Assessment of Squalor in Migrant Colonies of Thiruvalla Province of Kerala, India using Rapid Survey Technique.

BACKGROUND: Domestic squalor refers to households that are extremely cluttered, in a filthy condition, and where the accumulation of items such as personal possessions, rubbish, excrement and decomposing food creates an environment that jeopardizes the health and wellbeing of the occupant(s). In India, an estimated 258 million are migrants. They are more likely to live in squalor due to inferior socio-economic status and no permanent residence. This poses a threat to the health of the migrants and the neighbors.
OBJECTIVE: To assess the squalor and morbidity pattern among the migrants of Migrant colonies in Thiruvalla using Rapid survey technique.
METHODOLOGY: The state of squalor in migrant colonies was assessed by Lot Quality Assurance Sampling Methodology using the Environment Cleanliness and Clutter Scale (ECCS). The sample size for each lot/colony was '14' dwellings according to LQAS table. The details were collected from 14 inhabitants of different dwellings of the same colony. The inhabitants were selected randomly and were excluded if he belonged to the same dwelling. Fifteen colonies were randomly selected to achieve the sample size of 210 (15*14). The study was done in Tiruvalla municipality. RESULTS AND
CONCLUSION: Only two colonies (n = 15) were squalor free. Majority of the dwellings (n = 210) were having an ECCS score between 13 and 15. Common ailments affecting migrants include Common cold, Skin disorders, and dental caries and gastritis. Squalor was found in most of the migrant colonies as they are living in inhuman conditions. Copyright:

BACKGROUND

In India, an estimated 258 million adults are migrants, with a great majority being men migrating for employment.[1] The primary destination states for migrants within India are Maharashtra, Andhra Pradesh, Karnataka, and newly Kerala. International migration, primarily from other parts of south Asia to India, is also on the increase. Poverty and indebtedness are the most important factors that lead to migration.

Employment-driven migration is mainly from the “relatively less developed” states to Developed and developing areas, wherein the migrants get absorbed in low-paid jobs in the unorganized sectors.[23] Migrants live in temporary sheds. Most of the migrant workers live in inhuman living conditions with overcrowding, limited or no sanitation facilities and ill-ventilated homes.[4]

The workers' living conditions are poor with denial of basic amenities to maintain the standard of living, making them prone to health problems.[5] The workers often suffer from various diseases. The reasons for frequent illness may be due to the dirty water, unhygienic surroundings, and living places infested with flies and mosquitoes. In extreme cases, the poor living conditions may also have an impact on neighbors because the property may be a fire hazard, emit a foul odor and harbor vermin.[67] This finally results in an environment that is a potential health hazard.[8]

Kerala has seen a significant rise in the number of migrants from various parts of the country to work. This poses a threat to the health of the migrants and the neighbors. Domestic squalor refers to households that are extremely cluttered, in a filthy condition, and where the accumulation of items such as personal possessions, rubbish, excrement and decomposing food creates an environment that jeopardizes the health and wellbeing of the occupant (s).[9] Living in squalid conditions was generally associated with a mental or physical disorder, and there were possible deficits in the health care received.[10] People who live in squalor have high rates of infectious diseases, mental disorder. Squalor affects younger as well as older people.[7811]

Thus, this study focused on assessing the squalor in the migrant settlement colonies of Thiruvalla using Lot Quality Assurance Sampling methodology along with the assessment of morbidity pattern among the migrants. There are fewer studies on the living conditions of these workers in the unorganized sector. This study is the first of its kind in using rapid survey technique as a useful tool to assess the status of squalor in migrant settlement colonies.

METHODOLOGY

The study was done in Tiruvalla province with a population of 52,883 and also the headquarters of the Taluk of same name located in Pathanamthitta district in the State of Kerala in South India. The town is spread over an area of 27.94 km2, it is the biggest commercial center in the district of Pathanamthitta. Due to the close proximity with other towns and increased opportunities for laborers, it's a destination for migrant workers.

Squalor is defined as the state of being extremely dirty and unpleasant, especially as a result of poverty or neglect.[9] The state of squalor in migrant colonies was assessed by Lot Quality Assurance Sampling Methodology using the Environment Cleanliness and Clutter Scale (ECCS).

ECCS scale involved more of observations than data collected through interviews. The scale/questionnaire was translated into Hindi by one translator and then translated back into the English language by an independent translator who is blinded to the original questionnaire. The 2 source-language versions were then compared.

Data collection was done from May 20 to July 20, 2019. The data collection was done by an experienced senior social worker to ensure uniformity of the data. Migrants at the colony who are above the age of 18 years and resident of the colony for more than 2 months were the participants. The migrant worker needs to eat from the same kitchen and use the sanitation facilities of the dwelling. Another social worker was recruited to randomly check the quality of the data in 20% of the sample (3 colonies). The quality check was done independently and may or may not have included the same person interviewed during the primary survey.

The data was entered in MS Excel and expressed as simple proportions. The number of colonies with squalor was identified. Confidentiality of the information was maintained.

Theoretical and operational definitions

Lot Quality Assurance Sampling[121314]: is a sampling technique where the samples are selected randomly. Following the randomization, the LOT is declared with a positive or negative outcome. Lot Quality Assurance sampling (LQAS) is a classification methodology, which, in its elemental form, is designed to identify areas of 'high' or 'low' degree. With LQAS, information on a sample is collected in an area. For each indicator, the number of successes, X, is counted and compared with a predetermined cutoff, d. If there are fewer than d successes, then the area is classified as low performance; if there are d or more successes, then the area is classified as high performance. The determination of the cutoff, d, is a function of the sample size, targets for program coverage, and types of acceptable misclassification potential at different levels of coverage.

Colonies are formed by groups of dwellings. The sample size for the LQAS is based on the desired proportion of squalor free colonies (assumed as 95%). The sample size for each lot/colony was determined to be 14 (14 dwellings) based on the decision rule (Twelve [12]) for different coverage levels (95%). If there are less than 12 dwellings with squalor, the colony will be categorized as squalor free. The details were collected from 14 inhabitants of different dwellings of the same colony. The inhabitants were selected randomly and was excluded if he belonged to the same dwelling. Fifteen colonies were selected to achieve the sample size of 210.

Environment Cleanliness and Clutter Scale (ECCS)[81015] was the tool used to assess squalor in the migrant settlement colonies. A score of 12 or more will recognize the dwelling as one with squalor. Environmental Cleanliness and Clutter Scale is adopted from the South Australian Public Health Act. The scale was developed and validated by Halliday G and Snowdon J.[16] The scale has ten components. ECCS scale involved more of observations than data collected through interview

Settlement Colony is defined as a marked geographical area inhabited by a minimum of 150 migrant workers living in different dwellings (30-50 dwellings). Dwelling is defined as group of persons sharing the same room, kitchen, and sanitation facilities. Squalor refers to households that are extremely cluttered, in a filthy condition, and where the accumulation of items such as personal possessions, rubbish, excrement, and decomposing food creates an environment that jeopardizes the health and wellbeing of the occupant (s) Adequate Ventilation: When the window space is 2/5th of the floor space with cross ventilation, the room satisfies adequate ventilation. Adequate Lighting: In normal daylight, if a person can read and write in all four corners of the room, the room satisfies adequate lighting.

RESULTS

Two colonies were squalor free out of the fifteen colonies. Maximum (79%) number of the dwellings were having a score of 13 and above [Table 1]. Most of the dwellings (90%) had a mosquito breeding site. Most (98%) of the dwellers never used any mode of treatment for drinking water. Adequate ventilation was absent in 94% of the colonies [Table 2]. The two squalor free colonies had 14 dwellings without squalor [Table 3]. The common diseases affecting the migrants elicited through self-reporting were Dental disorders, Gastritis, Common cold and skin disorders. The disease load was more in colonies with squalor than the colonies without squalor and the result was statistically significant [Table 4].

Table 1

Profile of dwellings based on ECCS

	Score
	Less than 11	12	13-15	More than 16	Total
No. of dwellings	27 (13%)	17 (8 %)	123 (58.5%)	43 (20.5%)	210

Table 2

Selected living conditions of dwellings (n = 210)

Sl No.		Yesn (%)	Non (%)	Total
1.	Presence of Mosquito breeding site	189 (90)	21 (10)	210
2.	Adequate lighting	132 (62)	78 (38)	210
3.	Practices waste segregation	131 (62)	79 (38)	210
4.	Adequate Ventilation	13 (6)	197 (94)	210
5.	Uses Bed Linen	7 (3)	203 (97)	210
6.	Uses treated water at Home	3 (2)	207 (98)	210

Table 3

Status of colonies with squalor

Colonies	No of dwellings with		Status
	Score <12	Score >13
Colony 1	0	14	With Squalor
Colony 2	14	0	Squalor Free
Colony 3	0	14	With Squalor
Colony 4	0	14	With Squalor
Colony 5	1	13	With Squalor
Colony 6	14	0	Squalor Free
Colony 7	0	14	With Squalor
Colony 8	0	14	With Squalor
Colony 9	1	13	With Squalor
Colony 10	0	14	With Squalor
Colony 11	0	14	With Squalor
Colony 12	0	14	With Squalor
Colony 13	0	14	With Squalor
Colony 14	0	14	With Squalor
Colony 15	0	14	With Squalor

Table 4

Association of Morbidity pattern with squalor status (n= 210)

SQUALOR status	Common cold	Gastritis	Dental disorders	Skin disorders	Total	P value
	N (%)	N (%)	N (%)	N (%)	N (%)
Less than 12(No Squalor)	19 (31.7)	5 (14.7)	1 (3.1)	9 (16.4)	34 (19)	0.007
12 and Above(Squalor)	41 (68.3)	29 (85.3)	30 (96.8)	47 (83.6)	146 (81)

DISCUSSION

Two out of the fifteen colonies were squalor-free in this study which used the Lot Quality Assurance Sampling methodology using Environment Cleanliness and Clutter scale. The present study done using a different methodology joins with several studies from around the World that the living conditions of the migrant workers are poor and needs immediate attention. Several studies from around the globe on migrant workers which used the cross-sectional study has found that the Quality of life in the environmental domain which mainly deals with living conditions, health, and recreational facilities were found to be poor.[17] A recent study conducted by Siakia Dilip et al. has concluded that Kerala is a new destination for the migrants. The major motive of these migrants is money-making and that leads to spending less on housing, nutritional and health needs.[18] So this study throws light on using this rapid survey technique as a useful tool to assess the status of squalor in migrant settlement colonies.[19]

In the present study, the major morbidities that were identified through self-reporting were Dental disorders, Gastritis, Skin disorders and Common cold. The participant was asked about the major illness he had in the past 3 months which caused him partial or full non involvement in the day to day activities. A cross-sectional study conducted among migrant workers by Adsul et al. in Mumbai found that morbidity nearly 1/5th of the workers were having a febrile illness.[20] Another study by Bhatt RR et al. found that the Insomnia, headache and sleeping problems were common among the migrant workers which might be due to poor living conditions.[2]

The morbidity burden was more in the colonies with squalor than the squalor free colonies. A comparative study by Jan Sundquist et al. in Sweden stated that the living conditions of the immigrants from foreign countries were poor when compared with the swedes leading to poor health conditions of the immigrants.[11] A survey done by Rory Williams et al. among South Asian Migrant laborers in Glasgow found that the health outcomes were poor in the migrants.[14]

It's customary among the migrant workers in Kerala to return to their homeland if they have a major illness. This habit of the migrants along with recall bias together may have resulted in missing data. This study also didn't take into account the psychological domain of the workers. In this study, we were not able to identify symptomatic individuals. If all the individuals in the colony were included, maybe we could have identified some morbid persons.

Unequal living conditions among the migrants and the others can be a threat to the health of the community as a whole.[21] A time-series analysis done over 5 years by Nidhish G et al.[22] stated that among the migrants in Kerala, the prevalence of malaria especially P. falciparum species showed an increase of more than 20%. The re-emergence of malaria in various eradicated regions might be due to the impact of immigrants from different malaria-endemic areas. The overcrowding among migrant settlement colonies creates much unhygienic environmental pollution in the area, leading to the profuse multiplication of vectors and results the transmission of malaria and other vector-borne diseases such as Dengue, Chikungunya, Filariasis, and Japanese encephalitis.[23]

The migrants have started settling in groups in the early start of the decade. But no regulations in their housing and camping have led to poor housing and environmental conditions which have led to serious health issues and increased health spending for the state. The re- the emergence of infectious diseases like Malaria is an indirect indicator to look into this grave issue.[12]

Squalor is very common in the migrant settlement dwelling which can be a threat to the health and well-being of the neighbors and other co-inhabitants. So this warrants for immediate public health interventions.

CONCLUSIONS

Using LOT QUALITY ASSURANCE SAMPLING methodology the study found that squalor is very common in the migrant settlement colonies. Most of the dwellings have poor ventilation, moderately impaired accessibility, unhygienic toilets, unhygienic kitchen and vermin infestation. Most of the colonies have mosquito breeding sites also. The most common morbidities identified were dental disorders, gastritis, Skin disorders and Common cold. The morbidities were found to more in the colonies with squalor than the colonies without squalor.

Recommendations

The main aim of Migrant workers is money making. So hygiene and health forms secondary or nil consideration in their living. Awareness, Communication, and social mobilization is the need of the hour

Proper inspection of the dwellings and surroundings needs to implemented by the local administration and health authorities to ensure squalor free environment

System of collection of wastes and appropriate disposal of waste needs to be formulated

Mosquito breeding sites are present which could lead to outbreaks of dengue, chikungunya, and even malaria. So proper maintenance of environmental hygiene is a must.

Limitations

The scale used is a qualitative one and subjective bias may be there

LQAS is used assuming that most of the colonies needs to be squalor free

The overcrowding and detailed disease morbidity pattern could not be studied due to time and resource limitations

Migrants are nomadic in nature and would not be available in a location for more than a year. So difficult to plan interventional studies.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.