Access to improved water and household water treatment practice in rural communities of Amhara Region, Ethiopia

¹Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

^&Corresponding author
Muluken Azage, Department of Environmental Health, School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia

Introduction    

Access to safe drinking water is a fundamental requirement for human health and critical to socioeconomic development of the nation [1,2]. Efforts have been done to ensure access to improved drinking water supply in low and middle income countries [3]. However, improved drinking water supplies may not necessarily provide “safe drinking water” for human consumption [4,5]. Improved drinking water may be contaminated at the source, during distribution or during storage and while handling to use. There is evidence that show improved drinking water supplies are frequently contaminated with fecal waste, particularly in developing countries [5-8]. Studies have shown that stored water may often become contaminated due to unsafe storage and handling practices at household level [9-13].

Water storage is the common practice in rural communities who do not have safe water sources on premises. Water storage container types and handling practices were documented as determinants for water quality deterioration at point of consumption [11,12]. Drinking water during collection or immediately after disinfection/filtration stored in narrow-mouthed, closed vessels (safe storage) can prevent recontamination. Contaminated drinking water in storage vessels was also documented as important factor for the occurrence of diarrhea disease [14]. Point-of-use water treatment technologies have emerged as an approach that empowers people and communities without access to safe water to improve water quality [15-17]. Point-of-use water disinfection products, filtration systems or apparatuses and solar water disinfection are some of point-of-use water treatment technologies recommended as interim measures to improve drinking water quality until homes can be reached with safe, reliable, piped-in water connections [18]. In Ethiopia, there are controversy findings on access to improved water supply and household water treatment. Data from Demographic Health and Survey (DHS) showed that the provision of improved water supply at national level was 65% in 2016 [19] which did not consider the WHO recommended time for round trip (≤ 30 minutes). However, access to improved water by considering round trip travel time to/from source using the same DHS data in 2016 was 50% [20]. Household water treatment from DHS data was low at national level (7%) as well as in rural area (5.5%) [19,21]. However, few community based studies in rural households of Amhara Region, Ethiopia reported that household water treatment was ranged from 23% [22] to 44.8% [23]. The above studies are also lacking on safe water storage status which is important for safe water supply indicator as stated in Sustainable Development Goal (SDG).

The United Nation as program set the SDG 6.1 universal and equitable access to safe and affordable drinking water for all by the end of 2030 [24]. The government of Ethiopia has also planned to provide access to water supply with a minimum service of 25 liter/c/day with in a distance of 1km from the source for 85% of the rural population, of which 20% are provided with piped water supply by the end of 2020. The available community-based studies in Ethiopia so far do not provide comprehensive information on geographical variation of access to improved water supply using primary data. Understanding variation in access to improved water in the lowest administrative level units (Kebele) is imperative to identifying low-access areas or areas with high levels of access. Assessing access to improved water supply spatial variation by considering round trip travel time to/from source, household water treatment and safe storage are important to evaluate the progress and devise interventions. Therefore, the aim of the study was to assess the proportion of access to improved water supply, household water treatment and safe storage in rural households of Amhara Region, northwest Ethiopia.

Methods     

Study setting and period

The study was conducted on January, 2018 in three districts (Baso Liben, Yilmana Densa and Fogera) of Amhara National Regional State, northwest Ethiopia. Based on 2007 national census, the estimated population of the study areas in 2018 was 297,775, of which 156, 515 reside in rural area and 40,028 were men. There were 25 Kebeles (the lowest government administration unit) in Baso Liben, 32 Kebeles in Yilmana Densa and 44 Kebeles in Fogera districts. A total of 132,410 households were found in the three districts. This study was carried out in nine piloted Kebeles (three from each district) to assess the baseline information about access to improved water, household water treatment and safe storage to promotion behavioral intervention in the region.

Study design and population

A community based cross-sectional study design was employed to assess the proportion of access to improved water, household water treatment and safe storage practices. Access to improved water, household water treatment and safe storage practices were the main outcome variables of the study. Socio-demographic variables (age, marital status, educational and occupation status), types of drinking water sources, distance of water sources, time take to fetch water were also measured to explore the overall situation of the rural communities.

Sample size determination and sampling techniques

Sample size was determined using single population proposition formula,

Considering the following assumptions: level of confidence 95% (1.96), margin of error (3%), household water treatment at household level in rural communities was 44.8% from other study [23]. The final sample size considering design effect 2 and 13% non-response rate was 873. A total of nine kebeles from the three districts (three kebeles from each district) were selected randomly. Proportion to size allocation was made to determine the required sample size for each district and Kebele. Systematic random sampling technique was used to select households in each randomly selected Kebele.

Data collection tool and procedures

Data were collected using epicollect5 software. The tool was comprised of socio-demographic and economic variables, household and environmental condition variables mainly focus on drinking water source types, fetching time, household water treatment and safe storage practices. Nine master students from Bahir Dar University as data collectors and three second degree holders (MSc holders) as supervisors were recruited in data collection process.

Data quality assurance

Data collectors and supervisors were trained on the purpose of the study, data collection technique and tool for two days. Data template was created in Epi-collect5 data collection software which helps to minimize errors depending on the type of variables and sequencing of questions with skipping pattern. Before the template designed in the epicollect5 software, questionnaire was developed in English and then translated in to Amharic (local language) for easy understanding of questions for data collectors. The tool was pre-tested in rural communities of Bahir Dar Zuria district and the necessary amendments were done to clarify questions accordingly. The filled template was reviewed daily by supervisors for ensuring completeness of questions.

Data analysis

Data from epicollect5 were exported to Excel sheet and Stata software version 14 for analysis. Descriptive statistics such as frequency, mean and proportion were calculated. Bivariate and multivariable logistic regression were done to identify factors associated with safe water storage. Significant association was declared at p-value < 0.05. Adjusted odds ratio (AOR) and 95% confidence interval (CI) were used to report significant association of factors with safe water storage. Spatial analysis was done using GIS Getis-Ord statistics. The proportion of improved water access at Kebele level were exported into ArcGIS to visualize key estimations, and the Kebeles with low or high access to improved water was identified. In this study, the Local Getis-Ord G index (LGi) was applied to do spatial statistical analysis and described in detail in the literature [25]. The spatial heterogeneity of significant Kebeles with high/low proportion of improved water access were computed for each Kebele using the Getis-Ord G-statistic tools in ArcGIS. The Local Getis-Ord G index helped to classify the autocorrelations into positive and negative correlations. If proportion had similar high values or low values, they were defined as positive autocorrelation hotspots (represented as High-High or Low-Low autocorrelation). If the attributes held opposing high and low values, they were considered to have negative autocorrelation (represent as High-Low or Low-High autocorrelation). Z-scores and P-values were used to determine the level of significance. A Z-score near zero indicates no apparent clustering within the study area. A positive Z-score with P-value of <0.05 indicates statistical clustering of high access to improved water whereas a negative Z-score with p-value of <0.05 indicates statistical clustering of Kebeles with low access to improved water.

Ethical considerations

The study was approved by ethical review committee of College of Medicine and Health Sciences, Bahir-Dar University. Letter of permission was taken from Amhara Region Health Bureau, Zonal and District Health Offices. Verbal informed consent was taken from each study participant after informing the objective of the study. Confidentiality was maintained throughout the study period by excluding personal identifiers during data collection.

Results     

Socio-demographic characteristics of households

A total of 865 households were included in the survey with the response rate of 99.1%. Six hundred ninety-one (79.9%) of households were headed by males. Three hundred ninety-eight (46.0%) of the participants were in the age range between 30 and 49 years and 80.0% were married. Above one-third of the surveyed households (36.8%) had 4 to 5 family size and 43.7% of household had children under five years of age. Five hundred thirty-two (62%) of the surveyed households had school attendance of 6-18 years of age children. Above eighty percent (83.5%) of the mothers and 53.6% of parents in the surveyed households were unable to read and write. Three-fourth of the households (74.7%) had no television and/or radio. Six hundred thirty-three made a decision jointly in a household issue (Table 1).

Access to improved water, household water treatment and safe storage practices

One third of the surveyed households (32.6%) had a protected well water source for domestic purpose. Above one third of the surveyed households (34.6%) used unimproved water sources (unprotected spring =8.9, unprotected well=9.7 and rivers/pond=16.3) whereas 65.1% had an improved water source. One hundred twelve (13%) households took ≤ 30 minutes (round trip) to fetch water from the sources. Three hundred sixty-two households took less than 25 liters water per capita per day. Above ninety percent of surveyed households had got drinking water source within 1 km radius of their households in both seasons (dry and wet). Eight three percent of housewives was responsible to collect water for the source (Table 2). Nearly eight (7.8%) of the participants used any type of household water treatment, of which, 16.4% used water filter, 40.3% chlorination and 43.3% used boiling. Of those using boiling. Seven hundred seventy-eight households used covered container to collection water and nearly 60% of participants used pouring system to draw water from the container (Table 2).

Geographical variation of access to improved water, household water treatment and safe storage

The proportion of improved water coverage without fetching time consideration was 65% (95% CI:61.8% to 68.2%) in the study area. The highest proportion in improved water was found in Fogera District (773%). The highest proportion in access to improved water was found in Basoliben District (16.9%) followed by Fogera Districts (4.2%). The lowest proportion in household water treatment and safe storage was found in Fogera district (0.7%). The highest proportion in safe water storage was found in Yilmana Densa district (92.5%) (Table 3). The spatial distribution of households that had access to improved water sources by Kebele is shown in Figure 1. The spatial variation showed that there was no significant variation of access to improved water between Kebeles in the study area. However, relatively three kebeles from Basoliben were identified with high access but not significantly varied in the study area (Figure 1).

Factors associated with safe storage and handling

In multivariable analysis, age of participants, mother education status, and information received on safe storage from health extension workers were associated with safe water storage. The odds of having safe water storage among those whose age less than 29 years and the age between 30 and 49 years had increased 2 times (AOR:2.22 95%CI:1.38-3.57) and 1.9 times (AOR:1.91 95%CI:1:32-2.77) higher compared to participants whose age is greater than 49 years respectively. The odds of having safe storage and handling among mothers with primary and above education status were 1.8 times (AOR:1.76 95%CI:1:02-3:05) higher compared to those mothers with unable to read and write. The odds of those mothers who received information about safe water storage from health extension workers were 2 times (AOR: 1.99; 95%CI: 1.44-2.75) higher compared to those mothers who did not receive information about safe water storage practices (Table 4).

Discussion     

Access to safe drinking-water is essential to health, a basic human right and a part of sustainable development targets to provide safe and affordable drinking water for all by the 2030 [24,26]. Previous studies did not consider round fetching time which is failed to show the real access to improve water for policy makers to achieve the targets of SDGs [27,28]. There is a clear discrepancy of having improved water sources in the study area with considering fetching time (= 30 minutes) (7.6% (95%CI 6.0 -9.6%)) as well as without considering fetching time (65% (95%CI 61.8 to 68.2%)). Access to improved water with considering fetching time in this study is much lower than the study conducted in Amhara Region (45%) [20]. The possible explanation could be variation of the study population. For example, in this study only rural households were included in the study whereas in a study conducted in Amhara region was considered urban and rural households.

Measuring access to improved water without considering fetching time does not have a public health benefit [29]. The UN Sustainable Development Goal target 6.1 on clean water and sanitation is to achieve universal and equitable access to safe and affordable drinking water for all by the end of 2030 [30]. However, the time burden of water fetching to get drinking water from the sources remains a public health problem in developing countries including Ethiopia, particularly the rural community. Above 80% of households took 1 hour and above to get drinking water in the study area. If the drinking source is located at long distance, the work of water fetching relies on women and girls compared to men [31]. The burden of water fetching time may directly or indirectly affect the health and wellbeing of the water carrier [32] and the family members [33]. Carrying water for long time is associated with pain, fatigue and emotional distress and limit uptake of health services, or a person's capacity to engage in child caring and income generating activities [29,32-34]. This evidence supports the view of provision of drinking water on premises as indicated by the sustainable development goal, and where it is not possible, reducing the time of fetching water by developing water close to home should get an emphasis for water infrastructure investments in rural areas of developing countries.

There is significant variation of access to improved water, household water treatment and safe storage across three districts. Access to improved water is higher in Basoliben compared to Fogera and Yilmman Densa districts. On the other hand, household water treatment and safe storage is higher in yimmmna Desna compared to other districts. The possible explanation for household water treatment and safe storage could be due to the perceptions of household members on source of water quality. For instance, access to improved water in Basoliben is 2 times higher than yillman Densa. The variation in access to improved water source across districts is beyond the scope of the study and need further study. However, access to improved water supply did not randomly vary across kebeles using spatial analysis in the study area. The identified cluster villages with unimproved water source are the area of intervention and resource allocation to improve water access. This study also revealed that the majority of rural households which took over 30 minutes fetching time (round time) from an improved water source which is consistent with the national figure for rural households [28]. However, this finding is lower than a study done in Africa countries, which showed that 54% of the people travel more than 30 minutes to fetch drinking water [27]. This study also showed that almost in all households (96%), women and female children were found to be responsible to fetch water from the source which is consistent with previous study by Graham et al in sub-Saharan Africa countries [28].

Household water treatment and safe storage are the recommended options to improve drinking water quality [35]. Drinking water containers with "narrow mouth” are key practices to keeping water from being contaminated while being stored in the home [36]. In this study, only 6% of households used point of water treatment at household level which is consistent with the study in Ethiopia [37]. However, this finding is lower than the study conducted in Burie Zuriya District, Amhara Region, Ethiopia [23]. The possible explanation could be the knowledge of communities on water treatment methods, perceptions on water quality and availability of water treatment methods in the local market. Household water treatment and safe storage is one of the six recommended practices to achieve sustainable development goal 6.1 (universal and equitable access to safe water for all). There are studies that revealed safe water at the source water can be contaminated during storage and handling practices at the household. This study showed that HWTS was very low which is far from the government target to achieve 35% by 2020 from the baseline 10% in 2015 [38]. This study provides an evidence to revise or consider the strategies of HWTS to reach at the set target.

Age of mother was one of the predictors of safe water storage. As the age increase decreased the practice of safe water storage. The possible explanation might be these age group is more exposed to the current modern community-based health education than elderly mothers and ready to bring change than the elderly one, which may focus on what they know in their early age than the currently introduced approaches on household safe water storage practice. Being educated was one of the associated factors with safe water storage which is consistent with previous studies [22,23]. This possible reason could be due to educated mother can easily read and understand leaflets, brushers and oral messages, and can easily understand the diseases related with drinking of contaminated water. This study also showed that mothers who got information regarding to safe water storage from health extension workers had practiced safe water storage. The finding is supported with evidence from previous studies which showed that the health extension packages implemented by Health Extension Worker target in changing hygienic behaviors of mothers [39].

Conclusion     

The study revealed that the proportion of access to improved water, household water treatment and safe storage was low and varied across districts in the study area. However, access to improved water supply did not randomly vary across Kebeles using spatial analysis. The work of water fetching time remains the public health problem in the study area. Being in the reproductive age group, educated mother and mothers who got information on safe water storage from health extension workers had increased the practice of safe water storage. The identified areas with low access to improved water should get a priority to improve safe water access and modifiable factors are the areas of intervention to improve the practice of safe water storage which further contributes for public health improvements.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Muluken Aazage-Conceived and designed the study, collected data and analyzed, interpreted and wrote the manuscript. Achenef Motbainor-Conceived and designed the study, reviewed, interpreted and wrote the manuscript. Genet Gedamu-Reviewed, interpreted and wrote the manuscript. All authors have read and agreed to the final manuscript.

Acknowledgments     

The research team would like to thank SHASYASHONE trading plc for their financial support to conduct this research project. We would also like to thank Amhara Regional Health Bureau, East West Gojjam and South Gondar Zonal Health Department, Baso Liben, Yilmna Densa and Fogera District health office for their cooperation and support. Finally, our acknowledgement goes to supervisors, data collectors and study participants for their unreserved time and commitment during data collection.

Tables and figure     

Table 1: socio-demographic characteristics of survey populations, northwest Ethiopia, 2018

Table 2: water source type and its access in the survey community, northwest Ethiopia, 2018

Table 3: proportion of access to improved water source, household water treatment and safe storage by districts in rural communities of Amhara Region, northwest Ethiopia, 2018

Table 4: factors associated with safe water storage among rural community in Amhara Region, northwest Ethiopia, 2018

Figure 1: geographical variation of access to improved water among rural community in Amhara Region, northwest Ethiopia, 2018

References