This study is an investigation of the quality of drinking water used by the communities of Bungamati, a rural town of Kathmandu Valley, Nepal and of local knowledge of water quality and water borne diseases. We tested the drinking water used by the communities and then assessed their knowledge of water quality and water borne diseases. The results show that the physical and chemical parameters of the sample water of different water sources lie within the World Health Organization guideline values. The values of the bacteriological parameters such as coliform bacteria and Escherichia coli are such that the drinking water is not potable in terms of bacteriological point of view. We found that communities are unaware of the contaminants in their drinking water. Incidence of water borne diseases appears to be the common health problem among the sample households in the study area. It is found to be more serious during the dry season. Open defecation is still one of the common sanitation problems of the area. The local communities have been made aware of solar disinfection for water disinfection.
Nepal is predominantly a rural country. Over 85% of the population is rural. The literacy rate is below 40% (CBS, 2001). Sixty-six percent of the rural population has access to piped water and the rest are dependent on locally available water sources such as springs, streams and tube wells for drinking and household uses. The daily per capita water use in the rural areas is 45 l compared to 60 l in urban areas. The rural people in the hills usually have to travel longer distances to fetch water from local natural sources.
Drinking water quality is a major issue in rural areas of Nepal. Studies carried out by ADB (1985), IUCN (1991), Pradhan et al. (1995); Pradhan (2000) and MOPE (2001) in rural areas of Nepal show that rural people use the most convenient sources of water in their areas, irrespective of quality, due to lack of piped water. Likewise CEMAT (2000), ENPHO (1999), and DOHS (2003) found that about one third of deaths of children below the age of five in the rural regions of Nepal were due to water borne diseases such as cholera, typhoid fever, dysentery and gastro-enteritis. Yet the vital connection between water and health is given little emphasis in the government policy measures (UNICEF, 1987; MHPP, 1998; NPC, 1998; MOPE, 2001). The Water Resources Act-1993 of Nepal recognized drinking water as the first priority in terms of its use, followed by irrigation, farming enterprises like animal husbandry and fisheries, hydroelectric power, cottage industry, water transport, and others in order of priority of use.
This study investigates the quality of drinking water, water borne diseases and sanitation and the perception of the community toward them.
Bungamati VDC (Lalitpur district) consists of three major village localities, Bungamati, Chundevi and Phasidol (Figure 1). It has an area of 3.8 km2 and 5,667 inhabitants. Thus, the density is 1,491 persons km−1. This can be compared with the density of 1,830 persons km−2 of the Kathmandu Valley districts (Bhaktapur, Kathmandu and Lalitpur). The average household size of Bungamati VDC is 5.1. The population consists of a variety of castes and ethnic groups such as Bahun, Chhetri, Newar, Tamang, and so on. Of these, the Newar community is the largest at 64%. Agriculture is the main economic base of the rural communities and is characterized by an integrated farming system of crop and livestock. Bungamati lies on plateau, located at an elevation of about 1,352 meters above sea level between two rivers, the Bagmati in the west and the Nakhu in the east. Bungamati is connected with Patan city (Lalitpur district) by road.
Physical, chemical and bacteriological analyses
Twenty-five water samples, each with one replicate, were collected representing all drinking water sources such as wells, stone spouts, ponds, streams, and public and private taps, and analyzed in the laboratory for physical, chemical and bacteriological parameters. The physico-chemical parameters included temperature, pH, iron, chlorine, total hardness, chloride, N-NH4 (nitrogen ammonia), phosphate-phosphorus (PO4–P) and fluoride. The bacteriological parameters included Escherichia coli and coliform bacteria. The analyses of the physico-chemical parameters were based on the methods of APHA-AWWA-WEF (1995). Coliform bacteria were measured in terms of presence and absence of bacteria by the Hydrogen Sulphide Paper Strip Method (Manja et al., 1982) while E. coli was measured in terms of colony forming units (cfu) per 100 ml of E. coli by a membrane filter technique on Chromocult media (APHA-AWWA-WEF, 1995). For culture of E. coli, 100 ml of three consecutive dilutions of each sample water (e.g., 10, 10−1, 10−2) was placed in the culture medium. Average number, range and standard deviation were computed.
Community field survey
A cross-sectional study is based on data and information acquired from the field survey was carried out in March 2003 (Pradhan, 2003). Structured questionnaire sheets containing both open- and close-ended questions were administered to 110 sample households out of 1,110 total households of Bungamati Village Development Committee (VDC) in the Kathmandu Valley, Nepal. These questionnaires sought information on water quality and water borne diseases and perception of the communities. The sample size was obtained by using the formula
The 110 sample units accounted for 10% of the total households of 1,110 of the Bungamati VDC. The sample households for each of the three localities were as follows: Bungamati, 72, Chundevi, 23 and Phasidol, 15. The sample households were selected randomly for the questionnaire survey. The household list was obtained from the VDC records. Each household was given an identification number and the required number of households was selected by using a random table. Random with replacement method was used to complete effectively the survey within the stipulated time period. The sample household heads in our survey included men and women, different age groups, ethnic groups and socio-cultural status. These sample characteristics were assumed to represent a wide view regarding the use and management of drinking water sources. In addition, a focus group discussion was held with selected local communities using a participatory approach to gather information of water quality issues and problems. An observation checklist was used to record the environment and sanitation conditions of the surroundings of the water sources and the living area. The checklist acquired information on house types and their condition, kitchen conditions, locations of sources of water and their surrounding condition and distance, drainage conditions, solid waste disposal practices, types of toilet and maintenance, and distance of cattle-shed from living houses of the sample households. The information processed from both the focus group discussion and observations were used as supplements to the information and data obtained from the questionnaire survey.
The perception of the local communities towards water borne diseases was analysed in terms of the relative proportion method, that is, relative share of frequency of the respondents of particular type to the total number (Pradhan, 1998):
Results and discussion
Drinking water sources and quality
Water sources can be described in terms of location, amount, storage, distribution and access. In our study area, the communities have used different water sources such as stone spout, well, pond, stream and tap for drinking and other domestic purposes. These water sources can be put into two broad water supply systems: traditional (natural) and modern. The first four types of sources fall in the traditional or natural water source system, whereas the last type lies in the modern system (Table 1). Bungamati locality has all these types of drinking water sources, whereas the other two localities have few of them. Most of the houses of Phasidol have private taps, but they are now not working because the water source has dried up.
Bungamati VDC has 5 wells (Inⱥr), 2 stone spouts, 6 public water taps, 5 ponds and 2 rivers. The inhabitants use water of the wells for washing clothes, bathing and drinking. The use of water of these wells has diminished in recent years due to installation of a piped water system. The water of stone spouts is used for drinking, cooking and bathing. The pond water is used for ritual and religious purposes and washing clothes. Rivers water is used for washing clothes and bathing during the dry season when there is inadequate piped water supply. The Bungamati locality has 6 public water taps and 74 houses have piped water connections.
The results of the physical and chemical parameters viz. temperature, pH, iron, chlorine, total hardness, chloride, N-NH4, PO4–P and fluoride of the water samples as shown in Table 2 are found lying within World Health Organization (WHO) guidelines. But the values of coliform bacteria and E. coli, which are indicators of faecal contamination, are not within WHO guidelines (WHO, 1996). Particularly in case of some sample taps, the coliform bacteria was absent (negative) at source point but was present (positive) at consumption point. There was a great variation in number in case of E. coli, but all samples were above zero. Therefore the water of all sources was found to be not potable from the bacteriological point of view. The computed value of E.coli ranged from 3 to 200 cfu 100 ml−1. The highest variation of E.coli occurred in the samples of the well with ranging from 48 to 200 cfu 100 ml−1. These samples also showed highest mean and standard deviation values (Table 2).
Chlorination is one of the popular methods for water disinfection in Nepal. In our water supply system its effectiveness has been measured in terms of the concentration of free residual chlorine (FRC) present in the distribution system. In the water analysis FRC could not be detected in the water samples of both public and private taps. Thus, chlorination was not adequate.
The contamination of drinking water may occur in sources and/or at the consumption point. The collected water for domestic use may contaminate both outside and within the house environment through poor hygiene and sanitation practices. All water samples, as stated above, were contaminated with faecal material either at source points or consumption points. The information obtained from the observation checklist shows that the reasons of contamination of drinking water at source points included lack of protection, lack of proper treatment of water, poor surrounding environment, leakage in pipe distribution system, intermittent supply of water, and poor drainage system. The contamination at the point of consumption within the house was due to lack of proper cleaning of water containers, poor personal habits, and lack of awareness of cleanliness. However, the relative importance of these factors was not ascertained here, but they are factors of drinking water contamination in rural Nepal as observed in other studies (Pradhan et al., 1995; Pradhan, 1998; CEMAT, 2000).
Distance of drinking water sources is one of the major factors in determining water quality and sanitation in rural Nepal (BCHIMES, 2000). It is argued that as the distance of water sources from living area increases, the amount of water required for use decreases and the possibility of contamination increases and as a result, the health of people deteriorates. In our study area, all the water sources fell within 200 m of the sample households (Table 3), which is close compared to the distance for fetching water in other hill areas of Nepal (CBS, 1996). The drinking water contamination with faecal coliform at the consumption point was due to poor personal habits, so that the distance was not a significant factor of water contamination.
Perception of water borne diseases
Incidence of water borne diseases including diarrhoea is one of the basic health problems in the study area. The health record at the Bungamati VDC shows that the water-related diseases, including diarrhoea, intestinal worms and gastritis, were the second most prevalent problems in terms of number of the patients' visits to the health post (Table 4). Our survey data was somewhat different. According to the sample respondents, the incidence of diarrhoea was the most prevalent health problem, occurring in 57% of the sample households. The second most common health problem was cold and cough related to respiratory disease.
Diarrhoea occurs mainly due to the consumption of contaminated water, among other factors. Our attempt here was to assess the knowledge of local communities of the reasons of diarrhoea. We found that eating more food was stated as the most important cause of diarrhoea, followed by eating stale food and eating in restaurants (Table 5). Other causes included dirty surroundings, religious beliefs, polluted air and contaminated water. These beliefs could be compared with the causes of diarrhoea and illness as determined by the medical clinics. Traditional and religious beliefs were deeply rooted in the community as being main causes of diarrhoeal disease. The most common belief among the rural communities of Nepal is that eating more food than the required quantity particularly during special occasions such as feasts and social and religious gatherings causes diarrhoea. It is assumed that the level of education of the respondents is directly related to the awareness of diarrhoeal causes. However, in our study there was no distinct differentiation in the frequencies of respondents among the literate classes. As shown in Table 5, the majority (about 66%) of the sample respondents were not aware that diarrhoea occurred due to consumption of contaminated water.
The pattern of incidence of water borne diseases varied remarkably during different months of a year. On the whole, there was higher incidence of visits of all types of patients during the month of February than other months, while the incidence of diarrhoea disease was the largest in the month of June, the beginning of the monsoon (Figure 2). This is a common phenomenon in the hill region of Nepal (DOHS, 2003).
Sanitation and hygiene
Water may be contaminated if the sources are not properly or regularly cleaned. In our study area, cleaning of the water sources by the local communities was found be done once a year. Eighty-eight sample households fell into this category. During religious functions or occasions, such as Sithi Nakh of the Newar communities, regular annual cleaning of the public water sources was done, but the majority of the local community was not aware of the cleaning of their drinking water sources.
Environmental sanitation is essential to promote health and prevent diseases. It is described in terms of personal hygiene, toilet facilities and surrounding environment. These also may cause water contamination at source and consumption points.
In the study area, 71 sample households (65%) had access to latrine facilities such as pit and water seal toilets. The sanitation condition of the toilets can be related to the supply of water, housing density and physical space, practice, and so on. Among these, our observations showed that the shortage of water was the most important cause of poor sanitation in toilets. The members of households without a toilet used nearby open fields and riverbanks for defecation. In this open defecation practice, faeces drained directly into the river and other unprotected water sources during the rainy season. It was observed that most of the unprotected and open water sources were found to be contaminated by faecal matter by monsoon rains. As noted above, the incidence of diarrhoeal disease found to be highest during the month of June, which might be due to the first flush of the monsoon rains.
The local communities' awareness toward sanitation and personal hygiene was analysed in terms of their practices, particularly hand washing after defecation. Poor sanitation in the study area can be indicated by the lack of toilets or due to open defecation. The reasons for not having toilets in terms of order of proportion included lack of money (41%), preference for use of open field (35%) and bad smell associated with toilets (21%). The first reason can be related to poverty, whereas the second to shortage of water and limited physical space in the house and the last reason to the lack of awareness and utility facility. Our survey also sought information on hand washing practices after defecation. There were four different types of hand-washing practices: soap, ash (which acts as a disinfectant), water and soil. The highest proportion of households used soap after defecation (35%), followed by ash (26%), water alone (22%) and soil (15%). The latter two hand-washing practices are not considered appropriate practices in terms of personal hygiene, but accounted for 35% of the sample households (Table 6). These practices could also be causes of contamination of water sources.
All major streets of the Bungamati area are brick-paved. Through local effort, the locality contains garbage collection baskets along major streets. Being an agricultural village, collection and management of waste disposals are not a serious problem, as the organic wastes are being used as manure in the farm fields. Table 7 shows that 94 out of 110 households have used manure pits for the disposal of their household wastes and animal dung whereas the rest of the households have used containers and nearby open places. There was no significant relationship between the households with landholding size and practice of waste disposal. This has been examined with the chi-square test: χ2tv (table value) = 5.99; P (probability) = 0.05; χ2cv(calculated value) = 0.08; df = 2. The open place for waste disposal and manure pit may contaminate water sources particularly during the rainy season by draining the waste matter directly into the rivers and unprotected water sources. Again, hand washing practice after using manure is important in terms of personal hygiene.
Recommendation for community hygiene: Solar disposal
The bacteriological contamination of drinking water was found to be a major problem in our study area. Therefore, the water disinfection method solar disinfection (SODIS) was considered for intervention. In this method, ultraviolet radiation from sunlight inactivates the bacteria in the water of the plastic bottle, thus making the water safe for drinking. Findings of the study were shared with the local communities in several small groups through meeting in order to make them aware of the quality of the drinking water they consumed. The sanitation condition of the surroundings and their effect on the quality of water was also shared with them in an interactive manner. At that point, SODIS was demonstrated to the communities. This method was found to be effective in Nepal. The results of SODIS trials carried out at various places of Nepal indicate that more than 99% of faecal bacteria were found to be removed on a sunny day in most cases. Only on fully cloudy days, was the removal rate found to be low (ENPHO, 2002).
The SODIS method is appropriate drinking water treatment at the household level. It is an effective method as well in terms of cost and reliability. However, more such programs are required in the rural region of Nepal where there is still poor drinking water quality. In addition, delivery of awareness programs to the local communities, particularly to the children, is warranted for imparting knowledge of environmental sanitation and personal hygiene.
The authors would like to extend their sincere thanks to NHRC for supporting the study, and to all the people who we interviewed. Huge thanks for the useful comments of anonymous referees and to our English language editor, Mr. Asik Gongaju.