|Year : 2016 | Volume
| Issue : 3 | Page : 587-592
Promotion of sanitation and hygiene in a rural area of South India: A community-based study
Nagapraveen Veerapu1, P Subramaniyan2, BA Praveenkumar2, G Arun2
1 Department of Community Medicine, Viswabharathi Medical College, Kurnool, Andhra Pradesh, India
2 Department of Community Medicine, PES Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
|Date of Web Publication||30-Dec-2016|
Department of Community Medicine, Viswabharathi Medical College, Kurnool, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Globally, billions of people do not have access to improved sanitation and many defecate in the open air. Poor hand washing practices and limited access to sanitation facilities perpetuate the transmission of disease-causing germs. The objectives of the study were to find out the level of knowledge, attitudes, and practices (KAPs) on sanitary latrine, footwear, and hand washing among rural people and to assess the improvement in KAP after health education intervention. Materials and Methods: A health education intervention study was conducted from November 2012 to January 2014 in a rural area of Kuppam, Andhra Pradesh, South India among the people aged 15 years and above. The individuals were selected by multistage random sampling and interviewed using a structured questionnaire. After a baseline KAP assessment, intervention activities were conducted twice. The intervention activities were group level talks and discussions, free soap distribution, and display of posters at anganwadi centers. Post-KAP was assessed twice, and the significance of difference was found by using McNemar's test. Results: After the intervention, there was a significant improvement in the overall KAPs among the subjects in post test-1 and post test-2 (P1 < 0.0001, P2 < 0.0001), respectively. Conclusions: Health education as an intervention has significantly increased KAP more than 30%. Hence, it is imperative that education interventions are needed to bring or sustain positive change.
Keywords: Attitudes and practices, disease, footwear, hand washing, health education, knowledge, sanitary latrine
|How to cite this article:|
Veerapu N, Subramaniyan P, Praveenkumar B A, Arun G. Promotion of sanitation and hygiene in a rural area of South India: A community-based study. J Family Med Prim Care 2016;5:587-92
|How to cite this URL:|
Veerapu N, Subramaniyan P, Praveenkumar B A, Arun G. Promotion of sanitation and hygiene in a rural area of South India: A community-based study. J Family Med Prim Care [serial online] 2016 [cited 2019 May 26];5:587-92. Available from: http://www.jfmpc.com/text.asp?2016/5/3/587/197305
| Introduction|| |
Out of a global estimate of 7 billion people in 2012, about 2.5 billion people do not have access to improved sanitation and 1 billion people defecate in the open air.  In India, 53% of households or 600 million people defecate in open, out of which 69.3% belongs to rural areas and 18.6% belongs to urban areas.  Field studies indicate that usage of the existing toilets in both rural and urban areas is very low. 
Eighty-eight percent of diarrheal cases worldwide are linked to unsafe water and inadequate hygiene. Globally, every year diarrheal diseases account for about 1.8 million deaths.  An estimated 2000 children under the age of 5 years die every day from diarrheal diseases and out of this, 1800 deaths are due to unsafe water and poor sanitation. 
Worldwide, soil-transmitted helminths infect more than 1 billion people a year due to a lack of adequate sanitation and the burden due to helminths infection was estimated at 39 million disability adjusted life years.  In rural India, the hookworm infestation has been one of the major cause of iron deficiency anemia.  Poor hand washing practices and limited access to sanitation facilities perpetuate the transmission of disease-causing germs. Around 32% of diarrheal diseases can be reduced by improving sanitary conditions. Health education interventions including hygiene education and promotion of hand washing with soap can lead to a reduction of diarrheal cases up to 45%. Schistosomiasis disease can be reduced up to 77% by improving sanitation, and trachoma morbidity can be reduced up to 27% by improving access to safe water sources and improving hygiene.  Hand washing with soap has been the most cost-effective way of preventing diarrhea and pneumonia, which are leading causes of child mortality. 
India is to reduce the proportion of households having no access to sanitation to 38% by 2015. At the current rate of decline, India may achieve the proportion of households without any sanitation to 43% by 2015, missing the target by about five percentage points. 
The goal of Nirmal Bharat Abhiyan was to end open air defecation and adopt safe, hygienic practices. Thus, a clean and healthy nation that thrives and contributes to the welfare of our people could be achieved.  Community health mainly depends on sanitation and hygiene practices of the people. Health education improves the level of knowledge and change in the attitude of the people toward sanitation and helps the people to bring or to maintain a positive, healthy behavior.
In Andhra Pradesh, only a few intervention studies were conducted on this aspect. Therefore, we conducted a community-based interventional study on knowledge, attitudes, and practices (KAPs) regarding sanitary latrine, hand washing and usage of footwear among rural people of Kuppam, Andhra Pradesh, South India.
| Materials and Methods|| |
Study design, study area, and study population, study period
A community-based interventional study was conducted in the rural area of Kuppam, Andhra Pradesh, South India, among people aged 15 years and above. The study was conducted from November 2012 to January 2014.
Prior to the study, a pilot study was conducted and it was found that there was at least 10% increase in the knowledge or attitude or practice after the intervention in the piloted sample. Based on this, the sample size was calculated at α (type one error) = 0.5% and power (1−β) = 90% and the sample size were 266 individuals. Assuming a loss of 10% during follow-up, it was decided to take a sample of 300 individuals.
Study subjects were selected by multistage random sampling. All Gram Panchayats in Kuppam Mandal were listed. One Gram Panchayat was selected. There were five villages in Gram Panchayat. Out of five, three villages each having more than two hundred households was selected by simple random sampling. In each village, randomly households were selected until the number of households hundred was reached. Then, one person from the selected household aged 15 years and above was selected randomly and interviewed.
Data collection tool
A structured questionnaire was developed, translated into local language Telugu, and back into English. The questionnaire included four sections, namely sociodemographic characteristics of the study subjects, knowledge aspects, attitude aspects, and practice aspects regarding sanitary latrines, hand washing, and usage of footwear. The knowledge and practices were assessed by "Yes or No" questions. "Yes" indicates the presence of knowledge/positive practice. The attitude was assessed by sentences with three responses such as disagree, neutral, and agree. "Agree" indicates positive attitude. The questionnaire included a checklist for the presence of soap and to see whether latrine is sanitary or not. The reliability of the questionnaire was r = 0.71 (71%) by using test-retest. Approval for the study was obtained from the Institutional Ethics Committee.
Baseline survey (pretest)
A baseline survey was conducted to assess initial level of KAP using the questionnaire. The individuals were interviewed separately for 20-25 min. The survey was carried out during evening times (4-7 pm).
The intervention activities were conducted twice in all of the selected villages. The second intervention was done, 1 month after completion of the first intervention. Each health education session was a group level interactive lecture for 30-45 min using flip charts containing pictures and health messages. Each group consisted of about 5-10 study subjects and other persons in the locality. The dynamics of disease transmission was explained and the importance of sanitation and hygiene was emphasized. Question and answer pattern was followed during and after the health education and doubts were clarified. After health education, pamphlets explaining the importance of sanitary latrine, footwear and hand washing were distributed, and posters were displayed at schools and anganwadi centers. Free detergent soap was distributed and importance of hand washing with soap was stressed during health education sessions. Community participation was increased by free distribution of soap.
After a gap of 1 month from the completion of the second health education intervention, a postintervention survey was conducted to assess the level of KAP using the same questionnaire.
After a gap of 4 months from the completion of the second health education intervention, another postintervention survey was conducted to assess the level of KAP using the same questionnaire.
Statistical analysis of data
The data were entered into MS Excel 2007 version and further analyzed using IBM SPSS version 21. The categorical data were represented using percentages (%), and continuous data were represented using mean and standard deviation. The significance of difference was analyzed by using McNemar's test.
| Results|| |
Among the three hundred study subjects, most (53.3%) were females. The mean age of the study subjects was 37.03 ± 15.4. Most of the subjects were illiterates (64.7%), belonged to nuclear families (69.7%), and were in class 4 (55.3%) and class 5 (27%) socioeconomic status according to BG Prasad 2012 classification [Table 1].
[Table 2] shows that the knowledge scores among the study subjects increased after the intervention. There was statistically significant increase in the overall knowledge score and also each aspect of knowledge score (P1 < 0.0001, P2 < 0.0001). The knowledge regarding naming the diseases was poor, both before and after the intervention. The awareness about government schemes for construction of sanitary latrine was increased from 55% (pretest) to 98.6% and 98.9% after intervention in post test-1 and post test-2, respectively.
|Table 2: Knowledge about sanitary latrine, footwear, and hand washing with soap among the study subjects |
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[Table 3] shows that the positive attitude scores among the subjects increased after the intervention. There was statistically significant increase in the overall attitude scores and also each aspect of attitude scores (P1 < 0.0001, P2 < 0.0001).
|Table 3: Attitude toward sanitary latrine, footwear, and hand washing among the study subjects |
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The perception of the need for having sanitary latrine was increased from 54.3% to 95% and 96% after intervention in post test-1 and post test-2, respectively. The attitude score toward buying footwear was increased from 38% to 87.7% and 91.6% after intervention.
[Table 4] reveals that the practice scores increased after intervention among the study subjects. There was statistically significant increase in the overall practice scores and also in each aspect of practice scores (P1 < 0.0001, P2 < 0.0001). About 91.3% of the subjects were practicing open air defecation. After intervention 77.3% and 77.2% were practicing open air defecation. The practice of keeping latrine in a sanitary way was increased from 88.2% to 97.3% and 95.9% after intervention in post test-1 and post test-2, respectively.
|Table 4: Practices of latrine, usage of footwear, presence of soap at hand washing site, and hand washing with soap before food, after toilet, after work, before cooking food and after cleaning child's bottom/feces among the study subjects |
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The practices of hand washing with soap before/after some activities were studied. The score for practice before cooking food was increased from 29.7% to 63.2% and 81.3%. The score for the practice before food intake increased from 45% to 80.9% and 87.3%. The score for practice after toilet was increased from 54% to 94.7% and 95.3%. The score for practice after work was increased from 61.7% to 93.7% and 94.6%. The score for practice after cleaning child's bottom was increased from 78% to 93.2% and 97.3%. The score for the presence of soap at hand washing site in the subjects' households was increased from 32.7% to 77.3% and 69.8% in post test-1 and post test-2, respectively.
| Discussion|| |
In this study, the knowledge that "sanitary latrine protects from transmission of diseases/good for health" was increased after intervention. In a cross-sectional study conducted in rural Madhya Pradesh,  only 20% of the mothers were knowledge about diarrheal diseases were caused by consumption of contaminated food and water. In a cross-sectional study in rural area of Maharashtra,  people were afraid of getting diseases by consuming contaminated food and water by the fecal matter due to open air defecation (34.7%). In a study conducted in the rural area of Haryana,  people falsely perceived that open air defecation did not spread diseases (18-25%). In this study, the attitude toward the need for sanitary latrine and the willingness to construct sanitary latrine increased after the intervention. In a study in Palestinian territory,  the attitude of the school students toward using toilets was assessed; 44.1% of West Bank students and 42% of Gaza students refused to use school toilets and felt that the toilets were not clean. In this study, among the subjects having latrine in the households before the intervention, 88.2% of latrines were sanitary. After the intervention, 97.3% and 95.6% were sanitary in post test-1 and post test-2, respectively. The attitude toward agree "construction of sanitary latrine was not expensive" increased after intervention from 25.4% to 57.2% and 60% in post test-1 and post test-2, respectively. In a survey conducted in Thailand,  two groups were compared, 93.3% of the group committee having a sanitary latrine and 8.69% of the group committee not having sanitary latrine agreed "constructing sanitary latrine was not an economic problem" for them.
Among the subjects, only 11.3% had sanitary latrine in the household. After the intervention, 24.4% and 24.8% were having latrines. Among those having latrines, 76.5% of the subjects were using it routinely. After the intervention, the percentage of routine usage was increased to 93.2% and 91.1% in post test-1 and post test-2, respectively. In a study conducted in Tamil Nadu,  41.5% in Main village and 23.2% in Harijan colony had toilets and the usages among those having toilets were 88.2% in Main village and 76.9% in Harijan colony. In this study, the practice of open air defecation was more than 60% after intervention, which was similar to various cross-sectional studies conducted in the rural area of India, Maharashtra  (67%), Madhya Pradesh  (71% from Ichhawar block and 62% from Asha block), and Tamil Nadu  (74.2%). In an awareness evaluation study conducted in Chandigarh,  the usage of community latrines in urban slum area was assessed, and there was a significant increase in the awareness from the baseline, this study also showed a significant increase after the intervention.
The practice of going barefoot outside decreased after the intervention. During 1920's studies conducted in Porto Rico and Brazil showed that people having the habit of not wearing footwear and going on barefoot were highly infested with the worms. 
In the present study, knowledge that hand washing with soap protects from transmission of diseases/good for health increased after intervention from 41% to 91.3% and 91.6% (post test-1, post test-2). A study conducted in the rural areas of Maharashtra,  people (77.6%) had knowledge on the importance of hand washing. Another study conducted in the rural area of South India,  38.8% mothers had knowledge that hand washing could prevent diarrhea and 24.9% mothers had knowledge that hand washing could prevent acute respiratory infections. In an intervention conducted on hand washing in Eastern India,  majorities of the people wrongly considered that child's feces was free of germs.
In a KAP study conducted in Anuradhapura Teaching Hospital,  only 40% agreed they adhere to correct hand hygiene practices. In the present study, the need toward hand washing was assessed rather than adherence, and 62.3% subjects agreed that there is a need for hand washing with soap (and water). After the intervention, the need was increased to 96% and 95.3% (post test-1, post test-2).
In the present study, the practices of washing hands with soap (and water) before/after various activities, increased after the intervention. In a community-based cross-sectional study conducted in West Bengal,  the subjects practicing washing their hands with soap and water were 71% after defecation, 13% before meals, 1% before cooking, and 5% after cleaning child's feces. In a cross-sectional study conducted in South India among the mothers having under five children,  the mothers practicing hand washing with soap and water were 33.3% before food, 90% after defecation, 31.1% before cooking, and 87.8% after cleaning child's feces. In another study among the mothers,  the practices were 73.1% after defecation, 76.9% before food, 20% before cooking, and 63.9% after cleaning child's feces.
In the present study, the presence of soap at hand washing site in the households was less than studies done in Thailand (94%) and in Ethiopia (82%), where free soap was distributed. 
| Conclusions|| |
The present study showed that health educational interventions can significantly improve the overall KAPs of the study population pertaining to sanitary latrine, usage of footwear, and hand washing by more than 30%. Health education made the people to realize their unfelt needs. There should be regular follow-up visits and repetition of health education to bring and sustain the positive healthy behavior in the community. This study is limited as post test-1 and post test-2 surveys were conducted with a gap of a few months because of time constraint and so there was not much difference between post test-1 and post test-2 results. The questionnaire needs to be further standardized.
The authors would like to thank WHO for allowing us for reproducing information from, progress on drinking water and sanitation-2014 update.
The authors would like to thank Kuppam Mandal Parishad of Chittoor District, Andhra Pradesh for their support for research activities.
The authors would like to thank Dr. Anand D. Meundi, MD, Professor and Dr. Vijay Domple, MD, Assistant Professor for extending their support during the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]