Abstract

Author summary

Citation: Nabi MH, Rupa FH, Jahan I, Hasan ABMN, Naz F, Masud I, et al. (2025) Water, sanitation, and hygiene (WASH) factors and the incidence of communicable diseases in Urban Bangladesh: Evidence from municipal areas. PLoS Negl Trop Dis 19(7): e0013329. https://doi.org/10.1371/journal.pntd.0013329

Editor: Dawit Getachew Gebeyehu, Mizan-Tepi University, ETHIOPIA

Received: November 24, 2024; Accepted: July 8, 2025; Published: July 31, 2025

Copyright: © 2025 Nabi et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Water, sanitation, and hygiene (WASH) are critical for health and development [1]. They are considered a significant global public health issue [1]. Approximately 2.3 billion people still lack basic sanitation, and over half a billion lack access to adequate water sources globally [2]. In the 21st century, WASH remains a critical public health need in low- and middle-income countries (LMICs) [3]. Approximately half of the population in these countries suffers from diseases or infections caused by contaminated water and improper sanitation [4]. Infectious diseases are among the most prevalent causes of mortality globally [5]. They are the primary contributors to disability-adjusted life years (DALYs) [6]. Key infectious diseases responsible for global fatalities include acute lower respiratory tract infections, HIV/AIDS, diarrhoeal diseases, tuberculosis, and malaria [6].

The WASH issues are particularly severe in certain countries, and Bangladesh is one such country facing considerable challenges. With the eighth largest population globally [7], Bangladesh also has the highest percentage of people living below the national poverty line among all South Asian countries [8]. Despite its significant population size, Bangladesh struggles with considerable challenges in meeting basic healthcare needs [9]. Research indicates a direct link between WASH score and communicable diseases, such as diarrhoea, typhus, pneumonia, and skin infections [10–12]. These conditions pose a threat to public health in Bangladesh and significantly contribute to the global disease burden.

Improved hygiene practices are considered among the most cost-effective social interventions for reducing the burden of diarrhoeal and other communicable diseases. Hand washing is the most prominent and affordable hygiene practice among low-income populations [13]. Hand hygiene is an easy way to prevent the spread of infections. The WHO started a global hand hygiene campaign in 2005 called "Clean Care is Safer Care" [14]. Bangladesh actively engaged with this initiative and participated in a WHO regional workshop held in Bangkok, Thailand, in 2007, alongside several other countries. Since then, hand hygiene principles have been progressively integrated into the country’s infection prevention and control strategies, particularly within hospitals. The campaign’s significance was further reinforced during the COVID-19 pandemic through nationwide awareness and behavioural change programs.

However, the WASH situation in Bangladesh remains a significant challenge, despite progress in some areas. While 99.5% of households have access to basic water, only 60.7% have access to basic sanitation, and 56.3% have access to basic hygiene [15]. A substantial portion of the population lacks access to safe drinking water and sanitation, and many do not practice basic hygiene, leading to health concerns such as diarrhoeal diseases. The consequences of poor WASH scores are reflected in the high incidence of various infectious diseases in Bangladesh. Bangladesh has a notable incidence of diarrhoeal diseases, tuberculosis, dengue fever, and various other infectious ailments [16]. While the prevalence of tuberculosis (TB) has declined substantially, Bangladesh still ranks among the top ten countries in the world with the highest TB burden [17]. Regarding the human immunodeficiency virus (HIV), only less than 0.01% of the population is reported to be HIV-positive [18], but rates are much higher among high-risk populations such as injecting drug users, sex workers, and men who have sex with men [19]. Pneumonia and waterborne diseases are widely prevalent [20,21]. Diarrhea, which spreads quickly due to its short incubation period, is the most prevalent disease. It is estimated that approximately 88% of diarrhoeal diseases are attributable to drinking contaminated water, improper sanitation, and poor hygiene [22].

Improving WASH practices can significantly reduce disease burden. An earlier estimation suggested that nearly 2.4 million deaths (4.2% of all causes of death) worldwide could be avoided by adopting appropriate WASH practices [23,24]. Despite being a densely populated LMIC, Bangladesh has achieved substantial improvements in basic WASH services, such as improved drinking water, hand washing, and the elimination of open defecation. However, a significant proportion of the population is still exposed to unsafe WASH conditions [25,26]. Different studies have shown that hand washing can decontaminate hands and prevent cross-transmission [27,28]. Washing hands with soap can also reduce the risk of endemic diarrhoea, respiratory diseases, and skin infections [29]. Although previous studies have examined the effects of large-scale WASH interventions in rural Bangladesh [30] and explored gaps between hygiene knowledge and practice [31], most existing research remains rural-focused or intervention-based.

To address this gap, the present study investigates the association between hygiene-related factors and communicable diseases in two urban municipalities, Savar and Satkhira, selected for their contrasting socioeconomic and geographic characteristics. Community-level epidemiological studies in urban Bangladesh remain limited, yet understanding the relationship between hygiene behaviour and disease burden is essential. This study aims to generate evidence that can inform the design of targeted public health strategies and guide future policy development.

Methodology

Result

Table 1 presents the sociodemographic characteristics of the 607 participants involved in this study. The majority of respondents were aged 30 years or below (40.5%), followed closely by those in the 31–40 age groups (36.7%). Females and Muslims constituted significant portions of the sample (83.7% and 87.3%, respectively). Educational attainment varied with 23.1% reporting no formal education, 51.7% completing primary education, and 16.5% finishing junior high school. Occupationally, the majority were housewives (63.3%), followed by labourers (18.6%), with a small percentage engaged in service roles (10.4%) and others (7.7%). Marital status was prevalent among the participants, with 94.2% being married. Half of the participants’ monthly income was around 5001–10,000 taka, 31.8% earned 10001–15,000 taka, 10.5% made around 5000 taka or less, and only 7.7% earned more than 15,000 taka.

Regarding housing, the majority lived in tin shed homes (34.3%) or semi-built structures (41.7%), while only a minority resided in more modern building-type accommodations (9.1%).

Table 2 shows the hygiene and disease-related factors of the study participants. For the majority of respondents, tube well water (88.1%) met the need for drinking water. Other sources like supply water constituted the remaining sources of drinking water. The analysis also revealed the diverse sanitation practices among participants, with the majority (66.1%) utilising sanitary toilets, while 33.9% opted for water-sealing slab toilets. Notably, nearly all participants reported regular hand-washing habits, with 94.6% washing before or after food, and 95.6% practicing hand hygiene both before and after using the toilet. Waste disposal methods varied, with 46.8% disposing of household waste in dustbins, subsequently managed by municipal workers, while 53.2% of the waste was directly dumped in other ways. Regarding health factors, a substantial proportion of households (42.8%) reported at least one member with a chronic illness in the past 12 months, while 24.1% of households had at least one member affected by a communicable disease during the same period. These conditions were reported by the respondent as a representative of the household. Most (99.7%) received regular visits from PEPSEP volunteers, although opinions on the sufficiency of PEPSEP vouchers were mixed, with 78.9% considering them adequate and 21.1% considering them insufficient.

Fig 1 illustrates the distribution of specific communicable diseases among participants who reported being affected. Among those with communicable diseases (24.1% of the total sample), diarrhea was the most prevalent (12.9%), followed by typhoid (5.9%), jaundice (4%), tuberculosis (1.8%), dengue (1.3%), COVID-19 (0.8%), HIV/AIDS (0.3%), and other diseases (4.8%), respectively.

Table 3 presents the characteristics of the respondents and their correlation with communicable diseases. The results revealed several significant associations, including family income (p = 0.003), history of chronic diseases (p < 0.001), and source of drinking water (p = 0.001). Additionally, various hygiene-related variables were significantly associated with communicable diseases, including toilet type (p = 0.013), hand washing practices before and after food intake (p < 0.001), hand washing practices before and after toilet use (p < 0.001), and garbage dumping practices (p < 0.001).

Logistic regression analysis identified several significant associations between the explanatory factors and the likelihood of developing communicable diseases (Table 4). Gender was a significant factor, with females being 3.21 times more likely than males to develop the disease (OR: 3.21, 95% CI: 1.19 to 8.66, p = 0.003). The source of drinking water was also significant, with those using tube well water having higher odds ratios (OR: 2.81, 95% CI: 1.13 to 7.02, p = 0.015). The toilet type showed significant associations with sanitary latrines (OR: 0.18, 95% CI: 0.07 to 0.49, p = 0.002) and sanitary latrines connected to septic tanks, reducing the likelihood of disease. Unwashing hands before or after eating (OR: 23.1, 95% CI: 1.98 to 69.41, p = 0.003) and not washing hands before or after using the toilet (OR: 12.31, 95% CI: 2.86 to 53.03, p < 0.001) significantly increased the risk. A history of chronic disease also increased the odds of developing communicable diseases (OR, 3.73; 95% CI: 1.49 to 9.59, p = 0.007).

Discussion

This study adds to growing evidence of the association between hygiene-related factors and communicable diseases in urban Bangladeshi populations. By focusing on vulnerable households in two municipalities, the findings offer valuable insight into WASH-related disease patterns beyond rural settings where most previous work has focused. The present study assessed the association between hygiene-related factors and communicable diseases among the people of two municipalities in Bangladesh. To the best of our knowledge, this is one of the pioneer research studies to explore the association of hygiene-related factors with various communicable diseases in Bangladeshi urban settings. The findings of this study highlight the prevalence and correlation of communicable diseases among a sample of Bangladeshi population.

The study revealed that almost one-fourth of the participants had a communicable disease, with diarrhoea being the most common disease, followed by typhoid and jaundice.This information was self-reported by participants during face-to-face interviews, based on their disease history in the past year. These findings are consistent with previous studies conducted in Bangladesh that reported high rates of diarrhoeal diseases [33]. The study also identified several significant predictors of communicable diseases, including sex, source of drinking water, type of toilet, and hand hygiene practices. Specifically, females were more likely to develop communicable diseases than males in the current study. These results are consistent with the claims reported in existing literature [34]. A previous study reported a higher prevalence of diarrhoea among adult females than among adult males. This could be because adult females are more frequently involved in household activities, such as cooking, cleaning, and caring for children, which increases their exposure to unsafe water and poor sanitation conditions in the domestic environment [35]. These findings are consistent with results from the WASH Benefits trial in rural Bangladesh, which showed that improvements in water quality, sanitation, and hand washing significantly reduced diarrhoea and child growth faltering [36]. However, the trial also noted that single-component interventions were often insufficient on their own, highlighting the need for integrated WASH strategies, a conclusion aligned with our study’s findings from urban settings.

Our research findings show that, not washing hands before or after eating or using the toilet increases the risk of communicable diseases, highlighting the importance of promoting and improving hand hygiene practices among the population [37]. Most respondents in this study practiced hand washing before and after taking food and using the toilet, but it is essential to practice hand washing regularly before and after taking food and using the toilet to prevent disease. This study indicates that those who did not maintain their hand hygiene practices had significantly higher odds of developing communicable diseases. This result is consistent with findings from research conducted in Dhaka, which revealed that the majority of their study participants washed their hands with water, but only 22.5% washed their hands effectively by maintaining the correct steps and frequency of hand washing with water and soap or hand sanitisers [38].

The findings also claimed that the use of ring slab toilets and sanitary toilets connected to septic tanks is protective against communicable diseases, which is consistent with other studies [39]. These toilets are designed to prevent disease transmission by minimising human contact with faecal matter, which can contain pathogens. According to the CDC, proper sanitation facilities (e.g., toilets and latrines) promote health because they allow people to dispose of their waste appropriately, preventing contamination of their environment and reducing risks to themselves and their neighbours [40]. The present study reported that household source of drinking water is associated with having communicable disease among the study participants. The present study reported that household sources of drinking water were associated with communicable diseases among study participants. According to a recent study conducted in Bangladesh, many water sources had fecal contamination with pathogens, including E. coli [13]. Also, tubewell water was found to be contaminated with Rotavirus, Adenovirus, E. Coli, Shigella, Vibrio cholerae, and other fecal pathogens [41]. Tubewells commonly found in rural areas of Bangladesh are often situated close to the latrines and ponds. Possible mechanisms for tube well contamination with faecal pathogens include infiltration into groundwater from nearby latrines, septic tanks, and ponds [41].

This study also found that individuals with chronic illnesses were more likely to report communicable diseases. This may be due to weakened immune systems or compromised bodily functions, which can make individuals with chronic conditions more susceptible to infections. In turn, the presence of infections can exacerbate the complications of chronic illnesses, resulting in worse health outcomes. This finding supports the need for targeted preventive measures among people with preexisting health conditions to reduce their risk of communicable diseases.

Based on these findings, future WASH interventions in urban Bangladesh should prioritise safe water infrastructure, especially improving deep tube well quality control and distance from latrines or waste sources. Promotion of correct handwashing technique using soap, and upgrading sanitation facilities (e.g., from basic to improved/septic tank systems) should be central to urban public health campaigns. Community health workers and existing platforms like PEPSEP could be mobilised to deliver targeted WASH messaging, especially to households with chronic illness cases, who are at elevated risk of infection.

The strengths of this study include the use of population-based large survey data with poor municipal people who are vulnerable to developing communicable diseases and the use of rigorous statistical methods.

Limitation

In addition to its strengths, this study had several limitations. As the survey was restricted to only two municipal areas in Dhaka and Satkhira, it did not reflect the Bangladeshi population as a whole. While socio-demographic variables such as sex, education, and income were included in the analysis, the relatively homogenous nature of the sample may limit the generalisability and depth of subgroup comparisons. Additionally, disease data were based on self-report by household representatives and were not verified through medical records, which may introduce recall bias or misclassification of disease status. As a result, estimates of disease burden may be subject to measurement error. Finally, due to the cross-sectional design, the study can identify associations but cannot establish causal relationships between hygiene-related exposures and communicable disease outcomes. Future nationwide studies using longitudinal or mixed-method designs are recommended to validate and expand these findings.

Conclusions

In conclusion, this study highlights a significant burden of communicable diseases among urban populations in Bangladesh, with higher risk observed among females and individuals using deep tube well water. Conversely, good hand hygiene practices were associated with a lower risk of disease. These findings underscore the need for targeted interventions aimed at improving access to safe drinking water, promoting proper sanitation, and reinforcing hand hygiene behaviours, particularly among vulnerable groups. The results of this study can inform stakeholders such as policymakers, public health officials, and development agencies in designing evidence-based interventions, including WASH education campaigns, infrastructure development, and community-level health programs. Incorporating hygiene-focused strategies into national and local health plans may reduce disease burden and support long-term health outcomes. Further research across diverse regions of the country is recommended to validate and expand upon these findings, ultimately guiding a more coordinated public health response to communicable disease prevention in Bangladesh.

Supporting information

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