Determinants of safe water handling at the household level in an urban informal settlement in Kampala City, Uganda Open Access

Safe water is essential for most household (HH) purposes, including drinking, food preparation and personal hygiene, and is a gateway to good health, social equity and human dignity (WHO 2013). The World Health Organization (WHO) considers safe water handling as the practices that are performed to ensure that drinking water is free from physical, chemical and microbial contamination right from the time of collection at the source to consumption within the HH (Mugumya et al. 2020). Despite global efforts to ensure universal access to safe water, over 2 billion people, especially from low- and middle-income countries (LMIC), still obtain drinking water from sources contaminated with faeces, with 144 million entirely depending on surface water for drinking water needs (UNICEF 2019). Lack of access to safe water increases the risk of waterborne diseases, including diarrhoea, which claims over 800,000 children's lives annually (Mills & Cumming 2016). Efforts aimed at improving the status of water, sanitation and hygiene (WASH) have the potential to prevent approximately 9.1% of the global disease burden and 6.3% of all deaths (Prüss-Üstün et al. 2008). Lack of access to safe water is high in Sub-Saharan Africa compared with other regions of the world (Szopińska et al. 2024). The major challenges of safe water handling have mainly been attributed to the fact that most interventions to improve water quality are usually directed at controlling hazards at the source and along distribution systems while ignoring risks associated with contamination at the point-of-use or HHs (UNICEF 2008). Several other points of contamination have been given less focus. For example, faecal contamination has been reported to be low at the water source but increasingly deteriorates throughout storage, handling and treatment within the HH (Satapathy 2014). In Ugandan slum communities, water supply is not only inadequate, but the available water sources are usually also contaminated, thus necessitating safe water handling to prevent water-related diseases. Urban populations in Uganda continue to face safe water-related challenges even when there are government entities tasked with providing safe water (Dickson-Gomez et al. 2023). It is estimated that only 77% of the urban population in Uganda has access to safe drinking water, and piped water supply from government-owned National Water and Sewerage Corporation (NWSC) stands at 83.7% coverage. Access to safely managed water (available on premises) stands at 20%, and 515 zones in urban areas have access to an improved water source (MWE 2018). Although the majority of HHs in Kampala urban informal settlements use treated and piped water supply from NWSC, diarrhoeal disease outbreaks attributed to the consumption of contaminated drinking water have persisted which suggests other points of contamination (Kabwama et al. 2017). A recent study in Kasubi Parish – an informal settlement on the outskirts of Kampala City – indicated that only a third (32%) of HHs maintained safe water handling practices (Ssemugabo et al. 2019). This evidence is suggestive of several unaddressed points of water contamination that may be contributing to the burden of unsafe water in this area. Perhaps this may be explainable by the water handling practices and factors within individual HHs or related to individuals. It was anticipated that water handling practices could be poor and possibly influenced by individual, technological and environmental factors differently at the HH level. This study aimed to investigate the safe water handling practices at the HH level in Kasubi Parish in Kampala City and the determinants of safe water handling in this informal settlement.

We used a cross-sectional study design with quantitative data collection techniques to obtain data from study participants.

This study was carried out in Kasubi Parish, a predominantly informal settlement in Lubaga Division, Kampala City in central Uganda, approximately 5.5 km from the city centre. Kasubi Parish is one of the parishes that form Lubaga Division; one of the six divisions of Kampala City. Kasubi Parish had a population projection of 456,000 people by 2024 (Uganda Bureau of Statistics 2017) in 12 zones, and is predominantly a peri-urban informal settlement.

This comprised HH members aged 18 years and above residing in Kasubi Parish, Kampala City.

We included registered adult HH members of Kasubi, responsible for day-to-day HH drinking water handling, and who had stayed in the HH for at least 3 months. This population included: home helps, youths, housewives, husbands and members of single-person HHs. HH members who were not actively engaged in key HH water handling decisions (collection, treatment and storage), and people who had not been residents of Kasubi Parish for the previous 3 months at the time of data collection were excluded. One eligible person per HH was interviewed.

The outcome variable in this study was safe water handling, which was dichotomized as good or poor safe water handling based on Bloom's criteria from the sum of eight dichotomized practices. The explanatory variables included socio-demographic characteristics of the respondents; individual factors included knowledge, perceptions and technological factors.

The sample size was calculated using the standard formula for sample size determination for proportions (Kish 1965). Since there was limited published literature on the proportion of HHs that practiced safe water handling specifically for Kasubi Parish, we adopted a 50% hypothetical proportion of HHs that practice safe water handling. Considering the maximum variation between the two dichotomous groups of good and poor safe water handlers, a 5% precision and 95% level of confidence were used. Based on the formula and adjustment for 10% non-response, a final sample size of 424 HHs was estimated. Proportionate to size sampling was considered to estimate the number of HHs to be selected from each of the selected zones (Supplementary Table S1).

We employed a multistage sampling procedure for this study. First, we randomly selected six zones from a sampling frame of 12 zones. Next, proportionate sampling was used to estimate the number of HHs to be sampled in each zone. Systematic random sampling was then employed to select the HHs for the interview in each zone (Table 1). A line listing of HHs was done with the help of the Kasubi Local Council (LC I) or the village health team (VHT) in each zone. A sampling interval of 10 was employed between one HH and the next with the aid of systematic sampler software. The first HH was sampled randomly, but subsequent HHs were selected by skipping the number of HHs equivalent to the sampling interval calculated. In each HH, one eligible person was interviewed, preferably the HH head or spouse, but in any case, the person concerned with safe water handling. In case of denial of access or failure to find respondents at home, the immediate next HH was considered. Only HH members of each HH aged 18 years and above were interviewed. The study team visited each HH once.

We asked the respondents about the following: Demographic characteristics, current knowledge on safe water handling, perception towards safe water handling and water handling practices. We generated additive scores for water handling practices using Bloom's criteria (Voss 2024) to determine the overall water handling practice level and treated this as a dichotomous outcome of either good or poor safe water handling.

The semi-structured questionnaire used in this study was designed by the researchers with adaptation of a section on measurement of safe water handling and modified to suit the context in the Kasubi Parish (Ssemugabo et al. 2019; Mugumya et al. 2020). The questionnaire included questions on respondents' demographics, current knowledge on safe water handling, perception towards safe water handling and water handling practices. Data were collected by trained research assistants who had prior experience of conducting face-to-face survey interviews. Data were captured using an electronic questionnaire managed by Microsoft Forms. Interviews were conducted in the local language, ‘Luganda’, that is used predominantly in the Central region. Interviews lasted approximately 20 min.

Participants' characteristics were summarized using frequencies and percentages for categorical variables plus mean and standard deviations for continuous variables (Oppel et al. 2017). Knowledge and perception towards safe water handling were presented using proportions and their 95% confidence intervals (CIs).

We generated scores from the eight safe water handling practices, namely, cleanliness of the water collection container; water collection or transport container covered or provided with a suitable lid; water storage container lidded or covered; storage container different from the collection container; safe method of accessing the drinking water (using separate cup to scoop water; tilting storage container or using an attached tap or spigot); area around the storage container kept clean and where possible water is stored in an elevated position at least 40 cm off ground in a clean environment away from animals, solid waste, excreta, dampness, dust and children; normally washes hands before handling drinking water; and collected water was treated before drinking. An additive score from these was obtained and dichotomized based on Bloom's classification. Accordingly, HHs whose score was 80% of the maximum possible score or higher were regarded as having good safe water handling practice. We used a modified Poisson model to assess the association between safe water handling and various respondents' characteristics. For all multivariate analyses, only covariates with a p-value of ≤0.2 at bivariate analysis were considered for the multivariate model. Factors were considered significant in the multivariable model if the p-value was ≤0.05. Data were analysed in Stata v15.

We sought ethical clearance from Uganda Martyrs University and administrative clearance from Kampala Capital City Authority (KCCA) − Directorate of Public Health and Environment, and the Kasubi Local Council leadership prior to the study. Before data collection, written and informed verbal consent was obtained from each participant. Participation was strictly voluntary with free withdrawal at any stage of the study. Confidentiality of the information, privacy, respect, non-coercion and respect for participants' autonomy were accorded to study participants. Questionnaires were anonymous to avoid backtracking the safe water handling practices to specific individuals.

The data collection tool was tested among 10 respondents outside the study area in Kawempe division to ensure validity and reliability of the study questions, as well as social and cultural acceptability of the questions that were asked. The data collection tools were translated into Luganda and back translated to English, which is a widely spoken language among people in central Uganda in addition to English.

Respondents from 426 HHs were interviewed. Most respondents, 86.2% (367/400), were females, and 56.1% (239/426) were married. The mean age of respondents was 31.6 (SD = 12.2). About half of the respondents, 50.9% (217/426), had attained at least secondary level education, while 5.1% had no formal education at all. More than half, 56.9% (242/426), of participants had stayed in Kasubi Parish for at least 5 years, with a mean length of stay of 8.6 years (SD = 10.1). In terms of employment, 46.2% (197/426) of respondents were either self-employed or owned a business, while 41.6% (177/426) were unemployed. The majority, 68.8% (293/426), of housing was of multiple tenement type (Table 1).

More than half of the respondents, 255/426 (55.2%), mentioned their primary source of water was a public tap stand. For most HHs, 298/426 (70.0%), the water source was located at a distance of less than 100 m. About half of the respondents, 128 (49.2%), estimated their round-trip time for water collection to be between 5 and 15 min. Main containers for collecting water were open jerrycans (84.0%, 358/426); most participants reported that their containers were not cracked (90.3%) and were narrow-necked open (82.0%) (Table 2).

Overall, 31.5% of the HHs practised safe water handling based on Bloom's cut-off of 80%. For the six parameters considered and scored, respondents reported the following: water collection container was clean (59.3%), transportation container provided had no suitable lid or cover (81.5%), storage container covered or lidded (69.0%), storage container different from collection container (98.8%), method mainly used to draw drinking water was tilt and pour directly (91.1%) and area around storage area clean (89.2%).

The majority of the participants also reported that the structural condition of their water storage containers was intact (96.0%), clean (93.0%), with a main storage capacity of 3–9 litres (71.4%), and were frequently cleaned before every refill (73.2%). Most participants normally washed their hands before handling drinking water (59.2%), the majority of HHs treated their water before drinking (97.6%) and supplied piped water was perceived to be clean (80.5%) (Table 2).

‘Our study established that; semi-detached type of house (adjusted Prevalence Ratio, aPR = 2.0, 95% CI 1.05–3.80, p = 0.033), round trip time for water collection being 16–40 minutes (aPR = 2.15, 95% CI 1.07–4.34, p = 0.032), perception that water received is considered unclean (aPR = 1.56, 95% CI 1.01–2.43, p = 0.046) and size of storage container >20 litres (aPR = 3.56, 95% CI 1.25–10.14, p = 0.018) were associated with good safe water handling’. On the other hand, detached houses (aPR = 0.38, 95% CI 0.18–0.82, p = 0.014) were associated with poor safe water handling practices (Table 3).

The present study aimed to identify the water handling practices and determinants of safe water handling in an urban informal settlement among HHs. Our study showed that suboptimal safe water handling among HHs in Kasubi Parish was at only 31.5%. The observed safe water handling levels are below the WHO's expected standards of universal access to safe water. Most participants scored below expected levels (Table 2). This finding highlights gaps in the safe water chain, right from the water source to the point of consumption at the HH. Lack of safe water handling could lead to food and water contamination, which has been directly linked to high incidences of preventable waterborne disease (Kabwama et al. 2017). Problems arising from failure to practice safe water handling have been observed to be even higher in informal and crowded settlements where sanitation facilities such as toilet facilities are often inadequate or lacking (Iqrar & Musavi 2023; Kumar & Singh 2023). The observed levels of safe water handling in the current study are comparable to earlier findings in Kampala City (Dickson-Gomez et al. 2023; Tumwebaze et al. 2023) and in Mbarara City in western Uganda (Abaasa et al. 2024).

Our study established that the majority of residents who take care of their HH's water needs were female. This is perhaps attributable to their availability in the homesteads and the gender-specific prescribed roles in society, consistent with findings from slums in Ethiopia (Joshi et al. 2013). In addition, a large proportion of the population is literate up to secondary level, suggesting a higher proportion of the community who can understand public health messages when given information. Studies have previously linked the community level of education to the uptake of health-related messages (Jatho et al. 2020). Therefore, having a community that is literate to a higher level could be exploited by health promotion interventions through the use of digital technology and mass media to pass on health education messages, since most people are able to read and write. The fact that most of the respondents had stayed in Kasubi for several years translates into familiarity with what happens in their area in terms of having options for safe water sources. However, most houses are of a multiple tenement type common among the low socio-economic class. Slums are known to be of heterogeneous nature in many aspects, which come with several hygiene challenges (Ezeh et al. 2017). This housing status reduces their negotiating power for safe water handling due to shared facilities. Multiple tenant HH settings due to the number of people occupying a single dwelling may face significant challenges in maintaining hygiene, which directly affects the safe water handling chain. Some previous studies have listed challenges related to multiple HH sharing sanitation facilities on sanitation and overall hygiene (Prasad 2013; Heijnen et al. 2015).

In terms of water sources, more than half of the respondents mentioned their primary source of water was public tap stands, mainly located a distance of less than 100 m, with an estimated round-trip time for water collection of 5–15 min. The availability of public taps within an accessible distance for most of the HHs is suggestive that water is accessible for domestic use. However, studies have shown that this access is not sustainable due to challenges like changes in family income or seasonal changes, which may affect the ability to pay for water bills (Price et al. 2019). On the other hand, this study observed that most HH members use open jerrycans as their main container for collecting water. Although most participants reported that their containers were not cracked/good and were narrow-necked open, collecting water in an open jerrycan carries potential for contamination along the way from the water source to the house, which may result from contamination with dust or debris. Even with sophisticated technology of piped water supply systems, studies have shown evidence of water quality deterioration between the source and consumption phase due to contamination (Trevett et al. 2005; Lee, 2013).

Our study observed good practices in terms of water storage, except when participants were asked about hand washing before handling drinking water. Over half of the participants washed their hands before handling water. It is known that hand washing with soap and water is one of the basic interventions for preventing diseases, including diarrhoea (Ejemot et al. 2009; Hashi et al. 2017; Noguchi et al. 2021). As a consequence of low hand washing practices, this community, especially children under 5 years, remains at risk of disease resulting from consuming water that has been contaminated by unwashed hands. Additionally, the poor hand washing practices observed, the perception by the majority of HH that supplied piped water is clean, may be a potential setback to personal efforts that promote safe water handling and an indication of a knowledge gap. Although piped water may be clean at the point of production, contamination has been observed to occur at any point along the water supply process (Lee 2013; Shields et al. 2015). The possibility of consuming contaminated water thought to be safe remains high in this community, with potential impact on personal health. Respondents generally reported good practices in terms of the structural condition of their water storage containers being intact, cleanliness, capacity of 3–9 litres in storage, frequency of cleaning storage containers before every refill and treatment of their water before drinking. These practices highlight knowledge of participants on water storage as part of the safe water chain, as observed previously in Kampala City (Ssemugabo et al. 2019).

Other observations from our study were a lack of clean water collection containers: the transportation container provided had no suitable lid and there was a lack of lids on storage containers. All these factors increase the risk of water contamination across different points along the water chain. For example, contamination by rodents can occur during storage in the house. This study observed that, in most cases, the storage container was different from the collection container, the method used to draw drinking water was mainly tilt and pour directly, and the area around the storage area was clean in most cases. For most HHs in Kasubi Parish, their commonest water sources were improved with adequate access (distance to these sources) or time to these facilities. This is an indication of wider coverage of piped water through NWSC and easily accessible to HHs within accessible distances consistent with previous studies in Kampala (Ssemugabo et al. 2019; Tumwebaze et al. 2023).

Among the determinants of safe water handling, this study found that residing in a semi-detached type of house was associated with safe water handling practices. Most of the semi-detached houses are connected to a main house with better services, such as access to water and better sanitary facilities within the vicinity. This may justify their better compliance with safe water handling practices. However, living in a detached house was associated with poor safe water handling practices. In slum settings, living in a detached house most probably predisposes occupants to limited access to water sources and gives them limited options for sharing sanitary facilities in case their own facilities lack any. The current findings are consistent with previous observations in Kampala, which indicated poor latrine standards and poor use in Kampala slums resulting from shared sanitation facilities, leading to compromised water safety (Kwiringira et al. 2014).

Our study found that respondents whose round-trip time for water collection was 16–40 min were twice as likely to practice safe water handling compared with those whose round-trip time was shorter. This may be attributed to the fact that the nearby water sources could be the type that lack minimum water standards, such as open wells, compared with relatively distant community piped tap water sources that may not be affordable to everyone. Due to excessive queuing at public taps, some users have been observed resorting to nearby and convenient yet unsafe water sources (Trevett et al. 2005). Although it is highly recommended that water sources should be within minimal distances, the source of water being safe is highly recommended (Zerbo et al. 2021).

The perception that water received is considered unclean was associated with better safe water handling practices. This means that respondents who perceived an inherent risk in the water that they received made a significant effort to ensure that their water is safe at all points of the water supply chain. The current findings are consistent with study findings in Kampala and Mbarara Cities (Maniragaba et al. 2023; Abaasa et al. 2024). Although it is expected that smaller water storage containers would improve water safety due to frequency of replenishing the water, emptying and cleaning compared with storage tanks or vessels that are hard to clean (Manga et al. 2021), our study established that the size of water storage container >20 litres was three-fold associated with safe water handling compared with smaller containers. This is perhaps attributable to the affordability of large storage containers like sizable domestic plastic tanks commonly used for water storage that are affordable to relatively high socio-economic classes with better living standards. Considering the socio-economic setting in slums, it is likely that individuals whose economic standards are higher are likely to be the ones who live in a clean environment with better WASH practices. The current findings differ from a study in South Africa, which established no difference in water safety between traditional plastic containers and the improved Centers for Disease Control and Prevention (CDC) safe water storage containers, highlighting similar challenges in safe water handling during storage (Potgieter et al. 2009).

Our study included participants from different zones in Kasubi Parish, the largest urban informal settlement in Kampala City. We used trained and experienced data collectors who speak the local languages used in the central city of Kampala to reduce the likelihood of undesirable responses. We also interviewed participants individually and privately and maintained their responses anonymously. We believe that the findings can be generalized to other urban informal settlements in Kampala City. However, one limitation of this study is that safe water handling metrics were determined using self-reported responses that could have contributed to overestimation of positive responses resulting from social desirability bias. Nevertheless, this study highlights some key findings, which are of public health importance.

Our study found suboptimal safe water handling practices among the residents of Kasubi Parish. Determinants of safe water handling were the perception about the cleanliness of water, proximity to water source and type of homestead people live in. There is a need to increase the level of awareness about the importance of the safe water handling through sensitization of slum dwellers in Kasubi Parish, increasing access to safe water sources and empowering communities to improve their housing status.

We acknowledge KCCA Department of Public Health for their support towards the execution of this study. We thank all the leaders of Kasubi Parish at various levels for facilitating a smooth community entry process. Finally, we thank all members of HHs where this study was conducted. We thank the community leaders who guided the research assistants during the HH visits and the respondents for sparing time to respond to the study.

We obtained clearance from Uganda Martyrs University Faculty of Health Sciences and administrative clearance from KCCA to conduct the study. Finally, we obtained written informed consent from all study respondents before their participation. We obtained informed consent in English or in Luganda, the indigenous language spoken in central Uganda. For participants who could not read and write, we obtained informed consent in the presence of an independent witness who could read and write.

S.S.E., W.K., and A.K. conceptualized and designed the study. S.S.E. and W.K. obtained data. W.K., S.T.W., and A.K. analysed and interpreted data. S.S.E. and W.K. drafted the manuscript. S.S.E., W.K., S.T.W., and A.K. performed critical revisions. All authors read and approved of the final manuscript.

All relevant data are included in the paper or its Supplementary Information.

The authors declare there is no conflict.