Exploring the burden of diarrheal disease and associated WASH practices in rural West Bengal, India: an explanatory sequential mixed-method approach

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.