Knowledge, attitude and practice towards water, sanitation and hygiene (WASH) among holy water users in Amhara regional state Orthodox churches, Ethiopia, 2024: institutional based cross-sectional study

WASH

water, sanitation, and hygiene

KAP

knowledge, attitude, and practice

DALYs

disability-adjusted life years

SDGs

Sustainable Development Goals

EDHS

Ethiopian Demographic Health Survey

Sanitation is the quality of living that is expressed in a clean home, a clean firm, a clean business, and a clean community to prevent disease and promote health (Park's 2013). Hygiene consists of proper disposal of solid waste, use of sanitary latrine, cleanliness of the house and proper ventilation, spacing, lighting inside the house, daily bath, trimming the nails, use of clean clothes, and regular and appropriate hand washing practices (Greene 2001).

Poor water, sanitation, and hygiene (WASH) has a wide-ranging influence on health and development, hampers economic and social growth, and poses a substantial barrier to poverty alleviation (Boschi Pinto et al. 2008). Poor sanitation and hygiene, along with an inadequate supply of potable water, are the primary environmental causes of disability-adjusted life years (DALYs) (GBD 2017 Risk Factor Collaborators 2018) and significant risk factors for diarrheal mortality worldwide (GBD 2013 Risk Factors Collaborators 2015). Inadequate sanitation and contaminated water can lead to the spread of preventable health risks like cholera, typhoid, polio, diarrhea, and dysentery (WHO 2023). The sustainable development goals (SDGs) emphasize the importance of WASH, with SDG 6 aiming for universal access to safe water, sanitation, and hygiene by 2030 (Ababa 2016).

In 2023, the World Health Organization estimated that 27% of the world's population (2.2 billion people) lacked ‘safely managed drinking water,’ 43% lacked ‘safely managed sanitation,’ and 25% lacked access to a soap and water handwashing facility at home (WHO 2022). The report predicts that by 2030 (of 8.6 billion people), only 81% of the global population will have access to safe drinking water, 67% will have safe sanitation services, and 78% will have basic handwashing facilities (WHO/UNICEF 2021).

Based on the findings of a study conducted to assess knowledge, attitude, and practice regarding water sanitation and hygiene among mothers in Nepal from a total of 150 participants, 2.7% of respondents knew that the quality of water can affect health, 97% of respondents knew the benefit of hand washing and nearly 95% were using soap and water for hand washing, 96.70% use hand washing after defecation, 70% use the toilet as a place for defecation, 66% use tap water as source of drinking, 43.30 use community dustbins as waste disposal, and 63.30% think there is no need for treatment of drinking water (Sah et al. 2017). A study in Indonesia among food handlers found that despite having good knowledge (88%) and attitudes (84%), over 38% of them performed poorly on WASH (Palupi et al. 2020). A study conducted in another location in Pakistan with 250 participants found that 77.6% were aware of WASH, 52% were aware of water pollution during the storage process, 72.8% of respondents acknowledged knowledge of sanitation, 58.0% stated it was necessary to have a latrine in the house for sanitation, 35% threw waste into surrounding piles of filth, 48.0% stated that washing hands prevents sickness, and 70% stated that hand washing is required after using the latrine (Zeeshan et al. 2023).

Inadequate water supplies, hygiene, and sanitation in impoverished countries hinder productivity, increase healthcare costs, and hinder work, making WASH a critical public health need in the 21st century (Hutton et al. 2017; Rego et al. 2022; Mudadu Silva et al. 2023). In low- and middle-income countries, poor WASH caused 829,000 diarrheal deaths in 2016, accounting for more than 60% of all diarrheal deaths and approximately 297,000, or 62.2%, of all diarrheal deaths in children, which could have been avoided by providing cleaner drinking water and sanitation services, as well as using soap to wash hands (Prüss-Ustün et al. 2019). Deaths caused by diarrhea among children under 5 are highest in sub-Saharan Africa (UNICEF 2024). A study in Somalia found that 61.5 and 59.0% of respondents (671) always wash their hands before eating and after using the latrine, respectively, with 87.0% using soap and 13% using water only (Nahimana et al. 2017).

In Ethiopia, the EDHS 2016 reported national-level estimates of diarrhea (12%) and stunting (38%) (Ababa 2016). According to the study among household residents in peri-urban areas in Northwest Ethiopia, from 590 adults who took part in the study, 78.1% (95% CI: 76.7–79.4) had mean knowledge, and 73.6% (95% CI: 71.1–76.1) had favorable attitudes of water safety, sanitation, and hygiene, respectively (Abera et al. 2018). Ethiopia ranks among the African countries with the highest number of people lacking basic hygiene and sanitation services (GBD 2017 Risk Factor Collaborators 2018). In 2016, Ethiopian households had only 8% handwashing facilities (52% limited facilities, and 40% no facilities), with 50% using basic water sources and 6% having basic sanitation facilities (Ababa 2016). This highlights the fact that unimproved WASH still represents a significant burden for Ethiopia.

Unfavorable living and environmental conditions, crowding, and limited access to social and health services such as clean water, adequate sanitation, and medical care, are typical characteristics of such situations. Big gatherings where overcrowding is usual are very well known in holy water-provider sites. These circumstances make it more likely for foodborne and waterborne illnesses like cholera to spread and make it more difficult to contain those outbreaks promptly (Griffith et al. 2006; Haileamlak 2016). Enough clean water supplies (Sepehri & Sarrafzadeh 2019), better sanitation infrastructure, and a highly developed knowledge, attitude, and practice of WASH are all essential to the prevention and containment of such outbreaks. Most importantly, appropriate hygiene and sanitation measures must be applied correctly and consistently. To carry out these actions, it is essential to fully comprehend these dynamics among holy water. Even though there are many holy water-provider sites in Ethiopia, there has been no research on this area until this study was conducted. The study's goals were to determine the proportion of KAP on WASH among holy water users; the findings are anticipated to be used to reevaluate outbreak intervention tactics and implement prompt measures.

To assess knowledge, attitudes, and practice toward water, sanitation, and hygiene among holy water users in Amhara regional state Orthodox churches, Ethiopia, 2024.

• To assess knowledge regarding water, sanitation, and hygiene among holy water users.

• To assess the attitude on sanitation and hygiene among holy water users.

• To assess the practices on sanitation and hygiene among holy water users.

An institutional-based cross-sectional study was carried out at Amhara regional state Orthodox Tewahido churches, where holy water is used for various purposes, in Ethiopia. Amhara region is located in northern Ethiopia and has an estimated population of 22.5 million, accounting for 22% of Ethiopia's overall population. The study was conducted in April 2023 in five randomly selected Orthodox Tewahido churches in the Amhara region, namely Wonkshet Gebreal, Gono Gebreal, Megendi Giorgis, Andasa Giorgis, and Abunehara, which provide holy water daily. Wonkshet Gebreal, Abunehara, and Gono Gebreal are in the South Gondar district, whereas Megendi Giorgis and Andasa Giorgis are in the West Gojjam district.

The sample size was calculated using a single population proportion formula. The following assumptions were made to determine the minimum sample size:

• i. The maximum (50%) of households assumed to have sufficient knowledge, attitude, and practices on water safety and sanitation; p = 0.5.

• ii. Two-sided standard Z-score Zα/2 = 1.96; corresponding to a 95% confidence level.

• iii. The margin of error (MOE) = 0.05.

• iv. Contingency for nonresponse rate (NR) = 10%:

  

First, lists of holy water users at selected churches were taken from the registration books. After using the lists, systematic random sampling was applied to the selection of participants. To ensure homogeneity, a random number (K = 4) was determined to select participants by dividing the total number of holy water users by the sample size. So, the probability that any person will be included in this sample was selected by making a gap of four holy water users. The number of samples in each selected church was distributed proportionally based on the total number of holy water users in the individually selected churches.

All clients who used Orthodox Tewahido churches' holy water in the Amhara region are the study population, while all adults who used Orthodox Tewahido churches' holy water in the Amhara region during the study period are the study population.

The Ethiopian Orthodox Tewahido Church (EOTC) is the largest of the Oriental Orthodox Churches. According to the 2016 U.S. government estimates, the most recent available, 44% (around 50 million) of the population adheres to the EOTC, and a majority of individuals in Amhara are adherents of the EOTC (U.S. Department of State 2022). The majority of Orthodox Christians in Ethiopia attend church weekly (78%) and pray daily (65%), and nearly all (98%) say religion is ‘very important’ in their lives and health. One distinguishing factor of Ethiopian Orthodox is its usage of practices like holy waters to get relief from evil spirits and diseases (Pew Research Center 2017). Although the volume varies from individual to individual, almost all followers take holy water once a week on Sunday and every day in selected holy water-providing sites. Mainly the sources of holy waters are rivers.

The study included all holy water drinkers in the Amhara region who were 18 years old or older during the study period. Individuals with difficulties communicating, as well as holy water users who interrupted the interview, were excluded from the study.

A mean knowledge score of ≤0.50 was considered as poor knowledge.

A mean knowledge score of >0.50 was considered as good knowledge.

A mean attitude score of ≤0.60 was considered as having a negative attitude.

A mean attitude score of >0.60 was considered as having a positive attitude.

A mean practice score of ≤0.50 was considered as poor practice.

A mean practice score of >0.50 was considered a good practice.

Any setup of a container with water and soap in the household compound for handwashing purposes was observed at the time of data collection.

The household compound is free from solid and liquid wastes as determined by the data collector's observation.

The study explores sociodemographic factors, knowledge, attitude, and practice in water, sanitation, and hygiene. The study employed an interviewer-administered structured questionnaire to gather data from the participants. Observational checklists were utilized to document and verify holy water site compound cleanliness and latrine utilization practices, along with self-reported data. The questionnaire was developed from various literature, taking into account the local context. Five experienced environmental health professionals, under the supervision of principal investigators, collected the data. This study measured knowledge, attitude, and practice on WASH using knowledge-related questions, attitude-related questions, and practice-related questions. The correct responses were scored 1 for each question, while the wrong responses were scored 0. The scores were added, and the mean score was calculated. The study used a Likert scale (1–5) to measure attitudes toward WASH. In this study, responses of ‘very satisfied or strongly agree’ (scale 5) and ‘agree or satisfied’ (scale 4) indicated positive attitudes regarding WASH. In measuring practice, each correct response was assigned a score of one, while an incorrect response was assigned a score of zero.

The questionnaire was initially written in English, translated into Amharic for data collection, and then re-translated back to English by language experts for consistency. The training was given to data collectors and supervisors. A pretest was conducted on 5% of holy water users 1 week before data collection outside the study area to assess respondents' acceptance and willingness to participate in questionnaires. The researcher and supervisors regularly monitored the data's completeness and validity. The items have relatively high internal consistency (Cronbach's alpha = 0.839).

The data were coded, filtered, and inserted into Epi-Data version 4.6, then exported to STAT version 17 for analysis. The data were cleaned by running frequencies for each variable in STATA 17 to identify outliers, inconsistencies, and missed values. Descriptive statistics were computed to obtain frequencies and percentages of Knowledge Attitude Practice (KAP) on WASH. Pie charts, bar graphs, and tables were used to present the responses about knowledge, attitude, and practice on WASH and related questions. Confidence intervals (CI) for good practice, good knowledge, and a good attitude were calculated.

This investigation adhered to ethical standards set by research committees and the 1964 Helsinki Declaration, as well as its revisions or comparable standards (Dik & Doenges 2019). The study's purpose was discussed with church leaders before reaching respondents, and permission for data collection was obtained. Each study participant provided oral informed consent.

A total of 385 participants were included in the study, and the response rate was 91%. Two hundred nineteen (57% of the respondents) were female (Table 1).

Almost half (53%) of the respondents knew unclean water causes diarrheal diseases, and the majority of them, 267 (69.2%), knew liquid waste exposes people to diseases. Six out of 10 respondents, 240 (62.4%), believe that latrines are essential at holy water sites. Of the respondents, 39.2% (95% CI: 37.7%, 44.7%) had good knowledge of WASH (Table 2).

According to the study's findings, 345 (89.6%) of respondents agreed that drinking clean water can help prevent waterborne diseases. Of those who participated, 357 (92.7%) and 210 (54.5%) agreed that water containers should always be clean, and have a small mouth, respectively. On the contrary, 244 (63.4%) of respondents believe that boiling water before consumption does not effectively eradicate disease-causing germs. Nearly 8 out of 10 respondents, 290 (75.3%), consider that waste can be a breeding ground for flies and rodents, and 142 (63%) think that diarrheal disorders are caused by poor hygiene and sanitation. On the other hand, 128 (33.3%) of them are confident that disposal of liquid waste within the compound will not cause health issues. The majority of respondents, 271 (70.4%), hold the opinion that washing hands is essential before handling food. However, 214 (55.6%) believe that hand hygiene and diarrheal disorders are unrelated. The study revealed that 42.5% (95% CI: 38.7%, 48.0%) of respondents had a positive attitude toward WASH (Table 3).

The study found that 68% of respondents used unprotected water sources (river or spring) for residential purposes, whereas 32% used protected water sources (pump or spring). More than half of the respondents, 208 (53.9%), had appropriate waste disposal practices. The majority of respondents, 283 (73.5%), used only water for handwashing. The survey revealed that 47.2% (95% CI: 43.4%, 50.5%) of respondents exhibited good WASH practices (Table 4).

In this cross-sectional study, good knowledge, positive attitudes, and good practice (KAP) on WASH were found in 39.2, 42.5, and 47.2%, respectively. A study of 385 participants found that 69.2% were aware of the potential risks of liquid waste exposure to infections, and 62.4% acknowledged the necessity of latrines at holy water sites. According to the study's findings, 345 (89.6%) of respondents agreed that drinking clean water can help prevent waterborne infections. Among those who took part in this study (385), the majority of respondents (93.7%) agreed that clean water containers are essential, while 73.5% used water exclusively for hand washing.

The study revealed that 39.2% (95% CI: 37.7%, 44.7%) of respondents had a good knowledge of WASH. A study conducted in peri-urban areas of Northwest Ethiopia (Abera et al. 2018), Indonesia (Palupi et al. 2020), Tigray (Berhe et al. 2020), and Pakistan (Zeeshan et al. 2023) discovered that 78.1, 88, 42.2, and 77.6% of respondents had good knowledge of WASH, respectively. Almost half (53%) of the respondents knew unclean water causes diarrheal diseases. A study in Seepat, District-Bilaspur, Chhattisgarh, reported that 2.7% of respondents knew unclean water causes diarrheal diseases (Sah et al. 2017). The study also revealed that 240 (62.4%) of participants believe that latrines are essential at holy water sites. This finding is in line with the study. In a study done in Pakistan, 58.0% of respondents stated it was necessary to have a latrine in the house for sanitation (Zeeshan et al. 2023). The differences may be attributed to variations in healthcare promotion services, religious practices, and socioeconomic status.

Positive attitude toward WASH was observed in 42.5% (95% CI: 38.7%, 48.0%) of the respondents. Other studies found that 73.6% of respondents in peri-urban areas in Northwest Ethiopia (Abera et al. 2018), 84% in Indonesia (Palupi et al. 2020), and 48.5% in the Tigray region had a positive attitude (Berhe et al. 2020). Furthermore, 89.6% of participants concurred that drinking enough safe water can prevent waterborne illnesses, which is consistent with an 86% study done in northern Ethiopia (Berhe et al. 2020). The similarity between these studies might be due to the resemblance in healthcare services, religious practice, and socioeconomic status; hence, Amhara and Tigray are neighboring regions in Ethiopia. Besides, in this study, 68.6% of respondents deemed a latrine necessary for sanitation, lower than a study done in Pakistan, which was 58% (Zeeshan et al. 2023). Disparities in healthcare services, religious practices, and socioeconomic status may be the root cause of these disparities.

Of the respondents, 47.2% (95% CI: 43.4%, 50.5%) reported using good WASH practices, which is consistent with the study done in northern Ethiopia, 49.2% (Berhe et al. 2020), but higher than the study conducted in Northwest Ethiopia, 34% (Abera et al. 2018). On the other hand, it is lower than the study done in Indonesia, 38% (Palupi et al. 2020). Critical hand washing was performed by the majority of participants: 97% before handling food, 91.2% after defecating, and 88.6% after eating. In a related study conducted in October 2018 at the Za'atari camp, most people (84.5%) knew that washing hands is important after using the restroom, before eating (68.5%), and before preparing food (56%) (UNICEF R 2018). The majority of respondents, 102 (26.5%), used soap with water for handwashing, which is inconsistent with the study done in Nepal, 95% (Sah et al. 2017), and Somalia, 87.0% (Nahimana et al. 2017), using soap and water for hand washing.

In Ethiopian Amhara Orthodox Tewahido churches, holy water users frequently lacked information, had an unfavorable attitude, and practiced poor WASH. This demands immediate effort to raise knowledge about health education and hygiene in order to impact holy water users' attitudes toward personal and communal cleanliness and sanitation.

• As a result,

• Health extension programs, hygiene and environmental sanitation (proper and safe waste disposal, water supply safety measures, food hygiene and safety measures, healthy home and environment and personal hygiene), and health education and communication have been recommended, and should be reestablished in primary healthcare in a way that can increase interventional approaches to improve knowledge, attitudes, and practices on WASH.:

• Researchers: we recommend to investigate the microbial quality of holy water users' attitudes.

• Church authority: we recommend to use improved drinking water sources (piped water, boreholes, protected dug wells, protected springs, rainwater).

• It is imperative that UNICEF, UNDP, and other relevant parties step up their efforts to guarantee the availability of facilities like clean drinking water, safe latrines, and safe waste disposal.

• In the effort to encourage people to adopt improved personal hygiene practices based on their knowledge, behavior, and wants, hygiene education and promotion techniques should be employed.

• The use of health extension workers or community-based agents (CBAs) for advocacy and mass enlightenment can enhance and provide education on hygiene and promotion

• Nitrifying-enriched activated sludge (NAS) techniques are a better way to handle water waste (Sepehri & Sarrafzadeh 2019). Nitrifiers reduce ammonium ions into water, energy, nitrite, acid (H+), and water. They subsequently oxidize nitrite to nitrates (nitrification). Lastly, denitrification releases nitrogen into the surrounding air.

Limitation of this study:

• This study doesn't address factors associated with the KAP of holy water users on WASH, and we recommend other researchers to further investigate those factors associated with the KAP of holy water users on WASH.

• This study doesn't assess microbial quality of holy water and we recommend other researchers to further investigate microbial quality of holy water users' attitudes.

K.A. conceptualized, designed, and analyzed the study, with all authors contributing to tool design, data collection, analysis, and writing. All authors agreed to be accountable for accuracy and integrity.

The authors would like to acknowledge, the church leaders, and study participants for their cooperation during the study.

All relevant data are provided in this document.

The authors declare there is no conflict.