Water, sanitation, and hygiene (WASH) practices of mothers and the health status of under-five children: a study from Rural Nayagarh, Odisha

According to the Sustainable Development Goals (SDG) 6.1 and 6.2, access to water, sanitation, and hygiene (WASH) continues to pose challenges to the global public health sector (Global Sustainable Development Report 2023). Recent reports indicate that the availability of WASH infrastructure has increased significantly over the past three decades, yet an estimated 2 billion people do not have access to safe drinking water, and globally 3.6 billion people do not have access to safe sanitation, while another 2.3 billion are deprived of access to basic hygienic facilities (WHO 2022). Furthermore, the frequency of illnesses among young children is strongly linked to poor WASH services – one of the top-ranked for under-five mortality (UNICEF 2023a, 2023b). Poor access to WASH causes approximately 1,245,000 fatalities annually in low- and middle-income countries, accounting for 89% of all deaths related to WASH (WHO 2023). Estimates say nearly 525,000 children under five die every year due to diarrhoea that is connected with poor WASH (WHO 2017; Shine et al. 2020). In 2020, WHO estimated that 5 million under-five children's deaths were preventable and treatable through safe WASH practices. About half of those deaths (2.4 million) occurred in the first 28 days of life (WHO 2022; UNICEF 2023a, 2023b). Therefore, the provision of adequate WASH services is of paramount importance to improve under-five mortalities (Gaffan et al. 2023; Waddington et al. 2023).

In India, the high neonatal mortality rate (24 per 1,000 live births) is associated with insufficient WASH services (UNICEF 2018). An estimated 300,000 children die every year due to diarrhoea, which is the third most prevalent cause of under-five deaths and accounts for 13% of all deaths in this age range (Million Death Study Collaborators 2010; Lakshminarayanan & Jayalakshmy 2015).

With almost 42 million residents, Odisha is the eleventh most populous state in India that has one of the highest neonatal mortalities in the country. With 32 per 1,000 live births, Odisha has the highest newborn mortality rate in the nation (National Family Health Survey-5 (NFHS-5) 2019–2021). The majority of the population resides in rural and semi-rural areas (83%), while about 17% live in metropolitan regions (IIPS & ICF 2021). In terms of the WASH infrastructure and practices, around 89.7% of rural households in Odisha have improved supplies of drinking water as against 98.2% in urban pockets, around 50.7% households in rural areas did not have latrines (NSO India 2018). Furthermore, data from the NFHS-5 (2019–2021) reveal that 37% of families in rural areas still defecate in the open. The importance of good hygiene habits of mothers and access to sanitation in preventing mortality and morbidity among under-five children need no special mention (Goodwin et al. 2005; Azupogo et al. 2019).

Several studies on this subject have focused on the provision of the WASH infrastructure and behaviour of households in terms of personal hygiene and cleanliness in various regions of India. However, evidence about the prevalence of WASH practices among mothers of young children in rural Odisha and how such behaviours are linked to health outcomes of their children is limited. Thus, this study aims to (1) assess WASH practices of mothers with under-five children in rural pockets of the Nayagarh district of Odisha and (2) examine how those practices are associated with the health status of under-five children.

We adopted a cross-sectional study design and conducted a community-based household survey during February–April 2023 in rural areas of the Nayagarh district of Odisha. The specific time period was taken based on the researchers' familiarity to the study area and the availability of the respondents for the data collection.

The Nayagarh district was carved out from the erstwhile Puri district on 1 April 1993. The district is well connected to the state capital Bhubaneswar by road and railway. The total area of the Nayagarh district is 3,890 km² and it is the 18th largest district of Odisha. The district has about 1.2 million population, which accounts for 2.29% of the state population (Census 2011a, 2011b). Out of this population, 502,636 are males, 460,153 are females, and 113,180 are under-five children (Health Nayagarh 2024). The density of the population is 248 people per km² as against 270 km² of the state. The total literacy rate of the district is 80.4%, out of which the male literacy rate is 88.2% and the female literacy rate is 72.0%. The district comprises eight Revenue Tahasils, eight Development Blocks, and 1,702 revenue villages (Census 2011a, 2011b). The district water supply coverage was 82%. In this district, there are 166 sub-centres, 37 primary health centres, 12 community health centres, 1 district hospital, and 1 private health centre (Health Nayagarh 2024). The district is industrially backward. Agriculture is the main backbone of the district.

The population was all mothers residing in the rural villages of the Nayagarh district. The study population was mothers who had at least one under-five child in the selected villages. In this study, mothers who belonged to the study unit were randomly selected from the total number of mothers found in the selected villages.

Mothers in the sample villages had one under-five child on the date of the survey.

Mothers who were mentally disordered, severely ill during the survey, or refused to participate, were excluded from the study. ‘Mentally disordered mothers’ referred to mothers diagnosed with mental health disorders that hinder their ability to take care their children, as assessed by medical doctors. ‘Seriously ill mothers’ comprised mothers diagnosed with the major medical illnesses impeding their capacity to take care of their children.

The formula N = Z²* P (1 − P)/d² was used to determine the sample size (Charan & Biswas 2013), where Z represents the statistics corresponding to the level of confidence which is 1.96 for 95% CI; P represents the prevalence of improved sanitation facility in the Nayagarh district (NFHS-5 2019–21), which was 67.1%, and d denotes the error % which is 0.05. The final sample size was 370 inclusive of a 10% non-response rate.

A pre-tested structured questionnaire and an observation checklist were adapted from similar previous studies for data collection (Gaude & Desai 2019; Giri et al. 2022). The questionnaire was first prepared and further translated into the local language of Odia and then back into English by experts to maintain consistency. The data collection tool consisted of four sections: (a) socio-demographic profile of the respondents (10 items); (b) WASH practices of mothers (11 items); (c) handwashing practices of the mothers (6 items); and (d) the health condition of under-five children (5 items). Two trained data collectors were engaged who did face-to-face interviews of study participants, and the process of data collection was supervised by the principal investigator of the study. Furthermore, an observation checklist was used to gather data regarding the availability of water supply, type of toilet and bathroom used, and handwashing methods.

The data collector was given adequate training before actual data collection started, and objectives of the study, tools for data collection, and procedures were maintained while going through the questionnaire. The questionnaire was thoroughly checked, re-checked, and pre-tested among 20 mothers (5% of the total sample) in non-research areas before the actual data collection began. All the completed questionnaires were collected daily and verified manually by the principal investigator to ensure the consistency and completeness of the information gathered. Before data analysis, verified data were entered by the principal investigator, which were then cross-checked by the co-authors. In the case of any discrepancy/incorrect data entry, the data were verified again before the statistical analysis was performed. A backup repository was developed to keep the data in a safe place or to prevent the data loss, if any. Before analysing the data, the appropriate data cleaning and coding was performed.

Data were entered in the Statistical Package for the Social Sciences (SPSS) version 26 for further processing and analysis. Descriptive statistics was used to present the frequency, proportion, and percentage distribution of socio-demographic characteristics of the mothers and their under-five children, WASH practices of mothers and the health condition of their children. In this study, the socio-economic status of the households was determined based on the poverty line index (i.e. ‘below poverty line (BPL)’ and ‘above poverty line (APL)’) as defined the Health & Family Welfare Department, Government of Odisha (Odisha State Treatment Fund Guidelines 2020). It defines those families who had an annual income of less than Indian rupees 40,000 as being considered ‘BPL’. BPL cards were given to them to access various government aid facilities in order to improve their socio-economic status. During the data collection process, the data collector asked the study participants ‘whether your household belong to the BPL category or not’. If the response was ‘yes’, then the mother or head of the family was asked to show the BPL card. If they showed the BPL card and after verification by the data collector that household belonged to the BPL category. Other households whose annual family income is more than 40,000 Indian rupees belonged to the APL category (Odisha State Treatment Fund Guidelines 2020).

A binary logistic regression analysis was used to examine the association between mother's handwashing practices and the health status of under-five children. This assumption of logistic regression (such as multi-collinearity and model adequacy) was verified using appropriate methods. The variance inflation factor was used to check the absence of multi-collinearity. The model adequacy was checked by the Hosmer and Lemeshow's goodness-of-fit test. In the binary logistic regression, we considered the handwashing behaviour of mothers as the independent variable (IV) and health problem of under-five children as the dependent variable (DV). Odds ratio (OR) with 95% of confidence interval (CI) was used to identify the strength of significance between IV and DV. P-values of 0.05 or less were statistically significant.

Ethical clearance was obtained from the Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, India (Ref. No: KIIT/KIMS/IEC/1121/2023). Informed consent of the study participants was taken beforehand. The study participant was free to withdraw at any point during the interview and refused to answer any specific question or a set of questions. Confidentiality of the responses was maintained throughout the study period. The anonymity of responses was ensured through coding of respondents. The highest level of ethical standards was maintained throughout the study period.

The majority of respondents in this study, i.e. 44.9%, were in the 24–29-year age group. Only 9.2% of the mothers were graduates and most households (74.9%) were classified as BPL. Details of the socio-demographic profile of respondents are presented in Table 1.

Only 7.8% of households used piped water inside their houses. About 85.4% of respondents had a toilet or latrine in their home, while 14.6% still preferred to defecate outside. About 15.6% of homes did not have any access to a bathroom, and 13.2% of respondents had an open pucca drainage system, compared to 66.5% who had a covered pucca drainage system. Only 6.2% of dwellings had underground drainage systems, while 14.1% had no drainage system at all. About 33% of respondents admitted to throwing the faecal wastes of their children to household garbage site; only 27% of respondents disposed of their children's faeces in toilets and 9.7% of households left the faeces of their under-five children in the open, while 29.7% rinsed them down the drain. The majority of participants (53.7%) washed their hands through water only, while 37.3% of respondents used only soap for handwashing (Table 2).

The study indicated that each study participant washed their hands after using the toilet; 85.4% of mothers always washed their hands before they fed their children, compared to 14.6% of mothers who usually washed their hands before feeding. Prior to eating a meal, 34.3% of mothers washed their hands frequently and 1.1% occasionally. The majority of mothers (50.5%) always washed their hands after returning from the outside, whereas only 4.3% never washed their hands after returning from outside. More than half (52.7%) of mothers always made their children wash hands before and after eating, whereas only 4.1% of mothers never reminded their children. With respect to the health condition of the children, from all the mothers (n = 370) who had under five children in the study area, it was found that 28.9% of experienced diarrhoea during the last 1 year, 5.1% experienced symptoms of pneumonia, 3% were affected with meningitis, 11% of children were admitted with malnutrition, and 42.2% had a history of other childhood illnesses, such as common cold, cough, and fever in the last 1 year (Table 3).

We used a binary logistic regression model to examine the association between mother's handwashing practices and the health status of under-five children. The model revealed that there existed an association between handwashing practices and episodes of diarrhoea. Those mothers who encouraged their children to disinfect their hands ‘always’ had 55% fewer episodes of diarrhoea compared to those who never did it (OR = 0.448). This association was statistically significant with a p-value of 0.007 (Table 4). Also, the mothers who washed their hand ‘always’ after visiting outside, their children had 52% fewer episodes of diarrhoea than who never did it (OR = 0.484) and this association was also found significant (p = 0.027).

Further analysis of the handwashing habits of mothers and episodes of illnesses among their under-five children revealed that those mothers who ‘always’ resorted to handwashing before feeding their babies had 48% less episodes of other illnesses among their babies as against those mothers who ‘usually’ handwashed before initiating feeding (OR = 0.520). This association was also statistically significant with a p-value of 0.045 (Table 5).

The purpose of this current study was to examine the water, sanitation, and hygiene practices of mothers having under-five children in a rural pocket in Odisha. The study outlined only about 9.2% of the mothers were graduates, while 16.8% of the participants had completed primary school; furthermore, most households (74.9%) were classified as low-income category. A similar study conducted by Desmennu et al. found that for young children (0–24 months), maternal education is a significant factor associated with episodes of diarrhoea. Children with mothers who had no formal education had a higher risk of diarrhoea (Desmennu et al. 2017). This partly explains the associations found in this particular study. Even though 92.2% of families had access to government drinking water supplies, only 7.8% of households had access to piped water supply into their houses. Also, fewer than half of the respondents (40%) did not treat the water any further before using for drinking purposes. The Government of India and the state government of Odisha have launched mega-schemes to provide safe and portable water at the doorsteps of rural households (Hindustan Times 2023). However, periodic quality testing of water samples, piped water supply to every rural household, instantaneous correction of leakages, and regular feedback from the end-users would be crucial to maintain high standards of success of such schemes.

Around 14.6% households still followed open defecation. Only 33% of mothers threw their children's faeces in the garbage, which can infect with harmful pathogens and can increase the potential for negative health effects (Behera et al. 2022). Past studies have time and again emphasized the role of personal hygiene and sanitation in preventing water-borne diseases among under-five children. For instance, a similar study conducted in 2020 highlighted that open defaecation is one of the major contributing factors of having protozoal infection in under-five children in India (Banerjee et al. 2020). Thus, the opportunities for the government departments under Swachh Bharat (Clean India) mission to introduce and sustain behavioural changes at the grass root level need to be capitalized upon (Behera et al. 2022).

In this study, handwashing practice with soap among mothers having under-five children was 37.3%, which was lower than studies shown in Northwest Ethiopia (Adimasu & Baye Dagnew 2020). Similar studies from Eastern India revealed that handwashing practice with soap was nearly 36.3% (Behera et al. 2022). These results were corroborated with many studies that mentioned handwashing practice with soap was still challenging for universal practice. It is estimated that global handwashing prevalence with soap was nearly 1 among 5 (i.e. 19% of the world population wash their hands with soap) and this result arrived from a systematic review of 42 studies conducted worldwide (Freeman et al. 2014). On the other hand, a number of studies have shown that handwashing with soap can reduce the risk of diarrhoea by 42–47% that could have saved millions of preventable deaths every year. In addition, washing of soap and water may also help in the reduction of stunting and respiratory tract infections among children (Kwami et al. 2019; Waller et al. 2020).

64.6% of mother always washed their hands before eating meals, 52.7% mothers reminded their children to always clean their hands before eating, and 85.4% of mothers always used to wash their hands before feeding their children, respectively. Other studies also indicate mothers’ handwashing practices before eating meals was 86.3% (Taddese et al. 2020), and before feeding a child was 24.5% (Shukla & Agarwal 2016). These findings are indicative of the need to strengthen behavioural change communication through the frontline health workers of health and family welfare departments (e.g. ASHA workers, Auxiliary Nurse Midwife (ANMs)) and women and child development departments (e.g. Anganwadi workers). Similar studies have indicated that the general trend to practice handwashing before eating is common even in countries with low per capita income, but the use of soap is not that common, even though handwashing has been recognized as one of the simplest and yet most effective methods of disease prevention (Poague et al. 2022). This finding in the aftermath of COVID-19 is alarming and needs further qualitative enquiry to develop strategies for the reinforcement of desirable behaviours at the community level to make those a part of habit formation. The role of village heads, panchayat raj representatives, and school teachers may be delineated to sustain such campaigns in the long run.

With regard to the health status of under-five children and episodes of illness during the last 1 year, we found that about 28.9% respondents reported at least one episode of diarrhoea of their children; this finding is in sync with the study by Giri et al. that was conducted in a comparable setting of the Mayurbhanj district, Odisha (Giri et al. 2022). Unsafe drinking water, inadequate sanitation, and poor hygiene practices increase the risk of childhood diarrhoea (Nwokoro et al. 2020; Mebrahtom et al. 2022; Asgedom et al. 2023). Furthermore, a systematic review carried out by Bauza et al. pointed out the importance of sanitation measures to prevent diarrhoea in people of all ages, including small children (Bauza et al. 2023). Another study also highlighted the need to improve access to water and sanitation, which can have a synergistic impact on childcare practices and, in turn, reduce the prevalence of diarrhoea (Ramanathan & Vijayan 2019). Moreover, studies from across Africa have examined the factors associated with childhood illnesses and found that handwashing practices of mothers is an important determinant (Lange et al. 2019; Gaffan et al. 2023). A West Ethiopian study undertook illness profiling of children and found episodes of diarrhoea (28%), acute respiratory infection (25%), malnutrition (23%), and meningitis (10%) as some of the common types of illnesses (Taddese et al. 2020). Our study inferred that mothers' handwashing habits are strongly associated with episodes of diarrhoea in under-five children. This finding is in line with another study conducted in India that shows that the lack of proper handwashing practices by mothers had brought their children higher odds of suffering from diarrhoea (Chatterjee et al. 2023). The study results also revealed statistically significant association between handwashing practices with other illness of under-five children such as cough and fever. These findings were similar to those studies conducted in Addis Abba (Ezeh et al. 2014) and Nigeria (Adane et al. 2017) and showed that the evidence of infant mortality risks from fever and cough was from the lack of handwashing practices of mothers. This call for the introduction of behavioural change among mothers and promotion of handwashing practices with soap that can reduce the risk of diarrhoea and other childhood illness. The challenge is encouraging mothers to maintain handwashing practice in the longer period. Therefore, more studies may be conducted with longer follow-up duration using robust structured questionnaires that ensure primary outcomes should be met, as it is generally observed that the choice of methods can have a significant impact on the precision of estimates. In this study, self-reported outcome measures such as diarrhoeal frequency are prone to recall and reporting biases, which may have contributed to poor methodological quality ratings. Recently, a number of large-scale new studies on unprecedented cost and scale are underway where their results might shed light on the short- and long-term impact of WASH interventions (Humphrey et al. 2015; Luby et al. 2018; Null et al. 2018; Humphrey et al. 2019).

The importance of WASH practices among mothers and the health status of under-five children in reducing diarrhoea and other childhood illness are fairly established. But the challenge remains to increase these practices worldwide. Poor community preparedness, high burden of under-five morbidities and mortalities, and vulnerable nature of rural inhabitants pose systemic challenges to the government in bringing sustainable changes in the health profile and nutritional status of under-five children. Wasting and stunting have also caused serious concerns for the policymakers in the country in general, Odisha is no different. On the other hand, governments have responsible and innovative strategies to make WASH a mass campaign at the village level. For the prevention of outbreak of diarrhoea and respiratory illnesses, strengthening of both demand and supply side factors would play a crucial role. Provision of the WASH infrastructure, context-specific behaviour change communication strategies, and introduction of regulatory policies may help in the long run to nullify open defecation practices. WASH may be introduced as a part of the school curriculum and ASHA training modules to sensitize both service providers and beneficiaries. The role of appropriate Information Education & Communication (IEC) strategies can hardly be overemphasized to encourage appropriate WASH behaviour at the community level. This is especially important for countries like India which delivers healthcare and WASH services to most of the rural population with the help of limited resource envelope. In-depth qualitative studies may provide insights into workable and sustainable WASH strategies for the rural population.

SDG 6 covers the whole water cycle and mentions targets for universal access to WASH that are considerably more ambitious than the previous targets of the MDGs (Millennium Development Goals). To meets these goals, behavioural change and social norms are important, good governance and accountability must be ensured, and inequalities must be addressed.

Several policy implications can be drawn from the results of the study to address the health of the under-five children in rural settings. Investment in the WASH infrastructure should be prioritized especially in areas with poor access. An integrated horizontal approach that combines WASH intervention with health, nutrition, and education can harvest synergistic effects. Multi-sectoral collaboration with relevant actors and sectors, including government bodies, private firms, community-based organizations, and NGOs, is crucial for the implementation of the comprehensive programmes. Policies aimed to improve access to education, particularly for mothers and their children, can yield positive impact on child health. This may include various initiatives such as improvement in adult education programmes and awareness-generation campaigns. Households belonging to poorest quantile or the BPL should be improved through a poverty alleviation programme that can help in reducing health outcome disparities by improving access to healthcare, food, and education for marginalized families. Outreach programmes and community-based health initiatives can play a vital role in improving under-five children's health.

The study was carried out in only two rural blocks of the Nayagarh district and included mothers of under-five children in those two blocks; therefore, the results of this study may be used with caution for generalization. Second, social desirability bias may have affected the results of the study with regard to the WASH behaviour of mothers. Finally, due to the cross-sectional nature of the study design, it would be difficult to establish the cause-effect relationship among variables of interest.

M.J. and M.R.B. conceptualized the study. M.J., M.R.B., and D.B. contributed to data collection, data cleaning, and preliminary analysis. M.J., M.R.B., S.M., and B.P. contributed to manuscript writing and finalization..

Data cannot be made publicly available; readers should contact the corresponding author for details.

The authors declare there is no conflict.