Household Water Treatment and Storage Practices Among Residents in Mogadishu Somalia

: Background: Consumption of contaminated water can affect human health and even lead to high morbidity and mortality, particularly among under-five children. Thus, determining household water treatment and proper management is vital to eliminate contamination. This study aimed to assess the household water treatment and storage practices among Warta-Nabada residents in Mogadishu, Somalia. Methods: A community-based cross-sectional study was conducted in 386 households from the April to June 2018 period. A multistage cluster sampling technique was used to select sample units from the households to obtain accurate data. Data were collected using structured questionnaires. Also, SPSS version 21 was used for data entry and analysis, respectively. The univariate, bivariate, and multivariate levels were analyzed to see a significant association between variables. The statistical significance was declared at a value < 0.05 with 95% confidence intervals in the final model. Results: The majority of participants, 291 (75.4%), used plastic containers for water storage at a household level, while 48 (12.4%) used clay pots, followed by 47 (12.2%) cement tanks. Most containers used for water storage were plastic containers due to their availability and low cost. Participants who had containers were 227 (58.8%). Approximately 114 (29.5%) had two containers. The number of people who practice boiling water was relatively low (15.8%). The distance of the water source from household 143 (37.0%) were more than 50 meters, regards to methods for water treatment, 91 (23.6%) were used for chlorination, and 61 (15.8%) were used for boiling, but 45 (11.7%) were used for filtration, and 22 (5.7%) used solar disinfection as well. Therefore, the most common water treatment method used was chlorination, accounting for (23.6%) of the total water treated. Conclusion: According to the results, it can be concluded there were significant variables for age, marital status, occupational, and education of the husband of the household water treatment level. When there was a high risk of acute water diarrhea or cholera, drinking water chlorination, boiling, and filtration were the most common household water treatment practices. Among a group of good practices, there were (73%) while the poor practices group had (27%). However, the majority of residents practice precisely. This study recommended developing a comprehensive national plan for scaling up the household water treatment system with a holistic approach, allowing adequate service provision and addressing the need to provide for the most vulnerable groups with better practices.


Introduction
Today, millions of people worldwide do not have access to safe water, particularly among the population of developing and underdeveloped countries [1]. A study conducted by WHO and UNICEF highlighted that more than 700 million people in the world do not access improved drinking water sources, due to the nature of their construction, are protected from outside contamination. Drinking water quality has shown that hundreds of millions of people with "improved" drinking water do not have access to a source that is microbiologically safe to drink [2]. Globally, household water treatment is not feasible at the household level, indicating that they are left with the responsibility of needing to collect, treat, and store their water for safety and improved health [3]. Although many countries' groundwater is inaccessible or contaminated, these users depend on household water treatment systems for safe drinking water storage because 663 million people lack improved drinking water sources [4]. Therefore, contaminated water resulting from unsafe consumer storage and poor handling practices at the household level causes diarrhea [5].
Approximately half of the people using unimproved drinking water sources live in Sub-Saharan Africa, while one-fifth live in Southern Asia. Furthermore, Sub-Saharan Africa has made little progress, with 43% of its population having access to improved drinking water, while some developing countries in other regions are said to be falling behind the MDGs standards for drinking water that needs further consideration [6]. These household water treatment systems aim to provide safe drinking water affordably and sustainably [7]. However, the inhabitants can manage their use of water and easy to avoid water-borne diseases [8].
The regular practice of household-level water treatment is crucial in reducing the occurrence of diarrheal and other devastating illnesses [9]. Currently, 84 2000 people and 36 1000 children aged less than five years are estimated to die from diarrhea due to unsafe drinking water, poor sanitation, and hand hygiene practices. Although communities may have access to piped water at home, it may be contaminated by defects in the distribution system or improper storage [10]. A recent study in Somalia highlighted that (66.1%) are not treating their water instead of (31.5%) practicing any water treatment method. Water chlorination was used as a disinfectant by more than (27.3%). Around (4.0%) used boiling as a means of water treatment as well. Among those, (38.8%) believed that water is safe naturally. Most of the households (97.6%) had drinking water containers. Approximately (80.6%) of families indicated that they use Jerri cans for water collection and storage, and only (3.6%) have a bucket without a lid for water storage [11]. There is a commitment to safe household water treatment and storage, which has led to the formation of the WHO-sponsored international network promotion that has brought together several stakeholders to improve household water management as a component of water, sanitation, and hygiene programs [12]. This study aimed to assess household water and storage practices in Warta-Nabada district, Mogadishu, Somalia.

Study Design, and Site
Community-based cross-sectional study was conducted during the period between April to June 2018 in Warta-Nabada, Mogadishu, Somalia.

Sampling Technique
A multistage cluster sampling technique was used to select sample units from the sampled households: In the first stage, the sampling frame consists of five sections. In the second stage of each selected section, respondents were selected based on sub-sections. The third stage, from each selected sub-section, was divided into blocks. From each block, the study participants have been selected randomly through systematic sampling.

Data Collection Techniques and Instruments
This quantitative study used a structured questionnaire for interviews. Both closed-ended and open-ended questions were utilized for data collection. During the data, collection interviews were conducted in the local language and then professionally translated to English. Three qualified experts validated the translation process to ensure validity, and they prepared the manuscript in English.

Data Analysis
The Statistical Package for Social Sciences (SPSS) software, 21 versions, was used to code, enter, and analyze data. The univariate analysis was used to provide frequency, percentages and draw various charts. The logistic regression analysis and odds ratios were also used to determine the relationships between variables. The level of significance was set at P < 0.05 and 95% confidence intervals.

Water Accessibility and Environmental Characteristics
This study found that 386 (100%) of the respondents could access water. The distance of the water source from household 143 (37.0%) was more than 50 meters. In contrast, 30 and 50 meters were 133 (34.5%) of the water distance while 110 (28.5%) were less than 30 meters. The water tap is around 149 (38.6%). Even though 79 (19.7%) were obtained from the well, 158 (40.9%) were obtained from piped water, but 3 (0.8%) got surface water. Due to this reason, the most consumed water source is piped water at 158 (40.9%). Approximately one day per week, water is off for 255 (66.1%), and 113 (29.3%) two days per week, while 18 (4.7%) are off more than two days. Most of the time, water off is one day per week, 255 (66.1%). Regarding challenges of water accessibility, 214 (55.4%) were answered no, while 172 (44.6%) were answered yes. Around 220 (57.0%) got water from the water tap. The 140 (36.3%) get their water from a well, while 26 (6.7%) get it from a pipe, and 299 (77.5%) answered yes, while 87 (22.5%) answered no. We asked the participants if their tap was leaking; 260 (67.4%) answered no, and 126 (32.6%) answered yes, respectively.

Water Storage and Practice at the Household Level
In Table 3, most containers for water storage at the household level were plastic container 291 (75.4%). Approximately 48 (12.4%) were used clay pots, and 47 (12.2%) were cement tanks. Most containers used for water storage in households are plastic containers because of their availability and low cost in the market. Residents who have containers were 227, (58.8%). Among the 114 (29.5%) had two containers. Nearly 43 (11.1%) had three containers. Only two (0.5%) had more than three containers. In the Warta-Nabada district, residents had one container out of 227 (58.8%) with the proper capacity. For 144, (37.3%) were practiced ≤25 liters, and 242 (62.7%) were > 25 liters. Regarding the condition of containers, 280 (72.5%) were clean, while 106 (27.5%) were dirty. More than 230 (59.6%) covered their containers, and 156 (40.4%) answered no as well. Children use their cups for drinking water. The 163 (42.2%) and 138 (35.8%) were used with one single cup. The 59 (35.8%) were used with their hands, 26 (6.7%) were used with their mouth. Therefore, most children use it when they drink their cups, 163 (42.2%). The number of days for water stored in the household was two days, 124 (32.1%). Also, 140, (36.3%) were stored for three days in their water. For these results, 122 (31.6%) were stored for more than three days compared to the above results. The longest days were three days, 140 (36.3%). When asked if they washed their containers regularly, 281 (72.8%) said yes, and 105 (27.2%) said no. The study participants cleaned their water containers daily to keep them safe. Households of 41 (10.6%) and 122 (31.6%) were cleaned multiple times per week, respectively. Materials used for container washing, 1136 (35.2%) were used only for water for cleaning, while 26 (6.7%) were used for vegetation. Less than 83 (21.5%) were used as chemicals, and 36 (9.3%) were used as soap with water. More than 273 (70.7%) answered no in the water fetching test, while 113 (29.3%) answered yes. The respondents who use containers for fetching, 98 (25.4%) use Jerri cans, and 16 (4.1%) use clay pots. Twenty-four percent of the Jerri cans are the most usable water fetching in the study site. Furthermore, when it came to washing their hands, 207 (53.6%) did not wash their hands after dipping them in water, while 179 (46.4%) did so regularly. For instance, 39 (10.1%) were fetched one time, with 48 (12.4%) fetched two times, instead of 23 (6.0%) fetched three times, while 4 (1.0%) were fetched more than four times.

The Knowledge Level and Methods of Household
Water Treatment Table 4 shows the majority of the respondents have known the household water treatment and its practices properly 272 (70.5%), but 114 (29.5%) was not known how to practice household water treatment. Regarding the objectives of household water treatment, 163 (42.2%) answered prevent diarrheal disease, while 76 (19.7%) answered reduces infant mortality. In addition, these respondents know how to reduce water-borne diseases 32 (8.3%). Moreover, 262 (67.9%) of the participants did not have knowledge of the causes of water contamination. The 124 (32.1%) of the participants know the underlying causes of water contamination, and 226 (58.5%) answered diarrheal disease, while 105 (27.2%) answered infant mortality, 36 (9.3%) answered malnutrition, and 19 (4.9%) answered water borne-diseases. Of these, 219 (56.7%) used household treatment methods, and 80 (20.7%) were not used. Methods 91 (23.6%) were used for chlorination, 61 (15.8%) for boiling, 45 (11.7%) for filtration, and 22 (5.7%) for solar disinfection. In addition, the majority of the participants were practiced water for chlorination 91 (23.6%) as treatment.   Figure 1. Knowledge scores of household-level water treatment were divided into three main categories: high knowledge level, moderate knowledge level, and low-level knowledge. The high knowledge level was 205 (53%), the moderate knowledge level was 88 (23%), and 93 (24%) had a low level of knowledge, respectively. However, the majority of the residents in the study location have sufficient knowledge of household water treatment. Figure 2. Focused on the practice level of household water treatment, two categories based on which are good practice and poor practice. Also, the group of good practices was 281 (73%), while the poor practices group was 105 (27%). Therefore, the majority of residents practiced the accurately.

Association Between Socio-demographic and Knowledge Level
The results in

Discussions
The majority of respondents, 291 (75.4%), used plastic containers for water storage at a household level, while 48 (12.4%) used clay pots, followed by 47 (12.2%) cement tanks. Most containers used for water storage are plastic containers because of their availability and low cost. Residents who have containers were 227 (58.8%). Among 114 (29.5%), two containers were found. The number of people who practice boiling water was relatively low (15.8%). Compared to another study conducted in India that highlighted around 60% of the knowledge of boiling water, followed by chlorination (27%) and membrane filtering at (22.4%) [13]. In the Warta-Nabada district, the filtration rate was (11.7%) and only (5.7%) used solar disinfection for drinking and domestic water. Another study revealed that the level of knowledge on water chlorination was also comparable (23.6%) with that of the Myanmar study (10%) [14]. However, other research conducted in Somalia revealed that there was no variable association between latrine availability and household water treatment practices [11].
On the other hand, the respondents' ages in this study were between 16 and 39 years old, which has more knowledge than those ages between 40 and 86 years old (OR 0.652, 95% CI 0.424-1.002). The unmarried participants have better knowledge than the married respondents (OR 0.342, 95%CI. 212-554). The employed participants have good knowledge compared to the unemployed respondents (OR 1.611, 95% CI 1.040-2.495). Therefore, educated husbands have more knowledge than uneducated husbands in household water treatment practices (OR 0.534, 95%CI .305-.936).
However, nearly half of mothers and caregivers (49.3%) understood household water treatment methods [15]. The current study highlighted the use of the chlorination method was (23.6%). The other study highlights that chlorinated water was associated with a 48% reduction in diarrhea [16]. These results indicate that the chlorination of water can be successfully carried out locally to improve the health of the population. The majority of the participants are interested in household water treatment (62.8%). The findings also revealed that (43.0%) of respondents were male, while (57.0%) were female. The population sample that collected the data was categorized into single, married, divorced, and widowed. The (39.1%) could not read, while 86 (22.3%) could read and write, but 69 (17.9%) were at the primary level, and 43 (11.1%) were secondary. Besides, the lowest portion, 37 (9.6%), were universities. The majority of respondents (31.3%) were housewives, while 90 (23.3%) were government employees, and (22.8%) were private-sector employees. Furthermore, 16.3% were laborers, 5.2 percent were merchants, and farmers accounted for the minor proportion, around 4.0%. The husband's educational status (15.1%) was that he could not read and write, while (15.0%) could not read and write. The level of primary schools was (5.4%) and (11.9%) were secondary level. Nevertheless, 3.1% were Quranic level.

Conclusion and Recommendation
According to these results, it can be concluded there were significant variables for age, marital status, occupational, and education of the husband of the household water treatment practices in Mogadishu. When there was a high risk of acute water diarrhea or cholera, household water treatment methods were primarily related to drinking water chlorination, boiling, and filtration. The group of good practices was (73%), while the poor practices group was (27%). Nevertheless, the majority of residents practice the proper way. This study's findings suggest both a need for improving the handling and storage practices of drinking water at a household level and methods of water treatment practices for reducing health risks related to the drinkingwater supply.