Research Proposal

Title
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

1
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 [1].
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 [2].
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[3]

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. [4]
Water scarcity can lead to diseases such as trachoma (an eye infection that can lead to
blindness), plague, typhus and scabies. [7] 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. [4].

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. [10]

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 one-
hundredth of one percent is drinkable and renewed each year through precipitation.[5]
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

2
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. [5]
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 long-
developing 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. [6]
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 [11].
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. [8]
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. [9]
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.

3
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.

4
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

5
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.

6
References

1. 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/
2. 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
3. Robert D. Kaplan. The coming Anarchy. The Atlantic February 1994.
4. 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
5. Zafir Zia. Water scenario: Past, present and future of Pakistan. Chowk June
2009.
6. Riaz Haq. Pakistan Faces Unprecedented Water Scarcity. Chowk March 2009.
7. 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
8. 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
9. Tariq, S. A., Memon, M. H., Ghazi, R. R. A study on prevalence of scabies
(itch) in Karachi. Hamdard Medicus 1997.
10. 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
11. Dina M. Schreinemachers. Cancer Mortality in Four Northern Wheat-
Producing States. Environmental Health Perspectives Volume 108, Number 9,
September 2000.

7
Budget
Heads Numbers Unit cost inDuration Total cost in
PKR PKR
Training of data collectors/teams 3 300/day/person 2 days 1800
Per diem of teams 3 300/day/person 15 days 13500
Transportation 1 2000/day/vehicle 15 30000

Printing of questionnaire and300 2/copy 600

consent form
Stationary/mailing/posting/internet 4500
(Miscellaneous)
Total 50400

Tentative Work Plan

S.NoTask 1 2 3 4 5 6 7 8 9 10 11 12
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

8
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 Interviewer sign

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

9
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 # ID. #

Name of Subject:

Sex of subject:

Name of Village:

Name of Union council:

Name of Interviewer:

Date

Complete Not Complete

Field editing: 1.Done 2. Not done

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

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Socio-demographic information

S.no Variables Codes skip Responses

1 What is your age In years

2 What is your Sex 1.Male

2.Female
3.Others
3 What is your Religion 1.Muslim
2.Hindo
3.Kohli
4.Bhel
5.Jogi
6.Christen
7.Others
4 What is your marital 1.Married
status 2.Never married
3.Divorced
4.Widower
5.Seprated
6.Others
5 Can you read and write 1.Can read only
in your mother tongue 2.Can read and write
only
3.Cant read or write
6 No children

7 What kind of house you 1.Unbaked bricks

live 2.Backed
bricks/concrete
3.Wooden
4.Bamboos
5.Kacha
6.Others
8 In your home is there 1.Electricity
any 2.Radio
(Multiple responses 3.Television
allowed) 4.Refrigetor
8.Car /Tractor
9 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)

11
 5.Others
Regarding scarcity of water and its related diseases
S.n Variables Codes Skip Responses
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 How many room are there
in the house
13 How many persons sleep
in one room
14 Is there any attached wash 0.no
room in the house 1.yes
2.dont know
15 How many wash rooms
are there in the house
16 Do every person in the 0.no
house has separate towel 1.yes
2.dont know
17 Do the family members 0.no
share towel with each 1.yes
other 2.dont know
18 How many times an
average you take bath
every week
19 How many time you wash
your face each day
20 After how many days an
average you change your
clothes
21 After how many days an
average you change your
bed clothes
24 How often you clean your
home
25 Do you have any 0.no
knowledge regarding 1.yes
scabies 2.dont know
26 Do you suffer from this 0.no
kind of diseases in the last 2.yes
three months 3.dont know
27 Do you have any 0.no
knowledge regarding 1.yes
trachoma 2.dont know
28 Do you suffer from this 0. no
kind of disease in the last 1.yes
three months 2.dont know

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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

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1.Irrigatiory water
2.Wells
3.Hand pumps

Table 2
Asset Variables
Electricity Total % %
Yes No
Radio
Television
Refrigetor
Motorcycle
Automobiles

Table 3

Practices
Variable name Total % Yes No
(%) (%)
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

Variable Total % Yes No

(%) (%)

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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

16
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

17