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): absence of Feces Liquids Dirt within 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 Water seal present: 27% % 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 % 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) Water storage container available inside/beside clean toilet % 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 WSUP: Guy Norman Anita Layden Sam Drabble Abdus Shaheen Habibur Rahman Nasrin Akter Johns Hopkins University: Peter Winch Ronald Saxton Acknowledgement: Study participants; Diana DiazGranados; Astrid Dier; Mahbubur Rahman For more information: mahbubalam@icddrb.org 21

icddr,b thanks the study Donors 22