Qualitative exploration of local knowledge, attitudes and use of Moringa oleifera seeds for home-based water puri ﬁ cation and diarrhoea prevention in Niger State, Nigeria

This qualitative study explored stakeholders ’ knowledge of diarrhoea; their attitude to and perceptions of the use of Moringa oleifera seeds for home-based water treatment (HWT) and diarrhoea prevention in a low resource setting. Data were collected using semi-structured interviews with 13 respondents comprising rural community dwellers, health implementers and policy makers, and analysed using thematic analysis. Most rural community members interviewed had no knowledge of speci ﬁ c causes of diarrhoea or of the link between unsafe water and diarrhoeal diseases. They also practised inadequate or no methods of HWT. Although respondents were unaware of the use of M. oleifera seeds for HWT, community members and policymakers were keen on adopting it after observing demonstrations of its use for this purpose. Reasons for this behaviour change included easy accessibility to and a familiarity with M. oleifera for other uses. These results highlight the importance of providing health education on diarrhoea and water safety to motivate and empower community members to adopt healthy HWT behaviours. The use of M. oleifera seeds for HWT should be taught and advocated because it is a cheap, ef ﬁ cient and acceptable method of water puri ﬁ cation for stakeholders.


INTRODUCTION
Backgrounddiarrhoea and home-based water treatment Diarrhoea is the second leading cause of childhood mortality worldwide, responsible for >500,000 childhood deaths annually (WHO ). Predisposing factors to diarrhoea and other water-related illness include a lack of access to water supply and sanitation services, and poor personal and environmental hygiene (WHO ).  (Nkurunziza et al. ). The conventional recommended dose is one seed per litre for slightly contaminated water and two seeds per litre for heavily contaminated water (Mall & Tripathi ). Despite this increasing body of knowledge attesting to the efficacy and potential benefits of using M. oleifera for point-ofuse water purification, empirical documentation of its use for HWT and diarrhoea prevention is scarce in Nigeria.

The study
This study aimed at exploring the understanding and attitudes of local stakeholders on the use of M. oleifera seeds for home-based water purification and diarrhoea prevention in Niger State, one of the states with a high diarrhoea burden and low HWT practice in Nigeria (NPC and ICF ). The specific objectives were to explore the following:

Study design
To elicit data-rich information about local knowledge, perceptions, and attitudes of a range of stakeholders regarding the use of M. oleifera for HWT, we adopted a qualitative design for the study. The aim of the study was to ask 'what' and 'why' questions, which are often best answered through qualitative methods (Creswell ).
This cross-sectional exploratory research thus focused on an unexplored aspect of previous research, i.e. people's perceptions and practices of the use of M. oleifera seeds for home-based water purification.

Study setting
The study was conducted in Niger State, north-central Interviews were conducted in Hausa, in which researchers have some degree of fluency.

Sharuwadna in Shiroro
LGA -Its inhabitants are of the Gbagyi ethnic group and mainly speak Gbagyi language, in which interviews were conducted.

Participant recruitment
Altogether 13 stakeholderseight community members, two health implementers and three policy makerswere recruited as respondents and interviewed. Community members were recruited because they are caregivers to children under five years of age who are hardest hit by diarrhoea morbidity and mortality and because their disease prevention/health-seeking behaviour determines the incidence and severity of diarrhoea episodes. They are also responsible for HWT practices, if any. Health implementers serve as health promotion officers in the selected communities.
They are often the first and sometimes the only access the community members have to health services. They provide health education, including water safety and sanitation information to the clients. Policy makers were senior level staff of the NSPHCDA of the State Ministry of Health, whose responsibility it is to formulate and oversee implementation of policies regarding health promotion, which are then communicated to the community members by the implementers.
Of the 13 stakeholders, eight were female. We purposively selected a range of stakeholders as we were interested in the variety and diversity of information that will help achieve our study objectives (Creswell ). Convenience sampling was used to recruit community members who routinely accessed services at the HTR health post as households are scattered over a wide expanse of difficult terrain.

Interviews and data collection
Data were collected using a semi-structured interview guide, after obtaining informed verbal and/or written consent from participants. Information sheets and consent forms were given to respondents and translated by interpreters for uneducated community members. Thumb printing was accepted as a means of consent for those unable to sign their names, as is the accepted practice in Nigeria. Respondents were given up to 24 hours to decide whether they wanted to participate in the study.
Due to cultural considerations, interviews with community members were conducted either at the health post or a place of choice in the community that was out of hearing distance from other community members. On-spot translation was done, with all interviews audio-recorded.
The health implementers' and policy makers' interviews were conducted in English, privately, in their various offices.
Following the lack of familiarity of community members with using M. oleifera seeds for water purification, the researchers gave a demonstration in Sharuwadna community. Three identical transparent plastic bottles (A, B and C) were filled with water (see Figure 1(a) and 1(b)). In

Difficulty in obtaining water
Residents of the two communities primarily depend on polluted surface water for their water supply, i.e. the River Kaduna for Takalafiya Fulani community, and the Sharuwadna river for Sharuwadna community. Both rivers are located 25-30 km from the respective communities and often dry up during the dry season months of October to June each year. Thus, the water becomes dirtier and even harder to get in the dry season, as attested to thus: 'When the river dries up, community members go to the riverbed to dig until we get water. When we get the water, the women will form a queue to fetch, one after the other' -Community member, Sharuwadna.
Although the rivers are the primary sources of water for the two communities, it emerged during interviews that community members in Sharuwadna are forced to purchase water from a borehole in Shakwatu, a nearby semi-urban community. This secondary water source is regarded as unimproved for this community as it is fraught with challenges, i.e. the water is purchased at a price that is dependent on the availability of electricity supply, which is often irregular in the area: 'We buy a gallon for N50 when there is electricity [to power the borehole] and when there is no electricity, we buy for N70 … But the transformer that services the area is spoilt now [meaning water is costlier]' -Community member, Sharuwadna.

Knowledge of the link between unsafe water and diarrhoea
Six of eight community respondents were knowledgeable of the link between unsafe water and ill-health, citing stomach pain or diarrhoea as consequences of consuming dirty water, although they could not mention the risk factors for contracting diarrhoea (e.g. lack of access to safe water, poor personal and environmental hygiene). The following extract supports these points of view: 'Honestly, if we drink the water like that [without using any purification method], it will definitely cause illness' -Community member, Takalafiya Fulani.
Of the remaining two community members who thought dirty water neither caused ill-health nor diarrhoea, one respondent thought drinking unsafe water caused stomach pain but not diarrhoea.
'No, I don't think anything will happen. We drink this water, nothing happens to us' -Community member, Takalafiya Fulani. Some community members also linked the onset of the rainy season with an increase in the frequency of diarrhoea in the community, although they did not understand the reasons why. This was later explained by policy makers and health implementers as being due to increased contamination of water sources with faecal matter deposited close to water sources, which is more easily swept into water sources by the rains. This is a direct consequence of open defecation due to lack of sanitation facilities.

Knowledge and practice of HWT methods
The majority of the respondents knew at least one method of water purification. The most popular method cited was sedimentation and flocculation using alum (Aluminum sulphate). Unfortunately, knowledge of water purification methods did not translate to widespread or consistent practice for several reasons, chief of which were; the cost of purchasing Alum, the time needed to purify the water and the energy costs, as shown by the following quotes:  purify the water to the extent that is required. And if the 'The seeds, I know that they are used […] Yes, and they also use some of them, use it like tablets. […] They peel it, after… they also say it's medicinal, and they swallow it or chew it' -Health implementer.
Regarding the seeds, six of the eight community members mentioned that the seeds were only good for planting purposes; the remaining two community members, the health implementers, and a policy maker and said that any excess seeds that were not planted were either thrown away or sold in the market to make money.
None of the 13 respondents had heard of their use for water purification prior to this study. However, following the demonstration, all respondents present wanted to try it for themselves, pledging to adopt and promote the method among their friends. A remark typical of this enthusiasm read: 'I would like it very much. If the water becomes clear for me to see, I would be very happy to drink it and would continue using it' -Community member, Takalafiya Fulani.
The willingness to adopt M. oleifera for HWT may be attributed to: (i) familiarity with, and already established use of Zogale among this population, (ii) easy access to the seeds, and (iii) perceived low energy costs of using the method.

POLICY AND IMPLEMENTATION
All three policy makers acknowledged that though water safety and HWT were covered during sporadic health education campaigns, there was no formal policy for the population level use of M. oleifera seeds for HWT in Niger State. They also reported that although there was no fixed prevention before this study. Despite this, they demonstrated enthusiasm and willingness to adopt the method, possibly due to ease of access, low financial burden, low energy requirements and local acceptance of the plant in Niger State. Importantly, community respondents were planning to plant more M. oleifera trees to ensure increased accessibility to seeds. Policy makers expressed support for the idea of promoting M. oleifera seeds for HWT in the communities on the provision of scientific evidence that it works. They also raised the prospect of further research into its use for both for HWT and for remediation of lead-contaminated water, which is a problem in some parts of the states and is one of the documented properties of M. oleifera seeds.

CONCLUSIONS
Although this research was primarily directed at HWT and diarrhoea prevention and the potential for M. oleifera seeds as a viable, cost effective and energy-saving alternative to other known HWT methods, this qualitative study highlights the importance of providing accurate information and consistent health education to empower people to adopt healthy HWT behaviours.

LIMITATIONS
The following limitations were observed by the researchers during the study: 1. Urban dwellers were excluded from this exploratory study based on the assumption that they had access to improved sources of water supply. However, interaction with staff of the NSPHCDA revealed that urban dwellers were equally interested in testing M. oleifera for HWT due to a perceived lack of trust in the quality of water obtained from seemingly improved sources. It may therefore be useful to include this demographic in future studies.
2. A small sample size of 13 people was used. Perhaps a larger sample size would have yielded more diverse results. However, this was balanced by interviewing across stakeholder groups of community members, health workers and policymakers.