Water sanitation and hygiene practices of the indigenous Tharu community in Chitwan, Nepal

Nepal is a multi-ethnic country with cultural diversity according to ethnicity. Culturally rich, the Tharu ethnicity is the fourth largest ethnic group. Sanitation and hygiene are integral parts of their culture. Water, sanitation, and hygiene (WASH) are fundamental for everyone. This study aims to identify the WASH practices and situation of diarrhoeal diseases among the Tharu ethnic group in the Chitwan district of Nepal. A quantitative cross-sectional survey was used for the study. The study area and ethnic group were selected randomly. Primary data were collected using an interview schedule and observation checklist. Data analysis was carried out using SPSS version 24. The findings confirmed that all households clean their yards, and about 9 in 10 (87.5%) respondents have dustbins in their households. Almost all (98.8%) clean their kitchen utensils twice daily, and 96.8 percent use ash or soap as a cleaning agent. Nearly all (99.7%) households have a toilet (92.8% water seal), whereas 75.3 percent use water, brush, and cleaning agents, and 96.8 percent use separate slippers in the toilet. All the respondents wash their hands with soap before eating food and after defecation. Almost all (95.7%) wash their hands with soap after cleaning yards, 92.5 percent after cleaning the child’s bottom, 91.5 percent after touching cow dung, 89.9 percent after agricultural work, 73.1 percent after feeding the child, and 90.7 percent after cleaning the toilet. The study shows that 46.3 percent of women and girls use commercial sanitary pads during menstruation, and 43.7 percent use pieces of cloth as pads. About half (49.6%) clean their genitals four or more times daily, whereas nine in ten (92.6%) respondents take a bath four or more times during the menstrual period, and 76.8 percent use soap as a cleaning agent. In the previous year, only 26.1 percent of respondents’ families suffered from diarrhea; however, nobody was infected by cholera. The study suggests that socioeconomic status and contextual factors must be improved to strengthen and sustain WASH practices. Including good WASH practices of indigenous Tharu people in the local curriculum could motivate them to empower and develop further good practices, which is possible through the school curriculum, which the local and federal governments mandate.


Introduction
Nepal is the Federal Democratic Republic, the country of Mount Everest, and the birthplace of Lord Buddha, extending from north to south with an average width of 193 kilometers and east to west with an average length of 885 kilometers.It has diverse topography, including mountain, hilly, and Terai regions [1].Politically, it has seven provinces, 14 zones, 77 districts, and 753 local levels [2].Similarly, this multitude of multicultural, multi-religious, multi-lingual, and multi-ethnic groups scattered throughout the nation [3].It hosts 142 ethnic groups, including Tharu, the fourth largest.This is marginalized and backward from political, educational, and economic points of view.Every ethnic group has its cultural traits and heritage for their livelihood.Personal hygiene and sanitation are also integral to their culture and socio-economic status.Water, sanitation, and hygiene (WASH) are crucial aspects of human beings' livelihood for healthier living.Well-managed and equipped sanitation facilities in household premises tremendously affect the good health, economic status, and well-being of ultra-poor and marginalized people [4].The global burden of waterborne disease, helminths, preventable child mortality, and the high dropout rate of adolescent girls due to lack of privacy to dispose of sanitary pads during periods in school can be reduced through basic level WASH services in their households and schools [5,6].
About 6 billion people have access to improved sanitation facilities that their family members commonly use, whereas 2.3 billion still need sanitation facilities, including toilets, within their household premises.About one-fourth (27 %) of people in the least developed countries have access to hand washing facilities with detergents and safe water within the surrounding household [7].A study conducted by UN-HABITAT on the sustainability of an open defecation-free campaign among global sanitation fund-supported program districts of Nepal in 2017 found that Muslims have a topmost position with 96 percent.In contrast, Brahmin and Chhetri, known as the so-called higher class ethnic groups, had only 90 percent access to the toilet; similarly, 92 percent of Madheshi (an ethnic group of Terai {plan land} region), 90 percent of Dalit (scattered all over the nation, given common name to different so-called lower casts) and 89 percent Janajati have access on the toilet in their household premises [8].
Diarrhea is a common disease caused due to fecal contamination in drinking water, which is the result of poor WASH facilities in the community.A study conducted by Ministry of Health and Population, New ERA, and ICF in 2023 shows that 10 percent of children under five years of age suffered from diarrhea [9], whereas 27.6 percent of households had a lack of hand washing facilities on their premises with soap and water, open defecation, weak sanitation, and lack of hand washing facilities with detergent have a strong relation with diarrhea [10].WASH facilities are essential for good health, better education, qualitative livelihood, poverty alleviation, and strengthening sustainable development for a brighter future for an individual [11].Tharu is marginalized and deprived of the social, economic, and political mainstream.The Tharu community's access to governance, health, and WASH facilities could be better than other marginalized groups in Nepal [1].So, what is the situation of WASH practices of Tharu people in the study area?This study has tried to find the answer to this research question.

Methodology
A quantitative cross-sectional research design was used to obtain the objectives of this study.Through interview schedules and observation checklists, primary data were collected from ages 14 and above who are more responsible for WASH activities than men in their households.Only one young daughter-in-law (more accountable in WASH practices among the women) was taken from each household if there were two or more women in the same household.Study area Khairahani municipality wards 12 and 13 (the densely Tharu inhabitants) from Chitwan district was selected purposely.Out of 8,310 populations, 375 samples were selected randomly using Rao-soft software.The researcher visited every respondent in their household premises to collect data from the observation checklist.Two female teachers from the same ethnic group in the local area were taken as enumerators to help the researcher during data collection.Interview schedules were translated into the Nepali language to make data collection easy.
Similarly, the enumerator again translated Nepali tools into Tharu language during data collection for older women who needed help understanding the Nepali language.Verbal authority from the ward office was taken to collect data, and informed consent was obtained from every respondent before the interview.Univariate analysis was done using SPSS 24 version [12].

Household cleaning practices
The household's cleanliness makes the premises clean and free from germs and files.To keep households clean and tidy, produced waste must be appropriately managed.For the first time, waste must be collected, and then it must be separated as organic and inorganic.For this, each household needs to manage a dustbin.Such separated wastage is easy to manage in appropriate ways.Inorganic waste can be reused and recycled, whereas organic waste can be used as fuel and fertilizer after decomposition.The practices of household cleanliness are mentioned in table 1 The study found that all the respondents clean their yards, and the frequency is also quite good; out of 375 respondents, 99.7 percent do so daily.About 9 in 10 (87.5%) respondents have dustbins in their household.Only 45.4 percent of respondents have separate dustbins for organic and inorganic waste.However, about nine in ten (85.1%) have waste-separating practices that are classified as organic and inorganic.This study further shows that 44.4 percent of respondents dispose of their waste in manure pits, 28.5 percent in compost pits, and nominal respondents (1.6%) manage it in the open fields.Similarly, 74.2 percent of respondents transfer their wastes to municipality collection points, and 17.5 percent incinerate organic and inorganic waste beside their household premises.

Hand-washing practices with detergents
Hand washing with detergents before and after different activities is crucial to prevent infectious diseases like diarrhoea and COVID-19.After cleaning work, agricultural work, touching cow dung, cleaning the child's bottom, and defecation, and before eating food, feeding the child, and preparing meals, it is a must to wash hands.Similarly, hand washing after traveling by public vehicle and shaking hands with others is also essential to protect from germs and viruses.A self-reported practice of hand washing with detergents in the study area is given below as follows: Table 2 shows that all respondents wash their hands with detergent before eating food and after defecation.Almost all ((95.7%)respondents wash their hands with detergent after cleaning yards, 92.5 percent after cleaning their child's bottom, 91.5 percent after touching cow dung, 89.9 percent after agricultural work, 73.1 percent before feeding the child and 90.7 percent after cleaning the toilet.Data further shows that only about one in two respondents (46.6%) washed their hands with detergents before handling food.

Kitchen floor and utensils cleaning practices
The kitchen where foods are prepared and eaten beside it needs to be neat and clean.However, in poor households, cooking and eating are done in the same place.During preparation and eating, pieces of food are scattered and spoiled.To remove those scattered objects, they need to be cleaned.Similarly, kitchen utensils are frequently usable objects; to maintain cleanliness, they must be cleaned after every meal and keep these utensils dry, too.Table 3 shows the existing practices of cleaning kitchen floors and utensils.Table 3 shows that 35.1 percent of respondents wiped using soil and water to keep the kitchen floor clean, 87.1 percent brushed by broom, and 60.1 percent wiped with water to clean the floor.Similarly, almost all (98.8%) wash their kitchen utensils twice daily after lunch and dinner.Of the 375 respondents, 39.5 percent use water and ash to clean utensils; 57.3 percent use water and detergent; nominal (0.8%) use water, sand, and soil; and 2.4% use coal and straw to clean kitchen utensils.

Practices of toilet cleaning and its use
The toilet is a favourable zone to flies and warms; flies are the means to transport feces from the bathroom to the kitchen as well as serve meals and children's mouths.The feces have germs, parasites, and eggs of different worms.To protect from such germs, parasites, and worm flies must be controlled.The controlling measures of such problems are deeply rooted in toilet cleaning practices and their appropriate use.The cleanliness of the toilet breaks the chain of spreading flies and worms.Table 4 shows the toilet cleaning and use practices of the study area as follows: Menstruation is a natural phenomenon that occurs in every female from around ten years and remains up to 49 years.Personal and bed hygiene is also necessary to be safe from urinary tract infections and to control blood spreading.Frequently washing genital organs and using pads and pads-like substances helps to maintain menstrual hygiene.The availability of pads and the purchasing capacity of an individual are also associated with the use of pads, together with knowledge of menstrual hygiene.Socio-cultural beliefs, taboos, and practices during menstruation also play vital roles in menstrual hygiene.Table 5 reveals the practices of menstrual hygiene as follows: Table 5 shows that 46.3 percent of respondents use commercial pads, 43.7 percent use clean pieces of cloth after menstrual bleeding to absorb blood, 48.1 percent replace clean pieces of clothing, and 45.9 percent replace commercial pads.Almost all (91.5%) respondents wear their usual clothes, and 85.9 percent use their typical bed during menstruation.About half (49.6%) percent of the respondents clean their genital organs four and more than four times, and 46.7 percent do two to three times in a single day.Similarly, nine in ten (92.6%) respondents take a bath four or more times during the whole menstrual period.The use of detergent as a cleaning agent is 76.8 percent; however, 31.9 percent of them use only water as a cleaning agent.

Incidence of diarrhoeal diseases among families in the last year
Poor personal hygiene and household sanitation result in diarrhoeal diseases, skin infections, and urinary tract infections.In this study, the focus is given to diarrhoeal diseases.Fecal contamination in water and lack of appropriate hand washing with detergent might cause diarrhoeal diseases.To protect the food from fecal contamination, hand washing after defecation, cleaning the child's bottom, preparing the meal, feeding the child, and eating food are necessary.Feces are the primary source of bacteria and viruses causing diarrhoeal disease.The incidence of last year's history of diarrhoeal diseases among family members in the study area is shown below in Table 6.The study indicates that about one-fourth (26.1%) of the respondents or their family members suffered from diarrhea; however, three-fourths (73.9%) did not face the problem.Cent percent of them were safe from cholera, and nominal (6.9%) of them suffered from dysentery.Similarly, about nine in ten (89.6%) respondents were safe from worm infection, and only 10. 4 suffered from the same problem.

Discussion
WASH practices are a seminal aspect of healthier living, influenced by the practices of respective ethnic groups.This study also reveals that almost all (99.7%) respondents clean their yards daily, which is better than national data; according to the Ministry of Health and Population [Nepal], New ERA, and ICF survey 2023, people's access to improved sanitation facilities is only 92 percent.The finding indicates that 87.5 percent of households have dustbins [9]; however, the separating practices are poor (45.4%).The study further reveals that household sanitation waste is used as organic fertilizer to grow vegetables and crops.These practices would be sustainable for managing organic wastage from an ecological and economic point of view.According to the findings of this study, the cleanliness practices of the kitchen floor and utensils were hygienic.Almost all (99.5%) respondents wipe their kitchen floor daily using soil, water, and a broom, whereas 96.8 percent use water and ash/detergent to clean utensils, which proved that they are fully conscious of kitchen utensils cleanliness.Chang is a kind of open rack built using bamboo or wooden nearby utensils cleaning point to put cleaned utensils after cleaning where utensils are safe and dry.Constructing change is the indigenous practice of the Tharu community, which is safe, cost-effective, and hygienic, so it must be extended among Tharu and other communities.Almost all (99.7%) households had toilets, and all used these for urination and defecation during the study period 2019.However, in Nepal, only 95.5 percent of households have toilet facilities, and 10 percent of households in the Terai region still need toilets on their premises [9].Findings indicate that the study area's sanitation practices are better than those of other parts of the country and the Terai region.About three in four households use toilet cleaning agents, and 96.8 percent use separate slippers in the toilet.Appropriate toilet cleaning helps minimize the risk of spreading pathogens and flies associated with diarrheal disease.The incidence of diarrhea was 26.1 percent during the last year, whereas nobody was infected with cholera during the study period.However, the knowledge of the eco-san toilet still needs improvement (10.7%).Mass media, housing construction companies, and social activists can be mobilized to encourage the construction of eco-san toilets.Construction of an appropriate hand washing station within the household premises with soap and water gives easy access to hand washing after defecation, touching cow dung, agricultural activities as well as before preparing meals and eating/feeding children, which might be a milestone to save them from diarrheal and other infectious diseases too.Cent percent of respondents (only 51.5 % were literate) in the study area washed their hands with soap before eating.However, a study by Sharma in 2021 among secondary-level students in Nepal found that 94.8 percent of respondents washed their hands with soap before eating.Similarly, 90.7 percent in the study area washed their hands after defecation, whereas in the same study, only 84.1 percent washed their hands with soap and water [13].
The practices of using disposable/commercial pads in the study area (46.3 %) are poorer than the study conducted by Morrison in 2016 in Sindhuli (76.9%) and Udayapur (63.1%) districts in Nepal.
However, bathing practices are relatively better in the study area than in the same study; the data shows that nominal respondents in Udayapur (13.8%) and Sindhuli (2.3%) bathe every day [14], whereas 92.6 percent take baths in the study area.The study denotes that knowledge alone does not change an individual's behavior; contextual and socio-cultural factors also determine hygienic behavior [15].Appropriate feces management might cause cholera's absence in the study area, so focus must be given to managing feces properly to reduce the outbreak of diarrheal diseases.

Conclusion
Sanitation and hygiene are fundamental aspects of a healthier life and longevity, which are also integral to everyone.Socio-economic status and contextual factors must be improved to strengthen and sustain WASH practices.Knowledge, household practices, and the influence of family members and neighbors play crucial roles in changing the WASH behavior of community people.WASH must be practiced from early childhood in the household, where children learn and build on healthy behaviours.Including WASH practices such as hand washing, kitchen utensils cleaning, and menstrual hygiene of indigenous Tharu people in the local curriculum could help develop good sanitation and hygiene behaviors, which is possible through the school curriculum developed by the local and federal governments.Extending such practices will help reduce the burden of diseases and treatment costs for individuals and the country.

Acknowledgments
This paper is part of the first author's MPhil thesis.The NORHED-Rupantaran project of Tribhuvan University provided the thesis writing fellowship.Thanks to the NORHED-Rupantaran project for providing a fellowship to the first author to conduct this study.

Table 2 .
Hand-washing practices with detergents

Table 3 .
Kitchen floor and utensils cleaning practices Multiple response (percent exceeds more than 100).

Table 4 .
Practices of toilet cleaning and its use shows that almost all (96.8 %) respondents use separate slippers in the bathroom, and only 10.7 percent of respondents knew about eco-san toilets in the study area.

Table 6 .
Incidence of diarrhoeal diseases among families in the last year