
==== Front
J Family Med Prim Care
J Family Med Prim Care
JFMPC
J Family Med Prim Care
Journal of Family Medicine and Primary Care
2249-4863
2278-7135
Wolters Kluwer - Medknow India

JFMPC-13-3350
10.4103/jfmpc.jfmpc_330_24
Original Article
Assessment of water, sanitation and hand hygiene practices in rural households of Tamil Nadu: A cross-sectional study
Fazeela A
Borkar Rajnish S.
Mer Hetal T.
Department of Community Medicine, ACS Medical College and Hospital, Chennai, Tamil Nadu, India
Address for correspondence: Dr. Fazeela A, Department of Community Medicine, ACS Medical College and Hospital, Chennai, Tamil Nadu, India. E-mail: drfazeezi@gmail.com
8 2024
26 7 2024
13 8 33503354
29 2 2024
31 3 2024
19 4 2024
Copyright: © 2024 Journal of Family Medicine and Primary Care
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
ABSTRACT

Context:

Water is a basic human right essential to all for sustainable development. Sanitation is one of the determinants of quality of life and the human development index. Drinking unsafe water impairs health through illnesses such as diarrhoea, and untreated excreta contaminates ground waters and surface waters used for drinking, bathing and household purposes.

Aims:

To assess the existing facilities and practices related to drinking water, sanitation, and hygiene among household members in the rural population of Tamil Nadu and to assess whether accessibility and availability of safe drinking water and adequate sanitation under sustainable development goal 6 is being achieved in the rural population of Tamil Nadu.

Methodology:

This community-based cross-sectional study was carried out among 200 households in the rural field practice area of the Medical College and Hospital, Thiruvallur district, Tamil Nadu. The participants were interviewed using a predesigned semi-structured questionnaire on their existing water, sanitation, and hand washing facilities and practices

Results:

Our study observed that 71.5% of households had piped water supply into their dwellings, 82% were using sanitary latrines and 28% had closed drainage for draining wastewater. Twenty-eight percent were using soap and water for hand-washing before food, and 82.5% were doing hand-washing with soap after using the toilet. In our study, the association between sanitary practices and education, occupation and socioeconomic status was statistically significant

Conclusions:

Our study emphasized the need for strengthening health education and behaviour change communication regarding sanitation and hand hygiene practices.

Hygiene
open defecation
sanitation
SDG Goal 6
Swachh Bharat Mission
water
==== Body
pmcIntroduction

Access to safe water, sanitation and hygiene is the most basic human need for health and well-being.[1] Safe and sufficient water, sanitation and hand hygiene play a key role in preventing numerous Neglected tropical diseases (NTD s), such as trachoma, soil-transmitted helminths and schistosomiasis.[2] As per the 2019 update on the burden of disease attributable to unsafe drinking water, sanitation and hygiene, unsafe WASH was responsible for 395000 deaths and 17 million DALYs among under-5 children globally.[3] Safe WASH is not only a prerequisite to health but also contributes to livelihoods, school attendance and dignity and helps to create resilient communities in healthy environments.[2] In view of this, Sustainable Development Goal 6 sets targets for ensuring universal and equitable access to safe drinking water, adequate sanitation and hygiene for all by 2030.[4]

Billions of people have gained access to drinking water and sanitation services since 2000, but these services do not necessarily provide safe water and sanitation. Many homes, healthcare facilities and schools still lack soap and water for handwashing. Seventy-three percent of the world’s population used safely managed drinking water services in 2022. 3.5 billion people lacked safely managed sanitation services in 2022 and 2 billion people lacked handwashing facilities with soap and water at home in 2022.[5]

To accelerate the efforts to achieve universal sanitation coverage in India, the Swachh Bharat Mission was launched in 2014 with the concept of providing basic sanitation facilities like toilets, solid and liquid waste disposal and safe and adequate drinking water supply to every person.[67] Programmes that existed prior, such as the Total Sanitation Campaign[8] and Nirmal Bharat Abhiyan,[9] were integrated into the Swachh Bharat Mission, and its first phase was implemented from 2014 to 2019. With the successful completion of the first phase, phase 2 will be implemented from 2021 to 2025, focusing on the eradication of open defecation and solid and liquid waste management. To accelerate universal coverage ensuring access to potable water, the Jal Jeevan Mission[10] was launched in India in 2019 to provide tap water supply to every rural household by 2024.

According to the National Family Health Survey-5, 98.7% of the population in urban areas and 94.6% in rural areas were living in households with an improved drinking water source. The use of improved sanitation facilities was seen to be less in rural areas (64.9%) compared to urban areas (81.5%).[11]

As per NFHS-5, 99.1% of the population in urban areas and 98.1% in rural areas in Tamil Nadu were living in households with an improved drinking water source. 82.8% of the population in urban areas and 63.35% in rural areas were living in households with improved sanitation facilities in Tamil Nadu.[12]

With so many programmes in place, there is a need to understand the present scenario of the rural population regarding water, sanitation and hand hygiene for preventing diseases and addressing the root causes of health issues.

Subjects and Methods

This community-based cross-sectional study was conducted in the rural field practice area of the Medical College and Hospital under the Department of Community Medicine in Thiruvallur District, Tamil Nadu, between June 2022 and August 2022.

The sample size was calculated by taking the prevalence as 80.7% (NFHS-5 indicators for drinking water source and sanitation in Tamil Nadu) with a 95% confidence interval and 7% relative precision using the formula N = (1.96) 2PQ/L*L. It came to be 187.49, which was rounded off to 200. Ethical approval to conduct the study was obtained from the Institutional Ethics Committee of the Medical College and Hospital on June 21, 2022 (No. 541/2022/IEC/***MCH Dt. 21.06.2022).

One member from each household aged ≥18 years from Thiruvallur was included in the study. The participants from 200 households were selected using simple random sampling and interviewed using a predesigned, semi-structured questionnaire about their water and sanitation facilities and practices, as well as their hand hygiene practices. Informed consents were obtained from the participants before the start of the study. Individuals who were not willing to participate and who were mentally challenged were excluded. The purpose of the study was briefly explained to the population and strict confidentiality was assured.

Data collected were used only for research purposes and were entered in Microsoft Excel (Microsoft Corporation, Redmond, WA) and analysed using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp. Version 25.0.Armonk, NY: IBM Corp). Descriptive statistics, like frequencies and percentages, were used to summarise the data, and inferential statistics, like Chi-square and Fisher exact tests, were used for analysis. Significance was set at a P < 0.05.

Results

A total of 200 participants were included in the study. The mean age of the participants is 46.06 ± 13.5 years.

Table 1 shows the socio-demographic details of the study participants. Among the study population, 27 (13.5%) were males and 86.5% (173) were females. 98.5% of the subjects were married. The majority of them, 118 (59.0%), belonged to the age group ≥40 years. Seventy-seven (38.5%) of them had an intermediate/diploma degree and 146 (73.0%) were unemployed. One hundred and twenty-seven participants (63.5%) belonged to the upper middle class according to the Modified B. G. Prasad classification 2021.

Table 1 Socio-demographic variables of the study group

Variables	Subgroup	Frequency (n)	Percentage (%)	
Age (in years)	<40	82	41.0	
	≥40	118	59.0	
Gender	Male	27	13.5	
	Female	173	86.5	
Qualification	Illiterate	31	15.5	
	Primary school	6.5	6.5	
	Middle school	10	10	
	High school	20	20	
	Intermediate/diploma	77	38.5	
	Graduate	19	9.5	
Marital Status	Single	3	1.5	
	Unmarried	197	98.5	
Type of family	Nuclear	143	71.5	
	Joint	54	27	
	Three generation	3	1.5	
Occupation	Employed	146	73.0	
	Unemployed	54	27.0	
Socioeconomic status	Upper class	32	16.0	
(According to Modified BG Prasad 2021 Classification)	Upper middle class	127	63.5	
	Middle class	41	20.5	

Table 2 shows the existing water and sanitation facilities as reported by the study population. Among the 200 participants, 71.5% had the facility of piped water into the dwelling, and government supply (82.5%) was the major kind of water supply to the community. According to the study, 176 (88.0%) of the households stored their drinking water in closed containers, and about 184 (92.0%) households used to clean the water storage containers daily in their houses. One hundred and one (50.5%) used boiled water for drinking, and 29 (14.5%) used filtered water for drinking purposes. Only 56 (28.0%) had a closed drainage facility for waste water drainage. Most of them (164,82.0%) had household sanitary latrine facilities, and 172 (86.0%) used sanitary latrine (household and community).

Table 2 Existing water and sanitation facilities as reported by the study participants (n=200)

Variables	Subgroup	Frequency (n)	Percentage (%)	
Source of drinking water	Piped water into the dwelling	143	71.5	
	Public-tap/standpipe	18	9	
	Tube well/bore well	39	19.5	
Water suppliers in the community	Government/public	165	82.5	
	Private	35	17.5	
Kind of toilet/latrine facility used	Household	164	82	
	Community	8	4	
	Open field defecation	28	14	
Storage of drinking water	Open container	24	12	
	Closed container	176	88	
Cleaning of storage container	On becoming dirty	6	3	
	Every day	184	92	
	Every alternate day	7	3.5	
	Every week	1	0.5	
	Every month	2	1	
Measures for making the water safer to drink	Boiling	101	50.5	
	water filter	29	14.5	
	Straining through cloth	1	0.5	
	Nothing	69	34.5	
Drainage of wastewater	Open drainage	99	49.5	
	Closed drainage	56	28.0	
	To the field	45	22.5	
Usage of sanitary latrine	Yes	172	86	
	No	28	14	

The hand hygiene practices as reported by study participants are shown in Figure 1. Among the study participants, 56 (28%) were using soap and water for handwashing before food and 165 (82.5%) were doing handwashing with soap and water after using the toilet.

Figure 1 Hand hygiene practices as reported by study participants

In this study, we also found a significant association between sanitary practices and education, occupation and socioeconomic status (P < 0.05), which is displayed in Table 3.

Table 3 Association between sociodemographic factors and usage of sanitary practices

Variable	Yes, No. (%)	No, No. (%)	Total	Chi-square/Fischer’s exact test	P	
Gender						
 Male	23 (85.2)	4 (14.8)	27	0.017	1.000	
 Female	149 (86.1)	24 (13.9)	173			
Marital Status						
 Single	3 (100)	0 (0)	3	0.496	1.000	
 Married	169 (85.8)	28 (13.9)	197			
Type of family						
 Nuclear	123 (86.0)	20 (14.0)	143			
 Joint	47 (87.0)	7 (13.0)	54	0.980	0.613	
 Three generation	2 (66.7)	1 (33.3)	3			
Occupation						
 Unemployed	119 (81.5)	27 (18.5)	146	9.067	0.002	
 Employed	53 (98.1)	1 (1.9)	54			
Education						
 Graduate	18 (94.7)	1 (5.3)	19			
 Intermediate/diploid	74 (96.1)	3 (3.9)	77	28.310	0.000	
 High school	37 (92.5)	3 (7.5)	40			
 Middle school	14 (70.0)	6 (30.0)	20			
 Primary school	9 (69.2)	4 (30.8)	13			
 Illiterate	20 (64.5)	11 (35.5)	31			
Socioeconomic status (According to modified B G Prasad 2021 classification)						
 Upper class	32 (100)	0 (0.0)	32			
 Upper middle class	117 (92.1)	10 (7.9)	127	39.617	0.000	
 Middle	23 (56.1)	18 (43.9)	41			

Discussion

In this study, it was observed that the majority of the participants had piped water supply into their households (71.5%). This finding is similar to the Jal Jeevan Mission status report for Tamil Nadu, where 74.05% of households in rural areas had tap water connections as of September 2023.[13] Most of the participants had access to water within their household premises from water sources, with the majority using the government water supply (82.5%).

In the present study, the majority of the participants (82.0%) had household latrine facilities, which was slightly lower than what was reported in the National Annual Rural Sanitation Survey Round 2 (2018-2019), where 99.7% of households had access to toilet facilities and 96.9% of households had functional toilets.[14] However, 14% of the population was still practicing open defecation, and 4% only had access to community toilet facilities; this finding was similar to a study done in the rural population of Thandalam village, Chennai.[15] This implies that India has not achieved its open defecation-free target, and there are still households in Chennai that lack individual household toilets.

It was seen in the study that 88% of the participants reported storing water in closed containers for drinking purposes, and 65% reported using water purification before drinking, either by boiling or by using a water filter. Another study conducted by Ravi Pachori in Magudanchavadi, Salem district of Tamil Nadu, India, reported that 45.3% of the households used the boiling method for the purification of drinking water and 15.3% did not use any treatment for water purification.[16] This suggests the need for improved health education and behaviour change communication (BCC) in rural areas.

49.5% of the study participants reported discharging wastewater through open drainage and 28% through closed drainage. 22.5% of the participants reported discharging wastewater into the field. These findings signify the need for more concrete measures for waste management in the state.

The majority of the study participants (82.5%) were handwashing with soap and water after using the toilet, but only 28% were using soap and water for handwashing before having food and 2% before cooking food. A study conducted in two states of Eastern India also found that the majority (>90%) practiced hand washing after defecation,[17] and another study done among the tea garden population in Assam[18] also observed that the majority of the participants (83.8%) washed hands with soap after defecation. Another study conducted in rural South India reported that only 45% and 29.5% practiced handwashing with soap before having food and preparing food, which later improved after the intervention.[19] Based on the findings that handwashing practices are poor other than after defecation, it could be suggested that BCC should be conducted with an emphasis on handwashing before and after having food, before preparing food, and after work, as well as on the usage of soap for handwashing and on the steps of handwashing.

There were only a very few studies that analysed the sanitary and hygiene practices in South India, especially in Tamil Nadu. Our study explored the water, sanitation and hand hygiene practices in Tamil Nadu after the inception of many government initiatives like the Swachh Bharat Mission, the Jal Jeevan Mission, etc., but had limitations.

The first limitation was that it included a smaller sample size and was limited to one geographical area; hence, the results could not be generalized. Furthermore, the cross-sectional design of the study restricts the establishment of causal relationships, and the self-reporting on sanitary practices can probably bring in social desirability bias.

Therefore, future research should explore large-scale longitudinal studies tracking changes in behaviour over time. Targeted interventional studies aimed at improving sanitary practices and hygiene could provide insights for the successful implementation of BCC programmes.

Conclusion

Even though the availability of water was good in rural areas, sanitation and hand hygiene practices need improvement. The construction of household sanitary latrines and health education to prevent open defecation are crucial for achieving Sustainable Development Goals (SDG) Goal 3 targets 1 and 2. Despite the progress Tamil Nadu has made in potable water and sanitation through the Swachh Bharat Mission and the Jal Jeevan Mission over the past years, the state still has to make more improvements and has not yet made considerable progress in waste management. The Swachh Bharat Mission Phase 2 needs to be accelerated to achieve sanitation and hygiene for all by 2030.

The need for educational and behavioural change intervention was showcased by this study, as only repetitive health education can bring about an alteration in hand hygiene practices. Interventions from childhood through preschool and school education should be intensified in this regard. Education and awareness regarding this should be incorporated into the preventive aspect of primary health care.

List of abbreviations

Abbreviation	Definition	
SDG	Sustainable Development Goal	
NFHS	National Family Health Survey	
BCC	Behavioural Change Communication	

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.
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