Water usage, diarrhea and economic burden: life in a low-income urban community in Bangladesh

Abstract

In the last three decades (from 1990 to 2019), numerous efforts have been made globally to improve the water, sanitation and hygiene infrastructure and practices, to reduce diarrhea. Despite numerous public health efforts, diarrhea among all ages remained a major cause of morbidity and economic loss worldwide. In terms of economic indicators, it ranged from the third to sixth leading cause of disability-adjusted life-years (DALYs) between 1990 and 2019. The inverse relationship between low socio-demographic index (SDI) and of water, sanitation and hand washing (WASH) DALYs was noted, and implied that rigorous attention was needed to improve the health and hygiene of low-income populations. In 2015, the Sustainable Development Goals (SDGs) also included low-income urban communities (slums) in Target 6 and Target 11.1, to ensure “equity” and basic services for the slums by 2030. The surveillance data typically capture the number of severe diarrhea cases seen in health care facilities and thus missed to capture information on mild or moderate cases in the diarrhea prevalence estimation. It is estimated that 65-95% of all diarrheal episodes in low-income areas are mild and moderate. Since community-based surveillance is a challenge and scarce, particularly in low-income areas, the estimation of the true burden of diarrheal disease remains a concern. Similarly, the estimation of the household economic burden of diarrhea, which is mostly based on hospitalized patients, may not be pertinent to capture and represent the cost of diarrhea in lowincome urban communities. Hence, a comprehensive and holistic research approach is urged to address this prime public health problem in a contextual manner to enhance understanding of disease burden, transmission and prevention in low-income urban communities. Therefore, the

objective of this study is to provide an in-depth understanding of how low-income people perceive,

interact with, and respond to diarrheal diseases and related economic hazards.

The East Arichpur area, located in Tongi Sub-District, 15 km north of Dhaka, was selected for this study. The population density was around 100,000 per km 2 . The residents of East Arichpur were vulnerable to diseases including diarrhea, cholera and hepatitis E (HEV). In East Arichpur, 97% of the households used improved latrines and improved piped-to-plot water connections within the premises. Data collection for the different components of the study took place from April 2014 to July 2016. Community mapping identified a total of 13,876 households within 1,437 compounds (i.e., clusters of households sharing a common yard and other facilities) in East Arichpur. In East Arichpur, 98% of the compound residents reported sharing water points, kitchen, and toilet facilities with other households in the compounds, and had improved piped-to-plot water connections inside the compound yards. From the 13,876 low-income households, 477 were selected to conform an 18month cohort to collect longitudinal data on water, sanitation, hygiene and diarrhea. A subset of 24 households from the 18-month cohort were selected for in-depth exploration using an ethnographic

approach to understand water usage for personal and domestic hygiene, and the determinants of water usage for hygiene practices among the individuals of each household. To capture the cost

borne by the households per diarrheal episode, a total of 264 diarrhea cases among East Arichpur

residents were enrolled.

The mobile phone–based surveillance system, the "cholera phone", captured the real time incidence of this community and thus avoided recall bias/error, which is key in measuring the incidence and prevalence of diarrhea. The incidence rate (IR) per person-year was 0.16 (95% confidence interval [CI]: 0.13-0.19) for the "cholera phone" between August 12, 2014 and June 30, 2015 in East Arichpur. The IR per person-year for children two to five years old was 0.21 (95% CI: 0.12-0.38). The participants perceived the English word "diarrhea" as an identical term to "cholera" or "severe diarrhea". The terms "patla paykhana", "pet kharap (bad stomach)" and "pet naram (soft stomach)" were used by the participants to describe the World Health Organization (WHO) definition of diarrhea (three or more loose stools). The participants also offered their desire to receive treatment after reporting of diarrhea and self-treatment with antibiotic as reasons for not reporting diarrhea. These findings explained the low reporting of diarrhea through the "cholera phone", particularly between August 2014 and June 2015 (before replacing it with a modified intervention). The average total cost of illness per episode for severe diarrhea was 2,147 Bangladeshi Taka (BDT) (US$ 27.39), accounting for 17% of the average monthly household income of a severe patients. The average total cost of illness per episode for non-severe diarrhea was 499 BDT (US$ 6.36), accounted for 4% of the average monthly household income of a non-severe patients. Non-severe diarrhea was defined as three or more loose stools in 24 hours. Severe diarrhea patients were those who were admitted to the hospital and/or received intravenous saline (due to moderate or severe dehydration). The estimated annual cost for severe cases of diarrhea was US$ 6,355, and for nonsevere cases was US$ 55,008 in East Arichpur. The average water use was 75 liters per capita per day (LPCD) and the average water use for personal hygiene only (e.g., cleaning of body parts) was 39 LPCD in the study area. Male participants used more water compared to females. The volume of water used for domestic hygiene(e.g. cleaning dishes, toilets, houses and clothes) reduced to almost half or less among individuals with access to water <24 hours a day compared to individuals with access to water 24 hours a day. For example, the volume of water used for cleaning dishes was 7 LPCD with 24 hour access to water and 4 LPCD with <24 hour access to water. In contrast, access to water did not substantially change the volume of water used for personal hygiene. The volume of water used for personal hygiene was lowest in January (30 LPCD) and highest in September (46 LPCD). The notion of “hygiene” had two separate meanings among the study participants: “cleanliness” and “holiness”. The requirement of cleanliness was linked to feeling fresh, with comfort as an immediate reaction, and the requirement of holiness was related to following religious rules, beliefs and rituals. The distant (underlying) reason for cleanliness was to avoid germs or disease, and distant reason for holiness was accountability to God. The volume of water used was also influenced by the notion of hygiene. Participants practicing regular prayer were concerned about maintaining holiness and used more water (64 LPCD) in comparison to the participants who did not perform regular prayers (40 LPCD). The results of this study suggest that mobile phone surveillance could be useful in capturing the real-time prevalence of diarrhea, when used in conjunction with qualitative evaluation methods at the beginning of the surveillance to improve it and make it compatible and context-appropriate. Thestudy also suggests that though the average cost of non-severe diarrhea at the household level was low (US$ 6.36, 4% of the total household expenditure), the estimated incidence-based economic burden of the community was high (US$ 55,008). The qualitative findings suggest that availability of water alone cannot ensure improved hygiene practices among the residents with piped-to-plot water services, without taking the social norms, individual traits, beliefs and motivating factors into account. Furthermore, the germ theory of disease was not explicitly conceptualized/conceived as the reason for hygiene among the participants in this community; rather, they linked it with individual physical comfort and with their religious rituals and accountability to God. This thesis revealed that, when infrastructure is in place, emphasis should be given to learning the social, environmental and behavioral factors prevalent in the community, as these shape the related risk of disease transmission across the population. A community-tailored mobile-based data collection/surveillance system is useful not only to capture the incidence and prevalence of a disease, but also as an early warning system, particularly compatible with the current world situation dealing with the highly infectious COVID-19 pandemic. While the paucity of data on lowincome communities or slum settlements is well noted, this thesis incorporated some systematically

collected holistic insight into this population that could be useful for future research.