The cross-sectional study applied quantitative and qualitative methods. In the quantitative method, one to one interviews and observation checklists were conducted in a sample of 941 households selected by random sampling method. In the qualitative component, focus group discussion and key informant interviews with the local authorities and village elders were conducted.The study was conducted in the 49 villages of Paschim Medinipur and Jhargram districts of West Bengal, India. In each sample village, at least 10 household and one key informant were interviewed following questionnaire method.

The estimated sample size was calculated by ENA for Smart software following formula:

Where, desired precision (d) = ±3%, Average household size=5, Children under five= 25%, Non- response household= 3%, So, 940 households (HH) will be investigated.

The objectives of the study were informed to the local community leaders and the relevant authorities. A consent letter (the contents of the consent letter was read and explained to the woman) was collected from each woman for her interview and measurement prior to this field work. Ethical approval (vide letter no. IEC/10/2/C-2/18, dated 20-04-2018) was obtained from the human ethical committee of Vidyasagar University, Midnapore, West Bengal, India.

Socioeconomic status of household was assessed by Kuppuswamy Socioeconomic status scale 13.

Height, weight, mid upper arm circumference of mothers (MUAC) and childrenheight and weightwas made and recorded following standard procedure 14. Mother nutritional status was assessed based on BMI international classification as undernutrition (BMI<18.5 kg/m²), normal (BMI: 18.5-24.9 kg/m²) and overweight including obesity (BMI: ≥25 kg/m²) and Mother MUAC value of <22 cm and ≥22 cm is considered as undernutrition and normal, respectively 1516. Anthropometric indices of the children were wasting, stunting and underweight calculated by WHO anthro software according to the WHO Growth Child standards 2006 17. A child was classified as underweight, stunting and wasting as weight-for-age, height-for-age and weight-of -height Z-score below -2 standard deviation.

The researcher has developed this method to assess women's knowledge on nutrition. The method consisted of 15 multi-choice questions. Every right option was scored one, and every wrong option was scored zero. Knowledge score was arbitrarily graded as good knowledge: 11-15, average knowledge: 06-10 and poor knowledge: 0-5. WaSH score was calculated from the total of the four specific indicators; drinking water score (0-6 points), sanitation score (0-3 points), hygiene score (0-5 points), and hand washing score (0-12 points) and had a total of 26 points possible as recommended by Reddy et al 18.

Chi square test was performed to assess group differences in knowledge score and WaSH score with the socioeconomic status variables (education, income, number of family members, type of house, number of children, latrine facility, availability of safe drinking water etc.) and nutritional status of mother (BMI and MUAC) and children (underweight, stunting, wasting). Logistic regression analysis was conducted to determine the variables associated with diarrhea form of morbidity (within 15 days of the survey), WaSH score and a Knowledge score of respondent mothers. All statistical analyses were performed using the SPSS Package 21. Statistical significance was set at p less than 0.05.

This study engaged both respondent mother (n=941) and their preschool children (n=1043; 533 boys and 510 girls) of the Lodha community in Paschim Medinipur and Jhargram districts of West Bengal. The majority (63.2%) of the mother was the resident of Paschim Medinipur district. Almost two third (66.7%) of the respondent families were nuclear comprising single parent. The average family size was 4.5± 1.42. The majority (92.8%) of the mothers were aged less than 30 years. Only 23.2% mother was literate and most of them were primary dropped out. Literacy and income of the husband were also dismally low. The respondent mother contributes to family income also look after the children and family chore. They are mainly engaged as agricultural laborers. According to Kuppuswami Socioeconomic status (SES) scale, 98% respondents belongs to a lower SES class (Grade-IV of the SES scale). Most of the houses of Lodha families were ‘Kutcha’, made of mud and straw-thatched. Only, 6% families had ‘Pucca’ house made of brick wall and asbestos in the roof.

About 35% of the respondent families get their drinking water from clean and safe water sources (hand pumps or protected wells or piped water supply) throughout all season. Only 2% of the family had drinking water at their premises. Safe water sources (public or private) have been available usually within 5 minute walking distance from the house. Predominantly women (84%) collected water for everyday use in the household from outside (Figure 1).

About 37% of the respondent families use metal pot, 30% clay pot and 2% of the families use jerry-cans, 31% use plastic buckets and pots for storage of drinking water (Figure 2). It was observed during the survey that these water reservoirs were often without lids. Almost all respondent mothers (90 percent) habituated to take water by dipping glass in water pots.

In general they used to wash the drinking water containers by using water only. Almost, 14% of the respondent mothers used detergent and otherwise use ash or clay for this purpose. The respondent mothers wash their drinking water containers during fetching every time (77%), every day (14%) and whenever it stayed dirty (5%). (Figure 3) No households of the respondent mothers had ground and rooftop water tanks and don't have any home filters. Running water tap has been installed in some village pockets, but there were issues of safety and quantity.

Generally households uses bore-hole water, shallow well, pond or river water as domestic water like cleaning, cooking, and personal hygiene etc. But these sources are scarce during the summer season.

The respondent households were not connected to a waste water network. Sewage accumulation is worsened during rainfall.

Open defecation was the predominant practice among these families (96%) and the rest (4%) use traditional latrine (pit latrine with slab) for defecation (Figure 4). They have no place for such building and they did not have money for the constructing a standard latrine. The majority (89%) of Lodha mothers thrown children stool at nearby bush (Figure 5).

Community-generated solid wastes gathered nearby areas as household waste is thrown into the bush/garden (Figure 6). Open burning was ensured by young children and elders occasionally.

The respondent mothers did not wash their hands before eating and cooking every time (Figure 7). Hand washing after defecation is performed predominantly by water only (56%). About 24% of study participants reported utilizing soap and water after defecation (Figure 8). The study participants' household members reported washing their hands with water only pre and post meals. Soap was used when it was felt the hands were being dirty. Only, 3.5% of study participants, the hand wash score was higher than five.

The overall hand wash score (mean ± SD) of the respondent mothers was 3.17 ± 0.87, which fall under the low category. Almost 97.2% of them had the ‘low’ hand wash score, 2.8% of them had an ‘average’ hand wash score. The overall WaSH score (mean ± SD) of the respondent mothers was 6.55 ± 2.2, which lie in the moderate category.

The majority of the respondents took a bath every day, but cloths were not changed daily. Bathing every day was mostly hampered when they go for a whole day outside job or begging. Around, 17% of the respondent mothers reported cutting nails on a regular basis. Almost 94 % women responded that they had no appropriate material during menstruation. About 46.4% of mothers of them had the ‘low’ WaSH score and 53.6% of them had an ‘average’ and ‘good’ WaSH score. WaSH score had significantly correlated with the Kuppuswamy SES score (r=0.088**, p<0.01) and monthly family income (r=0.104**, p<0.01).

Boys wore comparatively more dirty clothes than girl children. Children wash their teeth at least once a day, usually (67%) without a toothbrush and paste. Around 91% of children had a habit of consuming raw vegetables / fruit, and just 13% of them used to wash them with water.

Majority (86%) of the respondent mothers takes a bath in the open water point predominantly at the pond (Figure 9). Bathing shelter was almost unavailable. If pond becomes dry, they bath at public tube well, bore whole water sources or open well water point which remained contaminated with garbage, plastics.

They don't have tables for drying household utensils after washing predominantly of water and ash only (45%) (Figure 10). This study also exhibits that about 59% do not have a good practice in handling household utensils. They dry them on the ground and do not wash them at all before taking food.

Only about a third (32%) of the entire population have clothing lines for drying clothes (Figure 11). The two third populations (68%) still do not care or use other hygienic methods of drying clothes.

The overall knowledge related to nutritional status and WaSH score (mean ± SD) of the mother was 3.3, which falls under low category. The results of this study showed that 79.2% of them had low nutritional knowledge, 14.8% of them had average nutritional knowledge. But, only 6.0% of them had good knowledge about nutrition. Only, 8.1% of mother knows about ORS is an essential for diarrhea patient. They were unaware about the common causes of diarrhea (Figure 12).

Predictors of knowledge score and WaSH score were calculated by logistic regression analysis (Table 1). It was observed that the resident district (AOR=0.24; 95% CI=0.17-0.33), number of children (AOR=1.08; 95% CI=0.76-1.5), mother education (AOR=1.28; 95% CI=0.9-1.8), type of family (AOR=1.10; 95% CI= 0.79-1.8) and type of house (AOR=3; 95% CI=1.4-6.2) was the predictor of poor WaSH scores of the respondent. Whereas, the Kuppuswamy SES score (AOR=5.2; 95% CI=1.3-21.8) and mother education (AOR=53.7; 95% CI=31.9-90.1) was the predictor of the knowledge score. The study also found that there is a significant relationship between knowledge score and residence district (χ²=26.09; p<0.01), Kuppuswamy SES score (χ²= 38.8, p<0.01), mother education (χ²= 5.144; p<0.05).

The stoppage of menstruation cycle (first sign of pregnancy) was not a major concern for childbearing mothers. The majority of Lodha mothers were aware of sterilization for birth control, but spacing methods of birth control were less known. Home delivery (54%) was the prevailing custom among the Lodha families surveyed. According to the antenatal report card of respondent mothers the prevalence of low birth weight baby was 49%. Exiling of the first colostrum (13%) after delivery has been reported especially home delivery cases. On the 21^stday after successful delivery both mother and baby take a purificatory bath and pare nails. Preference for boy children exists in the families.

The morbidities related to WaSH among Lodha mothers and children were very high (Table 2). A diarrheal form of morbidity within the 15 days of the survey was 2.6% of the mother and 9.2% of the children. Mother with age higher than 30 years, the prevalence of diarrhea was lower as compared to aged ≤30 years (0.4% Vs. 2.2%). But in case of children, the prevalence of diarrhea was increased gradually (1^st years- 0.4%, 2^nd year-0.9%, 3^rd year-1.9% , 4^th year-2.7%, 5^th year-2.3%) with age and it was statistically significant (χ²=21.34, p<0.01). Mothers usually consult with the local quack doctor when they become sick. Furthermore, they also had faith of their own traditional medicine.Prevalence of morbidity was decreased with increasing age of the mothers, but had no significant difference. Lodha children who were resident of Paschim Medinipur district had a higher risk to be suffering from diarrhea significantly (p<0.05). The children were susceptible to be suffering from diarrhea whose mother did not wash their hands properly and it was found statistically significant.

Logistic regression shows the respondent mother who had more than two children (AOR=1.1; 95% C.I=0.34-3.5), no formal education (AOR=2.23; 95% CI=0.59-8.34), takes unsafe drinking water (OR=6.9; C.I-0.34-3.5), resident of Paschim Medinipur district (AOR-3.4; 95% C.I=1.04-10.8), greater than four (> 4) family member (AOR=2.2; 95% C.I=0.78-6.4) was greater risk to be suffering from diarrhea.

Almost 41.6% Lodha mothers were suffered from chronic energy deficiency (CED: BMI <18.5 kg/m²). The prevalence of overweight & obesity (BMI≥25 kg/m²) among Lodha women was 1.6%. Whereas, 48.9% women were undurnutrition based on MUAC less than 22.0 cm. Moreover, the overall prevalence of wasting, stunting and underweight among preschool Lodha children was 31.9%, 62.1% and 61.3%, respectively. The WaSH score of the family was significantly associated with children to be stunted and underweight. The WaSH score of mothers was significantly different (P<0.01) with the occurrence of undernutrition, normal and overweight individual (BMI cut-offs) and MUAC. But knowledge score had no significant effects on BMI (Table 3).

The Logistic regression analysis showed that the Lodha boys were 1.2 times greater risk to be suffering from underweight than girls. Mother with CED had 1.6 (P<0.05) and 1.5 (P<0.05) times more risk to be developed child stunting and underweight. Lack of safe drinking water was also an important predictor, as children were 1.7 (P<0.05) times and 1.6 (P<0.05) times higher risk to be developed stunting and underweight. More importantly, children were significantly 2.5 times and 1.2 times higher risk for stunting and underweight, whose mothers do not wash their hands properly after defecation. Moreover, the children were 1.6 times greater risk to be wasted, if the family had no sanitary latrine facilities.