Changes in water treatment, hygiene practices, household floors, and child health in times of Covid-19: A longitudinal cross-sectional survey in Surkhet District, Nepal.

INTRODUCTION: Consistent and effective practice of water treatment, sanitation, and hygiene (WASH) behaviour is an indispensable requisite for realizing health improvements among children living in low-income areas with challenging hygienic conditions. Sustainably achieving such a behaviour change is challenging but more likely to be realized during epidemics, when health threats are high and the dissemination of information on preventative measures is intense. Our study conducted cross-sectional surveys in Surkhet District Nepal, before and during the Covid-19 pandemic to assess the impact of water safety interventions and hygiene training implemented before and during the pandemic on WASH conditions and practices and to assess the association of these changes with child health. METHODS: Information on WASH infrastructure, WASH behaviour, nutrition, and child health, including on parasitic infections, was obtained before and during the Covid-19 pandemic in spring 2018 and spring 2021, from 589 children aged between 6 months and 10 years and their caregivers. Data was collected through quantitative, structured face-to-face interviews, observations, health examinations of children including anthropometric measurements, analysis of children's stool, and water quality analysis. The association of changes in WASH factors with changes in child health was analysed using multivariate generalized estimating equations for repeated measures. RESULTS: Water safety management was significantly improved by the introduction of chlorination to piped water supply systems, which served 40% of households. In addition, the percentage of households using a ceramic water filter increased from 12.2% to 34.8%. Large and significant changes were observed in handwashing behaviour (frequency, use of soap and washing at critical times) and infrastructure: 35% of households constructed a new handwashing station. Kitchen and household hygiene also improved. An additional 22% of households improved the cleanliness of the toilet. The number of houses with a cemented floor increased by 20%. WASH changes were significantly associated with improved child health: the chlorination of piped water supply reduced odds ratios for diarrhoea (OR = 0.36, 95% CI = 0.15-0.88, p = 0.025), respiratory difficulties (OR = 0.39, 95% CI = 0.16-0.92, p = 0.033), fever (OR = 0.42, 95% CI = 0.26-0.71, p = 0.001) and cough (OR = 0.58, 95% CI = 0.36-0.93, p = 0.024), and. The frequency of handwashing with soap was associated with significantly reduced odds ratios for infections with Giardia lamblia (OR = 0.68, 95% CI = 0.50-0.91, p = 0.011), stunting and wasting (OR = 0.75, 95% CI = 0.66-0.92, p = 0.003) and fever (OR = 0.85, 95% CI = 0.75-0.96, p = 0.008),. The presence of a handwashing station at baseline was associated with significantly reduced odds ratios for respiratory difficulties (OR = 0.45, 95% CI = 0.26-0.78, p = 0.004). The construction of a handwashing station between baseline and endline was significantly associated with reduced odds ratios for pale conjunctiva (OR = 0.32, 95% CI = 0.17-0.60, p < 0.001), which is a clinical sign of iron deficiency and anaemia, respiratory difficulties (OR = 0.39, 95% CI = 0.17-0.89, p = 0.026) and cough (OR = 0.44, 95% CI = 0.26-0.76, p = 0.003). Using a clean container for the transport of drinking water was significantly associated with reduced odds ratios for infections with Giardia lamblia (OR = 0.39, 95% CI = 0.16-0.93, p = 0.033) and diarrhoea (OR = 0.48, 95% CI = 0.24-0.96, p = 0.038). Similarly, a cemented floor in the household was significantly associated with reduced odd ratios for diarrhoea (OR = 0.38, 95% CI = 0.16-0.87, p = 0.022) and infections with Giardia lamblia (OR = 0.44, 95% CI = 0.19-1.02, p = 0.056). CONCLUSION: WASH training and the promotion of preventative measures during the Covid-19 pandemic supported improved water safety management and hygiene behaviour, which resulted in a reduction in infectious diseases among children in the study area.

Water, sanitation, hygiene practices, health and nutritional status among children before and during the COVID-19 pandemic: longitudinal evidence from remote areas of Dailekh and Achham districts in Nepal.

BACKGROUND: The COVID-19 pandemic drew hygiene to the center of disease prevention. The provision of adequate water, sanitation, and hygiene (WASH) services is crucial to protect public health during a pandemic. Yet, access to levels of water supply that support adequate hygiene measures are deficient in many areas in Nepal. We examined WASH practices and their impact on child health and nutritional status in two districts before and during the COVID-19 pandemic. METHODS: A longitudinal and mixed method study was conducted in March-May 2018 and November-December 2021. In total, 715 children aged 0-10 years were surveyed at baseline. Of these, 490 children were assessed at endline. Data collection methods included observations, a questionnaire, stool analysis, anthropometric measurements, water quality analysis, and an assessment of clinical signs of nutritional deficiencies. We conducted 10 in-depth interviews to understand major problems related to COVID-19. RESULTS: Most respondents (94.2%) had heard about COVID-19; however, they did not wear face masks or comply with any social distancing protocols. Almost 94.2% of the households self-reported handwashing with soap 5-10 times per day at endline, especially after defecation, compared to 19.6% at baseline. Water quality was better at endline than at baseline with median 12 to 29 CFU Escherichia coli/100 mL (interquartile range at baseline [IQR] = 4-101) at the point of collection and 34 to 51.5 CFU Escherichia coli/100 mL (IQR = 8-194) at the point of consumption. Fever (41.1-16.8%; p = 0.01), respiratory illness (14.3-4.3%; p = 0.002), diarrhea (19.6-9.5%; p = 0.01), and Giardia lamblia infections (34.2-6.5%, p = 0.01) decreased at endline. In contrast, nutritional deficiencies such as bitot's spots (26.7-40.2%; p = 0.01), pale conjunctiva (47.0-63.3%; p = 0.01), and dermatitis (64.8-81.4%; p = 0.01) increased at endline. The inadequacy of the harvest and the lack of household income to meet households' nutritional needs increased drastically (35.0-94.2%; p = 0.01). CONCLUSION: We found that improved water quality and handwashing practices were associated with a decrease in infectious diseases. However, food security also decreased resulting in a high prevalence of nutritional deficiencies. Our findings underline that disaster preparedness should consider access to adequate WASH, nutrition, and health supplies.

Evaluation of System-Level, Passive Chlorination in Gravity-Fed Piped Water Systems in Rural Nepal.

Over 2 billion people globally lack access to safely managed drinking water. In contrast to the household-level, manually implemented treatment products that have been the dominant strategy for gaining low-cost access to safe drinking water, passive chlorination technologies have the potential to treat water and reduce reliance on individual behavior change. However, few studies exist that evaluate the performance and costs of these technologies over time, especially in small, rural systems. We conducted a nonrandomized evaluation of two passive chlorination technologies for system-level water treatment in six gravity-fed, piped water systems in small communities in the hilly region of western Nepal. We monitored water quality indicators upstream of the treatment, at shared taps, and at households, as well as user acceptability and maintenance costs, over 1 year. At baseline, over 80% of tap samples were contaminated with Escherichia coli. After 1 year of system-level chlorination, only 7% of those same taps had E. coli. However, 29% of household stored water was positive for E. coli. Per cubic meter of treated water, the cost of chlorine was 0.06-0.09 USD, similar to the cost of monitoring technology installations. Safe storage, service delivery models, and reliable supply chains are required, but passive chlorination technologies have the potential to radically improve how rural households gain access to safely managed water.

Assessing the Impact of a Risk-Based Intervention on Piped Water Quality in Rural Communities: The Case of Mid-Western Nepal.

Ensuring universal access to safe drinking water is a global challenge, especially in rural areas. This research aimed to assess the effectiveness of a risk-based strategy to improve drinking water safety for five gravity-fed piped schemes in rural communities of the Mid-Western Region of Nepal. The strategy was based on establishing community-led monitoring of the microbial water quality and the sanitary status of the schemes. The interventions examined included field-robust laboratories, centralized data management, targeted infrastructure improvements, household hygiene and filter promotion, and community training. The results indicate a statistically significant improvement in the microbial water quality eight months after intervention implementation, with the share of taps and household stored water containers meeting the international guidelines increasing from 7% to 50% and from 17% to 53%, respectively. At the study endline, all taps had a concentration of <10 CFU Escherichia coli/100 mL. These water quality improvements were driven by scheme-level chlorination, improved hygiene behavior, and the universal uptake of household water treatment. Sanitary inspection tools did not predict microbial water quality and, alone, are not sufficient for decision making. Implementation of this risk-based water safety strategy in remote rural communities can support efforts towards achieving universal water safety.