Factors associated with adherence to safe water chain practices among refugees in Pagirinya refugee settlement, Northern Uganda

Poor adherence to safe water chain practices is a major obstacle to consumption of safe drinking water. In refugee settings, adherence to safe water chain is critical in minimizing water-related diseases. Despite this, little is known about the level of adherence to safe water chain and associated factors, especially in emergency settings. In this study, we interviewed 400 household heads in Pagrinya refugee camp in Northern Uganda and assessed household level adherence to safe water chain practice and associated factors. Modified Poisson regression was used to model the association between adherence to safe water chain and independent variables. All households utilized improved water sources and 74.0% had high adherence to safe water chain. Having postprimary education and high level of knowledge about the safe water chain were positive predictors of high adherence to the safe water chain while round travel time exceeding 1 hour during water collection was negatively associated with high adherence. There is a need for awareness campaigns on safe water chain maintenance among refugees without any formal education. Constructing more water sources would also minimize round travel time during water collection and enable households to collect sufficient water that enables hygienic water storage and use. This is an Open Access article distributed under the terms of the Creative Commons Attribution Licence (CC BY 4.0), which permits copying, adaptation and redistribution, provided the original work is properly cited (http://creativecommons.org/licenses/by/4.0/). doi: 10.2166/wh.2020.230 om http://iwaponline.com/jwh/article-pdf/18/3/398/759733/jwh0180398.pdf er 2021 Thomas Mugumya John Bosco Isunju Tonny Ssekamatte Solomon Tsebeni Wafula (corresponding author) Richard K. Mugambe Department of Disease Control and Environmental Health, School of Public Health, Kampala, College of Health Sciences, Makerere University, P.O Box 7072, Kampala, Uganda E-mail: swafula@musph.ac.ug


INTRODUCTION
. Therefore, there is need to intensify efforts for improving safe water and sanitation provisions in emergency settings.
One critical measure that has been recommended for attaining safe water supplies for people in emergencies is the use of the safe water chain approach (Ali et al. ).
The safe water chain encompasses all practices that aim at ensuring that water remains safe between the water source and point of human consumption (Ssemugabo et al. ).
Safe water chain practices include: collection from protected and improved water sources; using clean and narrow-necked covered containers; transportation of the water in covered containers; treatment at the point of use/ consumption; storage in hygienic environments and containers with covers as well as drawing the water in a manner that prevents contamination (Ali et al. ; Ssemugabo et al. ). According to the World Health Organization (WHO), to reap the benefits of the safe water chain, adherence among populations is highly critical (Brown & Clasen ). Adherence to safe water chain practices is a crucial component of the Water Safety Plan (WSP), a comprehensive risk assessment and risk management approach that aims at ensuring that drinking water is safe from the source to the final consumer (WHO ).
However, sustaining safe water chain management practices among refugees and internally displaced persons has been reported to be a significant challenge ( Whereas many humanitarian agencies have guidelines on promoting safe water chain practices, the recontamination occurring after distribution in camp settings is not well understood, in part because this is not explicitly included in guidelines for water treatment in emergencies (Ali et al. ). The level of adherence to safe water chain practices and associated factors among refugees is not known (Mosler ). Adherence to safe water chain management in Uganda has only been assessed among slum dwellers whose adherence was low (Ssemugabo et al. ). In this study, we sought to determine the level of adherence to safe water chain practices and associated factors among refugees in Pagirinya refugee settlement, Uganda, to establish mechanisms of improving safe water supply for better health outcomes among the refugee population.

Sample size determination
The sample size was calculated using a formula for crosssectional studies (Kish ): The sample size was calculated using P of 56%, the reported percentage of Ugandans that purify their drinking water according to the National Service Delivery Survey report (Uganda Bureau of Statistics (UBOS) ). N ¼ the required sample size, Z ¼ standard score corresponding to 95% confidence level and a margin of error/precision of the study (δ) of 5%. After adjusting for a non-response rate of 5%, a total sample size of 400 households was obtained.

Selection of blocks and households
A multistage sampling procedure was followed. In the first stage, two of the six blocks in Pagirinya refugee settlement (C and D) were randomly selected. Simple random sampling procedure involved writing all block names in the settlement on identical sized small pieces of paper. These were then folded similarly and placed in a round container and closed. The pieces of paper were shuffled and later, the container was opened. One of the research assistants, with their eyes closed, was requested to pick two pieces of paper from the round container. After selecting the blocks, proportionate sampling was used to select 180 households from block C and 220 from block D. From the list by the settlement commandant, block C had a total of 900 households and block D had 1,100 households, from which we chose households. Individual households were picked using computer-generated random numbers. Systematic sampling was done in each block using a uniform sampling interval of five households. The sampling started at the block leader's household. If a selected household did not accept participation in the study, the next household as per the sampling frame replaced that household. At each household, an adult, i.e., household head or the spouse or any regular household member aged above 18 years was asked to participate in the study after written informed consent.

Data collection and quality control
A team of 17 research assistants fluent in English and any of the languages spoken by the refugees (Madi, Acholi, Lolubo, Dinka or Kuku) were recruited and trained on data collection for 2 days. The semi-structured questionnaire was pretested in two villages which were not part of the study area. A total of 17 households were reached during the pre-test exercise. The questionnaire was then revised and standardized after the pre-testing exercise.

Data analysis and management
Data were entered using Epi Info software and then analysed using Stata 14.0 (StataCorp, Texas, USA). The data were then analysed using both descriptive and inferential statistics. Categorical data were presented using frequencies and proportions while continuous data were expressed using means and standard deviation. The main outcome was adherence to safe water chain practices. We assessed adherence using a set of seven indicators developed following the International Federation of the Red Cross (IFRC) manual on household water treatment and safe storage in emergencies (IFRC ). The indicators included: 1. Obtaining water from an improved water source.
2. Safe collection using clean, narrow-necked water collection containers.
3. Safe transportation in appropriately covered containers.
4. Practice adequate household water treatment before storage.
5. Safe storage of drinking water in clean and covered storage containers (with no algal growth on the inside).
6. Household drinking water storage container in a clean environment (free from solid wastes, dust and dampness).
7. Safe method of accessing drinking water from the storage container.
In this study, adherence to safe water chain practices was categorized as follows: 1. Low adherence was defined by respondents meeting 1-4 of the 7 indicators.
2. Medium adherence was defined by respondents meeting 5-6 of the 7 indicators.
3. High adherence was defined by respondents meeting all requirements of the dependent variable (7/7).
To study the factors associated with adherence, respondents were dichotomized into two groups: low adherents versus high adherents after medium adherence was com-

Socio-demographic characteristics of participants
A total of 400 respondents with a mean age of 32.9 years (SD ¼ 8.5) participated in the study.       The study found that all households had access to improved water sources, the majority of whom could access water within a distance of 500 m, and only a small proportion had travel times of less than 30 minutes. Community health workers were the most common source of information on the safe water chain. The majority of households had high adherence to safe water chain practices. Having secondary or tertiary education, high level of knowledge about the safe water chain and taking over 1 hour to collect/fetch water from the water source were significantly statistically associated with adherence to the safe water chain practices.
All households had access to improved water sources.
An improved water source is essential in mitigating diarrhoeal incidents in such a vulnerable population.
Improved sources such as the tap stands and protected springs used by these refuges are known to provide rela-   Our study has some strengths, first, being one of the first studies to document adherence to the safe water chain in emergency settings and second, we assessed adherence to the safe water chain based on the seven indicators in the IFRC manual on household water treatment and safe storage in emergencies. However, the results of our study have to be interpreted with caution due to some limitations.
The information on all practices was self-reported and we could not rule out social desirability bias. However, we believe the study makes an important contribution to safe water chain maintenance in emergency camp settings which has been grossly under-researched. These findings can be generalized to other emergency settings in Uganda and around the world due to similar contexts.

CONCLUSIONS
The study found that all households had access to improved water sources; the majority of which were located within the recommended 500 m distance. There was high knowledge about the safe water chain and also high adherence to safe water chain practices. Post-primary education and high level of knowledge about the safe water chain were related to higher adherence, while taking over 1 hour to collect water from the water source was conversely associated with high adherence to safe water chain maintenance.
There is a need for knowledge and awareness campaigns among refugees without any formal education about household water treatment and safe storage. Constructing more water sources would adequately minimize round travel time during water collection and enable households to collect sufficient water which enables hygienic water storage and use.