Community Knowledge and Practice on Sanitation, Hygiene and Household Water Utilization in Afabet City, Northern Red Sea Zone of Eritrea: Cross Sectional Study

Background: Water and sanitation entitles the human right to affordable access and sanitation. The objective of this study was to determine the knowledge and practice on sanitation, hygiene and water utilization and to estimate the prevalence of diarrhea in Afabet city. Methods: It was a community-based descriptive cross-sectional type of study with a multistage cluster sampling technique. First, 12 clusters were selected from the city and 30 households were nominated from each cluster. Then, a total of 360 individuals were sampled and every family head was interviewed. A structured interviewer administered questionnaire and eld observation was used for data collection from December 05-20, 2020. Cross tabulation and association of variables using chi-square test was determined and results were weighted as cluster sampling was used. Results: A total of 360 respondents were enrolled in the study with females (75.3%) and Muslin (99.0%) predominance. About 66.2% and 66.9% respondents were satised with the amount and quality of water they received respectively. The prevalence of diarrhea in the community in the last six months of 2020 was 13.0%. The investigators practically approved that 90.7% of the communities revealed functional toilets and feces were observed in only 5.7% of the living area of the community. The community’s comprehensive good knowledge and practice was 99.4% and 93.0% respectively. Their comprehensive knowledge and practice showed signicant association with age, sex, marital status, level of education, household size and distance to municipality water source (p<0.001). Furthermore, their comprehensive knowledge and practice, prevalence of diarrhea, presence of latrine, distance from their home to municipality water source and hand washing practice were signicantly associated with the administrative area of the study participants (p<0.001). Conclusion: The community had good level of knowledge and practice but the prevalence of diarrhea was relatively high. Latrines were highly utilized but the usage of soap, personal and food hygiene was slightly low. The level of comprehensive practice, prevalence of diarrhea, distance to municipality water source and hand washing practice was associated to the administrative areas. Enhancing environmental sanitation, personal hygiene and provision of adequate and clean water are highly recommended. zoba’s and different ethnicities are necessary to have different responses


Introduction
According to a World Health Organization (WHO) report, globally 2.3 billion people lack safe water at home and 844 million people do not have basic drinking water supplies [1]. Furthermore, 2.5 million people worldwide do not have access to any type of improved sanitation [2]. Unsafe drinking water, along with poor sanitation and hygiene accounts for nearly 10% of the total burden of disease worldwide [3]. Safe, reliable and piped-in water is an essential goal, and treating water at the household or other point of consumption provides a means by which vulnerable populations can improve the quality of their own drinking water [4].
For populations without reliable access to safe drinking water, household water treatment (HWT) provides a means of improving water quality and preventing disease [5]. Unless people have adequate knowledge, attitudes and practices in relation to drinking water, sanitation and hygiene, mere access to the services is not su cient mitigate health problems related to unsafe water and poor sanitation and hygiene. Information on knowledge, attitudes and practices (KAPs) in relation to water safety, sanitation and hygiene in peri-urban areas is essential to prevent water-borne diseases [6]. Many communicable diseases can be effectively managed by improving water, sanitation and hygiene (WASH) practices. Waterborne disease prevalence can be reduced through implementing the three key WASH practices. Safe disposal of feces and hand washing with soap at critical times can reduce prevalence of waterborne diseases by 30% and 40%, respectively [7].
The prevalence of diarrhea in developing countries has encouraged the development of low-cost, behavior-based interventions to interrupt diarrhea-causing pathogen transmission by improving water quality at the point-of-use and by washing hands using soap. Meta-analysis of e cacy studies indicate that household water treatment reduces diarrhea in children < 5 years of age by 30-40% and hand washing with soap reduces diarrhea and acute respiratory infections by 31% and 24%, respectively [8]. In Sub-Saharan Africa, access to safe drinking water in peri-urban areas is inadequate and complicated by the in ux of people from rural to urban areas, poverty, and poor sanitation and housing conditions [9].
According to UNICEF-WHO Joint Monitoring Programme data from 2015, only 16% of the population in Eritrea has access to basic sanitation facilities and 76% practice open defecation [10]. In highland areas of Eritrea, many people practice open-air defecation for different reasons [11].
In Eritrea, currently most of the urban population gets clean water and the use of latrine is promising. But, it is mainly different in the rural areas and their distribution differs among the sub zones and also the level of knowledge and practice of the community is not well determined. To the knowledge of the researchers, there are no similar researches done before to identify this problem in the country in general and in the sub zone in particular. Thus, to ll this gap, the objective of this study was to assess the level of knowledge and practice of the community in sanitation, hygiene and water utilization, and also to determine the prevalence of diarrhea in Afabet city, Northern Red Sea Zone of Eritrea.

Study design and sampling method
It was a descriptive cross-sectional community-based type of study. A multistage cluster sampling technique was implemented as a sampling method to select the study households. First, the city was strati ed into six strata and from these strata 12 clusters were selected proportional to their size and 30 households were selected from each cluster. Finally, a total of 360 individuals were sampled from the study area and every head of the selected family was interviewed for the questionnaire.

Study population and site
The study was conducted in Afabet city, Northern Red Sea zone of Eritrea. This zone has a population of 491,657 and Afabet sub zone and Afabet city have a population of 91,813 and 34,676 respectively [12]. All household heads from the selected study area and who were available during the data collection time were included in the study. Household heads that were unable to speak and with no legible respondent and those with mental retardation were excluded from the study.

Sample size determination
The sample size for this study was calculated based on various aspects including diarrhea prevalence, precision level and con dence interval. The diarrhea prevalence (p) in the community was not known to the researchers; hence, it was assumed that 50% of the households in the community were infected with diarrhea. Besides, the precision level (d) and the con dence level (z) were taken at 6.5% and 95% respectively. The initial sample size was obtained using the formula n 1 = Z 2 *p*q/d 2 Thus, with the assumption of the estimates mentioned above the initial sample size were 228. Considering 95% response rate(r), the nal sample size (n) was: n = n1/r = 228/0.95 = 239 Considering a design effect of 1.5 the nal sample size was 359. The cluster size was determined at 30 individuals and hence 12 (359/30 =11.9 ~12) clusters were selected. Therefore, a total of 360 individuals were sampled from the study area.

Data collection
Data were collected from December 05-21, 2020 for an interval of 15 days. A structured interviewer administered questionnaire and eld observation were used to collect the data from the participants. The questionnaire had included the socio demographic characteristics of the study participants, questions which used to assess their awareness on general sanitation, hygiene, availability of water and household water treatment options and the prevalence of diarrhea in their community. The questionnaire was partly adopted from knowledge, attitude and practice study on sanitation, hygiene and solid waste management, private toilet survey 2014 in BO City [13] and nally modi ed and reformed to the context and objectives of this study. During data collection, eld observation was done to validate the response of the household member on speci c parameters. The presence of latrine, functionality, availability of water source, water cleanness and handling practices were evaluated. Personal and food hygiene of the family was practically assessed during the data collection time by trained investigators.

Data analysis and interpretation
Data were entered in CSPro 7.3 and transported to SPSS software and descriptive statistics were presented using frequencies and percentages. Chi-square test was implemented to assess the association of the variables to the background of the participants. P value < 0.05 was considered signi cant. Weighting of the results was done as cluster sampling design was used.

Operational de nitions
There were 11 knowledge and 8 practice questions. Those who respond correctly to the knowledge question were scored as 1 and for those responded incorrectly were given 0 point. Results were summed and converted to percent. Finally, those who scored less than 70% in the knowledge questions were considered as having poor knowledge and those who scored higher than 70% were considered as having good knowledge in sanitation and water treatment options. The same principle was applied to evaluate the level of practice of the participants.

Ethical consideration
Ethical approval was obtained from the Ministry of Health Research and Ethics Clearance Committee on 21/09/2020 and permission was asked from the zonal and local administrators. The con dentiality of the patient's information was kept secured. The head of the family had signed a written informed consent and participants had the right to withdraw from the research at any stage if they thought the questions are con dential.

Results
A total of 360 respondents were enrolled in the study and females were predominant respondents (75.3%). Almost all (99.0 %) of the respondents were Muslim in religion and Tigre in ethnicity. About 40.8% of the study participants were illiterate and 25.8% reached primary level of education. Most households (87.5%) own latrine and children (64.2%) usually collect water from the water source. Most of the study participants were aged between 21 to 40 years' (58.5%) and 41 to 60 years (34.1%).
Majority of the households had one to two children and owns one to two living rooms in their house, and more than half (59.8%) of the community had a household size of 4 to 7 individuals. As there is no piped tap water to the households, 58.4% of the households have access to water provided by municipality (public tap) in less than one kilometer away. While, 24.7% travel a distance of 1-2 kilometers and 16.9% travel more than 3 kilometers for water access. (Table 1) Knowledge and practice of the community on sanitation, hygiene and water utilization The community had good level of knowledge on most of the questions regarding sanitation and hygiene. Almost all respondents (98.5%) reported that diarrhea can be prevented and 37.5% answered that water which looked clean by their naked eye was clean and free of bacteria. Majority of them (91.2%) a rmed that defecation in toilet could help prevent diarrhea and regular hand washing is very important (99.8%).
The results showed that 88.3% of the communities in the city have some form of toilet in their compound. The commonly used types of toilets are direct pit (43.2%) and pit latrine with slab (41.4%) and from those who didn't own toilets, 14.2% would rather use neighbors toilet than openly defecate. One tenth (9.2%) of the toilets were not functional and the main reason was that construction was not nished. Burying was the common (77.3%) method of liquid waste disposal in the community. Even though 98.2% of the study participants were comfortable with their current sanitation situation, 52.8% had reported constraints to improve their sanitation in the community. Among the commonly mentioned constraints to improve their sanitation were shortage of material (34.1%), nancial constrains (32.1%) and no space (15.8%). The study participants reported that the positive aspects of using toilet are improved hygiene (88.6 %) and improved health (84.9%). Almost all (99.4%) of the study participants used water for cleansing after defecation and half of them (49.4%) reported that open defecation had never practiced in their community. (Table: 2) Almost all of the community had a good level of comprehensive knowledge (99.4%) and comprehensive good practice of 93.0%. only 7.0% of the study participants had poor practice on sanitation, hygiene and water treatment options. The self-reported prevalence of diarrhea during the last six months in the community was 13% and 10.1% in less than ve years children. And 5.9% of respondents reported of diarrheal illness in their household in the past two weeks and mostly (4.4%) reported single episode of diarrhea. (Table 3) Household water use and treatment practice The community's main sources of drinking water are well (61.7%), truck water supply (18.6%), and public tap (16.9%). The households were asked whether they treat the fetched water regularly and three quarters (76.6%) of the household con rmed that they treat their water at home, and the most common methods used was straining against cloth (48.9%), boiling (38.6%) and adding chlorine (31.7%). The common reasons mentioned for not treating water are lack of knowledge and materials. Sustainability of water access and amount is alarming as 47.1% households sometimes suffer shortages water for drinking. And still some family members drink unsafe and untreated water (73.7%) when either in the eld or away from home, and 23.0% when they are in a hurry.
Two third of the study participants were satis ed with the amount and quality of water they received. The main reasons for dissatisfaction mentioned are bad taste (11.8%), water turbidity (7.7%) and poor quality (3.0%). More than half (58.0%) of the households own water storage tank and they cleaned it using water and OMO (detergent) on weekly (67.6%) and monthly (24.1%) basis. (Table: 4)  Association of comprehensive knowledge and practice with their background the comprehensive knowledge of the respondents had showed signi cant association with their age, gender, marital status, level of education, distance to municipality water source and household size (p < 0.001).
Participants age, religion, ethnicity, level of education, distance to municipality water source and household size were also signi cantly associated with their comprehensive practice (p < 0.001). Study participants with distance to municipality water source greater than three kilometers were having poor practice on sanitation, hygiene and water use compared to these with one-kilometer distance to the municipality water source (p < 0.001). (Table 6)  Study participants from administrative area of one and three have the highest good practice compared to the other administrative areas and the lowest practice on sanitation and hygiene was reported in administrative area of two, (p < 0.001). The highest prevalence of diarrhea in the city was reported in administrative area of three and two respectively (p < 0.001). All study participants from administrative area of two where having greater than three kilometer distance from their home to municipality water source (p < 0.001). Majority of the respondents in administrative area of four were practicing hand washing of greater than ve times a day compared to the other administrative areas (p < 0.001). The level comprehensive knowledge, practice, prevalence of diarrhea, house with latrine, distance to municipality water source and hand washing practice of the participants showed signi cant association the administrative area in the city. (Table: 7)  Table 7 Association of administrative area to different background of study participants

Discussion
Three key hygiene practices of safe disposal of feces, hand washing with soap at critical times, and the treatment and storage of drinking water are the most effective ways of reducing diarrheal disease. The objective of this study was to determine the community awareness and practice on sanitation, hygiene and water use and to estimate the prevalence of diarrhea in the community.
The study has demonstrated that three quarters of the respondents regularly treat their drinking water and straining against cloth and boiling are the common ones. This result was higher to other studies that an estimated 33% of the households in these countries report treating their drinking water at home and boiling were the most dominant water treatment method (21%). [5] Other study also reported that household water treatment was practiced by 34% [6] and 18.3% [14] of the respondents and Chlorination was a major (20%) method of HWT [6].
This higher practice of water treatment could be mainly due to their higher level of knowledge on the methods and on the disease burden compared to the other study groups.
This study showed that the community has high level of good comprehensive knowledge and practice of on sanitation, hygiene and water treatment options. This result was high compared to other studies that the overall mean knowledge of adults in terms of water safety, sanitation and hygiene was 78.1% [6]. And in another study good knowledge and practice on WASH were observed in 42.2% and 49.2% of the respondents, respectively [14]. This high level of knowledge and practice in the city could be mainly due to the continuous input of the Ministry of This study indicates that about half of households claimed they wash their hands after defecating and most of them use water and soap. Similarly, peri-urban Ethiopian study showed that hand washing after using the toilet was practiced by 67% of households. And, 48% wash their hands with soap and water [6]. Despite these results and even though almost all self-reported that regular hand washing is very important, but during practical observation the narrative changes. Mothers' hands were not clean in 22.7% of them and only 22.9% of the households had soap at the toilet during the investigators visit, which is better than similar Ethiopian study (14.98%) [14]. This shows that the practice of hand washing with soap after defecation is questionable. And that actual practice of proper hand washing in the community seems lower to the self-reported practice and could be some of the reasons for the higher prevalence of diarrhea in the households.
This study depicted two third % of the households wash the water storage containers used for drinking water on weekly basis and majority with water and OMO (detergent). This practice was higher to other study where 46% of households clean their water tanks [16]. This further mirrors the higher awareness of the community on household water treatment techniques.
The trained investigators observation was crucial in assessing the gap on maintaining water safety, and personal sanitation and hygiene. And despite the communities' relatively better knowledge about waterborne fecal-oral disease, the results showed discrepancies on actual practice. Absence of garbage container, unclean mother's hand, absence of soap at toilet, uncovered food and feces in the living area were the noted indicators of actual sanitation and hygiene practices in the community. Hence, empowering the community to increase their practice through behavior change and sustaining the current results would be crucial.
Though the majority of participants are satis ed with the quantity and quality of water supplied; bad taste, poor quality and water turbidity were reported as major problem by one-third of them. Therefore, it is essential to introduce household piped water method or the household water treatment options should be enhanced.
The prevalence of diarrhea in the community in the last six months and in children less than ve years age was 13%% and 10.1% respectively. This was similar to other study that the two-week prevalence of diarrhea in children under 5 years of age was 13.6% [6]. And lower to other study that 19.1% households experience diarrhea symptoms in the last six months [15]. This lower prevalence in diarrhea in the community could be mainly due to that they had higher knowledge on the association between sanitation, hygiene and diarrhea and also higher percent of the community were using water treatment techniques in their house. The introduction of Rota virus vaccine could have also an impact on the lower prevalence of diarrhea in children less than ve years in the community.
Based on the results of this research, the administrative area in the city showed signi cant association with their comprehensive practice, prevalence of diarrhea, distance to municipality water source and hand washing practice.
Other studies showed that statistically signi cant differences were observed on the levels of knowledge and education [6].

Strength and limitation of the study
The self-reported practices of the respondents were veri ed by practical observation of the investigators, which increases the validity of the respondents. This research tries to answer all aspects (sanitation, hygiene and water use) which can cause diarrhea to increase the strength of the study. Further studies with larger sample size that includes the urban and rural communities from different zoba's and different ethnicities are necessary to have different responses The study was no without limitations. It was conducted in one city which the results can't be used to generalize to the whole country. Since there was no similar study conducted before in the country, it was di cult to associate the results with national previous studies.

Conclusions
The level of knowledge and practice of the community on sanitation, hygiene and household water treatment in Afabet city was very high and the utilization of toilets and household water treatment options was promising. The prevalence of diarrhea in the community was slightly higher and most of them were satis ed with the amount and quality of water they use. Open defecation was rarely used but personal and food hygiene was not such satisfactory in the community. The level comprehensive practice, prevalence of diarrhea, distance to municipality water source and hand washing practice of the participants showed signi cant association the administrative area in the city.
To end open defecation and meet the sustainable development goals, further monitoring and community control strategies for those who defecate in the elds and to sustain the high utilization of toilets are highly recommended. Awareness on personal, food and environmental hygiene and hand washing with soap at the critical times are vital and should be addressed to decrease the higher prevalence of diarrhea in the community.
Introducing affordable and reliable household water treatment techniques and providing household pipe water are necessary to improve the living standards of the households. Eritrea and written informed consent was obtained from the study participants. Personal information of participants was kept secured.

Consent for publication
All authors have approved the manuscript for publication, but consent was not applicable Availability of data and materials The data sets used and supplementary materials are available and can be requested from the corresponding author if necessary.

Competing of interest
Authors declare that they didn't have any competing of interest to disclose Funding This research had no any source of fund except for the data collectors in which their expense was covered by the Ministry of Health, Northern Red Sea region Author's contribution The proposal was designed by BT, FK and HM. FK varnished the study design and methodology part. All authors have participated on supervision of the data collectors. FK designed the data entry tool and BT and MG participated on data entry. Data analysis was done by FK and the rst draft of the manuscript was written by BT, MG and HB. All authors have contributed by analyzing, interpreting and writing the manuscript. The nal form of the manuscript was shaped by BT, HM, HB, FK and MG. Finally, all authors have read and approved the nal manuscript.