Assessing the challenges of utilizing fluoride filtered water and its factors, in Ethiopian central rift valley, Dugda district, Oromia region, south west Ethiopia,2019: A cross sectional study.

Background: The high level of fluoride in the Rift Valley water is due to naturally occurring fluoride that dissolves out of certain acidic volcanic rock formations. However, the utilization of drinking fluoride filtered water with appropriate level of fluoride provides more than 60% of fluoride required by the body. Dugda district is one of the parts of Ethiopian central rift valley(ECRV) that have high fluoride up to 14mg/l in their groundwater source. There are 11 village sized de-fluoridation schemes in Dugda district. Sothe aim of this study was to assess the challenges of utilizing fluoride filtered water, and associated factors, in Ethiopian rift valley, Oromia region, North East Shaw Zone, Dugdadistrict. Methods: A community-based cross-sectional study design complemented with the qualitative study was conducted from April 11-30, 2018Girigorian Colander. A total of 417 head of households were selected randomly for survey questioner interview,and six in-depth interviews were done with different water and sanitation experts at office level and 12 community key informant interview had done. Result:In this study, 56.3% of the studded participants utilized fluoride filtered water for drinking and cooking foods.Household with a family history of no fluorosis problem had a statically significant association with utilizing fluoride filtered water 44.4 times (AOR 44.42, CI, (18.83, 24.74) more likely utilized fluoride filter water as compared to their counterpart. More than three forth 321(79.3%) households prefer to utilize filtered water from the newly established filtering techniques so-called HAP (Hydroxyl Appetite Filter), but in practice only181(44.7%), 47(11.6%) utilizetheir water from HAP and bonechar fluoride filteringtechniques respectively. Conclusion: The results of this study revealed that those H/H utilized community level florid filterwater regularly were less likely affected by fluorosis problem than those H/H


Introduction
The purity of water is scared and gets always contaminated by several pollutants. Fluorine is one of such contaminants that contaminate water all place around the universes.
Fluoride is beneficial for the development of enamel when found in small concentration about 0.7 mg/l and causes severe health problems when finding above 1.5 mg/l in groundwater. The fluorosis was pervasive among the 200 million people groups from more than 30 nations over the globe (1). Fluorine (F 2 ) is a pale, yellow-green, corrosive gas which almost cannot be found in the natural environment in elemental form due to its high electronegativity and reactivity. Fluoride (F − ) is a fluorine anion characterized by small radius, great tendency to behave as ligand and easiness to form a great number of different organic and inorganic compounds in soil, rocks, air, plants, and animals. Some of those compounds are quite soluble in water, so fluoride is present in surface and groundwater as an almost completely dissociated fluoride ion (2). In most Ethiopian central refit valley (ECRV), the source of drinking water supply commonly comes from a groundwater source. The borehole water supply has several constraints in that it is limited in supply, often very brackish and hard and many times very high in mineral contents like fluoride (3).
The ECRV is part of a larger basin that extends from Syria and Jordan to Malawi and Mozambique. Due to its geological and climatic characteristics, the ECRV has some of the world's highest concentrations of Fluoride, found mainly in deep wells in the semi-arid parts of the region. The main source of F is the acid volcanic rocks found in the ECRV, 4 which have both high F and low soluble calcium concentrations. Over 40% of deep and shallow wells are contaminated with concentrations up to 26 mg Fluoride per litre, However, the distribution of Fluoride in the deep wells is variable, even among wells that are closely spaced (4). Multiple factors need to be considered when choosing the appropriate fluoride removal technology: Cost and availability of material, capital investment and running cost, simplicity in design and operation, by-products during the course of the treatment, removal capacity, acceptance by the community and willingness to pay (5). Fluoride in groundwater is influenced by surface water/groundwater interactions, geothermal inputs, and aquifer geology. Mitigation options include safe sourcing (locating primary low fluoride sources); alternatives are de fluoridation and multi-village piped water schemes the former dependent on NGO capacity and subsidy andcommunity involvement, the latter on investment, infrastructure, and professional management. Of the options, de-fluoridation is the least sustainable(6).
Many de-fluoridation techniques already exist, but there is still no one method that has been found effective, safe and cheap enough to implement widely; Tare is gap in choosing the locally acceptable, affordable and sound community de fluoridation technologies that implemented for local community in the study area. (7).Groundwater de-fluoridation options vary in scale (from household to community level), efficacy, sustainability, and user acceptance. Acceptance depends significantly on social problems experienced from fluorosis and on local beliefs, and experience has shown that awareness campaigns can play a significant role in determining acceptance (4).
A cross-sectional study done on preference of utilizing water from Community fluoride filter in ECRV revealed that out of 211H/H interviewed 45% state they use only filtered water for both drinking and cooking, 25.5% use filtered water between 50 to 75%, 20.9% use variable means that they use fluoride filtered water less than 50% of their total water 5 consumption; 8.1% use at least 75% of the water from community level fluoride filter and 1.3% reported not yet consuming filtered water. Moreover, on average 89.9% of the respondents reported thatthe source of their drinking water is from community filter water schemes, but only 62.8% use filtered water for cooking. On average one household buy 4.9 jerry can of filtered water per week this implies one person use 2.9 litter per day, but in practice, one person consumes 4.4liter per day in this village this indicate that almost 50% of water utilized by each household comes from high fluoride contaminated water sources (8). Identifying and assessing the utilization challenge of implemented technology options for community benefit is significant to sustain the implemented fluoride mitigation technology for community benefit. Few data is available regarding the current status of Fluoride mitigation programs implemented in the ECRV, Particularly in Dugdadistricts Assessing the challenges of utilizing fluoride filtered water from nalgonda, HAP, and bone char CF. and its factors, of these implemented mitigation technology help to identify its present history of community fluoride filter water supply schemes and used to explain how many people remain dependent on non-fluoride filtered water sources options. So the aim of this study is to assess the challenges of utilizing fluoride filtered water, and its factors, In Ethiopian central rift valley, Dugdadistricts, Oromia reign, April 2018.

Study design and setting
A community-based cross-sectional study complemented with the qualitative studywas in ECRV that respectively found at a distance around 5km, 6.5km, and 8km from Maki Town.

Sampling procedure
A total of 417H/H were selected by using malty stage sampling followed by simple randomsampling procedure. From a total of 23101 H/H in 34 clusters of Dugdadistrict 8 clusters ware purposively selected that have a fluoride mitigation implementation schemes; then from out of 8 clusters; 3clusters were selected randomly and finally a total of 417 sample size ware proportionally allocated for those selected 3 clusters, and each household were sampled by a simple random sampling method.

Data collection procedure
Data was collected using structured interviewer-administered questionnaire. The proportionally allocated for those selected 3 clusters and each household were sampled by a simple random sampling method.

Data quality control
7 The quality of the data was maintained before, during and after the data collection. To maintain the quality of data to be collected, interviewers and supervisors were trained on the significance of the research, independent factors, interviewing techniques, how to control the quality of data and effectiveness of data collectors, the importance of privacy, confidentiality, discipline and other relevant information on the questioner one day training was given for interviewers and supervisors about the data collection tools and the approach that they were to follow. Pre-test was done by taking 5% of sample questioners in one cluster out of the actual data collection area of Dugdadistrict and modification was made accordingly. Furthermore, supervisors and the principal investigator checked the collected data carefully on daily basis for their completeness, accuracy, and clarity. Pretest of the questionnaire was carried out on 5% of respondents whose socio-demographic factors are the same with those actual study participants at Abono Gabriel clusters of Dugdadistrict (out of actual data collection site). During pre-test, the interviewers & supervisors were assessed the clarity and understand ability of the questionnaire and some correction & changes were made on questionnaire be for it was duplicated for actual data collection.

Data process and analysis
The collected data were entered, cleaned, coded, and analyzed by using SPSS version 20.0 windows program. Frequencies, data validation, and cross tabulations were used to check for completeness and consistency whereas selecting cases and sorting was used to identify outliers. Descriptive statistics (Frequencies, proportions, and measure of central tendency and measure of variation) were used to describe the study subjects. Bivariate analysis was used primarily to check which variable is associated with dependent variable individually. To limit the number of variable and unstable estimates in the subsequent models, only variables with p value < 0.25 in the bivariate analysis were further entered 8 into the multivariate logistic regression model. In order to assess the goodness of fit of the final model Hosmer and Lemeshow goodness of fit test and log likelihood was applied.
The result was presented using the crude odds ratio (COR), Adjusted Odds Ratio (AOR) and Confidence level (95% CI). Finally in all analyses, P value<0.05 was considered as significant and presented by adjusted odds ratio (AOR) with 95%C.I. Odds ratio was used to measure strengthen and identify factors associated with utilization of fluoride filtered water by the community from implemented functional mitigation intervention water schemes. Multivariate analysis was used to evaluate independent effects of selected variables controlling the effects of others. Finally, the result of this study was presented using the adjusted odds ratio (AOR) and confidence level (95% CI). In all analyses, P value <0.05 was considered as a level of significance. For the qualitative data, the thematic content analysis was applied, through identifying and categorizing patterns in the data by exploring factor. After having transcribed the whole data set, an in-depth analysis was carried out, through careful reading of the data and finally, conclusions were made by triangulating both quantitative and qualitative results.

Multivariable Analysis
As it is indicated in the above bivariate logistic regression

Discussion
A Community survey study through one-time face-to-face interviews to assess the utilization and characterize existing fluoride filter water scheme systems and obtain public opinion for utilizing filtered water from different filtering methods and community acceptance to sustain the CF. methods were conducted in Dugda district, Oromia reign. was reviled a prevalence of mild, moderate, and severe DF in children's teeth was 17%, 29%, and 45%, (12), and in villages with very high fluoride levels (10-14 mg/L) like as some villages in Dugdadistrict fluoride levels up to ( 9-14.2mg/L) the percentage of lightly and severely affected children age less than 10 to 15 year in Metahara district were respectively 40% and 60 % that is to Mach higher than this study result that 5.1% prevalence among children age less than 14 years. Another case study concerns the area around Lake Lamentation in Kenya fluoride levels ranged between 2.1 and 20.1 mg/l, and fluorosis among children up to age 14 years was 96 %; as 90 % higher than in Dugda district respectively (13, 14). Alabadistricts on the knowledge and perception of the community on fluoride mitigation is poor (13, 15). Health extension workers (HEWs) did not teach about fluoride and related health consequences. Dental fluorosis was reported to start at early ages and not commonly perceived as a major problem. However, adolescents worried and felt that they might be singled out when going to other areas. Older people had a skeletal fluorosis, which interferes with their day to day activities (15) In some places in Ethiopian rift valley, most households perceives that whatever the chemical content is, the presence of water is considered as a blessing (15) However, in practise as this study revealed that prevalence of fluorosis among households who used filtered water for the last 10years had only 1.9% that compared to those households not utilized their drinking water from fluoride flittered source had a 7.7% prevalence of fluoride history; this implies these households who utilized their water from filtered source had nearly protected than those not utilized from community filters; even if the Daly fluoride intake is not only from drinking water only all foodstuffs and beverages including water contain at least trace amounts of fluoride. Food seems to be the source of 80-85% of fluoride intake; intake from drinking water is 0.03-0.68 mg d -1 and from toothpaste 0.2-0.3 mg d -1 (14,16) Questions regarding water quality showed that people were aware that their water may need to be treated and was intended to do so to minimize health impacts and waterborne diseases. They were also aware of the causes and effects of non-fluoride filtered water quality; however, the some of the community usually has no choice but to use the household level florid filter water they own or the one easily accessible community filter or deemed convenient. This study revile also religious reason had the main challenge for the acceptance of bone char filter in those rural villages; this result was similarly comparable with the community survey result of this study that more than 50% of the study H/Hs were orthodox religion followers and were completely oppose using filtered why and when they regenerate the filter material; but more than 325(80%) of the local community accept to use filtered water from the newly constructed HAP filtering schemes without considering the variation of cost among the two filtering alternatives that they expend 120 birrs for 1kg HAP and 0.75 birrs for 20 litter filtered water by HAP most of the local household prefer to use filtered water from HAP filter schemes. This is mainly due to that most of orthodox religion followers believe that drinking the water filtered by bone char filter was interrupt the fasting day so none of the orthodox religion followers can use water from bone char filter schemes and those Protestants and Muslims also complain change of test problem present in bone char filters that practiced as one mien of fluoride mitigation intervention in Dugda district.

Conclusion
The overall utilization of households used fluoride filtered water from community fluoride filter water schemes was 56.3%. Moreover more than three forth 321(79.3%) prefer to utilize filtered water from the newly established filtering techniques so-called (HAP), only 70(17.3%) preferred and bone char filter, however, none of the orthodox religion followers had used their water from bone char filter schemes; and only 14(3.5%) prefer Nalgonda techniques respectively. In the study area the implemented floured mitigation techniques of Nalgonda filter was almost 100% nonfunctional and the bone char filter was also faced a great opposition from the local community due to religious reason and currently the community shift to use filtered water by HAP even if its raw material is costly available.
The main reason for this faller was that simply implementing hardwires without assessing the felt need of the local community was the entire time end up by zero achievements. Office. All the study respondents were informed about the objective and the purpose of the study, and their verbal consent was obtained before conducting data collection.
Confidentiality of the information was assured and collected anonymously.

Consent for publication:"Not applicable"
Availability of data and materials: "The data that support the findings of this studyhas a sort of identifier of individual participants and researcher reserved to send it"

Competing of interest:
The author declaresthere is no any competing interest