*1.1. Background of Local Government Filtration Plants Project*

Lahore is one of the most populous cities and is considered the second-largest city in Pakistan, with 12,642,000 inhabitants [3]. Likewise, the public of Lahore city is also suffering from problems associated with drinking water quality. According to the Pakistan Council of Research in Water Resources (PCRWR) documentation in 2020 [11], in several areas of Lahore, drinking water quality is exceedingly tainted. Thus, the local government has started an initiative to ease this concern. Local government is a public administration found in cities, districts, and counties. In a community, the local government is liable for numerous services to meet the community's needs. Likewise, in Pakistan, the local government is held accountable for services such as waste management and collection, services related to infrastructure, health-associated services (i.e., water and food and water scrutiny, sewerage and toilet-related facilities, other water-based services, welfare, as well as community care services, transportation, and education-related services). At the outset, local government and community administrations were not involved in decisions associated with the provision and supply of water in the country. However, local governments were obligated to provide drinking water-related supplies in 2001 under an ordinance termed the Local Government Ordinance (L.G.O.). Hence, in Pakistan, the local government provides vital services associated with health and secure water supply. Besides, federal and provisional governments were held liable for providing sufficient funds to local governments to ensure the delivery of effective and good services to the public [15].

The endowment of unpolluted drinking water to the inhabitants of Pakistan is the foremost duty of the local government. Thus, to fulfill this purpose, the local government, coordinating the community development department (CD), fixed drinking water filtration plants at several places in Lahore. This decision of plant fixation by the government is based on the level of the arsenic chemical in water, microbiological and other viral contamination in drinking water, public income, as well as public access level, while the number of these water filtration plants fixed by the local government reached 215 in May 2020 in Lahore [15]. Each of these plants can filter about 500 gallons of water an hour. The elementary purpose of the fixation of these water plants is to remove contamination, chemicals, microbes, and arsenic from the water to convert it into a safe form for consumption and drinking by the public [16].

This study was devised to gauge the effect of polluted water on public health and to relate the probability of waterborne illnesses ensued in selected households in two types of study areas (i.e., areas retaining water filtration plants and areas abstaining from plants) in Lahore under the health lifestyle theory, which argues that several regular lifestyle practices implicate deliberations on health-related outcomes [17]. In this study, health-related behavior under collective patterns such as class circumstances, socialization/experience, dispositions to act (habitus), and practices (actions) based on drinking filtration plant water choices conferring on their life chances of waterborne illness was assessed. Thus, the main aim of this study was to discover the health threats and health-associated costs endured by households in the target study areas and the influence of drinking water on infants' and children's health in areas having and lacking plants. The impact of class circumstances (age, education, and family size), experience, or awareness in making life choices based on drinking filtration plant water was also measured.

Moreover, this study compared waterborne disease incidence in households in targeted areas with and without local government filtration plants. Studies which deeply investigated the association between drinking water, morbidity, and related concerns in filtration plants are scarce. Besides, no comparative study of filtration plants' projects and non-project areas under the health lifestyle theory has been conducted yet. This assessment discoursed a comprehensive layout concerned with the quality of drinking water in Pakistan through an exceptional focus on key water impurities, water degradation sources, and subsequent health-associated concerns. Thus, this review substantially contributes to endorsing consciousness in realizing hazards and threats of the factors causing water pollution and waterborne diseases.

This comprehensive investigation will likewise advance the public's ability to quantitatively comprehend the effects of drinking water effluence and the efficiency of prevailing inventiveness regarding clean drinking water for the public, undertaken by the local government by the fixation of filtration plants. However, this enumerated evaluation will

be a helpful instrument for the government to formulate and implement better strategies for the endowment of impurity-free drinking water to the community. Additionally, this evaluation will significantly contribute to the literature regarding health-associated issues. Another value of this detailed study is that it will be considered a strong reference tool in impending studies. As a whole, it will assist in enhancing the progression of research focused on concerns associated with drinking water quality.

#### *1.2. Drinking Water Degradation and Human Health*

Drinking water is becoming highly contaminated. The main reason behind this contamination is municipal solid waste leachate. Thus, highly toxic elements and chemicals are destroying water quality [18,19]. Contamination of drinking water is one of the major health concerns in today's world. In Pakistan, the high level of arsenic in drinking water endangered the health of more than 60 million people, especially in the province of Punjab. Moreover, the pollution of drinking water poses a greater threat to Pakistan's public health than any other factor. Despite violating drinking water quality standards established by the WHO, there is a lack of research regarding the drinking water risk perception of households in-country [6,8,10,12].

According to studies, cholera is caused by contaminated drinking water, untreated surface water, the detoxification points of water use, and poor sanitation. Moreover, this water contamination also causes waterborne diseases such as diarrhea. Thus, important interventions are needed to protect the public from the harmful impacts of waterborne illness [20,21]. In the same regard, a study by Adimalla [22] demonstrated that nitrate concentration in drinking water has adverse impacts on the health of residents in India. Nitrate concentration crossed the critical limit regarding non-carcinogenic risk. A high nitrate level had poor effects on children's and women's health.

Additionally, studies in different countries, including Mexico, Pakistan, and China, revealed that fluoride and arsenic concentration in drinking water poses a great threat to human life. This arsenic consumption is a cause of cancer among households due to households bearing the burden of illness. Arsenic in drinking water results in Type 2 Diabetes Mellitus (T2DM). Moreover, people were found to have arsenic skin lesion disease. As a result, arsenic-contaminated water seriously threatens human health [23–26]. Moreover, contaminated drinking water destroys the health of living beings around the globe. Different bacteria destroy the quality of drinking water. Contaminated drinking water causes cardiovascular diseases, skin disorders, respiratory problems, liver and splenic ailments, gastrointestinal tract complications, kidney and bladder infections, neurotoxicity, reproductive failure, and cancer. The immediate consequences of contaminated water are less well documented. Other waterborne diseases are cholera, hepatitis, diarrhea, dracunculiasis, ulcers, typhoid, endocrine damage, and arsenicosis [26–29].

Worldwide, drinking water quality is not meeting the standards the WHO and the environmental protection agency set. Thus, awareness regarding the adverse effects of contaminated water must be enhanced [30]. Treatment of these diseases at an early stage is essential; otherwise, they may lead to death [20,28]. Furthermore, previous research found that a high proportion of households drink contaminated water, while others use water from improved sources. Moreover, arsenic concentration risk is significantly associated with location and type of water source, place of residence, and living district. Thus, household water should be regularly tested to reduce the risk associated with arsenic. Moreover, arsenic-contaminated water adversely impacts human health, which ultimately forces people to lose their jobs and live a sub-standard life [31,32].

Moreover, studies in China, Korea, and Pakistan revealed that heavy metals toxify the quality of drinking water, whose consumption is harmful to human health. Different treatment methods can be applied to reduce the harmful effects of heavy metals in drinking water. Thus, water treatment by different methods helps reduce microbial, inorganic, heavy metal, and other types of contamination from drinking water and makes water safe for human consumption and health. Additionally, piped water helps in reducing infant

mortality, and both males and females gain equal health benefits from drinking piped water. Moreover, this piped water has a greater impact on post-neonatal mortality as compared with neonatal mortality [33,34].

#### *1.3. Knowledge, Waterborne Illness, and Health Expenditures*

Socioeconomic characteristics with psychological factors to study drinking water behavior are important as they provide a holistic framework to understand human behavior. Moreover, knowledge and norms play an important role in using water after treatment. Similarly, education and income levels were significant with water treatment before drinking. Thus, findings revealed that demographic and socioeconomic attributes such as age, education, income, past experiences, and social networks played an important role in perceiving vulnerability. Moreover, the health vulnerability of households is affected by their access to information, health facilities, and the availability of safe water [35–37]. Studies in Bangladesh revealed that households bear the cost of having access to safe water sources due to poor water quality and insufficient and unreliable water supply. The poor spend more income on having access to improved water resources [7,38].

In the same regard, studies have revealed that drinking contaminated water causes diarrhea in children and other family members; 50% of children suffered from acute watery diarrhea (AWD), with a mean age of five. Fewer respondents were found to know about drinking water quality and waterborne illnesses. Additionally, studies in Uganda and India revealed that demographic factors such as mother's education, income level of households, age of children, gender, and awareness of water quality and waterborne diseases influence the reduction of acute watery diarrhea and other waterborne illnesses. However, the government's role is essential in providing clean water to the public [37,39,40].

Similarly, according to Thakur and Gupta [41], in India, high arsenic levels in drinking water cause arsenisois. Awareness regarding arsenic contamination in drinking water and arsenisois played a vital role in the reduction of this waterborne disease. As a result of arsenicosis, people have to bear health care and treatment costs due to visiting doctors. This illness mostly attacks females as compared with males. Moreover, access to improved drinking water sources and income levels can potentially reduce arsenicosis. Children are found to be at greater risk of waterborne illness as compared with other age groups.

Furthermore, because they have access to safe drinking water sources, the general public expends less physical effort and time collecting water. Moreover, access to safe and clean drinking water resources causes fewer water-related illnesses, ultimately reducing public health expenditures [7,42]. In the United States and Pakistan, Surface water quality is seriously diminishing. Nationwide degradation of drinking water causes 90 million illnesses. This illness may result in a financial burden, healthcare, and hospitalization costs [8,43]. Likewise, in Europe, Australia, and China, lack of public awareness and ineffective political measures are huge hurdles to drinking safe water and taking preventive measures by the public. More knowledge and awareness must be created among the public to reduce water-related risks. Moreover, the governance system must be strengthened to communicate water-related risks to the public [44–46].

#### *1.4. Drinking Water and Government Roles*

One of the prominent roles played by any country's government is to resolve water quality issues. Governments spend large subsidies in low- and middle-income countries on improving water sources. According to a recent World Bank report, government spending on water resource improvement accounts for 2% of total G.D.P. However, findings in ten countries revealed that 56% of these subsidies benefited the wealthiest people, while only 6% benefited the poorest [6]. The government spends a lot on improving drinking water resources. Although the government enhanced its spending on water improvements in the U.S. and Americas, there is still a violation of standards regarding water pollution [47–49].

According to studies conducted in Germany, South Africa, India, and Pakistan, water treatment is necessary to protect people from the hazards of waterborne illness. Point-of-use

water treatment effectively makes drinking water safe and achieves the sustainable goal of clean drinking water [33,50,51]. The facilities for clean water provided by the government are declining drastically. Thus, people mostly rely on private water sources. Therefore, government policies need to be revised to overcome this waterborne disease problem [48,49,52].

Although the government has installed filtration plants in various cities of Pakistan, these plants are not fully reliable sources of safe and clean drinking water. A few samples were found to be contaminated. Due to the electricity shortage and poor water connections, some plants are not properly operational. Besides, in Punjab, the working conditions of filtration plants are much better than in other provinces [11,53,54]. Additionally, polluted water poses a greater threat to human life. Different private and government bodies such as T.M.A., district councils, PHEDs, and WASA provide services related to the public's provision and supply of clean drinking water. Still, water management by these bodies is not effective in urban areas. Coordination between the federal and interim governments appeared lacking [55]. In Nigeria, Uganda, and USA, people are mostly dependent on private water sources as facilities related to the government's provision of clean drinking water have been declining. Consequently, there is an urgent need for government actions to tackle this issue [39,48,52].

Thus, it is concluded from the literature that drinking water sources are degrading in Pakistan due to arsenic, fluoride, heavy metals, and other organic and inorganic pollutants. Drinking contaminated water has severe impacts on the health of people. Diseases that mostly occur due to drinking contaminated water are kidney infections, cholera, hepatitis, diarrhea, dracunculiasis, ulcers, typhoid, endocrine damage, arsenicosis, and respiratory tract infections. Any country's government plays a critical role in ensuring that the populace has access to safe drinking water. Water from improved drinking water sources or water filtration plants can prevent households from contracting waterborne illnesses. Moreover, the literature reveals that age, education, income, and family size are important determinants in choosing to drink water from improved sources; thus, waterborne illness is reduced.

#### **2. Underpinning Theory and Hypothesis Development**

Healthy lifestyles are collective patterns of health-related behavior that focus entirely on available options or choices for people conferring more life chances [17]. This description integrates the indigenous relationship among the life choices and life chances anticipated by Weber in one of his most important conceptions regarding lifestyle. According to the Weberian viewpoint, life choices and agency are alternatives, while life changes can be seen in structure form. Whereas lifestyle choices and health exist in a voluntary nature, on the other hand, life chances largely symbolize the class position, which may endow or restrict choices, as choices and chances work off each other to regulate the behaviorrelated outcomes.

Furthermore, Gochman [56] pointed out that if lifestyle behaviors are positive, they oppose risk behaviors such as good nutrition, which is the converse of bad nutrition. The twofold nature of health-related lifestyle practices refers to consequences resulting from the interchange of choices and changes that reflect positive or negative health impacts. Gochman detected that health-related lifestyles are anticipated to escape associated risks and stay slanted towards inclusive health or fitness. Nevertheless, a "healthy lifestyle" is intended to embrace healthy living.

Historically, people took their health less for granted, but this is not true in present cases. In this modern era, health is viewed as a great achievement. People imagine making an effort to boost their life quality or reduce the risks of persistent illness and untimely deaths [57]. However, Giddens [58] stated that lifestyle preferences are more important for people becoming more responsible for their health. These circumstances instigate the variations in (i) disease patterns, (ii) modernity, and (iii) social identities.

Health lifestyle theory argues that several lifestyle practices reflect health-related outcomes [17]. Thus, everyone is responsible for themselves by choosing healthy living options

to have a healthy lifestyle. It must be a life or death issue for the person to be responsible for achieving a healthy lifestyle. Figure 1 elaborates the flow of integral components of health lifestyle theory where class circumstance highlights age, education, gender, race/ethnicity, living conditions, and commonalities as all of these factors significantly impact the selection of drinking water and raise awareness about the waterborne illness; as stated by Bourdieu [59], the dispositions to act are built through socialization and experience. Moreover, experience establishes the basis for life choices, which means "the self-direction of one's behavior", which may lead to fewer occurrences of waterborne illness if households make life choices of using plant water. The interface of life choices and life chances takes the individual dispositions towards action, as shown in Figure 1—such dispositions are instituted as habits. Habitus refers to the cognitive/mental map or the perceptions that usually help evaluate and guide the person's options and choices. The disposition of an act (the preference to use clean drinking water) indulges households in practices. Practices refer to action; therefore, the arrow is pointing from the disposition of an act to practices.

**Figure 1.** Research framework based on Health Lifestyle Theory. Note: Solid arrows show the relationship directions among variables, and dotted lines show the relationships among variables.

(1) Class circumstances

This category comprises age, education, gender, race/ethnicity, living conditions, and commonalities. Age, education of the household head, and family size are considered class circumstances in this study because these factors significantly impact the selection of drinking water and raise awareness about waterborne illnesses. Thus, we hypothesize as follows:

**Hypothesis 1 (H1).** *The greater the age of the household head, the lesser the occurrence of waterborne disease.*

**Hypothesis 2 (H2).** *An increase in the education of household heads decreases the occurrence of waterborne diseases*.

(2) Socialization/Experience

Box 1 in Figure 1 depicts the social framework for the socialization/experience involving class circumstances and associated variables, as illustrated by the arrow pointing to Box 2. Thus, this concept is supported by Bourdieu's [59] suggestion that the dispositions to act are built through socialization and experience. In this study, variables in box 1 provide the basis for experience and influence the decision that either household has to go for plant water or not, as illustrated by the arrow from box 1 to box 2. Thus, we hypothesize as follows:
