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Learn more: PMC Disclaimer | PMC Copyright Notice Sci Rep . 2026 Mar 2;16:11771. doi: 10.1038/s41598-026-42042-9 Search in PMC Search in PubMed View in NLM Catalog Add to search Exploring the burden of diarrheal disease and associated WASH practices in rural West Bengal, India: an explanatory sequential mixed-method approach Suman Kanungo Suman Kanungo 1 Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India 4 Division of Epidemiology, ICMR-Regional Medical Research Center North East (ICMR-RMRCNE), Dibrugarh, Assam India Find articles by Suman Kanungo 1, 4, ✉, # , Shubhajit Pahari Shubhajit Pahari 1 Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Shubhajit Pahari 1, # , Aritra Paul Aritra Paul 2 Department of Health and Family Welfare, Government of West Bengal, Kolkata, India Find articles by Aritra Paul 2 , Rounik Talukdar Rounik Talukdar 1 Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Rounik Talukdar 1 , Sombuddha Biswas Sombuddha Biswas 1 Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Sombuddha Biswas 1 , Sougata Chatterjee Sougata Chatterjee 1 Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Sougata Chatterjee 1 , Diplina Barman Diplina Barman 1 Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Diplina Barman 1 , Debjit Chakraborty Debjit Chakraborty 1 Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Debjit Chakraborty 1 , Pramit Ghosh Pramit Ghosh 1 Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Pramit Ghosh 1 , Bipul Chandra Karmakar Bipul Chandra Karmakar 3 Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Bipul Chandra Karmakar 3 , Atreyi Chakrabarti Atreyi Chakrabarti 2 Department of Health and Family Welfare, Government of West Bengal, Kolkata, India Find articles by Atreyi Chakrabarti 2 , Swati Pramanick Swati Pramanick 2 Department of Health and Family Welfare, Government of West Bengal, Kolkata, India Find articles by Swati Pramanick 2 , Asish Kumar Mukhopadhyay Asish Kumar Mukhopadhyay 3 Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Asish Kumar Mukhopadhyay 3 , Ranjan Kumar Nandy Ranjan Kumar Nandy 3 Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Ranjan Kumar Nandy 3 , Alok Kumar Deb Alok Kumar Deb 1 Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Alok Kumar Deb 1 , Falguni Debnath Falguni Debnath 1 Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Falguni Debnath 1 , Shanta Dutta Shanta Dutta 3 Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India Find articles by Shanta Dutta 3 , Debasis Roy Debasis Roy 2 Department of Health and Family Welfare, Government of West Bengal, Kolkata, India Find articles by Debasis Roy 2 , Mukti Sadhan Maiti Mukti Sadhan Maiti 2 Department of Health and Family Welfare, Government of West Bengal, Kolkata, India Find articles by Mukti Sadhan Maiti 2 , Dipankar Maji Dipankar Maji 2 Department of Health and Family Welfare, Government of West Bengal, Kolkata, India Find articles by Dipankar Maji 2 Author information Article notes Copyright and License information 1 Division of Epidemiology, ICMR - National Institute for Research in Bacterial Infections, Kolkata, India 2 Department of Health and Family Welfare, Government of West Bengal, Kolkata, India 3 Division of Bacteriology, ICMR- National Institute for Research in Bacterial Infections, Kolkata, India 4 Division of Epidemiology, ICMR-Regional Medical Research Center North East (ICMR-RMRCNE), Dibrugarh, Assam India ✉ Corresponding author. # Contributed equally. Received 2025 Sep 21; Accepted 2026 Feb 24; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13066008 PMID: 41772137 Abstract Diarrheal diseases continue to be a major public health concern in low- and middle-income countries, where insufficient water, sanitation, and hygiene (WASH) practices lead to a substantial community burden. We conducted a cross-sectional census survey with follow-up qualitative interviews, which assessed the cumulative incidence and associated factors of diarrheal diseases in Bishnupur-II block of South 24 Parganas district in West Bengal, India, between April and June 2024. We conducted a census-based survey of 12,793 households, obtained valid responses from 10,000 and followed by qualitative interviews with mothers of under-five children and key health workers. Overall, the 6-months cumulative incidence was 16.9% (1690/10,000 households) with 75.9% of the families reported seeking treatment for their children at government health facilities. Households that relied on vendor-supplied drinking water had 2.71 times greater odds of diarrhea (AOR: 2.71; 95% CI 1.84–4.01), whereas those who only used water for handwashing had a threefold increased odds (AOR: 3.14; 95% CI 2.51–3.93). The majority (78.6%) of the households did not disinfect drinking water. Qualitative investigations identified awareness gaps, cultural views, financial limitations, poor infrastructure, and the importance of community engagement as crucial factors on hygiene behavior. Integrated quantitative and qualitative observations highlight the need for tailored interventions that combine health education, behavior modification, and improved WASH infrastructure to reduce diarrheal morbidity in rural West Bengal and other similar contexts. Keywords: Diarrhea, Rural population, Epidemiology, Hygiene, Public health Subject terms: Diseases, Health care Introduction Diarrheal diseases have been identified as a major global public health concern contributing substantially to morbidity and mortality worldwide, especially in low- and middle-income countries (LMICs) 1 . Globally, they account for 1.7 billion cases and nearly 440,000 fatalities annually among children under five, with India alone reporting 55.8 million cases and 66,000 deaths per year 2 , 3 . The increased incidence of diarrhea is closely linked to several factors, including hygiene practices, access to clean water, sanitation facilities, and the level of health literacy within communities especially among caregivers 4 – 6 . Open defecation and improper waste disposal increase the risk of exposure to fecal pathogens, leading to infectious disease outbreaks, including diarrhea 7 . Although open defecation has declined significantly in most parts of the world, it still persists in pockets of rural South Asia and Sub-Saharan Africa, particularly among marginalized populations 8 . Studies demonstrate how community-based hygiene education and better sanitation can lower diarrhea incidence by up to 36% in low- and middle-income countries 9 – 12 . In India, national programs like the Swachh Bharat Mission (2014) and Jal Jeevan Mission (2019) have expanded Water, Sanitation and Hygiene (WASH) infrastructure, boosting rural access to basic drinking water from 85% in 2000 to 94% by 2022 and sanitation coverage from 15 to 75% 8 . The National Family Health Survey-5 (NFHS-5), conducted across India during 2019–2021, reported that in West Bengal, rural sanitation coverage was 64.7% and access to improved drinking water was 96.9% while diarrheal prevalence among children under five remained 7.3% 13 . Maternal health literacy and hygiene practices have an important effect on diarrhea prevention. Caregivers who are knowledgeable about safe water storage and handwashing are more likely to practice protective behaviors 14 . However, in rural India, financial restrictions, insufficient health education, and infrastructure deficits restrict progress 6 . These factors, together with reliance on unregulated healthcare professionals, contribute to chronic diarrheal morbidity and risk such as antimicrobial resistance 15 . Although NFHS-5 provides crucial state-level estimates, it is based on a short two-week recall and focuses mostly on children under the age of five, underestimating the cumulative burden of diarrheal diseases. It also fails to provide information on specific WASH behaviors, such as water disinfection, stool disposal, and hand hygiene before handling food, as well as statistics at the block or community level. Our study addresses such gaps by generating six-month cumulative incidence estimates at the family level and using qualitative perspectives from caregivers and frontline health workers. To accomplish this, we executed an explanatory sequential mixed-method approach, in which the large-scale quantitative survey determined the extent and risk factors of diarrheal sickness, and the succeeding qualitative phase addressed the underlying reasons and contextual impediments. By combining quantitative and qualitative insights, we sought to generate community-level evidence that can inform more targeted and locally appropriate interventions, thereby contributing to Sustainable Development Goals (SDG) 3 (Good Health and Well-being) and 6 (Clean Water and Sanitation). Methodology Study design and study area This explanatory mixed-method study was conducted between April 2024 and June 2024 in the Bishnupur-II block of South24 Parganas district in West Bengal, during which the six-month household-level cumulative incidence of diarrheal disease was estimated. South 24 Parganas is a coastal district in West Bengal with a history of recurrent waterborne disease outbreaks, particularly during the monsoon season when water contamination peaks 16 . According to prior studies, the district has one of the highest incidences of diarrheal diseases in the state, driven by factors such as inadequate access to safe drinking water, poor sanitation facilities, and low hygiene awareness 17 . Further, the Bishnupur-II block of South 24 Parganas was strategically selected as the study area based on state health authorities’ recommendations, identifying it as a priority area due to its vulnerability to diarrheal diseases and WASH-related challenges. As per the Census, 2011 South-24 Pargana district consist of 8,161,961 population and 30 administrative blocks 18 . In the Bishnupur-II block there are total 11 Gram Panchayats (GP) (village-level elected local self-government bodies) among them we have selected three GP namely- Nahazari, Khagramuri and Bakrahat due to high burden of Diarrhea cases reported in recent years which consist total six number of Sub-centers (SC) (namely Nahazari South, Nahazari North, Angarberia, Ramnagar, Khagramuri and Chaksukdev) in the catchment area (Fig. 1 ). Fig. 1. Open in a new tab Location of the study area in South 24 Pargana district of West Bengal, India. Study population and sampling Based on Panchayat records and prior mapping data from local Accredited Social Health Activist (ASHA) workers, the area was estimated to include ~ 12,793 households. A door-to-door enumeration of all households was conducted as part of a comprehensive census in the chosen GPs. This method confirmed maximum representation and reduced sampling error. Following data validation, removal of incomplete entries, and deduplication, responses from exactly 10,000 families were included in the final analysis. Thus, while the study aimed to cover all families in the selected GP, the final number reflects fully completed, validated entries. For the qualitative part, we applied the data saturation concept, conducting interviews until no new themes came up. A total of ten in-depth interviews (IDIs) with mothers of under-five children and six key informant interviews (KIIs) with Auxiliary Nurse Midwives (ANMs) stationed at the six sub-centers in the study area were enough to achieve thematic saturation and cover varied community and health system viewpoints. Mothers of children under five years of age were identified using household census data collected during the quantitative phase for in-depth interviews. Additionally, six ANMs stationed at the six sub-centers in the study area were engaged for KIIs to gather healthcare provider perspectives. Data collection procedure The data collection process was designed to comprehensively capture the study’s quantitative and qualitative aspects, ensuring a robust mixed-method approach. Quantitative data collection Participation was voluntary among responsive families. Inclusion criteria included (i) a permanent resident adult aged ≥ 18 years willing to offer informed permission, and (ii) at least six months of residence in the study area. Exclusion criteria included unoccupied homes, families with no eligible respondent available after two visits, and those who refused to participate. Within each household, the preferred respondent was the adult female head; in her absence, another knowledgeable adult household member was interviewed. ASHA workers were crucial in collecting the data. The ICMR-NIRBI team trained them before the commencement of the data collection from their respective jurisdiction area under the catchment of the Samali Block Primary Health Centre (BPHC), serving as the headquarters for the 3-GPs. A semi-structured questionnaire was developed and piloted prior to its use as a data collection tool. It comprised of questions related to the socio-demographic status of the study participants, hygiene-practice and whether diarrheal episodes reported in the last six months. The major outcome variable, ‘Any incident of diarrhea in the last six months’, was determined at the household level. A household was considered to have experienced diarrhea if any member of the household reported at least one episode of diarrhea within the preceding six-months. The World Health Organization (WHO) defined Diarrhea as the passage of three or more loose or watery stools within 24 h, or an increase in stool frequency beyond the individual’s usual pattern. Passing solid stools frequently does not qualify as diarrhea nor does the passage of loose stools in an exclusively breastfed infant 19 . The complete data collection procedure was supervised and monitored by the research team from ICMR-NIRBI along with the officials of Govt. of West Bengal. Completed census forms were stored in respective Sub-centers before being transported to ICMR-NIRBI for further quality check. Qualitative data collection From the 2nd week of June until the last week, IDIs were conducted with selected mothers of children under five years of age who had reported at least one episode of diarrhea in the previous six months to explore their hygiene practices, perceptions of diarrheal diseases, and health-seeking behaviors. A total of 10 IDIs were carried out until thematic saturation was achieved. Key informant interviews (KIIs) were also conducted with six Auxiliary Nurse Midwives (ANMs) stationed at sub-centers within the study area to explore their perspectives on hygiene practices in the community, common barriers to behavior change, seasonal patterns of diarrheal disease, care-seeking behaviors among families, and the effectiveness of existing WASH interventions and health education efforts in their respective areas. Both IDIs and KIIs were conducted by trained interviewers fluent in local language using pre-tested interview guides. Prior to starting the interviews, efforts were made to establish a good rapport with the participants. To maintain privacy, interviews were conducted at convenient times and locations for the participants. Before the interview, all study participants provided written informed consent after being informed on the study’s purpose. After the interview, the essential aspects were summarized and their approval was obtained before the KII results were finalized. During the interviews, notes were taken on paper, and recordings were done according to the participant’s preferences. The audio recordings were transcribed the day it was conducted. In order to ensure data confidentiality, interview notes were deidentified and assigned distinct numerical numbers. Data analysis Quantitative data analysis Data entry was done using MS Excel (Version 2016) and the data analysis was done using IBM SPSS Statistics for windows, Version 25 (Released July, 2017; IBM Corp., Armonk, New York, United States). Descriptive statistics were computed for the categorical variables (demographic characteristics, WASH practices of the families, diarrheal episodes and health seeking behavior for diarrhea) and presented as frequencies and percentages to provide an overview of the study population. To examine associations between WASH practices and diarrheal episodes, bivariable logistic regression was performed to estimate crude odds ratios (COR). Subsequently, multivariable logistic regression was conducted to calculate adjusted odds ratios (AOR), controlling for potential confounders such as monthly family income, number of children, family size, and type of housing. The results were reported with corresponding 95% confidence intervals (CI) to assess the strength and significance of associations. We conducted the primary analysis using single-exposure logistic regression models, with each WASH component modelled separately and adjusted for major confounders (such as household income, number of children, family size, and house type). This method yielded precise estimates of the connection between individual habits and diarrheal outcomes. Then we performed a sensitivity analysis by fitting a multivariable model that included all WASH components simultaneously. The Variance Inflation Factors (VIF) were < 3, showing no serious multicollinearity. Qualitative data analysis The qualitative data from in-depth interviews (IDIs) and key informant interviews (KIIs) were transcribed verbatim and analyzed using thematic analysis following Braun and Clarke’s six-step framework 20 . This involved iterative reading of transcripts, open coding, and categorization of codes into themes based on both predefined study objectives and emergent content. Codes and themes were organized systematically using spreadsheets without software. To ensure analytical rigor, as outlined by Lincoln and Guba 21 the final coding framework and thematic structure were reviewed and validated by a senior qualitative research expert from the study team. The analysis followed COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines to ensure comprehensive and transparent reporting. Regular team talks during data collection and analysis helped to eliminate bias and enhance consistency. Ethical consideration —The study was cleared by the Institutional Ethics Committee of ICMR-NIRBI (No. A-10(2)/2024(OCV Trial)-IEC. All methods were carried out in accordance with the relevant guidelines and legislation. Operational definition —Drinking water sources were classified based on primary household use: own tap (piped), communal tap (shared standpost), hand pump/ tube well (groundwater), and well (dug). Vendor-supplied water was defined as informally delivered, untreated container water (excluding commercially packaged bottled water) that was considered potentially unsafe. Result Quantitative phase Socio-demographic characteristics Among the 10,000 households surveyed approximately 60% resided in the Nahazari Gram Panchayat, with a majority living in pucca (permanent, constructed with durable materials such as brick, cement, or concrete) (48.7%) or semi-pucca (semi-permanent) (40.5%) houses while 10.8% lived in kachcha (temporary) houses. Approximately 82.5% of participants had lived in the area for over 10 years (Table 1 a). Table 1. Socio-demographic characteristics of households included in the study ( N = 10,000) 1.a Location and characteristics of residence. Frequency (n) Percentage (%) 1.a Location and characteristics of residence Gram panchayat Nahazari 5980 59.8 Khagramuri 2730 27.3 Bakrahat 1290 12.9 Type of house Kachcha 1082 10.8 Pucca 4871 48.7 Semi-pucca 4047 40.5 No. of years of stay 0–5 years 148 1.5 5.1–10 years 1580 15.8 > 10 years 8272 82.7 1.b Characteristics of family Religion of family Hindu 5780 57.8 Muslim 4160 41.6 Christian 60 0.6 No. of family members 1–4 Members 7680 76.8 > 4 Members 2320 23.2 No. of children between 1 and 5 years No children of that age 7650 76.5 1 2180 21.8 2 170 1.7 > 2 20 0.2 Monthly Income of the family (INR) (based on Kuppuswamy Scale, June 2023) ≤ 7315 3580 35.8 7316–21,913 5980 59.8 21,914–36,526 370 3.7 36,527–45,588 60 0.6 45,589–54,650 10 0.1 Open in a new tab The population was predominantly Hindu (57.8%), followed by Muslim (41.6%). Most households (76.8%) had 1–4 members, while 23.5% had children under five years of age. We have classified households based on their monthly income using the Kuppuswamy scale (June 2023) 22 . Most families (59.8%) fell into the INR 7316–21,913/month (USD 88.14-264.01) income category (Table 1 b). Diarrhea prevalence and WASH practices The study revealed that 16.9% of households reported experiencing at least one diarrheal episode in the six months preceding the survey (Table 2 ). Drinking water sources varied across households: 22.8% relied on water vendors (usually sold by unofficial local vendors in barrels or containers, frequently without treatment or quality control), and 46.4% used community hand pumps for drinking water purposes. A majority of participants (78.6%) did not purify their drinking water in any way. Handwashing practices were explored, more than half of the households (52.5%) assessed in this study reported wash their hands with soap and water generally and almost everyone reported always uses soap and water (90.5%) after defecation, 65% of people always use soap and water before eating, and 57.5% always use soap and water before food handling. While 59.8% of participants reported using private flush toilets, 32.3% reported sharing flush toilets with others, and 1.5% reported practicing open defecation. Regarding stool disposal for children and older adults, 66.7% reported using their own toilets, while others reported relying on alternative methods, including municipality-identified spaces (~ 15%) and open space outside (~ 18%). Table 2. Hygiene practices reported by the households included in the study (N = 10,000). Frequency (n) Percentage (%) What kind of toilet do the household members usually use? Flush toilet used alone 5980 59.8 Flush toilet shared with other family members 3230 32.3 Dug hole 90 0.9 Open defecation 150 1.5 Open pit 550 5.5 Place of disposal of stool (For children and aged) (n = 6910) Specific place identified by municipality 1050 15.2 Own toilet 4609 66.7 Open place outside 1251 18.1 Main source of drinking water in the house Own tap 1020 10.2 Communal tap 1890 18.9 Tube well inside the household premises 140 1.4 Well 30 0.3 Community hand pump 4640 46.4 Water vendor 2280 22.8 Distance from house to the source of water (time) Inside the household premises 1580 15.8 < 5 min walking distance 3620 36.2 > 5 min walking distance 4800 48 Method uses for disinfecting your drinking water Boiling 940 9.4 RO Filter 1120 11.2 Chlorination 40 0.4 Sedimentation 40 0.4 None 7860 78.6 What is used in the household for washing hands in general? Normal water 4720 47.2 Soap and water 5250 52.5 Gul/Ash 30 0.3 When do you wash your hands with soap and water? After defecation Always 9050 90.5 Sometimes 460 4.6 Never 490 4.9 Before eating Always 6500 65 Sometimes 2320 23.2 Never 1180 11.8 Before food handling Always 5750 57.5 Sometimes 1530 15.3 Never 2720 27.2 Any episode of diarrhea in last 6 months? Yes 1690 16.9 No 8310 83.1 Open in a new tab Healthcare seeking behavior The study revealed that 64.8% of households preferred government health facilities for treating diarrheal diseases in adults across all surveyed households. For childhood diarrhea, 75.90% sought care at government facilities; this estimate was calculated only among families with at least one child in the household ( n = 5413) (Fig. 2 a). The study found that the most commonly reported care-seeking option for diarrheal diseases across religious groups was home-based care, followed by government health facilities. Among Hindu participants, 40.2% reported managing diarrhea at home and 36.8% visited government facilities. Similarly, among Muslim participants, 43% reported home-based care, and 33.1% used government services (Fig. 2 b). In the study, among the three Gram Panchayats (GP), the majority in Nahazari (41.3%) and Bakrahat (45.7%) opted for home-based treatment for diarrhea. People from Khagramuri GP mostly preferred govt health facilities for diarrhea treatment (Fig. 2 c). As income rises, the preference for seeking treatment for diarrhea from private practitioners appears to increase, indicating a potential income-related trend in care-seeking behavior (Fig. 2 d). Fig. 2. Open in a new tab Healthcare selection for Diarrhea among surveyed households included in the study. Factors associated with Diarrhea This study identified several WASH-related factors associated with diarrheal episodes: Households who reported using water from vendors had nearly three times higher odds of diarrhea compared to those using their own taps, after adjusting for income, family size, and housing type (AOR: 2.71; 95% CI 1.84–4.01). Families that did not disinfect their drinking water had 1.74 times higher odds of diarrhea compared to those who boiled their water, after adjusting for potential confounders (AOR: 1.74; 95% CI 1.05–2.88). Compared to families who used soap and water for handwashing, those relying solely on water had substantially greater odds of experiencing diarrhea, even after adjusting for household and environmental factors (AOR: 3.14; 95% CI 2.51–3.93). Individuals who never washed their hands with soap before handling food had 1.53 times higher odds of experiencing diarrhea compared to those who always did, after adjusting for relevant confounders (AOR: 1.53; 95% CI 1.17–2.01). Families disposing of stool in open areas near their homes were at a slightly higher odds of diarrhea compared to those using designated disposal methods (COR: 1.15; 95% CI 1.05–2.24), whereas adjusted odds ratio was nonsignificant (Table 3 ). The sensitivity analysis indicated that unsafe drinking water sources, untreated drinking water, and handwashing with water alone remained significantly associated with diarrheal diseases, and the direction of these effects was consistent with our primary findings. All VIF values were less than 3, implying that multicollinearity was not an issue (Table 4 ). Table 3. Determinants of diarrhea of the family included in the study (N = 10,000). Socio-demographics characteristics Categories Total number Diarrhea present (n, %) Measurement (unadjusted = bivariate adjusted**= multivariate) OR p -value Toilet used by household member (Ref = Flush toilet used alone) Flush toilet shared with other family members 3230 524 16.22 Unadj 1.04 (0.83–1.31) 0.68 Adj 0.89 (0.7–1.14) 0.37 Dug hole 90 8 8.88 Unadj 2.76 (0.65–11.69) 0.16 Adj 2.35(0.54–10.17) 0.25 Open defecation 150 13 8.66 Unadj 2.17 (0.77–6.12) 0.14 Adj 2.59 (0.78–8.56) 0.11 Open pit 550 80 14.54 Unadj 1.27 (0.81-2) 0.29 Adj 1.18 (0.74–1.88) 0.46 Place of disposal of stool (For children and aged) (Ref = Specific place identified by municipality) Own toilet 4609 915 19.85 Unadj 0.87 (0.52–1.48) 0.62 Adj 0.96 (0.56–1.66) 0.90 Open place outside 1251 129 10.31 Unadj 1.15 (1.05–2.24) < 0.01* Adj 1.12 (0.56–2.22) 0.90 Main source of drinking water in the house (Ref = Own tap) Communal tap 1890 304 16.08 Unadj 1.09 (0.44–3.02) 0.72 Adj 1.42 (0.63–3.03) 0.70 Tubewell inside the household premises 140 46 32.85 Unadj 4.02(0.49–32.86) 0.19 Adj 0.53 (0.04–6.24) 0.53 Well 30 5 16.66 Unadj 1.15 (0.59–2.24) 0.66 Adj 0.97 (0.66–1.44) 0.91 Community hand pump 4640 534 11.5 Unadj 0.69 (0.55–4.95) 0.83 Adj 0.34 (0.57–1.21) 0.34 Water vendor 2280 571 25.04 Unadj 1.92 (1.33–2.76) < 0.001* Adj 2.71 (1.84–4.01) < 0.001* Method uses for disinfecting your drinking water (Ref = B oiling) RO Filter 1120 50 4.46 Unadj 0.89 (0.17–4.66) 0.08 Adj 0.92 (0.63–11.35) 0.68 Chlorination 40 0 0 Unadj – – Adj – – Sedimentation 40 7 17.5 Unadj 1.94 (0.39–9.63) 0.41 Adj 1.56 (0.29–8.17) 0.59 None 7860 1523 19.37 Unadj 2.13 (1.32–3.45) < 0.01* Adj 1.74 (1.05–2.88) 0.03 What is used in the household for washing hands in general? (Ref = Soap and water) Normal water 4720 1252 26.52 Unadj 3.03 (2.45–3.75) < 0.001* Adj 3.14 (2.51–3.93) < 0.001* Gul/Ash 30 7 23.33 Unadj 0.89 (0.18–4.67) 0.88 Adj 1.8 (0.16–4.86) 0.89 After defecation (Ref = A lways) Sometime 460 124 26.95 Unadj 0.57 (0.11–2.86) 0.50 Adj 0.61 (0.12–3.13) 0.55 Never 490 0 0 Unadj – – Adj – – Before eating (Ref = Always) Sometime 2320 291 12.54 Unadj 0.2 (0.14–1.28) 0.08 Adj 0.24 (0.16–0.36) 0.34 Never 1180 464 39.32 Unadj 0.78 (0.60–1.01) 0.06 Adj 1.14 (0.87–1.50) 0.62 Before food handling (Ref = Always) Sometime 1530 387 25.29 Unadj 0.44 (0.32–1.05) 0.51 Adj 1.18 (0.85–1.65) 0.3 Never 2720 608 22.35 Unadj 1.64 (1.23–2.19) < 0.01 * Adj 1.53 (1.17–2.01) < 0.01 * Open in a new tab *Significant at p -value < 0.01. **Adjusted for total income, number of children, number of family member, type of house, Ref: Reference category. Table 4. Multivariable logistic regression of WASH exposures and diarrheal outcomes (sensitivity analysis). Predictor (reference category) AOR (95% CI), single-exposure model*, p -value AOR (95% CI), full multivariable model # , p -value VIF Main source of drinking water: Vendor-supplied (vs. Own tap) 2.71 (1.84–4.01), < 0.001 2.40 (1.62–3.56), < 0.001 2.3 Drinking water untreated (vs. boiled) 1.74 (1.05–2.88),0.03 1.62 (1.01–2.65), 0.04 1.9 Handwashing with water only (vs. soap and water) 3.14 (2.51–3.93), < 0.001 2.98 (2.35–3.79), < 0.001 2.8 Unsafe stool disposal (vs. specific place identified by municipality) 1.12 (0.56–2.22), 0.9 1.05 (0.50–2.10), 0.9 1.4 Toilet: Shared with other family members (vs. Flush toilet used alone) 0.89 (0.70–1.14), 0.37 0.95 (0.70–1.29), 0.76 1.7 Confounders (household income, family size, no. of children, house type) Adjusted Adjusted – Open in a new tab *Each WASH factor modeled separately, adjusted for confounders. # All WASH factors entered simultaneously in one model, adjusted for confounders. VIF values derived from auxiliary linear regression; all < 3, suggesting no serious multicollinearity. Qualitative phase The qualitative findings provided additional insights into the community context that strengthen the survey results. Five primary themes emerged: knowledge and awareness of diarrheal disease, hygiene practice and barriers, sanitation practices and community norms, perceptions of health-seeking behavior, and system level barriers and facilitators (Table 5 ). Table 5. Themes, sub-themes and codes based on thematic analysis. Sub-theme Code Illustrative quotes Theme1: Knowledge and awareness of diarrheal diseases Perceived causes Unhygienic condition “Due to unhygienic food consumption…. staying in dirty environment not maintaining hygiene causes some disease in stomach called diarrhea, also after coming back from bathroom we should wash our hands and even feet”—(40y housewife) “If surrounding will be clean and hygienic then no diseases will be there”-ANM (5) Fecal oral “I have heard it spreads through bare foot “—(32y housewife) “Some people will openly dispose fecal matter of their children, which later causes the problem”—ANM (6) Junk food and drinking water “I think it is more related with junk food eating and like eating outside foods “- (26y housewife) “Now a days people will eat a lot of outside food, junk food causing stomach problem and drinking water here is not good. Most of the household here use packaged water which cost only 5rs for 20 liters”—ANM (4) Rainy season “During rainy season I have seen the number of cases are more”—(36y housewife) “Previous year almost everyone in our house got diarrhea during the rainy season”—(33y housewife) Theme 2: Hygiene practices and barriers Handwashing Low prioritization before eating/cooking “We wash hand with water before eating. But before cooking we sometime wash our hands. I don’t think handwashing is so much important.” (34y housewife) Barriers Financial constraint “We cannot always afford to buy soap; with so many expenses, it is difficult to keep it at home every time.” (30y housewife) “We know the water may not be clean, but we are poor and this vendor water is the cheapest option for us. We have no other choice because the hand pump often does not work.” (26y housewife) Cultural “We only prefer Unani medicines and it works well for us “- (34 years old housewife) “Whatever information we will get; we will consult with our religious leaders”-(30y housewife) Theme 3: Sanitation practices and community norms Toilet practices Shared toilets “We have shared toilets with our neighbors. We don’t have so much money to build separate toilets for everyone but we always keep the toilets clean so that we don’t have diarrhea “—(32y housewife) “We heard like even when we use public toilets it can even spread from their also”—(30y housewife) “Now almost every one owns proper toilet like the KANTA bathrooms. Even sometimes they will go for outside for defecation even if they have toilets in their house.“—ANM (1) Open defecation “Even sometimes they will go outside for defecation even if they have toilets in their house.” ANM (2) Waste disposal Disposal of stool for children and old aged people “I usually throw the fecal of my baby in the open place outside my home. We all throw these things outside my house for many years.”—(31y housewife) “We usually throw the household waste just outside the home or in the nearby field, because there is no proper place for disposal.”—(32y housewife) “Some families are very obedient. They throw the waste in the designated place for garbage but most of them are not so much obedient they just throw their waste here and there and those families get Diarrhea almost throughout the year”—ANM (1) Theme 4: Perceptions of health-seeking behavior Initial response Home-based/traditional remedies/medicines from shop “If my child gets frequent stool I took him to Samali hospital, but if I or my husband gets frequent stool, I took medicine from store.”—(29y housewife) “When my child has diarrhea, we first try home remedies or buy tablets from the shop. If it doesn’t work, we go to the local quack, and only later to the health center if the problem continues.”—(32y housewife) “Whenever people do frequent stool, they take medicine from shop directly. They think it is useless to come to the health center.” (ANM 1) Awareness of ORS Widely known “I know about ORS, even in this summer season we are using a lot “—(31y housewife) “Almost everyone one knows about ORS and about the usage of it”—ANM (3) Theme 5: System-level barriers and facilitators Barriers Slow adoption “Awareness is there but the change is very slow, we are telling from a long time to wash their hands with soap and water but they are reluctant. Health promotion can help a lot, if an auto or a car goes inside village with a mic on it all are very interested and listens to it “—ANM (4) Distance to the facility “Distance of the health center from our house is around 1 hour which makes it difficult. It’s very far, for coming here and show the doctor it takes the whole day " (43y housewife) Vaccination Hesitancy “We don’t need any vaccine. After taking the COVID vaccine, we have faced various health related issues.”—(33 y housewife) “Even during the time of COVID people were very reluctant to take vaccines, talking with the religious leaders helped a lot. Cholera vaccines will be very helpful for this area. “—ANM (6) “People were hesitant to get vaccinated, even during COVID, but it really helped when we included religious leaders. The similar strategy might increase cholera vaccine adoption and confidence.”—ANM (6) Role of frontline workers “Regularly ASHA didi come and give us ORS and other necessary medicines.” (33y housewife) Open in a new tab Theme 1: Knowledge and awareness of diarrheal diseases Mothers had varying levels of knowledge about diarrhea, its causes, and prevention. While most participants recognized contaminated water and poor hygiene as key contributors, some misconceptions persisted. For instance, some mothers attributed diarrhea to “eating junk food” or “exposure to outside food.” Several mothers shared that they did not treat drinking water at home, citing reasons such as time constraints, limited fuel for boiling, and trust in the safety of vendor-supplied water. While some appeared unfamiliar with the need for household water treatment, others acknowledged it but prioritized convenience. These responses suggest that household water treatment practices may be influenced by a combination of knowledge, economic constraints, and perceived water safety. “ Due to unhygienic food consumption…. staying in dirty environment not maintaining hygiene causes some disease in stomach called diarrhea , also after coming back from bathroom we should wash our hands and even feet ” (IDI, mother of under-five). ANMs emphasized that while community health education campaigns had helped improved awareness about using oral rehydration solution (ORS) during diarrhea episodes, however awareness about preventive measures like handwashing before food handling were still inconsistently practiced in the community, especially among caregivers of young children. Some ANMs attributed this gap to low health literacy and competing household responsibilities. Theme 2: Hygiene practices and barriers While families understood the importance of hygiene, barriers such as lack of access to soap or clean water often hindered consistent practices. Mothers reported that handwashing was typically prioritized after defecation but was often neglected before eating or food preparation due to time constraints or unavailability of soap. Economic challenges often force families to allocate resources toward other necessities. The reliance on unsafe water sources, such as vendor-supplied water, emerged as a common theme during the IDIs. Mothers expressed concerns about the quality of this water, noting that while they were aware it might be unsafe, they had few alternatives due to inadequate access to piped water or malfunctioning hand pumps. “We know the water may not be clean , but we are poor and this vendor water is the cheapest option for us. We have no other choice because the hand pump often does not work” (IDI, mother of under-five). Theme 3: Sanitation practices and community norms Sanitation practices varied widely across households, with most families adopting safe disposal methods while others continued open defecation or used shared facilities. A few participants who practiced open defecation cited social norms, lack of privacy in shared toilets, and non-functional sanitation facilities as key reasons for avoiding household or community toilets. ANMs highlighted that despite government efforts such as the Swachh Bharat Mission, behavioral change was slow in certain communities due to deeply ingrained habits and cultural resistance. “Even sometimes they will go outside for defecation even if they have toilets in their house.” (KII, ANM). Theme 4: Perceptions of health-seeking behavior Mothers often preferred home-based care during initial diarrhea episodes, relying on traditional remedies or over-the-counter medications before seeking formal healthcare services. Several participants described managing diarrhea episodes at home using traditional remedies or oral rehydration solutions, a pattern commonly mentioned across both Hindu and Muslim families during the interviews. “ When my child has diarrhea , we first try home remedies or buy tablets from the shop. If it doesn’t work , we go to the local quack , and only later to the health center if the problem continues .” (IDI, mother of under-five). ANMs noted that while awareness about ORS had improved due to community outreach programs, delays in seeking professional care often exacerbated complications in children under five years old. Families cited financial constraints, distance to healthcare facilities, and long waiting times as barriers to accessing government health services. Theme 5: System-level barriers and facilitators Although awareness regarding hand hygiene was noted, acceptance remained modest, with frontline workers reporting persistent unwillingness to use soap despite repeated counselling. Community members reported vaccine hesitancy, typically citing negative experiences with COVID-19 vaccination; however, engaging religious leaders was suggested as a good technique for building confidence and acceptability for future vaccinations such as cholera. Mothers were also cited financial constraints, distance to healthcare facilities, and long waiting times as barriers to accessing government health services. “We don’t need any vaccine. After taking the COVID vaccine , we have faced various health related issues.”- (IDI, mother of under-five). “ Distance of the health center from our house is around 1 hour which makes it difficult. It’s very far , for coming here and show the doctor it takes the whole day ” (IDI, mother of under-five). Frontline workers, notably ASHAs, were identified as reliable sources of crucial supplies such as ORS and medicines, highlighting their critical role in community health promotion and service delivery. Discussion This mixed-method study assessed the burden of diarrheal disease and associated hygiene practices in rural West Bengal and identified substantial gaps in sanitation, hygiene behavior, and access to safe drinking water. A household-level cumulative incidence of 16.9% was observed over six months and the quantitative analysis demonstrated key findings of an increased odds of diarrhea associated with vendor-supplied water (AOR: 2.71; 95% CI 1.84–4.01), untreated drinking water (AOR: 1.74; 95% CI 1.05–2.88) and handwashing with water alone (AOR: 3.14; 95% CI 2.51–3.93). Qualitative findings highlighted barriers such as limited health literacy, financial constraints, and weak infrastructure that may influence hygiene behaviors and care-seeking practices. We deliberately used a six-month recall, which improves the sensitivity to capture cumulative incidence and seasonal variation not visible with a standard two-week window. Shorter recall minimizes memory inaccuracy, but it excludes numerous occurrences that occur outside the limited frame. We therefore present our estimate as a household-level six-month cumulative incidence rather than a point prevalence measure. Thus, our estimate may still be conservative for the true cumulative incidence 23 . Similar to other high-burden low-and middle-income Countries (LMICs) settings, our study observed a substantial household-level burden of diarrheal disease during a non-epidemic period 2 , 3 . A 2021 study showed diarrhea frequency of 9.3–20.6% among under-five children in different states of India, with rural areas frequently showing increased rates 24 while a Ethiopian study in 2023 reported a 29% prevalence among children under the age of five 25 . In-contrast, high-income countries showed a prevalence of less than 5% during four weeks before survey, indicating better WASH infrastructure 26 . In India, initiatives like the Swachh Bharat Mission (2014) and the Jal Jeevan Mission (2019) boosted rural sanitation coverage to 75% and water access to 94% by 2022 8 . Despite this progress, we found in our study that 22.8% of households still rely on vendor-supplied water, highlighting persistent gaps in last-mile access. Similarly, in our study 78.6% of households do not disinfect drinking water, which is consistent with a 2023 study in Northwest Ethiopia, where unimproved water sources doubled the odds of diarrhea 25 . In our study, washing hands with just water increased the odds of diarrhea three times than its counterparts, which is similar to a 2021 meta-analysis that found using soap and water reduces the incidence of diarrhea by 28% 9 . A notable intervention was Kerala, India’s “Children as Agents of Change school-based WASH campaign in 2023 27 and a systematic review 28 of similar interventions demonstrate that structured handwashing promotion in schools can reduce diarrhea in children by roughly 31%. These findings highlight the continued importance of behavioral and infrastructure interventions for the prevention of diarrhea. In our study, the substantial preference for government health facilities for diarrhea (64.8% for adults, 75.9% for children) reflects the families’ trust in public healthcare institutions, particularly in pediatric diarrhea. In contrast, a 2021 study carried out in tribal-predominant Kandhamal, Odisha, India found that for the treatment of diarrhea, just 37% of families accessed care at primary or community health centers, with 58% notifying community health workers (ASHAs), indicating low utilization of formal services 29 . In our study, 12.4% of families relied on self-medication and 4.6% on unlicensed practitioners, raising risks of delayed care and drug resistance. This matches findings from other parts of India, where people often turn to informal providers who frequently misuse antibiotics and anti-diarrheal 30 , 31 . A 2021 study from Kolkata discovered that educating informal carers on the proper use of ORS and zinc, as well as avoiding unnecessary antibiotics, improved diarrhea management, indicating a scalable way to address inappropriate care-seeking in West Bengal 32 and similar contexts in India. The qualitative phase explicated the mechanisms underlying quantitative associations. For example, the high AOR for vendor-supplied water (2.71) was explained by mothers’ faith in its perceived safety and economical constraints to residential water treatment, resulting in low disinfection rates (78.6%). Similarly, moms reported irregular handwashing with soap (AOR: 3.14), which was associated with time restrictions and soap availability. ANMs identified insufficient health literacy as a barrier to preventative behaviors, supporting the quantitative findings of knowledge gaps. This integration explains how structural (e.g., infrastructure) and behavioral (e.g., consciousness, awareness) aspects interact to inform targeted interventions such as community-driven soap distribution or water treatment initiatives. Limitations and strengths This study has a few limitations. The cross-sectional design limits causal inference. Questionnaire-based statistics can be influenced by recollection, self-report, and courtesy bias, especially for socially acceptable actions like handwashing or water treatment. The six-month recall span, while accounting for seasonal variance, may still underreport earlier occurrences. Although multivariable models account for crucial household characteristics, unmeasured confounding cannot be excluded. Key strengths of this study are its large, representative sample of 10,000 families and its mixed-method methodology, which combines estimations of cumulative incidence with contextual insights. Strong community engagement and collaboration with government agencies resulted in reliable data, providing actionable information to support targeted WASH interventions in rural West Bengal and other settings with similar socio-demographic and infrastructure circumstances. Conclusion This mixed-methods study in West Bengal, India demonstrates a persistent diarrheal burden in rural India, primarily driven by inadequate water, sanitation, and hygiene practices. Despite national initiatives such as Swachh Bharat (2014), Jal Jeevan Mission (2019), gaps in health awareness, financial hurdles, and infrastructural limitations continue to hinder progress. By combining survey data with community insights, our findings underscore the need for targeted interventions, including reliable access to safe water, the promotion of consistent soap use, strengthened health education and stronger engagement of frontline health workers to bridge knowledge, practice and access gaps. These strategies align with the Sustainable Development Goals on health and clean water. Future research should monitor long-term trends, evaluate the effectiveness of interventions, and address informal treatment practices to mitigate risks such as antimicrobial resistance. Overall, these activities have the potential to lead to healthier rural communities and more sustainable public health outcomes. Acknowledgements We are grateful to the Indian Council of Medical Research (ICMR) for providing technical assistance and funding for this work. The authors would like to thank the people under surveillance in the area as well as all of the ASHA workers who participated actively in the census enumeration. The authors also want to acknowledge Mrs. Ishita Majhi & Mrs. Santana Brahmachari (Senior Public Health Nurse, Samali BPHC, West Bengal) and Mr. Biswajit Pal (Block Account Manager, Samali BPHC, West Bengal) for their continuous support. We would also want to express our heartfelt gratitude to the Department of Health and Family Welfare, Government of West Bengal, for their unflinching assistance in the effective implementation of this initiative. Author contributions Conceptualization: SK, DC and SD; Data curation: SK, SP, AP, SC; Formal Analysis: SK, SP, SB, PG, RT; Supervision: SK, SP, SC, BK, SP, AP, AC, FD, SPK; Laboratory: AKM, RKN, BK; Writing—original draft: SK, SP, RT, PC, DB, SB, FD; Writing—review and editing: SK, RT. Overall supervision: DR, MSM, DM, SK. All the contributing authors have critically reviewed the final version of the manuscript. Funding This study received ICMR funding since it was a component of an intramural project. (Proposal ID-2023-0000054) Data availability The data that support the findings of this study are available from the corresponding author upon request. Declarations Competing interests The authors declare no competing interests. Ethics approval and consent to participate - The study was cleared by the Institutional Ethics Committee of ICMR- National Institute for Research in Bacterial Infections, (No. A-10(2)/2024)-IEC) dated 12.02.2024. Verbal informed consent was obtained from the participants prior enrollment in the study. Consent for publication - Not applicable as no individual identification were revealed. Footnotes Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Suman Kanungo and Shubhajit Pahari equal contributor References 1. Hénock Blaise, N. Y. & Dovie, D. B. K. Diarrheal diseases in the history of public health. Arch. Med. Res. 38 , 159–163 (2007). [ DOI ] [ PubMed ] [ Google Scholar ] 2. Thystrup, C. et al. Etiology-specific incidence and mortality of diarrheal diseases in the African region: A systematic review and meta-analysis. BMC Public. Health 24 , 1864 (2024). [ DOI ] [ PMC free article ] [ PubMed ] 3. 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