<b>Assessing Rural Drinking Water Quality, Sanitation and Hygiene Practices in Muzaffar Garh District, Pakistan</b>

Background: Access to safe drinking water is fundamental to public health, yet rural populations in Pakistan remain vulnerable to microbiologically contaminated water supplies, inadequate sanitation infrastructure, and unhygienic practices, resulting in a high burden of diarrheal disease. Current national data are insufficiently granular, with limited evidence from rural districts such as Muzaffar Garh where poverty, poor water infrastructure, and inadequate sanitation coexist. Objective: To assess the quality of rural drinking water, determine the extent of microbial contamination, and identify socio-demographic, sanitation, and hygiene factors associated with diarrheal illness among children under five years of age in Muzaffar Garh district, Pakistan. Methods: A cross-sectional observational study was conducted between November 2023 and January 2024 across six villages. A total of 56 water samples were analyzed for physicochemical and microbiological parameters. Structured interviews were conducted among 196 matched case-control pairs to capture socio-demographic characteristics, water use, sanitation, and hygiene practices. Multivariable logistic regression was used to identify independent risk factors for diarrheal disease. Results: Total coliforms and E. coli were detected in 62.4% and 37.2% of water samples, respectively. Poor socioeconomic status (AOR 3.42; 95% CI: 2.01–5.89) and households with >1 child under five (AOR 2.38; 95% CI: 1.44–3.94) were significantly associated with diarrheal illness. Unsafe water handling, open waste disposal, and latrine location outside the premises further increased risk. Conclusion: This study demonstrates substantial microbial contamination of rural water sources and identifies poverty and sanitation-related behaviors as key risk factors for diarrheal illness in children. Comprehensive, context-sensitive WASH interventions are urgently needed in rural Pakistan.