The association between water, sanitation and hygiene (WASH) conditions and drowning in Bangladesh

The present study investigated associations between water, sanitation and hygiene (WASH) factors and fatal and non-fatal drowning events in Bangladesh. Here, we report ﬁ ndings from a large household survey (89,700) conducted in Barisal Division of Bangladesh. Univariate analyses showed that the use of surface water rather than piped water was associated with an increased risk of both fatal and non-fatal drowning events. Additionally, increased risk of non-fatal drowning events was associated with shared toilet facilities, lack of toilet facilities and non-cemented ﬂ ooring such as bamboo and wood. The WASH measures reduce the need to access exposure to open water, thus reducing drowning events. content="Abstract. The present study investigated associations


INTRODUCTION
Previous works have largely overlooked possible associations between water, sanitation and hygiene (WASH) conditions with the incidence of fatal and non-fatal drowning. While the World Health Organization estimated that 74% of drowning events in low-and middle-income countries was attributable to environmental or occupational factors, which comprises a variety of causes including the lack of lifeguards and boating regulations (Meddings et al. ). Limited analysis has been conducted to date to understand how specific WASH facilities, such as drainage coverings and access to piped water, may influence the risk of drowning. This paper aimed to explore how WASH-related variables in Barisal Division, Bangladesh were associated with drowning. Bangladesh experiences a particularly high rate of drowning, causing 43% of deaths for children aged 1-4 (Meddings et al. ). Variable and poor WASH infrastructure may present a particular risk in this region (Hyder et al.    Questions for data collection were adapted from the validated Bangladesh Demographic Health Survey (BDHS), which is used to determine health outcomes and other socio-economic indices across Bangladesh. Questions relating to WASH were extracted for the study. The tools were adapted to be used for electronic data capture.

RESULTS
Drowning presents a large burden to mortality and morbidity in Bangladesh. Our survey findings reported three times higher mortality rate in Barisal (37.9/100,000 population) as compared to national drowning mortality rates (11.7/ 100,000 population) (Rahman et al. ).

WASH variables
Households who accessed surface water for their daily needs were found to be exposed to a greater risk of fatal drowning compared to those accessing piped water.
Additionally, those who share water sources with other households are more at risk of a fatal drowning event than those who had access to private water sources. Please see Table 1 for statistical results of analysis.

Socio-economic variables
Demographically, households which did not have ownership of a transportation asset, such as a bicycle, vehicle or motorcycle, were at higher risk of fatal drowning than those who had ownership of these assets. Please see Table 1 for statistical results of analysis.

WASH variables
As with fatal drowning, there was a greater probability of non-fatal drowning incidents in households that accessed surface water compared to piped water. This finding was corroborated by the multivariate analysis ( Figure 2). Similarly, households which do not share their toilet facilities with other households have a reduced risk of non-fatal drowning compared to those who share toilet facilities.
Specifically, compared to no toilet facilities, flush toilets and pit latrines were associated with a lower level of risk.
Please see Table 2 for statistical results of analysis.

Socio-economic variables
Demographically, households which did not have ownership of a transportation asset were at higher risk of nonfatal drowning than those who had ownership of these assets. This finding was corroborated by the multivariate analysis. Additionally, compared to those who use wood as a cooking fuel, there was a greater risk of non-fatal drowning for those who used agricultural crop, dung or other, while those who used LPG were at lower risk of non-fatal drowning. Participants who received microfinance or banks loans were also registered with low scores for risk of non-fatal drowning events. Further, household flooring and building materials also lowered the risk of non-fatal drownings. Please see Table 2 for statistical results of analysis.

DISCUSSION
This report aimed to investigate how WASH conditions may be associated with fatal and non-fatal drowning events in Bangladesh. This was the first analysis to investigate the relationship between WASH variables and drowning events in a lower-income country (LIC). A total of 89,700 households was included in the univariate analysis. The findings support the hypothesis that improving access to WASH may reduce drowning hazards and other exposure risks involved. Both fatal and non-fatal drowning events were associated with accessing surface water for household needs, such as unprotected wells, open ponds and rain water. These bodies of water have been identified