Diarrhoeal disease is one of the major causes of morbidity and mortality in children and is usually measured at individual level. Shared household attributes, such as improved water supply and sanitation, expose those living in the same household to these same risk factors for diarrhoea. The occurrence of diarrhoea in two or more children in the same household is termed ‘diarrhoea clustering’. The aim of this study was to examine the role of improved water supply and sanitation in the occurrence of diarrhoea, and the clustering of diarrhoea in households, among under-five children in India. Data were taken from the fourth round of the National Family and Health Survey (NFHS-4), a nationally representative survey which interviewed 699,686 women from 601,509 households in the country. If any child was reported to have diarrhoea in a household in the 2 weeks preceding the survey, the household was designated a diarrhoeal household. Household clustering of diarrhoea was defined the occurrence of diarrhoea in more than one child in households with two or more children. The analysis was done at the household level separately for diarrhoeal households and clustering of diarrhoea in households. The presence of clustering was tested using a chi-squared test. The overall prevalences of diarrhoea and clustering of diarrhoea were examined using exogenous variables. Odds ratios, standardized to allow comparison across categories, were computed. The household prevalence of diarrhoea was 12% and that of clustering of diarrhoea was 2.4%. About 6.5% of households contributed 12.6% of the total diarrhoeal cases. Access to safe water and sanitation was shown to have a great impact on reducing diarrhoeal prevalence and clustering across different household groups. Safe water alone had a greater impact on reducing the prevalence in the absence of improved sanitation when compared with the presence of improved sanitation. It may be possible to reduce the prevalence of diarrhoea in households by targeting those households with more than one child in the under-five age group with the provision of safe water and improved sanitation.

Program interventions like access to improved water supply, sanitation and hygiene do not have a systematic response to the aggregate health outcomes. Therefore, this is an attempt at recognising the concept of level sensitivity while verifying the association between prevalence of diarrhoea in under-five children in a district and its corresponding coverage of improved water supply and sanitation and hygiene. Information obtained in the DLHS—4 including 275 districts from 19 states and 2 union territories of India forms the database for this analysis. Universal access to safe drinking water, improving coverage of sanitation in a district beyond 71 percent across the country and beyond 78 percent among the non-south DLHS districts, has the potential to realise reductions in the prevalence of diarrhoea in under-five children in a district. The effect of improved sanitation seems to work synergistically with these indicators only at better levels of prevalence of diarrhoea in under-five children in a district. This offers lessons for the Clean India Mission in terms of universalising access to safe water and coverage up to three-fourths of households with sanitation in a district for the positive externalities to manifest in reduced prevalence of diarrhoea in under-five children.

Information on safe water, sanitation and hand washing obtained in large scale surveys are used to validate its responsiveness to childhood ailments. Definition of these variables are uniform to enable comparison within and across countries and devoid of the context and circumstance. Associating these variables with prevalence of diarrhoea overlooking the context seem to distort the relationship and lead to spurious results. An empirical verification of such an association in an Indian context based on the most recently conducted NFHS-4 data set brings to the fore apparent contradictions that cautions on the use of these variables as they are obtained. It calls for a redefinition of these variables prior to verifying their responsiveness to childhood diarrhoea as illustrated here.

To cite: Vijayan B. Observation of unsafe medical practice during research in a healthcare-deprived area.

Residential segregation of settlements on caste lines is common across Indian villages. Banjara settlements or tandas are an extreme form of residential segregation, rooted in colonial history and India's complex caste system, and an outcome of structural discrimination. This analysis examines the structural discrimination of tandas in the distribution of various infrastructure and compares it with the villages in proximity to it. A cross-sectional comparative study of infrastructure was conducted in Banjara tandas and villages in Gadag district, Karnataka, India. Composite scores were computed for various infrastructure and discriminant analysis done to classify tandas and villages. The villages have better physical infrastructure such as paved roads, multiple water supply sources, and better drains and amenities such as the community water filter, ration shop, veterinary center, milk society, banks, post office, and health facilities compared to tandas. Discriminant analysis indicated that social infrastructural indicators of health and education (Discriminant function coefficient −0.8689), followed by transportation (Discriminant function coefficient −0.3576) and water supply (Discriminant function coefficient −0.2939), are the most significant discriminating factors between tanda and villages. This disadvantage indicates structural discrimination that is a continuation of the stigma and labeling perpetrated upon them historically and the complex caste system in Indian societies.