Factors affecting cleanliness of shared urban slum toilets

Factors affecting cleanliness of shared urban slum toilets in Dhaka, Bangladesh Mahbub-Ul Alam Research Investigator; mahbubalam@icddrb. org Water, Sanitation and Hygiene Research Group, icddr, b Water and Health Conference, Chapel Hill, North Carolina October 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 2

Rationale • Shared toilets' cleanliness is a key health issue which needs to be measured accurately • Previous studies have measured cleanliness based on users’ perceptions • Objective indicators of cleanliness of shared toilets are lacking • Determinants of shared toilet cleanliness was not well identified 3

Objectives • To describe multiple objective indicators of cleanliness of shared toilets • To identify the factors associated with toilet cleanliness 4

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 5

Toilet and respondent selection • Selected first toilet after entering the slum: – Skip next – Select subsequent – <40 toilets per cluster • One adult user per toilet: – From second nearest household 6

Methods: spot check of toilet • Observed toilet: - Structure - Provision of water • Presence of: - Visible feces - Urine/other liquid - Solid waste – Within - Squatting area - Pan 7

Methods: interview of toilet user • Interviewed one adult user per shared toilet: – Demographic information – Toilet management 8

Data analysis • Definition of clean toilet (Günther et al. 2012): – within – absence of • Feces • Liquids • Dirt • Squatting area • Pan • To identify factors associated with toilet cleanliness: – Prevalence ratio – Generalized estimating equations to account for clustering 9

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) Type of toilet 100 80 60 57 % 40 20 0 18 14 Connected Piped sewer Septic tank to system canal/ditch 11 Water seal present: 27% Pit latrine • 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). 11

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% 12

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 13

Solid waste disposal inside toilet (n=1, 226) • Reported waste disposal practice in the toilet: – Menstrual cloths/rags: 16% – Paper: 12% – Plastic bags: 9% 14

Toilet cleanliness (n=1, 226) • Feces visible: – Inside pan hole: 47% – Inside the pan: 28% 15

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% • Toilets classified as clean*: 34% *Absence of feces, liquids or dirt within the squatting area and pan of the toilet 16

Determinants of toilet cleanliness (n=459) Water present inside/beside clean toilet 100 80 60 % 53 35 40 20 0 Available (N=150) Not available (N=1077) Toilets were more commonly clean when water was available inside or beside the toilet (PR: 1. 9, 95% CI: 1. 5 -2. 4) 17

Determinants of toilet cleanliness (n=459) 100 Water storage container available inside/beside clean toilet 90 80 % 70 60 50 40 30 40 Available (N=670) 34 Not available (N=557) Toilets were more commonly clean when there was a water storage beside the toilet (PR: 1. 1, 95% CI: 1. 1 -1. 2) 18

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 19

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 20

Study team Icddr, b: Leanne Unicomb Farzana Begum Fosiul Nizame Mahbubur Rahman Farzana Yeasmin Mahbub-Ul Alam Abdullah-Al Masud Probir Ghosh Stanford University: Stephen Luby Johns Hopkins University: Peter Winch Ronald Saxton WSUP: Guy Norman Anita Layden Sam Drabble Abdus Shaheen Habibur Rahman Nasrin Akter Acknowledgement: Study participants; Diana Diaz. Granados; Astrid Dier; Mahbubur Rahman For more information: mahbubalam@icddrb. org 21

icddr, b thanks the study Donors