3.1 Water quality status in Abeokuta, Nigeria
Water samples from all four (HDW, BH, STW, and SW) sources were slightly acidic with pH value range of 6.3 ± 0.2 and 6.9 ± 0.2 (Table I). The pH values (6.3) of both HDW and STW were lower than the permissible range of 6.5–8.5 (WHO, 2017). Electrical conductivity, which mirrors the enrichment of ions (particles with net electric charge) in water, showed a wide variation between 82 and 860 µS/cm but well within the 1000 µS/cm standard threshold and indicated a type I (low ions enrichment) conductivity classification. Higher levels of total dissolved solids (> 500 mg/L) in drinking water is often associated with diarrhea and abdominal pain (Chakraborty et al., 2019) but all the water samples contained dissolved solids below 500 mg/L (freshwater category) with concentrations in the order HDW > BH > SW > STW.
Turbidity values were generally less than the standard 5 NTU, except for SW (5.8 ± 4.1 NTU). All the water samples except STW contained hardness above 200 mg CaCO3 /L (i.e., hard water) in the order of BH > SW > HDW. Minerals in hard water can change the pH balance of human skin, weakening it as a barrier against harmful bacteria and infections like skin irritation and eczema (Gizaw, Addisu, and Dagne, 2019). The alkalinity and chloride contents were below the recommended levels of 120 mg/L and 250 mg/L, respectively (WHO, 2017). Nitrate (NO3), sulphate, and phosphate, essential dietary anions in humans but the origin of algae growth in waterbodies, were all below the WHO permissible limit. Calcium, an important trace element for the human body, was higher in all the sources but STW than the WHO 75mg/L threshold. In all the water sources, however, the average concentrations of magnesium, manganese, zinc, iron, chromium, and cadmium were all comparatively below the WHO recommended limits, including arsenic and lead, which were below the maximum detection limit.
Microbial analysis of the water samples identified total coliforms, two enteric (Escherichia. coli and Shigella dysenteriae/salmonella typhi) and three opportunistic (Vibrio cholerae, Acinetobacter baumannii and Actinobacter spp.) pathogens, while Escherichia coli 0157:H7 and Clostridium perfringens were not detected (Table 1). Total coliforms (0.002–1.5×10− 1 CFU 100 mL− 1 of water) were detected in 18 (51%) of 35 water samples, occurring more in STW samples (6 samples out of 10) and least in HDW (3 samples out of 10). Total coliform bacteria will likely not cause illness, but their presence in drinking water indicates the potential occurrence of disease-causing organisms. Shigella dysenteriae/salmonella typhi, often the cause of watery/bloody diarrhea and stomach pain in humans, was detected in 31% (n = 11) of 35 water samples, ranging from 0.004–1.96×10− 1 CFU 100 mL− 1 with maximum incidence (6 of 10) in borehole samples. Also, Escherichia coli - an enteric pathogen associated with bloody diarrhea, urinary tract infection, pneumonia, and sepsis, was recorded mostly in boreholes with detection levels ranging from 0.002–8.4×10− 2 CFU 100 mL− 1. Both Actinobacter spp (0.001–2.4×10− 2 CFU 100 mL− 1) from all four water sources and Vibrio cholerae (0.004–1.8×10− 2 CFU 100 mL− 1) from BH, HDW and SW, were detected in 11% (n = 4) of the samples while Acinetobacter baumannii (0.006–4.2×10− 2 CFU 100 mL− 1) from BH and SW were detected in 9% (n = 3) of the water samples. In particular, Vibrio cholerae, often known as the cause of cholera infection, has both a predisposition to cause an epidemic with pandemic potential and an ability to remain endemic in all affected areas (Liu G, 2020). Further genomic analysis on the most detected isolates through amplification showed more opportunistic pathogens (Klebsiella spp., Enterobacter spp., Citrobacter spp., and Salmonella enterica) in all the water sources except the STW samples (Appendix III).
3.2 Socio-demographic and economic characteristics of study participants
Data were collected from 456 participants, 129 (28%) of whom were women, 112 (25%) men, 107 (23%) girls, and 108 (24%) boys (Table II). Their ages ranged from adolescents (12 to 18 years) accounting for 49%, productive age (19 to 60 years), 48% to the elderly (above 60 years), 3%. Of the participants, 301 (66%) were single, 146 (32%) were married, 5 (1%) were widowed, and 4 (about 1%) were separated. Most (96%) of the participants had formal education (Secondary − 73%; Primary − 13%; higher education − 10%), leaving only 4% with no formal education. Also, 173 (38%) were found in the lower (below national minimum wage of 33,000NGN or < 70 USD), lower middle – 81 (18%), middle – 18 (4%), and 8 (2%) in the high economic classes, leaving 176 (38%) with no reported wealth status. In terms of occupation, 216 (47.5%) of the participants were business owners/artisans, 208 (45.7%) were of schooling age, 14 (3.1%) were unemployed, 12 (2.6%) were civil servants, and 5 (1.1%) with no reported occupation.
3.3 WASH- and Health-related characteristics and management practices
3.3.1 Drinking/Domestic water-related characteristics
More than half of the respondents, 269 (59%), reported the use of packaged (sachet water), communal boreholes − 122 (26.8%), 33 (7.2%) hand-dug wells, 17 (3.7%) in-house connections, 13 (2.9%) rainwater and 2 (0.4%) surface water as their main source of water for drinking purposes (Table III). But 252 (55.3%) reported communal boreholes, 149 (32.7%) hand-dug well, 47 (10.3) in-house connections, 6 (1.3%) surface water, and 2 (0.4%) rainwater as the main source of water for cooking. Similarly, 252 (59.7%) reported hand-dug well, 122 (29%) communal borehole, 28 (6.6%) rainwater, 10 (2.4%) in-house/reservoir, 9 (2.1%) packaged water and 1(0.2) surface for domestic purposes. 186 (49%) of the study participants use less than 20L of water per day, 127 (33.4%) use between 21-50L per day and 67 (17.6%) use above 50L per day. Of the study participants, 394 (86%) do not treat their water source for drinking purposes, leaving only 62 (14%) that applied various treatment methods (58% boiling, 12.9% disinfection with usable household hypochlorite, 11.3% settling without chemical, 9.7% use of alum, 6.5% filtration and 1.6% mixed method – e.g., two or more of the outlined methods) to treat their water for drinking. Similarly, about 417 (91%) do not treat their water for domestic activities, leaving only 39 (9%) of the participants that applied various treatment techniques (33.3% boiling, 33.3% disinfection, 23% use of alum, 5% hired experts for routine annual treatment, 2.6% filtration, and 2.6% settling without chemicals).
3.3.2 Sanitation and hygiene-related characteristics
Majority 333 (73%) of the study participants used flush toilet and 117 (25.7%) used latrine, leaving only 6 (1.3%) with open defecation (Table III). But the proximity of sanitary facilities of more than 30m (which is a safe distance) to a water source is reported by just 38%. Most (52%) claimed 6-30m, and about 10% reported an unsafe distance of < 5m. Regarding the proximity of water sources to other threats like solid waste dumps and burial sites, the majority (61%) claimed a safe distance of > 30m, while 30% claimed 6-30m and 9% reported an unsafe < 5m distance. Safely managed sanitation services (the actual global indicator for SDG 6.2) stipulate the use of improved facilities not shared with other households, among other conditions like safe disposal of excreta in situ. However, only 2% of participants do not share sanitation facilities with other households. Others reported sharing a facility with at least 1–3 households (30%), 4–10 households (51%), and over ten households (17%). The majority that reported sharing with 4–10 households is attributed to the most common residential housing style that allows multiple households. Of the study participants, 10 (0.2%) cleaned the sanitation facility with water, 129 (28.7%) cleaned with soap and water, 183(40.8%) with water and disinfectant only, and 136 (30.3%) with water, soap, and disinfectant. In addition, 8 (1.8%) reported cleaning the facility on demand, 118 (25.9%) at least once a day, 248 (54.4%) at least once a week, and 82 (17.9%) more than twice a week.
In terms of hygiene characteristics, only 97 (21.3%) of the study participants had access to a handwashing facility with soap and water (the best practice), 22 (4.8%) had access to a handwashing facility without soap, while the majority – 337 (73.9%) had no access to a handwashing facility. Of the 119 participants with the handwashing facility, 69% wash their hands on demand, 14% once daily, 15% at least twice daily, and 2% seldomly.
3.3.3 Gendered WASH practices
Expectedly, children and women were more burdened with water collection than men, with results showing 108 (23.7%) girls, 104 (23%) boys, 95 (21%) women, and only 38 (8%) men of the 456 study participants, leaving 93 (20.5%) with anyone available, 11 (2.4%) for shared responsibility between, e.g., children and adults, and 3 (0.7%) each for outsourced and in-house connections (Table III). The responsibility of toilet cleaning is more on women (47%) and girls (15%) than men (5%) and boys (4%), substantiating the known socially ascribed household gender roles. The other responses include anyone available (15%), shared responsibility (12%), and 2% outsourcing toilet cleaning. In terms of hygiene practices, 414 participants (30% women, 24% girls, 23% men, and 23% boys) reported hand washing after toileting, while 42 participants (38% men, 26% boys, 19% girls, and 17% women) do not wash their hands after toileting.
3.4 Gendered health-related practices and culture
The majority (68%) of the 456 study participants reported self-healthcare sponsorship, while 32% claimed third-party (e.g., parents, government/private insurance) healthcare support (Table IV). More women (60%) made household healthcare decisions than men (35%) and boys (1%) who fend for themselves, leaving either men/women adults (3%) or both adults (1%). Of the 454 participants that responded to the choice of healthcare facility, most (105/23%) reported private secondary facilities, followed by pharmacies (84/18%) and primary healthcare centers (68/15%). Other responses include homecare (66/14%), self-medication (35/8%), traditional means (32/7%), public secondary facility (25/6%), and tertiary facility (22/5%). Mixed approaches (12/3%), like pharmacy and primary healthcare centers, and both sleep therapy and application of faith (3/1%) were also reported. Of the 105 participants, more women (31%) than men (23%), and more boys (33%) than girls (13%) reported the use of private secondary health facilities. Also, more women (24%) than men (19%) and more girls (39%) than boys (18%) patronize pharmacies for their healthcare needs. But more men (32%) than women (22%) and more boys (28%) than girls (18%) use primary healthcare centers, like more men (34%) than women (17%) and more boys (29%) than girls (20%) that apply self-medication.
3.5 Menstrual Hygiene Management (MHM) practices
All 233 female study participants used blood-absorbent material during menstruation (Table V). The majority, 149 (52% women, 48% girls) used disposable sanitary pads, followed by 57 (46% women, 54% girls) using mixed absorbent materials such as disposable and reusable materials. Use of other types of blood-absorbent materials (cotton wool, mattress/foam, period underwear, tampon, toilet tissue paper and underwear alone) were comparatively low. Most (219/94%) of the female study participants changed their absorbent materials at least twice daily. Only 14 females, more girls (64%) than women (36%), changed absorbent materials once a day. Of those changing at least twice a day, 110 females; more girls (56%) than women (44%) changed twice a day, while 109 participants; more women (62%) than girls (38%) changed more than twice a day.
On menstrual hygiene, most (151) of the female participants; more women (54%) than girls (46%), reported washing their hands before changing absorbent material, while 82 females; more girls (51%) than women (49%) do not wash hands before changing the materials. Also, the majority (225/97%), more women (120/53%) than girls (105/47%), washed their hands after changing menstrual material, leaving 8 (3%) females who do not handwash after changing their absorbent material. 110; more women (54%) than girls (46%) washed their genital area with water only, while 123; more women (51%) than girls (49%) washed with soap and water. The most common water source for genitalia washing is communal boreholes (54%) and hand-dug wells (44%). Other reported water sources include surface water at 1% and packaged (sachet) water at lower than 1%. At home, 89 (37% women, 63% girls) of the 233 female participants changed their absorbent material in the privacy of their toilet, followed by 74 (61% women, 31% girls) in the bedroom, and 70 (63% women, 37% girls) in the bath/washroom. But only 125; more women (51%) than girls (49%) changed their absorbent material when away from home.
3.6 Prevalence of water-related illnesses in Abeokuta, Nigeria
Diseases associated with water are defined as water-related infectious diseases – WRID (Kulinkina et al., 2016; Bartram et al., 2023). Such diseases vary from water-borne (Ingestion of pathogens in contaminated water, e.g., typhoid) to water-washed (Poor hygiene/lack of access to safe water, e.g., diarrheal diseases), water-based (Infection by agents that spend part of their life cycle in water, e.g., schistosomiasis), and water-related vectors (Spread by vectors that breed or bite near water, e.g., malaria). In the study area, water-related illnesses accounted for 66.5% of the 33,522 diagnosed cases within the targeted 15 months at the selected PHCs. Of the diagnosed 22,316 water-related illnesses (Table VI), malaria (68.1%) was the most prevalent, followed by upper respiratory tract infection (14.4%), typhoid/enteric fever (7%), gastrointestinal tract infection (3.6%), diarrheal diseases (3.2%), pelvic inflammatory disease/urinary tract infection (1.9%) and skin/dermal infection (1.8%). By gender and age, more women (32%) than children (29% girls and 26% boys) and men (13%) suffered a water-related disease. It may be argued that malaria, the most prevalent in this study area, is water-vector borne and not due to ingesting unsafe water. It is nonetheless a WRID, and vector-infested water is of poor quality. Also, malaria and diarrheal diseases remained among the world's top 10 causes of death (WHS, 2022).
3.7 Potential health risk exposure to hydro chemical (metals) in water sources by gender
The hazard index- HI (depicting susceptibility to health impacts) of selected metals in the four water sources are presented in Table VII. The HI value less than or equal to one indicates no harmful health concerns, while HI > 1 flags an adverse health impact. In Abeokuta city, calcium in water sources showed the highest level of HI range from 784 to 2971, well above the safe threshold limit of 1.0, and in men more than women, boys more than girls for all four water sources in the trend BH > SW > HDW > STW. Suggesting susceptibility to a high risk of non-carcinogenic calcium-related health issues. Calcium is the most abundant mineral in the human body needed to maintain bone and teeth structure and allow blood clotting and hormonal secretion. Also, the lack of it causes loss of bone mineral density in postmenopausal women. But toxicity due to high concentrations has been linked to diarrhea and kidney failure (Tai et al., 2015). Relative to women and girls, men and boys are more vulnerable to high calcium exposure because they have a higher risk of developing kidney stones (linked with high calcium levels in the blood) and a higher rate of urinary calcium excretion – caused by higher testosterone levels (which can increase the calcium that is absorbed from the intestines), lower levels of physical activity, and higher animal protein intake than women and girls (Gillams et al., 2021). The HI values for all other hydro chemicals were less than 1.0, indicating they are of negligible/low-risk non-carcinogenic health issues but with varied susceptibility by gender and age (Figure III).