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typhoid fever, diarrheal diseases and hepatitis with unhygienic food and unboiled water but the practices did not match the level of knowledge. Among children ...

Original Article

Knowledge, Attitude and Practices Survey on Hygiene and There Impact on Health Ali Yawar Alam , Malik Muhammad Adil, Akhtar Ali Qureshi, From Community Health Sciences, Shifa College of Medicine, Islamabad. Correspondence: Dr Ali Yawar Alam, Assoc Prof Community Medicine. Received: September 9, 2007 Accepted: February 16, 2008

ABSTRACT Objective: To explore the knowledge, attitude and practices of general community regarding relationship of typhoid fever, diarrheal diseases and hepatitis with unhygienic food, water and un-hygienic practices at two urban slum areas of Islamabad. Methods: A Cross-sectional survey was carried out between October 2003 and April 2004 in two urban squatter settlements of Islamabad, involving 200 households. Sociodemographic characteristics and awareness levels were assessed by uni-variate analysis. Results: 91.5% of the respondents were using un-boiled water mainly because of economic constraints. General community was well aware regarding relationship of typhoid fever, diarrheal diseases and hepatitis with unhygienic food and unboiled water but the practices did not match the level of knowledge. Among children, jaundice (signifying hepatitis) was the most prevalent sign with 1.7±0.3 episodes per year. Among adults, typhoid fever was most prevalent with 1.2±0.1 episodes per year. Conclusions: Community was well aware of the un-hygienic practices and diseases associated with them, but were un-able to apply the principles of hygiene in their daily

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lives. Provision of safe drinking water to these communities can reduce burden of diseases substantially. Reinforcement messages to the community with respect to modulating their daily lives on the principles of hygiene, which are easy to follow, need to be given. (Rawal Med J 2008;33:67-70). Key Words: Hygiene,

K.A.P,

Diseases,

Safe drinking Water.

INTRODUCTION Personal hygiene involves those practices that promote mental, emotional, and physical health, as well as the social well being of the individual.”1 Lack of observance of the principles of hygiene do not only impact personal health, but they have implications on the health of the family as well as the community to which one belongs. Diarrhoeal diseases, cholera, typhoid fever and hepatitis could be spread in the community due to inadequate disposal of excreta by few members in the community. Biological vectors such as houseflies can spread the microorganisms by sitting on the food and water of healthy people in the community. The objective of this study was to explore knowledge, attitude and practices of general community regarding relationship of typhoid fever, cholera, diarrhoeal diseases and hepatitis with unhygienic food, unboiled water and unhygienic practices at two urban slum areas in Islamabad. St.Thomas’s Community Health Network is providing Primary Health care facilities to the residents of these areas. SUBJECTS AND METHODS A Cross-sectional survey was carried out between October 2003 and April 2004, involving 200 households. Two urban squatter settlements of Islamabad were included in the study. One of the settlements was in G-7/1 sector and the other in G-8/1 sector of

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Islamabad. 100 households from each of the two areas were included to make a total sample size of 200 households, as calculated using Epi-Info 6.0. St.Thomas Community Health Network is running a Primary health care program in these areas and Medical expertise is provided by Shifa College of Medicine, Islamabad. Starting from the 1st house we picked up every third house in the area till the desired sample size of 100 households was reached in one area of study. Knowledge, attitude and practices of the Community was treated as dependent (outcome variable) while socio-demographic characteristics of the subjects and there families were treated as independent variables. Pre-designed, structured questionnaire was used in the survey. The data was re-validated and analyzed regarding socio-demographic characteristics of the study participants and knowledge, attitude and practices were reported as percentages. SPSS version 10.0 (SPSS, Chicago, Illinois, USA) was used for data analysis. The St.Thomas Community Health Network allowed us to carry out this study and informed written consent was taken from each participant of the study. RESULTS The mean age of study participants was 33 ± 10 years and majority of them were married (88.5%). Average number of children per household was 4 ± 2.6. Number of rooms in each household was 2 ± 1. Mean family income was 3677 ± 1715 Pakistani Rupee. 151 of the women were illiterate with majority (71.4%) of them were housewives. 48.5%of the male counterparts were illiterate and laborer being the major profession (43.5%). 91% of the residents had pakka (stone built) houses and 85% of the households had electricity. Wood was the major fuel (83.5%) for cooking and heating purposes. 50% of the residents visit

local dispensary for health care facility, while the remaining avail either the

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government or private health care facilities. Majority of children were school going (60%) and those did not, laborer being the major profession (53%). Table 1. Awareness levels (%age aware) about diseases due to unhygienic food & water (n=200) Factors Awareness of diarrhea diseases, typhoid fever, cholera, jaundice due to unhygienic foods Drinking unboiled water can cause diarrhoea Drinking unboiled water can cause typhoid fever Drinking unboiled water can cause cholera Drinking unboiled water can cause hepatitis Awareness that more money is spent on treatment rather than prevention Intention to use only boiled water and clean food in future Awareness that using boiled water and hygienic food is safe for family

Number (%) 178(89%)

172(86%) 165(82.5%) 172(86%) 161(80.5%) 186(93%) 182(91%) 187(93.5%)

64.5% were using tap water, 20% relied on underground boring for water, while the rest used either well or other sources of water. The community was well aware regarding relationship of typhoid fever, cholera, diarrhea diseases and hepatitis with unhygienic food and unboiled water (table 1). While majority of interviewees informed that they and their family members washed hands before eating but this could not be confirmed by independent observation. 60.5% admitted that routinely eat foods sold on carts by vendors which are unprotected from flies and dust (table 2). 91.5% were using un-boiled water mainly because of economic constraints (65%).

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Among children jaundice was most prevalent with a mean of 1.7 episodes per year, followed by diarrhea and typhoid fever (table 3). Among adults, typhoid fever was most prevalent with a mean of 1.2 episodes per year, followed by jaundice and diarrhea. Table 2. Practices of the Community (n=200)

Regularly boil water Why not boil water -Lack of resources -Lack of knowledge Wash hands before eating Wash hands before cooking Wash fruits before eating Eat food unprotected from flies Children eat Ice-lollys, unhygienic foods and colored liquids

Percentage (%) 8.5 65 45 94 97 95 60.5 60

DISCUSSION Recommended methods of hand hygiene include hand washing (washing hands with plain soap), hygienic hand wash (washing hands with medicated soap) and hygienic hand-rub (use of antiseptic rubs). In most countries hand washing and hygienic hand wash are the methods of choice.2 In our study, hand washing was reported as a common practice before eating and before cooking, although this could not be authenticated by direct observation during the short period of interview. Table 3 Episodes of common diseases in children and adults per year (n=200). Diseases (Episodes per year) In Children -Jaundice -Diarrhoea -Typhoid Fever In Adults -Typhoid Fever -Jaundice

Mean±S.D

Range

1.7±0.3 1.3±2.5 0.1±0.5

0-4 0-12 0-5

1.2±0.1 1.1±0.2

0-2 0-2 5

-Diarrhoea

0.5±1.4

0-10

Today, food safety is one of WHO's top 11 priorities and is one of the major challenges for the 21st century with regard to food safety.3,4 Majority of subjects in our study were aware of food born diseases and also had awareness that unhygienic food is not safe for family. They gave a strong positive response that more money is spent on treatment rather than prevention. Despite this knowledge, children and adults were eating food sold on carts, unprotected from flies and dust. A substantial degree of community illness associated with exposure to contaminated water with sewage was observed in various studies.4-6 This highlights the importance of proper disposal of excreta, boiling of water or using other water purification techniques and hand hygiene. In the areas where we conducted our study, majority of people were using tap water without boiling it. Water-borne shigellosis outbreak traced to a piped public water system in northern Thai community was supported by the presence of faecal contamination in the piped water system.7-9 Absence of latrine in a house, low knowledge of mixing oral rehydration salts, garbage thrown anywhere around the house, not washing hands after using latrine and not washing hands before preparing food were risk factors for diarrhea in one study.10 Unboiled, unchlorinated drinking water is known to have been associated with epidemic transmission of cholera.11 A study carried out in pediatric unit in Karachi showed that out of 4346 children hospitalized with gastroenteritis during 1990 through 1995, 348 children, 8% were confirmed to have cholera.12 Typhoid fever is endemic in all the developing countries including Pakistan. 13 Drinking un-boiled river water and history of contact with other patients before the illness were

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and improper washing of hands after defecation were identified as the major risk factors of typhoid fever in an outbreak in a rural village in Central Myanmar in the year 2000.14 Hepatitis was common among children as well as adults in our study. In one study, majority of the children (52%), suffering from acute viral hepatitis were positive for markers of acute hepatitis A (HAV IgM).15 In conclusion, community was well aware of the un-hygienic practices and the hazards associated with them in their daily lives, but were un-able to apply the principles of hygiene effectively. Provision of safe drinking water supply to these communities can reduce the burden of disease associated due to lack of it. Reinforcement messages to the community with respect to modulating their daily lives on the principles of hygiene, which are easy to follow, need to be given.

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ACKNOWLEDGEMENTS Special thanks to Mrs.S.Robins (Incharge St.Thomas Community Health Network) and her team of Community Health workers who extended full support in making this study possible.

REFERENCES 1. Shah SK, Hansotia FM. Personal hygiene. Community Medicine and Public Health. Time publisher, 2003, 6th Edition pp 557-67. 2. Wendt C. Hand hygiene-comparison of international recommendations. J Hosp Infect. 2001;48 Suppl A:S23-8 3. Schlundt J. New directions in food borne disease prevention. Int J Food Microbiol. 2002;15;78(1-2):3-17. 4. Miettinen IT, Zacheus O, von Bonsdorff CH, Vartiainen T. Waterborne epidemics in Finland in 1998–1999. Wat Sci Tech 2001;43:67–71. 5. Exner M, Gornik V. Parasitic zoonoses transmitted by drinking water. Giardiasis and cryptosporidiosis. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2004;47(7):698-704 6. Cifuentes E, Suarez L, Espinosa M, Juarez-figueroa L, Martinez-palomo A. Risk of giardia intestinalis infection in children from an artificially recharged groundwater area in Mexico City. Am. J. Trop. Med. Hyg. 2003;69(3):234-235.

7. Ali SM. Diarrhea in urban slums: Karachi. Dialogue Diarrhea. 1987 Dec;(31):5

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8. Kuusi M, Klemets P, Miettinen I, Laaksonen I, Sarkkinen H, Hänninen ML, et al. An outbreak of gastroenteritis from a non-chlorinated community water supply. J Epidemiol Community Health 2004;58:273-277 9. Swaddiwudhipong W, Karintraratana S, Kavinum S. A common-source outbreak of shigellosis involving a piped public water supply in northern Thai communities. J Trop Med Hyg. 1995;98(3):145-50. 10. Mbonye AK. Risk factors for diarrhoea and upper respiratory tract infections among children in a rural area of Uganda. J Health Popul Nutr. 2004 Mar;22(1):52-8. 11. Cardenas V, Saad C, Varona M, Linero M. Waterborne cholera in Riohacha, Colombia, 1992. Bull Pan Am Health Organ. 1993;27(4):313-30 . 12. Nizami S, Farooqui B. Cholera in children in Karachi from 1990 through 1995: a study of cases admitted to a tertiary care hospital. J Pak Med Assoc 1998;48(6):171-3. 13. lmran S, Ahmed I. Problem of Multi-Drug Resistant Typhoid Fever in Rawalpindi / Islamabad Area. Pak Armed Forces Med J. 1996;46(2):48-54. 14. Aye TT, Siriarayapon P. Typhoid fever outbreak in Madaya Township, Mandalay Division, Myanmar, September 2000. J Med Assoc Thai. 2004 ;87(4):395-9. 15. Jaffery G, Hussain W, Anwer MS, Tayyab M, Maqbool S, Chaudhry NA. Serodiagnosis of acute viral hepatitis (AVH) in children. Pak Ped J 1996;20(1):17-20.

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