Assessment of Knowledge

Assessment of Knowledge, Attitude, Practices on Water Handling and Water Quality and Health effects by Mareba Community at Bugesera District, Rwanda
BUKURU GASHUGI Doris
A Thesis research submitted to the Department of Public and Community Health, School of Public Health in partial fulfilment of the requirement for the award of the degree of Master in Public Health of  Jomo Kenyatta University of Agriculture and Technology.’
2018
DECLARATIONThis Thesis research is my original work and has not been presented for a degree in any other University.

BUKURU GASHUGI Doris
TM310-C010-0084/2015
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This Thesis research has been submitted for examination with my/our approval as University Supervisor
Dr. Denis Magu                                                                    
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Table of Contents
TOC o “1-3” h z u DECLARATION PAGEREF _Toc496730820 h iiOPERATIONAL DEFINITIONS OF KEY TERMS PAGEREF _Toc496730821 h 4CHAPTER ONE PAGEREF _Toc496730822 h 81 Background of the Study PAGEREF _Toc496730823 h 81.1 Problem statement PAGEREF _Toc496730824 h 111.2 Justification of study PAGEREF _Toc496730825 h 121.3 General Objectives PAGEREF _Toc496730826 h 131.4 Specific Objectives PAGEREF _Toc496730827 h 131.5 Research Questions PAGEREF _Toc496730828 h 131.6 Conceptual framework PAGEREF _Toc496730829 h 14CHAPTER TWO PAGEREF _Toc496730830 h 172 Literature Review PAGEREF _Toc496730831 h 172.1 Safe drinking water PAGEREF _Toc496730832 h 172.2 Water collection from the water source PAGEREF _Toc496730833 h 182.3 Household level water Handling PAGEREF _Toc496730834 h 192.4 Household water storage PAGEREF _Toc496730835 h 202.5 Knowledge, attitude and practices on water handling PAGEREF _Toc496730836 h 212.5.1 Factors of Knowledge causing Water contamination PAGEREF _Toc496730837 h 222.5.2 Attitude or Perception on Water handling and storage PAGEREF _Toc496730838 h 222.5.3 Practices on water handling and water Quality PAGEREF _Toc496730839 h 232. 6 Water-borne Diseases PAGEREF _Toc496730840 h 232.7 Health hazards to unsafe water PAGEREF _Toc496730841 h 242.8 Status of Knowledge, attitude and practice on water handling in context of Rwanda PAGEREF _Toc496730842 h 24CHAPTER THREE PAGEREF _Toc496730843 h 263MATERIALS AND METHODS PAGEREF _Toc496730844 h 263.1Description of Study Area PAGEREF _Toc496730845 h 263.2 Study Design PAGEREF _Toc496730846 h 263.3 Study variables PAGEREF _Toc496730847 h 273.4 Study Population PAGEREF _Toc496730848 h 273.5 Sample Size Determination PAGEREF _Toc496730849 h 293.6 Water Sampling PAGEREF _Toc496730850 h 293.7 Sampling Technique PAGEREF _Toc496730851 h 303.8 Instrument for data collection PAGEREF _Toc496730852 h 313.8.1 Pre-Testing PAGEREF _Toc496730853 h 313.8.2 Data collection PAGEREF _Toc496730854 h 313.9 Data Processing and Analysis PAGEREF _Toc496730855 h 313.10 Ethical Consideration PAGEREF _Toc496730856 h 31CHAPTER FOUR PAGEREF _Toc496730857 h 334 RESULTS PAGEREF _Toc496730858 h 334.1 Introduction PAGEREF _Toc496730859 h 334.2 KAP on water handling and health effect in Rugarama and Gasagara communities PAGEREF _Toc496730860 h 334.2.1 Information of Demographic data PAGEREF _Toc496730861 h 334.3 Water Related Information and Attitude PAGEREF _Toc496730862 h 364.3.1 Main Source and distance taken for water Collection PAGEREF _Toc496730863 h 364.3.2 The ways of collecting water PAGEREF _Toc496730864 h 384.3.3 Time used per day to fetch water and Daily water consumption PAGEREF _Toc496730865 h 404.3.4 Knowledge on the Protection of water during Transportation PAGEREF _Toc496730866 h 424.4 Knowledge and attitude related to Hygiene Practices PAGEREF _Toc496730867 h 434.4.1 Knowledge and attitudes about water handling practices at home PAGEREF _Toc496730868 h 434.4.2 Knowledge, attitude and practices about waterborne diseases PAGEREF _Toc496730869 h 454.5 Sample location PAGEREF _Toc496730870 h 484.6 Quality Analysis of water Sample PAGEREF _Toc496730871 h 484.6.1 Methods of Analysis PAGEREF _Toc496730872 h 48CHAPTER FIVE PAGEREF _Toc496730873 h 565 DISCUSSION, CONCLUSION AND RECOMMENDATION PAGEREF _Toc496730874 h 565.1 Discussion PAGEREF _Toc496730875 h 565.2 Conclusion PAGEREF _Toc496730876 h 575.3 Recommendation PAGEREF _Toc496730877 h 57REFERENCES PAGEREF _Toc496730878 h 58Appendix 1: Budget PAGEREF _Toc496730879 h 73Appendix 2: Work plan PAGEREF _Toc496730880 h 74APPENDIX 3: QUESTIONNAIRE PAGEREF _Toc496730881 h 75

TOC h z c “Table 4.” Table 4. 1 : Household demographic data in Rugarama and Gasagara Villages PAGEREF _Toc496730937 h 35Table 4. 2: Family of Rugarama and Gasagara Villages by Age PAGEREF _Toc496730938 h 37Table 4. 3: Time used per day to fetch water PAGEREF _Toc496730939 h 41Table 4. 4: A hygiene practices in Rugarama and Gasagara Households PAGEREF _Toc496730940 h 45Table 4. 5: Indication of possible cause of diarrheal disease in Rugarama and Gasagara PAGEREF _Toc496730941 h 48Table 4. 6: Sampling location in Rugarama and Gasagara villages PAGEREF _Toc496730942 h 49Table 4. 7: Status of Water analysis from Rugarama and Gasagara Households PAGEREF _Toc496730943 h 51Table 4. 8: Patients data reported to Mareba Health Center in 2016 with waterborne PAGEREF _Toc496730944 h 53Table 4. 9: Correlation between knowledge, attitude and Hygiene practices of water PAGEREF _Toc496730945 h 55 TOC h z c “Figure 4.”
Figure 4. 1: Educational level of Rugarama and Gasagara Respondents PAGEREF _Toc496731097 h 36Figure 4. 2: Source of Water used by Rugarama and Gasagara Respondents PAGEREF _Toc496731098 h 37Figure 4. 3: Distance for fetching water at Rugarama and Gasagara Villages PAGEREF _Toc496731099 h 39Figure 4. 4: The ways of Water Collection in Rugarama and Gasagara villages PAGEREF _Toc496731100 h 40Figure 4. 5: A litters used per day at Rugarama and Gasagara Villages PAGEREF _Toc496731101 h 42Figure 4. 6: The type of Water protection during transportation PAGEREF _Toc496731102 h 43Figure 4. 7: List of Waterborne diseases raised by Rugarama and Gasagara respondents PAGEREF _Toc496731103 h 47Figure 4. 8: Intestinal and diarrheal symptoms of patients who reported to Mareba Health PAGEREF _Toc496731104 h 54Figure 4. 9: Intestinal and diarrheal diseases cases per month reported to Mareba Health PAGEREF _Toc496731105 h 55
ABREVIATION AND ACRONYMS
BRAC –WASH Bangladesh Rural Advancement Committee- Water, Sanitation and Hygiene
CDC Centres for Diseases Control
DHS Demographic and Health Survey
EWSA Energy, Water and Sanitation Authority
KAP Knowledge, Attitude and Practices
MININFRA
MINALOC Ministry of Infrastructure 
Ministry of Local Government
UNICEF United Nations International Children’s Emergency Fund
USAID United States Agency for International DevelopmentUV Ultra Violet
WHO World Health Organization
WSAC Water and Sanitation Corporation Ltd
GoRGovernment of Rwanda
IOM International Organization for Migration
UNDP United Nations Development Programme
OPERATIONAL DEFINITIONS OF KEY TERMS
Knowledge refers to the facts, skills and information obtained through education or experience, the theoretical or practical understanding of a thing that someone knows about a particular subjectCITATION Dar03 l 1033 (Darwin , 2003). The knowledge of participants in the study was referring to the understanding of water handling.
Attitude refers to perception, feelings or way of thinking CITATION Cha11 l 1033 (Chandon , 2011). It is also used as key concept on consumer behaviour setting as beliefs, experience that reflects a state of mind or the way of a person tends to act in a given direction. It was found that attitude was making people unable or able to practice basic hygiene CITATION Was14 l 2057 (Wasonga et al, 2014).

Practice refers to the action or behaviour of doing something regularly and constantly in order to become better at itCITATION Tef071 l 1033 (Abegaz, 2007).

Water Quality is pure and clean as defined in its guideline. On another, it does not cause any risk to the human health that consume water over a lifetime with its suitability for personal hygiene including all domestic purposes as well CITATION WHO04 l 1033 (WHO, 2004). The current study determined the KAP on quality of water used in the study households.

Health is a state of complete physical, social and mental well-being and not merely the absence of disease or infirmity CITATION Mic13 l 1033 (Michael, 2013). Kindig and Stoddart, (2003) define also health as the health outcome of individuals or the distribution of health outcomes within the group.

Cross-sectional study is a type of observation study on a specific exposure, disease or any other health related occurrence in a defined population at a specific point in time (Bowling,2001). This study carried out to determine the KAP on water handling types among the communities of selected villages in the study areas
ABSTRACT
Lack of access to safe water combined with inadequate hygiene practices play major roles in the increased burden of waterborne diseases in population. In developing countries, 88% of diarrheal diseases in low income countries including Rwanda are documented that they are caused by unsafe drinking water, inadequate hygiene practices. A cross-sectional study design was used to collect data on KAP regarding water handling and hygiene practice among rural communities of Mareba District, Eastern province of Rwanda and conducted from January 2017 to April 2017. A total sample size of 211 households were consistently located to Rugarama and Gasagara villages of the Mareba and selected by systematic random sampling technique. Data was collected using a structured questionnaire framed and administered in Kinyarwanda with female heads of households or responsible adult member between 18 and 50 years old.
Descriptive analysis was performed to obtain the frequency distribution of the variables. Data were entered and analysed on SPSS program. Majority of the respondents showed swamp water as main drinking water source which is a 64.3 % in Gasagara. Other used both tap and swamp water as the primary source of drinking water which is about 59.4% in Rugarama. Households of Rugarama (67.9 %) and Gasagara (51 %) had accessed water more than 30 minutes dairy. The majority 64.3% in Gasagara practiced dipping method to withdraw water from the source and 56.1% of Rugarama used tap water by collecting in buckets. This practice increases the risk of microbial contamination of drinking water by contact with potentially contaminated hands. It was found that 98.2 % in Gasagara and 93.5% of Rugarama had covered their container during transportation. During water storage, most of respondents use Jerri-can about 88% in Rugarama and Gasagara respondents, 9 % with a pot, 4 % in Rugarama 2 % in Gasagara used a gallon. Only 1% used bucket in Rugarama and kept for two days.
Many studies showed that the storage water for hours or even days increased the possibility of fecal contamination of good quality water inside the household. Household water treatment was also not common in these two villages, only 25% of Rugarama and 7% of Gasagara households practiced. People gave reasons like 68 % Gasagara and Rugarama and 34% of respondents did not have time to treat and 34 % of Rugarama and 14 % Gasagara respondents have no wood, 14 % of Rugarama and 2% Gasagara respondents showed that water can lose its tasty, 14% of respondents in Gasagara and 11%in Rugarama Respondents said that water is clear. Only 8% and 2 % of Rugarama and Gasagara respondents respectively indicated that water is very clear even when obtained from open sources like swamp water. However all 54 samples of stored water from Rugarama and Gasagara households were examined for total coliforms and fecal coliforms using the Spreading methods. It was found that in Gasagara, stored drinking tap water samples from jerry-can were tested positive for total (94.4%) and fecal coliforms (93.8%) while in Rugarama 95.5% of Total and 91.7% of fecal coliforms were detected. However, behaviour study showed that most people believed that their water quality was good so they did not have intention to treat their water as indicated in above results. Thus urgent of health education is needed in this area especial villages by creating demand for household water treatment, create awareness about safe water handling, and change people bad habit of getting water from unsafe sources.

Keywords: Attitude, knowledge, hygiene, practice, water handling, Water Quality, Health effect

CHAPTER ONE1 Background of the Study
Drinking water quality is an issue for human health in developing countries. The WHO has stated that 4 billion cases of water related disease cause at least 1.8 million deaths in developing countries every year and making it one of the leading causes of morbidity and mortality. About 99.8% of deaths occur in developing countries and 90% are children under five years’ olds CITATION Aso16 l 1033 (Asokan et al., 2016). In developing countries, 88% of diarrheal diseases in low income countries including Rwanda are documented that they are caused by unsafe drinking water, inadequate sanitation and poor hygiene practicesCITATION WHO15 l 1033 (WHO, 2015).These diarrheal diseases are commonly reported in low-income countries as provision of safe water, sanitation and hygiene is sub-optimal CITATION Prü14 l 1033 (Prüss-Ustün , et al., 2014).
As elsewhere in low income countries that include Rwanda, accessibility of safe drinking water is still a problem where 3 million of Rwandans do not have access to safe drinking water CITATION wat15 l 1033 (Water Aid, 2015). People are forced to use available unimproved water sources where 27 % of households are still using unimproved water sources. These are considered unhealthy and they increases household members’ risk of waterborne diseases such as diarrheal diseases CITATION DHS16 l 1033 (DHS, 2016). In Rwanda, Diarrhoea ranks as the third disease leading cause of both mortality and morbidity among infectious diseases. Children are mostly affected where 600 children under five year die from diarrheal disease every year. These diarrheal diseases are caused by parasites entering in water which are found in the fecal matter of an infected human or animal CITATION DHS16 l 1033 (DHS, 2016).
Access to potable water in Rwanda, is a basic amenity and classified among the highest priority public services. It reduces time spent on getting water and has a positive impact on health of population in particular for Women and girls include children because their life are strongly affected by unsafe, distant water supply and poor sanitation and also they are generally responsible for water collection and handling, household hygiene and taking care of people who are sick. The health impact of improved water supply alone is further known to be limited without adequate attention for hygiene awareness CITATION GoR14 l 1033 (GoR, 2014)
That is why Rwanda has committed to reaching very ambitious targets in clean water supply and sanitation with the vision to attain 100% water coverage by 2020. Achieving these targets, Decentralization has been a key policy of the Government of Rwanda (GoR) since 2000. The government began a process of decentralization and giving the 30 districts in the country more revenues and decision-making authority. Districts which are already nominally the owners of rural water infrastructure develop their capacity to plan and execute infrastructure projects CITATION wik16 l 1033 (Wikipedia, 2016).
In spite of this process, inadequate safe water in Rwanda are still low due to the insufficient financial resources, insufficient technical, lack of adequate qualified person and low private sector capacity especially in technical and policy advisory. All criteria mentioned above increase the vulnerability to waterborne diseases CITATION Wat14 l 1033 (WaterAid, 2014)In this Rwandan case, among the most affected regions is the Eastern Province, notably the district of Bugesera. It is one having clean water shortage. It indicates that access to clean water has increased about 59.79% within 2013-2014, where 44 % of the population still use unimproved water CITATION Placeholder3 l 1033 (MININFRA, 2014). For instance, Potable water in Mareba frequently unavailable and forcing residents to use untreated water from unimproved water source which is 10.5 %. This is resulting, waterborne diseases such as diarrhoeal diseases which are the one of the leading causes of morbidity and mortality in this area CITATION MIN15 l 1033 (MINISANTE, 2015).

In 2015, out of 1000 patient records, 451 cases with diarrheal diseases were identified in this Mareba sector, this outbreak was linked to the use of contaminated water (DHS 2015). The diarrheal diseases are caused by the ingestion of water contaminated due to the fecal matter entering in it. Various pathogenic microorganisms have been suggested as indicators of fecal pollution of domestic water quality CITATION WHO03 l 1033 (WHO, 2003). The most commonly used bacterial indicator to determine the microbiological quality of domestic water usage is total coliform, fecal coliform CITATION Bri14 l 1033 (Oram, 2014). Fecal coliforms are an indicator of fecal contamination and are commonly used to evaluate microbiological water quality in order to estimate disease risk CITATION Abe11 l 1033 (Abera et,al., 2011). The ratio of fecal coliform to total coliform as bacterial indicators of microbial water quality is based on the evidence that coliforms are present in high numbers in the faeces of humans and worm blooded animals. Their presence in water samples indicates that fecal matter has entered drinking water CITATION EPA09 l 1033 (EPA, 2009). Nevertheless, these indicators are not specific and sensitive enough to indicate the presence of certain microorganisms such as parasites, enteric protozoa and viruses. Therefore, their absence in water provides no guarantee that pathogens such as enteric protozoa and viruses, are also absent CITATION Pot12 l 1033 (Potgieter et,al., 2012). The overall concepts adopted for microbiological quality is that water intended for drinking should contain zero fecal coliform and coliform organisms per 100 ml CITATION Men04 l 1033 (Mengesha et,al., 2004). Lack of access to clean and safe water supply combined with good sanitation has significant health impacts in rural areasCITATION WHO061 l 1033 (WHO, 2006). Furthermore, people in rural communities generally lack knowledge on route of waterborne diseases which increases the risk. Many people lack knowledge about potential risks of uncovered and inappropriately stored water, hand washing with soap before eating, preparing food and after defecation CITATION Ahm10 l 1033 (Ahmed et,al, 2010).

The WHO stated also that in order provide safe and reliable water services to people who lack access, water quality interventions at the household level are capable of greatly improving the microbial quality of water stored in the household and reduce the risks of diarrhoeal disease and deathCITATION Placeholder2 l 1033 (WHO, 2007).

A similar study showed that, improving water combined with sanitation and hygiene practices could prevent at least 9.1% of the global burden of disease and 6.3% of all deaths CITATION Sal09 l 1033 (Sally F. Bloomfield et,al., 2009).

In the recent study, Interventions to improve unsafe water in Zambia, Bolivia and South Africa as well as in developing countries have reported the effectiveness of water treatment techniques at the household level such as boiling, Filtration, ultraviolet radiation from the sun, sedimentation and disinfection with sodium hypochlorite solutions CITATION Mon14 l 1033 (Uwimpuhwe et,al., 2014).

These efforts to improve water quality are lost if consumers do not exhibit hygienic practices and behaviors such as safe storage and community education CITATION Dak15 l 1033 (Dakhin et,al. , 2015).

Others Studies have shown also that contamination at point of use can occur through use of contaminated utensils during collection, transportation, poor storage practices which can save on the side the life of 1.5 million children per year who can then succumb to diarrheal diseasesCITATION She09 l 1033 (Holt, 2009).

Bhattacharya, (2011) confirmed that morbidity levels can be reduced by 6 to 25% through improved water supply and 32% by improving sanitation, 47% reduction by hand washing with soap and 35% reduction by with microbial water treatment at the point of use CITATION Bha111 l 1033 (Bhattacharya et.al, 2011).

Therefore, this present study is to assess the knowledge, attitudes and practices of rural households in Mareba Sector particularly in Rugarama and Gisagara villages with regards to both the source and the household practice on water handling such as collection, transportation, treatment and storage of drinking water. This study was also determined levels of water contamination and the consumers’ risk for diarrhoeal related illnesses
1.1 Problem statementThe Rwandan government’s commitment is to provide potable water but 3 million of people still underserved, suffering suffer from diarrheal illnesses caused by unsafe water, and most children are more affected , with 600 children under five die each year from diarrheal diseaseCITATION wat15 l 1033 (Water Aid, 2015). For example, existing water supply facilities in rural areas are still estimated at 30% where Bugesera District is included. Jenny Clover has shown that many childhood illnesses in Bugesera are linked to water contamination where 19% of deaths in children under five is caused by Diarrhoeal disease CITATION Jen11 l 1033 (Jenny Clover, 2011). As indicated by MININFRA, only 59.79% of drinking water is distributed in Bugesera and 27% of households are forced to seek an unprotected water sources such as rivers and lakes and take a long time to reach to water point sources where over 5.9% take more than an hour CITATION Placeholder3 l 1033 (MININFRA, 2014).
Daily per capita consumption in this area is 6 to 8 litres which is well below the standard consumption of 20 litres CITATION MIN10 l 1033 (MININFRA, 2010).
For instance, at the sector level, Mareba is one third of the sectors of Bugesera with drinking water where 88.6 % of its population are served by clean water but the problem is that Potable water in this sector is frequently unavailable or completely unavailable and forcing residents to use untreated water from other available water source that is about 10.5 % CITATION MIN15 l 1033 (MINISANTE, 2015).
Report by DHS, showed that 451 cases of out 1000 patient records with diarrheal diseases caused by this unclean water in 2015. The water that they get comes from lakes or rivers that which are a poor common quality and having bacteria and causing the residents to get water borne diseases, especially children. As result, households without access to safe clean drinking water are forced to use less reliable and hygienic sources and often pay more. For instance, the difficulty of getting less water means that people has a large impact on the health especially on the health of young children where their immune systems are less than optimal. These are due to the inadequate of general household cleanliness and knowledge of households on the practices of Hygiene on the handling of water chain. Therefore, this research was intended to determine the Knowledge attitude and practice (KAP) on water handling and Water Quality and Health effects by Mareba Community in Mareba sector especially Rugarama and Gisagara villages living nearby Mareba swampy water
1.2 Justification of studyClean water with adequate sanitation and hygiene is important for human health because it prevents fecal-oral transmission of pathogens responsible for diarrheal diseases CITATION Ada12 l 1033 (Adam et al., 2012). Previous studies in developing countries have demonstrated that water interventions treatment was effective between source and point of use to reduce water-borne diseases up to 94% CITATION Mar16 l 1033 ( Maiorca, 2016). These were chlorination, boiling, sedimentation, solar disinfection, filtration at the point of use.
However, currently, to our knowledge, no studies were published on the link of water quality of unimproved water sources and knowledge, attitude and hygiene on water handling practices in rural areas of Rwanda where communities use unimproved water as their water sources. A study by CITATION Gas021 l 1033 (Gasana et al., 2002) investigated the effects of water supply and sanitation on diarrheal morbidity in young children in Rwanda. The results from this study showed that contaminated water and high open defecation affected young children rendering them more susceptible to diarrhoea. In addition, study done by Uwimpuhwe, she has shown the impact of hygiene and localised treatment on the quality of drinking water in Masaka, RwandaCITATION Mon14 l 1033 (Uwimpuhwe et,al., 2014). Therefore, this study was providing a basis for insights regarding knowledge, attitudes and practices of household toward unimproved water source control and water handling in Mareba Sector especially in Rugarama and Gasagara Villages at Bugesera District. Then obtained results was providing the information to the government of Rwanda especially to the ministry of health researchers and practitioners about the constraints existing in water handling and effective risk-reduction measures.

1.3 General ObjectivesTo determine the Knowledge, Attitude, Practices on water handling and water quality of Rugarama and Gisagara Communities in Bugesera in securing and maintaining water quality for home consumption
1.4 Specific Objectives
To determine the Knowledge on the collection, transportation, storage and usage of water consumption
To determine attitude of study participant towards the collection, transportation, storage and usage of water consumption
To determine hygiene practices used by these communities of Rugarama and Gisagara villages for household purposes
To examine total coliform and faecal coliform concentration in water source at the point of use
1.5 Research QuestionsWhat are the knowledge in collection, storage and usage of water used by the community of Mareba sector specially Rugarama and Gisagara Communities?
What are the attitude in collection, storage and usage of water used by the community of Mareba sector specially Rugarama and Gisagara Communities?
What is hygiene practices related to water utilization and consumption among the Mareba community?
What are the health effects of the community regarding to water quality

1.6 Conceptual frameworkDrinking water is contaminated when fecal matter is entering in it. This is due to inadequate of water protection, poor hygienic practices of the community such as poor household handling practicesCITATION Des13 l 1033 (Amenu et al, 2013). For instance, water which are located at some distance from the home and vice versa, requiring collection, transportation and storage of water within the household. It has often been observed that the microbiological quality of water in container in the home is lower than that at the source, which suggests that contamination is widespread during collection, transport, storage and taking of water CITATION Ste04 l 1033 (Stephen, 2004).
In addition, CITATION Ogu14 l 1033 (Ogunyemi et al., 2014) conformed that use of wide mouthed containers for collection and storage of drinking water has been associated to increased microbial contamination. Wright et al, (2004) found that, 68% of households used a bucket and a clay pot are more prone to contamination because of their large wide-mouthed containers. Children can easily also play with the exposed water. Similar research has shown that even drinking water is safe at the source, it is subject to frequent and extensive fecal contamination during collection, storage and use in the home CITATION Wri04 l 1033 (Wright et al, 2004).

Crampton et al., (2005) states on other side that water is vulnerable to contamination by bacteria at many points along its route from the reservoir to the mouth. The safe handling and storage of water is essential for homes that collect water from household sources.

Moreover, according to Tambekar (2011), the research study on hygiene practice in Maharashtra, India has shown that the students taking drinking water with dipping hands, the water reduced its potability to 55% while those who collected water without dipping hands retains 100% potability which proves that dirty hands and household containers appeared to contribute to contamination at the point-of-use. Dirty hands carry the bacterial pathogens and cause most of the serious intestinal infections. The study also proved that the number of different types of pathogens may be present in water which comes mainly from human or animal faeces and the coliform group has been widely used as an indicator of water and the coliform group has been widely used as an indicator of water contamination and public protection concept.

In addition, another challenge is regarding to a perception of the population on taste, odours and appearance. This lead to have different opinions about the aesthetic values of water qualityCITATION Des14 l 1033 (Amenu, 2014).
According to the study conducted in 2012, in peri- urban communities, western Kenya showed that people do not treat water before drinking even from open sources. It is found that a majority of the households assumed that water which is clear, colourless and odourless and does not contained suspended solids are safe for drinking and it was not need to treat it CITATION Kim12 l 1033 (Kimongu et al, 2012). Study in Bangladesh on other hand, found that almost half of respondents about 14 out of 30 reported that they were aware of the effects of cholera but could not always drink boiled water because of inadequate of gas and fuel CITATION Tas13 l 1033 (Wahed et al, 2013). Attitudes and knowledge influence the choice and decision of a household on the water treatment or not CITATION Kim12 l 1033 (Kimongu et al, 2012) . Moreover, political will at the top and at all levels was seen as one of the driving forces behind the adoption of safe hygienic practices. For instance, politicians have the ability to influence the attitude of their peoples towards water, the moral choices they make and their behaviour for water treatment. In addition, politicians have also the ability to motivate and mobilize individuals or group of people in different roles for common purposes and help educating their people about critical role played by water in achieving social and developing goals. CITATION Mic03 l 1033 ( Kropac, 2003). Several studies have showed the perceptions and attitudes of people about the quality of the drinking water CITATION Wat111 l 1033 (Water Aid, 2011).
Education and the promotion of hygiene have mostly encouraged people to replace their ignorance with simple and safe household water treatment methods such as boiling, filtration or chlorination which have reduced diarrhoea diseases by up to 94% CITATION Mar16 l 1033 ( Maiorca, 2016). Therefore, the current study will aim to determine the knowledge and practice of household handling of drinking water, its relationship with the occurrence of diarrhea in the community and to assess microbiological quality of the point of use drinking water in the selected community.

-295275365760Dependent variable
Independent variables
Knowledge on water handling:
Water related variable:
Knowledge of water treatment such as Boiling, Chlorination, Ceramic filter Slow-sand filter etc.
Hygiene such as hand wash
Eg. Unwashed hand, uncover container
Attitude on water handling
Attitude behaviours such as personal beliefs, perception, Culture on water handling
Practices on water handling
Hygiene of Storage system : open, uncovered or poor covered
Sanitation level: cleanliness of containers
Hygiene handwashing related waterborne diseases
Hygiene of water collection, transportation
Effect of Water contamination:
Health Risk
Barriers:Poor Government commitment
Ignorant community awareness
Neglected community
Intervening variable
Dependent variable
Independent variables
Knowledge on water handling:
Water related variable:
Knowledge of water treatment such as Boiling, Chlorination, Ceramic filter Slow-sand filter etc.
Hygiene such as hand wash
Eg. Unwashed hand, uncover container
Attitude on water handling
Attitude behaviours such as personal beliefs, perception, Culture on water handling
Practices on water handling
Hygiene of Storage system : open, uncovered or poor covered
Sanitation level: cleanliness of containers
Hygiene handwashing related waterborne diseases
Hygiene of water collection, transportation
Effect of Water contamination:
Health Risk
Barriers:Poor Government commitment
Ignorant community awareness
Neglected community
Intervening variable

CHAPTER TWO2 Literature Review2.1 Safe drinking waterSafe water is defined as having an acceptable quality in terms of its acceptable physical, chemical, bacteriological parameters in order to be safely used for drinking and cooking . World Health Organization (WHO) shows that a drinking water is safe when it does not pose any significant health risks to the population throughout the consumption period.CITATION WHO04 l 1033 (WHO, 2004). On other hand , a drinking water quality may become unsafe during collection, transportation and storage as a result of multiple factors linked to unhygienic practices when water is in contact with dirty hands ; dust air enter into the water if the container is uncovered or dirty collection container during usage CITATION Fol13 l 1033 (Folarin et al.,, 2013). The lack of water quality puts people’s health at risk by exposing them to diarrhoeal diseases such as cholera, dysentery as well as typhoid and schistosomiasis.  According to Clasen and Bastable (2003) examined faecal contamination of drinking water during collection and household storage, he reported that even water from safe sources was subject to frequent faecal contamination with over 90% of samples containing faecal coliforms after collection . The correlation between diarrhoea risk and presence of faecal indicator bacteria such as E. coli has been reported. Household water treatment and safe storage known as point of use water treatment has been shown to be an effective in reducing diarrhoea and other diseases associated with unsafe drinking water CITATION And05 l 1033 (Andrew F et al.,, 2005). A recent study found that water quality interventions in the household were effective in preventing diarrheal disease 47% than community infrastructure such as improved wells and standpipes 27% CITATION Cla06 l 1033 (Clasen T at al., 2006). However, water treatment intervention begin with an improved water source and followed by safe water collection, handling and storage. In circumstances where the source is not considered safe, point of use water treatment at the household level should be performed. All of these should be coupled with hygiene promotion activities to use and cleanliness of containers. Hygiene promotion aims to ensure that people gain the greatest health benefits from both the proper use and maintenance of the interventions coupled with hygiene practices improvement. In addition, it is permitting people to take action to prevent or mitigate water and sanitation related waterborne diseases and also it encourages healthy choices in life. It is important to understand what motivates people to make healthy choices and what motivates them to change their behaviour CITATION And05 l 1033 (Andrew F et al.,, 2005). The most important components of a hygiene promotion programme is education or communication programmes. Hygiene education or communication programme is based on an understanding of the factors that influence behaviour at the community level. These might include: knowledge and attitudes among community members with respect to the hygiene behaviour, and especially the perceived benefits and disadvantages of taking action and the understanding of the relationship between health and hygiene. An understanding of the factors that influence hygiene behaviors will help in identifying the key points of water handling such as collection, transportation and storage water containers. This will help to ensure that the content of the hygiene education is relevant to the community CITATION Orl10 l 1033 (Orlando, 2010). Esrey and colleagues (2009) conducted a review of 144 studies in order to determine the health impact of sanitation, water quality and water supply interventions. They concluded that hygiene yielded greater reductions in diarrheal disease in 33% than water quality interventions CITATION Esr09 l 1033 (Esrey et al., 2009). Therefore, the key individuals in the household and community should be taken into account during all stages of water handlingCITATION Ren04 l 1033 (Renate and van Wijk, 2004)2.2 Water collection from the water sourceIn many developing countries, drinking water collected from sources are either exposed such as unprotected springs, unprotected wells and rivers, lake, swamps or improved such as public standpipes, boreholes and protected wells. CITATION Wil15 l 1033 (William et al., 2015) . Several studies in developing countries have showed that the water quality of the improved water sources and unimproved can be contaminated in depending on the water source. Wright et al. (2004) showed also that contamination of water occurs between source and point of use. As an example he gave that the quality of water from improved water sources has significantly deteriorated after collection. More than 40% of the survey in the households by testing improved water sources were unsafe at point-of-use with 10 cfu / 100 ml of E. coli. He confirmed that inadequate of cleanliness and transport containers as well as storage containers has been described as a key source of water contamination in many settings CITATION Wri041 l 1033 (Wright et al., 2004). However, in order to understand the factors impacting on water source of the community, the present study was assessing the knowledge attitude and practices regarding water handling at community level in Mareba Sector, Bugesera.
2.3 Household level water HandlingInadequate access to safe water and sanitation services coupled with poor hygiene practices continues to kill, sick and diminish opportunities of millions of people in developing countries. Almost two million of the deaths are the result of diarrheal diseases caused by the ingestion of water contaminated by faecal matter associated with inadequate sanitation and hygiene. For example, direct use of drinking water from unimproved sources without household water treatment raised from 3% to 38% by region, with an overall average of 12% among low and middle-income countries CITATION UNI081 l 1033 (UNICEF, 2008).

Numerous studies have shown that improving the water quality of household water by on-site or point of use treatment and safe storage in improved containers reduces diarrheal and other waterborne diseases in communities and households of developing as well as developed countries. Reductions in household diarrheal diseases of 6 -90% have been observed, depending on the interventions and the exposed population and local conditions CITATION Mon07 l 1033 (Montgomery et al., 2007).

And also, several interventions to improve the microbial quality of household water and reduce waterborne disease have been developed and include a number of physical and chemical treatment methods CITATION WHO07 l 1033 (WHO, 2007). The intervention methods include boiling, sedimentation, solar disinfection, filtration, chlorination, were have been proven to improve microbiological quality by reducing bacteria, viruses and in some cases protozoa in water samples in developing countries CITATION WHO10 l 1033 (WHO, 2010). The advantages and disadvantages with regards to the use of these household treatments methods used in developing countries are indicated below:
Boiling: water is widely used since it is easy and is highly effective at removing pathogens. A study carried out in rural indicated that boiling significantly improved the microbiological quality of drinking water CITATION Bar10 l 1033 (Bartram et al., 2010) . The results showed that boiling water was associated with 86.2% reduction in mean faecal coliforms. However, due to rising fuel costs and disappearing forests, this is increasingly out of reach for most people CITATION Pot08 l 1033 (Potgieter et al, 2008).A further concern is that water is often transferred to storage container for cooling and thus can become re-contaminated CITATION Pot08 l 1033 (Potgieter et al, 2008).

Filtration is the process used to filtrate the clean water on top once the flock or sediments has settled to the bottom of water through varying compositions as sand, gravel, and charcoal. In laboratory and field testing, the sand, gravel, and charcoal consistently reduces bacteria, on average, by 81 -100 %and protozoa by 99.98-100%. However, its effectiveness against microbes is low and its lack of residual protection may lead to recontamination CITATION Bar10 l 1033 (Bartram et al., 2010).

Disinfection: Chlorine is the most widely used and the most affordable of the drinking water disinfectants CITATION Sob02 l 1033 (Sobsey, 2002). The source of chlorine can be sodium hypochlorite. It is kill any remaining parasites, bacteria and viruses and protecting the water from microbes when it is piped to households and elsewhere. Studies have showed that the use of sodium hypochlorite has improved the microbiological quality of drinking water and reduced the risk of diarrheal disease CITATION Pot08 l 1033 (Potgieter et al, 2008).

2.4 Household water storageAccess to clean water and adequate sanitation has been a challenging issue in developing Countries. Due to distances and unavailability of piped water to home in many rural area, people are forced to store their drinking water which may not be fit for drinking CITATION Sam14 l 1033 (Samuel et al., 2014).

However, storing water can provide a number of opportiny for microbiological contamination. Transmission of microorganisms in the household can occur through several routes household containers, lack of cover, ignorance of washing of containers before collection and transferring to storage containers, transfer of water out of storage container, dipping and placement of drinking or water drawing containers on floor. All these favourites the fecal coliforms increase in household container than sources CITATION Tho04 l 1033 (Thomas et al., 2004). This is because that water storage containers are more exposed to faecal contamination due to unhygienic handling of the water storage containers or the use of dirty containers to take water, dust, animals, birds and various types of insects CITATION Gob13 l 1033 (Gobena et al., 2013).

Studies from several counties have indicated that poor storage conditions and inadequate water storage containers are factors contributing to increased microbial contamination compared to either source waters or water stored in improved vessels. With higher levels of microbial contamination associated with storage container decreased water quality. These are depending with container having wide openings, vulnerability to introduction of dirty hands or cups carrying faecal contamination CITATION Tre05 l 1033 (Trevett et al. , 2005). Various reasons have been proposed for the deterioration of water quality between the source and point-of-use. The hygienic condition of the water storage containers and the environment in which these containers are stored, are believed to be major factors leading to the deterioration of stored water CITATION Gun042 l 1033 (Gundry et al, 2004)A recent study in Malawi found that faecal coliform levels increased in household storage containers after only 1 hour of water storage. Even when investigators chlorinated water in storage containers contamination was only eliminated for the first 4 hours after collection. After 6 hours of storage, there was considerable microbiological growth CITATION Rob01 l 1033 (Roberts et al., 2001). These containers had wide openings in which water was easily dipped out. This indicates that contamination was occurring in the point of use and the bacteria were able to grow within the household storage container. In order to understand the factors impacting on water source of the community, the present study determined the knowledge attitude and practices regarding water handling at community level in Mareba Sector, Bugesera.
2.5 Knowledge, attitude and practices on water handling
Improved water with adequate sanitation and hygiene is one of the most effective means of reducing disease occurrence. However, Hygiene practice becomes difficult in many parts of the world, including Rwanda due to lack of safe water CITATION Uwi12 l 1033 (Uwimpuhwe, 2012).

Hygiene practice and education on proper water handling is very important. There are different ways in which to treat water: boiling, chlorination, solar disinfection etc. It is important that people understand the correct instructions for those methods to be effectives. In the study done on the knowledge, attitude and practice on cholera prevention in 2010 reported that household’s treatment practices increased from 30.3% to 73.9 %. Hygiene education is then changing attitudes and behaviours, to break the chain of disease transmission associated with inadequate water supply and sanitation CITATION Chr13 l 1033 (Christiana, 2013)In addition, another challenge in developing countries including Rwanda have, is also a limited knowledge, misinformation, attitudes and practice on ensuring that drinking water is safe. Humans think that the taste of the water determined its purity and they do not consider that even the best tasting water could contain disease-causing organisms. Lack of knowledge on safe water creates also an enormous burden of waterborne disease such as diarrhoea which is the second most common cause of death among children under the age of fiveCITATION UNI081 l 1033 (UNICEF, 2008)Kamla (2006) confirmed that ignorance, poor hygienic practices and cultural practices associated with consumption of water were found to be the determinants of high incidence of morbid diarrheal condition in the village. Ineffective promotion and low public awareness, ignorance of people, lack of capacity building, lack of hygiene education and training, negligence of people were said to be de-motivating factors for adoption of safe hygienic practices.
2.5.1 Factors of Knowledge causing Water contamination
Lack of potable water creates an enormous burden in the form of diarrheal and other waterborne disease. Water safety in a community depends on a range of factors, from the quality of source water to storage and handling in the domestic setting. Water sources and sanitation facilities have an important influence on the health of household members, especially childrenCITATION Kum131 l 1033 (Kumar et al, 2013). In study done Swarnakar and Sharma, (2003) it has been observed that in developing countries like India, social institutions, cultures and beliefs of the people had bearing upon everyday water consumption pattern of the people. Others studies have shown that chronic diarrhoea was a consequence of poverty, poor hygiene and environmental contamination. They found that only 33.5 % of informants had knowledge that unsafe water can cause diarrhoea CITATION Bha11 l 1033 (Bhattacharya et al, 2011).

2.5.2 Attitude or Perception on Water handling and storage
In many parts of the developing world, drinking water is collected from unsafe surface sources outside the home and it is then kept in household storage containers. However, drinking water may be contaminated at the source or during storage; strategies to reduce waterborne disease transmission must safeguard against both events CITATION Min95 l 1033 (Mintz et al, 1995). Comparing the bacterial content of drinking water at its source with water stored in the home, a study done CITATION Wri04 l 1033 (Wright et al, 2004) found that in many situations, the bacteriological quality of drinking water declined significantly after collection.
2.5.3 Practices on water handling and water Quality
Protection of water quality from contamination is the first line of defence against diarrheal diseases, because of the essential role water plays in supporting human life, it has if contaminated, great potential for transmitting a wide variety of disease and illnesses. Protection of water source as well as Home water consumption is almost the best method of ensuring safe drinking water. However, failure to provide adequate protection, poor site selection and unhygienic practices of the may contribute the contamination of water quality and resulting water borne diseasesCITATION Tef071 l 1033 (Abegaz, 2007). In Rwanda, water supply and sanitation is still inadequate. Most of the population in urban and rural areas do not have access to safe and adequate water supplies and sanitation facilities. Regarding to water and personal hygiene, only few households show sufficient understanding of environmental sanitation or hygienic practices. As Results of 3% to 5% of the health problems of people in Rwanda are due to communicable diseases attributable to unsafe or inadequate water supply and unhygienic or unsanitary waste management particularly excreta CITATION IVA15 l 1033 (Ngoboka, 2015). Diarrheal diseases in children caused by improper management of water and sanitation are among the major causes of infant and child morbidity and mortality about 44 % of children receive diarrhoeaCITATION DHS15 l 1033 (DHS, 2015).

2. 6 Water-borne DiseasesWater-borne diseases are transmitted directly through drinking, swimming or bathing in the contaminated water. Pathogenic microbes and some parasitic organisms are responsible for various diarrhoea diseases. Diarrheal diseases caused by drinking unsafe water cause 16,700 deaths in Rwanda each year CITATION htt l 1033 (http://impactcarbon.org/where-we-work/rwanda). Children are more affected and accounting for an estimated 24 % of child deaths in Rwanda, CITATION UNI09 l 1033 (UNICEF, 2009).

It is known that the prevalence of water-borne diseases can be greatly reduced by provision of clean and safe drinking water as well as safe disposal of faeces CITATION Mah00 l 1033 (Haque, 2000).
In Rwanda, impact Carbon organization is developing a water program to reach families who rely on unimproved sources of drinking water, providing them with devices such as water filters, chemical treatment and UV treatment systems CITATION htt l 1033 (http://impactcarbon.org/where-we-work/rwanda)2.7 Health hazards to unsafe waterUnsafe water is any physical chemical, or biological change in the water quality. When human drinks unsafe water, it often has serious effects on his or her health. This unsafe water causes diarrhoea and the dehydration by losing too much water in body up to death CITATION Pet021 l 1033 (Peter, 2002). Diarrheal diseases caused by drinking unsafe water cause 16,700 deaths in Rwanda each year CITATION htt l 1033 (http://impactcarbon.org/where-we-work/rwanda). Children are more affected and accounting for an estimated 24% of child deaths in Rwanda CITATION UNI09 l 1033 (UNICEF, 2009).

2.8 Status of Knowledge, attitude and practice on water handling in context of Rwanda
Rwanda boasted an abundance of surface and sub-surface water sources, more than half of its population obtained water from unprotected sources, 85% of which are believed to be contaminated. However, water consumption in rural areas was estimated at only 8 litres/person/day1 below the national recommendation of 20 litres. Consequently, Diarrhoea and other water related disease conditions remained a major cause of morbidity and mortality in Rwanda. In addition , regarding to sanitation, the people of Rwanda have latrines with very high cover of about 85% in rural areas but only 0.8% of these latrines are “hygienic” and the rules of good hygiene are not respected everywhere. This situation shows that in terms of attitude and hygienic and sanitation practices, the population is not sufficiently informed or sensitised. Ignorance, lack of awareness to have a health Risk of diseases CITATION UNI01 l 1033 (UNICEF, 2001). Despite of this situation, Rwanda Government plays a vital role in the mobilisation and awareness creation among the population on environmental issues helping to ensure that the concerns of the disadvantaged levels of society are taken into account in the national development Programs such as information, education and communication domains CITATION NBI05 l 1033 (NBI, 2005).For instance, there are several intervening parties such as public institutions and NGOs. To the Ministry of Health, the Information, Education and Communication concerning hygiene makes itself below according to situations appeared:
To the level of the Division Public Hygiene an IEC section that identifies the problems of important hygiene exists and that, in collaboration with the Division EPS of the Health Ministry, compose the messages deliver to the population. These messages arrive to the population has shortcoming the media: – Imvaho newspaper – Radios. A magazine Health is created and is public every three months: it sums up the main problems of health and hygiene and the preparation and the organization of the formation sessions also for the staff of health.
To the level of the Health Centers: There is a program of educational talks dispensed by the staff of health has the intention of the patients and other people who come with them in the center of health. In these talks the staff of health is often guide by the sanitary situation that prevails. Concerning struggle against the pollution of water, talks are cantered on themes as for example, the conservation of water has domicile in clean containers; the importance to make boil the water of drink when one doesn’t have a source of drinking water, how to protect some sources. During the sessions of IEC, the access is also put on the importance to use the adequate latrines to avoid the pollution of water by excreted them. The individual hygiene especially occupies an important place in talks the washing of the hands has the exit of the toilets and before eating;
To the level of the sanitary districts the staff of hygiene affects in the locality is compelled has lead the activities of IEC has shortcoming the meetings that he organizes and even at the time of the visits has domicile (to see assignments).
To the local level (or communal), animators of health exist (to the level of every cell that follows the problems of health and hygiene to the level of the cell). They are loads to bring the populations has search for by themselves of the solution approaches has their problems, thanks to the sessions of formation. Those messages have improved the population hygiene and the improvement of the provision systems in drinking water of the population and the sanitary means of evacuation of excreted them.
CHAPTER THREE3MATERIALS AND METHODS3.1Description of Study Area
The study Area was carried out in Bugesera District which is one of the seven districts of Eastern Province located in south of Kigali and has 15 sectors and 40 cells (Villages) which include Mareba Sector. Bugesera is a predominantly rural area and the main occupation of the population is subsistence agriculture CITATION GOR07 l 1033 (GOR, 2007). Its population is 363,339 people in the following proportion: 177,404 males and 185,935 females CITATION MIN121 l 1033 (MINALOC, 2012). Compared to other regions of the country, the climate of Bugesera District is dry with a temperature varying between 20°C and 30°C with an average ranging between 26 and 29°CCITATION MIN13 l 1033 (MINALOC, 2013).
3.2 Study Design
The researcher used a Descriptive cross sectional study conducted from February to March 2017 in Mareba Sector. The sampling frame was the 2 villages of Mareba Sector such as Rugarama and Gasagara with a population of about 1205 people with its total of 319 households.
These two villages are situated along Mareba water swamp with linear settlements. Under this study, both quantitative and qualitative methods will be used because it involves the measurements of quantitative and qualitative characteristics. In quantitative method, a structured questionnaire was administered in Kinyarwanda with female heads of households in priority, if the head of household is not available, a responsible adult member was selected because Female in the home have often an active role in overall household management as primary care-givers to children CITATION Hal11 l 1033 (Halvorson et,al., 2011). The information was about demographics details, sources of water, handling practices within the home such as treatment methods for drinking water and a basic understanding perceptions and knowledge of household members concerning water quality and safety and health concerns regarding causes of diarrhoea. 211 households were interviewed via systematic sampling method. One member aged between 18 and 50 years old from each household was registered as participant in this study. The design has also included laboratory investigation by taking water samples from selected households in order to assess microbiological quality of drinking water. Water samples was then analyzed at the CST former Kigali Water Laboratory (KWL) in University of Rwanda. Fecal coliforms was used as indicator organisms to determine the microbiological quality of household water samples. To test this, the plate culture method was used.
3.3 Study variables
The main variables of this study are independent and dependent variables as described below:
Independent variables :
Knowledge of point of water handling was based on water treatment where Information gathered on individuals’ knowledge, attitudes and hygiene practice towards water handling practices and hygiene. For example: – Boiling, Chlorination, Ceramic filter Slow-sand filter interventions and poor awareness of unwashed hand, uncover container.
Attitude on water handling:
– Perception: Feelings such as norms, beliefs and culture
Practices on water handling:
-Distance, time such as water collection, transportation
-Storage system such as open, uncovered or poor covered containers
Dependent variable : contamination of water quality
Intervening Variables: Weak policy such as lack of prioritization of needs
3.4 Study PopulationThe study population were residents of Rugarama and Gasagara villages in Mareba Sector because they are situated along Mareba water swamp. In each village, sample size was selected depending upon the population size. Rugarama has 825 with a total of 254 households and population size for Gasagara is 380 with a total of 65 households. These were selected for the purpose of assessing the knowledge and attitudes and practices of respondents to issues of water handling such as collection, treatment and storage. Systematic sampling method was used to draw representative sample of households from each village. The criteria for participation was a voluntary consent of the female heads of households in priority, if the head of household is not available, a responsible adult member was selected because, Female in the home have often an active role in overall household management as primary care-givers to children using a structured questionnaire. Often, Female in the home have an active role as primary care-givers to children and overall household managers CITATION Hal11 l 1033 (Halvorson et,al., 2011).

Table 4. SEQ Table_4. * ARABIC 1: Sampling Place and households.

Name Households (N)
Rugarama Village 254
Gasagara Village 65
Total 319
Inclusion:
Individuals aged from 18 years to 50 residing in these two villages
Respondents that are willing to participate in the study and have signed an informed consent
Exclusion:
Population living below one year in these two villages because the target population of the study was the people who live in two villages for at least one year and who were from 18 years older. The reason is that People who live in these two villages for a long period of time can have sufficient experience regarding specific hygienic knowledge and practices that can be applied in handling water and to determine their effects on their health. This age group was specified to avoid interviewing children who cannot consent or who are not old enough to speak on their own behalf with regards to giving consent. Other household’s members who were not included in this study are indicated below:
Indication of list of all households from Rugarama and Gasagara. Those who have above 50 years were not included because they have mild memory lapses such as forgetting everyday words or where things are kept CITATION Jen14 l 1033 (Wegerer, 2014)Participants with mental or physical challenges making it difficult to participate in the study.

Visitors.
3.5 Sample Size Determination The sample size was obtained from 254 and 65 households proportional to the population living in Rugarama and Gasagara villages. This was calculated by using the following formula for sample size: n = N/ (1 + N x e²). Participant in this study was aged between 18 and 50 years old.
Where:
n = sample size
N = Total population of the coverage area
e² = Margin of error =0.05
1= is given as part of the standard formula
Sample Size (n) in Rugarama =254/ (1+ 254x 0.052) = 155
Sample Size (n) in Gasagara =65/ (1+65x 0.052) = 56
Table 4. SEQ Table_4. * ARABIC 2 : Sample size of representative households in study area
Name Households (N) Sample size
Rugarama Village 254 155
Gasagara Village 65 56
Total 319 211
3.6 Water Sampling
Water sample was collected from a selected household as representative sample of all households using systematic method because every household has an equal chance of being included in the survey. Then collected water samples was analysed to the Lab for the Fecal coliform test. Water sample was collected in a 100 mL plastic bottle provided by Microbiological Laboratory in CST former Kigali Water Laboratory (KWL) and stored in a cooler box at 4°C Plate culture method helped to determine water quality.
3.7 Sampling Technique
In the same selected households, systematic sampling method was adopted following the interval number of the selected households in order to reduce bias CITATION Jin06 l 1033 ( Jingyu Zou, 2006). For Rugarama village with total of 254 households, a sample size of 155 households in the study was selected. On the other hand, 56 households was selected from Gasagara village with a total number of 65 households in order to take water sample, the kth value was used to calculate interval number of selected households. In this case, the Kth value is the total number of selected households divided by the sample size in each village CITATION Sai09 l 1033 (Saifuddin Ahmed, 2009)k=Nn K: Sampling interval
N: Population size
n: Sample size.
Name village Population size Sample Size Kth No of water samples to be collected in households
Rugarama 254 155 1.6 ~ 2 77
Gasagara 65 56 1.1 ~ 1 56
The kth value in Rugarama village will be 2 while Gasagara village was 1. The first household was randomly selected for each village and thereafter every 2 nd household for Rugarama was selected while for Gasagara village, every 1 st household was selected.
3.8 Instrument for data collection
3.8.1 Pre-Testing
The pre-test was pre-tested in one of village nearing the two selected villages to be studied. This aimed to identify any problems/mistakes in the questionnaire in order to eliminate them and to ensure adequate delivery of the required data. The questionnaire was translated from in English and Kinyarwanda language in order to administer the questionnaire. And then, the answers of the questions in Kinyarwanda was translated in English. The researcher monitored then the administration of the questionnaires in the field and check the filled questionnaire for the purpose of quality control.

3.8.2 Data collection
Data was collected using the structured questionnaires that is designed to answer research questions on relationship of the knowledge, attitude and practice during water handling and water quality and also the specimen will be taken to the lab for analysis. However, it took a period of three weeks and it was starting by training data Collectors and getting permission from the village head. Therefore, the instrument was prepared in English and translate into Kinyarwanda.
3.9 Data Processing and AnalysisTo interpret the results, the data was returned, sorted and entered into a computer and analysed using Excel sheet. Data was then presented in tables, bar and pie-charts by showing percentages (%) and proportions. In addition, the chi-square test was used to test association between variables while P-value test determined the differences in the levels of Knowledge, attitude and practice on water handling and water quality.
3.10 Ethical ConsiderationThe Research proposal was approved by the Public Health Department at Jomo Kenyatta University of Agriculture and Technology where it is registered. Application letter for Authority to conduct Research in Rwanda was obtained from Ministry of Education. Ethical Validation and approval letter was obtained from Rwanda National Ethics committee in the Ministry of Health for further step. Authorization to field survey was obtained from to local Authority of Bugesera District and Mareba Health Centre. In each of the two villages, the selected participants was receiving a letter informing that a research proposal was conducted. Every participant has signed informed consent. Informed consent was then formulated in English and then translated into Kinyarwanda as the local language of the community. However, all participation was voluntary and withdrawal from the study. No financial incentives were provided for participation in this study. All data collected was collected from Participants and was treated and kept with confidentiality. The results was used for the research purpose only.

CHAPTER FOUR4 RESULTS
4.1 IntroductionThis chapter presents results of this study that were obtained from KAP questionnaires of the participants from Rugarama and Gasagara villages of Mareba sector; water analyses, retrospective clinic records during 2016 and a comprehensive discussion, conclusion and recommendations of the results will follow in Chapter Five.
4.2 KAP on water handling and health effect in Rugarama and Gasagara communities
Structured questionnaires were administered to residents in the households of Rugarama and Gasagara communities of Mareba sector to assess the resident’s KAP in terms of water handling, usage and health effect during water consumption. Only residents between 18 and 50 years old were chosen to participate in the interview on KAP about water handling during water collection, transportation, storage and treatment at home. From a total of 254 household in Rugarama village, 155 households were interviewed while out of 65 households in Gasagara village, 56 participated in this study. Therefore, the total sample size in the two villages were 211 households.
4.2.1 Information of Demographic data
In demographic data of the study population, the respondents were aged between 18-50 years. The majority of the respondents were between 26-35 years and makes 43% in Rugarama village and 71% in Gasagara Village as shown in table 4.1. It was also found that the minority of the respondents are aged between 46 – 50 years were in Rugarama it is 10% and 4% in Gasagara.

Table 4. SEQ Table_4. * ARABIC 3 : Household demographic data in Rugarama and Gasagara VillagesLocation Gender Total %
Male Female GASAGARA Age of Category 18-25 0 5 5 9%
26-35 6 34 40 71%
36-45 3 6 9 16%
46-50 1 1 2 4%
Total 10 46 56 100%
RUGARMA Age of Category 18-25 4 21 25 16%
26-35 6 60 66 43%
36-45 7 41 48 31%
46-50 3 13 16 10%
Total 20 135 155 100%
In addition, the majority of respondents who were interviewed, 30.9 % in Rugarama had Secondary school level as their highest education while 14.4 % in Gasagara Village had primary school level as their highest education, most them are the female as indicated below in figure 4.1

Figure 4. SEQ Figure_4. * ARABIC 1: Educational level of Rugarama and Gasagara Respondents
Moreover, majority of family member per household are above 18 years old, 45% and 49% in Rugarama and Gasagara respectively. Children below 5 years accounted 18 % and 24 % while children between 5-10 years accounted 19% and 15% in Rugarama and Gasagara villages respectively.

Table 4. SEQ Table_4. * ARABIC 4: Family of Rugarama and Gasagara Villages by Age
Age RugaramaGasagaraNo of member % No of member %
? 5 yrs126 18% 71 24%
5-10 yrs133 19% 45 15%
11-18 yrs129 18% 33 11%
> 18 yrs315 45% 144 49%
TOTAL 703 100% 293 100%
4.3 Water Related Information and Attitude4.3.1 Main Source and distance taken for water Collection
It was found that the people of Rugarama and Gasagara Villages in Mareba sector use often water from either Mareba swamp water or Public tap water. This research showed that the main water used in the Gasagara village is Swamp water which is about 64.3 % while for Rugarama, it is 59.4% of both tap and swamp water as shown in figure 4.2. This indicates that the high percentage of people using swamp water is Gasagara village because it is bordering Mareba marshland and has few public water tap while some of them are located very far from home. However, the WHO revealed that 75 % of all diseases in developing countries arise from contaminated drinking water. This lack of access to water also limits hygiene practices in many households because of the priority given for drinking and cooking purposes CITATION WHO001 l 1033 (WHO, 2000). In addition, 44.6 % and 45.8% of Rugarama and Gasagara respondents walk between 50 and 100 meters to fetch water as illustrated in below figure 4.3.

Figure 4. SEQ Figure_4. * ARABIC 2: Source of Water used by Rugarama and Gasagara Respondents

Figure 4. SEQ Figure_4. * ARABIC 3: Distance for fetching water at Rugarama and Gasagara Villages4.3.2 The ways of collecting water
Following that the water source used in Rugarama and Gasagara villages is swamp water and Public tap water, it was found that 64.3% in Gasagara fetch water by dipping while in Rugarama, respondents indicated that 56.1% fetch water by either taping or pouring. It is found that the respondents were not mostly aware on the best practice of collecting water that could help them to minimize contamination as indicated in figure 4.4. Several studies provide evidence that many of the hygiene-related behaviours including hand-water contact or dipping dirty container and inadequate washing of storage containers are involved in recontamination CITATION Tre08 l 1033 ( Trevett et al., 2008). Similar studies have reported on collection or storage containers that are designed to prevent hand water contact and facilitate withdrawal of water by means of tapping , dipping or by pouring. The evidence from these studies suggests that physical measures are unable to completely prevent the deterioration of water quality on their own. It is accepted either that some deterioration of water quality will occur, or alternatively a method of treatment of household water must be considered CITATION Tre08 l 1033 ( Trevett et al., 2008).

Figure 4. SEQ Figure_4. * ARABIC 4: The ways of Water Collection in Rugarama and Gasagara villages4.3.3 Time used per day to fetch water and Daily water consumptionRegarding the frequency of travel to fetch water from home to the source, 67.9 % of the Rugarama and 51 % of Gasagara respondents indicated that they do two trips a day. Previous studies revealed that household members who spent more than one trip or equal to more than 30 minutes to collect water usually fail to fulfil the household daily water consumption CITATION Abe13 l 1033 (Abebe Tadesse et al., 2013) . A similar study found that the households whose water sources are located more than 30 minutes away or round trip, often collect less water than is believed necessary for basic needs CITATION Amy12 l 1033 (Amy J et al. , 2012). This time spent walking to water source was found to be a significant determinant of human health CITATION Oli14 l 1033 (Oliver et all., 2014)

Figure 4. SEQ Figure_4. * ARABIC 5: Time used per day to fetch waterIn addition, based on the data gathering on the litres used per day, most respondents fetched water between 25-40 litres per day with 91 % in Rugarama and 80.4 % in Gasagara village as indicated in below figure 4.5. According to WHO, between 50 -100 litres of water per person per day are needed to ensure that most basic needs are met and few health concerns arise. Therefore, access to 20-40 litres per house per day represents a minimum to meet basic hygiene and consumption requirements CITATION WHO101 l 1033 (WHO, 2010).

Figure 4. SEQ Figure_4. * ARABIC 6: A litters used per day at Rugarama and Gasagara Villages4.3.4 Knowledge on the Protection of water during TransportationConcerning the protection of water during transportation, most respondents were aware that containers should be covered with a lid. This will help to prevent contamination of water by flies and other vectors that carry fecal matter on their containers filled with water. Figure 4.3 presents findings on the practice of covering containers during transportation. 98.2 % in Gasagara and 93.5% of Rugarama respondents said they covered their containers before transporting water from source to their home. However, Containers have an impact on the quality of the water. Containers without covers increase the risk of water becoming contaminated during collection, transport and storage. Therefore, covering the container can reduce contamination and leakage during transport CITATION Ede17 l 1033 (Edessa Negera et al., 2017).

Figure 4. SEQ Figure_4. * ARABIC 7: The type of Water protection during transportation4.4 Knowledge and attitude related to Hygiene Practices
4.4.1 Knowledge and attitudes about water handling practices at homeAmong all the respondents interviewed, 88% of both Rugarama and Gasagara respondents used Jerri-can containers and 9 % of pot are in the two villages. The remaining container was 4 % of gallon in Gasagara and 2 % in Rugarama and Gasagara. Only 1% of plastic busket are used in Rugarama. the lid container for covering water storage were used as resulting in table 4.4 that most of respondents covered their water storage containers, 92% and 89% of respondents covered their water containers in Rugarama and Gasagara respectively. Only 11% anad 8% and the containers were not covered. In case of keeping water storage, 100% and 97% of respondents kept their container water storage inside home in Rugarama and Gasagara respectively. Only 3% of the containers filling with water in Rugarama are kept outside. Concerning the maximum duration of storing water, 65% and 46% of respondents Rugarama and Gasagara respectively store water for two days. The majority of 83 % of Rugarama and 68% of Gasagara respondents are using separated containers for drinking water and other purposes. From the total respondents, 78 % of Rugarama and 43 % of Gasagara are using water with soap to clean water container storage, 25 % and 10 % of Gasagara and Rugarama respondents respectively wash their container storage with water and sand, 21% of Rugarama and 5 % of Gasagara respondents are using water with sand and soap and only 11% of Gasagara and 6% Rugarama respondents cleaned containers with water only.
Treating water was not common in the study area, only 25% of Rugarama and 7% of Gasagara respondents boil water before consumption, 9% of Rugarama 7% of Gasagara respondents used Sûr’Eau to treat water and 6% of Rugarama only use filtration . It observed that the majority of them using settlement treatment method before drinking water which are about 86 % of Gasagara and 60% of Rugarama consumed water without any home base treatment. The reason was that 68 %and 34% of respondents do not have time to treat it both in Gasagara and Rugarama respectively and 34 % of Rugarama and 14 % Gasagara respondents have no wood, 14 % of Rugarama and 2% Gasagara respondents showed that water can lose its tasty, 14% of respondents in Gasagara and 11%in Rugarama Respondents said that water is clear. Only 8% and 2 % of Rugarama and Gasagara respondents respectively indicated that water is very clear.
Table 4. SEQ Table_4. * ARABIC 6: A hygiene practices in Rugarama and Gasagara Households
Data Rugarama % Gasagara %
Container For storing water usage        
Jerry-can 136 88 49 88
Pot 14 9 5 9
Gallon 3 2 2 4
Other (Plastic bucket) 2 1 0 0
Container storage condition        
Covered 143 92 50 89
uncovered 12 8 6 11
Water container storage kept        
Inside 151 97 56 100
Outside 4 3 0 0
Duration water storage        
One day 16 10 15 27
Two days 100 65 26 46
Three days 36 23 14 25
More than 3 3 2 1 2
Cleaning water Container with        
Water only 10 6 6 11
Water with Sand 16 10 14 25
Water with Soap 121 78 24 43
Water with sand and soap 8 5 12 21
Separating container for storing drinking water and other purposes      
Yes 128 83 38 68
No 27 17 18 32
Drinking water treatment        
Boiling 38 25 4 7
Sur eau 14 9 4 7
Filtration 9 6 0 0
Settling 93 60 48 86
No treatment 1 1 0 0
The reason of not treating water (Water appearance Perception):      
Clean 17 11 8 14
Very clean 12 8 1 2
No tasty 21 14 1 2
No time 53 34 38 68
Lack of Wood 52 34 8 14
4.4.2 Knowledge, attitude and practices about waterborne diseases
4.4.2.1 Knowledge about waterborne diseases as result of consuming an untreated water
Respondents were asked to the field, about waterborne diseases caused by drinking unsafe water and which practices done to prevent these diseases. The waterborne diseases have been listed by the respondents as a result of consuming untreated water, 58.7% of respondent from Rugarama raised diarrhea as the most common water borne disease known to majority while 39.3 % of Gasagara respondents indicated that intestinal worms were mostly affecting their health, 4.5% and 3.6 % of respondents indicated Amoeba in respectively Rugarama and Gasagara villages, 2.6% and 1.8 % of respondents said that they have thyphoides when they drink unsafe water. Only 0.6 % of Rugarama respondents indicated that cholera is the disease caused by unclean water. Others 21.4% from Rugarama and 6.5% Gasagara respondents said that they don’t know about waterborne diseases caused by un-cleaned water as indicated below in figure 4.6. Therefore, it is clear that respondents are not completely ignorant about the occurrence of water borne diseases.

Figure 4. SEQ Figure_4. * ARABIC 8: List of Waterborne diseases raised by Rugarama and Gasagara respondents
4.4.2.2 KAP Data on the transmission route and prevention measures
During the interview, 83% and 80% of the respondents in Rugarama and Gasagara respectively indicated that a contaminated water is the possible causes of diarrhea and 8% is caused by inadequate environmental hygiene in respective Rugarama and Gasagara. Other causes identified were 4 % of dirty hands and eating contaminated food was about 3% in Rugarama only. In addition, the interviewees were also asked if they have been reported to the clinic after getting diarrhea, A total of 80% and 59% of the respondents in Gasagara and Rugarama respectively indicated that they went to the clinic while 41% and 20% they treated themselves diarrhea at home with traditional medicines in Rugarama and Gasagara respectively.
About prevention measures, 94.6% and 92.3% of the most respondents in Gasagara and Rugarama respectively indicated that it is good to treat the drinking water and do an adequate hygiene, washing hands, cleanliness of containers including open defecation avoidance. Only 3.9 % Rugarama and 3.6% of Gasagara respondents said that cleaning containers is the best way in preventing waterborne diseases while 0.6% of Rugarama respondents said that open defecation should be a good method to prevent waterborne diseases as shown in below figure 4.5. However, regarding the above data analysis made, it can be concluded that there exist knowledge deficit on the causes of water-borne diseases as well as the practical measures employed in the prevention of their occurrence as evidenced by the diverse responses gotten from them. Their understanding of the notions of hygiene, the knowledge and practices on the prevention of water-borne diseases were based on how much information they got via public health education concerning the causes and preventive measures of waterborne diseases. Therefore, an up-to-date knowledge and practices on the prevention of the occurrence of water-borne diseases through community health workers ( abajyanama) is necessary for the wellbeing of the Mareba community. The Mareba local Council hygiene authorities through community health workers should take it as responsibility to organize regular household checks for the availability of treatment methods facilities in homes including a public health education training in order to enlighten the community on the importance of water handling from source to avoid water contamination.

Table 4. SEQ Table_4. * ARABIC 7: Indication of possible cause of diarrheal disease in Rugarama and Gasagara
by Respondents
Data Rugarama% Gasagara%
Possible cause of diarrhea in household        
Contaminated water 128 83 45 80
Eating contaminated food 4 3 0 0
Dirty hands 6 4 0 0
Inadequate environmental hygiene 13 8 1 2
Don’t know 4 3 10 18
Households which reported to the clinic after getting diarrhoea        
Yes 92 59 45 80
No 63 41 11 20
What the respondent think should be done to prevent diarrhoea       
Water treatment 4 2.6 0 0
Adequate hygiene 0 0 0 0
Washing hands 1 0.6 1 1.8
Cleanliness of container 6 3.9 2 3.6
open defecation 1 0.6 0 0
all 143 92.3 53 94.6
Don’t know 0 0 0 0
4.5 Sample locationTable 4. SEQ Table_4. * ARABIC 8: Sampling location in Rugarama and Gasagara villages
N/S Sample location Type of sample Sample size
(N= samples )
1 Rugarama Tape Water 26
Swamp water 26
2 Gasagara Tape water 28
Swamp water 28
4.6 Quality Analysis of water Sample
4.6.1 Methods of Analysis4.6.1.1 Method of microbiological analysis of water sample
Lactose broth with agar were used for the isolation of micro-organisms. These medium were prepared and autoclaved at 1210C for 30 minutes before being inoculated (APHA, 1992; Anonymous, 1982). The numbers of total coliform and fecal coliforms were determined using spreading method. This method gives a direct count of total coliforms and fecal coliforms present in a given sample of water. A measured volume of water (0.1 mL) was pipetted and inoculate on plate dish with Lactose broth with agar and incubated at an appropriate temperature. If coliforms and/or faecal coliforms were present in the water sample, characteristic colonies form could be counted directly.
For Isolation of Fecal coliforms: Water sample (0.1 mL) was inoculated on the plate with lactose broth and agar. Then the plate was incubated at 440C for 24 hours (APHA 1992; Balogun, 2000). Plate with lactose agar and for Isolation of total coliforms, 0.1 mL of water sample was pipetted and inoculated on the plates and incubated at 370C for 24 hours (APHA, 1992; Balogun, 2000). After incubation, the results were expressed as colony forming units per unit volume. In case of polluted surface water, it was necessary to dilute a portion of the sample in sterile diluents to ensure that fewer bacteria are deposited at widely separated points on the surface of the medium, the results were expressed as number of colonies per 0.1 mL of sample. Therefore, results were calculated from the following formula belowCITATION Lab121 l 1033 (Lab Manual 14, 2012):
N=?C(N1+0.1N2)D4.6.1.2 Microbiological Quality of the Rugarama and Gasagara Water Samples
In results of the bacteriological analysis of the water samples presented in figure 4.7, the tap water showed that 95.5% and 94.4% of water samples taken from Jerry can used for storing water 4.5% and 4.6% of samples from gallon container were polluted with Total coliforms and Fecal coliforms respectively in Rugarama and Gasagara. Swamp water by total coliforms and fecal coliform was also 100% from gallon and Jerrycan in Rugarama while the result from Gasagara water households showed the 100% of Gallon and 96.2% of Jerry can contained with water were contaminated with the total and fecal coliforms. Only 3.8% of Jerry can was empty in Rugarama. It is indicated that their stored water in house were at high risk to get sick due to faecal contamination because the majority of the respondents had poor water handling and hygiene practice. Therefore, it underscores that they should be great attention and education on appropriate household drinking water storage and handling practices is also recommended
Table 4. SEQ Table_4. * ARABIC 9: Status of Water analysis from Rugarama and Gasagara HouseholdsLocation Sample Parameters Type of Water Storage container
Gallon Jerry-Can
GASAGARA Tap water Total coliforms 5.6 94.4
Fecal coliforms 6.2 93.8
No contamination 0 0
No sampled 10 90
RUGARAMA Total coliforms 4.5 95.5
Fecal coliforms 8.3 91.7
No contamination 0 0
No sampled 25.0 75.0
GASAGARA Swamp water Total coliforms 100 96.2
Fecal coliforms 100 96.2
No contamination 0 0
No Sampled 0 3.8
RUGARAMA Total coliforms 100 100
Fecal coliforms 100 100
No contamination 0 0
No Sampled 0 0
The WHO’s Guidelines for Drinking Water Standards is recommended that Total and Fecal coliform bacteria must be free from in all water directly intended for water consumption (WHO, 2011). In contrary, public tap water used by Rugarama and Gasagara residents was contaminated due the inadequate unhygienic conditions during handling at household levels. Many studies showed that handling and the used of dirty utensils will all contribute to the contamination of stored water (Fewtrell et al., 2005). Similar study has indicated that even if water is improved, it can be contaminated during consumer handling. (Andrea N.C. and Wolfe B.S., 2000). For swamp water indicates that there is no treatment methods from the source to household level. Surface water such as streams, rivers and lakes are mostly untreated and associated with various health risks (Okonko et.al, 2008). Therefore, point-of-use water treatment has been shown to be the most effective way to provide clean drinking water to individuals such as boiling, filtration and chlorination (Lenton, Wright and Lewis, 2005).
4.6.1.3 Information of waterborne diseases from Mareba Health Center especially in
Rugarama and Gasagara communities
Retrospective clinic records from Mareba Health centre were reviewed to identify patients with diarrheal diseases and intestinal worms reported in 2016. However, clinic records did not specify diarrhoeal diseases instead of reporting the symptoms of diarrhoeal diseases either by bloody diarrhoea or by watery stool while intestinal worms such as abdominal pain, vomiting and Nausea. Following by the coded patients who visited the clinic. Out of 631 records reviewed, the majority of patients who visited the clinic with diarrheal diseases were children between 1-4 years old in Gasagara and 0-11 months in Rugarama while the patients between 30 and 39 have intestinal worms with 95% in Gasagara and 85 % in Rugarama for the patients with above 50. In addition, the figure 4 shows also the distribution of the symptoms of diarrhea and intestinal worms in each village. Mazari-Hiriart et al. stated that the effects arising from contact with water borne pathogens vary depending on the volume of the water ingested by an individual and the individual’s immune status, with the children and elderly being the most susceptible. The higher incidence of waterborne infections among children might be attributable to lack of well-developed immune system and lack of personal hygiene by the children CITATION Maz05 l 1033 (Mazari-Hirriart et al., 2005). The possible reason for this finding is that females with diarrhoea and intestinal worms cases generally might be as a result of cross-infection of the mothers to their children below the age of 5 years had highest percentage of infection being closer to them than their male counterparts. This higher incidence of waterborne infections among children are attributable to lack of well-developed immune system and lack of personal hygiene by the children CITATION Raj11 l 1033 (Raji M and Ibrahim, 2011). Most women are engaged in domestic activities which expose them to this infection CITATION Raj11 l 1033 (Raji M and Ibrahim, 2011). It is recommended that Government should make drinking water in the communities fit for drinking and people should be enlightened on the importance of personal hygiene.

Table 4. SEQ Table_4. * ARABIC 10: Patients data reported to Mareba Health Center in 2016 with waterborne
Diseases especially for Rugarama and Gasagara Villages
Location Age Diseases
Diarrhea Intestinal worms
GASAGARA 0-11 64.3 35.7
1-4 66.7 33.3
5-14 57.1 42.9
15-19 26.7 73.3
20-29 22.2 77.8
30-39 5.0 95.0
40-49 15.4 84.6
ABOVE 50 36.9 63.1
RUGARAMA 0-11 73.7 26.3
1-4 53.7 46.3
5-14 66.7 33.3
15-19 35.0 65.0
20-29 23.3 76.7
30-39 19.3 80.7
40-49 29.4 70.6
ABOVE 50 15.0 85.0
In addition, the figure 4.8 indicated also the distribution of the symptoms of diarrhea and intestinal worms in each village. In this figure indicates that 48% of the symptoms of abdominal pain victims were females than 37.5 % of males. For diarrhoea with watery stools, it was indicated that 39.8% of female were more affected than males who have 34. 9%.

Figure 4. SEQ Figure_4. * ARABIC 9: Intestinal and diarrheal symptoms of patients who reported to Mareba Health
Center during 2016
In addition, the number of diarrheal and intestinal cases varies among the months of a year. The higher incidence of intestinal cases were remarkably seen in June-July during the summer season while the case of diarrheal diseases increases during the rainy season in this area study.

Figure 4. SEQ Figure_4. * ARABIC 10: Intestinal and diarrheal diseases cases per month reported to Mareba Health
Table 4. SEQ Table_4. * ARABIC 11: Correlation between knowledge, attitude and Hygiene practices of water
Treatment at Household level
Chi-Square Tests
Value Asymp. Sig. (2-sided)
Pearson Chi-Square 40.630a .000
Likelihood Ratio 44.904 .000
Linear-by-Linear Association 9.769 .002
N of Valid Cases 211 The relationship between knowledge, attitude and hygiene practices to the choice methods of water treatments was determined using Pearson’s Chi-square correlation and p- value (p; 0.01) considered as the level of significance. In table 4.7 shows that there is a strong evidence relationship (Pearson’s Chi-square correlation coefficient r =40.630a, P< 0.01) between KAP on water treatments. In this study, some of respondents indicated that water which is clear, very clean and tasty, it is safe for drinking and there is no need to treat it while others showered that the challenges of having no time and lack of woods lead them to not treat water as shown in above table 4.4. This is comparable to a study in Liberia showered that in 37% of the community lack a knowledge on how to treat as a reason for not treating water before use while 7% of families is not treating water because they believe that the water is safe and 9% says they are used to the water and therefore do not find the need to treat CITATION UNI13 l 1033 (UNICEF, 2013). Despite water household intervention programmes being in places, still significant proportion of respondents had poor knowledge and attitude toward practice on household water treatment which contribute to the high burden of disease in the study community especially among children CITATION EAS11 l 1033 (EAST, 2011). Therefore, the local authority should embark on the mass campaign on the importance and methods of household water purification in rural communities.

CHAPTER FIVE5 DISCUSSION, CONCLUSION AND RECOMMENDATION
5.1 DiscussionThis research was to determine the knowledge , attitude and practices of communities of Mareba District especially in Rugarama and Gasagara villages on the collection, transportation, storage and usage of water consumption and how these practices influences the occurrence of water-borne diseases. From this study, it was revealed that respondents are not well educated on the protection and water treatment of water consumption, 60% of Rugarama and 86 % Gasagara respondents do not treat water collected from public tap potable or swamp which is the main reason for community education campaign on how to protect household drinking water and domestic use water from contamination in order to the prevention against water borne diseases. In addition, 65% of Rugarama and 46% Gasagara respondents stored their water in duration of more than one day. According to Subbaraman, the storage water for hours or even days increases the possibility of fecal contamination of a good quality water inside the household CITATION Sub13 l 1033 (Subbaraman et al, 2013).
Eschol et al. (2009) found also after studying drinking water from 50 households in Hyderabad, India, that water collected from an improved source then stored in the home for 20-36 hours had increased in contamination by 36% CITATION Mah09 l 1033 (Mahapatra et al, 2009). This led to conclude that even if a water comes from pipes and spouts directly into the homes, storage practices need also to be the crucial area of focus CITATION Tre04 l 1033 (Trevett et all , 2004). From the data collected and analysis made, it can be concluded that there exist deficit knowledge on the collection, treatment and storage of potable water as evidenced by the diverse responses gotten from them. Their understanding of the hygiene practices on the collection, treatment and storage of potable water are based on how much information they got via community education campaign concerning drinking water collection, treatment and storage. For example, this study revealed that The quality of household water examined was poor and this is an indication also that basic hygiene practices are lacking, there is more likely hood of indicator bacteria from feces to be introduced in to stored water.

5.2 ConclusionThe researcher, basing on the study findings, concludes that practices on the collection, treatment and storage of potable water are necessary for the wellbeing of the Mareba community. The local authorities should take it as duty function to organize regular community education campaign in social institutions in order to enlighten the community and to create also the awareness among communities on the importance of water hygiene practices by using various media for educate to them.

5.3 Recommendation
Based on the results and conclusions of this study, it is good to propose the following recommendations in order to guarantee improved water quality and health of the community in the short and long term:
In the short term, implementation of a community education campaign on how to protect household drinking water and domestic use water from either contamination or recontamination to the sector. Although people know water can be contaminated and can have effects on their health, their knowledge on how some of their actions could contribute to the faecal contamination of drinking water at the point-of-use is limited. There is a need to educate the public on efficient water use practices and the intensification of educational awareness on how to handle and locally treat water for domestic use.
In the long term several steps should be taken to reduce the intermittency of the distribution system. Reducing intermittency will help improve water quality in the system by reducing low pressure episodes that could lead to contamination. Reducing intermittency will also decrease the need for users to store water in their homes and decrease the risk of contamination through home storage.
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APPENDICESAPPENDIX 1: QUESTIONNAIRELETTER OF INFORMATION AND CONSENT
A cross sectional study to determine the KAP on water quality that is used by the two rural communities of Gisagara and Rugarama . Knowledge, attitudes and practices of the rural communities will also be assessed on water handling, to determine if there is a link to the Diarrheal diseases.
Principal Investigator: BUKURU GASHUGI Doris
Brief Introduction and purpose of the study:
Diarrheal diseases are associated with water polluted by human excreta, poor disposal of sewage and hygiene; and are a major cause of disease and death worldwide and particularly in developing countries. This study will look at the microbiological status of water used by the community in Mareba and to determine if there is no link to the diarrheal diseases.
The study aims to achieve the following objectives for a 6 months period in 2017
To assess the knowledge, attitudes and practices of the rural community of Mareba regarding water handling and diarrheal diseases.
Outline of procedures:
A trained interviewer will come to your house and you must sign this letter that you are reading now if you want to take part in this study. A questionnaire will be used and you must answer the questions.
Risks to the subject:
There will be no harm to you. It will be greatly appreciated if you take your time to answer the questionnaire.
Benefits:
The study will help to know if water used by the community is safe, if the two communities are aware of the causes of diarrheal diseases and what can be done to reduce the diarrheal diseases. The results will assist in improving the policy on water provision and sanitation in rural areas.
Reasons why the subject may be withdrawn from the study:
If you fill that you cannot continue answering the questions you are allowed to stop. Nothing will happen to you if you do not want to take part in the study.
Costs of the study:
You will not pay to take part in this study.
Confidentiality:
The questionnaire used in the interview will be treated confidentially. Only the researcher will have access to your identification.
Research –related injury:
You will not be paid because you will not be hurt in this study.
The contact to be addressed in case of any problems or queries:
BUKURU GASHUGI DORIS 0788872833
Statement of agreement to participate in the research study:
I…………………………………………………………………………………………………
(Subject’s name and ID number)
Have read this document in its entirety and understand its contents. Where I have had any questions or queries, these have been explained to me by ——————————————– to my satisfaction. In addition, I fully understand that I may withdraw from this study at any stage without any adverse consequences and my future health care will not be compromised. I, therefore voluntary agree to participate in this study.
Subject’s name ……………………………Subject’s signature…………….Date………….
Researcher’s name …………………………Researcher’s signature…………Date…………
Supervisor’s name:…………………………Supervisor’s signature…………..Date…………
Appendix To: Mayor of Bugesera District
REF: Request for Permission to carry out a Research Study
Dear Sir /Madam
I am BUKURU GASHUGI DORIS, an MSc student of Jomo Kenyatta University, especially in Public Health as part of my requirement for the Degree award; I have to present a research paper which is about “An assessment of Knowledge, Attitude, and Practices on Water Handling and Water Quality and Health effects by Mareba Community at Bugesera District, Rwanda”. In order to obtain this data for the study, I will require your permission to collect information from residents of Rugarama and Gisagara communities in September, 2016. If you allow me, it will hopefully identify areas of risk in terms of water borne diseases. And also, this study will determine the factors in which KAP can be successfully introduced with preventive measures to improve water quality when handling water for home consumption.
Therefore, I will be grateful to have your permission to carry out my research study.
Thank you and looking forward for your support.

Yours Sincerely
BUKURU GASHUGI Doris
Msc in Public Health at Jomo Kenyatta University in Rwanda
Mobile 0788872833
Email: [email protected]
KNOWLEDGE REGARDING TO WATER TREATMENT AND HEALTH HAZARDS OF DRINKING WATER SOURCE OF MAREBA SECTOR
Before filling in this Form of Questionnaire, please read, if you agree:
Write an X in appropriate box
Answer the questions
Interview questionnaire
26289006350000Place of interview: Rugarama
2628900952500Gasagara
SECTION A: DEMOGRAPHIC DATA
Name of respondent ( Optional) : —————————————————-
50093221361100Age
50463451079500Date of birth/year
50577751143000How many people living in your household?
50292001722700Children < 5 years old
5059016828300Children from 6 – 10 years olds
5059016927700Children from 11 – 18 years
50114201016000Adults above 18 years
SECTION B: QUALIFICATION OF GENDER AND EDUCATION LEVEL
Gender
1895475698500Male
1876425889000Female
Level of Education
24669751397000No schooling
2495550952500Certificate
2514600825500Diploma
25241255162550025241251333500Degree
25527001460500Masters
PhD
SEGeCTION C: WATER RELATED INFORMATION AND ATTITUDE
1. Where do you fetch water from?
25298406667500Tap Public water
25336506540500Spring
25336507493000Borehole
25336502603500 Well
2562225336550002552700-4635500Swamp water
Other source
What is the current status of this water source collected?
Good
Bad
Do you know what potable water is?
Yes No
How?
3. Which container do you use to fetch water or store it?
25527004699000Clay pot
2552700952500Jerrican
25527005651500Other ( Please specify)
4. During water collection, how do you collect water from the source?
Tapping
Pouring
Dipping
5. Do you cover the container after collecting water?
Yes
No
If yes, How;
6. How many meters do you take to reach to source?
2116455-127000Less 10
22574251587500 10 – 50
23006053549650022955251206500 50-100
100 – 500
23241001016000Above 500
23622001968500If above 500, how many?
7. How many time do you collect water per day?
Once a day
Twice a day
Three times a day
Other , specify
8. How many litre do you use per day?
20097759525005 litre?
2009775336550010 litre?
200977535179000200025082550020 litre?
Above 20 Litre
9. Have you special container for drinking water? If yes what is it?
JerrycanPot
Tank

SECTION D: KNOWLEDGE RELATED TO HYGIENE PRACTICES
5648325241935001. How do you treat your drinking water at home?
Boiling
56578501460500 Add chemicals (“Sûr’Eau” is a chlorine based water disinfection product)
right635000I don’t treat drinking water
right2393700 Filtration
Other (Specify) —————————-
If no, Why?
Water is very clean
Water doesn’t well tasty after treated?
It is no time for treatment
Other, specify
2. What do you use to clean the storage container?
Only 21812253111500water
water 22288501016000with Soap
22466303873500 water with Sand
22669501206500Other (Specify)…
3. After washing container, what kind of storage container do you use to store water?
a. Jerry can
Pot
Basket
Other , specify ——————————
4. How do you protect a stored water?
23050502794000covered
23145754508500uncovered
Which place do you keep water?
22479001778000Outside
2247900698500 Indoors
5. How many days do store water in the container?
0ne day
Two days
More than 2 days
Other specify
SECTION E: KNOWLEDGE TAWARD HEATLH DESEASE
Do you know diseases caused by unsafe water?
3886200184150014573251841500a. Yes No
Please specify:
b. Are you aware of the link between unsafe water with inadequate hygiene health problems such as diarrheal diseases etc.? How?
c. In your family, have any of members experienced with diarrheal diseases?
414337595250017621253810000Yes No
Why? ……………………………………………….

3562350290830002. What do you know the cause of diarrhoea?
Contaminated water
35623504064000 dirty hands
Open defecation
3562350889000Dirty surroundings
3561080952500Other (Please specify)
46863001206500 3. When you have a diarrhoea, do you go to the clinic? If no Why?
30099001651000 4. What do you do to prevent diarrhoea?
Water treatment
Personal hygiene
Wash hands more frequently
Cleanliness of container
Combination of indicated creteria above
Don’t Know
Other , specify
CLINIC RETROSPECTIVE RECORDS OF DIARRHOEA DISEASE OF 2015
District :
Sector :
Village :
Health Centre :
Date Gender Age Symptoms Cause Died Live
Thank you very much for your participation

IBIBAZO
UBUMENYI KUBIJYANYE NO GUTUNGANYA AMAZI YO KUNYWA MU NGO NDETSE NINGARUKA KUBUZIMA
Mbere yo gusubiza ibi bibazo banza usome neza, noneho wuzuze mu kadirishya kari mbere y’ ikibazo:
Subiza ibibazo byose wifashishije ahabugeneweAndika X mukadirishya kabugenewe
Ibibazo bibazwaAho ubazwa aherereye : 26289006350000 Rugarama
2628900952500 Gisarara
ICYICIRO 1: UMWIRONDO
Izina ry’ ubazwa ( k’ubishaka )………………………..

50292004708110050093221361100 Imyaka y’ amavuko
Igihe yavukiye
5049078566000Murabantu bangahe murugo
50292001722700 Abari munsi y’imyaka itanu
5059016828300 Abarihagati y’ imyaka 5-10
5068956396903005059016927700 Abarihagati y’ imyaka 11-18
Abarengeje imyaka 18

ICYICIRO CYA 2 : IGITSINA N’ICYICIRO CY’AMASHURI YIZE
IGITSINA
1895475698500 GABO
1876425889000GORE
Amashure afite
center444500Ntiyize
center952500 Ntiyarangije amashure abanza
3019425825500 Yarangije amashure abanza
35528251333500Yarangije icyiciro cyambere cya Kamunza
36861752857500 Yarangije icyiciro cya Kabiri cya Kaminuza2790825889000Yarangije amashure ahanitse
ICYICIRO 3: AMAKURU KU IMITEKEREREZE KUBIJYANYE N’ AMAZI
Nihe uvoma amazi?
3091815952500Amazi ya robine rusange31051505588000 Kw’ Isoko
31051504635500 Kw’ impompero (impombo)
30956253136900031051504508500 Iriba
Mu gishanga
30861006223000Ahandi
Nigute ubona aya mazi muvoma?
Nimeza
Nimabi
Mbese Muzi amazi meza?, nimba ari yego, aba ameze gute wabisobanura?
N’ ikihe gikoresho muvomesha cyangwa mubikamwo amazi?
26765253746500 Gikozwe mu Icyuma
26860503746500 Gikozwe muri Palasitike
2990850889000 Ikindi (kivuge)
Igihe muvoma amazi, n’ubuhe buryo muyavomamo?
Muratega
Murasuka
Muradaha
Ese mupfundikira igikoresho iyo mumaze kuvoma amazi
Yego
Oya
Nimba ari yego, mubuhe buryo?
Ni metero zingahe mukoresha kugirango mugere aho muvomera ?21717003810000Munsi ya metero 10
2181225635000 Hagati 10-50
2181225297815002190750254000 Hagati 50-100
Hagati 100-500
22002751016000Hejuru 500
36671255778500Nimba ari hejuru 500, mukoresha zingahe?
N’ incuro zingahe ujya kuvoma ku munsi?
Rimwe ku munsi
Kabiri ku munsi
Gatatu ku munsi
Izindi ncuro, zivuge
Ni litiro zingahe mukoresha ku munsi
2247900952500Litiro 5
2266950762000Litiro 10
2276475342265002266950825500Litiro 20
Hejuru yaritiro 20
Izindi —————
Ese mwaba mufite igikoresho cy’umwihariko kibikwamo amazi yo kunywa? Nimba ari yego, n’ikihe?

ICYICIRO 3: KNOWLEDGE RELATED TO HYGIENE PRACTICES
UBUMENYI BUJYANYE NO GUSUKURA AMAZI
564832524193500Nigute mutunganya amazi yokunywa murugo?
Murayateka
56578501460500 Gushyiramo Suro
right635000Ntabwo tuyatunganya
right2393700Gukoresha umwenda mukuyayungurura
Ubundi buryo , ubuhe —————————-
Nimba adatunganywa , ni kubera iki?
Amazi tuvoma nimeza cyane
Amazi ntagira uburyohe iyatunganyijwe
Atwara umwanya wo gutunganywa
Iyindi , yivuge
219075034417000Ukoresha iki mugusukura ibikoresho ubikamo amazi?
Amazi yonyine
32766002921000Ukoresha amazi n’isabune
30372051016000Umucanga n’ amazi
27051001206500Ibindi nibihe
Ni ubuhe bwoko bw’ibikoresho mubikamo amazi?
Ijerekani
Ikibindi
Indobo
Ibindi , bivuge ——————————
Ni gute ubika amazi
23050502794000Arapfundikirwa
23145756413500Ntapfundikirwa
Ese Amazi abikwa:
23241008445500Hanze
2428875698500 Imbere munzuAmazi abikwa iminsi ingahe
Umunsi umwe
Ibiri
Iminsi irenze 2
Iyindi, yivuge
ICYICIRO 4: UBUMENYI BUJYANYE N’INDWARA ZIKOMOKA KU MAZI MABI
Mbese mwaba muzi indwara ziterwa n’ amazi mabi
514350018415002028825889000 Yego Oya
Wazivuga
Ese waba uzi isano ry’ amazi mabi , umwanda n’ impiswi ndetse n’ibindi bibazo by’ubuzima?
Mu muryango wawe, hari umuntu waba warigeze arwara impiswi?
414337595250017621253810000 Yego Oya
Kubera iki ………………………………………………….

332422529083000 N’iki utekereza gitera impiswi?
Amazi yanduye
33337503111500 Kurya ufite intoke zanduye
3381375889000Umwanda udukikije
3381375444500Imyizerere y’amadini3399155952500Ibindi bivuge
Igihe warwaye impiswi, ujya kwamuganga?
161925076200040821661496300Yego Ntagikorwa
Nigute wirinda impiswi?
Gukaraba intoke burigihe
Koza ibikoresho
Ibindi bivuge
Ntabyo nzi
Murakoze kubwisubizo byiza umpaye
APPENDIX 4: WATER ANALYSIS
Appendix 4: Water analysis by Spread Plate Method CITATION Lab12 l 1033 (Lab Manual 14, 2012)Laboratory Apparatus
Petri dishes
Disposable Tip Pipet
Micropipettes.
Incubator or drying oven
Safety cabinet
Spreader
Media
Lactose broth
Bacteriology Agar is used best
Peptone water
Preparation of Plates
Pour 15 mL of the lactose agar medium into sterile 90 × 15 petri dishes
Let agar solidify.
Dry in a laminar-flow hood at room temperature at 24 to 26°C
Procedure
Make a 1:10 dilution of homogenized sample and transferring it aseptically to peptone water solution
Pipet 0.1 mL sample onto surface of dried agar plate. Using a sterile bent glass rod, distribute inoculum over surface of the medium by rotating the dish by hand
Let inoculum be absorbed completely into the medium before incubating
Pipet desired sample volume 0.1 ml onto the surface of the dried lactose agar plate
Incubation
Incubate the prepared dishes inverted at 370C for 24hours for Total coliforms and at 440C for 24hours for fecal coliforms
Counting
Following incubation counted all colonies on petri dishes were recorded and the results were taken per dilution counted
Calculation CITATION iné13 l 1033 (Inés arana, Maite orruño ; Isabel barcina, 2013)The colonies counted were done by using the formula given below:
N=?C xDFVolume plated (ml) ?C: is the sum of colonies counted on all the dishes retained
DF: is the dilution factor corresponding to first dilution