major impact on child health, growth and development. Infants Conflict of Interest should Exclusively Breast Feed (EBF) for six months, then, The author declared no conflict of interest. nutritionally adequate and safe complementary foods should be introduced [32]. Diet of mothers during pregnancy contributes both to the long-term nutritional status of women References and well-being of the children [33]. Although women may 1. WHO (2003) Global strategy for infant and young child feeding. know that a pregnancy requires extra food intake, in practice WHO Geneva, pp: 5-10. they do not eat that much [34]. Intra-family biasness for 2. Bern C, Martines J, De Zoysa I, Glass RI (1992) The magnitude of allocation of food also deprives mothers (pregnant and the global problem of diarrhoeal disease: a ten-year update. lactating) from the amount of food they should intake. Bulletin of the World Health Organization 70: 705. Incorporation of nutritional education should help reducing Chen LC (1973) Disaster in Bangladesh. 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