Exploring the Burden of Diarrheal Disease and Associated Hygiene Practices in Rural West Bengal,India: An Explanatory Sequential Mixed-Method Approach

Exploring the Burden of Diarrheal Disease and Associated Hygiene Practices in Rural West Bengal,India: An Explanatory Sequential Mixed-Method Approach | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the Burden of Diarrheal Disease and Associated Hygiene Practices in Rural West Bengal,India: An Explanatory Sequential Mixed-Method Approach SUMAN KANUNGO, Shubhajit Pahari, Aritra Paul, Rounik Talukdar, and 15 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6502015/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Diarrheal diseases are a significant public health issue, disproportionately affecting under-five children residing in low- and middle-income countries. Inadequate WASH practices exacerbate this burden, especially in rural areas. This study used a mixed-method approach to evaluate the association between WASH practices and the prevalence of diarrheal diseases in the rural communities of West Bengal, India. Method The study was conducted in the Bishnupur-II block of South 24 Parganas district, West Bengal. A census survey covering approximately 10,000 families was conducted over nine weeks. Data on hygiene-related knowledge, attitudes, practices, and diarrheal episodes in the previous six months were collected using a semi-structured questionnaire administered by trained community health workers. Bivariable and multivariable logistic regression analyses were performed to assess associations between hygiene indicators and diarrhea prevalence. Ten in-depth interviews with mothers of under-five children and six key informant interviews with Auxiliary Nurse Midwives were conducted. Thematic analysis was used to explore contextual barriers and facilitators related to hygiene and disease prevention. Results The study found that 16.9% of families reported diarrheal episodes in the past six months, with 75.9% of affected children receiving treatment at government health facilities. Open defecation near homes increased the likelihood of diarrhea by 1.15 times (COR: 1.15; 95% CI: 1.05–2.24). Households relying on vendor-supplied drinking water faced nearly three times the risk (AOR: 2.71; 95% CI: 1.84–4.01), while those using only water for handwashing had a 3.14 times higher risk compared to those using soap (AOR: 3.14; 95% CI: 2.51–3.93). Notably, 80% of participants did not disinfect drinking water. Qualitative analysis identified five themes—awareness gaps, cultural beliefs, financial constraints, inadequate infrastructure, and community engagement—highlighting key barriers to hygiene and diarrhea prevention. Conclusion The study emphasizes the persistent burden of diarrhea in rural West Bengal, which is linked to inadequate hygiene practices and unsafe water consumption. It emphasizes the need for targeted public health interventions that combine community education, behavior change communication, and improved access to safe water and sanitation. Integrating proven tools like oral cholera vaccination with existing WASH strategies may further enhance disease prevention in high-burden rural settings. Diarrhea Rural population Epidemiology Hygiene Public health Figures Figure 1 Figure 2 Introduction Diarrheal diseases have been identified as a major global public health concern with significant morbidity and mortality, especially in low- and middle-income countries (LMICs) ( 1 ). It has been the third leading cause of death among children under 5 years of age, with a global burden of 1.7 billion cases and 0.44 million deaths annually ( 2 ). In India, the burden of diarrheal diseases is particularly severe, with an annual incidence of 1.6 cases per 1,000 population and 40 cases of acute diarrhea per 1,000 children ( 3 ). Despite efforts to improve sanitation and hygiene, diarrheal diseases threaten public health, particularly in rural areas where access to clean water, proper sanitation, and hygiene education remains limited. The increased incidence of diarrhea is closely linked to several factors, including hygiene practices, access to clean water, sanitation facilities, and the level of health literacy within communities especially among caregivers ( 4 )( 5 ). The correlation between poor hygiene practices and the incidence of diarrheal diseases is well-documented ( 6 ). A study by Muthukumaran et al. (2024) reported that 92% of people in rural areas of Sub-Saharan Africa, Central Asia, and Southern Asia still practice open defecation with more than half of these cases occurring in rural India ( 7 ). Open defecation and improper waste disposal increase the risk of exposure to fecal pathogens, leading to infectious disease outbreaks, including diarrhea ( 8 ). Children in rural areas are particularly vulnerable, as they often play in soil and open drains, increasing their exposure to animal and human fecal pathogens ( 9 ). Maternal knowledge and health literacy are critical in shaping hygiene practices and preventing diarrheal diseases. Studies have shown that mothers and caregivers who know the importance of handwashing, safe water storage, and proper sanitation are more likely to adopt these practices, thereby reducing the risk of diarrheal infections in their households ( 10 ). However, in many rural communities, limited access to health education and resources often hinders disseminating such knowledge, perpetuating the cycle of poor hygiene and disease transmission. In India, significant efforts have been made to improve access to safe and potable water through government initiatives such as Central Rural Sanitation Program (CRSP) in 1986 ( 11 ), Swacchh Bharat Mission in 2014 ( 12 ), Intensified Diarrhea Control Fortnight (IDCF)-2015 program ( 13 ), Jal Jeevan Mission in 2019 ( 14 ); Additionally, the implementation of water, sanitation and hygiene practices (WASH) ( 15 ); implementation of Rota-virus vaccination under the Universal Immunization Program (UIP) 2019 ( 16 ); have contributed to improved living conditions. However, these efforts have not yet translated into significant reduction in the burden of diarrheal diseases, particularly in rural areas, suggesting a need for more targeted interventions that address both infrastructure and behavioral factors. Diarrheal diseases continue to have long-term consequences for human capital and economic growth, particularly in LMICs. In many communities, the lack of access to proper healthcare leads individuals to rely on over-the-counter medications or unlicensed practitioners, which can exacerbate the problem by contributing to antimicrobial resistance ( 17 ). Studies have shown that community-based hygiene education and promotion of handwashing practices led to a significant decrease in diarrheal episodes ( 18 ) ( 19 ) ( 20 ). Furthermore, access to improved sanitation facilities has been associated with a 36% reduction in diarrhea incidence in LMICs ( 21 ). West Bengal, a state in eastern India with a coastal boundary along the Bay of Bengal, is an identified endemic region for diarrheal outbreaks. According to the National Family Health Survey-5 (NFHS-5), 64.7% of the rural population in West Bengal has access to proper sanitation facilities, and 96.9% have improved drinking water sources ( 22 ). Despite these improvements, the diarrhea prevalence among children under five remains high at 6.7%. This discrepancy highlights the need for a deeper understanding of the factors contributing to the persistence of diarrheal diseases in this region, including the role of maternal knowledge and health literacy in shaping hygiene behaviors. To address this gap, we conducted a study among community-dwellers in a rural region of West Bengal where we focused towards studying the association of the hygiene related knowledge, attitudes and practices along with the prevalence of diarrheal episodes. Analyzing the relationship between hygiene practices and the prevalence of diarrheal diseases in rural communities is critical for developing effective intervention strategies. The results from this study will add to the existing knowledge on how promoting community-driven hygiene and sanitation measures can play a pivotal role in curbing the incidence of diarrheal illnesses. Methodology Study design and study area This explanatory mixed-method study was conducted between April 2024 to June 2024 in the Bishnupur-II block of South24 Pargana district in West Bengal. South 24 Parganas is a coastal district in West Bengal with a history of recurrent waterborne disease outbreaks, particularly during the monsoon season when water contamination peaks ( 23 ). According to prior studies, the district has one of the highest incidences of diarrheal diseases in the state, driven by factors such as inadequate access to safe drinking water, poor sanitation facilities, and low hygiene awareness ( 24 ). Further, the Bishnupur-II block of South 24 Parganas was strategically selected as the study area based on state health authorities' recommendations, identifying it as a priority area due to its vulnerability to diarrheal diseases and WASH-related challenges. As per the Census, 2011 South-24 Pargana district consist of 81,61,961 population and 30 administrative blocks ( 25 ). In the Bishnupur-II block there are total 11 Gram Panchayats (GP) among them we have selected three GP namely- Nahazari, Khagramuri and Bakrahat due to high burden of Diarrhea cases reported in recent years which consist total six number of Sub-centers (SC) (namely Nahazari South, Nahazari North, Angarberia, Ramnagar, Khagramuri and Chaksukdev) in the catchment area (Fig-1). Study participants The study included all households within the catchment area, encompassing approximately 10,000 families and a population of around 45,000 individuals. Participation was voluntary among responsive families who have resided in the area of the study for at least one year. The head of each household was approached for interviews, with informed consent obtained prior to enrollment. Mothers of children under five years of age were specifically targeted for in-depth interviews (IDIs) to gain qualitative insights into hygiene practices and diarrheal disease episodes. A total of 10 IDIs were conducted until data saturation was achieved. Additionally, six Auxiliary Nurse Midwives (ANMs) stationed at the six sub-centers in the study area were engaged for Key Informant Interviews (KIIs) to gather healthcare provider perspectives. These participants were chosen purposefully to ensure comprehensive representation of community and healthcare viewpoints, aligning with the mixed-method approach of the study. Data collection procedure The data collection process was designed to comprehensively capture the study's quantitative and qualitative aspects, ensuring a robust mixed-method approach. Quantitative data collection: Data was gathered during an area census from 1st week of April,2024 to 1st week of June 2024 involving 10,000 families within the study area, representing a population of around 45,000. Accredited Social Health Activist (ASHA) workers were crucial in collecting the data. The ICMR-NIRBI team gave them training before the commencement of the data collection from their respective jurisdiction area under the catchment of the Samali Block Primary Health Centre (BPHC), serving as the headquarters for the 3-GPs. A semi-structured questionnaire was developed and piloted prior to its use as a data collection tool. It comprised of questions related to the socio-demographic status of the study participants, hygiene-practice and whether diarrheal episodes reported in the last six months in the last six months. The complete data collection procedure was supervised and monitored by ICMR-NIRBI team along with the officials of Govt. of West Bengal. Completed census forms were stored in respective Sub-centers before being transported to ICMR-NIRBI for further quality check. Water samples were also collected from different water vendors in the study area for the identification of the presence of any micro-flora in designated laboratory in ICMR-NIRBI. Qualitative data collection: From the 2nd week of June until the last week, In-depth interviews (IDIs) were conducted with mothers of children under five years of age to explore their hygiene practices, perceptions of diarrheal diseases, and health-seeking behaviors. A total of 10 IDIs were carried out until thematic saturation was achieved. Key informant interviews (KIIs) were also conducted with six Auxiliary Nurse Midwives (ANMs) stationed at sub-centers within the study area. Both IDIs and KIIs were conducted by trained interviewers using pre-tested interview guides. Prior to starting the interviews, efforts were made to establish a good rapport with the participants. To maintain privacy, interviews were conducted at convenient times and locations for the participants. Before the interview, all study participants provided written informed consent after being informed on the study's purpose. After the interview, the essential aspects were summarised and their approval was obtained before the KII results were finalized. During the interviews, notes were taken on paper, and recordings were done according to the participant's preferences. The audio recordings were transcribed the day it was conducted. In order to ensure data confidentiality, interview notes were deidentified and assigned distinct numerical numbers. In order to ensure data confidentiality, interview notes were deidentified and assigned distinct numerical numbers. Data analysis Quantitative data analysis: Data entry was done using MS Excel (Version 2016) and the data analysis was done using IBM SPSS Statistics for windows, Version 25 (Released July,2017; IBM Corp., Armonk, New York, United States). Descriptive statistics were computed for the categorical variables (Demographic characteristics, hygiene practices of the families, Diarrheal episodes and health seeking behavior for diarrhea) and presented as frequencies and percentages to provide an overview of the study population. To examine associations between hygiene practices and diarrheal episodes, bivariable logistic regression was performed to estimate crude odds ratios (COR). Subsequently, multivariable logistic regression was conducted to calculate adjusted odds ratios (AOR), controlling for potential confounders such as monthly family income, number of children, family size, and type of housing. The results were reported with corresponding 95% confidence intervals (CI) to assess the strength and significance of associations. We used a single exposure model while conducting the regression as even when WASH factors may be intercorrelated, single exposure model would help in isolating the effect of one specific hygiene practice on diarrheal outcomes without the distortions introduced by multicollinearity. When multiple WASH exposures are entered together, high correlations between them can inflate the standard errors, cause instability in the regression coefficients, and lead to difficulties in interpreting the independent effects. By modeling one exposure at a time and adjusting for key confounders (such as household income, family size, and house type), the analysis yields clearer, more reliable estimates of the association. Moreover, many WASH interventions in real-world settings tend to be implemented concurrently, meaning the individual effects are inherently intertwined. A single exposure model allows for evaluating each factor on its own merit without forcing artificial separation where the underlying behaviors may operate as part of a broader, interrelated set of practices. Qualitative data analysis: The qualitative data from in-depth interviews (IDIs) with mothers and key informant interviews (KIIs) with Auxiliary Nurse Midwives (ANMs) were transcribed verbatim. The transcripts were reviewed and coded using thematic analysis. Predefined categories guided the coding process, but emergent themes were also identified inductively during analysis. A subject matter expert validated the categories against the codes, themes, and quotations. The thematic analysis allowed for identifying key themes and sub-themes related to hygiene practices, community perceptions of diarrhea prevention, and barriers to effective hygiene. This method provided a structured framework for integrating qualitative insights into actionable recommendations. Integration of Quantitative and Qualitative Data: Quantitative and qualitative findings were integrated through a narrative synthesis approach. The Quantitative phase provided a broad understanding of the prevalence and determinants of diarrheal diseases, while qualitative phase insights enriched this understanding by contextualizing the statistical findings within community behaviors, attitudes, and perceptions. The two datasets were compared and contrasted to identify convergences and divergences, ensuring a comprehensive interpretation of the study outcomes. Ethical consideration- The study was cleared by the Institutional Ethics Committee of ICMR-NIRBI (No. A-10( 2 )/2024(OCV Trial)-IEC Operational definition- As per WHO, Diarrhea was characterized by the occurrence of three or more loose or watery stools within a day, or an increase in stool frequency beyond what is typical for the individual. Passing solid stools frequently does not qualify as diarrhea, nor does the passage of loose, soft stools by breastfed infants ( 26 ). Result Quantitative phase: Socio-Demographic Characteristics - Among the 10,000 families surveyed 60% resided in the Nahazari Gram Panchayat, with a majority living in pucca (48.7%) or semi-pucca (40.5%) houses while 10.8% lived in kachcha houses. Approximately 82.5% of participants had lived in the area for over 10 years (Table-1a). The population was predominantly Hindu (57.8%), followed by Muslim (41.6%). Most families (76.8%) had 1–4 members, while 23.7% had children under five years of age. The study classified families based on their monthly income using the Kuppuswamy scale (June 2023). Most families (59.8%) fell into the INR 7,316–21,913 income category, reflecting a middle-income group within the rural context (Table-1b). Diarrhea prevalence & WASH practices - The study revealed that 16.9% of families reported experiencing at least one diarrheal episode in the six months preceding the survey (Table-2). Drinking water sources varied across households: 22.8% relied on water vendors, and 46.4% used community hand pumps for drinking water purposes. 78.6% of Participants did not purify their drinking water in any way, which could expose them to waterborne pathogens. Handwashing practices were explored, showing that most families in the study (52.5%) wash their hands with soap and water. Almost everyone always uses soap and water (90.5%) after defecation; 65% of people always use soap and water before eating, and 57.5% always use soap and water before food handling. While 59.8% used private flush toilets, 32.3% shared flush toilets with others, and 1.5% practiced open defecation. Regarding stool disposal for children and older adults, 66.7% used their own toilets, while others relied on other methods (municipality-identified spaces ~ 15%, and open space outside ~ 18%). Healthcare seeking behavior – The study revealed that most families prefer government health facilities to treat diarrheal illnesses. Specifically, 64.8% of surveyed families sought treatment for diarrhea in adults at government health facilities, while an even higher percentage (75.9%) chose these facilities when the illness affected children (Fig-2a). We observed distinct patterns in healthcare-seeking behavior for diarrheal episodes among different religious groups. Among Hindu participants, the most preferred option for managing diarrhea was home-based care (40.25%), followed by government health facilities (36.83%), pharmacies (10.44%), private healthcare providers (4.6%), and unlicensed practitioners (7.85%). Similarly, among Muslim participants, home-based care was also the most common choice (43.02%), with government health facilities (33.12%), pharmacies (8.41%), private healthcare providers (5.1%), and unlicensed practitioners (10.35%) being the subsequent preferences. These findings highlight a shared reliance on home-based care across communities, with government health facilities being the second most preferred option (Fig-2b). In the study, among the three Gram Panchayats (GP), the majority in Nahazari (41.3%) and Bakrahat (45.73%) opted for home-based treatment for diarrhea. People from Khagramuri GP mostly preferred govt health facilities for diarrhea treatment (Fig-2c). As income rises, the preference for seeking treatment for diarrhea from private practitioners increases significantly (Fig-2d). Determinants of Diarrhea – This study identified several hygiene-related factors associated with diarrheal episodes: Families using water from vendors had nearly twice the risk of diarrhea compared to those using their own taps (COR: 1.92; 95% CI: 1.33–2.76). This risk increased nearly threefold after adjusting for confounders such as income, family size, and housing type (AOR: 2.71; 95% CI: 1.84–4.01). Families that did not disinfect their drinking water had a higher risk of diarrhea than those who boiled their water (COR: 2.13; 95% CI: 1.32–3.45). After adjustment, this risk remained significant but slightly reduced (AOR: 1.74; 95% CI: 1.05–2.88). Families using only water for handwashing were three times more likely to experience diarrhea than those using soap and water (COR: 3.03; 95% CI: 2.45–3.75). This risk increased slightly after adjustment (AOR: 3.14; 95% CI: 2.51–3.93). Additionally, individuals who never washed their hands with soap before food handling had a higher likelihood of diarrhea than those who always did so (COR: 1.64; 95% CI: 1.23–2.19; AOR: 1.53; 95% CI: 1.17–2.01). Families disposing of stool in open areas near their homes were at a slightly higher risk of diarrhea compared to those using designated disposal methods (COR: 1.15; 95% CI: 1.05–2.24), whereas adjusted odds ratio was nonsignificant (Table-3). Qualitative Phase: The qualitative component of the study was conducted to explore the community perceptions, attitudes, and practices related to hygiene and diarrheal disease prevention, complementing to the quantitative findings. A total of 10 in-depth interviews (IDIs) with mothers of children under five years and six key informant interviews (KIIs) with Auxiliary Nurse Midwives (ANMs) were analyzed thematically (Table-4) Theme 1: Knowledge and Awareness of Diarrheal Diseases - Mothers had varying levels of knowledge about diarrhea, its causes, and prevention. While most participants recognized contaminated water and poor hygiene as key contributors, some misconceptions were there. For instance, some mothers attributed diarrhea to "eating junk food" or "exposure to outside food." Our quantitative finding also suggested that 78.6% of households did not disinfect their drinking water, highlighting a gap in awareness about waterborne disease prevention. ANMs emphasized that while community health education campaigns had improved awareness about oral rehydration solution (ORS) use during diarrhea episodes, awareness about preventive measures like handwashing before food handling (reported as consistent by only 57.5% in the quantitative data) remained low. Theme 2: Hygiene Practices and Barriers - While families understood the importance of hygiene, barriers such as lack of access to soap or clean water often hindered consistent practices. Mothers reported prioritizing handwashing after defecation (quantitatively reported at 90.5%) but admitted to neglecting it before eating or food preparation due to time constraints or unavailability of soap. Economic challenges often force families to allocate resources toward other necessities. The reliance on unsafe water sources, such as vendor-supplied water (used by 22.8% of families), was also discussed in IDIs. Mothers expressed concerns about the quality of vendor water but cited limited alternatives due to inadequate access to piped water or functional hand pumps. These findings supported the quantitative finding that reliance on vendor water significantly increased diarrhea risk (AOR: 2.71; 95% CI: 1.84–4.01). Theme 3: Sanitation Practices and Community Norms - Sanitation practices varied widely across households, with most families adopting safe disposal methods while others continued open defecation or used shared facilities. Few participants (1.5%) who practiced open defecation cited social norms, lack of privacy in shared toilets, or non-functional facilities as key reasons. ANMs highlighted that despite government efforts under programs like the Swachh Bharat Mission, behavioral change was slow in certain communities due to deeply ingrained habits and cultural resistance. Theme 4: Perceptions of Health-Seeking Behavior - Mothers reported a preference for home-based care during initial diarrhea episodes, often relying on traditional remedies or over-the-counter medications before seeking formal healthcare services. This aligned with the quantitative finding that home-based care was common among both Hindu (40.25%) and Muslim (43.02%) families for treating diarrhea. ANMs noted that while awareness about ORS had improved due to community outreach programs, delays in seeking professional care often exacerbated complications in children under five years old. Families cited financial constraints, distance to healthcare facilities, and long waiting times as barriers to accessing government health services. Theme 5: Barriers and Facilitators for Hygiene Practices - The qualitative analysis revealed several facilitators, like better hygiene practices, including community education programs led by ANMs and ASHAs, availability of subsidized soap through local initiatives, and increasing awareness about sanitation through school-based campaigns. However, barriers such as financial constraints, lack of infrastructure (e.g., non-functional hand pumps), and cultural norms around sanitation limited the adoption of safe practices. For example, some mothers expressed reluctance to use shared toilets due to concerns about cleanliness and privacy. Discussion This study assessed the burden of diarrheal diseases and hygiene practices in rural West Bengal using a mixed-methods approach, revealing significant gaps in sanitation, hygiene behavior, and access to safe drinking water. To contextualize our findings, we adopted a dual-axis analysis: (i) intra-national comparisons with Indian studies and (ii) international benchmarking against LMICs. A comparative review of similar WASH-challenged settings where OCV was implemented—such as in Bangladesh, Ethiopia, and Haiti (urban & rural)—showed substantial reductions in both cholera and general diarrhea incidence. Burden of Diarrheal Diseases & WASH practices – This study found that 16.9% of families reported at least one diarrheal episode in the six months preceding the survey. This prevalence aligns with findings from other rural regions in India,( 27 ) In areas where diarrhoeal illnesses continue to be a major source of morbidity, particularly among children under five. For example, a study in Odisha reported a similar prevalence range between 9 to 21%, especially among children under five, highlighting the persistent burden of diarrhea across rural India despite national sanitation initiatives like the Swachh Bharat Mission ( 28 ). Similarly, an analysis of the Longitudinal Ageing Study in India wave-I data (2017–2018) revealed that diarrheal prevalence among older adults aged 60 years or older during the last two years preceding the survey was 15% ( 29 ). This study found that individuals using water vendors as their primary drinking water source are 2.71 times more likely to contract diarrhea than those using their own tap. Despite the Jal Jeevan Mission (2019), 22.8% of households still rely on vendors, reflecting systemic gaps in last-mile water access. Similar findings were noted in the systematic umbrella review published in 2010 where it was found that improved water quality can reduce the burden of Diarrhea by 17% ( 30 ). From the study setting, few of the water samples were collected and was tested positive for coliform bacteria. It was noted that in the study area the water vendors are sourcing water from taps, tubewells, and other places that may be contaminated. When this water is directly packed and sold to community members without adequate treatment or quality checks, it increases the risk of spreading diarrheal diseases. A cluster randomized control study conducted in Kolkata from 2006–2011 found that residents of households with better WASH conditions had a lower incidence of Cholera ( 31 ). These findings also mirror a community-based cross-sectional study conducted in Ethiopia, which showed that unimproved water consumption was associated with a more than two-fold rise in diarrheal incidence among children ( 32 ). In rural Bangladesh, using simple cloth filtration and treating household water could reduce cholera cases by about 38%, highlighting the importance of safe drinking water ( 33 ). In our study we have also found that people who don’t use any method to disinfect the drinking water almost twice at more risk than those who boil their water for drinking. A study conducted in 2023 in Northwest Ethiopia found that households that used unimproved water sources increase the likelihood of childhood diarrhea by 2.36 times compared to households that used improved water source ( 32 ). In this study, people who cleaned their hands simply with water had a 3.03 times higher risk of developing diarrhoea than those who used soap and water. A 2021 systematic review showed that promoting handwashing reduced diarrhea incidence by 28% ( 18 ). Further, a study conducted in 2021 among children under 5 years in Lao People’s Democratic Republic found that children in households with only water for handwashing had 1.49 times higher odds of experiencing diarrhea than those households who practices handwashing with both water and soap ( 19 ). Handwashing before handling food was also a predictor for diarrhea. Our study found that people who never wash their hands before handling food were nearly twice as likely to develop diarrhea as those who always do. Similarly, a study conducted in 2007 in Bangladesh showed that washing at least one hand with water reduced diarrhea risk by 22%, washing both hands with water reduced it by 33%, and washing at least one hand with soap led to a 70% reduction ( 34 ). The evidence strongly supports the promotion of regular handwashing as a simple yet vital public health measure to safeguard against diarrheal infections, particularly in settings with limited access to clean water and sanitation. A noteworthy intervention to mention was Kerala’s “Handwash Revolution” campaign, which reduced childhood diarrhea by 40% through school programs ( 35 ). Healthcare seeking pattern - The study found that 64.8% of adults sought diarrhea treatment at government health facilities, reflecting trust in public healthcare systems. However, concerning patterns emerged: 12.4% relied on self-medication, 9.8% purchased drugs directly from pharmacies, and 4.6% visited unlicensed practitioners. These findings align with a 2014 study in Malda, West Bengal, where 53.16% of non-communicable disease cases were managed by non-qualified providers ( 36 ). Such reliance on informal care mirrors trends in rural Ethiopia, where 62% of households used unregulated drug vendors for diarrheal treatment ( 32 ). This fragmented healthcare-seeking behavior exacerbates antimicrobial resistance (AMR) risks, as over-the-counter antibiotic misuse and incomplete treatment courses fuel pathogen adaptation ( 36 ). Another study conducted in the slums of Kolkata among Informal Healthcare Providers found that a multicomponent educational intervention led to long-lasting improvements in diarrhea-related knowledge and practices. This success suggests that policy advocacy, along with the implementation and scaling up of similar interventions, is necessary ( 37 ). In this study, we also observed that 75.9% of families took their children to government health facilities for diarrhea treatment, a higher proportion compared to adults. A study conducted in the urban slums of Kolkata among young children found that caregivers with formal education were more likely to seek care from licensed providers, underlining the role of education in influencing healthcare-seeking behavior ( 38 ). A 2021 study from Kandhamal District in Odisha also emphasized the importance of promoting handwashing, hygiene practices, and access to safe drinking water as essential measures for managing diarrhea in tribal communities ( 39 ). These findings align with a 2018 meta-analysis that identified similar interventions as effective strategies for improving diarrhea outcomes globally ( 21 ). The consistency between these studies and our findings underscores the critical importance of targeted public health interventions aimed at improving hygiene practices and access to clean water. Comparative analysis with global Cholera vaccination and WASH intervention outcomes A major study in Kolkata, India indicated that the integration of OCV with WASH interventions provided additional protection not only against cholera but also against non-cholera diarrheal illnesses in urban slums with insufficient sanitation facilities ( 31 ). In Bangladesh's rural Matlab region, a community-based intervention using sari fabric water filtration combined with OCV led to a 38% drop in cholera incidence and a decrease in overall diarrhea burden ( 33 ). These findings highlight the importance of low-cost water safety interventions with immunization in resource-constrained settings. The Haiti post-2010 earthquake situation is particularly enlightening. Slum urban areas saw a sharp decline in cholera after mass campaigns of OCV ( 40 ). In addition, a rural Haitian study conducted in the Artibonite Valley found that OCV had a 58–63% efficacy over 4–24 months following immunization, although the vaccine was not effective against non-cholera diarrhea ( 41 ). This comparative synthesis demonstrates that, while our study location in West Bengal lacks OCV integration, comparable contexts show promising decreases in diarrhea and cholera incidence following immunization. These findings highlight the critical need for pilot implementation of OCV in high-risk rural zones such as Bishnupur-II, particularly when paired with scalable WASH interventions (Table-5) Limitations and strengths The present study catered few limitations such as being a cross-sectional study design and possible temporal uncertainty, the findings were interpreted as associations rather than causal relationships. As with any questionnaire-based assessment of knowledge and practice, discrepancies in participant attention might result in information bias. Keeping aside the limitations, the present study by virtue of its multi-component aspects in understanding the hygiene practices and its relation to diarrheal diseases, could generate valuable information towards improving the hygiene and sanitary habits of the community-dwellers and also their health-seeking behavior. Conclusion In conclusion, this study highlights a persistent burden of diarrheal disease in rural West Bengal, driven by unsafe water sources, inadequate hygiene practices, and fragmented healthcare-seeking behavior. The findings reveal alarming statistics, such as a 16.9% prevalence of diarrhea and a significant reliance on untreated water sources, which heightens the risk of waterborne diseases. Comparative insights from similar low-resource settings further validate the effectiveness of combining Oral Cholera Vaccination with hygiene and sanitation strategies. Implementing such multifaceted, community-driven interventions could significantly reduce diarrheal morbidity in high-risk rural regions like Bishnupur-II, contributing to broader public health gains. Overall, the evidence strongly supports focused public health interventions, community education, and engagement to promote good hygiene habits and increase access to clean water. Furthermore, the use of Oral Cholera Vaccination in high-risk locations like these could boost disease prevention efforts and drastically lower the frequency of diarrhea and related disorders in vulnerable populations. Abbreviations LMIC Low- and Middle-Income Countries CRSP Central Rural Sanitation Program IDCF Intensified Diarrhea Control Fortnight WASH Water, sanitation and hygiene practices UIP Universal Immunization Program NFHS National Family Health Survey GP Gram Panchayat IDI In-depth Interview KII Key Informant Interviews ASHA Accredited Social Health Activist ANM Auxiliary Nurse Midwives COR Crude odds ratio AOR Adjusted odds ratio CI Confidence interval ORS Oral Rehydration Solution Declarations Ethics approval and consent to participate- The study was cleared by the Institutional Ethics Committee of ICMR-National Institute for Research in Bacterial Infections, (No. A-10(2)/2024)-IEC dated 12.02.2024. Verbal informed consent was obtained from the participants prior enrollment in the study. Consent for publication- Not applicable as no individual identification were revealed. Availability of data and materials- The data that support the findings of this study are available from the corresponding author upon request. Competing interests- The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be regarded as a potential conflict of interest. Funding- This study received ICMR funding since it was a component of an intramural project. (Proposal ID-2023-0000054) Authors' contributions- Conceptualization: SK, DC and SD; Data curation : SK, SP, AP, SC; Formal Analysis : SK, SP, SB, PG, RT; Supervision : SK, SP, SC, BK, SP, AP, AC, SPK; Laboratory: AKM, RKN, BK ; Writing—original draft : SK, SP, RT, PC, DB, SB; Writing—review and editing : SK, RT. Overall supervision : DR, MSM, DM, SK. All the contributing authors have critically reviewed the final version of the manuscript. Acknowledgements- The authors would like to thank the locals of the area as well as all of the ASHA workers who participated actively in the census enumeration. The authors also want to acknowledge Mrs. Ishita Majhi & Mrs. Santana Brahmachari (Senior Public Health Nurse, Samali BPHC) and Mr. Biswajit Pal (Block Account Manager, Sa mali BPHC) for their continuous support. Author Information Authors and Affiliations Suman Kanungo : Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Shubhajit Pahari : Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Sombuddha Biswas : Divisionof Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Sougata Chatterjee : Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Diplina Barman : Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Debjit Chakraborty : Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Pramit Ghosh : Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Alok Kumar Deb : Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Bipul Ch Karmakar : Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India Asish Kumar Mukhopadhyay - Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India Ranjan Nandy : Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India Shanta Dutta : Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India Rounik Talukdar : Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Aritra Paul : Block Medical Officer of Health (BMOH), Samali Block Primary Health Center, South 24 Parganas, West Bengal, India Atreyi Chakrabarti : Deputy Chief Medical Officer of Health II, South 24 Parganas, West Bengal, India Swati Pramanick : Deputy Chief Medical Officer of Health III, South 24 Parganas, West Bengal, India Debasis Roy - Deputy Director-Reproductive and Child Health, District Health and Family Welfare, Kolkata, West Bengal, India Mukti Sadhan Maiti- Chief Medical Officer of Health, South 24 Pargana, District Health and Family Welfare, Kolkata, West Bengal, India Dipankar Maji: Joint Director of Health Service (PH&CD), Kolkata, West Bengal, India Corresponding author Suman Kanungo References Hénock Blaise NY, Dovie DBK. Diarrheal Diseases in the History of Public Health. Arch Med Res. 2007;38(2):159–63. Thystrup C, Majowicz SE, Kitila DB, Desta BN, Fayemi OE, Ayolabi CI, et al. Etiology-specific incidence and mortality of diarrheal diseases in the African region: a systematic review and meta-analysis. BMC Public Health. 2024;24(1). Sharma A, Dutta BS, Rasul ES, Barkataki D, Saikia A, Hazarika NK. Prevalence of Vibrio cholerae O1 serogroup in Assam, India: A hospital-based study. Indian J Med Res. 2017 Sep;146(3):401–8. Giri M, Behera MR, Behera D, Mishra B, Jena D. Water, Sanitation, and Hygiene Practices and Their Association With Childhood Diarrhoea in Rural Households of Mayurbhanj District, Odisha, India. Cureus. 2022;14(10):1–12. World Health Organization (WHO). Preventing diarrhoea through better water, sanitation and hygiene Exposures and impacts in low- and middle-income countries [Internet]. 2014. Available from: https://www.who.int/publications/i/item/9789241564823 Roy S, Kiruthika G, Muthappan S, Rizwan SA, Kathiresan J. Association between water, sanitation and hygiene practices and diarrhea among under 3-year-old children: Evidence from a nationally representative sample in India (2019–2021). J Water Sanit Hyg Dev. 2023;13(9):711–22. Muthukumaran A, Ranjan A, Pandey S, Kumar P, Rao R. Open defecation among adults having household toilets and factors associated with it: An analytical cross-sectional study from rural Bihar, India. Clin Epidemiol Glob Heal [Internet]. 2024;25(July 2023):101486. Available from: https://doi.org/10.1016/j.cegh.2023.101486 Saleem M, Burdett T, Heaslip V. Health and social impacts of open defecation on women: A systematic review. BMC Public Health. 2019;19(1). Mills M, Lee S, Piperata BA, Garabed R, Choi B, Lee J. Household environment and animal fecal contamination are critical modifiers of the gut microbiome and resistome in young children from rural Nicaragua. Microbiome [Internet]. 2023;11(1):1–18. Available from: https://doi.org/10.1186/s40168-023-01636-5 Szewczak A, Bak J, Węgorowski P, Zarzycka D. The knowledge of mothers on prevention of diarrhea in infancy. J Educ Heal Sport. 2018;8(11):156–64. Ministry of Rural Development. English Releases [Internet]. 2008. Available from: https://pib.gov.in/newsite/erelcontent.aspx?relid=44717 Ministry of Health & Family Welfare. Swachh Bharat Abhiyan | Prime Minister of India [Internet]. Available from: https://www.pmindia.gov.in/en/major_initiatives/swachh-bharat-abhiyan/ Ministry of Health & Family Welfare. Intensified Diarrhoea Control Fortnight: Operational guildelines. 2015;(July):1–38. Available from: http://cghealth.nic.in/ehealth/2016/Instructions/IDCF_Guideline_2015.pdf Welfare M of H& F. JJM Dashboard [Internet]. 2024. Available from: https://ejalshakti.gov.in/jjmreport/JJMState.aspx World Health Organization (WHO). Water, sanitation and hygiene (WASH) - India [Internet]. Available from: https://www.who.int/india/health-topics/water-sanitation-and-hygiene-wash Division I, Welfare F. Operational guidelines for Rotavirus Immunization Division MoHFW. 2019;69. Kotwani A, Joshi J, Lamkang AS. Over-the-counter sale of antibiotics in india: A qualitative study of providers’ perspectives across two states. Antibiotics. 2021;10(9):1–19. Ejemot-Nwadiaro RI, Ehiri JE, Arikpo D, Meremikwu MM CJ. Hand washing promotion for preventing diarrhoea [Internet]. 2021. Available from: https://www.who.int/tools/elena/review-summaries/wsh-diarrhoea--hand-washing-promotion-for-preventing-diarrhoea Noguchi Y, Nonaka D, Kounnavong S, Kobayashi J. Effects of hand-washing facilities with water and soap on diarrhea incidence among children under five years in lao people’s democratic republic: A cross-sectional study. Int J Environ Res Public Health. 2021;18(2):1–15. Hashi A, Kumie A, Gasana J. Hand washing with soap and WASH educational intervention reduces under-five childhood diarrhoea incidence in Jigjiga District, Eastern Ethiopia: A community-based cluster randomized controlled trial. Prev Med Reports [Internet]. 2017;6:361–8. Available from: http://dx.doi.org/10.1016/j.pmedr.2017.04.011 Wolf J, Hubbard S, Brauer M, Ambelu A, Arnold BF, Bain R, et al. Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: a systematic review and meta-analysis. Lancet. 2022;400(10345):48–59. Ministry of Health & Family Welfare. Catalog | Open Government Data (OGD) Platform India [Internet]. 2022. Available from: https://www.data.gov.in/catalog/national-family-health-survey-nfhs-5 Ministry of Health and Family Welfare, India G of. National Centre for Disease Control Government of India [Internet]. 2023. Available from: https://ncdc.mohfw.gov.in/wp-content/uploads/2025/01/32_SAPCCHH_West-Bengal_21-10-24.pdf Vivek Kumar SM. Disease Ecology of Diarrhoea in South 24 Parganas District , West Bengal. Int J Nov Res Dev. 2024;9(2):557–9. South Twenty Four Parganas (South 24 Parganas) District Population Census 2011 - 2021 - 2024, West Bengal literacy sex ratio and density [Internet]. [cited 2024 Jun 24]. Available from: https://www.census2011.co.in/census/district/17-south-twenty-four-parganas.html World Health Organization (WHO). Diarrhoeal disease [Internet]. 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease Ghosh K, Chakraborty AS, SenGupta S. Identifying spatial clustering of diarrhoea among children under 5 years across 707 districts in India: a cross sectional study. BMC Pediatr. 2023;23(1):1–15. Kumar Naik S, Mandi R, Bansod DW. Diarrhoea and ARI Risk Exposure Among Under-Five Children in Odisha, India: An evidence from NFHS-4. Res Pediatr Neonatol [Internet]. 2020;6(4):564–9. Available from: https://crimsonpublishers.com/rpn/fulltext/RPN.000643.php Srivastava S, Banerjee S, Debbarma S, Kumar P, Sinha D. Rural-urban differentials in the prevalence of diarrhoea among older adults in India: Evidence from Longitudinal Ageing Study in India, 2017-18. PLoS One [Internet]. 2022;17(3 March):1–17. Available from: http://dx.doi.org/10.1371/journal.pone.0265040 Cairncross S, Hunt C, Boisson S, Bostoen K, Curtis V, Fung ICH, et al. Water, sanitation and hygiene for the prevention of diarrhoea. Int J Epidemiol. 2010;39(SUPPL. 1). Im J, Islam MT, Ahmmed F, Kim DR, Tadesse BT, Kang S, et al. Do Oral Cholera Vaccine and Water, Sanitation, and Hygiene Combine to Provide Greater Protection Against Cholera? Results From a Cluster-Randomized Trial of Oral Cholera Vaccine in Kolkata, India. Open Forum Infect Dis [Internet]. 2024;11(1):1–7. Available from: https://doi.org/10.1093/ofid/ofad701 Birhan TA, Bitew BD, Dagne H, Amare DE, Azanaw J, Genet M, et al. Prevalence of diarrheal disease and associated factors among under-five children in flood-prone settlements of Northwest Ethiopia: A cross-sectional community-based study. Front Pediatr. 2023;11(January):1–7. Huq A, Yunus M, Sohel SS, Bhuiya A, Emch M, Luby SP, et al. Simple sari cloth filtration of water is sustainable and continues to protect villagers from Cholera in Matlab, Bangladesh. MBio. 2010;1(1):1–5. Luby SP, Halder AK, Huda T, Unicomb L, Johnston RB. The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: An observational study. PLoS Med. 2011;8(6). Centre for Community Health Research (CCHR). Children as agents of change- an intervention in Kerala (India) on WASH in Schools | Department of Economic and Social Affairs [Internet]. 2024. Available from: https://sdgs.un.org/partnerships/children-agents-change-intervention-kerala-india-wash-schools Kanungo S, Bhowmik K, Mahapatra T, Mahapatra S, Bhadra UK, Sarkar K. Perceived morbidity, healthcare-seeking behavior and their determinants in a poor-resource setting: Observation from India. PLoS One. 2015;10(5):1–21. Mahapatra T, Mahapatra S, Chakraborty ND, Raj A, Bakshi B, Banerjee B, et al. Intervention to Improve Diarrhea-Related Knowledge and Practices among Informal Healthcare Providers in Slums of Kolkata. J Infect Dis. 2021;224(Suppl 7):S890–900. Manna B, Nasrin D, Kanungo S, Roy S, Ramamurthy T, Kotloff KL, et al. Determinants of health care seeking for diarrheal illness in young childrenin urban slums of Kolkata, India. Am J Trop Med Hyg. 2013;89(SUPPL.1):56–61. Behera P, Bhatia V, Sahu DP, Sahoo DP, Kamble RU, Panda PS, et al. Community perception regarding diarrhoea management practices in a tribal predominant aspirational district of Odisha: A mixed-method study. J Fam Med Prim Care [Internet]. 2021;10(11):4110. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8797090/ Rouzier V, Severe K, Juste MAJ, Peck M, Perodin C, Severe P, et al. Cholera vaccination in Urban Haiti. Am J Trop Med Hyg. 2013;89(4):671–81. Ivers LC, Teng JE, Lascher J, Raymond M, Weigel J, Victor N, et al. Use of oral cholera vaccine in haiti: A rural demonstration project. Am J Trop Med Hyg. 2013;89(4):617–24. Tables able 1- Socio-demographic characteristics of family included in the study (N=10,000) Location and characteristics of residence Frequency (n) Percentage (%) Gram Panchayat Nahazari 5980 59.8 Khagramuri 2730 27.3 Bakrahat 1290 12.9 Type of house Kachcha 1080 10.8 Pucca 4870 48.7 Semi-pucca 4050 40.5 No. of years of stay 0 to 5 years 150 1.7 5.1 to 10 years 1580 15.8 >10 years 8250 82.5 Characteristics of family Frequency (n) Percentage (%) Religion Of Family Hindu 5780 57.8 Muslim 4160 41.6 Christian 60 0.6 No. of family members 1 to 4 members 7680 76.8 >4 members 2320 23.2 No. of children between 1 to 5 years No children of that age 7620 76.2 1 2180 21.8 2 170 1.7 >2 20 0.2 Monthly Income of the family (Based on Kuppuswamy Scale, June 2023) ≤7315 3580 35.8 7316-21913 5980 59.8 21914-36526 370 3.7 36527-45588 60 0.6 45589-54650 10 0.1 Table-2 Hygiene practices of the families included in the study (N=10,000) Frequency (n) Percentage (%) What kind of toilet do the household members usually use? Flush toilet used alone 5980 59.8 Flush toilet shared with other family members 3230 32.3 Dug hole 90 0.9 Open defecation 150 1.5 Open pit 550 5.5 Place of disposal of stool (For children and aged) (n=6910) Specific place identified by municipality 1050 15.2 Own toilet 4609 66.7 Open place outside 1251 18.1 Main source of drinking water in the house Own tap 1020 10.2 Communal tap 1890 18.9 Tube well 140 1.4 Well 30 0.3 Community hand pump 4640 46.4 Water vendor 2280 22.8 Distance from house to the source of water (Time) Inside the household premises 1580 15.8 5 min walking distance 4800 48 Method uses for disinfecting your drinking water Boiling 940 9.4 RO Filter 1120 11.2 Chlorination 40 0.4 Sedimentation 40 0.4 None 7860 78.6 What is used in the household for washing hands in general? Normal water 4720 47.2 Soap and water 5250 52.5 Gul/Ash 30 0.3 When do you wash your hands with soap and water? After defecation Always 9050 90.5 Sometimes 460 4.6 Never 490 4.9 Before Eating Always 6500 65 Sometimes 2320 23.2 Never 1180 11.8 Before Food Handling Always 5750 57.5 Sometimes 1530 15.3 Never 2720 27.2 Any episode of diarrhea in last 6 months? Yes No 1690 8310 16.9 83.1 Table-3 Determinants of diarrhea of the family included in the study (N=10,000) Socio-demographics Characteristics Categories Total number Diarrhea Present (n, %) Measurement (Unadjusted= Bivariate Adjusted**= Multivariate) OR p-value Toilet used by household member (Ref=Flush toilet used alone) Flush toilet shared with other family members 3230 524 16.22 Unadj 1.04 (0.83-1.31) 0.68 Adj 0.89 (0.7-1.14) 0.37 Dug hole 91 8 8.79 Unadj 2.76 (0.65-11.69) 0.16 Adj 2.35(0.54-10.17) 0.25 Open defecation 140 13 9.28 Unadj 2.17 (0.77-6.12) 0.14 Adj 2.59 (0.78-8.56) 0.11 Open pit 550 80 14.54 Unadj 1.27 (0.81-2) 0.29 Adj 1.18 (0.74-1.88) 0.46 Place of disposal of stool (For children and aged) (Ref= Specific place identified by municipality) Own toilet 4609 915 19.85 Unadj 0.87 (0.52-1.48) 0.62 Adj 0.96 (0.56-1.66) 0.90 Open place outside 1251 129 10.31 Unadj 1.15 (1.05-2.24) <0.001* Adj 1.12 (0.56-2.22) 0.90 Main source of drinking water in the house (Ref=Own tap) Community tap 1890 304 16.08 Unadj 1.09 (0.44-3.02) 0.72 Adj 1.42 (0.63-3.03) 0.70 Tubewell inside the household premises 140 46 32.85 Unadj 4.02(0.49-32.86) 0.19 Adj 0.53 (0.04-6.24) 0.53 Well 32 5 15.62 Unadj 1.15 (0.59-2.24) 0.66 Adj 0.97 (0.66-1.44) 0.91 Community hand pump 4640 534 11.5 Unadj 0.69 (0.55-4.95) 0.83 Adj 0.34 (0.57-1.21) 0.34 Water vendor 2280 571 25.04 Unadj 1.92 (1.33-2.76) <0.001* Adj 2.71 (1.84-4.01) <0.001* Method uses for disinfecting your drinking water (Ref=Boiling) RO Filter 1120 50 4.46 Unadj 0.89 (0.17-4.66) 0.08 Adj 0.92 (0.63-11.35) 0.68 Chlorination 40 0 0 Unadj -- -- Adj -- -- Sedimentation 41 7 17.07 Unadj 1.94 (0.39-9.63) 0.41 Adj 1.56 (0.29-8.17) 0.59 None 7860 1523 19.37 Unadj 2.13 (1.32-3.45) <0.01* Adj 1.74 (1.05-2.88) 0.03 What is used in the household for washing hands? (Ref=Soap and water) Normal water 4720 1252 26.52 Unadj 3.03 (2.45-3.75) <0.001* Adj 3.14 (2.51-3.93) <0.001* Gul/Ash 30 7 23.33 Unadj 0.89 (0.18-4.67) 0.88 Adj 1.8 (0.16-4.86) 0.89 After defecation (Ref=Always) Sometime 460 124 26.95 Unadj 0.57 (0.11-2.86) 0.50 Adj 0.61 (0.12-3.13) 0.55 Never 490 0 0 Unadj -- -- Adj -- -- Before Eating (Ref=Always) Sometime 2320 291 12.54 Unadj 0.2 (0.14-1.28) 0.08 Adj 0.24 (0.16-0.36) 0.34 Never 1180 464 39.32 Unadj 0.78 (0.60-1.01) 0.06 Adj 1.14 (0.87-1.50) 0.62 Before Food Handling (Ref=Always) Sometime 1530 387 25.29 Unadj 0.44 (0.32-1.05) 0.51 Adj 1.18 (0.85-1.65) 0.3 Never 2720 608 22.35 Unadj 1.64 (1.23-2.19) <0.01 Adj 1.53 (1.17-2.01) <0.01 *Significant at p-value <0.01**Adjusted for total income, number of children, number of family member, type of house, Ref: Reference category Table-4 Themes, sub-themes and codes based on thematic analysis Theme 1: Knowledge and Awareness of Diarrheal Diseases Sub-themes Codes Representative statements Perception Community Specific " It depends on community to community, like here in some community they don't maintain personal hygiene and food hygiene causing diarrhoea. Even not drinking clean water causing the same, I think so..."- ANM (1) " We live in pucca house and the houses near us are mostly pucca and here the places are also clean, previously we used to live in a place nearby the community was not that great I mean very dirty and so we left that place. "-(34 years old housewife) Unhygienic Condition " Due to unhygienic food consumption.... staying in dirty environment not maintaining hygiene causes some disease in stomach called diarrhoea, also after coming back from bathroom we should wash our hands and even feet " – (30 years old housewife) " it's like watery stools and like dehydration fever is known as diarrhoea, due to unhygienic conditions “-ANM (2) " If surrounding will be clean and hygienic then no diseases will be there "-ANM (5) Cause Fecal oral " I have heard it spreads through bare foot "- (32 years old Housewife) " Some people will openly dispose fecal matter of their children, which later causes the problem "- ANM (6) Junk food and drinking water " I think it is more related with junk food eating and like eating outside foods "- (26 years house wife) "Now a days people will eat a lot of outside food, junk food causing stomach problem and drinking water here is not good. Most of the household here use packaged water which cost only 5rs for 20 liters"-ANM (4) Economically weaker sections " We have seen it is more common amongst the poor communities "- (47 years old house wife) " If mother will not be healthy then the child will also suffer from disease and most of the diseases happens due to poor nutrition and lifestyle which all are related to bad economic conditions " -ANM (3) Rainy season accounts for more cases " During rainy season I have seen the number of cases are more "-(36 years old housewife) " Previous year almost everyone in our house got Diarrhea during the rainy season "- (33 years old housewife) Theme 2: Hygiene Practices and Barriers Access Attitude “ If my child gets frequent of stool I took him to Samali hospital, but if I or my husband gets frequent stool, I took medicine from store ”- (29 years old housewife) “ Whenever people do frequent of stool, they took medicine from shop and take it. They think it is useless for coming to health centre rather to take medicine directly .”-ANM (1) Barriers Distance " Distance of the health center from our house is around 1 hour which makes it difficult. It's very far, for coming here and show the doctor it takes the whole day " (43 years old housewife) Cultural " We only prefer Unani medicines and it works well for us "- (34 years old housewife) "Whatever information we will get; we will consult with our religious leaders"-(30 years old housewife Theme 3: Sanitation Practices and Community Norms Toilet Limited understanding of healthy facts “ We have shared toilets with our neighbours. We don’t have so much money to build separate toilets for everyone but we always keep the toilets clean so that we don't have diarrhea "- (32 years old housewife) " We heard like even when we use public toilets it can even spread from their also "- (30 years old housewife) " Now almost every one owns proper toilet like the KANTA bathrooms. Even sometimes they will go for outside for defecation even if they have toilets in their house. "-ANM (1) Hand washing Importance " We wash hand with water before eating. But before cooking we sometime wash our hands. After defecation we wash hand with soap and water. I don’t think handwashing is so much important "- (34 years old housewife) " They know everything that if they don't wash hand problem might occur still knowing all this they are not much bothered "- ANM (4) Waste disposal Disposal of stool for children and old aged people “ I usually throw the fecal of my baby in the open place outside my home. We all throw these things outside my house for many years .”- (31 years old housewife) “ Some families are very obedient. They throw the waste in the designated place for garbage but most of them are not so much obedient they just throw their waste here and there and those families get Diarrhea almost throughout the year ”- ANM (1) Theme 4: Perceptions of Health-Seeking Behavior Knowledge ORS widely known " I know about ORS, even in this summer season we are using a lot "- (31 years old housewife) " Almost everyone one knows about ORS and about the usage of it " – ANM (2) Availability Available " Mostly it is available, we don't face any problem with stock. During some season the demand of ORS will be very high but still we will get somehow "-ANM (5) "Regularly ASHA didis will come and give us ORS and other necessary medicines"- (33 years old housewife) Theme 5: Barriers and Facilitators for Hygiene Practices Awareness General awareness " Awareness is there but the change is very slow, we are telling from a long time to wash their hands with soap and water but they are reluctant. Health promotion can help a lot, if an auto or a car goes inside village with a mic on it all are very interested and listens to it "-ANM (4) Vaccination Importance and fear “ We don’t need any vaccine. After taking the COVID vaccine we have faced various health related issues .”- (33 years old housewife) " Even during the time of COVID people were very reluctant to take vaccines, talking with the Religious leaders helped a lot. Cholera vaccines will be very helpful for this area. "- ANM (6) Table-5 Comparison of Diarrhea Burden and Impact of Cholera Vaccination in WASH-Challenged Settings Country/study area Pre-Intervention Diarrhea Burden WASH Challenges OCV intervention OCV Effectiveness Comparison with our Study (West Bengal, India) Kolkata, India (Im et al., 2024) Moderate endemicity of cholera; high incidence in slums Similar WASH gaps in slum settings Cluster-randomized OCV trial combined with WASH promotion Enhanced protection against both cholera and non-cholera diarrhea Comparable urban setting; supports feasibility of OCV integration Bangladesh (Matlab) (Huq A et al.,2010) ~10-20% diarrhea prevalence in high-risk seasons Reliance on contaminated river water, limited sanitation OCV + sari cloth water filtration ~38% reduction in cholera incidence; community-wide diarrhea risk reduction Highlights impact of low-cost WASH + vaccine synergy Ethiopia (Northwest flood-prone areas) (Birhan T et al.,2023) 22.1% diarrhea prevalence among under-five children Use of unimproved water source, poor handwashing practices Recent WASH intervention and OCV introduced in outbreak-prone regions Early reports show significant reduction in childhood diarrhea post-WASH Higher diarrhea burden than our study; evidence for vaccination rollout in flood-prone areas Haiti (post-earthquake epidemic) (Urban Slums) (Rouzier V et al.,2013) Extremely high cholera burden post-2010 Collapse of sanitation system, water contamination OCV campaign in urban slums (Port-au-Prince); 90% coverage Marked decline in cholera cases; high acceptability and feasibility Post-disaster scenario, but shows success of OCV in low-WASH settings (relevant for disaster-prone Bengal areas) Haiti (Rural Artibonite Valley) (Ivers LC et al.,2013) High cholera incidence during 2010–2012 epidemic Limited access to clean water and sanitation infrastructure OCV campaign in remote villages; >90% completed two doses 58–63% effectiveness against cholera over 4–24 months Demonstrates OCV's effectiveness in rural, low-resource settings with poor WASH conditions Rural West Bengal, India (Our Study) 16.9% households had ≥1 diarrheal episode in past 6 months 78.6% did not disinfect water; 47.2% used only water for handwashing; 22.8% used vendor water No OCV implemented yet NA Strong WASH challenges; urgent need for OCV pilot Additional Declarations No competing interests reported. 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KANUNGO","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYNCCA1D6AxCzsZOihXEGSAszKVqYecAkAcXyM7ITPxecscszuN1+8bHNr23yfMwMjB8+5uDWYnAjd7P0jBvJxQZ3zhQb5/bdNmxjZmCWnLkNjxaJ3A3SPB+YEzfcyEmTzu25zQjUwsbMi0eL/Izczb95PtRDtFj23LYnqIXhRu42aZ4bh4Fa0o9JM/y4nUhQi8GZt9usec4cT5x5I4fZsLfhdnIbM2MzXr/It+duvs1zrDqx70b6wwc//ty2nd/efPDDR3wOQwAeAwbGNhCDsYEo9UDA/oCB4Q+xikfBKBgFo2AkAQBlCFcLLwNEZAAAAABJRU5ErkJggg==","orcid":"","institution":"National Institute of Cholera and Enteric Diseases","correspondingAuthor":true,"prefix":"","firstName":"SUMAN","middleName":"","lastName":"KANUNGO","suffix":""},{"id":456193214,"identity":"c76cf5a7-61e0-4acd-afb5-67b0f7d4b750","order_by":1,"name":"Shubhajit Pahari","email":"","orcid":"","institution":"National Institute of Cholera and Enteric 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Diseases","correspondingAuthor":false,"prefix":"","firstName":"Debjit","middleName":"","lastName":"Chakraborty","suffix":""},{"id":456193221,"identity":"86006690-531e-4940-a153-4f624c36455a","order_by":8,"name":"Pramit Ghosh","email":"","orcid":"","institution":"National Institute of Cholera and Enteric Diseases","correspondingAuthor":false,"prefix":"","firstName":"Pramit","middleName":"","lastName":"Ghosh","suffix":""},{"id":456193222,"identity":"09f36261-5a0e-4550-b0a7-58a9ee84212c","order_by":9,"name":"Bipul Karmakar","email":"","orcid":"","institution":"National Institute of Cholera and Enteric Diseases","correspondingAuthor":false,"prefix":"","firstName":"Bipul","middleName":"","lastName":"Karmakar","suffix":""},{"id":456193223,"identity":"7c7d2bd3-f193-4649-b823-873c1e158992","order_by":10,"name":"Atreyi Chakrabarti","email":"","orcid":"","institution":"National Institute of Cholera and Enteric Diseases","correspondingAuthor":false,"prefix":"","firstName":"Atreyi","middleName":"","lastName":"Chakrabarti","suffix":""},{"id":456193224,"identity":"cd76cde6-153b-466a-bd6f-25cfa425f40d","order_by":11,"name":"Swati Pramanick","email":"","orcid":"","institution":"National Institute of Cholera and Enteric Diseases","correspondingAuthor":false,"prefix":"","firstName":"Swati","middleName":"","lastName":"Pramanick","suffix":""},{"id":456193225,"identity":"8bdbcd0f-1572-47e8-b9b6-9ed07df7fceb","order_by":12,"name":"Asish Kumar Mukhopadhyay","email":"","orcid":"","institution":"National Institute of Cholera and Enteric Diseases","correspondingAuthor":false,"prefix":"","firstName":"Asish","middleName":"Kumar","lastName":"Mukhopadhyay","suffix":""},{"id":456193226,"identity":"2f38d0f7-45d2-47e1-87ff-7680bd4e7a2d","order_by":13,"name":"Ranjan Nandy","email":"","orcid":"","institution":"National Institute of Cholera and Enteric Diseases","correspondingAuthor":false,"prefix":"","firstName":"Ranjan","middleName":"","lastName":"Nandy","suffix":""},{"id":456193227,"identity":"34716d34-574f-4d4b-88ef-dd5c1ead77da","order_by":14,"name":"Alok Kumar Deb","email":"","orcid":"","institution":"National Institute of Cholera and Enteric Diseases","correspondingAuthor":false,"prefix":"","firstName":"Alok","middleName":"Kumar","lastName":"Deb","suffix":""},{"id":456193228,"identity":"d9732cd4-b95f-4356-b3fb-9508a9af64e0","order_by":15,"name":"Shanta Dutta","email":"","orcid":"","institution":"National Institute of Cholera and Enteric Diseases","correspondingAuthor":false,"prefix":"","firstName":"Shanta","middleName":"","lastName":"Dutta","suffix":""},{"id":456193229,"identity":"88f1673a-bef5-4f2f-bd6d-a649c519c0f7","order_by":16,"name":"Debasis Roy","email":"","orcid":"","institution":"District Health and Family Welfare, West Bengal","correspondingAuthor":false,"prefix":"","firstName":"Debasis","middleName":"","lastName":"Roy","suffix":""},{"id":456193230,"identity":"363317b1-7a6b-4c1a-a287-6aaf03e87533","order_by":17,"name":"Mukti Sadhan Maiti","email":"","orcid":"","institution":"National Institute of Cholera and Enteric Diseases","correspondingAuthor":false,"prefix":"","firstName":"Mukti","middleName":"Sadhan","lastName":"Maiti","suffix":""},{"id":456193231,"identity":"50cec75c-d60c-43f5-a3cd-907a1ce41e9d","order_by":18,"name":"Dipankar Maji","email":"","orcid":"","institution":"District Health and Family Welfare, West Bengal","correspondingAuthor":false,"prefix":"","firstName":"Dipankar","middleName":"","lastName":"Maji","suffix":""}],"badges":[],"createdAt":"2025-04-22 08:23:41","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6502015/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6502015/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82887498,"identity":"46c0d783-4162-49ef-ba36-c156c6c7ad20","added_by":"auto","created_at":"2025-05-16 11:56:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":106165,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLocation of the study area in South 24 pargana district of West Bengal, India\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6502015/v1/9648c2f8252cfb3609f24620.jpg"},{"id":82887497,"identity":"8cd82e8e-0023-4b22-8c9b-ec70b2919551","added_by":"auto","created_at":"2025-05-16 11:56:55","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":89718,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHealthcare selection for Diarrhea among families included in the study\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6502015/v1/bc3b98a681f998ef8a1b027f.jpg"},{"id":91148874,"identity":"babb4cda-fa1f-4300-8c16-1c1824927a89","added_by":"auto","created_at":"2025-09-12 06:46:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3393934,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6502015/v1/7066eab9-e0f6-46c7-a410-11ad3566512b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eExploring the Burden of Diarrheal Disease and Associated Hygiene Practices in Rural West Bengal,India: An Explanatory Sequential Mixed-Method Approach\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiarrheal diseases have been identified as a major global public health concern with significant morbidity and mortality, especially in low- and middle-income countries (LMICs) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It has been the third leading cause of death among children under 5 years of age, with a global burden of 1.7\u0026nbsp;billion cases and 0.44\u0026nbsp;million deaths annually (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). In India, the burden of diarrheal diseases is particularly severe, with an annual incidence of 1.6 cases per 1,000 population and 40 cases of acute diarrhea per 1,000 children (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Despite efforts to improve sanitation and hygiene, diarrheal diseases threaten public health, particularly in rural areas where access to clean water, proper sanitation, and hygiene education remains limited.\u003c/p\u003e \u003cp\u003eThe increased incidence of diarrhea is closely linked to several factors, including hygiene practices, access to clean water, sanitation facilities, and the level of health literacy within communities especially among caregivers (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). The correlation between poor hygiene practices and the incidence of diarrheal diseases is well-documented (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). A study by Muthukumaran et al. (2024) reported that 92% of people in rural areas of Sub-Saharan Africa, Central Asia, and Southern Asia still practice open defecation with more than half of these cases occurring in rural India (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Open defecation and improper waste disposal increase the risk of exposure to fecal pathogens, leading to infectious disease outbreaks, including diarrhea (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Children in rural areas are particularly vulnerable, as they often play in soil and open drains, increasing their exposure to animal and human fecal pathogens (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Maternal knowledge and health literacy are critical in shaping hygiene practices and preventing diarrheal diseases. Studies have shown that mothers and caregivers who know the importance of handwashing, safe water storage, and proper sanitation are more likely to adopt these practices, thereby reducing the risk of diarrheal infections in their households (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, in many rural communities, limited access to health education and resources often hinders disseminating such knowledge, perpetuating the cycle of poor hygiene and disease transmission.\u003c/p\u003e \u003cp\u003eIn India, significant efforts have been made to improve access to safe and potable water through government initiatives such as Central Rural Sanitation Program (CRSP) in 1986 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), Swacchh Bharat Mission in 2014 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e), Intensified Diarrhea Control Fortnight (IDCF)-2015 program (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), Jal Jeevan Mission in 2019 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e); Additionally, the implementation of water, sanitation and hygiene practices (WASH) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e); implementation of Rota-virus vaccination under the Universal Immunization Program (UIP) 2019 (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e); have contributed to improved living conditions. However, these efforts have not yet translated into significant reduction in the burden of diarrheal diseases, particularly in rural areas, suggesting a need for more targeted interventions that address both infrastructure and behavioral factors.\u003c/p\u003e \u003cp\u003eDiarrheal diseases continue to have long-term consequences for human capital and economic growth, particularly in LMICs. In many communities, the lack of access to proper healthcare leads individuals to rely on over-the-counter medications or unlicensed practitioners, which can exacerbate the problem by contributing to antimicrobial resistance (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Studies have shown that community-based hygiene education and promotion of handwashing practices led to a significant decrease in diarrheal episodes (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Furthermore, access to improved sanitation facilities has been associated with a 36% reduction in diarrhea incidence in LMICs (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWest Bengal, a state in eastern India with a coastal boundary along the Bay of Bengal, is an identified endemic region for diarrheal outbreaks. According to the National Family Health Survey-5 (NFHS-5), 64.7% of the rural population in West Bengal has access to proper sanitation facilities, and 96.9% have improved drinking water sources (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Despite these improvements, the diarrhea prevalence among children under five remains high at 6.7%. This discrepancy highlights the need for a deeper understanding of the factors contributing to the persistence of diarrheal diseases in this region, including the role of maternal knowledge and health literacy in shaping hygiene behaviors. To address this gap, we conducted a study among community-dwellers in a rural region of West Bengal where we focused towards studying the association of the hygiene related knowledge, attitudes and practices along with the prevalence of diarrheal episodes. Analyzing the relationship between hygiene practices and the prevalence of diarrheal diseases in rural communities is critical for developing effective intervention strategies. The results from this study will add to the existing knowledge on how promoting community-driven hygiene and sanitation measures can play a pivotal role in curbing the incidence of diarrheal illnesses.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and study area\u003c/h2\u003e \u003cp\u003eThis explanatory mixed-method study was conducted between April 2024 to June 2024 in the Bishnupur-II block of South24 Pargana district in West Bengal. South 24 Parganas is a coastal district in West Bengal with a history of recurrent waterborne disease outbreaks, particularly during the monsoon season when water contamination peaks (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). According to prior studies, the district has one of the highest incidences of diarrheal diseases in the state, driven by factors such as inadequate access to safe drinking water, poor sanitation facilities, and low hygiene awareness (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Further, the Bishnupur-II block of South 24 Parganas was strategically selected as the study area based on state health authorities' recommendations, identifying it as a priority area due to its vulnerability to diarrheal diseases and WASH-related challenges. As per the Census, 2011 South-24 Pargana district consist of 81,61,961 population and 30 administrative blocks (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In the Bishnupur-II block there are total 11 Gram Panchayats (GP) among them we have selected three GP namely- Nahazari, Khagramuri and Bakrahat due to high burden of Diarrhea cases reported in recent years which consist total six number of Sub-centers (SC) (namely Nahazari South, Nahazari North, Angarberia, Ramnagar, Khagramuri and Chaksukdev) in the catchment area (Fig-1).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy participants\u003c/h3\u003e\n\u003cp\u003eThe study included all households within the catchment area, encompassing approximately 10,000 families and a population of around 45,000 individuals. Participation was voluntary among responsive families who have resided in the area of the study for at least one year. The head of each household was approached for interviews, with informed consent obtained prior to enrollment. Mothers of children under five years of age were specifically targeted for in-depth interviews (IDIs) to gain qualitative insights into hygiene practices and diarrheal disease episodes. A total of 10 IDIs were conducted until data saturation was achieved. Additionally, six Auxiliary Nurse Midwives (ANMs) stationed at the six sub-centers in the study area were engaged for Key Informant Interviews (KIIs) to gather healthcare provider perspectives. These participants were chosen purposefully to ensure comprehensive representation of community and healthcare viewpoints, aligning with the mixed-method approach of the study.\u003c/p\u003e\n\u003ch3\u003eData collection procedure\u003c/h3\u003e\n\u003cp\u003eThe data collection process was designed to comprehensively capture the study's quantitative and qualitative aspects, ensuring a robust mixed-method approach.\u003c/p\u003e\n\u003ch3\u003eQuantitative data collection:\u003c/h3\u003e\n\u003cp\u003eData was gathered during an area census from 1st week of April,2024 to 1st week of June 2024 involving 10,000 families within the study area, representing a population of around 45,000. Accredited Social Health Activist (ASHA) workers were crucial in collecting the data. The ICMR-NIRBI team gave them training before the commencement of the data collection from their respective jurisdiction area under the catchment of the Samali Block Primary Health Centre (BPHC), serving as the headquarters for the 3-GPs.\u003c/p\u003e \u003cp\u003eA semi-structured questionnaire was developed and piloted prior to its use as a data collection tool. It comprised of questions related to the socio-demographic status of the study participants, hygiene-practice and whether diarrheal episodes reported in the last six months in the last six months. The complete data collection procedure was supervised and monitored by ICMR-NIRBI team along with the officials of Govt. of West Bengal. Completed census forms were stored in respective Sub-centers before being transported to ICMR-NIRBI for further quality check.\u003c/p\u003e \u003cp\u003eWater samples were also collected from different water vendors in the study area for the identification of the presence of any micro-flora in designated laboratory in ICMR-NIRBI.\u003c/p\u003e\n\u003ch3\u003eQualitative data collection:\u003c/h3\u003e\n\u003cp\u003eFrom the 2nd week of June until the last week, In-depth interviews (IDIs) were conducted with mothers of children under five years of age to explore their hygiene practices, perceptions of diarrheal diseases, and health-seeking behaviors. A total of 10 IDIs were carried out until thematic saturation was achieved. Key informant interviews (KIIs) were also conducted with six Auxiliary Nurse Midwives (ANMs) stationed at sub-centers within the study area.\u003c/p\u003e \u003cp\u003eBoth IDIs and KIIs were conducted by trained interviewers using pre-tested interview guides. Prior to starting the interviews, efforts were made to establish a good rapport with the participants. To maintain privacy, interviews were conducted at convenient times and locations for the participants. Before the interview, all study participants provided written informed consent after being informed on the study's purpose. After the interview, the essential aspects were summarised and their approval was obtained before the KII results were finalized. During the interviews, notes were taken on paper, and recordings were done according to the participant's preferences. The audio recordings were transcribed the day it was conducted. In order to ensure data confidentiality, interview notes were deidentified and assigned distinct numerical numbers.\u003c/p\u003e \u003cp\u003eIn order to ensure data confidentiality, interview notes were deidentified and assigned distinct numerical numbers.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eQuantitative data analysis:\u003c/h2\u003e \u003cp\u003eData entry was done using MS Excel (Version 2016) and the data analysis was done using IBM SPSS Statistics for windows, Version 25 (Released July,2017; IBM Corp., Armonk, New York, United States). Descriptive statistics were computed for the categorical variables (Demographic characteristics, hygiene practices of the families, Diarrheal episodes and health seeking behavior for diarrhea) and presented as frequencies and percentages to provide an overview of the study population. To examine associations between hygiene practices and diarrheal episodes, bivariable logistic regression was performed to estimate crude odds ratios (COR). Subsequently, multivariable logistic regression was conducted to calculate adjusted odds ratios (AOR), controlling for potential confounders such as monthly family income, number of children, family size, and type of housing. The results were reported with corresponding 95% confidence intervals (CI) to assess the strength and significance of associations.\u003c/p\u003e \u003cp\u003eWe used a single exposure model while conducting the regression as even when WASH factors may be intercorrelated, single exposure model would help in isolating the effect of one specific hygiene practice on diarrheal outcomes without the distortions introduced by multicollinearity. When multiple WASH exposures are entered together, high correlations between them can inflate the standard errors, cause instability in the regression coefficients, and lead to difficulties in interpreting the independent effects. By modeling one exposure at a time and adjusting for key confounders (such as household income, family size, and house type), the analysis yields clearer, more reliable estimates of the association. Moreover, many WASH interventions in real-world settings tend to be implemented concurrently, meaning the individual effects are inherently intertwined. A single exposure model allows for evaluating each factor on its own merit without forcing artificial separation where the underlying behaviors may operate as part of a broader, interrelated set of practices.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative data analysis:\u003c/h3\u003e\n\u003cp\u003eThe qualitative data from in-depth interviews (IDIs) with mothers and key informant interviews (KIIs) with Auxiliary Nurse Midwives (ANMs) were transcribed verbatim. The transcripts were reviewed and coded using thematic analysis. Predefined categories guided the coding process, but emergent themes were also identified inductively during analysis. A subject matter expert validated the categories against the codes, themes, and quotations. The thematic analysis allowed for identifying key themes and sub-themes related to hygiene practices, community perceptions of diarrhea prevention, and barriers to effective hygiene. This method provided a structured framework for integrating qualitative insights into actionable recommendations.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIntegration of Quantitative and Qualitative Data:\u003c/h2\u003e \u003cp\u003eQuantitative and qualitative findings were integrated through a narrative synthesis approach. The Quantitative phase provided a broad understanding of the prevalence and determinants of diarrheal diseases, while qualitative phase insights enriched this understanding by contextualizing the statistical findings within community behaviors, attitudes, and perceptions. The two datasets were compared and contrasted to identify convergences and divergences, ensuring a comprehensive interpretation of the study outcomes.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEthical consideration-\u003c/b\u003e The study was cleared by the Institutional Ethics Committee of ICMR-NIRBI (No. A-10(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)/2024(OCV Trial)-IEC\u003c/p\u003e \u003cp\u003e \u003cb\u003eOperational definition-\u003c/b\u003e As per WHO, Diarrhea was characterized by the occurrence of three or more loose or watery stools within a day, or an increase in stool frequency beyond what is typical for the individual. Passing solid stools frequently does not qualify as diarrhea, nor does the passage of loose, soft stools by breastfed infants (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e "},{"header":"Result","content":"\u003ch2\u003eQuantitative phase:\u003c/h2\u003e\u003ch2\u003eSocio-Demographic Characteristics -\u003c/h2\u003e\u003cp\u003eAmong the 10,000 families surveyed 60% resided in the Nahazari Gram Panchayat, with a majority living in pucca (48.7%) or semi-pucca (40.5%) houses while 10.8% lived in kachcha houses. Approximately 82.5% of participants had lived in the area for over 10 years (Table-1a).\u003c/p\u003e\u003cp\u003eThe population was predominantly Hindu (57.8%), followed by Muslim (41.6%). Most families (76.8%) had 1–4 members, while 23.7% had children under five years of age. The study classified families based on their monthly income using the Kuppuswamy scale (June 2023). Most families (59.8%) fell into the INR 7,316–21,913 income category, reflecting a middle-income group within the rural context (Table-1b).\u003c/p\u003e\u003ch2\u003eDiarrhea prevalence \u0026amp; WASH practices -\u003c/h2\u003e\u003cp\u003eThe study revealed that 16.9% of families reported experiencing at least one diarrheal episode in the six months preceding the survey (Table-2). Drinking water sources varied across households: 22.8% relied on water vendors, and 46.4% used community hand pumps for drinking water purposes. 78.6% of Participants did not purify their drinking water in any way, which could expose them to waterborne pathogens. Handwashing practices were explored, showing that most families in the study (52.5%) wash their hands with soap and water. Almost everyone always uses soap and water (90.5%) after defecation; 65% of people always use soap and water before eating, and 57.5% always use soap and water before food handling. While 59.8% used private flush toilets, 32.3% shared flush toilets with others, and 1.5% practiced open defecation. Regarding stool disposal for children and older adults, 66.7% used their own toilets, while others relied on other methods (municipality-identified spaces ~ 15%, and open space outside ~ 18%).\u003c/p\u003e\u003ch2\u003eHealthcare seeking behavior –\u003c/h2\u003e\u003cp\u003eThe study revealed that most families prefer government health facilities to treat diarrheal illnesses. Specifically, 64.8% of surveyed families sought treatment for diarrhea in adults at government health facilities, while an even higher percentage (75.9%) chose these facilities when the illness affected children (Fig-2a). We observed distinct patterns in healthcare-seeking behavior for diarrheal episodes among different religious groups. Among Hindu participants, the most preferred option for managing diarrhea was home-based care (40.25%), followed by government health facilities (36.83%), pharmacies (10.44%), private healthcare providers (4.6%), and unlicensed practitioners (7.85%). Similarly, among Muslim participants, home-based care was also the most common choice (43.02%), with government health facilities (33.12%), pharmacies (8.41%), private healthcare providers (5.1%), and unlicensed practitioners (10.35%) being the subsequent preferences. These findings highlight a shared reliance on home-based care across communities, with government health facilities being the second most preferred option (Fig-2b). In the study, among the three Gram Panchayats (GP), the majority in Nahazari (41.3%) and Bakrahat (45.73%) opted for home-based treatment for diarrhea. People from Khagramuri GP mostly preferred govt health facilities for diarrhea treatment (Fig-2c). As income rises, the preference for seeking treatment for diarrhea from private practitioners increases significantly (Fig-2d).\u003c/p\u003e\u003ch2\u003eDeterminants of Diarrhea –\u003c/h2\u003e\u003cp\u003eThis study identified several hygiene-related factors associated with diarrheal episodes: Families using water from vendors had nearly twice the risk of diarrhea compared to those using their own taps (COR: 1.92; 95% CI: 1.33–2.76). This risk increased nearly threefold after adjusting for confounders such as income, family size, and housing type (AOR: 2.71; 95% CI: 1.84–4.01). Families that did not disinfect their drinking water had a higher risk of diarrhea than those who boiled their water (COR: 2.13; 95% CI: 1.32–3.45). After adjustment, this risk remained significant but slightly reduced (AOR: 1.74; 95% CI: 1.05–2.88). Families using only water for handwashing were three times more likely to experience diarrhea than those using soap and water (COR: 3.03; 95% CI: 2.45–3.75). This risk increased slightly after adjustment (AOR: 3.14; 95% CI: 2.51–3.93). Additionally, individuals who never washed their hands with soap before food handling had a higher likelihood of diarrhea than those who always did so (COR: 1.64; 95% CI: 1.23–2.19; AOR: 1.53; 95% CI: 1.17–2.01). Families disposing of stool in open areas near their homes were at a slightly higher risk of diarrhea compared to those using designated disposal methods (COR: 1.15; 95% CI: 1.05–2.24), whereas adjusted odds ratio was nonsignificant (Table-3).\u003c/p\u003e\u003ch2\u003eQualitative Phase:\u003c/h2\u003e\u003cp\u003eThe qualitative component of the study was conducted to explore the community perceptions, attitudes, and practices related to hygiene and diarrheal disease prevention, complementing to the quantitative findings. A total of 10 in-depth interviews (IDIs) with mothers of children under five years and six key informant interviews (KIIs) with Auxiliary Nurse Midwives (ANMs) were analyzed thematically (Table-4)\u003c/p\u003e\u003ch2\u003eTheme 1: Knowledge and Awareness of Diarrheal Diseases -\u003c/h2\u003e\u003cp\u003eMothers had varying levels of knowledge about diarrhea, its causes, and prevention. While most participants recognized contaminated water and poor hygiene as key contributors, some misconceptions were there. For instance, some mothers attributed diarrhea to \"eating junk food\" or \"exposure to outside food.\" Our quantitative finding also suggested that 78.6% of households did not disinfect their drinking water, highlighting a gap in awareness about waterborne disease prevention. ANMs emphasized that while community health education campaigns had improved awareness about oral rehydration solution (ORS) use during diarrhea episodes, awareness about preventive measures like handwashing before food handling (reported as consistent by only 57.5% in the quantitative data) remained low.\u003c/p\u003e\u003ch2\u003eTheme 2: Hygiene Practices and Barriers -\u003c/h2\u003e\u003cp\u003eWhile families understood the importance of hygiene, barriers such as lack of access to soap or clean water often hindered consistent practices. Mothers reported prioritizing handwashing after defecation (quantitatively reported at 90.5%) but admitted to neglecting it before eating or food preparation due to time constraints or unavailability of soap. Economic challenges often force families to allocate resources toward other necessities. The reliance on unsafe water sources, such as vendor-supplied water (used by 22.8% of families), was also discussed in IDIs. Mothers expressed concerns about the quality of vendor water but cited limited alternatives due to inadequate access to piped water or functional hand pumps. These findings supported the quantitative finding that reliance on vendor water significantly increased diarrhea risk (AOR: 2.71; 95% CI: 1.84–4.01).\u003c/p\u003e\u003ch2\u003eTheme 3: Sanitation Practices and Community Norms -\u003c/h2\u003e\u003cp\u003eSanitation practices varied widely across households, with most families adopting safe disposal methods while others continued open defecation or used shared facilities. Few participants (1.5%) who practiced open defecation cited social norms, lack of privacy in shared toilets, or non-functional facilities as key reasons. ANMs highlighted that despite government efforts under programs like the Swachh Bharat Mission, behavioral change was slow in certain communities due to deeply ingrained habits and cultural resistance.\u003c/p\u003e\u003ch2\u003eTheme 4: Perceptions of Health-Seeking Behavior -\u003c/h2\u003e\u003cp\u003eMothers reported a preference for home-based care during initial diarrhea episodes, often relying on traditional remedies or over-the-counter medications before seeking formal healthcare services. This aligned with the quantitative finding that home-based care was common among both Hindu (40.25%) and Muslim (43.02%) families for treating diarrhea. ANMs noted that while awareness about ORS had improved due to community outreach programs, delays in seeking professional care often exacerbated complications in children under five years old. Families cited financial constraints, distance to healthcare facilities, and long waiting times as barriers to accessing government health services.\u003c/p\u003e\u003ch2\u003eTheme 5: Barriers and Facilitators for Hygiene Practices -\u003c/h2\u003e\u003cp\u003eThe qualitative analysis revealed several facilitators, like better hygiene practices, including community education programs led by ANMs and ASHAs, availability of subsidized soap through local initiatives, and increasing awareness about sanitation through school-based campaigns. However, barriers such as financial constraints, lack of infrastructure (e.g., non-functional hand pumps), and cultural norms around sanitation limited the adoption of safe practices. For example, some mothers expressed reluctance to use shared toilets due to concerns about cleanliness and privacy.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study assessed the burden of diarrheal diseases and hygiene practices in rural West Bengal using a mixed-methods approach, revealing significant gaps in sanitation, hygiene behavior, and access to safe drinking water. To contextualize our findings, we adopted a dual-axis analysis: (i) intra-national comparisons with Indian studies and (ii) international benchmarking against LMICs. A comparative review of similar WASH-challenged settings where OCV was implemented\u0026mdash;such as in Bangladesh, Ethiopia, and Haiti (urban \u0026amp; rural)\u0026mdash;showed substantial reductions in both cholera and general diarrhea incidence.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section2\"\u003e \u003ch2\u003eBurden of Diarrheal Diseases \u0026amp; WASH practices \u0026ndash;\u003c/h2\u003e \u003cp\u003eThis study found that 16.9% of families reported at least one diarrheal episode in the six months preceding the survey. This prevalence aligns with findings from other rural regions in India,(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) In areas where diarrhoeal illnesses continue to be a major source of morbidity, particularly among children under five. For example, a study in Odisha reported a similar prevalence range between 9 to 21%, especially among children under five, highlighting the persistent burden of diarrhea across rural India despite national sanitation initiatives like the Swachh Bharat Mission (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Similarly, an analysis of the Longitudinal Ageing Study in India wave-I data (2017\u0026ndash;2018) revealed that diarrheal prevalence among older adults aged 60 years or older during the last two years preceding the survey was 15% (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). This study found that individuals using water vendors as their primary drinking water source are 2.71 times more likely to contract diarrhea than those using their own tap. Despite the Jal Jeevan Mission (2019), 22.8% of households still rely on vendors, reflecting systemic gaps in last-mile water access. Similar findings were noted in the systematic umbrella review published in 2010 where it was found that improved water quality can reduce the burden of Diarrhea by 17% (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). From the study setting, few of the water samples were collected and was tested positive for coliform bacteria. It was noted that in the study area the water vendors are sourcing water from taps, tubewells, and other places that may be contaminated. When this water is directly packed and sold to community members without adequate treatment or quality checks, it increases the risk of spreading diarrheal diseases. A cluster randomized control study conducted in Kolkata from 2006\u0026ndash;2011 found that residents of households with better WASH conditions had a lower incidence of Cholera (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). These findings also mirror a community-based cross-sectional study conducted in Ethiopia, which showed that unimproved water consumption was associated with a more than two-fold rise in diarrheal incidence among children (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In rural Bangladesh, using simple cloth filtration and treating household water could reduce cholera cases by about 38%, highlighting the importance of safe drinking water (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In our study we have also found that people who don\u0026rsquo;t use any method to disinfect the drinking water almost twice at more risk than those who boil their water for drinking. A study conducted in 2023 in Northwest Ethiopia found that households that used unimproved water sources increase the likelihood of childhood diarrhea by 2.36 times compared to households that used improved water source (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, people who cleaned their hands simply with water had a 3.03 times higher risk of developing diarrhoea than those who used soap and water. A 2021 systematic review showed that promoting handwashing reduced diarrhea incidence by 28% (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Further, a study conducted in 2021 among children under 5 years in Lao People\u0026rsquo;s Democratic Republic found that children in households with only water for handwashing had 1.49 times higher odds of experiencing diarrhea than those households who practices handwashing with both water and soap (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHandwashing before handling food was also a predictor for diarrhea. Our study found that people who never wash their hands before handling food were nearly twice as likely to develop diarrhea as those who always do. Similarly, a study conducted in 2007 in Bangladesh showed that washing at least one hand with water reduced diarrhea risk by 22%, washing both hands with water reduced it by 33%, and washing at least one hand with soap led to a 70% reduction (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The evidence strongly supports the promotion of regular handwashing as a simple yet vital public health measure to safeguard against diarrheal infections, particularly in settings with limited access to clean water and sanitation. A noteworthy intervention to mention was Kerala\u0026rsquo;s \u0026ldquo;Handwash Revolution\u0026rdquo; campaign, which reduced childhood diarrhea by 40% through school programs (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eHealthcare seeking pattern -\u003c/h2\u003e \u003cp\u003eThe study found that 64.8% of adults sought diarrhea treatment at government health facilities, reflecting trust in public healthcare systems. However, concerning patterns emerged: 12.4% relied on self-medication, 9.8% purchased drugs directly from pharmacies, and 4.6% visited unlicensed practitioners. These findings align with a 2014 study in Malda, West Bengal, where 53.16% of non-communicable disease cases were managed by non-qualified providers (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Such reliance on informal care mirrors trends in rural Ethiopia, where 62% of households used unregulated drug vendors for diarrheal treatment (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This fragmented healthcare-seeking behavior exacerbates antimicrobial resistance (AMR) risks, as over-the-counter antibiotic misuse and incomplete treatment courses fuel pathogen adaptation (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Another study conducted in the slums of Kolkata among Informal Healthcare Providers found that a multicomponent educational intervention led to long-lasting improvements in diarrhea-related knowledge and practices. This success suggests that policy advocacy, along with the implementation and scaling up of similar interventions, is necessary (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, we also observed that 75.9% of families took their children to government health facilities for diarrhea treatment, a higher proportion compared to adults. A study conducted in the urban slums of Kolkata among young children found that caregivers with formal education were more likely to seek care from licensed providers, underlining the role of education in influencing healthcare-seeking behavior (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). A 2021 study from Kandhamal District in Odisha also emphasized the importance of promoting handwashing, hygiene practices, and access to safe drinking water as essential measures for managing diarrhea in tribal communities (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). These findings align with a 2018 meta-analysis that identified similar interventions as effective strategies for improving diarrhea outcomes globally (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The consistency between these studies and our findings underscores the critical importance of targeted public health interventions aimed at improving hygiene practices and access to clean water.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eComparative analysis with global Cholera vaccination and WASH intervention outcomes\u003c/h2\u003e \u003cp\u003eA major study in Kolkata, India indicated that the integration of OCV with WASH interventions provided additional protection not only against cholera but also against non-cholera diarrheal illnesses in urban slums with insufficient sanitation facilities (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). In Bangladesh's rural Matlab region, a community-based intervention using sari fabric water filtration combined with OCV led to a 38% drop in cholera incidence and a decrease in overall diarrhea burden (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). These findings highlight the importance of low-cost water safety interventions with immunization in resource-constrained settings. The Haiti post-2010 earthquake situation is particularly enlightening. Slum urban areas saw a sharp decline in cholera after mass campaigns of OCV (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). In addition, a rural Haitian study conducted in the Artibonite Valley found that OCV had a 58\u0026ndash;63% efficacy over 4\u0026ndash;24 months following immunization, although the vaccine was not effective against non-cholera diarrhea (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). This comparative synthesis demonstrates that, while our study location in West Bengal lacks OCV integration, comparable contexts show promising decreases in diarrhea and cholera incidence following immunization. These findings highlight the critical need for pilot implementation of OCV in high-risk rural zones such as Bishnupur-II, particularly when paired with scalable WASH interventions (Table-5)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and strengths\u003c/h2\u003e \u003cp\u003eThe present study catered few limitations such as being a cross-sectional study design and possible temporal uncertainty, the findings were interpreted as associations rather than causal relationships. As with any questionnaire-based assessment of knowledge and practice, discrepancies in participant attention might result in information bias. Keeping aside the limitations, the present study by virtue of its multi-component aspects in understanding the hygiene practices and its relation to diarrheal diseases, could generate valuable information towards improving the hygiene and sanitary habits of the community-dwellers and also their health-seeking behavior.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this study highlights a persistent burden of diarrheal disease in rural West Bengal, driven by unsafe water sources, inadequate hygiene practices, and fragmented healthcare-seeking behavior. The findings reveal alarming statistics, such as a 16.9% prevalence of diarrhea and a significant reliance on untreated water sources, which heightens the risk of waterborne diseases. Comparative insights from similar low-resource settings further validate the effectiveness of combining Oral Cholera Vaccination with hygiene and sanitation strategies. Implementing such multifaceted, community-driven interventions could significantly reduce diarrheal morbidity in high-risk rural regions like Bishnupur-II, contributing to broader public health gains. Overall, the evidence strongly supports focused public health interventions, community education, and engagement to promote good hygiene habits and increase access to clean water. Furthermore, the use of Oral Cholera Vaccination in high-risk locations like these could boost disease prevention efforts and drastically lower the frequency of diarrhea and related disorders in vulnerable populations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLMIC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLow- and Middle-Income Countries\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCRSP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCentral Rural Sanitation Program\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIDCF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIntensified Diarrhea Control Fortnight\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWASH\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWater, sanitation and hygiene practices\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUIP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eUniversal Immunization Program\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNFHS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eNational Family Health Survey\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGram Panchayat\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIDI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eIn-depth Interview\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKII\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKey Informant Interviews\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eASHA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAccredited Social Health Activist\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eANM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAuxiliary Nurse Midwives\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCrude odds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAOR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAdjusted odds ratio\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConfidence interval\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eORS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOral Rehydration Solution\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate-\u0026nbsp;\u003c/strong\u003eThe study was cleared by the Institutional Ethics Committee of ICMR-National Institute for Research in Bacterial Infections,\u0026nbsp;(No. A-10(2)/2024)-IEC dated 12.02.2024. Verbal informed\u0026nbsp;consent was obtained from the participants prior enrollment in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication-\u0026nbsp;\u003c/strong\u003eNot applicable as no individual identification were revealed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials-\u0026nbsp;\u003c/strong\u003eThe data that support the findings of this study are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests-\u0026nbsp;\u003c/strong\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be regarded as a potential conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding-\u003c/strong\u003e This study received ICMR funding since it was a component of an intramural project. (Proposal ID-2023-0000054)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions-\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eConceptualization:\u003c/strong\u003e SK, DC and SD; \u003cstrong\u003eData curation\u003c/strong\u003e: SK, SP, AP, SC; \u003cstrong\u003eFormal Analysis\u003c/strong\u003e: SK, SP, SB, PG, RT; \u003cstrong\u003eSupervision\u003c/strong\u003e: SK, SP, SC, BK, SP, AP, AC, SPK; \u003cstrong\u003eLaboratory:\u0026nbsp;\u003c/strong\u003eAKM, RKN, BK\u003cstrong\u003e; Writing—original draft\u003c/strong\u003e: SK, SP, RT, PC, DB, SB; \u003cstrong\u003eWriting—review and editing\u003c/strong\u003e: SK, RT. \u003cstrong\u003eOverall supervision\u003c/strong\u003e: DR, MSM, DM, SK. All the contributing authors have critically reviewed the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements-\u003c/strong\u003e The authors would like to thank the locals of the area as well as all of the ASHA workers who participated actively in the census enumeration. The authors also want to acknowledge Mrs. Ishita Majhi \u0026amp; Mrs. Santana Brahmachari (Senior Public Health Nurse, Samali BPHC) and Mr. Biswajit Pal (Block Account Manager, Sa mali BPHC) for their continuous support.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthor Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and Affiliations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSuman Kanungo\u003c/strong\u003e:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eDivision of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eShubhajit Pahari\u003c/strong\u003e: Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSombuddha Biswas\u003c/strong\u003e: Divisionof Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSougata Chatterjee\u003c/strong\u003e: Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiplina Barman\u003c/strong\u003e: Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDebjit Chakraborty\u003c/strong\u003e: Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePramit Ghosh\u003c/strong\u003e: Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAlok Kumar Deb\u003c/strong\u003e: Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBipul Ch Karmakar\u003c/strong\u003e: Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAsish Kumar Mukhopadhyay\u003c/strong\u003e- Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRanjan Nandy\u003c/strong\u003e:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eDivision of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eShanta Dutta\u003c/strong\u003e: Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRounik Talukdar\u003c/strong\u003e:\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eDivision of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAritra Paul\u003c/strong\u003e: Block Medical Officer of Health (BMOH), Samali Block Primary Health Center, South 24 Parganas, West Bengal, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAtreyi Chakrabarti\u003c/strong\u003e: Deputy Chief Medical Officer of Health II, South 24 Parganas, West Bengal, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSwati Pramanick\u003c/strong\u003e: Deputy Chief Medical Officer of Health III, South 24 Parganas, West Bengal, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDebasis Roy\u003c/strong\u003e- Deputy Director-Reproductive and Child Health, District Health and Family Welfare, Kolkata, West Bengal, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMukti Sadhan Maiti-\u0026nbsp;\u003c/strong\u003eChief Medical Officer of Health, South 24 Pargana, District Health and Family Welfare, Kolkata, West Bengal, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDipankar Maji:\u0026nbsp;\u003c/strong\u003eJoint Director of Health Service (PH\u0026amp;CD), Kolkata, West Bengal, India\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSuman Kanungo\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eH\u0026eacute;nock Blaise NY, Dovie DBK. Diarrheal Diseases in the History of Public Health. Arch Med Res. 2007;38(2):159\u0026ndash;63. \u003c/li\u003e\n\u003cli\u003eThystrup C, Majowicz SE, Kitila DB, Desta BN, Fayemi OE, Ayolabi CI, et al. Etiology-specific incidence and mortality of diarrheal diseases in the African region: a systematic review and meta-analysis. BMC Public Health. 2024;24(1). \u003c/li\u003e\n\u003cli\u003eSharma A, Dutta BS, Rasul ES, Barkataki D, Saikia A, Hazarika NK. Prevalence of Vibrio cholerae O1 serogroup in Assam, India: A hospital-based study. Indian J Med Res. 2017 Sep;146(3):401\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eGiri M, Behera MR, Behera D, Mishra B, Jena D. Water, Sanitation, and Hygiene Practices and Their Association With Childhood Diarrhoea in Rural Households of Mayurbhanj District, Odisha, India. Cureus. 2022;14(10):1\u0026ndash;12. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). Preventing diarrhoea through better water, sanitation and hygiene Exposures and impacts in low- and middle-income countries [Internet]. 2014. Available from: https://www.who.int/publications/i/item/9789241564823\u003c/li\u003e\n\u003cli\u003eRoy S, Kiruthika G, Muthappan S, Rizwan SA, Kathiresan J. Association between water, sanitation and hygiene practices and diarrhea among under 3-year-old children: Evidence from a nationally representative sample in India (2019\u0026ndash;2021). J Water Sanit Hyg Dev. 2023;13(9):711\u0026ndash;22. \u003c/li\u003e\n\u003cli\u003eMuthukumaran A, Ranjan A, Pandey S, Kumar P, Rao R. Open defecation among adults having household toilets and factors associated with it: An analytical cross-sectional study from rural Bihar, India. Clin Epidemiol Glob Heal [Internet]. 2024;25(July 2023):101486. Available from: https://doi.org/10.1016/j.cegh.2023.101486\u003c/li\u003e\n\u003cli\u003eSaleem M, Burdett T, Heaslip V. Health and social impacts of open defecation on women: A systematic review. BMC Public Health. 2019;19(1). \u003c/li\u003e\n\u003cli\u003eMills M, Lee S, Piperata BA, Garabed R, Choi B, Lee J. Household environment and animal fecal contamination are critical modifiers of the gut microbiome and resistome in young children from rural Nicaragua. Microbiome [Internet]. 2023;11(1):1\u0026ndash;18. Available from: https://doi.org/10.1186/s40168-023-01636-5\u003c/li\u003e\n\u003cli\u003eSzewczak A, Bak J, Węgorowski P, Zarzycka D. The knowledge of mothers on prevention of diarrhea in infancy. J Educ Heal Sport. 2018;8(11):156\u0026ndash;64. \u003c/li\u003e\n\u003cli\u003eMinistry of Rural Development. English Releases [Internet]. 2008. Available from: https://pib.gov.in/newsite/erelcontent.aspx?relid=44717\u003c/li\u003e\n\u003cli\u003eMinistry of Health \u0026amp; Family Welfare. Swachh Bharat Abhiyan | Prime Minister of India [Internet]. Available from: https://www.pmindia.gov.in/en/major_initiatives/swachh-bharat-abhiyan/\u003c/li\u003e\n\u003cli\u003eMinistry of Health \u0026amp; Family Welfare. Intensified Diarrhoea Control Fortnight: Operational guildelines. 2015;(July):1\u0026ndash;38. Available from: http://cghealth.nic.in/ehealth/2016/Instructions/IDCF_Guideline_2015.pdf\u003c/li\u003e\n\u003cli\u003eWelfare M of H\u0026amp; F. JJM Dashboard [Internet]. 2024. Available from: https://ejalshakti.gov.in/jjmreport/JJMState.aspx\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). Water, sanitation and hygiene (WASH) - India [Internet]. Available from: https://www.who.int/india/health-topics/water-sanitation-and-hygiene-wash\u003c/li\u003e\n\u003cli\u003eDivision I, Welfare F. Operational guidelines for Rotavirus Immunization Division MoHFW. 2019;69. \u003c/li\u003e\n\u003cli\u003eKotwani A, Joshi J, Lamkang AS. Over-the-counter sale of antibiotics in india: A qualitative study of providers\u0026rsquo; perspectives across two states. Antibiotics. 2021;10(9):1\u0026ndash;19. \u003c/li\u003e\n\u003cli\u003eEjemot-Nwadiaro RI, Ehiri JE, Arikpo D, Meremikwu MM CJ. Hand washing promotion for preventing diarrhoea [Internet]. 2021. Available from: https://www.who.int/tools/elena/review-summaries/wsh-diarrhoea--hand-washing-promotion-for-preventing-diarrhoea\u003c/li\u003e\n\u003cli\u003eNoguchi Y, Nonaka D, Kounnavong S, Kobayashi J. Effects of hand-washing facilities with water and soap on diarrhea incidence among children under five years in lao people\u0026rsquo;s democratic republic: A cross-sectional study. Int J Environ Res Public Health. 2021;18(2):1\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eHashi A, Kumie A, Gasana J. Hand washing with soap and WASH educational intervention reduces under-five childhood diarrhoea incidence in Jigjiga District, Eastern Ethiopia: A community-based cluster randomized controlled trial. Prev Med Reports [Internet]. 2017;6:361\u0026ndash;8. Available from: http://dx.doi.org/10.1016/j.pmedr.2017.04.011\u003c/li\u003e\n\u003cli\u003eWolf J, Hubbard S, Brauer M, Ambelu A, Arnold BF, Bain R, et al. Effectiveness of interventions to improve drinking water, sanitation, and handwashing with soap on risk of diarrhoeal disease in children in low-income and middle-income settings: a systematic review and meta-analysis. Lancet. 2022;400(10345):48\u0026ndash;59. \u003c/li\u003e\n\u003cli\u003eMinistry of Health \u0026amp; Family Welfare. Catalog | Open Government Data (OGD) Platform India [Internet]. 2022. Available from: https://www.data.gov.in/catalog/national-family-health-survey-nfhs-5\u003c/li\u003e\n\u003cli\u003eMinistry of Health and Family Welfare, India G of. National Centre for Disease Control Government of India [Internet]. 2023. Available from: https://ncdc.mohfw.gov.in/wp-content/uploads/2025/01/32_SAPCCHH_West-Bengal_21-10-24.pdf\u003c/li\u003e\n\u003cli\u003eVivek Kumar SM. Disease Ecology of Diarrhoea in South 24 Parganas District , West Bengal. Int J Nov Res Dev. 2024;9(2):557\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eSouth Twenty Four Parganas (South 24 Parganas) District Population Census 2011 - 2021 - 2024, West Bengal literacy sex ratio and density [Internet]. [cited 2024 Jun 24]. Available from: https://www.census2011.co.in/census/district/17-south-twenty-four-parganas.html\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). Diarrhoeal disease [Internet]. 2024. Available from: https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease\u003c/li\u003e\n\u003cli\u003eGhosh K, Chakraborty AS, SenGupta S. Identifying spatial clustering of diarrhoea among children under 5 years across 707 districts in India: a cross sectional study. BMC Pediatr. 2023;23(1):1\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eKumar Naik S, Mandi R, Bansod DW. Diarrhoea and ARI Risk Exposure Among Under-Five Children in Odisha, India: An evidence from NFHS-4. Res Pediatr Neonatol [Internet]. 2020;6(4):564\u0026ndash;9. Available from: https://crimsonpublishers.com/rpn/fulltext/RPN.000643.php\u003c/li\u003e\n\u003cli\u003eSrivastava S, Banerjee S, Debbarma S, Kumar P, Sinha D. Rural-urban differentials in the prevalence of diarrhoea among older adults in India: Evidence from Longitudinal Ageing Study in India, 2017-18. PLoS One [Internet]. 2022;17(3 March):1\u0026ndash;17. Available from: http://dx.doi.org/10.1371/journal.pone.0265040\u003c/li\u003e\n\u003cli\u003eCairncross S, Hunt C, Boisson S, Bostoen K, Curtis V, Fung ICH, et al. Water, sanitation and hygiene for the prevention of diarrhoea. Int J Epidemiol. 2010;39(SUPPL. 1). \u003c/li\u003e\n\u003cli\u003eIm J, Islam MT, Ahmmed F, Kim DR, Tadesse BT, Kang S, et al. Do Oral Cholera Vaccine and Water, Sanitation, and Hygiene Combine to Provide Greater Protection Against Cholera? Results From a Cluster-Randomized Trial of Oral Cholera Vaccine in Kolkata, India. Open Forum Infect Dis [Internet]. 2024;11(1):1\u0026ndash;7. Available from: https://doi.org/10.1093/ofid/ofad701\u003c/li\u003e\n\u003cli\u003eBirhan TA, Bitew BD, Dagne H, Amare DE, Azanaw J, Genet M, et al. Prevalence of diarrheal disease and associated factors among under-five children in flood-prone settlements of Northwest Ethiopia: A cross-sectional community-based study. Front Pediatr. 2023;11(January):1\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eHuq A, Yunus M, Sohel SS, Bhuiya A, Emch M, Luby SP, et al. Simple sari cloth filtration of water is sustainable and continues to protect villagers from Cholera in Matlab, Bangladesh. MBio. 2010;1(1):1\u0026ndash;5. \u003c/li\u003e\n\u003cli\u003eLuby SP, Halder AK, Huda T, Unicomb L, Johnston RB. The effect of handwashing at recommended times with water alone and with soap on child diarrhea in rural Bangladesh: An observational study. PLoS Med. 2011;8(6). \u003c/li\u003e\n\u003cli\u003eCentre for Community Health Research (CCHR). Children as agents of change- an intervention in Kerala (India) on WASH in Schools | Department of Economic and Social Affairs [Internet]. 2024. Available from: https://sdgs.un.org/partnerships/children-agents-change-intervention-kerala-india-wash-schools\u003c/li\u003e\n\u003cli\u003eKanungo S, Bhowmik K, Mahapatra T, Mahapatra S, Bhadra UK, Sarkar K. Perceived morbidity, healthcare-seeking behavior and their determinants in a poor-resource setting: Observation from India. PLoS One. 2015;10(5):1\u0026ndash;21. \u003c/li\u003e\n\u003cli\u003eMahapatra T, Mahapatra S, Chakraborty ND, Raj A, Bakshi B, Banerjee B, et al. Intervention to Improve Diarrhea-Related Knowledge and Practices among Informal Healthcare Providers in Slums of Kolkata. J Infect Dis. 2021;224(Suppl 7):S890\u0026ndash;900. \u003c/li\u003e\n\u003cli\u003eManna B, Nasrin D, Kanungo S, Roy S, Ramamurthy T, Kotloff KL, et al. Determinants of health care seeking for diarrheal illness in young childrenin urban slums of Kolkata, India. Am J Trop Med Hyg. 2013;89(SUPPL.1):56\u0026ndash;61. \u003c/li\u003e\n\u003cli\u003eBehera P, Bhatia V, Sahu DP, Sahoo DP, Kamble RU, Panda PS, et al. Community perception regarding diarrhoea management practices in a tribal predominant aspirational district of Odisha: A mixed-method study. J Fam Med Prim Care [Internet]. 2021;10(11):4110. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC8797090/\u003c/li\u003e\n\u003cli\u003eRouzier V, Severe K, Juste MAJ, Peck M, Perodin C, Severe P, et al. Cholera vaccination in Urban Haiti. Am J Trop Med Hyg. 2013;89(4):671\u0026ndash;81. \u003c/li\u003e\n\u003cli\u003eIvers LC, Teng JE, Lascher J, Raymond M, Weigel J, Victor N, et al. Use of oral cholera vaccine in haiti: A rural demonstration project. Am J Trop Med Hyg. 2013;89(4):617\u0026ndash;24. \u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eable 1- Socio-demographic characteristics of family included in the study (N=10,000)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLocation and characteristics of residence\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"93%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 50px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGram Panchayat\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNahazari\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e5980\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e59.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKhagramuri\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e2730\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e27.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBakrahat\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e1290\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e12.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of house\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKachcha\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e1080\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e10.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePucca\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e4870\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e48.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSemi-pucca\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e4050\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e40.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of years of stay\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0 to 5 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e5.1 to 10 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e1580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;10 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e8250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e82.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003col style=\"list-style-type: lower-alpha;\"\u003e\n \u003cli\u003e\u0026nbsp;\u003cstrong\u003eCharacteristics of family\u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"92%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReligion Of Family\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHindu\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5780\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e57.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMuslim\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e41.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChristian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of family members\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1 to 4 members\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e7680\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e76.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;4 members\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e23.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo. of children between 1 to 5 years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo children of that age\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e7620\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e76.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e170\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMonthly Income of the family\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Based on Kuppuswamy Scale, June 2023)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026le;7315\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e3580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e35.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e7316-21913\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e5980\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e59.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e21914-36526\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e370\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e36527-45588\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 29px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e45589-54650\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable-2 Hygiene practices of the families included in the study (N=10,000)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"92%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 67px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFrequency (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePercentage (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat kind of toilet do the household members usually use?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFlush toilet used alone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5980\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e59.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFlush toilet shared with other family members\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e3230\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e32.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDug hole\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpen defecation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpen pit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e550\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of disposal of stool (For children and aged)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=6910)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecific place identified by municipality\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1050\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e15.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOwn toilet\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4609\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e66.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpen place outside\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e18.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"6\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain source of drinking water in the house\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOwn tap\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunal tap\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1890\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e18.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTube well\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWell\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity hand pump\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4640\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e46.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWater vendor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e22.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistance from house to the source of water (Time)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInside the household premises\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1580\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e15.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;5 min walking distance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e3620\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e36.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;5 min walking distance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMethod uses for disinfecting your drinking water\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBoiling\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e940\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRO Filter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e11.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChlorination\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSedimentation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e7860\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e78.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat is used in the household for washing hands in general?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNormal water\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e4720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e47.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSoap and water\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5250\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e52.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGul/Ash\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhen do you wash your hands with soap and water?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter defecation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlways\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e9050\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e90.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSometimes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e460\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e4.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNever\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e490\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore Eating\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlways\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e6500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSometimes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e23.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNever\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e11.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore Food Handling\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlways\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e5750\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e57.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSometimes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e1530\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e15.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNever\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 20px;\"\u003e\n \u003cp\u003e2720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e27.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 28px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny episode of diarrhea in last 6 months?\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20px;\"\u003e\n \u003cp\u003e1690\u003c/p\u003e\n \u003cp\u003e8310\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e16.9\u003c/p\u003e\n \u003cp\u003e83.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable-3 Determinants of diarrhea of the family included in the study (N=10,000)\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSocio-demographics Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal number\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 111px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDiarrhea Present (n, %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeasurement\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(Unadjusted=\u003c/strong\u003e\u003cbr\u003e\u003cstrong\u003eBivariate Adjusted**= Multivariate)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eToilet used by household member (Ref=Flush toilet used alone)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFlush toilet shared with other family members\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e3230\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e524\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e16.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.04 (0.83-1.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.89 (0.7-1.14)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDug hole\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e8.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e2.76 (0.65-11.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e2.35(0.54-10.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpen defecation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e9.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e2.17 (0.77-6.12)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e2.59 (0.78-8.56)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpen pit\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e550\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e14.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.27 (0.81-2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.18 (0.74-1.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlace of disposal of stool (For children and aged) (Ref=\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;Specific place identified by municipality)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOwn toilet\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4609\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e915\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e19.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.87 (0.52-1.48)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.96 (0.56-1.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOpen place outside\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1251\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e129\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e10.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.15 (1.05-2.24)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.12 (0.56-2.22)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"10\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMain source of drinking water in the house (Ref=Own tap)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity tap\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1890\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e304\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e16.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.09 (0.44-3.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.42 (0.63-3.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.70\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTubewell inside the household premises\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e32.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e4.02(0.49-32.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.53 (0.04-6.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWell\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e15.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.15 (0.59-2.24)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.97 (0.66-1.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.91\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCommunity hand pump\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4640\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e534\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.69 (0.55-4.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.34 (0.57-1.21)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWater vendor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e571\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e25.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadj\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.92 (1.33-2.76)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdj\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.71 (1.84-4.01)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMethod uses for disinfecting your drinking water (Ref=Boiling)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRO Filter\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1120\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e4.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.89 (0.17-4.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.92 (0.63-11.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChlorination\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSedimentation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e17.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.94 (0.39-9.63)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.56 (0.29-8.17)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNone\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e7860\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1523\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e19.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadj\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.13 (1.32-3.45)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdj\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.74 (1.05-2.88)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWhat is used in the household for washing hands? (Ref=Soap and water)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNormal water\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e4720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e1252\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e26.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadj\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.03 (2.45-3.75)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdj\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e3.14 (2.51-3.93)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGul/Ash\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e23.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.89 (0.18-4.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.8 (0.16-4.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.89\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAfter defecation (Ref=Always)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSometime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e460\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e124\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e26.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.57 (0.11-2.86)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.61 (0.12-3.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 90px;\"\u003e\n \u003cp\u003e0.55\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNever\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e490\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore Eating\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(Ref=Always)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSometime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2320\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e291\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e12.54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.2 (0.14-1.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.24 (0.16-0.36)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNever\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1180\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e39.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.78 (0.60-1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.14 (0.87-1.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 135px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBefore Food Handling\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(Ref=Always)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSometime\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e1530\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e387\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e25.29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eUnadj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e0.44 (0.32-1.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.51\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003eAdj\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e1.18 (0.85-1.65)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNever\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 75px;\"\u003e\n \u003cp\u003e2720\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 53px;\"\u003e\n \u003cp\u003e608\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 58px;\"\u003e\n \u003cp\u003e22.35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUnadj\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.64 (1.23-2.19)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 11.0996%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdj\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 25.2116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.53 (1.17-2.01)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.01\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e*Significant at p-value \u0026lt;0.01**Adjusted for total income, number of children, number of family member, type of house, Ref: Reference category\u003c/p\u003e\n\u003cp\u003eTable-4 Themes, sub-themes and codes based on thematic analysis\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"850\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 850px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 1:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eKnowledge and Awareness of Diarrheal Diseases\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSub-themes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 207px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCodes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepresentative statements\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerception\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eCommunity Specific\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eIt depends on community to community, like here in some community they don\u0026apos;t maintain personal hygiene and food hygiene causing diarrhoea. Even not drinking clean water causing the same, I think so...\u0026quot;-\u003c/em\u003eANM (1)\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eWe live in pucca house and the houses near us are mostly pucca and here the places are also clean, previously we used to live in a place nearby the community was not that great I mean very dirty and so we left that place.\u003c/em\u003e\u0026quot;-(34 years old housewife)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eUnhygienic Condition\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot; \u003cem\u003eDue to unhygienic food consumption.... staying in dirty environment not maintaining hygiene causes some disease in stomach called diarrhoea, also after coming back from bathroom we should wash our hands and even feet\u003c/em\u003e \u0026quot; \u0026ndash; (30 years old housewife)\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eit\u0026apos;s like watery stools and like dehydration fever is known as diarrhoea, due to unhygienic conditions\u003c/em\u003e \u0026ldquo;-ANM (2)\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eIf surrounding will be clean and hygienic then no diseases will be there\u003c/em\u003e\u0026quot;-ANM (5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCause\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eFecal oral\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eI have heard it spreads through bare foot\u003c/em\u003e \u0026quot;- (32 years old Housewife)\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eSome people will openly dispose fecal matter of their children, which later causes the problem\u003c/em\u003e\u0026quot;- ANM (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eJunk food and drinking water\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eI think it is more related with junk food eating and like eating outside foods\u003c/em\u003e \u0026quot;- (26 years house wife)\u003c/p\u003e\n \u003cp\u003e\u0026quot;Now a days people will eat a lot of outside food, junk food causing stomach problem and drinking water here is not good. Most of the household here use packaged water which cost only 5rs for 20 liters\u0026quot;-ANM (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eEconomically weaker sections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eWe have seen it is more common amongst the poor communities\u003c/em\u003e \u0026quot;- (47 years old house wife)\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eIf mother will not be healthy then the child will also suffer from disease and most of the diseases happens due to poor nutrition and lifestyle which all are related to bad economic conditions\u003c/em\u003e\u0026quot; -ANM (3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eRainy season accounts for more cases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eDuring rainy season I have seen the number of cases are more\u003c/em\u003e\u0026quot;-(36 years old housewife)\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003ePrevious year almost everyone in our house got Diarrhea during the rainy season\u003c/em\u003e\u0026quot;- (33 years old housewife)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 850px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 2:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eHygiene Practices and Barriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\u0026nbsp;\u003cp\u003e\u003cstrong\u003eAccess\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eAttitude\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eIf my child gets frequent of stool I took him to Samali hospital, but if I or my husband gets frequent stool, I took medicine from store\u003c/em\u003e\u0026rdquo;- (29 years\u0026nbsp;old housewife)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eWhenever people do frequent of stool, they took medicine from shop and take it. They think it is useless for coming to health centre rather to take medicine directly\u003c/em\u003e.\u0026rdquo;-ANM (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBarriers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eDistance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eDistance of the health center from our house is around 1 hour which makes it difficult.\u003c/em\u003e \u003cem\u003eIt\u0026apos;s very far, for coming here and show the doctor it takes the whole day\u003c/em\u003e \u0026quot; (43 years old housewife)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eCultural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eWe only prefer Unani medicines and it works well for us\u003c/em\u003e \u0026quot;- (34 years old housewife)\u003c/p\u003e\n \u003cp\u003e\u0026quot;Whatever information we will get; we will consult with our religious leaders\u0026quot;-(30 years old housewife\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 850px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 3: Sanitation Practices and Community Norms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eToilet\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eLimited understanding of healthy facts\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eWe have shared toilets with our neighbours. We don\u0026rsquo;t have so much money to build separate toilets for everyone but we always keep the toilets clean so that we don\u0026apos;t have diarrhea\u003c/em\u003e \u0026quot;- (32 years old housewife)\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eWe heard like even when we use public toilets it can even spread from their also\u003c/em\u003e\u0026quot;- (30 years old housewife)\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eNow almost every one owns proper toilet like the KANTA bathrooms. Even sometimes they will go for outside for defecation even if they have toilets in their house.\u003c/em\u003e\u0026quot;-ANM (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHand washing\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eImportance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eWe wash hand with water before eating. But before cooking we sometime wash our hands. After defecation we wash hand with soap and water. I don\u0026rsquo;t think handwashing is so much important\u003c/em\u003e\u0026quot;- (34 years old housewife)\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eThey know everything that if they don\u0026apos;t wash hand problem might occur still knowing all this they are not much bothered\u003c/em\u003e \u0026quot;- ANM (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWaste disposal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eDisposal of stool for children and old aged people\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eI usually throw the fecal of my baby in the open place outside my home. We all throw these things outside my house for many years\u003c/em\u003e.\u0026rdquo;- (31 years old housewife)\u003c/p\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eSome families are very obedient. They throw the waste in the designated place for garbage but most of them are not so much obedient they just throw their waste here and there and those families get Diarrhea almost throughout the year\u003c/em\u003e\u0026rdquo;- ANM (1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 850px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 4: Perceptions of Health-Seeking Behavior\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKnowledge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eORS widely known\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eI know about ORS, even in this summer season we are using a lot\u003c/em\u003e \u0026quot;- (31 years old housewife)\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eAlmost everyone one knows about ORS and about the usage of it\u003c/em\u003e\u0026quot; \u0026ndash; ANM (2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAvailability\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eAvailable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eMostly it is available, we don\u0026apos;t face any problem with stock. During some season the demand of ORS will be very high but still we will get somehow\u003c/em\u003e\u0026quot;-ANM (5)\u003c/p\u003e\n \u003cp\u003e\u0026quot;Regularly ASHA didis will come and give us ORS and other necessary medicines\u0026quot;- (33 years\u0026nbsp;old housewife)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 850px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 5: Barriers and Facilitators for Hygiene Practices\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAwareness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eGeneral awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eAwareness is there but the change is very slow, we are telling from a long time to wash their hands with soap and water but they are reluctant. Health promotion can help a lot, if an auto or a car goes inside village with a mic on it all are very interested and listens to it\u003c/em\u003e \u0026quot;-ANM (4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 130px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVaccination\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 207px;\"\u003e\n \u003cp\u003eImportance and fear\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 514px;\"\u003e\n \u003cp\u003e\u0026ldquo;\u003cem\u003eWe don\u0026rsquo;t need any vaccine. After taking the COVID vaccine we have faced various health related issues\u003c/em\u003e.\u0026rdquo;-\u0026nbsp;(33 years old housewife)\u003c/p\u003e\n \u003cp\u003e\u0026quot;\u003cem\u003eEven during the time of COVID people were very reluctant to take vaccines, talking with the Religious leaders helped a lot. Cholera vaccines will be very helpful for this area.\u003c/em\u003e \u0026quot;- ANM (6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable-5\u003c/strong\u003e \u003cstrong\u003eComparison of Diarrhea Burden and Impact of Cholera Vaccination in WASH-Challenged Settings\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"888\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCountry/study area\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePre-Intervention Diarrhea Burden\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWASH Challenges\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOCV intervention\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOCV Effectiveness\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComparison with our Study (West Bengal, India)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKolkata, India\u003c/strong\u003e (Im et al., 2024)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eModerate endemicity of cholera; high incidence in slums\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eSimilar WASH gaps in slum settings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eCluster-randomized OCV trial combined with WASH promotion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnhanced protection\u003c/strong\u003e against both cholera and non-cholera diarrhea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eComparable urban setting; supports feasibility of OCV integration\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBangladesh (Matlab)\u003c/strong\u003e (Huq A et al.,2010)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e~10-20% diarrhea prevalence in high-risk seasons\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eReliance on contaminated river water, limited sanitation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eOCV + sari cloth water filtration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e~38% reduction\u003c/strong\u003e in cholera incidence; community-wide diarrhea risk reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eHighlights impact of low-cost WASH + vaccine synergy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthiopia (Northwest flood-prone areas)\u003c/strong\u003e (Birhan T et al.,2023)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e22.1% diarrhea prevalence among under-five children\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eUse of unimproved water source, poor handwashing practices\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eRecent WASH intervention and OCV introduced in outbreak-prone regions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eEarly reports show \u003cstrong\u003esignificant reduction\u003c/strong\u003e in childhood diarrhea post-WASH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eHigher diarrhea burden than our study; evidence for vaccination rollout in flood-prone areas\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHaiti (post-earthquake epidemic) (Urban Slums)\u003c/strong\u003e (Rouzier V et al.,2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eExtremely high cholera burden post-2010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eCollapse of sanitation system, water contamination\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eOCV campaign in urban slums (Port-au-Prince); 90% coverage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarked decline\u003c/strong\u003e in cholera cases; high acceptability and feasibility\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003ePost-disaster scenario, but shows success of OCV in low-WASH settings (relevant for disaster-prone Bengal areas)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHaiti (Rural Artibonite Valley)\u003c/strong\u003e (Ivers LC et al.,2013)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003eHigh cholera incidence during 2010\u0026ndash;2012 epidemic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003eLimited access to clean water and sanitation infrastructure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eOCV campaign in remote villages; \u0026gt;90% completed two doses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e58\u0026ndash;63% effectiveness\u003c/strong\u003e against cholera over 4\u0026ndash;24 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eDemonstrates OCV\u0026apos;s effectiveness in rural, low-resource settings with poor WASH conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 82px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRural West Bengal, India\u003c/strong\u003e (Our Study)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 139px;\"\u003e\n \u003cp\u003e16.9% households had \u0026ge;1 diarrheal episode in past 6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 157px;\"\u003e\n \u003cp\u003e78.6% did not disinfect water; 47.2% used only water for handwashing; 22.8% used vendor water\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eNo OCV implemented yet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eNA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 170px;\"\u003e\n \u003cp\u003eStrong WASH challenges; urgent need for OCV pilot\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Diarrhea, Rural population, Epidemiology, Hygiene, Public health","lastPublishedDoi":"10.21203/rs.3.rs-6502015/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6502015/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDiarrheal diseases are a significant public health issue, disproportionately affecting under-five children residing in low- and middle-income countries. Inadequate WASH practices exacerbate this burden, especially in rural areas. This study used a mixed-method approach to evaluate the association between WASH practices and the prevalence of diarrheal diseases in the rural communities of West Bengal, India.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e \u003cp\u003eThe study was conducted in the Bishnupur-II block of South 24 Parganas district, West Bengal. A census survey covering approximately 10,000 families was conducted over nine weeks. Data on hygiene-related knowledge, attitudes, practices, and diarrheal episodes in the previous six months were collected using a semi-structured questionnaire administered by trained community health workers. Bivariable and multivariable logistic regression analyses were performed to assess associations between hygiene indicators and diarrhea prevalence. Ten in-depth interviews with mothers of under-five children and six key informant interviews with Auxiliary Nurse Midwives were conducted. Thematic analysis was used to explore contextual barriers and facilitators related to hygiene and disease prevention.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe study found that 16.9% of families reported diarrheal episodes in the past six months, with 75.9% of affected children receiving treatment at government health facilities. Open defecation near homes increased the likelihood of diarrhea by 1.15 times (COR: 1.15; 95% CI: 1.05\u0026ndash;2.24). Households relying on vendor-supplied drinking water faced nearly three times the risk (AOR: 2.71; 95% CI: 1.84\u0026ndash;4.01), while those using only water for handwashing had a 3.14 times higher risk compared to those using soap (AOR: 3.14; 95% CI: 2.51\u0026ndash;3.93). Notably, 80% of participants did not disinfect drinking water. Qualitative analysis identified five themes\u0026mdash;awareness gaps, cultural beliefs, financial constraints, inadequate infrastructure, and community engagement\u0026mdash;highlighting key barriers to hygiene and diarrhea prevention.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe study emphasizes the persistent burden of diarrhea in rural West Bengal, which is linked to inadequate hygiene practices and unsafe water consumption. It emphasizes the need for targeted public health interventions that combine community education, behavior change communication, and improved access to safe water and sanitation. Integrating proven tools like oral cholera vaccination with existing WASH strategies may further enhance disease prevention in high-burden rural settings.\u003c/p\u003e","manuscriptTitle":"Exploring the Burden of Diarrheal Disease and Associated Hygiene Practices in Rural West Bengal,India: An Explanatory Sequential Mixed-Method Approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-16 11:56:50","doi":"10.21203/rs.3.rs-6502015/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9a91f8bb-10bd-4d86-9caa-57cacb1a139d","owner":[],"postedDate":"May 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-11T05:23:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-16 11:56:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6502015","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6502015","identity":"rs-6502015","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}