Water, sanitation, and hygiene for schistosomiasis prevention: a qualitative analysis of experiences of stakeholders in rural KwaZulu-Natal

uMkhanyakude District in KwaZulu-Natal province is one of the districts in the six provinces in South Africa where schistosomiasis is endemic. The area is characterized by poor access to water and sanitation. While it is well established that schistosomiasis is a public health problem in the district and that efforts to prevent and control the disease are being made, very little is being done to involve stakeholders in the implementation of water, sanitation, and hygiene (WASH) strategies for schistosomiasis control. Hence, this study sought to document current WASH practices and explore how that can play a role in schistosomiasis prevention and control in Madeya Village through the engagement of different stakeholders. Qualitative data were collected through eight key informant interviews with community leaders, nurses, community caregivers (CCGs), and pre-school teachers; and four focus group discussions with members of the community during the dry season. This study adopted a grounded theory approach. Data were analyzed manually using the six steps of thematic analysis described by Braun & Clarke. Findings show that there was limited knowledge on who the key players are in the promotion of WASH. Although effective implementation, promotion, and adoption of WASH can only be fully achieved with the involvement of various stakeholders, we found that there was a limited collaboration with and various WASH stakeholders. However, the role being played by the Department of Health through CCGs to promote WASH was evident. This, however, is not suf ﬁ cient as the collaboration between the water and sanitation service providers, the Department of Health, the Department of Education, community leadership, and the general members of the community is essential for greater impact.

There are two forms of the disease, namely urogenital and intestinal schistosomiasis (World Health Organization ).
Water, sanitation, and hygiene (WASH) is critical for prevention of schistosomiasis; yet such interventions have not been fully incorporated into schistosomiasis control programs (Campbell et al. ). Although mass drug administration (MDA) with praziquantel has clear benefits, people are easily re-infected after treatment if they come into contact with water containing infectious cercariae (Evan ).
The literature informs us that people with safe water and adequate sanitation have significantly lower odds of a Schistosoma infection (Grimes et al. ). Access to water and sanitation in Sub-Saharan Africa is interwoven with environment, culture, economics, and human behavior necessitating the need for interdisciplinary research and policy interventions (Armah et al. ). Similarly, schistosomiasis transmission is deeply entrenched in social-ecological behavior (Grimes et al. ). Mulopo et al. () reported on the influence of psychosocial factors on behavior associated with the risk of contracting schistosomiasis. Improving WASH infrastructure and behavior is a primary prevention method for the elimination and eradication of NTDs including schistosomiasis (Waite et al. ). This can be achieved through health promotion which is defined as 'the process of enabling people to increase control over, and to improve their health, health promotion promotes a holistic approach of empowering individuals and communities to take action' (World Health Organization ; Kumar & Preetha ).
Furthermore, intersectoral action is one component of this definition which focuses on building healthy public policies and a sustainable health system (Hussain et al. ).
A wide range of innovative health promotion approaches have been applied in low-income countries.
These include the Participatory Hygiene and Sanitation  (Msweli & Ngobese ). The objective of this study was to explore the adoption of WASH through the involvement of a wide range of stakeholders and document prevailing practices and experiences with WASH in the context of schistosomiasis prevention in Madeya Village. Our findings will contribute to the WASH knowledge gaps in stakeholder involvement in the prevention of schistosomiasis in rural KwaZulu-Natal where focus has primarily been biomedical (screening and treatment). This study uses a qualitative bottom-up approach which places the community at the center in a way that one can better understand the roles that different stakeholders can play in schistosomiasis prevention.

Study design and area
A qualitative study (Ulin et al. ) was conducted in Madeya Village located in uMkhanyakude district situated in Northern KwaZulu-Natal. The province is located on the east coast of South Africa bordering three countries: Mozambique, Swaziland, and Lesotho. The district covers an area of 12,821 km 2 and has a population of over 600,000 people. Ingwavuma has a population of approximately 1,300 people. The area is arid and experiences water scarcity. It has limited infrastructure and experiences challenges with service delivery such as access to water. The area is surrounded by many water bodies including the Pongola and Ingwavuma Rivers, both major rivers in KwaZulu-Natal, as well as some ponds. IsiZulu is the primary language spoken in the area and the majority of the households are of a low socio-economic status (Leonard et al. Qualitative data were used to identify contextual and behavioral risk factors of schistosomiasis that may not be captured using quantitative methods, to inform the design of an intervention strategy for the prevention of schistosomiasis in poorly resourced communities. Study participants and selection of participants of the study Five categories of stakeholders were selected to participate in this study. The clinic that serviced the community had five nurses and we purposively selected two nurses who were familiar with the study area and had worked at the clinic for more than 10 years. Two community caregivers (CCGs) who work in the community also participated in this study. There were only two crèches in the community, and therefore, we included one teacher from each crèche in this study. Two village headmen responsible for the wellbeing of the community were included in this study. In addition, all households in the study area with children below the age of five (we included children below the age of five because they are the most susceptible to WASHrelated diseases) were invited to participate in focus group discussions (FGDs); we asked the CCGs that worked in the community to invite household heads to participate in FGDs and the response rate was at 32% out of just over a hundred households.

Inclusion and exclusion criteria
A consenting household member of 18 years and above whose household had a child below the age of five was eligible to participate in this study. We chose children below the age of 5 years because that age group is vulnerable to WASH-related diseases. The other stakeholders were identified for participation on the basis of their knowledge on WASH resources in the community and the strategic positions related to developmental issues in the community that they hold. We excluded households that had no children or that had children older than 5 years.

Data collection procedures
Data were collected through key informant interviews and FGDs with members of the community. Data from semistructured key informant interviews were used to refine

Key informant interviews
A total of eight key informant interviews were conducted with stakeholders. Stakeholders comprised of nurses, community health workers, village headmen, teachers, and the general members of the community. Key informant interviews were used to extract information on WASH conditions, experiences of stakeholders with WASH within their various institutions as well as barriers to WASH promotion. A semi-structured interview guide with the following themes was used: Provision of WASH services; role of the stakeholder; and local experiences with WASH issues. All data from key informants were captured on an audio recorder.

Focus group discussions
Four FGDs were conducted with mothers (two groups) and fathers (two groups) of children aged below 5 years. FGDs were used to identify common practices in community regarding WASH as well as perceptions toward WASH.
Each FGD comprised of 6-12 participants who were recruited purposively with the assistance of community research assistants to provide diversity in age, employment activities, and their location of residence within their neighborhood. A focus group guide was developed and refined using issues raised in the earlier key informant interviews, and covered the following topics: water sources and use, sanitation practice, and hygiene. All FGDs were recorded using a digital audio recorder with the consent of the participants.

Data analysis
All interviews and FGDs were transcribed verbatim and translated into English. Data were analyzed manually (Basit ). Guided by the grounded theory approach (Strauss & Corbin ), we identified core themes and grouped them into broader conceptual processes to understand schistosomiasis risk factors in Madeya Village.
Transcripts were analyzed using the six steps of thematic analysis described by Braun & Clarke (). The first step (1) was familiarization of the data through reading and rereading the transcripts. The second step (2) involved systematically coding of interesting features of the data. A codebook with both inductive codes from the data and deductive codes from the topics in the interview guides and concepts from the literature was developed. For quality assurance, an inter-coder agreement was conducted between the researcher and the research assistant to assess and improve consistency in coding data. Thirdly (3), the initial codes were collated to develop themes. The fourth step (4) involved reviewing the themes by checking if they related to the coded extracts and the entire data set. Furthermore, themes were defined and named (step 5) and lastly, a report was produced (step 6). Table 1 summarizes the results into two broad themes and sub-themes. Theme I focused on access to facilities, subthemes: water (sources and practices), sanitation (basic Is the use of safe water sources being promoted and who is responsible for promoting the use of safe water sources?

Findings
Members of the community were mainly using unsafe water sources.
No stakeholders were identified that promoted the safe use of water in the community.

THEME I: ACCESS TO FACILITIES Water sources and practices
Community members reported that they could not easily access safe water because most of the safe water sources were not operational. Some of the safe water sources were working but could go for several months without discharging water. Consequently, in the months when water could not be accessed at safe water points, members of the community used unsafe alternative water sources: 'The clean water from the tap can go for 3 to 4 months without being available, that's why we have to dig at the river' -(Village headman, male, 55 yrs).
Alternatives sources commonly used included unprotected dug wells, the spring, and the river. Members of the community dug wells in the riverbed when the river was dry as well as in areas close to the river. The two springs used by members of the community were unprotected.
When asked whether water was treated before consumption, respondents reported that water treatment was not a common practice. Furthermore, since the majority of water sources were not protected, the water sources were often shared with livestock. Some parents believed that their children got sick because of consuming water from sources shared with animals: 'the water which is available to us for consumption is often shared with other animals and our children get sick from drinking this water' -(unemployed, male, 45 yrs).
Members of the community covered dug wells with dry tree branches and hence believed that the water that they collected from the dug wells was safer and better than the water collected directly from the river. These dug wells around the river were reserved for drinking water (Figure 1). reported that some members of the community still preferred using the bush to defecate because they had been doing that for a very long time:

Basic sanitation practices in the community
'sometimes we go out there in the bush to do our business (defecate) especially when we are out there in the fields, because it's something that we are used to' -(unemployed, male, 28 yrs).
Members of the community also said that snakes found their way into the toilet structures; hence, they avoided using the toilets in some instances fearing that there could be snakes in the toilet. They encouraged children not to go to the toilets but to defecate in the yard and then adults would clean up after them. At a crèche, a teacher reported that sometimes a child would defecate on the premises and not inform them.
In such cases, feces remained exposed in the environment.

Access to primary health care
The community is serviced by a clinic located 8 km away.
According to the community members, access to the facility was limited because of the long distance, and hence, they preferred to use a mobile clinic that was made available every week. Members of the community that stayed far away from the mobile clinic station felt disadvantaged as it was difficult for them to access the services provided.
'The mobile clinic does not get close enough to us, we can conclude that we do not have a clinic' -(unemployed, male, 43 yrs).
However, mothers reported that they took children to the clinic when they noticed symptoms of diarrhea or observed rash on the skin: 'We are struggling a lot in this area but when my child had a rash, I took him to the clinic for treatment' -(community caregiver, female, 35 yrs).

THEME II: KNOWLEDGE ABOUT DISEASES INCLUDING SCHISTOSOMIASIS
Health education and hygiene The responsibility of promoting handwashing in the community has mainly been placed on CCGs and nurses. CCGs 'We can't go out into the community but we teach them when they are here at the clinic on how to wash their hands. We tell them that they should wash their hands with soap' -(Nurse, female, 50 yrs).
CCGs reached out to the community by going door-to-door to promote handwashing. However, they were not sure if members of the community practiced what they taught them: 'As a CCG all I do is deliver information, I go home at the end of the day so I cannot guarantee that they will use it' -(community caregiver, female, 43 yrs).
CCGs taught the parents about handwashing when they went door-to-door and hoped that the messages they gave were used to protect children. They could not directly access the children because they were usually at school when they did their rounds: 'We work from Monday to Friday, the children are either at crèche or school so we cannot talk to them. I have never taught children' -(Community caregiver, female, 35 yrs).
CCGs said that they were not sure how much information on handwashing children were getting in schools: 'Maybe they can give us some other time with the children so we can also teach them' -(community caregiver, female, 43 yrs).
CCGs expressed concern that not all children were taught about handwashing by their parents and they preferred that a handwashing intervention tailored for children should be put in place to teach children about handwashing.
CCGs argued that even though they provided information on handwashing, change on handwashing behavior could only be achieved through access to safe water.
During the FGDs, mothers indicated that they were responsible for teaching their children about handwashing; the fathers were not involved in promoting handwashing because they did not spend much time with the children: 'We are the ones that tend to always be at home, the children are taught by us mothers' -(unemployed, woman, 28 yrs).
They indicated that whenever there is water available they help children to wash their hands making sure that the water was used sparingly: 'We teach the children to wash their hands and we teach them to use water sparingly so that they do not waste it' -(unemployed, woman, 32 yrs).
Handwashing practices among pre-school-going The basin was only made available on demand: 'No there isn't a special place to wash your hands, you just take water and put it in a basin and wash your hands' -(unemployed, male, 42 yrs).
In addition, people also washed their hands at a jojo tank (rainwater harvesting and water storage tank) whenever water was available in the tank. Availability of water in the jojo tank was dependent on rainfall. Consequently, people were only able to wash their hands at the jojo tank during periods of rainfall: 'I use the jojo tank after it rains and that's how I wash my hands' -(unemployed, woman, 37 yrs).
Although children were taught about handwashing in school, handwashing behavior at the crèche was reported to be low. All the children at the crèche were on a feeding scheme. Some teachers reported that children ate food without washing their hands: 'Yes, they can get taught at crèche as well but because of the water shortage they sometimes will give the children food without making them wash their hands, and then you find children getting sick because of these unhygienic circumstances' -(preschool teacher, female, 40 yrs).
'Sometimes the children eat their lunch without washing their hands' -(preschool teacher, female, 40 yrs).
Sometimes water for handwashing was not available at the crèche if the person responsible for providing the water was either absent or forget to prepare water for the children to wash their hands during break time. When asked if children ask for water to wash their hands when it is not provided, the response was that they did not as they were not accustomed to washing their hands: 'Children do not ask us for water to wash their hands when the water is not provided because it's not something they practice even when they are at home' -(preschool teacher, female, 40 yrs). 'We suspect that we get these diseases from water, especially schistosomiasis, it's definitely the water' -(unemployed, male, 52 yrs).
Some of them had the misconception (in the case of schistosomiasis) that they contracted diarrhea and schistosomiasis through drinking dirty water: 'Diarrhea and schistosomiasis is caused by the dirty water that we drink' -(unemployed, female, 23 yrs).
Schistosomiasis was reported to be prevalent in both girls and boys, with the latter being affected more because they swam in the river more often than the girls did. During the FGD, it was reported that boys usually swim in the river when they accompany other members of the households that go to the river to collect water: 'The children swim in the river because they go there to fetch water' -(unemployed, male, 34 yrs).
Members of the community indicated that adults were also suffering from schistosomiasis but to a lesser extent compared with children.

Knowledge on schistosomiasis
Members of the community had poor knowledge on schistosomiasis transmission; they associated schistosomiasis with drinking dirty water: 'I know that if a child drinks contaminated water it is likely for them to get Bilharzia' -(preschool teacher, female, 40 yrs).
Their knowledge of the symptoms of schistosomiasis was generally poor although some parents were able to identify symptoms such as the presence of blood in the urine: 'They usually have blood in the urine when they urinate and that's how we know that the child is infected with schistosomiasis' -(Village headman, female, 65 yrs).
The teachers seemed to know very little about schistosomiasis claiming that no one had ever taught them about the disease. In contrast, they were very much aware of diarrhea.
When asked what preventative measures that they could take to prevent schistosomiasis, they said that they did not do anything because they had little knowledge about the disease: 'We don't know much about Bilharzia but we are more educated about Diarrhoea

…'
'We don't really do anything to prevent the disease because we are not really taught about it' -(preschool teacher, 45 yrs).
An immunization and deworming program for schools had been operational in the area for 2 years. It involved nurses going into the schools to immunize and deworm the children. The nurses indicated that when they got into the schools or the crèche they focused on immunization and deworming. They did not screen for schistosomiasis or educate the children about schistosomiasis. It was also noted by the village headman that since the inception of our research project through which children were screened for schistosomiasis, many people had become aware of the disease: 'TIBA (research project) has come and taught us how to prevent schistosomiasis, so we now have an understanding on how people get schistosomiasis' -(Village headman, male, 55 yrs).

DISCUSSION
We found that the community did not have access to reliable safe water sources and that existing safe water sources were often not functional for prolonged periods. This resulted in community members collecting water from unprotected water sources which were usually contaminated. A study conducted in Uganda reported that consumption of raw water from unprotected water sources was the primary route of reported that households that still practiced open defecation even when they had a toilet were dissatisfied with their toilet. However, in the current study, the majority of participants indicated that they were happy with the toilets provided and that they were using them. They only encountered problems when they were out in the field or at church because places of worship did not have toilets.
Feces in the environment pose a public health threat to the members of the community but particularly to children who may come into contact with feces at crèche if the teachers do not notice when a child has defecated in the environment.
Stakeholders such as the municipality can promote toilet ownership and use of sanitation facilities by including an education intervention to complement the infrastructure interventions.
This means that while they are providing infrastructure they should also target behavioral change and work closely with the communities to understand their needs as well as promote acceptance of the infrastructure.

RECOMMENDATIONS
Members of the community need to be taught about water safety and different low-cost water treatment methods that they can use. They also need to be aware that covering a dug well with branches does not make water safe for consumption. Strong collaborations are needed between the municipality, the DoH, and the community, for the provision of water sources and the use of these water sources to prevent diseases such as schistosomiasis. There is a need for a structured ongoing handwashing intervention that includes activities tailored for children. This can be built in the already existing system of using CCGs, but should also include teachers and parents in the handwashing promotion campaigns. Additionally, handwashing promotion needs to go beyond knowledge-based interventions to include behavior change and provision of infrastructure.
This study has also highlighted the importance of health education in the provision of sanitation facilities. Furthermore, the provision of sanitation facilities in rural settings should go beyond household provision but also include facilities being provided at places of worship as well as in the fields where men herd cattle and women cultivate their crops.

CONCLUSION
The findings from this research highlight the importance of collaboration among stakeholders in order to bring about the effective use of safe water sources, use of sanitation facilities, and promotion of handwashing. Access to facilities such as water, sanitation, and health care was a challenge and members of the community were not aware of the stakeholders who were responsible for the provision of these facilities. In addition, health care was deemed inaccessible due to distance. Knowledge on WASH-related diseases and schistosomiasis was found to be poor.

LIMITATIONS OF THE STUDY
This study was a cross-sectional study and, therefore, may not have been able to provide data for other times, for seasons.

CONSENT FOR PUBLICATION
Consent was granted for publication of any personal information for the purpose of this study.

COMPETING INTEREST
We have no conflicts of interest to disclose.

AUTHOR CONTRIBUTIONS
Chanelle Mulopo conceived and designed this study, took part in the data collection process, developed the data collection tool, performed the analysis, and wrote all the first drafts of the paper. Prof. Moses Chimbari supervised the project and reviewed several drafts of the manuscript.

DATA AVAILABILITY STATEMENT
All relevant data are available from an online repository or repositories.