Factors affecting cleanliness of shared urban slum toilets in Dhaka, Bangladesh

Mahbub-Ul AlamResearch Investigator; mahbubalam@icddrb.org

Water, Sanitation and Hygiene Research Group, icddr,b

Water and Health Conference, Chapel Hill, North CarolinaOctober 26, 2015

Background

• Shared toilets in urban slums are often unclean and poorly maintained

• Unclean, poorly maintained toilets may be underutilized or abandoned encouraging open defecation

• Poor hygiene and maintenance can lead to negative health outcomes

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Rationale

• Objective indicators of cleanliness of shared toilets are lacking

• Determinants of shared toilet cleanliness was not well identified

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• Shared toilets' cleanliness is a key health issue which needs to be measured accurately

• Previous studies have measured cleanliness based on users’ perceptions

Objectives

• To describe multiple objective indicators of cleanliness of shared toilets

• To identify the factors associated with toilet cleanliness

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Study design

• A behavior change intervention to improve toilet cleanliness and maintenance– 1,226 shared toilet users in 23 urban slums of Dhaka

• Slums were divided into 38 clusters– by road, market, canal, drain

• Conducted pre-intervention baseline survey• Analyzed baseline data

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Toilet and respondent selection

• Selected first toilet after entering the slum:– Skip next – Select subsequent– <40 toilets per cluster

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• One adult user per toilet:– From second nearest

household

Methods: spot check of toilet• Observed toilet:

- Structure- Provision of water

• Presence of:- Visible feces- Urine/other liquid- Solid waste

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– Within- Squatting area - Pan

Methods: interview of toilet user

• Interviewed one adult user per shared toilet:– Demographic

information– Toilet management

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Data analysis• Definition of clean toilet (Günther et al. 2012):

– absence of • Feces• Liquids• Dirt

• To identify factors associated with toilet cleanliness:– Prevalence ratio– Generalized estimating equations to account for

clustering

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– within • Squatting area • Pan

Toilet characteristics (n=1,226)

• Toilet built by:– Landlord: 65%– NGO: 18%

• Average user households: 6

• Average users: 24

Landlord built toilets were more commonly connected to a canal or ditch than NGO built toilets (63% vs. 26%, PR: 2.7)

Toilet excreta released (n=1,226)

Water seal present: 27%

Connected to canal/

ditch

Piped sewer system

Septic tank Pit latrine 0

20

40

60

80

100

57

18 14 11

%

Type of toilet

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• NGO built toilets were more commonly pit, septic tank or piped sewer system toilets with a functional water seal than landlord built toilets (39% vs. 3%, PR: 8.3, 95% CI: 4.2-16).

Facilities for toilet (n=1,226)

• No water storage facility: 45%• Water available: 12%• Average distance to water

source: 18 feet• Waste bin inside toilet: 0.5%• Brush and washing agent

available: 5%

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Toilet maintenance

• Toilet cleaning responsibilities (n=1,226):– Rotated among the user households: 78%– Landlord paid a caretaker: 10%

• Emptying septic tank or pit was landlord’s responsibility: 83% (n=290)

• Hired manual labor to emptying: 75% (n=81)• Among 81 toilets, 98% of fecal sludge was

disposed into the slum environment

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Solid waste disposal inside toilet (n=1,226)

• Reported waste disposal practice in the toilet:– Menstrual cloths/rags: 16%– Paper: 12%– Plastic bags: 9%

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Toilet cleanliness (n=1,226)

• Feces visible:– Inside pan hole: 47%– Inside the pan: 28%

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Toilet cleanliness (n=1,226)• Feces visible:

– Outside pan: 8%– On the footrest of the pan: 2%– On the path leading up to the

toilet: 14%

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*Absence of feces, liquids or dirt within the squatting area and pan of the toilet

• Toilets classified as clean*: 34%

Determinants of toilet cleanliness (n=459)

Available (N=150)

Not available (N=1077)

0

20

40

60

80

100

53

35

Toilets were more commonly clean when water was available inside or beside the toilet (PR: 1.9, 95% CI: 1.5-2.4)

Water present inside/beside clean toilet

%

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Determinants of toilet cleanliness (n=459)

Toilets were more commonly clean when there was a water storage beside the toilet (PR: 1.1, 95% CI: 1.1-1.2) 18

Available (N=670) Not available (N=557)0

102030405060708090

100

4034

%

Water storage container available inside/beside clean toilet

Conclusion

• Majority of shared toilets in urban slums were not clean

• Presence of water and water storage container were associated with toilet cleanliness

• It is possible to measure toilet cleanliness using objective indicators

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Recommendations

• Use combined scale/matrix using multiple objective indicators to measure toilet cleanliness

• Efforts to provide adjacent sources of water will likely have an impact on cleanliness

• Efforts to reduce excreta release in the environment should be emphasized

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Study teamIcddr,b:

Leanne UnicombFarzana BegumFosiul NizameMahbubur RahmanFarzana YeasminMahbub-Ul AlamAbdullah-Al Masud Probir Ghosh

For more information: mahbubalam@icddrb.org

Stanford University:

Stephen Luby

WSUP:

Guy NormanAnita LaydenSam DrabbleAbdus ShaheenHabibur RahmanNasrin Akter

Johns Hopkins University:

Peter WinchRonald Saxton

Acknowledgement:

Study participants; Diana DiazGranados; Astrid Dier; Mahbubur Rahman

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icddr,b thanks the study Donors

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