Meeting: 6th International Perspective on Water Resources and the Environment, Izmir, Turkey, January 7-9, 2013This paper assesses diarrhea occurrence in two urban slums to identify salient factors influencing case prevalence. Rapid urbanization in settings of poor economic performance and governance has increased the number of people living in urban slums to about 1 billion people worldwide. In this study, water quality analysis showed contamination at the household level due primarily to the location of water storage tanks. Significant difference in diarrhea cases in both study areas correlated with the educational level of household head, financial status, type of water storage tank and cleaning frequency, along with adoption of measures to treat water, or use bottled water

El-Fadel, M.

Maroun, R.

International Development Research Centre: IDRC Digital Library

1 6th International Perspective on Water Resources and the Environment Izmir, Turkey, January 7-9, 2013    Environmental Health Risks in Disadvantaged Urban Slums  R. Maroun1 and M. El-Fadel2  1 American University of Beirut, Faculty of Engineering and Architecture, Bliss street, PO Box 11-0236 Beirut, Lebanon Fax: +961-1-744 462; email: ram11@aub.edu.lb 2 Corresponding author: American University of Beirut, Faculty of Engineering and Architecture, Bliss street, PO Box 11-0236 Beirut, Lebanon Fax: +961-1-744 462; email: mfadel@aub.edu.lb   ABSTRACT  This paper presents a comparative assessment of diarrhea occurrence in two urban slums to identify salient factors influencing case prevalence. Primary data were collected using a structured closed-ended questionnaire coupled with water quality sampling and analysis at households reporting diarrhea cases. The water quality analysis showed contamination at the household level due primarily to the location of water storage tanks. Descriptive statistics and Chi-Square distribution tests revealed significant difference in diarrhea cases in both study areas which was correlated with the educational level of household head, financial status, type of water storage tank and corresponding cleaning frequency as well as the adoption of measures to treat water or the use of bottled water.  Keywords: Urban Slum; Water supply quality; Sanitation; Diarrhea prevalence.   INTRODUCTION  Rapid industrialization and urbanization in a setting of poor economic performance and governance has led to an increase in the number of people living in urban slums, reaching around 1 billion people worldwide (UN-HABITAT, 2003). Slums are characterized by inadequate access to safe water, sanitation, poor quality housing, and other infrastructure as well as overcrowding and insecure residential status (Keraka and Wamicha, 2003; UN-HABITAT, 2003). In these types of settings and living conditions, slum dwellers become more susceptible to various health problems, including diarrhea (Sclar et al., 2005), which represents a key public health challenge to the unsanitary nature of these settlements (Pahwa et al., 2010). In this study, a systematic community-based comparative assessment approach was adopted to define determinants of diarrhea prevalence in urban slums. For this purpose, the incculthavred ST Theis cBesabshouslumsimBotothsevslum  RE Primsoustanadm(29survdrincasdrinsampHmicidence of wural and deme been impuce the incidUDY AREA study areaonsidered aides being ence of prosing, and p area. An-ilar social fh slums areer urban areeral urban cs. SEARCH Mary data rrces and udardized, inistered u3 householdeys, a wateking water es of diarrhking waterples). The , color, turrobiologicaater-related ographic croved in onence of diarS s are locateds one of tdisadvantagper hygienicoor waste mNasr area iabric, cultur overcrowdea within thehallenges coFETHODOelated to sosage, wasteclose-endedsing stratifis) and then r sampling in ~60 percea within th supply nesamples webidity, total parametersdiarrhea waharacteristice area withrhea in the  in Lebanonhe poorest ed at vario sanitation,anagemenn the city oal backgroud with popir respectivemmonly asigure 1. LoLOGY cio-demograwater collec, structureded random at Tebbanehprogram waent of house last threetwork (76 re analyzedl dissolved (fecal colif2 s examineds and where the aim to other slum. and Jordanurban areasus socio-eco inadequatet practices, f Irbid, Jornd, and econulation dens countries. Isociated witcation of stuphics, econtion, amon and codsampling pr, Lebanons initiated ineholds that months. Twater samp for selecte solids, reorm and tota in two slu water and assist in de (Figure 1) in the citynomic leve access to csatisfying tdan, is equomic charaities reachinn addition, h poverty ady areas omic and hg others, wed field qocedures fi(325 sample Tebbaneh  reported, dhe samplingles) and std physico-csidual chlol coliform).ms with neasanitation mfining inter. The Tebba of Tripolils, it sufferlean water he characteally an urbcteristics asg 10 times both regionnd congestiealth indicaere collectuestionnairrst at An-Ns). Followinto assess thuring the fi program tored waterhemical (terine and n  rly similar anagementventions toneh region , Lebanon. s from the and quality ristics of a an slum of  Tebbaneh. that of any s are facing on in urban tors, water ed using a e. It was asr, Jordan g the field e quality of eld survey, argeted the  tanks (63 mperature, itrate) and 3  The collected data were analyzed descriptively and inferentially using the Statistical Package for Social Sciences (SPSS 16.0). The Analysis of Variance (ANOVA) and Pearson’s Chi-Square tests were conducted to assess the significance of the various variables that differed between both study areas, and to evaluate their possible correlation with the occurrence of diarrhea episodes in Tebbaneh. The Kendall tau-b statistic was employed to measure the sign and the strength of the association between the variables, whenever it was found to be statistically significant.   RESULTS AND DISCUSSION  The survey results revealed a statistically significant difference at α = 0.05 regarding the incidence of diarrhea in the two urban slums whereby, during the last three months prior to administering the questionnaire, 14.8 percent of households in An-Nasr reported the occurrence of one or more cases of diarrhea, as compared to 38.5 percent of households in Tebbaneh (p < 0.001). Since the wastewater infrastructure has been recently rehabilitated in Tebbaneh similar to An-Nasr area, as outlined below, this difference in diarrheal incidence can be attributed more to water sources, water supply systems, or hygienic practices at the household level rather than direct wastewater management at the community level. Water quality monitoring in the Tebbaneh revealed that network water is of relatively acceptable quality with few contamination incidences at deteriorated sections, whereby Fecal Coliform was detected at low ranges (0-3 CFU/100 ml) in 4 percent of the surveyed households (N = 3). The main quality problems are from the piping within the buildings and the use of attic tanks, whereby total coliforms were detected in water from 26 surveyed households (41 percent) of which 10 had their storage tanks in the attic.  Figure 2 illustrates the main differences in the layout of the water supply systems within buildings in Tebbaneh and An-Nasr. In the Tebbaneh study area, the water supply is almost continuous, but at low pressure. People store water in tanks (96 percent of respondents) whereby each household has an individual water pump located at the building entrance to pump water from the network to household storage tanks. The stored water is not used for drinking purposes but usually used for common household chores. The survey revealed that household storage tanks were located either in the attic (45 percent of respondents) or on the building’s roof. Most storage tanks are not well covered and often not covered at all. At An-Nasr, the public water supply reaches consumers at an acceptable pressure and is either stored in a reservoir at ground level from where it is pumped to roof-top storage tanks, or it reaches the roof top storage tanks directly. No attic storage tanks are present (Figure 2) thus eliminating cross contamination from potential sanitary leakage. In addition, buildings in An-Nasr seldom exceed three stories. In both areas, more than 90 percent of respondents withdraw water from water storage tanks using the household pipe system and without additional treatment. However, at α = 0.05, a statistically significant difference was discerned in the percentage of respondents cleaning their water storage tanks and in the percentage implementing measures to improve drinking water quality (p < 0.001). Nearly 40 percent at Tebbaneh reported never cleabettimpstatwatTebAnin Tonl F Thebetwheaa ufemhigstatobsthewh Eacning water er at An-Nrove drinkistically siger between baneh hous-Nasr. All reebbaneh. Hy when a mea) Exigure 2. Ge main socioeen the Teds (p < 0.00niversity edales, more her as compistically sigerved in their ability toereby these h factor shotanks compasr, more hing water nificant diffTebbaneh eholds use tspondents inowever, in mber of theisting systemneral layout-demographbbaneh and1), wherebyucation cothan 75 percared to onnificant diff number of secure 10economic inwing a statared to 17 pouseholds quality thanerence at αand An-Nashe tank wat An-Nasr pboth areas, h household  in Tebban of water suic indicato An-Nasr s around 42 mpared to ent of hously 4 percenerences betw household 0 USD witdicators appistically sign4 ercent at An(34 percent) at Tebban = 0.05 wasr (p < 0.00er for drinkurchased boalf of thoseis sick. eh pply systemr showing alums was tpercent of Aonly 1.2 peewives at At of houseween Tebbanmembers whin one weeared betterificant diffe-Nasr. Also were impleh (18 pe found in t1) wherebying as compttled water c who purchb) Existis within bui statisticallyhe education-Nasr malrcent of thn-Nasr hadives in Tebeh and Anorking andek, and in  at An-Nasrrence betw, while wateementing mrcent). In he sources  only 3.85 ared to 66.2ompared toase bottled wng system inldings in stu significantnal level ofe householdose at Teb a secondarybaneh. Eco-Nasr (p < 0 generating household .  een Tebbanr quality is easures to addition, a of drinking percent of  percent at  51 percent ater do so  An-Nasr dy areas  difference  household  heads had baneh. For  degree or nomically, .001) were income, in ownership, eh and An-5 Nasr was correlated with the occurrence of diarrhea in Tebbaneh. Statistically significant associations were found for educational level of the female household head, household ownership, the ability to secure an amount of 100 USD within one week, type of water storage tanks (attic versus roof), frequency of water tank cleaning, and the use of bottled drinking water (Table 1). These associations were significant at α = 0.05 except for correlation of diarrhea cases with frequency of tank cleaning and type of water tank which were found to be significant at α = 0.1. The Kendall tau-b (τb) statistic revealed a negative association between the incidence of diarrhea and the educational level of the female household head (-0.141), household ownership (-0.112), the ability to secure 100 USD within one week (-0.123), and the type of water storage (--0.097). Accordingly, the likelihood of diarrhea incidence at the household increases with a lower level of education of the female household head. Similarly, the likelihood of diarrhea incidence decreases with increased household ownership and the ability to secure 100 USD within one week.  The presence of roof top tanks was also found to be less associated with diarrhea incidence whereas the frequency of tank cleaning was positively correlated with diarrhea incidence (+0.118), whereby the incidence of diarrhea increased with less frequent tank cleaning. On the other hand, a positive relationship was discerned between bottled water use for drinking purposes and diarrhea (+0.135) which can be attributed to 1) bottled water was found to be polluted at times, thus increasing the incidence of diarrhea, and 2) a higher tendency to use bottled water as an aversive behavior in households with diarrhea incidence.  The main variable of interest from the water sampling program was the presence/absence of fecal and total coliforms. At α = 0.05, a significant association was evident between the type of storage tank used (attic vs. roof top) and the presence of fecal coliforms (p = 0.032). The association between the type of storage tank and the presence of total coliforms in the water was significant at α = 0.1 (p = 0.066). The Kendall tau-b (τb) statistic revealed a relatively strong positive correlation between attic tanks and fecal coliform (+0.279), supporting the hypothesis that wastewater is likely to leak into water stored in attic tanks as illustrated in Figure 2.  CONCLUDING REMARKS  The overall analyses of the statistically significant correlations imply that the condition of the water system at the household level is an equally strong factor impacting the incidence of diarrhea. This situation is aggravated by poor hygienic practices influenced by a low educational level of housewives and the lack of enforced monitoring of bottled water quality emphasizing the need for interventions to improve water supply network, storage, and handling. Diarrhea morbidity can reportedly be reduced by ~21 percent through improved water supply (Bartram et al., 2005). Recent studies have also shown that point of use drinking water treatment have a higher impact on diarrheal outcome than source quality since deterioration of microbiological drinking water quality could also occur during storage (Herbst et al., 2008) which is more representative of the situation in the subject area. A better water 6 source alone may not accomplish full health benefits if it is not accompanied with improved water storage practices and hygienic habits at the household level (Checkley et al., 2004; Mafuya and Shukla, 2005). Table 1. Association between variables identified as statistically significant relative to  An-Nasr and occurrence of diarrhea cases at Tebbaneh Dependent variable Independent Variable Association Pearson’s Chi Square (X2) p-value Kendall Tau-b Reporting of diarrhea cases in the past three months Educational level of female household head Yes 11.47 0.009 - 0.141 Household ownership Yes 4.04 0.044 - 0.112 Ability to secure 100 USD within one week Yes 4.89 0.027 - 0.123 Type of water storage tank (roof versus attic) Yes 2.90 0.089 - 0.097 Frequency of water tank cleaning Yes 6.99 0.072 + 0.118 Use of bottled water for drinking purposes Yes 6.65 0.036 + 0.135 Educational level of male household head No 3.08 0.379 - Use of tank water for drinking purposes No 0.489 0.484 - Measures to improve drinking water quality No 2.294 0.807 - Reporting wastewater problems No 1.35 0.246 - Presence/ absence of Total Coliform Type of water storage tank (roof vs. attic) Yes 3.39 0.066 - 0.192 Wastewater problems No 2.62 0.105 - Presence / absence of Fecal Coliform Type of water storage tank (roof vs. attic) Yes 4.62 0.032 + 0.279 Reporting wastewater problems No 1.36 0.243 -  Thus, simple structural interventions (replacing attic tanks with roof tanks, rehabilitation of water and sanitary pipes at the household and building levels, maintenance of roof tanks, avoiding direct pumping from the network) coupled with enforcement of monitoring programs of network and bottled water as well as targeted awareness campaigns on proper hygienic practices constitute effective and low cost measures for reducing diarrhea incidence in Tebbaneh and similar slums.    7 ACKNOWLEDGEMENTS  This study is part of a program on water and sanitation in poor urban slum areas funded by the International Development Research Center (IDRC) of Canada at the American University of Beirut (AUB). Special thanks are extended to Mr. Mark Redwood and Dr. Marwan Owaygen at IDRC for their continuous support throughout the implementation of this program.  REFERENCES  Bartram, J., Lewis, K., Lenton, R., and Wright, A. (2005). Focusing on improved water and sanitation for health. Lancet, 365, 810-812. Checkley, W., Gilman, R.H., Black, R.E., Epstein, L.D., Cabrera, L., Sterling, C.R., and Moulton, L.H. (2004). Effect of water and sanitation on childhood health in a poor Peruvian peri-urban community. Lancet, 363, 112-118. Herbst, S. Fayzieva, D., and Kistemann, T. (2008). Risk factor analysis of diarrhoeal diseases in the Aral Sea area (Khorezm, Uzbekistan). Int. J. Env. Health. Res. 18(5), 305-321. Keraka, M.N. and Wamicha W.N. (2003). Child morbidity and mortality in slum environments along Nairobi River. E. Afr. Soc. Sci. Res. Rev., 19(1), 41-57. Mafuya, N., and Shukla, N. (2005). Factors that could motivate people to adopt safe hygienic practices in the Easter Cape Province, South Africa. Afr. Health Sci., 5(1), 21-28. Pahwa, S., Kuman, G.T., and Toteja, G.S. (2010). Performance of a community-based health and nutrition-education intervention in the management of diarrhoea in a slum of Delhi, India. J. Health Popul. Nutr., 28(6), 553-559. Sclar, E.D., Garau, P., and Carolini, G. (2005). The 21st century health challenge of slums and cities. Lancet; 365, 901-903. UN-HABITAT (United Nations Human Settlements Programme). (2003). The challenge of slums: global report on human settlements 2003. London and Sterling VA, Earthscan Publications Ltd.  

Environmental health risks in disadvantaged urban slums

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Environmental health risks in disadvantaged urban slums

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