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Background to the Study

Water hygiene knowledge, attitude, practice (KAP) and enhancement strategies are key to ensuring the sustenance of good health, wellbeing, comfort and survival of man, including women attending antenatal care (ANC). This is because water has impurities that affect it in the environment. These impurities are often ingested as a result of man’s inability to embark on correct water hygiene, which results to dire consequences. For instance, in many homes, water related diseases have been one of the leading causes of mortality and morbidity in developing countries (World Health Organization and United Nation International Children Fund [WHO/UNICEF], 2000). In addition, WHO (2004) further revealed that approximately 88 per cent of water related diseases were attributable to unsafe water use, inadequate sanitation and hygiene. Furthermore, the consequences of inappropriate water hygiene according to UNICEF/WHO (2009) led to diarrhoea that killed 1.5 million children of less than five years of age annually more than deaths from acquired immune deficiency (AIDS), malaria and measles combined globally. According to Craun, Brunkard, Yoder, Roberts, Carpenter, Wade,…Roy (201 0), from 1971 to 2006, 54 per cent of reported water related disease outbreaks were due to the use of untreated water. Jones (2011) showed that 37 per cent of people not using improved source of water lived in sub-Saharan Africa, which included Nigeria and Plateau State. Jones further pointed that poor practices of water hygiene were on the increase and accounted for 2.2 million children deaths of less than 5 years of age.

The scourge of water related diseases had been on the increase. Nigeria Center for Disease Control – NCDC reported an increase in wate r borne diseases with 9,006 cases and 106 deaths in the first quarter of 2014 (Leo, Sadiq, Alao, Auwal, Liman & Mohammed, 2014). When untreated water was ingested, cholera occurred (Igomu, 2011). It may be in this regard that in 2013, Plateau State government reported 130 cases of cholera disease and 11 deaths (Sadiq, Auwal & Joseph, 2013). Therefore, the ingestion of untreated water can lead to many health problems such as gastrointestinal illness, reproductive problems and neurological disorders (Center for Disease Control [CDC], 2013). Moreover, infants, young children, pregnant women, the elderly and patients with compromised immune system due to AIDS, chemotheraphy or transplant medications may be especially susceptible to illness (United States Environmental Protection Agency [USEPA], 2013). Thus, safe water supports


life. The above statistics lend credence to the importance of the ingestion of safe water if good health is desired.

Water is an important ingredient necessary to all forms of life. Mathur (2007) viewed water as a great cleaning agent that is used both externally and internally. Moshby (2009) defined water as a chemical compound, which one molecule contains one atom of oxygen and two atoms of hydrogen. Leeds (2014) conceived water as a compound that is made of two parts, hydrogen and one part oxygen. Quotes (2015) posited that water is the fluid which decends from the clouds in rain and which forms rivers, lakes, seas and oceans. Water as used in this study refers to any clear, colourless, odourless, pleasant tasting liquid that is necessary for all forms of life. Thus, it may imply that water is a transparent fluid which forms the world's streams, lakes, oceans and rain that is a major chemical constituent of the fluids of living things. Furthermore, water can be used for domestic, irrigation, commercial, industrial and hydroelectric power purposes (Heaton, 1999).

Domestic water includes water used for normal household purposes such as drinking, food preparation, bathing and personal hygiene, dish washing, laundry, general household cleaning, watering of lawns and gardens. Water is used for irrigation, which involves the supply of an area of land through pipes or channels with water to grow crops. Commercial and industrial water is used for manufacturing of goods, while water is also used for the generation of electricity, known as hydro-electricity.

Water is required in the human body for the maintenance of vital physiological and biochemical processes such as digestion, respiration, excretion and circulation. Water used for these purposes need to be clean, clear and free from harmful substances, minerals, chemicals and microorganisms. This implies that water introduced into the human body must be safe. The consumption of safe water does not cause illness or health problems but maintains health. Safe water ought to be free from dirts, wastes, feaces and germs. Also, it must be free from poisonous chemical compounds or the presence of chemicals, which must be below permitted level and minerals therein not exceeding tolerant level. It must also be tasteless, colourless, odourless, and drinkable. Unfortunately, water often contains particles, dirts, microorganisms, bacteria of cocci, bacilli or flagella, coliforms, viruses, algae, Escherichia coli, Pseudomonas aeruginosa, Campylobacter spp, Salmonella spp, protozoas of Crysptosporidium and giardia lamblia thus making it unclean. In other to make water clean and safe for use, measures of hygiene like purification of water among others become important.


Hygiene is a term that refers to practices that help maintain sound health and prevent disease. Pugh, Warner, Filardo, Binns, Francis, Lukens,…Cradle (2000) defined hygiene as any practice of cleanliness that promotes health and wellbeing especially of a personal nature. Rand and Frazier (2007) referred to hygiene as including practices that relate to personal hygiene, food hygiene; environmental hygiene and keeping household environment free of excreta and solid wastes, as well as keeping drinking water supplies safe and free from contaminants. It involves regular washing of the body, clothing, hair, brushing of teeth and caring for the gums (Ilika & Obanu, 2009). In addition, Center for Disease Control (CDC, 2014) referred to hygiene as behaviors that can improve cleanliness and lead to good health such as frequent hand washing, face washing and bathing with soap and water. Nyanghura (2014) viewed hygiene as any personal effort to make oneself clean. Hygiene as used in this study refers to keeping water odourless, tasteless, colourless and free from microorganisms to prevent illness or disease in other to promote sound health when used. It involves all the practices that help people stay healthy. This implies that hygiene is an embodiment of cleanliness of the human body, food, kitchen, environment and keeping water clean. The focus of this study was water hygiene.

Water hygiene eliminates or removes impurities and microorganisms from water to keep it safe for use. According to Business (2015), water hygiene is a process for enhancing the quality of water so that it meets the quality criteria for its fitness for intended use. To achieve correct water hygiene, Mintz, Reiff and Tauxe (1995) revealed that one needs to have container with single opening five to eight centimeters in diameter with strong, tightly fitting cover that makes it easy to fill and add disinfectant but difficult to immerse hands or utensils. In addition, Sobsey (2002) pointed that water carrying vessels should be between 10-25 liters capacity, rectangular or cylindrical with one or more handles and flat bottoms for portability and ease of storage among others. In the context of this study, water hygiene refers to the use of various ways to eliminate impurities, odour, taste, colour and pathogens from water in order to keep it suitable for use to prevent disease and promote sound health when used. In order to eliminate impurities, filtration, disinfection, aeration, coagulation, flocculation and sedimentation are important (Joint Departments of the Army and Air Force United States of America (JDAAUSA, 1985). Therefore, for any water hygiene to be effective, the multiple barrier principles identified by JDAAUSA (1985) as ways for the removal of contaminants in raw water is necessary.

Filtration is the process where liquid is passed through a medium that helps to remove smaller particles in it. JDAAUSA (1985) defined filtration as the separation of larger


particles from water by passing it through a porous medium, usually sand, granular coal or granular activated carbon. CDC (2015) viewed filtration as the process of removing impurities from water by means of physical barrier, chemical or biological processes. In this study, filtration refers to the process of passing water through a porous medium to remove impurities from it. Various types of filtration media include slow sand, pressure sand, diatomaceous earth, porous stone or ceramic, paper or cloth and charcoal, membrane filters and depth filters among others. Filtration media is better enhanced to purify water when such is disinfected.

To disinfect requires cleaning a substance with something to inactivate or kill micro-organisms. According to Chlorine Chemistry Council (2003), disinfection is a means of destruction of harmful microorganisms usually by the use of bactericidal chemical compounds. Lenntech (2014) conceived disinfection as the removal, deactivation or killing of pathogenic microorganisms in water. Disinfection as used in this study means the deactivation or killing of pathogenic microorganisms in water using chemical or physical disinfectants to make it suitable for use. Disinfection thus destroys organic contaminants from water, which serve as nutrients or shelters for microorganism. Moreover, disinfectants do not only kill microorganism but also have residual effect, which means that they remain active in the water after disinfection. In addition, disinfection can be attained by means of chemical and physical disinfectants. The chemical disinfectants for water include the use of chlorine, chlorine dioxide, calcium hypochlorite, ozone, halogens of bromine, iodine, bromine chloride, copper, silver, kaliumpermanganate, fenols, alcohols, hydrogen peroxide, and several acids and bases. Ultraviolet light such as electronic radiation, gamma rays, sounds and heat as in boiling of water can all be used for disinfection of raw water.

Aeration implies the exposure of water to surface air. As conceived by Hofkes and Huissman (1987) aeration is the blending of water with air in order to increase oxygen content in water; increase the pH in water by reducing its carbon dioxide content; remove iron, magnesium, hydrogen sulphate, methane, various volatile and organic compounds responsible for flavour and smell in water. As pointed by Paulson (2012), aeration is used to mix, circulate or dissolve air into a liquid or other substance(s). Aeration as used in this study refers to the process of exposure of water to air so as to remove volatile substances in water such as odour. It may follow that aeration could be used for the oxidation of substances such as iron and manganese; removal of carbon dioxide; taste and odour producing substances such as hydrogen sulfide; volatile organic compounds; removal of compounds suspected to


be carcinogenic such as methane, and increase pH. Aeration gives better results when sedimentation is attained.

Sedimentation may mean the process where fluid is allowed to move slowly, causing heavy floc particles to settle to the bottom. According to CDC (2015), sedimentation is a process where floc particles are caused to settle to the bottom of water supply due to its weight. Sedimentation in this study refers to the settling under gravity of dirt particles in raw water. Sedimentation implies the movement of solid particles to settle downward through the force of gravity, centrifugal force or electromagnetism. In the case of water, heavy particles (flocs) settle to the bottom and clear water is left above to be filtered. For sedimentation to be achieved in causing flocs formation, coagulation is important.

Coagulation is a process in the formation of small particles in raw water. LeChevallier and Au (2004) submitted that coagulation is the addition of a substance that forms hydrolysis products that cause particle destabilization and interparticle collisions in water. Environmental Protection Agency (EPA, 2011) conceived coagulation as a process by which dirt and other small suspended solid particles are chemically bound, forming flocs using coagulant so that they can be removed from water. Coagulation in this study refers to the process that involves addition of iron or aluminum salts such as aluminum sulphate, ferric sulphate, ferric chloride or polymers to raw water in other to bring dirt particles close together. Thus, it implies that the process of coagulation require having positive charge of the chemicals (coagulant) neutralizing negative charge of dissolved and suspended particles in raw water. When this reaction occurs, the particles bind together or coagulate. Large coagulates is formed through floculation.

Flocculation could be any physical process in the formation of solids into large mass. LeChevallier and Au (2004) defined flocculation is the physical process of producing interparticle contacts that lead to the formation of large particles. EPA (2011) posited that flocculation is the physical process of growing particles (flocs) in water. CDC (2015) conceived flocculation as the binding of dirt particles with chemicals to form larger particles called floc. In this study, flocculation is the physical process which leads to the production of larger interparticle formation of flocs in raw water. It implies that flocculation join together small particles into larger, settleable and filterable particles. It occurs when alum, potash ash, magnesium hydroxide, ferric sulfate or ferrous sulfate are added to water and colloidal particles of minerals, clay, silt, organic debris and microscopic organisms ranging in size from about 0.001 to 1.0 micrometer to form tiny sticky particles called floc which attract the dirt particles. Flocculation is an important technology for larger scale water treatment, which


requires a degree of skill, technical competence and knowledge. From the foregoing discourse on water, water hygiene and water hygiene knowledge and practice appeared to be an important means to achieving correct water hygiene for the maintenance of sound health.

The right knowledge of hygiene of water when practiced influences correct water hygiene. Adequate knowledge, positive attitude and correct practises of hygiene have been identified by WHO (2004) as important measures that yield correct knowledge of water hygiene. Knowledge as defined by Carter and Winifred (2005) is accumulated facts, truths, principles and information to which the human mind has access. Comfort (2005) viewed knowledge as the sum of our conceptions, views and predispositions which have been established and tested. Knowledge in the present study refers to facts, truths, principles or information that people have acquired with regard to water hygiene. This may imply that if correct facts, truths, principles or information are applied to water hygiene, the right knowledge of water hygiene occur.

Knowledge of water hygiene could be an important ingredient in forestalling water related diseases. Knowledge of water hygiene as depicted by Clarke (2001) refers to the facts and principles accumulated by people with regard to water hygiene. In this study, water hygiene knowledge refers to the facts, truths, principles or information that help people to eliminate impurities, odour, taste, colour and microscopic organisms in water so as to keep it suitable for use to prevent disease and promote sound health. This implies that if knowledge of water hygiene is compromised, the presence of pathogen, toxic chemicals and particles found in such water when ingested can cause disease affecting man’s health like diarrhoea among others. Whereas water related diseases may stem from incorrect knowledge of water hygiene. In Plateau State, observation has shown that domestic water was collected from unhygienic sources such as streams, rivers and shallow wells that may be unsafe. Moreover, all and sundry including women attending ANC chose wide opened containers without lid to fetch and store domestic water. This implies incorrect knowledge of water hygiene that can have implications on health. In this regard, there is the need for all including women attending ANC have correct knowledge of water hygiene facts; truths, principles or information if they must enjoy safe water devoid of disease causing organisms even in Plateau State.

In Plateau State, water was got from source closest to the user irrespective of its quality. This implied incorrect water hygiene attitude. They also fetched and mixed stored water with freshly fetched one implying incorrect practises of water hygiene. The situations above concerning water hygiene KAP even of women attending ANC is troubling and point


to problems, which justify the study. From the foregoing discourse on water; water hygiene and practices of water hygiene, it follows that knowledge of water hygiene, attitude and practices are very important for the maintenance of safe water that when ingested leads to sound health. However, women attending ANC are at liberty to express their feeling.

When feelings or disposition are expressed, attitude is expressed. Attitude according to Kerlinger (2002) is an organized predisposition to feelings, perception and behaviour towards a referent or cognitive object. Mudary (2003) viewed attitude as a feeling tone directed towards a person, object or idea. Luthans (2007) defined attitude as persistence tendency to feel and behave in a particular way towards some object. Attitude in the context of this study refers to predisposition women have concerning water hygiene. Therefore, the disposition women attending ANC may have could be either positive or negative. Thus, when positive or negative disposition towards water hygiene occurs, attitude towards water hygiene is observed.

When attitude to water is expressed, attitude towards water hygiene has occurred. Hogg and Vanghan (2005) viewed attitude as a person’s expression of any relatively enduring organization of beliefs, feelings and behavioural tendencies. The view of Hogg and Vanghan concerning attitude may imply that when attitude is directed to water hygiene, attitude to water hygiene has occurred. Therefore, in this study; attitude to water hygiene refers to the feeling women attending ANC have toward water impurities, odour, taste, colour and microscopic organisms in water. This implies that attitude of water hygiene can be expressed by the manifestation of liking or disliking the condition of water as it concerns one. Moreover, when positive attitude towards water hygiene is expressed, Morankola and Okanlawon (2003) opined that it leads to good practice toward health.

Practice is opined as product of the application of what one knows. Grove (1993) viewed practice as the application of knowledge. Brown (1993) conceived the term practice as carrying or performing an act habitually or consistently. Funks and Wagnalls (2003) submitted that practice is any customary action or proceeding regarded as individual’s habit. Gillard (2003) viewed practice as having to do something usually repeatedly, habitually, regularly, often and customarily. Practice in this study refers to the actions or ways women attending ANC handle water to keep it safe. Therefore, it implies that any action women take concerning water hygiene may be termed water hygiene practice.

Water hygiene practice may mean habitual actions taken to keep water clean. The right practice of water hygiene as described by Mintz, Reiff and Tauxe (1995) involved the removal of pathogens from water and preventing recontamination. Pugh et al. (2000) posited


that it is the action of cleanliness that promotes health and wellbeing through safe water. In this study, practice of water hygiene refers to habitual actions or ways by which women attending ANC take to keep water safe from impurities and or microorganisms. Thus, it implies that practice of water hygiene can be performed consistently. Moreover, it can be practiced by women attending ANC who may be reffered to as respondents.

The respondents in this study were women attending ANC. They consisted of all women who attended ANC and received some hygienic orientation in health facilities in Plateau State in 2014 here-in-after referred to as women attending ANC. It was expected that women attending ANC mostly were involved in fetching water, using same to cook, serving water at family meals and for other domestic purposes. On the basis of their interactions with water, they were able to present their experiences concerning water hygiene as adult members of the family. Although women who attended ANC were involved and interacted with water more often than not, they had poor access to safe water which affected their health and family members. No wonder, Ilahi and Grimard (2000) noted that poor access and interaction with safe water resulted to reduced market-oriented activities of women, which implies could increase the total work burden of women including those attending ANC.

Antenatal care helps women attending ANC through normal pregnancies. WHO (2002) posited that ANC is the care women receive throughout pregnancy. Akinsola (2006) defined ANC as the care given to women immediately pregnancy has been confirmed at about the third month. Okereke (2006) asserted that it is a specialized care given to women who conceive to ensure survival of both the woman and her baby. In this study, ANC refers to the care given by health professionals to women who are conceived throughout pregnancy to six weeks after delivery. The onset of ANC commences from the time pregnancy is diagnosed until six weeks after delivery. Good ANC increases the chance of using skilled attendant at birth and contributes to good health and economy throughout life cycle. The economic status of women attending ANC may influence water hygiene KAP.

Economic status influences water hygiene. Phaswana-Mafuya and Shukla (2005) implicated safe hygienic practices as rich people's affair. In another research conducted in Ethiopia, discrimination experience was associated with the economic status of one third of the respondents at water source and being forced to go far distance to fetch water for their family use (Tibebu & Belachew, 2007). Appropriate knowledge is a factor of water hygiene.

Knowledge has been implicated as a factor of water hygiene. Lian, Phing, Chat, Shin Baharruddin and Che Jalil (2010) implicated age groups with no significant difference in terms of knowledge level but associated schools in the influence on knowledge.


Bhattacharyal, Joon and Jaiswal (2011) implicated all households with the storage of drinking water in containers. Furthermore, they also associated mothers with the thought that unsafe water was not responsible for diarrhoea but spicy foods. Concerning the status of knowledge of water hygiene of people, Sibiya and Gumbo (2013) implicated majority of the respondents with having no knowledge when it comes to water based diseases and its prevention.

Level of education is associated to water hygiene KAP. Chipeta (2004) implicated mothers’ low education as responsible for morbidity of children due to diarrhoea while more girls showed higher positive rate on knowledge of water hygiene (Nematian, Nematian, Gholamrezanezhad, Asgari, 2004). Mpazi and Mnyika (2005) implicated level of education as responsible for female’s low knowledge concerning difference in water source of shallow and deep well. Moreover, Kaiko (2012) indicated that male were knowledgeable and have positive attitudes about methods of water hygiene.

Findings from researches showed that location is a factor associated with water hygiene KAP. No wonder, Church World Service (CWS, 2008) implicated those in rural than urban areas of inappropriate water hygiene KAP. Oswald, Hunter, Lescano, Cabrera, Leontsini, Pan…Gilman (2008) showed that due to dif ficulty in accessing water, those in rural settings re-use water for cooking and domestic activities daily. Adams, Bartam, Charter and Sims (2009) found that rural students’ inadequate water supply to them was responsible for the poor hygiene conditions in schools. In addition, they added that rural students lacked water hygiene knowledge in schools, and again completely lacked adequate drinking water. UNICEF.Org (2012) pointed that more students in rural than urban areas preferred and drank water from school faucets. Whereas respondents’ location has implication on households water use, households has influence on water quality.

Households have been implicated in influencing their water quality in diverse ways. Suthar (2011) implicated water sample collected from households to be contaminated. Suthar further associated potable water samples from towns and villages which showed E.coli contamination. In this study, the demographic variables that were used for the study involved location and level of education. Whereas location and level of education have been implicated as factors of water hygiene KAP; it was used to produce the enhancement strategies in this study.

Measures that facilitate improvements in water hygiene KAP are referred to as enhancement strategies. Bostrom and Roache (2007) defined enhancement as making efforts to improve beyond normal state. Brey (2008) conceived enhancement as modification of


human minds and bodies that equips them with supernormal abilities. Enhancement in this study refers to improvement aimed at promoting water hygiene KAP. It implies that enhancement may be improvement rules that are aimed at refining behaviour or knowledge, dispositions or practices. In this regard, an existing state of doing things can be improved upon. Therefore, well planned practices of water hygiene can be achieved through water hygiene enhancement strategies.

A strategy is anything you do to achieve a target. Strategy as conceived by Mintzberg (1987) is a plan. United Nations Emergency Scientific and Cultural Organization (UNESCO, 1998) posited that strategies are actions that stimulate interests, feelings, aspirations, beliefs, convictions and goals that one holds as this forms a basis for his practices in life. Jonas (2000) referred to strategy as that which is not the mission but the plan that allows the mission to be accomplished. Nickols (2012) refers to strategy as any complex web of thoughts, ideas, insights, experiences, goals, expertise, memories, perceptions and expectations that provide general guidance for specifications in pursuit of particular ends. Strategy in this study refers to the application of conscious and purposeful action plans or rules that allow improvement to practices of water hygiene KAP. The strategy used in this study was to elicit interests, action plans, ideas and thoughts from women attending ANC concerning KAP of water hygiene. Enhancement strategy which was necessary and effective in improvement of water hygiene involved communication strategy.

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