Swach Bharat Abhiyan: insights from students of a central university

INTRODUCTION

The word “hygiene” is defined as “conditions or practices conducive to maintaining health and preventing disease, especially through cleanliness”.¹ Hygiene can be achieved through cleanliness and not vice versa. It can be practiced at personal, domestic, and community levels.² Without hygiene, the lives of millions of people are at risk. All disease control interventions to a greater extent rely on hygiene to achieve their goal.

Sanitation has been identified as one of the important determinants of the health and hygiene since ages. As per the report of environmental performance index 2016, 2.4 billion people across the world do not have access to basic sanitation. Addressing sanitation issue is the need of the hour which not only helps in reducing the burden of the communicable diseases but also provides the scope for gross domestic product (GDP) growth, reduction in health care costs and a source of employment.³ Sanitation and hygiene is critical to health, survival and development. Hygiene causes a global health challenge especially in the developing world. These practices affect the perception of the individual and influence their selection of healthcare facilities. As reported by Hoornweg and Bhada-Tata (2012), world cities are producing about 1.3 billion tons of solid waste annually and this is projected to reach 2.2 billion by 2025.⁴ In recognition of this, improved sanitation through appropriate waste management is being prioritized in major Global developmental agendas including the sustainable development goals (SGD). Despite its awareness, knowledge about segregation and the long-lasting side effects of wastes is not considered to be a major concern. Municipal solid waste collection, treatment and/or disposal remains a challenge to many cities.^5,6 The developing world continue to struggle with basic collection and disposal issues.

The pathetic state of sanitation index in India has put the country behind many countries. To overcome the sanitation related challenges in any country and to ensure the success of health-related campaigns, the participation of community is very much essential. Considering the importance of hygiene, a cleanliness drive has been started in India i.e., Swach Bharat Abhiyan. SBA is a national campaign which was started on October 2^nd 2014.³ Their major goals included elimination of open defecation municipal solid waste management, healthy sanitation practices, generate awareness etc. by 2019. The central focus being building toilet to eliminate open defaecation.⁶

Cleanliness being an integral part of health and hygiene needs to be maintained at an individual level and also of the surrounding. Issues related to cleanliness remain a major challenge in India. Cleanliness and Hygiene promotion practices had always been neglected in purview of public health care services, demanding for deployment of strategies for its improvement.² Therefore, it becomes important to take the view of the society who is responsible for each and every act they do which can take their country to a significantly different level. Considering this view, this study has been undertaken among the students of central university.

As the implementation of hygiene faces more challenges due to the difference in attitude, beliefs and lifestyles of participants; knowledge and perception towards SBA was assessed among the university students. A younger group was chosen as they are the workforce and backbone of the country. Assessing their viewpoint might give a brief idea about the understanding of SBA and their contribution in this cleanliness drive. Their view might also give an idea about the effectiveness of SBA mission and the changes which can be considered to complete the SBA goals. Also, to know the people’s feedback whether it is holding its value in regards of its goal of 2019 as large amount of expenditure was made in SBA.

With this background, this study was undertaken to assess knowledge, perception and practices regarding SBA. To know the perception to draw comparison between medical and non-medical students towards clean India and to compare them and to determine whether SBA plays its role in improving the attitude of people towards cleanliness.

METHODS

This study was conducted at Jawaharlal Nehru medical college, Aligarh Muslim university, Aligarh, U.P. India. It was a cross sectional study done for a period of 5 months (15^th September 2018 to 15^th February 2019). Self-explanatory semi-structured questionnaire were used in this study with close ended questions in English language.

Part 1of the study contains student particulars i.e., name, age, sex, qualification, college and contact address. The name of students was kept confidential. Part 2 of the paper had three divisions i.e., knowledge, attitude and practices regarding the programme. This included 10, 14 and 7 questions of knowledge, attitude and practices respectively. We had taken the questions from the previous study Kishore et al. The pilot study was conducted on thirty students and the questions were modified accordingly. The time allotted to fill the questionnaire was about 20 minutes.

The enrolled students of Aligarh Muslim university, belonging to medical and non-medical fields in the age group of 17 to 30 years were selected according to their availability in the University. The medical students from MBBS, BDS, BUMS and non-medical undergraduate and post graduate students from the faculty of engineering, science, commerce and arts were selected to fill the questionnaire. The consent was taken from the available students present in the classes and hostels and then the students were randomly selected and the proforma were distributed amongst them (and explained according to the need). The students were asked to fill up the proforma to assess their knowledge, attitude and practice the complete filled up proformas were included in the study. The incomplete performs, the students who were not aware of SBA were excluded from the study. The pilot study which was conducted among 30 students were not included in the survey. The sample size was 416.

Taking the prevalence, the sample size (N) was taken as 416 where:³ p=55%, q=45, l=5-10% at 95% confidence level. N=4pq/l²

Equal proportion of medicos and non-medicos i.e., 208 students from both groups participated in the study. The data was entered in Microsoft excel and analyzed in SPSS statistical software version 20.0. The value of p<0.05 was considered as statistically significant.

The participation was strictly voluntarily and was dependent on oral consent by the participants. The respondents were informed of the study and the data was strictly kept confidential.

RESULTS

The students were taken in the age group of 17 to 30 years (median age 21 years). Out of 416 participants, 201 (48.5%) were male while 215 (51.7%) were female. The distribution of people who took the part to make the India clean, 194 (46.63%) were medicos while 190 (45.67) were non-medicos.

Out of 416 participants (98.1%) were aware of SBA while others remain unaware (Table 1). The survey analysis showed that media had a major role whether they are medico or non-medico in increasing awareness regarding SBA as shown in Figure 1, in comparison to awareness created due to newspaper and people. Knowledge regarding source of information about SBA (through newspaper, media, and paper) was found to be significantly different (p<0.05) between medicos and non-medicos as shown in the Table 1. This shows the significance of medical education towards cleanliness and hygiene.

The difference in knowledge about the amount spent in SBA between both the group were found to be significant (p<0.05). Hence medical education plays an important role in creating awareness towards making of any policies and programmers (its pros and cons).

The study reflects that majority of the medicos felt that SBA required in India and this difference was found to be statistically significant.

The difference of opinion about SBA responsibilities which has been shifted from actual worker to the people were significantly different (p<0.05) and 220 (52.9%) of the students were agreed while 70 (16.8%) were disagreed.

The believe that only building infrastructure like public toilets etc. can help to achieve clean India were only 20.9% while all others were disagreed over this.

The knowledge regarding improvement of public toilet 175 (42.5%) students said yes while 137 (32.9%) of them said no.

While regarding cleanliness which has increased after launch of SBA 181 (43.5%) people were agreed, 125 (30.1%) were disagreed while others remained neutral as shown in Figure 3. This means government efforts to provide sanitation leaves more to be desired (Table 1).

While judging the attitude of participants (as described in Table 2), 240 (57.7%) of the agreed that SBA is for political benefit while 176 (42.35%) disagreed over this. Total 241 (58%) people felt that participation of celebrity is only for publicly while 78 (18.7%) participants disagreed. 271 (65.1%) people said that there is no decrease of vector borne disease while 145 (34.9%) people said it is.

Poor municipal solid waste management in developing countries is epitomized in inappropriate dump sites, which are often located close to residential facilities. This proximity to residential spaces has been associated with disease outbreaks including cholera, acute respiratory infections and malaria (WHO, 2013).

The present study stated that 346 (83.2%) students agreed that it is useful programme, 25 (6%) disagreed over this while others remained neutral. Figure 4 and 5 describes the perception regarding improvement of the city after SBA and perception of medical and non-medical students regarding usefulness of SBA respectively (Table 2).

Table 3 contains some questions which reflects the student’s behaviour and practices. Regarding the part played at individual level to make India clean, 194 (47.08%) medicos 190 (46.11%) non-medicos said yes. Students perceived that behavior change communication is very important to bring change in community whether one belongs to medical field or non-medical field. Hence the difference in opinion among the two groups were same. The difference of opinion amongst the two groups regarding SBA was found to be significant.

Treating your society as your own property and not dumping the waste at a corner can be the first step in making India clean. Majority of the students 366 (88%) believe in disposing the solid wastes in community bins while 50 (36.6%) used to dispose in open (Table 3). This shows the active participation at individual level about clean India is still lacking. While if you talk about to volunteer oneself towards clean India majority said no. The difference of opinion regarding SBA required in India amongst the two groups was found to be significant. 346 (83.2%) were agreed while 25 (6%) were disagreed over this. If talking about the usefulness of this programme in a country, the reviews from both the group was also found to be significant.

In the current study about 92.3% played their part to make India clean, 83.7% encouraged other individuals to participate while only 32% volunteer themselves to clean the streets. The distribution amongst the two groups i.e., medico and non-medicos, males and females remain the same. The perception regarding disposal of solid waste is mainly in the community bins by the students which show that they are responsible and taking a step forward for cleanliness (Table 3).

DISCUSSION

In the current study 201 were males while 215 were females. Most of them falls between 19 to 25 years. In the Kishore et al study, most (29.6%) of the subjects falls under 21-30 years age category and were females.³In the similar study done by Karan et al in Jharkhand, it was observed that majority (39%) of the study subjects falls into 21-30 years age category and most (76%) of the subjects were females. In the current study young individuals were targeted.

Knowledge regarding SBA

In our study 408 students were aware of SBA. That seems to be a very good proportion and highest among all the studies which were done previously. This can be due to awareness which is being spread and the initiatives being taken by the government and non-government organizations through mass media, newspaper etc. Secondly, the students are more active and aware to spread the change to make India clean. In the Kishore et al study it was found that 204 out of 328 participants have heard about SBA.³ Swain et al study which was conducted in Uttar Pradesh and Madhya Pradesh in the year 2015 stated that only 24% of the subjects were aware of SBA which was shockingly low.⁹ In contrast it was found that 93.62% of the participants were aware of SBA in Karan et al study. In the current study about 247 were aware of the objectives of SBA while 169 were unaware. In the study by Kishore et al (87.7%) of the subject were aware of the objective of SBA regarding disposal of solid wastes only whereas this is only 62.3% according to Karan et al.

271 people said that there is no decrease of vector borne disease while 145 people said it played its impact.

The success of any cleanliness programme in reducing epidemic outbreak is equally important. Epidemic particular like diarrhea, dysentery, cholera, hepatitis etc. are considered by the public health experts to be the most important determinants of cleanliness of the environment and its impact on the health of the community.⁷ Cleanliness drive should be impactful enough to decrease the number of epidemics reported within the community. Hence any success with the SBA should have made some dent in the outbreak of these epidemics but the current data is against it. Though it remained insignificant.

Attitude towards SBA

The present study suggested that about 346 students agreed that SBA is a useful programme for the community. Kishore et al study found that 85.78% of the subjects felt the same. Pradhan study stated that 76.08% of the subjects agreed that SBA helps in the development of the country and also 54.34% agreed that SBA has brought changes on the ground level.¹⁰ In another study conducted by Utpat et al in Pune, it was found that 80.43% subjects thought that there is need of SBA and 72.82% felt that SBA is effective.¹¹ These findings reflect the positive perception of the community towards SBA.

Current study revealed that 342 of the study subjects thought that all the people must actively participate in SBA activities. 77.45% according to Kishore et al and 91.30% of the subjects wanted to participate in SBA according to Utpat et al study.¹¹

In the present study 240 students agreed that SBA is for political benefit. Interestingly 22.05% felt that political benefits are other side of the coin for propagating SBA according to Kishore et al If the political benefit is there definitely it will add benefits to the better improvement of the city.⁷ One should keep in mind that the primarily focus should be implementation of the programme rather than its promotion and events of the scheme.

Practice regarding SBA

In the present study 366 of the students using the community bins that remains the large number and showed the positive perception of students towards cleanliness.

In the Kishore et al study it was found that only 34.75% of the subjects were disposing solid waste in community bins.³ Yoada et al in their study reported that 61% of the subjects were utilizing community bins.¹² Other studies showed the low percentage for using community bins. This can be due to illiteracy and lack of awareness amongst the people. Two of the deploying tools which can be used positively are mass media and interpersonal communications.

In the current study about 384 played their part to make India clean, 348 encouraged other individuals to participate while only 133 volunteer themselves to clean the streets. The distribution amongst the two groups i.e., medico and non-medicos, males and females remain the same.

In Kishore et al study, only 25.98% of the subjects have participated in SBA activities, however 59.31% of the participants would like to motivate people to participate in SBA activities.³ Contrast findings were observed in Karan et al report which showed that 94% subjects have participated in SBA.⁸ This shows that the knowledge is increasing among the people but the practice is still lacking. More steps and restricted laws should be made in order to reach the goal to make the country clean. It is the fundamental duty of every citizen to protect and improve the natural environment (article 51 A (g)) of constitution of India.

About whether municipal corporation is active only 133 said yes while 173 said denied of them being active. Sustainable and active participation of public and government and non-government organization in the national cleanliness drive can help proper development of our cities, towns, and villages. This is possible only if adequate steps are taken to create awareness, impart education and develop a sense of responsibility towards our surroundings.

Often the government’s helplessness come to the fore on the cleanliness front and the disparity between policy and practice in waste management and disposal can be due to fundamental reasons i.e., no laws, wrongful operation, shortage of resource, inability of the individual/community to utilize the resources at its best. Every level situation is becoming worst whether you talk about individual or community level. Spending lots of money, building toilets and other infrastructure will not going to solve the problem alone. Behavior change communication with community participation is very important with the enforcement of laws in order to make one’s nation clean and green.²

Limitations

As the study subjects are drawn only from the students of one Central university, it would have been a good scientific idea to draw sample considering various other universities so as to draw better scientific conclusion in order to diversify the study. In the present case due to non-availability of funds and paucity of time, the above-mentioned sampling procedure with multicentric approach could not be taken into consideration.

CONCLUSION

The cost of public health crises is far greater than the price of fixing it. That’s why SBA must power on its efficacy sharpened by regular impact assessment studies and learning they provide SBA could have been much more impactful if it was clubbed with issuance of certain ordinance or act giving more teeth to the environment pollution act and at the same time invigorating the existing environment laws.

The current study reflects that majority of the population were aware of SBA and its objective and the amount spent and the students of central university had shown positive attitudes and perception towards SBA to make India clean. Students perceive that initiative should start at the ground level. “Charity begins at home”. “Be the change you want to see in the world”. The first and foremost step towards any proper waste management process depends on positive attitude towards clean environment. It should be a program for public sensitization. Therefore, education should be the priority at school level, university level and national level too. Majority agreed that the programme is needful in one’s country and government should take more steps to achieve its goal and municipal and other organization should become more active and come forward from its slumber to make India clean and green. Actions are required and actions do speak louder than words. Government should build up momentum.

ACKNOWLEDGEMENTS

Author would like to thanks to Dr. Nafis Faizi and Dr. Tabassum Nawab and Prof. Anees Ahmad and Dr. Samreen Khan for their motivation and support and Dr. Fauzia Farheen and Dr. Sana Shadab who helped to write this paper.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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