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Knowledge, Attitudes, Practices and Implications of Safe Water Management and Good Hygiene in Rural Bangladesh: Assessing the Impact and Scope of the Brac Wash Programme

Stephanie Fisher (corresponding author)
Centre for Global Health, 3–4 Foster Place, Trinity College, Dublin 2, Ireland

Babar Kabir
BRAC Centre (8th floor), 75 Mahakhali, Dhaka 1212, Bangladesh

Edward Lahiff
Centre for Global Health, 3–4 Foster Place, Trinity College, Dublin 2, Ireland

Malcolm MacLachlan
Centre for Global Health, 3–4 Foster Place, Trinity College, Dublin 2, Ireland

Abstract/ Executive Summary:

A substantial component of BRAC’s WASH programme involves educating rural Bangladeshis about safe water management, good hygiene and the causes of diarrhoea. By conducting questionnaires and focus group discussions in two BRAC WASH villages and one control village, this investigation sought to assess the impact of BRAC’s programme on knowledge, practices and diarrhoeal burden, to explore the extent to which knowledge determines practices, and to evaluate which factors were most predictive of diarrhoeal incidence. It was found that the programme had a beneficial effect on the subjects’ knowledge and practices, and on the diarrhoeal incidence among their children. Furthermore, except for where personal financials expenditure was required, practices tended to follow on from knowledge. However, BRAC’s intervention affected neither the frequency of soap use in hand washing by the mother, nor the child’s consumption of unclean water outside of the home. These factors, along with the child’s consumption of unclean water inside the home, were shown to be those most predictive of diarrhoeal incidence among the under-fives. It is recommended that BRAC continues to emphasize the importance of these points, while also potentially promoting the use of less costly alternatives to soap and cheaper point-of-use treatment materials, to induce positive behaviour change.

Keywords: Attitudes, Diarrhoea, Hygiene, Knowledge, Practice

Location: Mymensingh District

Start Date:

End Date:

Program Area: Knowledge Management

Commodity: Water management

Objectives:

The purpose of this investigation therefore was to assess, using a case study approach, the impact of the BRAC WASH programme on the knowledge and practices of caregivers of children under five years of age in two rural Bangladeshi villages, by comparing them with equivalent women from a comparable near by village not subject to the intervention, and to study the link between knowledge and practice among the respondents.

Methodology:

The study area The study was conducted in three rural villages, selected using purposive sampling, in the Mymensingh District of the Dhaka Division of Bangladesh. The villages, Kuchundhora, Boyalmara and Makiar Knda, which were within 7 km of each other, were chosen because of their geographical proximity, and their similarity in terms of accessibility, socioeconomic status, employment, education, and use of tubewell water. They are however split across two sub-districts; Kuchundhora and Boyalmara are situated within the Haluaghat upazila (sub-district) and Makiar Kndais situated within the Dhobaura upazila. The Haluaghat upazila is one of the 150 upazilas in which the BRAC WASH programme operates, but the Dhobaura upazila is not. Accordingly, the villages of Kuchundhora and Boyalmara are subject to the BRAC WASH intervention, and have been for precisely the same length of time, while the village of Makiar Knda has not received WASH equipment or education from BRAC or indeed any other NGO. Data collection and analysis By going door-to-door within the three study villages, every caregiver of a child under five years old (who was in most cases the mother, and in every case a woman) was invited to answer a pre-piloted 35-question survey conducted in the Bangla language by a BRAC fieldworker from the area. With the exception of one mother from Kuchundhora who was sick and therefore unable to partake, and one mother from Makiar Knda who was deemed insane and therefore excluded from the study, every caregiver of an under-five took part; a total of 107 women, 80 from the BRAC WASH villages and 27 from Makiar Knda. The questionnaire explored the caregiver’s knowledge of the causes of diarrhoea, her knowledge, attitude and practices of household water management, her water, sanitation and hygiene practices, and her child’s burden of diarrhoeal disease during the month prior to data collection. Wherever possible, the answers given concerning her water source and latrine type and cleanliness were verified by observation. Diarrhoea was defined according to the WHO definition, as three or more loose or watery stools within a 24-hour period. The impact of the BRAC WASH programme on the variables covered in the survey was determined using Fisher’s exact test (for qualitative answers), the Student’s t-test (for quantitative parametric answers) and the Mann–Whitney test (for quantitative non-parametric answers) to explore which answers were associated with the presence or absence of the intervention. A comparison between the two BRAC WASH villages was then performed in order to verify that any differences found to be significant by the first analysis were more likely to be due to the presence/absence of the intervention rather than some intrinsic difference between the three villages being studied. The same tests that were used to examine the impact of the intervention were then used to examine associations between the survey answers and the respondent’s child having suffered from diarrhoea within the previous month. Having found the factors associated with incidence of diarrhoeal disease among the under-fives, backward stepwise multiple logistic regression was used to eliminate those variables which did not play a significant role in predicting whether or not the child had suffered from diarrhoea, leaving only those which had a significant impact on the incidence of diarrhoea. All statistical calculations were performed using the computer programme SPSS Statistics 17.0. In addition, in each of the three villages, a focus group discussion was conducted among eight of the questionnaire respondents, selected using convenience sampling by the BRAC WASH fieldworkers. The focus group discussions were carried out in order to explore their answers, beliefs and attitudes in a greater depth than enabled by questionnaire. The discussion, facilitated by a BRAC fieldworker or interpreter with a note-taker present, was recorded using a digital voice recorder. Following the focus group, the recording was transcribed and translated by the interpreter present at the discussion. The three translated transcripts were analysed by identifying emerging themes and patterns in order to support, expand upon or dispute the results already obtained from the questionnaire. Free and informed consent of the participants was obtained for all aspects of the methodology, and the study protocol was approved by the Faculty of Health Sciences Ethics Committee, Trinity College, Dublin, on 2 April 2009.

Source of Information: Journal of Water and Health 9 9 9 909.19 9 9 92011

Article Link (Online Journal): https://iwaponline.com/jwh/article-pdf/9/1/80/397603/80.pdf

Funding Source:

Budget:

Total Budget (Tk.) :

Achievement/Findings:

The results of this investigation suggest that the BRACWASH programme has had a beneficial effect on the knowledge, practices and diarrhoeal incidence of the inhabitants of Kuchundhora and Boyalmara. The results suggest that BRAC’s teaching can increase the participants’ motivation to act, and imply that, where performing the water management or hygiene practice does not require the expenditure of personal finances, knowledge can be translated into practice, and that such practices can have a beneficial impact on the diarrhoeal disease burden. It also appears as if good practice can even occur in the absence of knowledge, if it is part of a long-standing tradition or has recently become integrated in to the community norms, something that was also demonstrated byHoqueetal.in1996.Unfortunately,however,it seems that for all three of the villages, a lack of disposable income represents a barrier between knowledge and practice where personal expenditure is required. The respondents in Makiar Knda who ought to have treated their water could not afford to do so, nor could most of the respondents from the BRAC villages were it to have been required. In all three villages, mothers frequently allowed their children to consume potentially unclean water (or water-based products) outside the home, where safe equivalents are available, but at a price. Likewise, in the context of this result, and the findings of Hoque et al. (1995) of the unaffordability of soap elsewhere in Bangladesh, it seems likely that lack of money was the cause of the inconsistent use of soap within the BRAC villages. Our findings also highlight that, while the theory of reasoned action has value in understanding the effects of BRAC’s WASH programme, there are important and very basic limitations of the theory ,such as available financial resources. As such we stress the importance of considering the context in which, and the process by which, interventions are delivered, especially in low-income settings (MacLachlan et al. 2010). Indeed enhancing the wish or intention to behave in a health-promoting manner, without providing the capability to enact, may only disempower and frustrate people. As the child’s consumption of unclean water inside the home, its consumption of potentially unclean water or waterbased products outside the home, and the frequency with which the caregiver used soap when washing her hands, all proved strongly predictive of the child’s incidence of diarrhoeal disease, it is recommended that BRAC continues to focus on these three points and to emphasize their importance in future community education programmes. Furthermore, it might be advisable for BRAC to promote the use of less costly alternatives to induce positive behaviour change. Potential alternatives could include the use of readily available soil or ash as an alternative tosoap (Hoque etal. 1995), and the promotion of less expensive or more available methods of water treatment, such as potash, which is also readily available in Bangladesh (Islam et al. 2006). If such promotion were to be carried out alongside reinforcement of the importance of these factors, then the impact of the BRAC WASH programme might increase to an even greater extent, further lessening the preventable incidence of childhood diarrhoeal disease.

Knowledge Management: Journal