1. Factors affecting cleanliness of shared urban slum toilets in Dhaka, Bangladesh
Mahbub-Ul Alam
Research Investigator;
Water, Sanitation and Hygiene Research Group, icddr,b
Water and Health Conference, Chapel Hill, North Carolina
October 26, 2015

2. Background
Shared toilets in urban slums are often unclean and poorly maintained
Unclean, poorly maintained toilets may be underutilized or abandoned encouraging open defecation
Poor hygiene and maintenance can lead to negative health outcomes 2

3. Rationale
Shared toilets' cleanliness is a key health issue which needs to be measured accurately
Previous studies have measured cleanliness based on users’ perceptions
Objective indicators of cleanliness of shared toilets are lacking
Determinants of shared toilet cleanliness was not well identified 3

4. Objectives
To describe multiple objective indicators of cleanliness of shared toilets
To identify the factors associated with toilet cleanliness 4

5. Study design
A behavior change intervention to improve toilet cleanliness and maintenance
1,226 shared toilet users in 23 urban slums of Dhaka
Slums were divided into 38 clusters
by road, market, canal, drain
Conducted pre-intervention baseline survey
Analyzed baseline data 5

6. Toilet and respondent selection
Selected first toilet after entering the slum:
Skip next
Select subsequent
<40 toilets per cluster
One adult user per toilet:
From second nearest household 6

7. Methods: spot check of toilet
Observed toilet:
- Structure
- Provision of water
Presence of:
- Visible feces
- Urine/other liquid
- Solid waste
Within
Squatting area
Pan 7

8. Methods: interview of toilet user
Interviewed one adult user per shared toilet:
Demographic information
Toilet management 8

9. Data analysis Definition of clean toilet (Günther et al. 2012):
absence of
Feces
Liquids
Dirt
within
Squatting area
Pan
To identify factors associated with toilet cleanliness:
Prevalence ratio
Generalized estimating equations to account for clustering 9

10. Toilet characteristics (n=1,226)
Toilet built by:
Landlord: 65%
NGO: 18%
Average user households: 6
Average users: 24
Landlord built toilets were more commonly connected to a canal or ditch than NGO built toilets
(63% vs. 26%, PR: 2.7)

11. Toilet excreta released (n=1,226)
Type of toilet
Water seal present: 27% %
NGO built toilets were more commonly pit, septic tank or piped sewer system toilets with a functional water seal than landlord built toilets (39% vs. 3%, PR: 8.3, 95% CI: ). 11

12. Facilities for toilet (n=1,226)
No water storage facility: 45%
Water available: 12%
Average distance to water source: 18 feet
Waste bin inside toilet: 0.5%
Brush and washing agent available: 5% 12

13. Toilet maintenance Toilet cleaning responsibilities (n=1,226):
Rotated among the user households: 78%
Landlord paid a caretaker: 10%
Emptying septic tank or pit was landlord’s responsibility: 83% (n=290)
Hired manual labor to emptying: 75% (n=81)
Among 81 toilets, 98% of fecal sludge was disposed into the slum environment 13

14. Solid waste disposal inside toilet (n=1,226)
Reported waste disposal practice in the toilet:
Menstrual cloths/rags: 16%
Paper: 12%
Plastic bags: 9% 14

15. Toilet cleanliness (n=1,226)
Feces visible:
Inside pan hole: 47%
Inside the pan: 28% 15

16. Toilet cleanliness (n=1,226)
Feces visible:
Outside pan: 8%
On the footrest of the pan: 2%
On the path leading up to the toilet: 14%
Toilets classified as clean*: 34%
*Absence of feces, liquids or dirt within the squatting area and pan of the toilet 16

17. Determinants of toilet cleanliness (n=459)
Water present inside/beside clean toilet %
Toilets were more commonly clean when water was available inside or beside the toilet (PR: 1.9, 95% CI: ) 17

18. Determinants of toilet cleanliness (n=459)
Water storage container available inside/beside clean toilet %
Toilets were more commonly clean when there was a water storage beside the toilet (PR: 1.1, 95% CI: ) 18

19. Conclusion Majority of shared toilets in urban slums were not clean
Presence of water and water storage container were associated with toilet cleanliness
It is possible to measure toilet cleanliness using objective indicators 19

20. Recommendations
Use combined scale/matrix using multiple objective indicators to measure toilet cleanliness
Efforts to provide adjacent sources of water will likely have an impact on cleanliness
Efforts to reduce excreta release in the environment should be emphasized 20

21. Study team
Icddr,b: Leanne Unicomb Farzana Begum Fosiul Nizame Mahbubur Rahman Farzana Yeasmin Mahbub-Ul Alam Abdullah-Al Masud Probir Ghosh
Stanford University:
Stephen Luby
WSUP:
Guy Norman
Anita Layden
Sam Drabble
Abdus Shaheen
Habibur Rahman
Nasrin Akter
Johns Hopkins University:
Peter Winch
Ronald Saxton
Acknowledgement:
Study participants; Diana DiazGranados; Astrid Dier; Mahbubur Rahman
For more information: 21

22. icddr,b thanks the study Donors22