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Most cholera outbreaks in Bangladesh are seasonal, peaking in the dry and post-monsoon periods. Therefore, we investigated whether changes in water, sanitation, and hygiene (WASH) behavior in three populations in Bangladesh during the year could help explain why these two periods are particular to cholera transmission. The study used a mixed-method design, including a repeated cross-sectional study, focus group discussions, and key informant interviews. Through a repeated cross-sectional study, WASH-related variables were assessed during the dry, monsoon, and control seasons in 600 households from coastal Satkhira, inland Sirajganj, and the Dhaka slums. Seasonal behavioral changes were observed in all study areas. Dhaka and Satkhira had an increased mean distance to water sources during the dry and monsoon seasons (Dhaka: control season, 12 m [95% CI, 11–13]; dry season, 36 m [95% CI, 18–55]; and monsoon season, 180 m [95% CI, 118–243]; Satkhira: control season, 334 m [95% CI, 258–411]; dry season, 669 m [95% CI, 515–822]; and monsoon season, 2,437 m [95% CI, 1,665–3,209]). The participants attributed this to pollution of the usual water source. Perceived water quantity was lowest during the dry season in Dhaka and Sirajganj, and during the monsoon season in Satkhira. Handwashing with soap declined in all areas during the dry and monsoon seasons. Open defecation was frequent among children younger than 5 years, increasing during seasonal climate hazards. Results show that WASH-related behavior changed seasonally, increasing the risk of cholera transmission through multiple hygiene-related transmission pathways. Future research would benefit by ensuring that the length of studies covers all seasons throughout the year and also by looking in more detail at people’s behavior and hygiene practices.
Financial support: This work was funded by the University of Copenhagen Star program and DANIDA, the Danish foreign ministry (FFU grant no. 12-040KU).
Disclosure: Study participation was voluntary. All respondents gave informed consent and were free to withdraw from the study at any time. Ethical clearance was provided by the Environment and Population Research Center Executive Committee in Bangladesh and the Bangladesh NGO Bureau.
Authors’ addresses: Stephen Lawrence Grant, Sina Lange, Sara Almeida, and Peter Kjær Mackie Jensen, Copenhagen Center for Disaster Research, Section of Global Health, Department of Public Health, University of Copenhagen, Copenhagen, Denmark, E-mails: email@example.com, firstname.lastname@example.org, email@example.com, and firstname.lastname@example.org. Bilqis Hoque, Environment and Population Research Centre, Dhaka, Bangladesh, E-mail: email@example.com.