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An Assessment of Water Scarcity related diseases among the general population of three union councils of Tehsil Taftan, District Chagai, Balochistan.
Course Research Process I Submitted to Course Supervisor Dr Rukhsana Khan
Submitted by Dr Abdul Majeed MSPH 2009 Health Services Academy Islamabad
Introduction: Water is an essential resource for life and good health. A lack of water to meet daily needs is a reality today for one in three people around the world. Globally, the problem is getting worse as cities and populations grow, and the needs for water increase in agriculture, industry and households . Almost one fifth of the world's population (about 1.2 billion people) lives in areas where the water is physically scarce. One quarter of the global population also live in developing countries that face water shortages due to a lack of infrastructure to fetch water from rivers and aquifers . Water which is most important among all above mentioned factor is as important for survival as blood is to life: So elemental it goes unnoticed until it dries up or bursts its arteries; so essential we die fighting for it. In a sobering forecast of life in the twenty-first century water scarcity in the next century will lead to brutal wars, many over what we calls "the most important fluid of the twenty-first century Common diseases related to poor water, sanitation and unsafe hygiene practices are: Cholera, hepatitis A, dysentery, giardiasis, polio, e-coli, diarrhea, typhoid, salmonella food poisoning, guinea worm, intestinal parasites like hookworm and tapeworm, scabies and trachoma.  Water scarcity can lead to diseases such as trachoma (an eye infection that can lead to blindness), plague, typhus and scabies.  Trachoma is the main cause of preventable blindness in the developing world, with four million sufferers, an estimated 500 million at risk and six million permanently blinded. It is common in areas that are hot, dry and dusty and where there is not enough water for people to wash regularly. Scabies occurs in areas where there is a lack of water and people are unable to wash themselves, their clothes, bedclothes or houses regularly. . Literature Review: In a study conducted in 1991 in Brazil, it was revealed that 7.2% of the population had evidence of one or more signs of trachoma.  Global and Pakistan Situation regarding water shortage Viewed from space, our planet seems flushed with water. Yet most of the earth’s blueness is the ocean, too salty for humans and agriculture. Only about 2.5 percent of the water is freshwater, and two-third of that is locked in glaciers and icecaps. Less than onehundredth of one percent is drinkable and renewed each year through precipitation. The amount available per person has fallen steadily. It has dropped by about 60% since 1950, as the population climbed from 2.5 billion to 6 billion, a will fall and additional 33 percent within fifty years if our numbers reach 9 billion, the middle of the projected range. As expected, the shortage affects mainly the poor. More than a billion people lack potable water, and nearly 3 billion lack even minimal sanitation. The World Health Organization estimates that 250 million cases of water-related diseases such as cholera arise annually, resulting in 5-10 million deaths. Intestinal worms infect some 1.5 billion people, killing nearly 100,000 a year. Tens of millions of poor farming families cannot afford to irrigate their land, which lowers their crop production and leaves them
vulnerable to drought. Much of the earth stable year-round supply resides in aquifers, some of which formed over thousands of years and are not being replenished. In ones which are, the extraction far exceeds what the annual rains provide. In California, which provides half of America’s fruits and vegetables, like Quetta, aquifers are overdrawn. InIndia, a 1996 report found that in critical farming regions the water table was dropping precipitously, and jeopardizing perhaps as much as one-fourth of the country’s grain harvest. Similar conditions afflictChina, andPakistan. The worlds urban population is expected to double to 5 billion by 2025, which will further increase diversion of water from agriculture to the city. This will exacerbate the rural to urban migration, and overall food production.  Pakistan, like the rest of the developing world is headed for serious water shortage in the near future. The current drought in Sindh and Balochistan has highlighted this longdeveloping problem. In the 50s, Quetta was considered Pakistan’s prime orchard, capable of providing fruit for the country and export. Rising population, over-use of ground water, and natural droughts, now threaten the existence of its remaining growing areas.  Health is influenced by different environmental and social determinants such as, income, employment, exposure to agents in air, soil, access to food and water particularly in the mountainous and desert area . Millennium Development Goal number 7, target 10 aims to halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. Water scarcity could threaten progress to reach this target.  A study was conducted to determine the prevalence of scabies in Karachi, Pakistan during 1996-97. Results revealed that the prevalence of scabies was greater in adults than in children in both years. It also revealed that the prevalence was higher in females than in males in 1996; this situation altered in 1997. Maximum incidence was observed during winters. It was concluded that scabies is a common health problem in Pakistan.  Rationale There is a dearth of major research regarding the water washed diseases such as trachoma and scabies and associated behavioral patterns and practices that make the people vulnerable for acquiring the diseases in Pakistan. The purpose of this study is to explore the extent and factors responsible for contracting the diseases. This study also intends to identify and collect evidence regarding any concrete out come like any revolving fund for provision of adequate water supply safe drinking water for the community. This study will also yield recommendations from the data collected and at the end the whole community can be benefited by formulation of policies. The majority of research studies focused on common water borne diseases but unfortunately little work is done particularly on Water washed diseases which are caused by water scarcity and poor hygienic conditions such as trachoma and scabies.
Aim of Study To improve health status of people by improving personal hygiene Objective of study 1. To determine the frequency of water shortage related diseases (Scabies and Trachoma) among the general population aged between 15-65 years in all three union councils of Tehsil Taftan, District Chagai in given period of study. 2. To assess the knowledge of people regarding water scarcity related diseases. Methodology Study design It will be a descriptive cross sectional study. Study site All Three union councils of Tehsil Taftan, District Chagai, Baluchistan Pakistan Study population All males & females of age 15 – 65 years Duration of Study Study will be conducted in three months Inclusion criteria All male and female aged between 15 to 65 yrs residing and working for more than one year in three union councils of Tehsil Taftan, District chagai. Exclusion criteria 1. Persons having any limb, mental disability, and chronic illness (like diagnosed cases of allergy, urticaria, eczema, major eye infections etc. 2. Not residing in the study area for last one year 3. Do not give consent for participation in the study. Sampling technique Tehsil Taftan of District Chagai has 3 union councils. All the three Union councils will be included in the study. Each union council will be considered as a cluster and form these 3 union councils 25% of villages will be selected randomly to ensure representative sampling of the rural areas of the Tehsil. The sample size will be divided into the villages based on proportionate contribution of households. In village a central common place will be selected (Mosque, shop, or Otaaq) and then every kth home starting from this central area will be selected. The k will be defined once we have information about the total number of households in the selected villages. The person coming out on the knock will be considered as our study subject after ascertaining inclusion/exclusion criteria and seeking informed consent. If that person is excluded then another person of the house will be checked for inclusion in the study otherwise the house to the left or right will be selected.
Sample size Calculation As we don’t have any study in Pakistan about prevalence of water washed diseases trachoma and scabies I assume the prevalence of diseases as 50% which gives the maximum sample size with a bound on error of estimation of 10% and level of significance (α) of 99%. The sample size is calculated to be 167 using the formula n= z2p(1-p)/e2 n= (1.96)20.5(1-0.5)/(0.05)2 n= 385 Further adjusting for 10% non-response rate the final minimum sample size comes out to be 425 study participants. Variables Change in the practices of farmers regarding use, storage, disposal of pesticides after health education. 1. Socio-demographic variables 1. Age 2. Education of the subjects 3. Marital status of subjects 4. No of children of subjects 5. Type of house of subjects 6. Type of water source used by subjects II. Study variables 1. Water source 2. Distance from water source 3. Methods of water fetching 4. Water storage methods 5. Amount of daily water use 6. No of rooms in a house 7. Share common towel 8. No. of bathes per week 9. Frequency of clothe changes 10. Frequency of bed clothes changing 11. Frequency of house cleanliness 12. Knowledge regarding scabies 13. Knowledge regarding trachoma 14. No of cases of having itchy sores (scabies) patients 15. No of cases having eye infections (Trachoma) Data collection tool A Questioner has been developed by Principal investigator. This Questionnaire will be translated to Urdu as well as in Balochi language. Questionnaires have set of questions which will lead us to understand the present behaviors/ practices of people regarding the study diseases and water scarcity. Data collection
Data will be collected through structured questionnaire by 3 teams, each comprising 1 data collector and a volunteer. Selected data collector will be at least a graduate from the local area. Base line data will be collected with in two weeks during my three months study period. Training of Data Collectors Two days of training of data collectors will be done and they will be guide how to retrieve maximum information keeping the subject at ease and take session of health/hygiene promotion education along with PI. Copies of manual of operations will be provided to all selected data collectors before start of training as to make them familiar with different steps in study and with guidelines for the health/ hygiene education to be given to study participants Data quality control Supervisor will supervise the data collecting procedure at the field on regular basis. Questioner will be translated into urdu and balochi language for easy understanding of participants. Pre-testing of 5% of questionnaire in other union councils of district Chagai will be carried out. Changes will be made on feed back as well as on suggestion of data collectors on flaws and weaknesses of questionnaire. Supervisor will supervise the data collecting procedure at the field. Data management and statistical analysis The completed questionnaires will be checked for errors, edited; coded and the data will be entered into the software Epi-data 3.0 and transferred to SPSS 16.0 for the statistical analysis. The descriptive analysis will be conducted reporting proportions of the categorical variables such as gender, age, knowledge etc. expressed as percentages and means and standard deviations of quantitative variables such as age, income etc. The inferential analysis will be conducted using chi square and or Fisher exact test where appropriate to compare the characteristics of knowledgeable study participants with others. A p-value of less then 5% will be considered as statistically significant. Ethical Considerations Ethical approval will be given by Ethical committee of Health Services Academy. Apparently there will be no Ethical issues. Informed/ written consent will be taken. Confidentiality of all information of subjects will be maintained. Hence all questionnaires will be kept in lock and key. If any of the participant found suffering from either scabies or trachoma will be helped in seeking medical advice. Dissemination of Results The study result will be shared to the study subjects of each village in small gatherings, and people will be encouraged to improve personal hygiene and hand washing. Results of the study will be disseminated through editorials, writing, and advertisements in local as well as national news papers. The study result will also be explained to the Nazims and community leaders of each union council through dissemination conferences.
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 10 facts about water scarcity. [online]. 2009. [cited 2009 Dec 14 on 10:05].Available from:URL:http://www.who.int/features/factfiles/water/en/ Water scarcity. [online]. 2009. [cited 2009 Dec 14 on 10:30].Available from:URL:http://www.who.int/features/factfiles/water/water_facts/en/index2. html Robert D. Kaplan. The coming Anarchy. The Atlantic February 1994. Water washed diseases.[online].2009. [cited 2009 Dec 14 on 11:45].Available from:URL:http://www.wateraid.org/uk/what_we_do/the_need/disease/686.asp Zafir Zia. Water scenario: Past, present and future of Pakistan. Chowk June 2009. Riaz Haq. Pakistan Faces Unprecedented Water Scarcity. Chowk March 2009. Water Scarcity. [online]. 2009. [cited 2009 Dec 14 on 10:50].Available from:URL:http://www.who.int/features/factfiles/water/water_facts/en/index4. html Water Scarcity. [online]. 2009. [cited 2009 Dec 14 on 11:00].Available from:URL:http://www.who.int/features/factfiles/water/water_facts/en/index8. html Tariq, S. A., Memon, M. H., Ghazi, R. R. A study on prevalence of scabies (itch) in Karachi. Hamdard Medicus 1997. EXPEDITO J A LUNA, NORMA H MEDINA, MARCIA B OLIVEIRA, OSWALDO M DE BARROS, ALEXANDRE VRANJAC HELOISA HELENA B MELLES, SHEILA WEST and HUGH R TAYLOR. Epidemiology of Trachoma in Bebedouro State of São Paulo, Brazil: Prevalence and Risk Factors. International Journal of Epidemiology. Volume 21, Number 1, Pp. 169-177 Dina M. Schreinemachers. Cancer Mortality in Four Northern WheatProducing States. Environmental Health Perspectives Volume 108, Number 9, September 2000.
Heads Training of data collectors/teams Per diem of teams Transportation Numbers Unit cost inDuration PKR 3 300/day/person 2 days 3 1 300/day/person 15 days 2000/day/vehicle 15 2/copy Total cost in PKR 1800 13500 30000 600 4500
Printing of questionnaire and300 consent form Stationary/mailing/posting/internet (Miscellaneous)
Tentative Work Plan
S.NoTask Research Design (preparation and 1 approvalof proposal) Selection of data collectors and their 2 training 3 Data collection Data entry and 4 cleaning 5 Data analysis 6 Report Writing 1 2 3 4 5 6 7 8 9 10 11 12
Annexure 1 Consent Form (This form is available in Urdu and Balochi) House no Id no
An Assessment of Water Scarcity related diseases among the general population of three union councils of Tehsil Taftan, District Chagai, Balochistan.
Assalam-O- Aliakum: My name is ----------------------------.We are conducting a survey to Assess Water Scarcity related diseases among the general population of three union councils of Tehsil Taftan, District Chagai, Balochistan. This study is going to be conducted by Dr Abdul Majeed who student of MSPH 2009 Course at Health Services Academy Islamabad. Water is scarce in this part of Pakistan. Due to this, personal hygiene is affected leading to few diseases. We request you to reply to a set of questions related to your, knowledge, attitudes, and practices regarding the use of water and your personal hygiene. Among these set of questions few questions will be regarding your personal life. You have every right to withdraw from the study at any time. This is also guaranteed that the information obtained through the questionnaire shall be kept secure and will not be disclosed to anyone. It will be used for research purpose only. The study result will be disseminated to the study subjects of each village in small gatherings. You will not be paid or granted with any monetary incentives for participating in the study; however you will be given with the sufficient knowledge/training regarding storage of water and personal hygiene. The study results will also be explained in disseminations conferences and meetings to the Distict Nazims and policy makers at district level to help and guide them in making policies regarding the improvement in water scarcity. If there is any query regarding this study please feel free to ask as we will try to answer your queries. If you are not satisfied you can contact the Principal Investigator from Monday to Friday at the following phone numbers or address. Participants Sign / Thumb impression Date Reason for Refusal 1. 2. Dr Abdul Majeed Student of MSPH, Health Services Academy Opposite to National Institute of Health Park Road, Chak Shahzad, Islamabad Interviewer sign
Ph.0300-9385527 Annexure 2 Serial no. Questionnaire To Assess Water Scarcity related diseases among the general population of three union councils of Tehsil Taftan, District Chagai, Balochistan. Household # Name of Subject: Sex of subject: Name of Village: Name of Union council: Name of Interviewer: Date Complete Field editing: Not Complete 1.Done 2. Not done ID. #
Principal Investigator address Dr Abdul Majeed Student of MSPH, Health Services Academy Opposite to National Institute of Health Park Road, Chak Shahzad, Islamabad Ph.0300-9385527
Socio-demographic information S.no Variables 1 What is your age 2 3 What is your Sex Codes In years skip Responses
1.Male 2.Female 3.Others What is your Religion 1.Muslim 2.Hindo 3.Kohli 4.Bhel 5.Jogi 6.Christen 7.Others What is your marital 1.Married status 2.Never married 3.Divorced 4.Widower 5.Seprated 6.Others Can you read and write 1.Can read only in your mother tongue 2.Can read and write only 3.Cant read or write No children What kind of house you 1.Unbaked bricks live 2.Backed bricks/concrete 3.Wooden 4.Bamboos 5.Kacha 6.Others In your home is there 1.Electricity any 2.Radio (Multiple responses 3.Television allowed) 4.Refrigetor 8.Car /Tractor What is the source of 1.Irrigatiory water drinking water in your 2.Wells home 3.Hand pumps (Multiple responses 4.Rain water reservoir allowed) (Nawar)
5.Others Regarding scarcity of water and its related diseases S.n Variables Codes Skip o 1 What is the source of 1.Irrigatiory water water for other uses in 2.Wells your home 3.Hand pumps (Multiple responses 4.Rain water allowed) reservoir (Nawar) 5.Others 2 How much time it take to bring water to home from water source 3 Do you use store rain 0.N water 1.Y 2.Dont Know 4 What is the distance of from water source to your home 5 How you bring water from 1.Self water source to home 2.Animal 3.Vehicle 4.Other 6 In which utensil you bring water from water source 7 How you store your water in home 8 In which container you store your water at home 9 Who bring water from 1.My self water source 2.brother 3.Father 4.Cousin 5.Wife 6.Sister 7.Mother 8.Others 10 How much water is used every day by you for cooking 11 How much water is used every day by you for drinking 11 How much water is used every day by you for your washings 12
12 13 14 15 16 17 18 19 20 21 24 25 26 27 28
How many room are there in the house How many persons sleep in one room Is there any attached wash 0.no room in the house 1.yes 2.dont know How many wash rooms are there in the house Do every person in the 0.no house has separate towel 1.yes 2.dont know Do the family members 0.no share towel with each 1.yes other 2.dont know How many times an average you take bath every week How many time you wash your face each day After how many days an average you change your clothes After how many days an average you change your bed clothes How often you clean your home Do you have any 0.no knowledge regarding 1.yes scabies 2.dont know Do you suffer from this 0.no kind of diseases in the last 2.yes three months 3.dont know Do you have any 0.no knowledge regarding 1.yes trachoma 2.dont know Do you suffer from this 0. no kind of disease in the last 1.yes three months 2.dont know
Dummy Tables Table 1 Socio-demographic variables Variables Name Total Age 15-25 yrs 25-35 36-45 46-55 56-60 65+ Sex 1.Male 2.Female 3.Others Education of the subjects 1.Can read only 2.Can read and write only 3.Cant read or write 4.Primary 5.Middle 6.Matric 7.Intermediate 8.Graduate Marital status of subjects 1.Married 2.Never married 3.Divorced 4.Widower 5.Seprated 3.Others No of children of subjects Socio-demographic variables Variables Name Total Type of house of subjects 1.Unbaked bricks 2.Backed bricks/concrete 3.Wooden 4.Bamboos 5.Kacha Type of water source used by subjects
1.Irrigatiory water 2.Wells 3.Hand pumps Table 2 Asset Variables Electricity Radio Television Refrigetor Motorcycle Automobiles
Table 3 Practices Variable name Source of water 1. well 2. tap water 3. Nawar 4. rain water 5. other Distance from water 1.< 500 m 2. b/w 500m 1km 3.1km-2km 4.2km-5km 5. >5km Methods of water fetching 1. by foot 2. by hand cart 3. by donkey cart 4. by tractor Total % Yes (%) No (%)
Source of information regarding storage of scabies 1.No source of information 2.shop keepers 3.other farmers 4.relatives 5.land lord 6.TV 7.Radio 8.News paper Others Source of information regarding trachoma 1.No source of information 2.shop keepers 3.other farmers 4.relatives 5.land lord 6.TV 7.Radio 8.News paper Others Knowledge about scabies 0.no 1.yes Knowledge about Trachoma 0.no 1.yes Water used for water cooking 1. <1 liter 2. b/w 1-2 liters 3. 2-3 liters 4. 3-4 liters 5. >5 liters Water used for water Drinking 6. <1 liter 7. b/w 1-2 liters 8. 2-3 liters 9. 3-4 liters 10. >5 liters Water used for water washings 11. <1 liter 12. b/w 1-2 liters 13. 2-3 liters 14. 3-4 liters 15. >5 liters
No of rooms in house 1. one 2. two 3. three 4. four 5. five 6. >5 No of wash rooms 1. one 2. two 3. three 4. four 5. five 6. >5 Change of clothes 1. every day 2 every second day 3. every week 4. other