Knowledge, Attitudes, Practices, and Determinants Towards Wastewater Management in Northwest Ethiopia: A Community-Based Cross-Sectional Study.

BACKGROUND: Globally, waste management has been a major public health problem. Public knowledge, attitudes, practices (KAP) and participation are key elements of any waste management program. In Ethiopia, however, the level of KAP and associated factors regarding wastewater management (WWM) at the household level are not well studied and understood. This study was, therefore, conducted to assess the knowledge, attitude, practice and associated factors of wastewater management (WWM) among the residents in Gondar town, Ethiopia.
METHODS: A community-based cross-sectional study was conducted during March and April, 2016. A total of 422 participants were selected using the systematic random sampling technique. A structured questionnaire was employed to collect data which were entered and analyzed using the Statistical Package for Social Science (SPSS) version 20. A multivariable binary logistic regression analysis was used to ascertain the significance of associations at <0.05 p-value and the adjusted odds ratio (AOR) with a 95% confidence interval (CI).
RESULTS: Among 422 study participants included, 63.5%, 43.4%, and 48.6% of them had good knowledge, attitudes, and self-reported practices regarding WWM, respectively. Knowledge of participants was significantly associated with house rent (AOR 1.12, 95% CI (1.22, 3.69), civil servant (AOR 5.47, 95% CI (1.87, 8.02), and positive attitudes (AOR 2.69, 95% CI (1.68, 4.30), while space availability (AOR 1.84, 95% CI (1.23, 2.75), and good knowledge (AOR 2.46, 95% CI (1.61, 3.77) were associated factors of attitudes. Moreover, good knowledge (AOR 1.32, 95% CI (1.87, 2.02), and positive attitudes (AOR 1.03, 95% CI (1.01, 2.34) were significantly associated factors of self-reported practices.
CONCLUSION: Limited knowledge, attitudes and practices were seen among study population. A great emphasis on improvement of knowledge, attitudes and practices towards WWM is necessary. Moreover, it would be better to qualitatively explore variables which explain the qualitative attributes of the community, like community Attitudes and knowledge.

Introduction

Waste management includes all activities related to the handling, treatment, disposal or recycling of waste materials.1,2 Alongside the WHO and World Bank reports, several studies have reported that the management of waste has been a major challenge globally.1,3–7 Aside from sanitation, improper household wastewater management (WWM) may have health, environmental and economic problems.8–10 The US report, for example, traces 22 diseases to improper WWM.11 Researchers also reported that inadequate WWM has contributed to the degradation of air, soil, water, insect and vermin spread, and to the loss of aesthetic beauty.7,12 Furthermore, the economic burden of improper WWM in Funafuti costs nearly half million dollars per year13 and Tonga spent 5.6 million TOP annually.14

In Ethiopia, it is estimated that around 70–80% of the disease burden are preventable by improving environmental sanitation.15,16 Conversely, nearly half of the inhabitants handle household liquid waste by openly discharging it into any accessible public properties, such as streets, drainage lines and nearby open spaces.17,18

Public awareness and participation is a key element of any waste management program.19 Similarly, researchers have reported that knowledge of adverse health effects of waste is correlated with the good practice of household waste management.20,21 Although many factors could be attributed to inadequate WWM, it is essential to emphasize the role of the community, their attitudes, practices, and interactions.20,22

However, the level of KAP and the factors contributing to WWM at household level are not well studied and understood in Ethiopia. The current study is solely concerned with Wastewater management. Therefore, this study aimed to assess the level of KAP and associated factors towards WWM among residents in Gondar town, Ethiopia.

Methods

Study Design and Setting

A community-based cross-sectional study was conducted in Gondar town from March to April 2016. The town is located in the Amhara region, at a distance of 747 Km from Addis Ababa, the capital city of Ethiopia. Gondar had 12 sub-cities and 12 urban and 10 rural kebeles, with an estimated 360,600 population and 3200/km2 of surface area.23 Despite the city’s numerous tourist attractions, the wastewater management capacity is limited to 24m3/day, but the town’s production capacity exceeds 32,411m3/day.24 At the time of this study, 51,304 households were registered.25 Map of the study area (Figure 1).

Figure 1

Map of the study area 2016.

Source and Study Population

All households in the town of Gondar were the source population, while participants selected from each households using a systematic sampling technique were the study population. Residents living in selected households as heads or any other household members ≥18 years of age were included in the study and those who were unable to communicate easily during data collection were excluded.

Sample Size Determination

The single population proportion formula26,27 was used to determine the sample size with the following assumptions: p (proportion of KAP assumed to be 50% since there was no previous study at the time of this study), d (margin of error = 5%) and Zα/2 (standard score value for 95% confidence level = 1.96), the minimum sample size (n) was 422 having considered 10% non-response rate.

Data Collection Instrument and Procedures

The data were collected using a pre-tested, structured interviewer-administered questionnaire that investigators developed after reviewing numerous literature.25,28–31 The questionnaire consisted of four separate components. The first component of the questionnaire covered demographic information that included age, sex, and marital status, education level, occupation, and etc. The second part assessed general knowledge about WWM (Yes/No). The third part assessed the attitudes of the respondents towards WWM; and the final part covered the household’s practice towards WWM. Five point Likert scale was used to assess attitude (5=strongly agree) and (1=strongly disagree) and practice was assessed by different category of questions related to WWM. Internal consistency and reliability were examined using Cronbach’s alpha which were greater than 0.72. The full survey questionnaire is provided in the .

A systematic sampling technique was used to select participants from the study population. Lottery method was used to select a respondent whenever more than one eligible respondent found in the selected household. The data collectors visited all of the systematically selected households and interviewed the heads or any other members of the households aged ≥18 years.

Data Quality Control

All questionnaires were prepared in English and then translated into Amharic (local language) which were used for data collection and re-translated back to English. We recruited five final year Environmental Health Science students for data collection and two Environmental Health lecturers as supervisors. One day training was offered for data collectors and supervisors on topics related to research objectives, clarity of questions, the confidentiality of information and consent in the study. The questionnaires were pre-tested on 30 households that were not included in the final analysis and the relevant modifications were made before the actual data collection was conducted.

Operational definitions: Knowledge:-We calculated the mean score of the 12 items of knowledge questions and categorized as good (if participants scored ≥ mean score of the correctly answered questions) or poor (if participants scored

Data Management and Analysis

The data were checked for completeness and entered into EPI info version 7 and exported to SPSS version 20 for analysis. Using a binary logistic regression analysis, we fitted each predictor variable in to a bivariate logistic regression model separately to explore associations with the dependent variable (knowledge, attitudes, and practices). Explanatory variables with p-value < 0.2 in the bivariate analysis were exported to the multivariable logistic regression model using backward variable selection method. Hosmer and Lemeshow goodness-of-fit test was used to check the model fitness (P>0.05). A multi co-linearity assumption was checked using Variance Inflation Factor (VIF < 5). Odds ratios (OR) with 95% confidence intervals (CI) and p -value< 0.05 were applied to establish the significance of associations.

Results

Socio-Demographic Information

A total of 422 of the 422 sampled participants responded fully to the interview, yielding a 100% response rate. Out of the respondents, (47.9%) were male with a mean age of 34.5 years and a standard deviation of ±4.11. The largest number of respondents, (28.4%) attended secondary school grade 9–12, (22.7%) attended religious schools and (22.5%) had technical or vocational trainings. Furthermore, almost more than half of the respondents (58.1%) had no space to construct wastewater disposal facilities (Table 1).

Table 1

Socio Demographic Characteristics of Study Participants to Assess Knowledge, Attitudes, and Self-Reported Practices and Associated Factors Towards Wastewater Management Among Residents in Gondar Town, Northwest Ethiopia, 2016

Variables (N=422)	Category	Number	Percent (%)
Sex
	Male	202	47.9
	Female	220	52.1
Age
	18–20	14	3.3
	21–29	135	32.0
	30–39	216	51.2
	> 40 years	57	13.5
Religion
	Orthodox	203	48.1
	Muslim	145	34.4
	Protestant	40	9.5
	Catholic	15	3.6
	Others	19	4.5
Educational status
	Cannot read and write	2	0.5
	Read only	5	1.2
	Religious schooling	96	22.7
	Read and write	26	6.2
	Primary education (1–8)	30	7.1
	Secondary (9–12)	120	28.4
	Technical and vocational training	96	22.7
	Higher education	48	11.4
Family size
	1–5	284	67.3
	Greater than 5	138	32.7
Occupation
	Student	40	9.5
	Unemployed	33	7.8
	Self employed	229	54.3
	Civil servant	90	21.3
	Retired	30	7.1
Income
	Less than 500 ETB/month	48	11.4
	501–1000 ETB/month	105	24.9
	Greater than 1000 ETB/month	269	63.7
Tenure
	Owner	302	71.6
	Renter	120	28.4
Space availability
	Have space	177	41.9
	Have no space	245	58.1
Marital status
	Single	93	22.0
	Married	279	66.1
	Divorced	20	4.7
	Widowed	30	7.1

Level of Knowledge, Attitudes, and Self-Reported Practices of Respondents Towards WWM

It was found that the mean knowledge score was 9.84 (S.D 1.29). Most of the respondents had good knowledge of WWM, 63.5%, 95% CI (59, 68). The mean attitudes along with the standard deviation was 12.52 (SD 3.16). Above half (56.6%) of study participants had poor attitudes with 95% CI (47.2, 58.3). The mean value of the self-reported practices together with the standard deviation was 8.45 (SD 2.31). Among the study population (51.4%), 95% CI (44, 54) had poor self-reported WWM practices.

Factors Associated with Participant’s Knowledge Level

Housing tenure, occupational status, and attitude were significantly associated with knowledge in the multivariable regression analysis. Accordingly, as compared with the participants who owned the house, the probability of a good level of knowledge among participants who rent the house was 1.12 times higher [AOR: 1.12; 95% CI (1.22, 3.69)]. The odds of good knowledge were 5.47 times higher [AOR: 5.47; 95% CI (1.87, 8.02)] among respondents who were civil servant than those who were retired by their occupational status. The probability of good knowledge was 2.69 times higher [AOR: 2.69; 95% CI: (1.68, 4.30)] among participants who had a good level of attitude towards WWM (Table 2).

Table 2

Factors Associated with Knowledge Level Among Residents in Gondar Town, Northwest Ethiopia, 2016

Variables (N=422)	Knowledge Level		COR (95% CI)	AOR (95% CI)	p-value
	Poor n (%)	Good n (%)
Age
Less than 20	5 (3.2%)	9 (3.4%)	1.51 (0.45, 5.06)	1.05 (0.47, 8.01)	0.092
21 to 29	56 (36.4%)	79 (29.5%)	1.18 (0.63, 2.21)	1.06 (0.75, 3.67)	0.923
30–39	67 (43.5%)	149 (55.6%)	1.87 (1.03, 3.38)	1.40 (1.02, 3.93)	0.082
Above 40	26 (16.9%)	31 (11.6%)	1	1
Marital status
Single	45 (29.2%)	48 (17.9%)	1	1
Married	84 (54.5%)	195 (72.8%)	2.18 (1.35, 3.52)	2.00 (1.09, 4.35)	0.091
Divorced	10 (6.5%)	10 (3.7%)	0.94 (0.36, 2.46)	1.44 (0.44, 4.74)	0.553
Widowed	15 (9.7%)	15 (5.6%)	0.94 (0.41, 2.14)	1.08 (0.37, 3.13)	0.892
Average monthly income (ETB)
≤500	24 (15.6%)	24 (9.0%)	1	1
501–1000	40 (26.0%)	65 (24.3%)	1.625 (0.82, 3.24)	2.20 (0.97, 5.00)	0.060
>1000	90 (58.4%)	179 (66.8%)	1.99 (1.07, 3.70)	2.21 (0.98, 4.97)	0.061
Housing tenure
Owner	117 (76.0%)	185 (69.0%)	1	1
Renter	37 (24.0%)	83 (31.0%)	1.42 (0.90, 2.23)	1.12 (1.22, 3.69)*	0.001
Space availability
Have space	55 (35.7%)	123 (45.9%)	1.53 (1.02, 2.30)	1.24 (0.75, 2.03)	0.403
Have no space	99 (64.3%)	145 (54.1%)	1	1
Occupation
Civil servant	24 (15.6%)	66 (24.6%)	6.42 (2.58, 15.94)	5.47 (1.87, 8.02)*	0.002
Self-employed	79 (51.3%)	150 (56.0%)	4.43 (1.94, 10.13)	3.16 (0.95, 7.99)	0.09
Unemployed	13 (8.4%)	20 (7.5%)	3.59 (1.26, 10.23)	3.20 (0.94, 10.96)	0.064
Student	17 (11.0%)	23 (8.6%)	3.157 (1.16, 8.59)	4.58 (1.32, 15.90)	0.061
Retired	21 (13.6%)	9 (3.4%)	1	1
Attitudes
Poor	109 (70.8%)	130 (48.5%)	1	1
Good	45(29.2%)	138 (51.5%)	2.57 (1.69, 3.92)	2.69 (1.68, 4.30)*	0.0001
Practices
Poor	87(56.5%)	130 (48.5%)	1	1
Good	67 (43.5%)	138 (51.5%)	1.38 (0.93, 2.05)	1.26 (0.81, 1.96)	0.301

Notes: *Significant in multivariate logistic regression analysis. Hosmer and Lemeshow test = 0.821 showed that the model fitted well.

Abbreviations: AOR, adjusted odds ratio; COR, crude odds ratios; ETB, Ethiopian Birr, n, number.

Factors Associated with Participant’s Attitudes Level

In the multivariable regression analysis space availability for disposal [(AOR: 1.84; 95% CI (1.23, 2.75)] and good knowledge [(AOR: 2.46; 95% CI (1.61, 3.77)] were significantly associated with good attitudes (Table 3).

Table 3

Factors Associated with Attitudes Among Residents in Gondar Town, Northwest Ethiopia, 2016

Variables (N=422)	Attitudes Level
	Poor n	Goodn	COR (95% CI) AOR (95% CI) p-value	COR (95% CI) AOR (95% CI) p-value	p-value AOR (95% CI) p-value
Marital status
Single	62	31	1	1
Married	148	131	1.77 (1.08, 2.89)	1.34 (1.71, 2.50)	0.062
Divorced	15	5	0.67 (0.22, 2.00)	0.71 (0.21, 2.38)	0.580
Widowed	14	16	2.29 (0.99, 5.28)	2.40 (0.91, 6.33)	0.077
Average monthly income in ETB
≤500	26	22	1.00 (0.54,1.86)	0.99 (0.51,1.82)	0.060
501–1000	67	38	0.67 (0.423,1.07)	0.36 (0.65,1.10)	0.063
>1000	146	123	1	1
Family size
1–5	173	110	1	1
> 5	66	73	1.74 (1.16, 2.62)	1.41 (1.91, 2.21)	0.07
House
Owner	164	138	1.40 (0.91, 2.16)	1.20 (0.71, 2.01)	0.501
Renter	75	45	1	1
Space availability
Have space	84	94	1.95 (1.32, 2.89)	1.84 (1.23, 2.75)*	0.0001
Have no space	155	89	1	1
Occupation
Civil servant	53	37	1.92 (0.77, 4.78)	0.95 (0.36, 2.53)	0.25
Self-employed	120	109	2.50 (1.07, 5.84)	1.66 (0.68, 4.04)	0.256
Unemployed	17	16	2.59 (0.90, 7.46)	1.91 (0.64, 5.71)	0.248
Student	27	13	1.32 (0.47, 3.77)	1.0 (0.34, 3.02)	0.978
Retired	22	8	1	1
Knowledge
Poor	109	45	1	1
Good	130	138	2.57 (1.69, 3.92)	2.46 (1.61, 3.77)*	0.00001
Practices
Poor	124	93	1	1
Good	115	90	1.04 (0.71, 1.53)	0.91 (0.60,1.38)	0.662

Notes: *Significant in multivariate logistic regression analysis. Hosmer and Lemeshow test = 0.941 showed that the model fitted well.

Abbreviations: AOR, adjusted odds ratio; COR, crude odds ratios; ETB, Ethiopian Birr; n, number.

Factors Associated with Participants Practices Level

Good knowledge [(AOR: 1.32, 95% CI: (1.87, 2.02)] and positive attitudes [(AOR: 1.03, 95% CI: (1.01, 2.34)] were significantly associated factors with self-reported practice (Table 4).

Table 4

Factors Associated with Self-Reported Practices Among the Residents in Gondar Town, Northwest Ethiopia, 2016

Variables (N=422)	Practices level
	Poor (n)	Good (n)	COR (95% CI)	AOR (95% CI)	p-value
Marital status
Single	49	44	1	1
Married	139	140	1.12 (0.70, 1.79)	1.10 (0.11, 1.52)	0.063
Divorced	15	5	0.37 (0.13, 1.11)	0.36 (0.11, 1.10)	0.076
Widowed	14	16	1.27 (0.56, 2.90)	1.22 (0.56, 2.93)	0.758
Family size
1–5	150	133	1	1
> 5	67	72	1.21 (0.81,1.82)	1.01 (0.65, 1.58)	0.961
Housing tenure
Owner	158	144	1	1
Renter	59	61	1.13 (0.74,1.73)	1.13 (0.73, 1.75)	0.677
Space availability
Have space	85	93	1.29 (0.88, 1.90)	1.19 (0.77,1.83)	0.444
Have no space	132	112	1	1
Knowledge
Poor	87	67	1	1
Good	130	138	1.38 (0.93, 2.05)	1.32 (1.87, 2.02)*	0.0001
Occupation/job
Civil servant	42	48	1.97 (0.84, 4.62)	1.96 (1.01, 4.59)	0.480
Self-employed	118	111	1.63 (0.74, 3.57)	1.57 (0.72, 3.50)	0.121
Unemployed	15	18	2.07 (0.76, 5.69)	1.97 (0.70, 5.50)	0.253
Student	23	17	1.28 (0.48, 3. 37)	1.23 (0.46, 3.29)	0.198
Retired	19	11	1	1
Attitudes
Poor	124	115	1	1
Good	93	90	1.04 (0.71, 1.53)	1.03 (1.01, 2.34)*	0.001

Notes: *Significant in multivariate logistic regression analysis. Hosmer and Lemeshow test = 0.673 showed that the model fitted well.

Abbreviations: AOR, adjusted odds ratio; COR, crude odds ratios, n, number.

Discussion

About 63.5% of those interviewed had good WWM knowledge. This result was lower than the study in other parts of Ethiopia (81.8%).32 This difference might be due to the participants’ educational level, study time and period, sample size, and differences in the sanitation levels of the towns.

This study demonstrated that 43.4% had good attitudes to WWM. This result was lower than studies in Ethiopia (76.9%),32 Pakistan (95%),33 and India (93.8%).34 The disparity could be influenced by cultural differences and the way waste is managed in the towns, sample sizes, data collection methods and study periods.

The present study found that 51.4% of participants reported poor WWM practices. This finding was consistent with a study in Pakistan (52.0%).33 This could be due to comparable socio-economic status, developing countries could experience similar waste management practices.

In the current study, the ownership status of houses was linked to the level of knowledge. Indonesian report found a similar outcome.35 One possible explanation could be that people living in their own homes could offer concern and try to correct the waste they produce from their own homes and handle it properly.

We also found a significant association of participants’ attitudes and levels of knowledge. Another study supported this.33 Persons with a positive attitude about human health and environmental consequences as a result of proper waste management can often handle waste from home and the nearby.

This study also showed that occupational status was associated with knowledge level of study participants. This was comparable to other findings.36,37 Community members employed by the government may usually have access to information on the variety of WWM laws and regulations available and are likely to have more knowledge of WWM than other working groups.

In the current study, resident attitudes were correlated with the level of knowledge, as indicated by previous work.33,34,38 It could be suggested that good knowledge would lead to good attitudes towards waste handling and management measures.39

Space availability was another factor that significantly associated with attitudes. Similar results were found in past studies.31,40 Having appropriate places to treat, dispose or discharge the wastes generated could likely affect community attitudes towards managing liquid wastes.

This study found that the respondents’ level of knowledge was related to the practices. Similar to previous reports.32,38 One possible explanation could be that participants with good knowledge could understand the potential health and environmental impact of improper waste management practices.

Our study revealed that a community’s attitudes was associated with good practice.38 It is reasonable that the positive feelings of people about the ultimate fate of waste generated from each home could contribute to the proper practices of WWM.

Conclusions

Overall, knowledge, attitudes, and self-reported practices were limited. Occupational status, housing tenure, and attitudes were identified as the factors having significant association with good knowledge level of residents. Availability of space and good knowledge were identified as factors that have associations to a good level of attitude. Good knowledge and good attitude were identified as factors that contributed significantly to respondents’ good practices. Therefore, it’s important to improve good knowledge, positive attitudes, and good practices.

Limitations of the Study

Finally, this study was limited by its cross-sectional design that prevented causality determination. Another limitation was that we did not include direct practical observations. Thus, there might be a bias of social desirability. Also, the tool we used in this study was not a standard.