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Al-Azhar University-Gaza
Deanship of Postgraduate Studies
Institute of Water and Environment (IWE)
Master program in water and environmental science
Environmental Factors Associated with Common
Waterborne Diseases among Al Shuka Community-
Rafah Governorate
By:
Ghada A. Al Khatib
Supervised By:
Dr. Mazen Hamada
Associated Professor of Analytical Chemistry
Al-Azhar University-Gaza
Dr. Amal Sarsour
Assistant Professor of Environmental Health
Earth and Human Center for Researches
and Studies
Thesis submitted to the Institute of Water and Environment (IWE),
In partial fulfillment of the requirements for the degree of
Master in Water and Environmental Science
2015
Al-Azhar University-Gaza
Deanship of Postgraduate Studies
Institute of Water and Environment (IWE)
Master program in water and environmental science
Environmental Factors Associated with Common
Waterborne Diseases among Al Shuka Community-
Rafah Governorate
والشائعة في منطقة المياهب المنقولة الأمراضمع العوامل البيئية المرتبطة
محافظة رفح - شوكةلا
By:
Ghada A. Al Khatib
Supervised By:
Dr. Mazen Hamada
Associated Professor of Analytical Chemistry
Al-Azhar University-Gaza
Dr. Amal Sarsour
Assistant Professor of Environmental Health
Earth and Human Center for Researches
and Studies
Thesis submitted to the Institute of Water and Environment (IWE),
In partial fulfillment of the requirements for the degree of
Master in Water and Environmental Science
2015
II
DEDICATION
I dedicate this humble study to my beloved late mother soul, my loving father, darling husband, loving children, dearest brothers and loving sisters!
III
ACKNOWLEDGMENT
First I wish to give all appreciation to our "GREAT ALLAH" Who Has provided me the
courtesy, capacity, forte and time to write and complete this dissertation.
A minimum of gratitude from someone will make your work worthwhile. And no work will be
completed without acknowledging these people. I would like to extend my sincere gratitude to my
supervisor Dr. Mazen Hamada for his immense support and motivation throughout my study
period. It was a great privilege knowing him and working under his continuous supervision. I am
also thankful to Dr. Amal Sarsour for her excellent suggestions and giving me generous extent of
time whenever I needed to complete my thesis. She showed me different means to approach a
research problem and taught to be adamant to accomplish any aim.
My sincere thanks and appreciation goes to Mr. Khalil Meqdad for helping me in the statistical
analysis. Similarly, I would like to thank the people of Al Shuka area who directly or indirectly
supported me to make my study complete with their active participation.
I would like to thank the higher authorities of Al Azhar University, Dr. Adnan Aish, and Dr.
Khaldon Abu-Alhon, Director of the Institute of Water and Environment for making it convenient
in various aspects to carry out this research.
I thank the Department of Health and Environment in the Municipality of Gaza, and especial
thanks go to Engineer: Abdul Rahim Abu-Alkonboz (Director General of the Health and
Environment Department), Engineer: Suhail Abu-Abdu (Director of Health and Environment),
and Engineer: Kamal Al-Kolak (Head of Preventive Health Department in the Health and
Environment Directorate) and Engineer: Montaser Shihada (Head of Parks Department) for their
efforts on providing me with all the necessary means to take chemical and biological water
samples.
I would like to express my sincere appreciation to Ministry of Health and MoH laboratory.
Sincere appreciation is given to Mr. Sami Lubbad, director of MoH laboratory, Mr. Mohammed
El Khateeb, Mr. Saleh El Taweel, Mr. Hitham Abu Marasa, Mr. Yasser El Bayoumi, Mr.
Mohammed Seada and all staff members of MoH laboratory.
I wish to thank my colleagues in the community guidance department of the Holst cultural center
in the municipality of Gaza, and special thanks and gratitude goes to my colleague Mr. Said Abu
Ramadan, for his good efforts in computer software. I thank the honorable sister- Fulla Sharaf,
the head of the information systems department at the Ministry of Health, for providing me with
the necessary information for the completion of this study. I feel grateful to all my friends and
colleagues for encouraging and support me. The completion of this study is a result of the
encouragement and support of many friends and individuals who have provided professional
direction and friendship during the time of this work.
And lastly, genuine thanks go to my husband for his love, support and encouragement during my
study period and to my children for their patience, support and help during the completion of this
thesis. I am also thankful to my sisters and brothers for their appreciated support.
Ghada A. Al Khatib
IV
ABSTRACT
Lack of sustainability of water supply and sanitation services are always considered as
major issue in developing countries that accounts for high prevalence of water borne
diseases. The aim of this study is to identify the environmental determinants and socio
demographic factors of common water borne diseases among people of Al Shuka area in
Rafah Governorate in the Gaza Strip. In addition to, measure if there are differences in
the water borne diseases prevalence among people after intervention by Oxfam-GB at Al
Shuka area through providing the people with healthy water and conducting awareness
program to improve people behaviour and environment. In order to achieve this aim, the
researcher utilized quantitative and qualitative measures by incorporating pre and post
face to face questionnaire, with observation tool to assess the environmental health
situation and personal hygiene of surveyed households, in addition to conduct focus
groups discussions with females households after the intervention to verify the achieved
results. Water samples collection and analysis before and after Oxfam-GB intervention
were also implemented to evaluate the water quality. Data were analyzed by performing
the descriptive and inferential statistics, Chi-square test of independence, determining P
values and logistic regression analysis.
Based on the study results it is concluded that the most common water borne diseases in
the area of Al Shuka are including: diarrheal, dermal and eye diseases. The results
showed that in pre-test questionnaire which was filled before Oxfam-GB intervention,
there were about (34.6%) of the study sample (n=208) have suffered from diarrhea,
during last two weeks before answering the questionnaire of the pre-test stage, while in
post-test after Oxfam-GB intervention the incidence of diarrhea decline, but unfortunately
it increased again among the people in 2-3 months after Oxfam ended distributing water
tanks according to what mentioned by households in the focus groups discussion. About
(45.2%) of the study sample suffered from other water borne diseases with (78%) of them
suffered from dermal diseases and about (57%) of them suffered from eye diseases, while
after the implementation of Oxfam project only one person suffered from other water
borne diseases. Considering the most age group affected by the identified common water
V
borne diseases, the results demonstrated that the most common age group who suffered
from diarrheal diseases among the infected people was children less than 5 years (68%),
while out of people who suffered from other water borne diseases; women were the
highest age groups who suffered from dermal (37.7%). Whereas, the most age group who
were infected with eye diseases were from children above 5 years with about (20.2%).
Furthermore, water borne diseases found to be associated with environmental factors and
personal hygiene such as (drinking water tank is closed properly, there is stagnant /algae
below drinking tank, there is a basin near/inside the bathroom, the level of hygiene in the
sanitary facilities, the basin in the bathroom is much higher than the children's level, there
are flies inside the bathroom/kitchen, there is a bad smell inside the bathroom), whereas
the results of logistic regression analysis showed that demographic variables
(qualification, type of occupation, level of monthly income) did not have a significant
effect on the spread of water borne diseases in the area of Al Shuka-Rafah governorate.
There was significant positive improvement in the rate of diseases incidence at Al Shuka
area during the intervention of Oxfam. However, after the end of Oxfam project the
situation returned as it was before Oxfam intervention where people became suffering
again from water borne diseases. Given these results further concern by local and
international organizations should be paid to improve the environmental situation at Al-
Shuka area and all vulnerable areas in the Gaza Strip.
VI
الملخص
رئيسية في البلدان ال من القضايااستدامة خدمات إمدادات المياه والصرف الصحي معد
الهدف من هذه الدراسة هو .ارتفاع في معدل انتشار الأمراض التي تنقلها المياه يسُبب ماالنامية
التي ضار الأمراالاجتماعية المرتبطة بانتشوالتعرف على المحددات البيئية والعوامل الديموغرافية
محافظة رفح في قطاع غزة، وإذا ما كان هناك تحسن بعد -مياه بين الناس في منطقة الشوكة تنقلها ال
تدخل مؤسسة أوكسفام البريطانية من خلال تزويد سكان منطقة الشوكة بالمياه الصحية وتنفيذ برامج
هدف، قامت الباحثة باستخدام لتحقيق هذا ال توعية بهدف تحسين سلوك السكان الصحي والبيئي.
منهجية البحث الكمي والكيفي من خلال دمج كُلاً من استبانة جمع بيانات قبل وبعد تدخل أوكسفام،
مع أداة مراقبة لتقييم الوضع البيئي والصحي لعينة الدراسة وقياس درجة المحافظة على النظافة
مّقة مع مجموعات بؤرية من نساء ع ونقاشات مُ الشخصية لأفراد الأسرة، بالإضافة إلى تنفيذ حوارات
وأخيرا تم تحليل المياه ،منطقة الشوكة بهدف الحصول على إجابات أكثر عمقا لدعم نتائج الدراسة
المستخدمة للشرب في منطقة الشوكة قبل، وبعد تدخل أوكسفام للتأكد من جودة هذه المياه. هذا و قد
حصاء الوففي والاستدلالي، ومعامل مربع كا ، وتحديد قيمتم تحليل البيانات عن طريق إجراء الإ
P وتحليل الانحدار اللوجستي ،.
في منطقة الشوكة الأكثر شيوعا والمنتقلة بواسطة المياه خلصت الدراسة إلى أن الأمراض
حيث بلغت نسبة انتشار الإسهالأمراض الإسهال، الأمراض الجلدية ، وأمراض العيون . :هي
ين سكان الشوكة خلال الأسبوعين الأخيرين قبل تعبئة الاستبيان معهم للاختبار القبلي %( ب34.6)
أ قبل تدخل أوكسفام، بينما أظهرت الدراسة عدم إفابة أ من سكان الشوكة بالإسهال بعد تدخل
%(45.2 (قد بلغت نسبة انتشار الأمراض الأخرى والمنتقلة بواسطة المياه حوالي وهذا أوكسفام،
بينما أفيب فرد واحد فقط بهذه %(57%( والعيون )78التي تتضمن الأمراض الجلدية ) و
فيما يتعلق بالفئات الأكثر إفابة بهذه الأمراض فقد كانت النسبة الأمراض بعد تدخل أوكسفام.
%(، أما من بين 68.1للإفابة بأمراض الإسهال بين فئة الأطفال أقل من خمس سنوات )الأكبر
فابة إيبوا بالأمراض الأخرى المنتقلة بواسطة المياه فقد كانت فئة النساء الفئة الأكثر الذين أف
أما فيما يتعلق بالإفابة بأمراض العيون فكانت نسبة الإفابة الأكبر .%(37.7بالأمراض الجلدية )
ة (. كما أكدت نتائج الدراسة أيضاً إلى وجود علاق%20.2سنوات ) 5من نصيب الأطفال أكبر من
VII
ذات دلالة إحصائية ما بين انتشار الأمراض التي تنقلها المياه والعوامل البيئية مثل: )خزان مياه
الشرب مغلق جيدا، يوجد طحالب راكدة أسفل الخزان، يوجد مغسلة قرب/داخل الحمام، مستوى
خل النظافة في المرافق الصحية، المغسلة في الحمام أعلى من مستوى الأطفال، يوجد حشرات دا
الحمام/المطبخ، يوجد رائحة كريهة داخل الحمام(، في حين أظهرت النتائج أن المتغيرات
الديموغرافية )المؤهل العلمي، نوع المهنة، مستوى الدخل الشهر ( لم يكن لها أثر جوهر على
رفح. -انتشار الأمراض في منطقة الشوكة
طقة خلال تدخل أوكسفام ، حيث على انتشار الأمراض في المنيوجد تحسن إيجابي ملحوظ
من الأمراض أنه بعد التدخل عاد الوضع على ما كان عليه قبل التدخل وأفبح السكان يعانون
بناءا على نتائج الدراسة المعطاة لابد من تركيز الاهتمام أكثر بتحسين الظروف .المنقولة بالمياه
مهمشة في قطاع غزة.الاجتماعية، الصحية والبيئية لمنطقة الشوكة والمناطق ال
VIII
TABLE OF CONTENTS
Dedication II
Acknowledgements III
Abstract IV
Abstract in Arabic VI
Table of contents VIII
List of Notations XI
List of Abbreviations XIII
List of Tables XV
List of Figures XVI
List of Annexes XVII
CHAPTER 1 INTRODUCTION 1
1.1 Background 1
1.2 Problem definition 2
1.3 Study justification 4
1.4 Main objective of the study 4
1.5 Specific objectives of the study 5
1.6 Research methodology 5
1.7 Operational definitions 6
1.8 Thesis outline 9
CHAPTER 2 LITERATURE REVIEW 10
2.1 Water resources, quality and quantity in the Gaza Strip 10
2.1.1 Water resources 10
2.1.2 Water quality and quantity 11
2.2 Health effects of contaminated water 14
2.3 Water related-diseases 17
2.3.1 Classification for water-related diseases according to
biological health hazards 18
2.4 Brief description of common waterborne diseases 20
2.5 Impact of water, sanitation and hygiene interventions on
reducing water related diseases and improving health 22
2.6 Previous studies 24
2.7 Palestinian water rights 32
CHAPTER 3 STUDY AREA 36
3.1 Geographic and demographic (Al Shuka area) 36
3.2 Economic situation, environmental and land use 37
3.3 Educational situation 38
3.4 Infrastructure 38
3.5 Power resource in the area 39
3.5.1 Community 39
IX
3.5.2 Municipality of Al Shuka 40
3.5.3 Local CBOs 41
3.6 Risks which threaten the study area 42
3.6.1 Health problems 42
3.6.2 Social isolation 42
3.7The role of Oxfam in improving water situation at Al Shuka
area
43
CHAPTER 4 MATERIAL AND METHODS 44
4.1 Introduction 44
4.2 Study design 44
4.3 Study period
4.4 Study population 45
4.5 Study sample 45
4.5.1 Sample size 45
4.6 Sampling process 45
4.7 Study setting 46
4.8 Site visit and selection process for the study 47
4.9 Study instruments 47
4.9.1 In quantitative method 47
4.9.2 In qualitative method 50
4.10 Data collection 50
4.11 Data management and statistical analysis 52
4.11.1 In quantitative part 52
4.11.2 In qualitative part 57
4.12 Limitations of the study 58
CHAPTER 5 RESULTS AND DISCUSSION 59
5.1 Demographic variables of the study area 59
5.2 Results of knowledge and practices about general health
(pre/post-test) 61
5.3 Results about water sources, uses and its quality at Al Shuka
area 62
5.4 The results of common waterborne and related diseases at
Al Shuka area 68
5.5 Results of awareness about hygiene among people of Al
Shuka area
75
5.6 Results of the observation sheet 77
5.7 Environmental and socio-demographic factors associated with
common water-borne diseases at Al Shuka area 80
5.7.1 Demographic variables and environmental determinants on
the prevalence of diarrheal disease in the individuals of Al
Shuka area
80
5.7.2 Environmental and socio-demographic factors Associated 82
X
with common Water-borne diseases at Al Shuka area
5.8 Results of water samples analysis 84
5.8.1 pH 85
5.8.2 Electrical conductivity (EC) 86
5.8.3 Total dissolved solids (TDS) 88
5.8.4 Chloride (Cl-) 90
5.8.5 Nitrates (NO3) 91
5.8.6 Total coliform (TC) 93
5.8.7 Faecal coliform (FC) 93
CHAPTER 6 CONCLUSIONS AND RECOMMENDATIONS 95
6.1 Conclusions 95
6.2 Recommendations 97
REFERENCES 99
ANNEXES 113
XI
LIST OF NOTATIONS
% percentage
< less than
> more than
µmhos/cm micro ohms per centimeter
µS/cm micro Simon per centimeter
AgNO3 Silver nitrate
Alk(SO4)2 Aluminum potassium sulfate
B The relationship between the odds ratio and the coefficient
C.I Interval confidence
Ca Calcium
Cl- Chloride
D Expected frequency value minus (-) worst acceptable value
Df Degrees of freedom
EC Electrical conductivity
etc. et cetera
Exp(B) Exponential linear regression
FC Faecal coliform
H hour
H2O Water
HCl Hydrochloric acid
K+
Potassium
K2CrO4 Potassium chromate
K2HPO4 Dipotassium phosphate
KH2PO4 Monopotassium phosphate
Km Kilometer
Km2
Square kilometer
M meter
m3/yr cubic meter per year
Mg Magnesium
mg/l milligram per liter
Mg2+ Magnesium ion
Ml milliliter
mm/yr millimeter
mS/m meter Simon per meter
N Sample size
Na+
Sodium ion
Na2S2O3 Sodium thiosulfate
XII
NaCl Sodium chloride
NIS New Israeli shekel
Nm Nanometer unit of length in the metric system
No. Number
NO3-
Nitrate
ºC Celsius degrees
OR Odds ratio
P True proportion of factor in the population, or the expected
frequency value
pH Hydrogen ion
Ppm Part per million
R Correlation Coefficients /Parson Correlation
S.E Standard error
sig. Test of significance
Std. Deviation Standard deviation
TC Total coliform
TDS Total dissolved solids
US$ US dollars
Wald Wald test for logistic regression
Z Area under normal curve corresponding to the desired
confidence level
XIII
LIST OF ABBREVIATIONS
APHA American Public Health Association
Arc GIS Geographic Information System (GIS) for working with maps and
geographic information
CBOs Community Based Organizations
CDHA Canadian Dental Hygienists Association
CMWU Coastal Municipalities Water Utility
CSDH Commission on Social Determinants of Health
EPA Environment Protection Agency
GCA Gaza Coastal Aquifer
GEMS Global Environment Monitoring System
GS Gaza Strip
GVC Gruppo di Volontariato Civile
GW Ground Water
HACH Hach Company manufactures and distributes analytical
instruments and reagents used to test the quality of water and other
liquid solutions
HCT Humanitarian Community Team
HIV/AIDS human immunodeficiency virus/ Acquired immunodeficiency
syndrome
HWWS Hygiene Procedure Hand Washing With Soap
IFRC International Federation of Red Cross
INGOs International Nongovernmental Organizations
INP National Plan
Kh.Y Khanyounis
MDGs Millennium Development Goals
MoH Ministry of Health
MoHE Ministry of Higher Education
MSL Mean Sea Level
OPT Occupied Palestinian Territories
Oxfam-GB Oxford Committee for Famine Relief-Great Britain
PCBS Palestinian Central Bureau for Statistics
PEF Palestinian Environment Friends
PHG Palestinian Hydrology Group
PS Palestinian Standard
XIV
PWA Palestinian Water Authority
SPSS Statistical Package for Social Sciences
UK United Kingdom
UN United Nation
UNCT United Nation Country Team
UNDP United Nation Development Program
UNEP Untied Nation Environmental Program
UNICEF United Nations International Children's Emergency Fund.
UNRWA United Nation Relief Work Agency
UV Ultra Violet
WASH Water Sanitation And Hygiene
WHO World Health Organization
YEC Youth Empowerment Center
XV
LIST OF TABLES
Table 4.1 List of chemicals used for water samples test 54
Table 4.2 List of instruments used for water samples analysis 54
Table 5.1 Study samples characteristics 60
Table 5.2 The level of general health and personal hygiene among the
study sample at pre and post stages 61
Table 5.3 Status of water , water sources and how much clean it among the
study of Al Shuka at pre and post-test stages 63
Table 5.4 Incidence of diarrheal and other disease among the study sample
of Al Shuka 69
Table 5.5 Effects of hygiene awareness program among the study sample
of Al Shuka 75
Table 5.6 Researcher observations card among the sample at pre and post
test 77
Table 5.7 The results of the gradual test method (Wald) to model logistic
regression demographic variables and environmental variables on
the prevalence of diarrheal disease in the individuals of Al Shuka
area in Rafah Governorate
81
Table 5.8 Results of the gradual test method (Wald) to model logistic
regression for demographic variables and environmental
variables on the spread of other diseases among individuals of Al
Shuka area in Rafah Governorate
83
Table 5.9 Bacteriological contamination of collected water samples 94
XVI
LIST OF FIGURES
Fig.3.1 Map shows the study area of Al Shuka district in Rafah governorate 37
Fig.5.1 pH values for pre-test water samples collected from Al Shuka area 85
Fig.5.2 pH values for post-test water samples collected from Al Shuka area 86
Fig.5.3 EC values for pre-test water samples collected from Al Shuka area 87
Fig.5.4 EC values for post-test water samples collected from Al Shuka area 88
Fig.5.5 TDS values for pre-test water samples collected from Al Shuka area 89
Fig.5.6 TDS values for post-test water samples collected from Al Shuka area 89
Fig.5.7 Chloride concentrations of water samples collected from Al Shuka
area
91
Fig.5.8 Nitrate concentrations of water samples collected from Al Shuka area 92
XVII
LIST OF ANNEXES
Annex-1 Questionnaires and observation sheet 114
Annex-2 Permissions from responsible authorities for collecting data and
conducting the experimental work
119
Annex 2.1 Permission letter from Al Azhar university to Oxfam-GB office in Gaza
for collecting data purpose
120
Annex 2.2 Permission letter from Al Azhar university to UNRWA public health
department Gaza for collecting data purpose
121
Annex 2.3 Permission letter from Al Azhar university to MoH for collecting data
purpose
122
Annex 2.4 Permission letter from Al Azhar university to MoH for collecting data
purpose
123
Annex-3
Laboratory reports show water chemistry analyses given from MoH
124
Annex-4 Water samples quality data 125
Annex 4.1 Water quality analytical results for pre-test samples (Oxfam-GB office) 125
Annex 4.2 Water quality analytical results for post-test samples (Oxfam-GB office) 128
Annex 4.3 Water quality analytical results conducted during Oxfam intervention
(Sabha Health Lab – Gaza)
131
Annex-4.4 Results of water analysis from Al-Shuka water wells (MoH) 133
Annex-4.5 Results of water analysis from Al-Shuka water wells (MoH) 134
Annex-5 Incidence of various water-related diseases in Al-Shuka area on a yearly
basis as obtained from the records of Department of Epidemiology,
UNRWA
135
Annex-6 Incidence of various water-related diseases in Al-Shuka area on a yearly
basis as obtained from the records of Department of Epidemiology,
Ministry of Health.
137
1
CHAPTER 1
INTRODUCTION
1.1 Background
Drinking water is considered as a major source of microbial pathogens in developing
regions, although poor sanitation and food sources are integral to enteric pathogen
exposure (Zawahiri and Weinthal, 2011). Moreover, the failure to provide people with
safe drinking water and basic sanitation services is estimated to contribute to the deaths
of approximately 3.57 million people annually from water-related diseases, around 6
percent of all deaths worldwide (Prüss-Üstün et al., 2008). The World Health
Organization (WHO), the most widely-cited source of global health data, estimates that
more than 780 million people lack access to an improved source of drinking water, while
some 2.5 billion have no access to improved sanitation (UNICEF and WHO, 2012).
Consumption of or contact with contaminated water contributes to waterborne diseases,
water-washed diseases and water-based diseases, all of which produce diarrhea
responsible for 60 per cent of infant mortality throughout the world (Zawahri et al.,
2011). Thus, access to safe drinking water, basic sanitation and proper hygiene education
could not only prevent diarrheal diseases by nearly 90% (United Nation, 2010), but
furthermore lead to improved health, poverty reduction and socio-economic
development (Fewtrell et al., 2005; Oksanen, 2015).
The risk factor associated with waterborne diseases is defined as including multiple
factors, namely the ingestion of unsafe water, lack of water linked to inadequate hygiene,
poor personal and domestic hygiene and agricultural practices, contact with unsafe water,
and inadequate development and management of water resources or water systems
(Green et al., 2009). In addition, the socioeconomic factors may affect, directly and
indirectly, as well as environmental, behavioral, nutritional, and demographic risk factors,
with the exception of age and gender as reported by (Ashbolt, 2004). Furthermore, the
improper liquid waste systems such as septic tanks, bad links to the sewage water
2
networks; improper waste treatment may generate suitable breading sites for insects
of public health importance such as mosquitoes and flies, hence this situation may
create health problems to the population (El-Nahhal and Harrarah, 2013). As a result of
increasing interest in such risk factors, the World Health Organization is currently
involved in assessing the disease burden of about 20 risk factors in an internally
consistent way. Six of these risk factors focus on environmental and occupational health
concerns, one of which is water, sanitation, and hygiene (Pruss-Ustun, and Corvalán,
2006).
Gaza Strip’s population suffers markedly from water-borne infections due to the lack of
safe and sanitary water supply and disposal (Sarsour and Salem, 2013); as people are
struggling for access to water, and against contamination of the only and precious
resource that they have (Sarsour and Omran, 2011). Resembling any other parts in the
Middle East, the Gaza Strip, the southern part of Palestinian groundwater has a manifest
and significant scarcity of water supply (Al-Najar, 2011); that over 90% of the population
benefits of drinking water supplied from municipal water mains while the remaining 10%
of the population lives in rural area and uses private wells (Abbas et al., 2013). PWA in a
recent study for groundwater evaluation (2014) reports that out of 211 wells under
monitoring and taking in consideration the combined concentrations of both chloride and
nitrate, it's clear that 3.8% of the domestic water is only matching with WHO drinking
limit, while the remaining 96.2% is exceeding the limit (PWA, 2015). Accordingly,
improvements in various aspects of water supply represent important opportunities to
enhance public health.
1.2 Problem definition
Al-Shuka area is small district in Rafah governorate located in the south-east of the Gaza
Strip, with area about 22 square km; and 16,800 people distributed among 3000 houses,
and the most area is agricultural areas (Alnahhal and Aljojo, 2013). According to the
report prepared by Palestinian Environmental Friend Association 2013; emphasizes that
the health situation of most people in Al Shuka is not good and not accepted, where
3
residents always complained from different communicable and skin diseases mainly
among children; which may related to the infectious diseases of the waste water bad
situation. Whereas, Al Shuka area suffers from the lack of the infrastructure, no paved
streets, no sewage systems, no drainage networks and the municipality water networks
cover only 60 % of the whole area, with water sources from 3 municipality wells only
located 10 km far from the area to the west, whereas the quality of available water either
from the municipality wells or the agricultural (private) wells is not suitable for the
drinking purposes (Alnahhal and Aljojo, 2013).
Citizens depend upon the cesspits to manage their wastewater, as the cesspits are not the
suitable environmental solution for managing the wastewater. However, the bad
economic situation and the weaknesses of the municipality infrastructures such as the
sewers systems force people to don’t take care of these cesspits, that flooding of the
cesspits is regular and forming waste water pools in the roads and the yards is existent all
through the year; and people always discharge the cesspits and the pools manually
(Alnahhal and Aljojo, 2013).
Accordingly, providing citizen with safe water and conducting awareness campaign
among them is decided by different organizations in attempt to minimize the health risk
and improve the living status of Al Shuka community.
Given these data, the identification of the environmental determinants and socio
demographic factors of common water borne diseases among people of Al Shuka area-
Rafah Governorate before and after the intervention which was planned to be
implemented by Oxfam-GB will be helpful to evaluate if there will be any change in the
trend of these disease after providing the community with safe water and behavioural
change sessions, and to put recommendation for better solution and improvement in the
living status of Al-Shuka community.
4
1.3 Study justification
Commonly, inadequate water supplies, such as insufficient or contaminated domestic
water, lead to disease through two principal transmission routes: either by drinking
contaminated water, which leads to ‘waterborne’ diseases, or by a lack of sufficient water
for washing and hygiene purposes, which leads to ‘water-washed’ diseases (Montgomery
and Elimelch, 2007). Human beings are continuously affected by external environmental
pollutants. Everyday activities may involve contact with many sources of environmental
contamination; these may be touched with the hand, present on shoes while walking, or
contained in dust on the body and hair; moving the hand to the mouth also causes
microorganisms to enter the body (WHO, 2000a).
As a consequence of the substandard environmental health and economical situation at Al
Shuka-area, Oxfam GB–Gaza office has conducted a health promotion project and
intended to distribute desalinated water tanks among household in Al Shuka area in
addition to apply total behaviour change session to the community to improve their
behaviour towards water usage and hygiene performance aiming to improve the health
level among them. Accordingly, determining the environmental factors and determinants
associated with common waterborne diseases among the people of Al Shuka area–Rafah
Governorate is helpful to identify the suitable intervention to improve the environmental
health situation at Al Shuka area. Also, the study aims to measure if there will be
differences in the waterborne diseases prevalence among people after water supply and
total behaviour change intervention by Oxfam-GB at Al Shuka area (Pre-Post Test) and
this may be helpful in evaluating the influence of improving the environmental situation
as well as water quality and quantity among the community.
1.4 Main objective of the study
The main objective of this study is to identify the environmental determinants and socio
demographic factors of common water borne diseases among people of Al Shuka area-
Rafah Governorate.
5
1.5 Specific objectives of the study
1. To identify the common water borne diseases among people of Al Shuka area.
2. To detect the most age group affected by the identified common water borne
diseases.
3. To identify the environmental determinants and socio demographic factors
associated with common water borne diseases among individuals of Al Shuka
area.
4. To measure if there are differences in the waterborne diseases prevalence
among people at Al Shuka area after intervention by Oxfam-GB (water supply
and total behaviour change).
1.6 Research methodology
To achieve the above mentioned objectives, the following steps are applied:
Data collection from different available published reports, research papers and
internet websites.
Site visit and selection of study area.
Design the study tools (Questionnaires, obsrevation sheet).
Water sample collection and analysis before Oxfam-GB intervention.
Data collection pre-test (before Oxfam-GB intervention) (questionnaire,
obsrevation sheet).
Data entry, and result analysis.
Results presentation and writing for pre-test.
Data collection post test (after Oxfam-GB intervention) (questionnaire,
obsrevation sheet).
Water analysis after Oxfam-GB intervention.
Records of diseases from UNRWA and MoH health department
6
Conducting focus groups discussion with households after the intervention to
verify the achieved results.
Results presentation and thesis writing.
1.8 Operational definition
Environmental determinants: An environmental determinant of health is, in general,
any biological, chemical, physical, social, or cultural factors external to a person, and all
the related factors impacting behaviours targeted towards preventing disease and creating
health-supportive environments (including clean air and water, healthy workplaces, safe
houses, community spaces and roads and managing climate change). This definition
excludes behaviour not related to environment, as well as behaviour related to the social
and cultural environment, and genetics (WHO, 2014).
Sociodemographic factors: Socioeconomic characteristics of a population expressed
statistically, such as age, sex, education level, income level, marital status, occupation,
religion, birth rate, death rate, average size of a family, average age at marriage.
Sociodemographic factors can be defined as the complicated, united, and meeting social
structures and economic arrangements that are accountable for most health imbalances.
These social structures and economic arrangements consist of the social environment,
physical environment, health amenities, and structural and societal influences. Social
determinants of health are shaped by the distribution of money, power, and resources all
through local communities, nations, and the world (CSDH, 2008).
Behavioral change: Is defined as a central objective in public health interventions
(WHO, 2002), with an increased focus on prevention prior to onset of disease. This is
particularly important in low and middle income countries, where efficiency of health
spending and costs and benefits of health interventions has come under increased scrutiny
in recent decades (Jamison et al., 2006).
7
Sanitation: The term “sanitation” has been given several definitions by various authors
and has been used often in different aid programs. The Oxford Advanced Learner’s
Dictionary defines sanitation as: “systems that protect people’s health, especially those
that dispose efficiently of human waste”. Therefore, sanitation states to approaches of
hygiene that relate to safe collection, removal and disposal of human excreta and
wastewater (Drewko, 2007).
Hygiene: Hygiene is defined as any application made and any sanitary precaution taken
to be protected from environments that can damage our health (Erkal and Sahin, 2011).
Personal Hygiene: Personal hygiene is "the physical act of cleansing the body to ensure
that the hair, nails, ears, eyes, nose and skin are maintained in an optimum condition. It
also includes mouth hygiene which is the effective removal of plaque and debris to
ensure the structures and tissues of the mouth are kept in a healthy condition. In addition,
personal hygiene includes ensuring the appropriate length of nails and hair" (Aslan et al.,
2006; Yelmaz and Ozkan, 2009).
Health: WHO has defined health as “a state of complete physical, mental and social
well-being and not merely the absence of disease or infirmity” (WHO, 2006).
Health promotion: Health promotion is the process of enabling people to increase
control over their health and its determinants, and thereby improve their health. It is a
core function of public health and contributes to the work of tackling communicable and
non-communicable diseases and other threats to health (WHO, 2005). CDHA (2002)
defined health promotion as “the process of enabling people to increase their awareness
of, responsibility for, control over, and improvement of their health and well-being”.
Health protection: It is a useful term to define significant activities of public health,
specifically in food hygiene, water distillation, environmental cleanliness, drug safety and
other activities that eradicate as far as possible the risk of adverse consequences to health
attributable to environmental risks (CDHA, 2008).
8
1.8 Thesis outline
The thesis describes results of the common waterborne diseases among the people of Al
Shuka area, the environmental determinants and sociodemographic factors associated
with common waterborne diseases among the individuals of Al Shuka area and the
differences in the waterborne diseases prevalence among the people after water supply
and total behavior change intervention by Oxfam-GB at Al Shuka area (Pre-Post Test).
The thesis consist of six chapters as following:
Chapter one (Introduction): chapter one covering background about drinking water and
its association with waterborne diseases in the Gaza Strip, study problem definition, study
justification, objectives of present study, research methodology, operational definitions
and thesis outline.
Chapter two (Literature Review): chapter two includes general literature review of
water resources, quality and quantity in the Gaza Strip, health effects of contaminated
water, water-related diseases, brief description of common waterborne diseases, impact of
water, sanitation and hygiene interventions on reducing water related diseases and
improving health, previous studies and Palestinian water rights.
Chapter three (Study Area): chapter three covers the study area used for this research
work including: geographic and demographic (Al Shuka area), economic situation,
environmental and land use, educational situation, infrastructure, power resources in the
area, the needs of people, municipality and local CBOs, risks which threaten the study
area.
Chapter four (Material and Methods): chapter four covers the appropriate steps of the
methodology which includes the study design, the study sample, the study instruments,
data collection, and data management and analysis.
Chapter five (Results and Discussion): chapter five discuss the results obtained during
this study from the laboratory analysis of water samples and the results of questionnaires
analysis including: demographic variables of the study population, knowledge and
9
practice about general health (pre-post), water sources, uses and its quality at Al Shuka
area, observed common waterborne and related diseases at Al Shuka area, awareness
about hygiene among people of Al Shuka area and the results of observation sheet.
Chapter six (Conclusions and Recommendations): chapter six presents the main
conclusions and recommendations made during this study.
10
CHAPTER 2
LITERATURE REVIEW
2.1 Water resources quality and quantity in the Gaza Strip
2.1.1Water resources
In the region of Gaza Strip there are about 1.82 million inhabitants (PCBS, 2015), and
about 376 km2 of superficies (UNEP, 2009). The southern part of Palestine which is
represented by the Gaza Strip is considered as one of the most densely populated areas in
the world, with an average population density of about 4,986 people/km2, such numbers
are still increasing due to rapid population growth in the Gaza Strip of approximately
4.5% (Hilles et al., 2014; PCBS, 2015). The climate of Gaza Strip is semi-arid area where
rainfall is falling in the winter season from September to April, and the rate of rainfall is
varying and ranges between 200mm/year in the south (Rafah area) to about 400mm/year
in the north (Beit-Lahia and Beit-Hanoun), while the long term average rainfall rate in all
over the Gaza Strip is about 317mm/year (Alastal et al., 2015).
The water source in Palestine is composed of renewable groundwater only. Palestinians
living in the Gaza Strip are forced to rely on the underlying portion of the coastal aquifer
as their only natural water resource for different purposes, and is extensively utilized to
satisfy agricultural, domestic, and industrial water demands (CMWU, 2010; Alastal et al.,
2015). The groundwater of the coastal aquifer of Gaza Strip is mainly refilled by
precipitation, agricultural and domestic coming back of flows and natural side
groundwater flow from the east (Aish, 2010; PWA, 2013).
Groundwater level is considered to be an important indicator to recognize the
groundwater unbalance. Any changes in the groundwater level of the wells reflect the
disruption in the aquifer production and its recharge, that water level change leads to
change in ground water flow direction and henceforth, seawater could interfere to prevent
11
unbalance phenomenon of groundwater pressure. In ultimate conditions of groundwater
flows in the Gaza coastal aquifer is toward the Mediterranean Sea (PWA, 2013).
Though, the water balance of water resources in Gaza Strip has been suffering from
considerable annual deficit since more than several decades in addition to exhaustive
groundwater pumping through more than four thousands of pumping wells, that natural
flow pattern has been significantly disturbed and large pinecones of dejection have
formed in northern and southern Gaza Strip where water levels below sea level were
documented (Aish, 2010; Albanna and Abu Heen, 2010; PWA, 2013).
At the present time the overall deficit in the water balance shows about 30 to 40% of the
total water demand. In the south west of the Gaza Strip, groundwater levels have been
declining dramatically in the last few years. In the center of Rafah governorate the rate of
groundwater level decay has been documented in a number of monitoring wells as 0.5-1
m/yr (Albanna and Abu Heen, 2010).
Where, the decay and difference in water level in the coastal aquifer varies from 11.7 m
above mean sea level (MSL) in the southeastern side of the Gaza Strip to -18m below
MSL in Rafah area which is considered as the maximum water level decay (PWA, 2013).
This pinecone of despair covers a large area and extending to Khanyounis and some parts
of Egypt. There is another visible pinecone of despair located in the northern area of the
Gaza Strip with a maximum water level decline of -6m below MSL. As well as, the water
level decay in Gaza and middle governorates ranges from 2m above MSL to - 4m below
MSL (PWA, 2013).
2.1.2 Water quality and quantity
The Palestinian people have suffered tremendously over the last 67 years and they
continue to suffer today from shortages, deprivation, and loss of livelihood resources
(UNDP, 2012). The rapidly increasing Gaza’s 1.82 million residents depend on the
coastal aquifer to supply them with water but overuse and contaminants seeping into the
12
ground, in addition to restriction on using the Palestinian water rights by the Israeli
authorities, are threatening this vital resource (PWA, 2015).
Gaza coastal aquifer (GCA) has been faced a deterioration ranging from quality problems
to quantity due to expected shortage of water supplies not only for agricultural and
industrial usage but also for drinking, scarcity, insufficiency, pollution and high salinity.
Ninety eight percent of Gaza’s are connected to the municipal water network but supply
is in complicated intermittent schemes and the quality is failing, making its drinkability
questionable (UNICEF, 2010; PWA, 2014).
As a consequence, up to 90% of the ground water (GW) in the Gaza Strip (GS) is
currently not safe for drinking purposes without adequate treatment (Alastal et al., 2015).
PWA in a recent study for groundwater evaluation (2014) reports that out of 211 wells
under monitoring and taking in consideration the combined concentrations of both
chloride and nitrate, it's clear that 3.8% of the domestic water is only matching with
WHO drinking limit, while the remaining 96.2% is exceeding the limit (PWA, 2015) .
With more water to exist extracted (pumping) of groundwater than annually natural
recharge rates; sea water and brackish water surrounding aquifers break into this
freshwater source raising the salinity level in some areas beyond WHO guidelines for
safe drinking water as a result in pressure differences between the groundwater elevation
and sea water level (Aish, 2010; CMWU, 2010; UNRWA, 2012).
Furthermore, it is reported that based on the current water and sanitation situation, the
Gaza water (GW) in the Gaza Strip (GS) could become unusable as early as 2016, and
moreover, the damage of the GW in the GS would become irreversible by 2020 (UNCT,
2012). Another study (Abbas et al., 2013) found that no groundwater in Gaza Strip meets
all WHO drinking water standards. The concentrations of many chemical parameters,
particularly nitrate (NO3-) and chloride (Cl
-), have reached dangerous levels in many
locations within the GS. PWA status report stated that 24.6% of them have chloride
concentration less than 250 while the remaining (75.4%) exceeds the WHO chloride
13
level. Almost 90% of the groundwater wells of the Gaza Strip have nitrate concentrations
two to eight times higher than the WHO guideline values (PWA, 2015).
The concentrations of other physicochemical parameters such as TDS, EC, Ca2+
and
Mg2+
, were also above recommended WHO standards (Alastal et al., 2015). According to
PWA last evaluation report, more than 50% of the groundwater quality database showed
TDS of more than 2,000 mg/l. The level of fluoride in the Gaza’s drinking water range
between 0.8– 3.8 ppm. It also found that there was an increase in the incidence of fluoride
poisoning in areas where increased concentrations of fluoride have been recorded. Most
of the cations Magnesium (Mg2+
), Sodium (Na+) and Potassium (K
+) show concentrations
higher than the WHO guideline values (30); (200) and (10) mg/l, respectively.
Fortunately, the pH in the Gaza aquifer is matching the WHO and PWA guideline values.
According to produced GIS maps, and considering the accepted range of pH from 6.5 to
8.5, the pH quality records are in good condition (PWA, 2015). Additionally, traces of
metal pollution such as lead have been found in several wells in the Gaza Strip (Abbas et
al., 2013).
Biological contamination of drinking water through Fecal and Total coliform have been
found in numerous wells in the Gaza, most likely caused by inefficient sewage systems
and improper disposal of animal waste (El Nahal and Harrarah, 2013).
Due to the contamination, the municipal water from the tap is not suitable for drinking or
cooking, which means people have to purchase water from private vendors despite being
connected to a water network. Many residents in Gaza cannot afford to continuously buy
extra water due to the high unemployment and poverty rates, and therefore obliged to
drinking the contaminated water (Nettnin, 2005; UNICEF, 2012). In many cases, the
quality of water from private vendors has also been reported unsafe because the PWA
does not have the capacity to control and regulate all private vendors (GVC and PHG,
2009; El-Tabash, 2014).
14
2.2 Health effects of contaminated water
“Access to safe water is a fundamental human need and, therefore, a basic human right.
Contaminated water jeopardizes both the physical and social health of all people. It is an affront
to human dignity” (Kofi Annan, UN Secretary-General, 2001).
Safe water and adequate sanitation are basic necessities for the health of every person on
the planet. It is essential to sustain life, and a satisfactory (adequate, safe and accessible)
supply must be available to all. Yet, many people throughout the world do not have
access to these fundamental needs, but for several decades almost 1 billion people in
developing countries have lacked access to such a supply (Hunter et al., 2010; Mogheir,
and Albahnasawi, 2014; Sellathurai et al., 2014). It is worth to mention that, water
security has been proposed as a possible leading concept for post-2015 sustainable
development goals to follow the millennium development goals (MDGs) (UN, 2012).
Water, sanitation and hygiene is directly linked with the United Nation’s (UN)
Millennium Development Goals (MDGs), and is now recognized by the UN as a
fundamental human right, essential for human dignity and wellbeing. Now it is concerned
with domestic water and sanitation, and associated behavior, to derive benefit from them
and cause no harm to others. While its predecessors had targeted ‘water and sanitation for
all’ or similar policy objectives, the Millennium Declaration formulated the target as ‘To
halve, by the year 2015, the proportion of people who are unable to reach or to afford safe
drinking water’ adopted because it represented a continuation of the proportionate decline
in ‘unserved’ populations achieved in the preceding period (Bradley and Bartram, 2013;
UN, 2013). Water quality will also influence particularly human health and disease
prevention, where improving access to safe drinking water can result in tangible benefits
to health (Mogheir and Albahnasawi, 2014).
Water pollution may be defined as any impairment in its native characteristics by addition
of anthropogenic contaminants to the extent that it either cannot serve to humans for
drinking purposes and/or to support the biotic communities, such as fish (Agrawal et al.,
2010). Also, it is the contamination of water bodies (e.g. lakes, rivers, oceans, and
groundwater). This may be defined in terms of the undesirable changes in the chemical
15
and physical properties of water which are not favorable to all those living things
utilizing water for their lives. There are two basic forms of water pollution; 1) changing
the types and amounts of materials carried by water, and 2) altering the physical
characteristics of a body of water (Gupta et al., 2009).
Examples of sources of water pollution, including animal and human waste, chemicals
disposed of inadequately, and landfills. If not treated properly for drinking, and drinking
water can pose serious health risks for humans. Many rivers, streams and wells globally
are affected by fecal contamination leading to increased health risks to persons exposed
to the water, degradation of recreational and drinking water quality (Obiri-Danso et al.,
2009).The possible of drinking water to transport microbial pathogens to great numbers
of people causing subsequent illness is well documented in countries at all levels of
economic development (Medema et al., 2003).
Poor water quality continues to pose a major threat to human health (WHO, 2013), water
pollution is a major cause of global concern as it leads to onset of numerous fatal diseases
(Daniel, 2011) which is responsible for the death of over 14,000 people every day (Cheng
et al., 2012). Diarrheal disease alone amounts to an estimated 4.1% of the total Disability
Adjusted Life Year (DALY) global burden of disease and is responsible for the deaths of
2 million people every year. It was estimated that 88% of that burden is attributable to
unsafe water supply, sanitation, and hygiene is mostly concentrated on children in
developing countries (WHO, 2014). In addition, water quality and safety related to
environmental chemicals adds to the considerable disease burden (Prüss-Üstün et al.,
2011). A number of people are more vulnerable to diseases of the water pollution more
than other populations (Karanis, 2006). As well, poor water supply impacts health by
causing acute infectious diarrhea, repeat or chronic diarrhea episodes, and non-diarrheal
disease, which can arise from chemical species such as arsenic and fluoride. It can also
affect health by limiting productivity and the maintenance of personal hygiene (Hunter et
al., 2010).
16
The vast majority of deaths are mostly of children in developing countries from diarrhea
and subsequent malnutrition, and from other diseases attributable to other disorders in
both developed and developing countries (Bartram and Cairncross, 2010). For instance,
infants and children are exposed to diseases related to the nurse because their immune
systems are not fully and strong enough to fight the evolving toxic pollutants and injuries
resulting from it. Globally, one in 10 deaths in children under the age of five years results
from diarrhea (Chola et al., 2015). Statistics indicated that of the 0·71 million annual
diarrheal deaths, 90% occur in children, mainly from developing countries (Kattula et al.,
2014). Other people who are vulnerable to diarrheal diseases cancer patients, patients
with HIV/ AIDS and transplant patients, the elderly, and pregnant women (including a
child who has not yet) generates.
Although microbiological contamination remains the largest cause of water-related
morbidity and mortality globally, chemicals in water supplies may also cause disease, and
evidence of the human health consequences is limited or lacking for many of them.
Health risks that result from chemical contamination of drinking water include skin
lesions, vascular and heart problems, cancer of the bladder, lungs, skin, liver or kidney
failure, and damage to the nervous system, and suppress the immune system, and birth
defects (Rajendran et al., 2013; Villanueva et al., 2014). Many other diseases associated
with water in other ways. Water may act positively in control of each through its use in
hygiene, and can attend as a source of path or other diseases where necessary to contact
with water for the transfer of the disease or as mediators of disease or insect paths
necessitate water to complete their life cycle (Bartram and Cairncross 2010; Hunter et al.,
2010; Sellathurai et al., 2014).
A World Health Organization (WHO) report found that almost one tenth of the global
disease burden could be prevented by improving water supply, sanitation, hygiene and
management of water resources (Prüss-Üstün et al., 2008).
17
2.3 Water-related diseases
Water related disease encompasses illness resulting from both direct and indirect
exposure to water, whether by consumption or by skin exposure during bathing or
recreational water use. It includes disease due to waterborne or water associated
pathogens and toxic substances (Grabow, 2007; Stanwell-Smith, 2009). WASH expert
Peter Gleick disaggregates water-related diseases into four classes based on their
connection to water quantity and quality (Gleick, 2002). ‘Waterborne diseases’ are those
caused by pathogenic bacteria and viruses ingested along with water contaminated by
human or animal feces and include cholera, typhoid, amoebic and bacterial dysentery,
and other diarrheal diseases. ‘Water-washed diseases,’ that is, favored by inadequate
hygiene conditions and practices and susceptible to control by improvements in hygiene
such as scabies, trachoma, and flea, lice, and tick-borne diseases, as well as skin or eye
contact with contaminated water. ‘Water-based diseases, referring to transmission by
means of an aquatic invertebrate host which includes dracunculiasis, schistosomiasis, and
other helminthic parasites, are found in intermediate organisms inhabiting contaminated
water. Finally, ‘water-related insect vectors’ are diseases spread by insects that breed or
feed in or near contaminated water, including malaria, onchocerciasis, filariasis,
trypanosomiasis, and yellow fever. To these recognized categories might be added a
fourth, ‘water-enabled diseases,’ such as malnutrition, vitamin deficiency, anemia, and
immune system conditions which, although not directly caused by water, may be
exacerbated by chronic water deprivation, and a fifth, ‘water-related injury,’ which
includes drowning due to floods and extreme weather events. Diseases related to the
contamination of drinking water with toxic chemicals, including those linked to cancer,
are generally not included in most measures of water-related disease, despite the fact that
they have long been the primary water quality concern in wealthier countries and are of
increasing importance in the developing world (Gleick, 2002; Parkin, et al., 2002;
Cairncross and Valdmanis, 2006; Salzman, 2012). It is worth to mention that many
water-related infectious diseases have been stated to as the “neglected diseases of
neglected populations,” due to their receiving of little attention and disproportionately
affect poor people in developing countries, those water-related diseases likely to occur in
18
isolation; populations with limited access to clean water and sufficient sanitation
(Ehrenberg and Ault, 2005). Consequently, face simultaneous exposure to all categories
of these illnesses and thus face multiple, repeated, and chronic infection, greatly
increasing the risk of mortality. Isolating a specific cause of death in these circumstances
is a difficult task made even more so because such communities also tend to lack access
to basic medical care and public health programs (Ehrenberg and Ault, 2005).
2.3.1 Classification for water-related diseases according to biological health hazards
Classification for water related-diseases according to biological health hazards based
mainly on the pathogens which are characteristically placed in four classes according to
the various aspects of the environment in which change with human intervention
(Ahmed, 2010); waterborne, water-washed, water-based, and water-related insect-
vectors. The first three classes are utmost evidently related to the lack of enhanced
domestic water supply (Gleick, 2002). These given as following:
Water-borne diseases: Among water-related diseases, waterborne illnesses, is the most
widely associated with the WASH sector. They are related to poor sanitation, inadequate
hygiene, arise from ingestion of and contact with water contamination by human body
secretions and/or animal faeces or urine infected with viruses or pathogenic bacteria,
which are directly transmitted when the water is consumed or used for the preparation of
food, in addition to deficiency of access to acceptable amounts of safe water (WHO,
2008). Viruses are transmitted as organisms much smaller than bacteria and incapable of
multiplying outside the host, but often associated with larger particles in the water
environment, some viruses that infect perorally are later transmitted to other tissues (e.g.,
the liver), where their infection causes illness more significant than common
gastroenteritis (World Health Organization WHO, 2004). Example for viral waterborne
diseases (hepatitis (A), Poliomaylities, and viral dihariael diseases). For bacterial water
borne diseases (cholera, typhoid, cryptosporidiosis, amoebic and bacillary dysentery,
Shigellosis). Waterborne diseases also include over 30 species of parasites that infect the
human intestines. Seven of these are distributed globally or cause serious illness:
19
Ameobiasis, giardiasis, Taenia Solium Taeniasis, Ascariasis, Hookworm, Trichuriasis,
and Strongyloidiasis.
1. Water- washed disease (Water-privation diseases): They are influenced by the
amount of water. The disease spreads through contact from person to person
(infected) or through contact with infected materials. Poor personal hygiene and
skin or eye contact with contaminated water are the common factor leading to water
insufficiency diseases; such as scabies, trachoma, typhus, diarrheal diseases and
flea, lice and tick-borne diseases, that can be passed from person to person mainly
when there is no adequate water for personal hygiene.
2. Water-based diseases: They introduced by the water provides habitat for
intermediate host objects that parasites are able to pass on part of their life cycle and
then forms infective worms in the water is passed to humans. Such diseases are
generally passed to humans when they drink polluted water or use it for washing.
The records of widespread examples in this group are schistosomiasis and
Dracunculiasis. Schistosomiasis currently infects 200 million people in 70 countries.
3. Water-related insect vectors diseases: Includes those diseases spread by insects
that breed or feed near contaminated water, including: malaria, onchocerciasis, and
dengue fever necessitate water to promulgate insect vectors such as (mosquitoes,
black flies) that spread pathogenic microbes when taking blood from human being
(WHO, 2008). Another group of water-related insect-vectors disease,
schistosomiasis which is caused by a worm or blood fluke whose life cycle involves
specific aquatic snails and human contact with contaminated water. Environment
requirements of such insect and snail vectors are species-specific and can contain
large and small water bodies and channels such as (lakes, lagoons, rivers, ditches,
culverts and sewers), poorly drained soils, and containers (for example; pots, tires,
leaves, tree stumps). It is worth to be mentioned that these diseases are not
characteristically associated with lack of access to clean drinking water or sanitation
services, and they are not included here in estimates of water-related deaths. It is
20
needed to be noted, though, that their spread is often eased by the construction of
large-scale water systems that create conditions auspicious to their swarms.
2.4 Brief description of common waterborne diseases
The following are the most common of waterborne diseases according to the
Environmental Protection Agency (EPA, 2002):
Amebiasis: caused by protozoa and the indications include fatigue, diarrhea, flatulence,
abdominal discomfort and weight loss.
Campylobacteriosis: caused by bacteria and the symptoms include diarrhea, abdominal
pain and fever.
Cryptosporidiosis: caused by protozoa and symptoms include watery diarrhea, loss of
appetite, substantial loss of weight, bloating, increased gas, nausea.
Giardiasis: caused by protozoa and the symptoms include Diarrhea, abdominal
discomfort, bloating, and flatulence .
Hepatitis: caused by a virus and the indications include fever, chills, jaundice, dark urine
and abdominal discomfort.
Shigellosis: caused by bacteria and the symptoms include bloody stool, diarrhea and
fever.
Typhoid: caused by bacteria due to eating contaminated food. Symptoms are
characterized by headaches, nausea and loss of appetite, fever, constipation, diarrhea,
vomiting, and an abdominal rash (Unicef, 2003).
Viral gastroenteritis: caused by a virus and the symptoms include gastrointestinal
discomfort, diarrhea, vomiting, fever and headache.
Diarrhea: Diarrhea is caused by a variability of micro-organisms together with viruses,
bacteria and protozoans. Diarrhea causes a person to lose both water and electrolytes,
21
which leads to dehydration and, in some cases, to death. Frequent incidents of diarrheal
disease makes children more exposed to other diseases and malnourishment. Diarrhea is
the most significant public health problem which is associated with water and sanitation.
The humble act of washing hands with soap and water can censored diarrheal disease by
one-third. Subsequent to providing acceptable sanitation facilities, it is the basic to
avoiding waterborne diseases (Unicef, 2003).
Cholera :
Cholera is a severe bacterial infection of the intestinal tract. It causes severe attacks of
diarrhea that, without treatment, can quickly lead to serious dehydration and death.
Cholera is a world-wide problem, especially in emergency situations. It can be prevented
by access to safe drinking water, sanitation and good hygiene behavior (including food
hygiene) (Unicef, 2003).
Guinea worm disease:
People contract the disease (also known as Dracunculiasis) when drinking water
contaminated with Dracunculus worms. The worms mature into large (up to a meter long)
adult Guinea worms and leave the body after about a year, causing debilitating ulcers.
The rate of Guinea worm disease cases is steadily decreasing worldwide as a result of a
concerted international inventiveness (Unicef, 2003).
Intestinal worms:
People become infected with intestinal parasitic worms (also known as helminthes)
through contact with soil that has been polluted with human feces from an diseased
person, or by eating polluted food. Intestinal worms infect about 10% of the inhabitants
in the developing countries and, depending upon the severity of the infection, lead to
malnourishment, anemia or slow growth. Children are particularly vulnerable and
naturally have the largest number of worms.. In fact, roundworm and whipworm alone
are expected to affect one-quarter of the world’s population (Unicef, 2003).
22
Trachoma:
Trachoma is an eye infection spread mostly through poor hygiene caused by lack of
adequate water supplies and unsafe environmental sanitation conditions. About 6 million
people are blind today because of trachoma. It affects women 2 to 3 times more than
men. Children are also especially vulnerable. Studies have found that providing adequate
water supplies could decrease infection rates by 25% (Unicef, 2003).
2.5 Impact of water, sanitation and hygiene interventions on reducing water related
diseases and improving health
The relationship between ill-health and poor water supply, sanitation and hygiene has
been a concern of public health since the beginning of the discipline in the 19th century
(Loevinsohn et al., 2014). Despite the full list of water-related infections is large and
varied, most are only marginally affected by water supply improvements (Cairncross and
Valdmanis, 2006). Many studies have reported the results of interventions to reduce
illness through improvements in drinking water, sanitation facilities, and hygiene
practices in less developed countries (Fewtrell et al., 2005). Quality of water, sanitation
systems and hygiene behavior are all connected to infectious diseases frequency in
communities. For instance, promoting the simple and inexpensive hygiene procedure
hand washing with soap (HWWS) has proved to be a remarkable effective way to prevent
infections in the rural settings of developing countries (Ejemot-Nwadiaro et al., 2008;
Cairncross et al., 2010b).
It is worth to mention that the global burden of disease and mortality rates could be
reduced by about 9.1% and 6.3%, respectively, if rapid success is attained in facilitating
access to water, sanitation, and hygiene facilities (Prüss-Üstün, 2008; Joshi and Amadi,
2013). Previous literature has shown considerable studies regarding the effects of lack of
appropriate water facilities, hand washing, and hygiene practices on child health
outcomes. Impaired cognitive learning and learning performance are long-term outcomes
of the negative effects of infections such as diarrhea, worm infestations, and dehydrations
which are largely attributed to poor water, sanitation, and hygiene conditions (Gottfried,
2010). Scholars suggest that water, sanitation, and hygiene interventions are effective at
23
reducing diarrheal illness significantly (Joshi and Amadi, 2013). Besides, water supply,
sanitation and hygiene interventions act at different points along faecal-oral transmission
paths (Waddington and Snilstveit, 2009) and may interact synergistically to reduce
exposure to pathogens (Bartram and Cairncross 2010; Mara et al., 2010). However, it is
not enough merely to know that an intervention aimed at improving health works in order
to adapt it to new situations and widen its impact. Understanding how it achieves its
effects how it is made to work or not, is crucial (Loevinsohn et al., 2014). Whereas the
prevention of waterborne disease transmission requires improvements in water quality,
water-washed transmission is interrupted by improvements in the availability and hence
the quantity of water used for hygiene and the purposes to which it is put. Water supply
may affect water-based transmission (for example, if it reduces the need for people to
enter schistosomiasis-infected water bodies) or water-related insect vectors of disease (for
example, if a more reliable supply averts the need for the water-storage vessels in which
dengue vectors breed), though that will depend on the precise life cycle of the parasite
involved and the preferred breeding sites and behavior of the vector (Cairncross and
Valdmanis, 2006).
On the other hand, the motivations of individuals to practice hygiene are often not
primarily based on biomedical facts or a possibility to get sick (Rheinländer et al., 2010)
and that is why traditional health education based on knowledge of germs and disease
transmission do not bring change in people’s hygiene behavior (Scott et al., 2003). In
Egypt, the government invested heavily for twenty-five years in a programme to increase
child survival, focusing on the provision of preventative health measures, such as
vaccinations and potable water. The reductions in child mortality rates were ‘spectacular’,
yet the rate of improvement has slowed dramatically. Some Egyptian experts argued that
this is because children’s living conditions, particularly with regard to sanitation, have
not improved commensurately with health services and provision of potable water
(United Nations Development Programme (UNDP) and Institute for National Planning
(INP), 2004). Providing potable water and safe sanitation systems is thus a relatively
inexpensive, effective means to improve public health (Montgomery and Elimelech,
2007).
24
Accordingly, promotion programs cannot be successful without considering the cultural
and social aspects of local individuals (Jumaa 2005, Panter-Brick et al., 2006). That is
why community-based approaches that notice community priorities and enable the
participation of community members are recommended in hygiene promotion
(Rheinländer et al., 2010).
Notwithstanding, the knowledge alone is not usually enough for changing habitual
behavior (Rajaraman et al., 2014). Habit is learned behavior which is performed
automatically by cues and usually part of a routine (Curtis et al., 2009). To change old
habits, interventions must change the environment so that the old cues will be disrupted
and new ones created. Transformation from behavior to habit requires also numerous
repetitions in a stable environment (Verplanken and Wood, 2006).
In conclusion, hygiene behavior change is nevertheless complex and requires in order
succeeding paying attention to the local culture, values and socioeconomics. The role of
local people who work in the hygiene promotion programs and the coming true of the
project in practice are rarely studied topics but important and necessary perspectives
when there is a need for effective hygiene promotion (Joshi and Amadi, 2013). Finally,
understanding the level of knowledge and practices related to basic personal hygiene
among target populations is needed to plan and design behavioral interventions
(UNICEF, 2008).
2.6 Previous studies
Al Zarqa (2010) In his study focused on the relationship between water pollution in
central and northern governorates of Gaza Strip, and the effects of using such water on
health. He justified in his study that Gaza Strip is suffering from water quality and
quantity problems, and consequently such poor quality of water caused many diseases.
He focused on main four common water borne diseases such as bloody diarrhea,
amobiases, Giardiases and hepatitis A. The results confirmed that microbiological
pollution in the governorates greater than the standards of World Health Organization to
all years from 2004 to 2008, and also it verified statistical relations between water
25
contamination with total and fecal coliforms and infected with bloody diarrhea -
amobiases- Giardiases- hepatitis A.
Haneya (2010) In his study verified if there is microbiological contamination at
desalinated water in Gaza city schools in order to determine the source of contamination
if any. Also, to determine the difference between drinking water microbiological quality
between schools moderated by Ministry of Higher Education (MOHE) and schools
moderated by United Nations Relief and Works Agency (UNRWA). Results indicated a
microbiological contamination in the desalination plants inlet and in schools’ water tanks.
The results illustrated that, the microbiological safety of desalinated drinking water at
Gaza city schools has improved in the last three school years (2008-2009 to 2010-2011).
Haneya mentioned in his study that due to weakness of monitoring program of
desalinated drinking water, this lead to increase the ratio of contaminated schools. Results
demonstrated that well maintenance of the desalination plant lead to keep the product of
the plant safe and well accepted. As well, when the inlet of the plant was contaminated
the UV unit helped to kill the source of contamination, and the chlorination process
insures the safety of the plant product.
Padilla (2012) evaluated the effectiveness of water, hygiene, and sanitation interventions
in lowering diarrheal morbidity across the Globe. The findings of this study conclude that
all types of interventions can be successful in lowering diarrheal rates, and that more
implementation of interventions is necessary in order to eventually provide universal
access to increased sanitation and potable water. The amount of few of sanitation
interventions, along with the absence of water quantity interventions and research studies
performed in Oceania since 2003, highlight the crucial necessity for more research in
these areas.
Taleb (2014) in his study, investigated if there is potential water- borne diseases caused
by waste in Wadi Gaza, through collecting soil sampling along the course of the Wadi
and analyzing the samples in accredited laboratories. The study includes a statistical
analysis of the infected of water- borne diseases of urban areas close to and far from the
26
Wadi, through collection data Which contains number of injured by three diseases that
have been identified in this research as an indicator of the presence of bacterial infections
then analysis this data by Excel and Arc GIS 9.3. The analysis of infected people data
showed Al-Buraj and Al-Nusirat got highest value in Dysentery infections among all
Gaza Governorates. This revealed that Wadi Gaza bad conditions can contribute in
increasing the dysentery infections. The analyses also show that Al-Nusirat and Wadi
Gaza area got the highest value of Typhoid infections in the middle area, Wadi Gaza and
Al-Nusirat got the highest number of Hepatitis A infections of the middle area that is very
close Wadi Gaza.
Yassin et al. (2006) evaluated the contamination level of total and faecal coliforms in
water wells and distribution networks, and their association with human health in Gaza
Governorate, Gaza Strip. Results indicated the contamination level of total and faecal
coliforms exceeded that of the World Health Organization (WHO) limit for water wells
and networks. However, the contamination percentages in networks were higher than that
in wells. From the other hand, the results emphasized that diarrheal diseases were the
highest self-reported diseases among interviewees in Gaza city. Such diseases were more
prevalent among people using municipal water than people using desalinated water and
water filtered at home for drinking (OR ¼ 1.6). Intermittent water supply and sewage
flooding seemed to contribute largely to self-reported diseases. The researchers in their
study reported that water quality has deteriorated in Gaza Strip, and this may contribute
to the prevalence of water-related diseases. Self-reported diseases among interviewees in
Gaza City were associated with source of drinking water, intermittent water supply,
sewage flooding and age of water, and wastewater networks.
El-Nahhal1 and Harrarah (2013) in their study characterized the current situation of
drinking water in Khan Younis Governorate (Kh.Y.), Gaza, Palestine and correlates it
with an associated heath problem. About 21 fresh water samples were collected from
different water supply sites in Kh.Y. and analyzed for nitrate, chloride, total dissolved
salts (TDS) and for fecal and total bacteria. They also analyze the environmental situation
among the population in Kh.Y. and correlates it with the current health problems.
27
Chemical parameters indicate that only 3 wells contained nitrate, Chloride and total
dissolved salts (TDS) levels below the WHO standards respectively, whereas the
remaining wells contained nitrate, chloride and TDS levels far above the WHO standards.
Biological parameters indicate that only 6 wells above all were contaminated with fecal
coliform and total coliform. Data from the ministry of health indicate that disease cases
are progressively increased from one year to the next one indicating a high health risk.
The researchers justify that this situation may have a correlation with the growing
incidence of infectious and non-infectious diseases. Improvement of water quality can be
possible by implementing strong environmental initiatives such as pollution control
measures and clean water act.
Aryal et al. (2012) In their study was aimed to find out the burden of diarrhoeal diseases
at different scenario of water supply system and sanitation status in Nepalese context.
The results revealed that most of the households didn’t treat water before drinking. Hand
washing practice was found to be more than 90% regardless of toilet availability. The
greater risk of acquiring diarrheal disease and higher burden of disease in situation of
unprotected water source and absence of toilet shows that these are still important
contributing factors for diarrheal disease in Nepal. Use of sanitary toilets and protected
water source are the important measures for diarrheal disease prevention in Nepal.
The United Nations Children’s (UNICEF) and World Health Organization (2009)
The study investigated why children are still dying? And what can be done? The study
examined the latest available information on the burden and distribution of childhood
diarrhea. It also analyzed how well countries are doing in making available key
interventions proven to reduce losses diarrhea. Most importantly, it lays out a new
strategy for diarrhea control, one that is based on interventions drawn from different
sectors that have demonstrated potential to save children’s lives. It sets out a 7-point plan
that includes a treatment package to reduce childhood diarrhea deaths, as well as a
prevention package to make a lasting reduction in the diarrhoea burden in the medium to
long term.
28
UNICEF- occupied Palestinian territory (2011) In the report of protecting children
from unsafe water in Gaza strategy, action plan and project resources, paints a panorama
of environment degradation in Gaza. Of particular concern to the Humanitarian Country
Team HCT, it documents an alarming situation of dangerously contaminated water and a
heavily polluted, toxic environment, with consequent threats to infants and children. The
multiple needs associated with child exposure to unsafe water are revealed by following
the water contamination cycle from source through distribution, handling and storage, to
consumption and resulting child health outcomes. They are addressed by the action plan
insofar as they fall within the scope of the assigned theme.
UNICEF and Palestinian Hydrology Group (PHG) (2010) In its study about water,
sanitation and hygiene household survey Gaza focused on several aspects of the
environmental and health. The most important aspects are drinking water, domestic
water, wastewater, solid wastes, hygiene and health. The study showed that most
households do not use municipal water supplies for drinking, as 90 to 95 percent of the
aquifer. Gaza’s only water source, is considered unfit for human consumption due to
levels of chlorides and nitrates as high as six times the WHO guidelines. Risks of other
water- borne disease including typhoid or hepatitis are also present because the water
table is not deep and sewage infiltration is probable. Forty-four per cent of respondents
said they take daily showers and 65% wash their hands before eating. Although
appropriate hygienic supplies for menstruation are available, they are costly and public
awareness of proper hygiene practices is low. Due to poor water quality and hygiene
practices, one in five households (20%) had at least one child under the age of five who
had been infected with diarrhea in the four weeks prior to being surveyed. The results
showed that incidence of diarrhea were much higher in Beit Hanoun, with 38% of
households reporting at least one child affected by severe diarrhea symptoms during the
survey period. Two immediate priorities include a comprehensive survey on water quality
and health indicators to correlate the incidence and prevalence of water borne diseases
with water quality; and additional desalination units to expand access to safe water for
drinking and home. Based on the results of data analysis study recommended the
following: Advocate for an end to the Gaza blockade, conduct a comprehensive
29
household needs assessment, introduce additional desalination units, and strengthen
monitoring and surveillance system.
Pathak (2015) In his study, he was documented that groundwater in one-third of India is
not suitable for drinking purpose. Waterborne diseases such as cholera, gastroenteritis,
malaria, and diarrhea occur every year during summer and rainy seasons in India because
of poor quality drinking water supply and sanitation. Waterborne diseases may spread as
a result of inadequate administration of the water supply as well as discharge. The poor
water quality spreads disease, causes death and obstructs socio-economic development.
About five million people die due to waterborne diseases. These diseases affect education
and result in loss of work days.
Maxwell et al. (2012) examined the profile of water related diseases in Benue State in
Nigeria from 2000 to 2008. The researchers mentioned that their examination was done
against the backdrop of the intervention effort of governments and organizations in the
State with a view to assessing the successes and constraints; analyze the trend and spatial
dimension of these diseases in the study area and to suggest appropriate
recommendations for management purposes. The results showed that cases of water
related diseases were recorded in all areas of the state with varied dimension. In order of
magnitude of cases studied, malaria ranked the highest, followed by diarrhea, dysentery,
filariasis, onchereriasis, schistosomiasis, typhoid and cholera. The study also showed a
decline in the number of cases of these water related diseases within the period under
examination. This probably may be attributed to some intervention by some
organizations. The researchers recommended the need for intensified public
enlightenment on personal hygiene, provision of improved water supply in communities
where is lacking, and rehabilitation of broken down water infrastructures, water quality
surveillances, re-commitment on the part of government and non-governmental
organizations in effort to combat water related diseases in the state.
Azizullah et al. (2011) In his study discussed a detailed layout of drinking water quality
in Pakistan with special emphasis on major pollutants, sources of pollution and the
30
consequent health problems. The main findings of this review disclosed that both surface
and groundwater sources in Pakistan are highly polluted and not safe for human
consumption as most of the pollutants exceed the quality standards for drinking water.
The researchers reported a lack of proper monitoring of water quality particularly in rural
areas. Water disinfection practices like chlorination are either nonexistent or
unsatisfactory and treatment plants, if they exist, are not providing quality water to the
public. Bacteriological and chemical pollution of public drinking water have been the
cause of waterborne diseases in many parts of the country. However, comparatively little
data are available regarding water-related diseases due to the lack of diagnostic facilities
and maintenance of records. Accordingly, a surveys need to be conducted in various parts
of the country to obtain a clear picture of water-linked diseases. One of the main
recommendations accomplished by the researchers is the necessity of public awareness
campaigns to be launched to educate the population about the importance of safe drinking
water.
Fuller et al. (2014) In their study assessed whether the joint effects of water and
sanitation infrastructure, are acting antagonistically (redundant services preventing the
same cases of diarrheal disease), independently, or synergistically; as well assessing how
these effects vary by country and over time. The researchers used data from 217
Demographic and Health Surveys conducted in 74 countries between 1986 and 2013.
They used modified Poisson regression to assess the impact of water and sanitation
infrastructure on the prevalence of diarrhea among children under 5 years old. The results
revealed that impact of water and sanitation varied across surveys, and adjusting for
socio-economic status drove these estimates towards the null. Sanitation had a greater
effect than water infrastructure when all 217 surveys were pooled; however, the impact of
sanitation diminished over time. Based on survey data from the past 10 years, the study
disclosed no evidence for benefits in improving drinking water or sanitation alone, that
water and sanitation interventions should be combined to maximize the number of cases
of diarrhoeal disease prevented in children under 5 years old. Accordingly, the
researchers recommended conducting further research which should identify the sources
of variability seen between countries and across time.
31
Abu Amr and Yassin (2008) evaluated the total and faecal coliform contamination in
water wells and distribution networks for a period of seven years, and their association
with human health in Khan Younis Governorate in the Gaza Strip. Data were obtained
from the Palestinian Ministry of Health on total and faecal coliform contamination in
water wells and distribution networks, and on the incidence of water-related diseases in
Khan Younis Governorate. An interview questionnaire was conducted with 210 residents
of Khan Younis Governorate. Results showed that total and faecal coliform
contamination exceeded the World Health Organization’s limit for water wells and
networks. The contamination percentages were higher in networks than in wells.
Diarrhoeal diseases were strongly correlated with faecal coliform contamination in water
networks (r = 0.98). This is consistent with the finding that diarrheal diseases were the
most common self-reported diseases among the interviewees. Such diseases were more
prevalent among subjects who drank municipal water than subjects who drank
desalinated or home-filtered water (odds ratio = 2.03). Intermittent water supply,
insufficient chlorination and sewage flooding seem to be associated with self-reported
diseases.
Abu-Hejleh (2004) investigated the relationship between water quality and health
among the people of Tubas district. The researcher used several strategies were used
including: examination of available patients records from local governmental clinics; a
random sample of school children and questionnaires distributed to households. Results
showed that, with respect to water-related diseases, diarrhea was the most common
disease, particularly among students, followed by eye and skin diseases. There was a
significant relationship between hygienic conditions and the place of residence and this
was clear among the residents of the village of Tammon. The percentage of water-related
diseases in Tammon area was the highest among the different areas as it reached
(43.39%), Tubas, and Aqqaba respectively. Although, a high level of wariness was
reported regarding the knowledge of importance of water and health (79.7%), practices
do not reflect that as most of the study population do not practice the cleaning of their
water storage resources (63.7%), and only (15.8%) seems to boil water as a method for
32
disinfection. Other practices such as lack of proper use of chlorine, raising of animal at
homes and ways of collected rain water, all seems to indicate a high risk for water
pollution. Reviewing patients files also seems to indicate that the area in general is
suffusing from several health related problems. A significant relationship between water-
related diseases and the following variables: Place of residence, quantity of available
water for use, methods of water collection, public awareness, existence of toilets, the
distance between toilets and water source, raising of animals at home, distance between
water storage sources and sepses was observed.
2.7 Palestinian water rights
Palestine has accepted the international law for freshwater resources. Palestine is allowed
to an equitable and reasonable distribution of shared freshwater resources, counting those
in the groundwater aquifers and the Jordan River. Israel has ignored the international law
and determined for a one-sided decision. The Water Law No. 3 of 2002 is measured to be
as the basic legislation for any activities related to water sector. This law contains all
regulations that govern water in the Palestinian territory and Gaza Strip (Husseini, 2004).
Water rights between Israel and Palestine are in dire need for a reassessment. The key
players are clearly aware that the Oslo Accords, that were fundamental pro-Israeli in the
first place have become almost a sidesplitting mandate with regards to water. The small
number of policies that were implemented in 1993 in favor of Palestinian rights have
been systematically rejected or unimplemented by Israel. Institutions and Organization
that have surrounded the issues have become mere pawns of Israel’s continued
dominance. The International Community has no power whatsoever to remedy the
fundamental flaws that ravage the management of water in the area.
There is enough water to go around in the Occupied Palestinian Territory (OPT), but
discriminatory policies mean that many Palestinians are left with a trickle. Average
Palestinian daily consumption of water is about 70 liters per person, well below the 100
liters recommended by the World Health Organization (WHO). The average Israeli daily
33
per capita consumption is about four times the Palestinian average (300 liters). This is in
contrast to European levels where for example the average daily water consumption in
the UK is 149 liters per person. As an Occupying Power, the Israeli government is
responsible under International Humanitarian Law for the well-being of Palestinians,
including ensuring that they have adequate water supply. Even though it exercises
sovereign control over water resources, the Israeli government has neglected this
obligation and prevents the development of water and sanitation infrastructure in the OPT
(Howard and Bartram, 2003).
The threshold for “absolute scarcity” in relation to water resource availability is generally
considered to be 500 m3/yr per capita bases. Israel currently has per capita utilization of
fresh water for about 330 m3/yr, while the equivalent figure for Jordan is 160 m3 /yr, and
that for Palestine is presently about 70 m3/yr. It is clear from these figures that the per
capita use of water in Israel is almost five-fold greater than that in Palestine. International
authorities on water use, such as the World Health Organization and the Food and
Agriculture Organization, make no distinctions between the magnitude of the demand for
water by different communities within countries, noting only that the degree of
attainment of adequate water supplies may differ markedly according to the level of
socio-economic development and other factors (Howard and Bartram, 2003; WHO,
2003).
The International Covenant on Economic, Social and Cultural Rights of 1966 (ratified by
Israel in January 1992 and by the other riparian States to the Jordan River basin in 1976)
has been interpreted to include the human right to water (United Nations, 2002; see also
Guissé, 2004). These authorities suggest that all persons should have access to water, and
that no distinctions should be made on the basis of color, creed or other matters. It is
argued here that this should extend to Israelis and Palestinians. The concept of equal per
capita shares of water for Palestinians and Israelis in the region is not new, having been
proposed in the early 1990’s and repeated more recently. Thus, (Shuval 1992, 2000)
suggested that 125 cubic meters/person/year (equivalent to 342 liters/person/day) would
be an appropriate volume for “domestic, urban and industrial use” for both the
34
populations, with supplies for agriculture being additional to this currently, but deriving
mainly from recycled wastewaters in the future. In addition, strong arguments have been
made that there is no basis for discrimination between the Israeli and Palestinian
populations in this respect, and that many stakeholders on both sides have accepted this
principle (Shuval, 2000). Consistent with this analysis, it is argued here that the
permanent status negotiations should seek to allocate water on an equal per capita basis in
Israel and Palestine as a prima facie reflection of their equitable entitlements.
Summary
Recently, water, sanitation and hygiene are recognized by the UN as a fundamental
human right, essential for human dignity and wellbeing. Now it is concerned with
domestic water and sanitation, and associated behavior, to derive benefit from them and
cause no harm to others. Water quality will also influence particularly human health and
disease prevention, where improving access to safe drinking water can result in tangible
benefits to health.
According to the Environmental Protection Agency (EPA, 2002), there are many
waterborne diseases worldwide, but the most common of these waterborne diseases are
Amebiasis, Campylobacteriosis, cholera, Cryptosporidiosis, Giardiasis, Hepatitis,
Shigellosis, Viral gastroenteritis, Tayphoid, Diarrhea, Guinea worm disease, intestinal
worms, Trachoma. Despite the full list of water-related infections is large and varied,
most are only marginally affected by water supply improvements (Cairncross and
Valdmanis, 2006).
Previous literature has shown considerable studies regarding the negative health impact
of access to contaminated water on health. Another studies have reported the results of
interventions to reduce illness through improvements in drinking water, sanitation
facilities, and hygiene practices in less developed countries. In the same context,
literatures studied the effects of lack of appropriate water facilities, hand washing, and
hygiene practices on child health outcomes. Scholars suggest that water, sanitation, and
35
hygiene interventions are effective at reducing diarrheal illness significantly (Joshi and
Amadi, 2013)
In conclusion, hygiene behavior change is nevertheless complex and requires in order
succeeding paying attention to the local culture, values and socioeconomics. The role of
local people who work in the hygiene promotion programs and the coming true of the
project in practice are rarely studied topics but important and necessary perspectives
when there is a need for effective hygiene promotion (Joshi and Amadi, 2013). Finally,
understanding the level of knowledge and practices related to basic personal hygiene
among target populations is needed to plan and design behavioral interventions
(UNICEF, 2008).
36
CHAPTER 3
STUDY AREA
3.1 Geographic and demographic (Al Shuka area)
Al-Shuka area is small district in Rafah governorate located in the south-east of the Gaza
Strip, where bounded on the western side of Rafah and it is separated from Rafah by
Salah Al-Din street from the west. Egyptian-Palestinian border is to the south of Al
Shuka. It is bounded from the east by the occupied territories in 1948 and Sufa crossing
boarder, Al-Fakharri area is in the northern part of Al Shuka. The total area of Al Shuka
is about 22 square km and the most area is agricultural areas as documented by (Alnahhal
and Aljojo, 2013). According to Al Shuka municipality, the last demographical Statistic
in Al Shuka was held in 2011. Based upon to the survey conducted by Alnahhal and
Aljojo in 2013, the number of houses was 3,000 with 16,800 people without Gender
disaggregation result. According to Palestinian Centre Bureau, they include the
population and gender disaggregation of all Rafah and don’t mention Al Shuka as
separated area.
37
Fig.3.1: Map shows the study area of Al Shuka district in Rafah governorate
3.2 Economic situation, environmental and land use
Most of Al Shuka residents are mainly depending on the agriculture sector. The economic
situation of the people is very weak as they mostly are depending in the agricultural
sector. The agricultural sector is facing huge sufferings and problems in Gaza Strip
because of the Israeli siege and blockade since long time. No external and abroad markets
which suffering in this sector. Depending only on local markets, make the production and
maintenance costs considerably higher than the products revenues.
Particularly, in Al Shuka as agricultural area, there are other main reasons make the
people suffer more and more. The reasons back to the regular abuse practices of the
Israeli militaries such as the demolition of homes, the destruction of roads, roughing
lands, cutting water lines. Moreover, the lack of fresh water and limited suitable water for
38
agricultural increase the sufferings. Therefore, there is a serious threat about the total
collapse of the agricultural sector in the area.
According to the Municipality, the unemployment rate is significantly raised to 90% in
the area. The high rate of the unemployment is due to the deteriorated conditions of
agricultural sector and no job opportunities in the occupied Palestinian “Green Line”. The
vast majority of the Al Shuka population become below the poverty line (Alnahhal and
Aljojo, 2013).
3.3 Educational situation
In Al Shuka area there is two schools (one primary and one preparatory). The two school
work on two shifts because of the high number of student and less availability of schools.
According to the schools’ records, there are about 4,000 students. No secondary schools
are located in the area; therefore, the students have to travel every day to Rafah city to
join the secondary schools (Alnahhal and Aljojo, 2013). In Al Shuka area, there is about
5 kindergartens, of 100 to 150 children in each kindergarten. The kindergartens were
located in the dense areas especially south sub area. There is less number of kindergartens
because of the low economic levels of the family, which make their children go directly
to the schools instead of the kindergarten. According to the municipality, there are many
qualified, university degree holders, and fresh graduates in the area. However limited job
opportunities increase the sufferings of the people in the areas (Alnahhal and Aljojo,
2013).
3.4 Infrastructure
Al Shuka area suffers from the lack of the infrastructure. No paved streets, no sewage
systems, and no drainage networks. The municipality water networks cover only 60 % of
the whole area. The municipality water sources are from 3 wells located 10 km far from
the area to the west. The agricultural wells are constructed either legally or illegally.
There are huge shortages in the quantity of the need water. The quality of available water
39
either from the municipality wells or the agricultural (private) wells is not suitable for the
drinking purposes.
3.5 Power resources in the area
According to the collected data through the interviews and field visits with the key
informant, local community, local municipality, local CBOs, and the INGOs, besides the
team observation through the mapping phase, the power resources and status in Al Shuka
area were explored as following:
3.5.1 Community
Social condition:
The source of the power in Al Shuka is the people themselves and they are the only
decision makers in the area. The people don’t take any action towards their rights and
needs. Based upon focus group discussion held with men, men have the power among the
women, girls, and boys in most life features and aspects: the women movement,
transport, education, work, and any other activities outside the home. Men think that the
women are oppressed in all features.
In this regard, based upon the interview with the Municipality, there are different stories
about losing women rights and having the women bad situation was registered.
Therefore, in cooperation with the municipality, Local Community Based Organizations
(LCBOs), and INGOs, Al Shuka people need to be aware how to actively participate in
the different community activities. Motivation of people with more focus toward women
participation, saving their roles and how to advocate against their rights is highly
required. The motivation need to be with thoroughly men coordination and cooperation.
Economic situation:
About 90 % of Al Shuka people are unemployed and have no permanent jobs. Food
security of people is relatively accepted by depending on not permanent jobs which can
secure only the food day by day. No savings could be secured.
40
Health situation:
In the area, there are two clinics. One is owned by Government and the other is belonged
to the UNRWA. Both clinics have relatively equipped and have qualified staff. Both
clinics are not specialized and deal with the general and common epidemics. was
obtained through the researcher visit to the main clinics at AlShuka area. As wand
according to the survey conducted by Environment Friends Association in the area.
People can visit both clinics. The health situation of most people in Al Shuka is not good
and not accepted. They always complained from chest and skin diseases which may relate
to the infectious diseases of the waste water bad situation.
Environmental condition:
People depend upon the cesspits to manage their waste water. The cesspits are not the
suitable environmental solution for managing the waste water. However, the bad
economic situation and the weaknesses of the municipality infrastructures such as the
sewers systems force people to don’t take care of these cesspits. Flooding of the cesspits
is regular and forming waste water pools in the roads and the yards is existent all through
the year. Always, people discharge the cesspits and the pools manually.
3.5.2 Municipality of Al Shuka
Al Shuka municipality has several duties, roles and responsibilities as all other
municipalities in Gaza Strip. Al Shuka Municipality showed that it has the technical and
human resources capabilities in planning and designing, managing and implementation of
vital and developmental projects such as infrastructure projects in the area. However, the
Municipality has limited financial resources and advanced equipment to lunch itself such
kind of these projects. Therefore, the Municipality is mostly searching funds from
different donors working in Gaza Strip.
From Al Shuka area residents’ point of view, the Municipality did not work hardly to
change and improve the services that it provides in the area since some time ago.
41
Therefore, the residents mostly claim and complain to the municipality to improve the
services that it provides to the community and there is a lot of work and duties that the
Municipality can accomplish.
Major role of the municipality of Al Shuka is providing water service to citizens, where
the municipality supplies the water to the most of Al Shuka homes except homes that
have private wells. Water is distributed to the citizens every two to three days, from four
main wells located 10 km to the west of the region. The municipality of AlShuka monitor
water wells every three months in cooperation with the Palestinian Ministry of Health
(MoH) and Coastal Municipalities Water Utility (CMWU). The analysis includes the
most important tests: TC, FC, CL-, NO3. The Oxfam-GB in collaboration with the
Municipality of Al Shuka to distribute desalinated water to citizens . Currently, the
municipality has signed a project for the distribution of desalinated water with the Maan
Development Center.
Regarding the current condition of the waste water, people have cesspits only as no
sewage systems in the area. Therefore they asked from the municipality to help in solving
the discharging problems of available cesspits and to release their pressure related to the
cost of discharging of the cesspits. Therefore, the cesspits mostly flood in the streets and
open yards. While in the future, there should be a sewage system and households
networks to manage the waste water.
Regarding the current condition of the solid waste, people complain the collection system
of the waste. The solid waste collection is not daily. Therefore, there will be
accumulation of the waste in the streets for some days. Moreover, the collection of the
solid waste could not cover the whole area because of limited resources of the
municipality, solid waste based vehicles, and the unpaved and difficult roads.
3.5.3 Local CBOs
Based upon the power survey, there are about 7 independent local CBOs work in Al
Shuka area, two CBOs are active on the ground, while other CBOs are not active and
42
neglect the area. Based upon held focus group discussions, most available CBOs are not
famous, not active and don’t provide services in the area except the two active CBOs
according to (Alnahhal and Aljojo , 2013). Regarding the active CBOs, one is called
“Mariam Alazraa”. However, it has less capability and needs much support and technical
capacities. While, the other active one is called “Albatool” which is so strong and has a
lot resources and capacities.
Moreover, these CBOs concentrated their activities in the implementation of awareness
and educational programs and courses (health - social - educational). And implementation
of health projects (distribution wheelchair - Uecker - an initial first-aid kit bag).
Agricultural projects (distribution of seedlings - seeds - water tanks), and relief
(distribution of material assistance – food packages).
3.6 Risks which threaten the study area
The risks threaten the community based upon the first priority: the waste water (sewage)
problem.
3.6.1 Health problems
The sewage problem and flooding of the cesspits and waste water pools in the streets and
yards is the main healthy risk and threats the people health. Therefore, transmit of many
diseases in the area such skin diseases (scabies, Abscesses), parasites especially worms,
and chest asthma. From another hand, existent of waste water pools in the streets and
yards considered as the suitable environment for outbreak of the insects and mosquitoes
which transmit many epidemic diseases.
3.6.2 Social isolation
Flooding of the cesspits and forming of waste water pools in the streets and yards cause
bad social situation inside and outside the community through:
Causing many conflicts between the neighbors and nephews.
Social isolation from the surrounding communities.
43
3.7 The role of Oxfam in improving water situation at Al Shuka area:
OXFAM-GB with its partner Palestinian Environmental Friends (PEF) and Youth
Empowerment Center (YEC) jointly have identified 8 areas locate over the Gaza Strip for
most vulnerable beneficiary who are currently suffering from the deterioration of
drinking water quality and bad hygiene situation which may have a severe public health
effects. Al Shuka was one from these identified areas in the Gaza Strip. Oxfam supplied
5,138 families (29,874 people) with water for bi-monthly rounds (based on 6 liters per
person per day) over the whole project period. The implementation of the project
intended to achieve the following goals:
Eliminating potential sources of water borne diseases.
Preventing the reallocation of financial resources to acquire water.
For achieving the study objective and before starting its activities there was a good
coordination with Oxfam-GB team in the Gaza Strip to carry out this study in the region
of Al-Shuka. Oxfam-GB has expressed its cooperation with the researcher dramatically in
terms of facilitating access to any information about the area, or analyses results of water
samples with respect to the study.
44
CHAPTER 4
MATERIAL AND METHODS
4.1 Introduction
The goal of this study is to identify the environmental determinants and socio
demographic factors of common water borne diseases among people of Al Shuka area-
Rafah Governorate, in addition to specific objectives start with intention to identify the
common water borne diseases among people of Al Shuka area, and detect the most age
group affected by the identified common water borne diseases, in addition to identify the
environmental determinants and socio demographic factors associated with common
water borne diseases among individuals of Al Shuka area. Moreover, the researcher
measured if there is a difference in the waterborne diseases prevalence among people
after water supply and total behaviour change intervention by Oxfam- GB at Al Shuka
area (Pre-Post Test).
To implement this study, the researcher followed the appropriate steps of the
methodology which includes the study design, study population, the study sample, the
study instruments, data collection, and data processing and analysis.
4.2 Study Design
Descriptive study was conducted to identify the environmental determinants and socio
demographic factors of common water borne diseases among people of Al Shuka area-
Rafah Governorate. The researcher used a methodological triangulation provided a
combination between quantitative (oral-administrated questionnaire, observation sheet for
households, in addition to water analysis) and qualitative paradigms (focus group
discussion with females’ households). The dependent variable include knowledge,
attitudes, and practices of hygiene; as well the prevalence of water borne diseases at Al
Shuka area, where the independent variables include socio demographic characteristics
including economic status, gender, educational level of households and family size, and
behavioral change intervention.
45
4.3 Study period
The data collection started in the middle of June 2014 and completed at the end of June
2015. Data entry was finished by the end of June 2015, followed by data analysis and
report writing until August 2015.
4.4 Study population
The study population is Al Shuka community which contains 3000 houses with 16.800
individuals.
The population of this study was categorized as follow :
In Quantitative part
The first population was all 3000 households of Al Shuka area.
In Qualitative part
The second population in this study was all females’ households in Al Shuka area.
4.5 Study sample
4.5.1 Sample size
1. In Quantitative part
According to the formula: Sample size = n / [1+ (n/population)] in which n= Z*Z [P (1-
P)/ (D*D)], the confidence level was at 95%, Z (1.96) and the confidence interval was at
(20% ± 5% ), and population size is 3000 households, the detected sample was 227
households for pre-post Oxfam-GB intervention test. However, different limitations
which will be discussed in the section of limitations, forced the researcher to reduce the
sample size to 208 households as the pre-test group, and 153 households as post-test
group. In addition 208 observation sheets were filled before Oxfam–GB intervention and
153 Observation sheets were completed after Oxfam-GB intervention. Water samples
(90) before Oxfam–GB intervention , (48) during and (90) after Oxfam-GB intervention .
46
2. In Qualitative part
Deep discussion was conducted with five focus groups of females from Al Shuka area to
focus on the major drinking water issues that correlated with water borne diseases. The
total number of females in all focus groups was 40. The first focus group was including
(7 females), the second group including (7 females), the third group contain (7 females),
the fourth group contain (10 females) and the fifth group contain (9 females).
4.6 Sampling process
Where Oxfam-GB planned to conduct a health promotion project and planned to
distribute desalinated water tanks among Al Shuka area population, accordingly the
researcher coordinate with social workers at Al Shuka area and local community based
organization at Al Shuka area to facilitate the researcher access to the targeted households
by Oxfam–GB. A simple random sample technique was conducted to collect data.
Selection of households was randomly from the targeted areas to ensure representative
sampling and avoid any selection bias.
In order to support the study findings, qualitative approach were applied by utilizing
observation sheet. Moreover, the study covered females’ household to obtain deep
answers about the health situation and common water borne diseases at al Shuka area
before and after Oxfam-GB intervention.
4.7 Study setting
The study was applied on the households of Al Shuka area.
47
4.8 Site visit and selection process for the study area
This study area was selected in cooperation with Oxfam GB-Gaza office as they have
conducted a health promotion project and planned to distribute desalinated water tanks
among Al Shuka area population. However, the main purpose for selection this study area
was to identify the environmental determinants and sociodemographic factors of common
waterborne diseases among the people of Al Shuka area. Several visits were conducted to
Al Shuka Municipality, Local Organizations and Environmental Friends Association to
identify the study area boundaries and understand the environmental conditions and
health problems in the area.
4.9 Study instruments
The researcher conducted three different tools in order to collect quantitative and
qualitative data from the households of Al Shuka area:
4.9.1 Quantitative method
1. Oral-administered questionnaire
Oral questionnaire was developed in coordination with Oxfam GB-Gaza office to
accomplish the objectives of this research to identify the environmental determinants and
socio demographic factors of common water borne diseases among people of Al Shuka
area- Rafah Governorate. Few modifications were made for matching with the study
objectives. This questionnaire was the main instruments used in data collection. It was
used for the households who were targeted by Oxfam-GB intervention.
Most of the questions were one of two types: the yes/no question, which offers a
dichotomous choice; and the multiple choice question, which offers several fixed
alternatives. A questionnaire was piloted among 10 residents who was excluded the
sample from the actual study sample, and modified as necessary for improving reliability.
The questionnaire addressed the following issues: (1) General socio-economic and
48
demographic characteristics such as income of a family, age, housing condition, family
size, and level of education; (2) Knowledge and behaviour of household towards water
usage and hygiene practice before and after Oxfam-GB intervention (3) Various aspects
of domestic water supply for the people who live in the study area, such as source of
drinking water and interruption of water supply; (4) Usage of roof water tanks and
information about cleaning; (5) Occurrence of water-related diseases and treatment; and
(6) Knowledge of the study population on drinking water contamination in Al Shuka
area. (7) Impact of Oxfam hygiene and water supply intervention on the health status of
people of Al Shuka area (see Annex-1).
A pilot test was carried out on 10 households of Al Shuka area to test the questionnaire
and make the required modification as necessary for improving reliability, and then the
10 participants were not included in the real study. A cover page was provided to give
explanation about the purpose of the study, and a verbal explanation was also given to the
households to ensure that they understood the aim of the study.
2. Observation checklist
An observation checklist was designed to assess the environmental health situation and
personal hygiene of surveyed household is used during this study. It was filled in through
direct observation from the data collector depending on her notice concerning
households’ hygiene and environmental situation. It assessed the following issues:
Is the home clean?
Is the mother dressing clean?
Is the water tank is closed well?
Is the private drinking water tank tap closed well?
Is there stagnant water or algae down drinking water tank?
Is there soap in the bathroom?
Are there flies inside the bathroom/kitchen?
Are there animals in the house or in the vicinity of the house?
49
3. Water samples
Pre-test water samples were conducted by Oxfam-GB team in the middle of March 2014.
These water samples conducted in order to assess the quality of utilized water by Al
Shuka community before Oxfam-GB intervention by distributing desalinated water tanks
among the community of Al Shuka area. The total number of samples was 90.
Also, post-test water samples were conducted for the same number of samples in
February and March 2015. These water samples conduced after Oxfam intervention for
improving the water quality in Al Shuka area. The water quality parameters measured
included the following: pH, EC, TDS, TC and FC. The laboratory analyses results of all
water samples are presented in (Annex-4). A forty eight (48) water samples were taken
by the researcher during December 2014 to measure the level of chloride and nitrate
contamination in drinking water as these tests were not done by Oxfam.
Water samples collection was made according to the Standard Methods for the
Examination of Water and Wastewater 21th edition (APHA, 2005). Plastic bottles of one
liter capacity were used to collect water samples for chemical test. Nonreactive
borosilicate bottles of 250ml capacity were used to collect water samples for
microbiological (TC and FC) test. Before taking water samples all bottles were cleaned
and rinsed carefully, given a final rinse with deionized or distilled water, and sterilized.
For microbiological test a sufficient amount of sodium thiosulfate (Na2S2O3) was added
to all sampling bottles anticipated for the collection of drinking water to eliminate
residual chlorine toxic influences which may kill coliforms. All samples were taken from
one of the taps which connected to the drinking water tank. Tap was opened fully to let
water run to waste for 2-3 minutes. Then the tap was closed to apply disinfection (inside
and outside) using 70% Ethanol then was disinfected again by flame for a minute. After
that water was run for additional 2-3 minutes. Then water flow was reduced to permit
filling bottle without splashing. While the sample is collected, air space was left in the
bottle to facilitate mixing by shaking. All collected samples were delivered in icebox to
the laboratory immediately and then kept in the refrigerator at 40C for 20 hours then
50
analysis was completed. The volume of sample was sufficient to carry out all tests; the
volume taken for TC and FC tests was 250 ml for both.
Complete and accurate identifying and descriptive data was written on every sampling
bottle. A sheet of overall sample information was documented during sampling period;
including the date, location, sample number and the name of the sampler. A copy of this
sheet was delivered for laboratory.
4.9.2 Qualitative method
1. Focus groups discussion
To support the data obtained from the study, five focus groups discussion were conducted
with the females’ households from Al Shuka area, so as to be a representative sample of
all districts of Al Shuka area. Moreover, this method allowed the researcher to obtain
deep answers about the health situation and water usage of Al Shuka households where in
the quantitative methods the percentage of males were higher than females due to cultural
aspect and conservation of people there which restrict filling the questionnaire with
females.
4.10 Data collection
Data collection is the process of gathering and measuring information on variables of
interest, in an established methodical approach that assists the researcher to answer
specified research questions and evaluate the obtained results. The data collection
component of research is common to all fields of study including physical and social
sciences, humanities, etc. The objective for all data collection is to capture qualified
evidence that then renders to rich data analysis and allows the building of a considerable
and reliable answer to questions that have been made. However, during this study the
required data was collected by conducting different meetings with stakeholders and
relevant individuals and organizations to gather data about Al Shuka area and Oxfam
51
intervention, focus groups discussion in addition to reviewing the available published
reports, research articles and internet websites.
The data were collected by the researcher and one female volunteer assistant from Al
Shuka area residents, who is familiar with the study area and households. The volunteer
assistant received training on the scope and the objectives of the study. Also, she was
given the needed instructions related to ethics and approaches of dealing with the
participants and filling the questionnaires. The researcher and the volunteer completed
the questionnaire by themselves through applying oral administered questionnaire with
households to make sure that all questions were completed and the households
understood the questions, where the researcher simplified the questions to the households
to make it clear but without guiding them to the answer. Moreover, the households’
observation sheet was completed by going inside the house setting.
4.11 Ethical and Administrative Approvals:
The researcher applied the study tools after receiving an official approval letter from
Ministry of Health (MoH) and UNRWA to use the available data. Another approval letter
from the Ministry of Health to collect biological and chemistry analysis data, as well as,
permissions were obtained from both MoH and UNRWA to visit clinics to collect data
about prevalence of common water borne diseases at Al Shuka area. Also, MoH helped to
conduct a limited number of microbiological analyses for Total coliform (TC) and Fecal
coliform (FC), NO3 and CL at the laboratory of MoH , and provided the needed tools
and substance as possible. The permission letters provided to researcher from Al Azhar
university-Gaza to Oxfam-GB office in Gaza, UNRWA Public Health Department and
Public Health Department in the ministry of Health-Gaza are presented in (Annex-2). In
addition to, the laboratory reports that shows water chemistry and microbiological
analyses given from the Ministry of Health laboratories are presented in (Annex-3).
52
4.12 Data management and statistical analysis
4.12.1 In Quantitative part
1. Questionnaire and observation sheet
The questionnaires (pre- and post-test) and observation sheet were carefully checked to
screen out any incompletely answered questions. Statistical Package of Social Science
(SPSS) program was used for data entry and analysis. After collecting and revising the
filled questionnaires, the second step was coding these questionnaires using the computer
software Statistical Package for Social Science (SPSS) version 19.0 and then, the coded
questionnaires were entered into the computer. Data filtration was made through checking
out a random number of the questionnaires and through exploring descriptive statistic
frequencies for all variables. Means and standard deviations were computed for the
continuous numeric variables and then coded. The data were entered in the prepared
software. The variables were coded numerically. The data were filtered. Then statistical
analysis was made including descriptive and inferential statistics. A statistical relationship
between variables was assessed using different and relevant statistical test as needed, the
Chi-square-test for categorical variables was used. For continuous variables the P values
were determined to be (<0.05%) with 95% confidence interval. Logistic regression
analysis was used to build a model to predict the values of the variable (the dependent
variable- water borne diseases) If the value of the variable or other variables (independent
variables- Environmental and Socio-demographic factors) are known.
2. Water analysis
The procedures used for water samples analysis followed the American Standard
Methods for the Examination of Water and Wastewater (APHA, 2005). The methods
used for measuring water samples parameters are given as bellow:
53
pH
pH is a measure of how acidic/basic water is. The range goes from 0-14, with 7 being
neutral. pH of less than 7 indicate acidity, whereas a pH of greater than 7 indicates a base.
pH is a measure of the comparative amount of free hydrogen and hydroxyl ions in the
water (EPA, 2007). PH meter was used to measure pH values directly in the field during
collecting the water samples.
Electrical conductivity (EC)
The ability of water to conduct an electric current is known as conductivity or specific
conductance and depends on the concentration of ions in solution. Conductivity is
measured in millisiemens per meter (1 mS/m=10 µS/cm=10 µmhos/cm). The
measurement is recommended to be made in the field immediately after a water sample
has been obtained, because conductivity changes with storage time (APHA, 2005). In this
study the conductivity meter was used to measure the electrical conductivity. Before
reading the EC of water sample the temperature was adjusted at 25 degrees Celsius
(25ºC) then the EC reading was recorded.
Total dissolved solids (TDS)
TDS comprise inorganic salts (principally calcium, magnesium, potassium, sodium,
bicarbonates, chlorides and sulfates) and small amounts of organic matter that are
dissolved in water. TDS in drinking-water originate from natural sources, sewage, urban
runoff and industrial wastewater (WHO, 2008). The TDS was measured by using the
Conductivity/TDS meter.
Chloride
Chloride in drinking-water originates from natural sources, sewage and industrial
effluents, urban runoff containing saline intrusion. Excessive chloride concentrations
increase rates of corrosion of metals in the distribution system, depending on the
54
alkalinity of the water (WHO, 2008). Titration technique was used to measure the
chloride in water. The common unit used for chloride is mg/l. The details of the method
used to measure chloride concentration during this study can be seen in (APHA, 2005).
Nitrate
Nitrate is a form of dissolved nitrogen that occurs naturally in soil and water. Sources of
nitrate in water come from human activities including: fertilizers, animal feedlots, septic
systems, wastewater treatment lagoons, animal wastes, industrial wastes, and food
processing wastes (Daniels and Mesner, 2010). To measure nitrate concentrations in
water ultraviolet spectrophotometer was used. The spectrophotometer was adjusted to
wave length at 220 nm. The spectrophotometer was set at zero absorbance by reading the
absorbance of blank sample and then the reading of unknown water sample was recorded
at the absorbency. Finally the reading was calibrated with nitrate calibration curve and
the concentration of required nitrate was calculated (APHA, 2005).
Total coliform
The purpose of collecting samples for microbiological analysis is to guarantee that the
water distributed to the public is microbiologically safe for drinking purpose. For total
coliform measurement 100 ml was taken which it is the standard sample size. This
sample volume usually yields 20 to 80 coliform colonies and not more than 200 colonies
of all types on a membrane-filter surface. A sterile filtration unit was used at the
beginning of each filtration series as a minimum precaution to avoid accidental
contamination. Sterile forceps was also used; a sterile membrane filter (grid side up) was
placed over porous plate of receptacle. The samples then filtered under partial vacuum.
The interior surface of the funnel was rinsed by filtering 20 to 30ml portions of sterile
dilution water. Then the membrane filter was placed on the agar-based medium directly,
the dish was inverted, and it incubated for 22 to 24 hours at 35 ± 0.5°C. A white
fluorescent light source was directed to provide optimal viewing of sheen. Finally the
coliform colony which has a pink or dark-red color with a metallic surface sheen was
numbered (APHA, 2005).
55
Fecal coliform
The presence of Fecal Coliform in well water may indicate recent contamination of the
groundwater by human sewage or animal droppings which could contain other bacteria.
For fecal coliform laboratory examination a sample of 250ml volume was taken to yield
20 to 80 coliform colonies. A sterile membrane filter was placed over porous plate of
receptacle. Sample then was filtered under partial vacuum. The interior surface of the
funnel was rinsed by a flow of sterile dilution water from a squeeze bottle. The funnel
was removed, immediately membrane filter was removed with a sterile forceps, and then
placed on M-FC agar. The dish was inverted to be ready for incubation. The dishes were
incubated for 24 +/- 2h at 44.5 +/- 0.2°C. Finally the total number of fecal coliform
bacteria colonies produced on M-FC with blue color was recorded (APHA, 2005).
3. Laboratory Materials and instruments
Chemicals used for analysis
During the water samples laboratory analysis several analytical reagent-grade chemicals
were employed for the preparation of all solutions. Freshly prepared doubled distilled
water was used in all measurements. All chemicals used during this study are given in
Table 4.1.
56
Table 4.1: List of chemicals used for water samples test
S. No Parameters Chemicals used in the laboratory
1 pH Buffer solution
2 EC
3 TDS Distilled water
4 Chloride Potassium chromate indicator solution (K2CrO4 and AgNO3),
standard silver nitrate titrant (AgNO3 in distilled water),
standard sodium chloride (NaCl in distilled water) and
Aluminum hydroxide suspension (AIK (SO4)2. 12H2O in
distilled water).
5 Nitrate Nitrate free water; stock nitrate solution; standard nitrate
solution and hydraulic acid (HCl).
6 TC Tryptose; Lactose; Dipotassium hydrogen phosphate
(K2HPO4); Potassium dihydrogen phosphate (KH2PO4);
Sodium chloride (NaCl); Sodium lauryl sulphates; peptone;
ox gall; brilliant green and distilled water.
7 FC Trypitcase; Lactose; Bile salts mixture; Dipotassium
hydrogen phosphate(K2HPO4); Potassium hydrogen
phosphate(KH2PO4); Sodium chloride(NaCl)&distilled water.
Instruments used for analytical purpose
Apparatus prior to analysis, all instruments were calibrated according to manufacturer's
recommendations. The method and apparatus used to analyze the water samples are given
in Table 4.2.
57
Table 4.2: List of Methods and Instruments used for water samples analysis
S. No Parameters Method Ref. Instrument Model & Company
1 pH 4500-H+B.
Electrical method
Benchtop PH/ISE
Meters
710 A USA
2 EC 2510B. Laboratory
method
Conductivity /
Meters
HACH Company
3 TDS 2510B. Laboratory
method
Conductivity /
Meters
HACH Company
4 Chloride 4500-cl-B
Argentometric
method
_ _ _ _
5 Nitrate 4500-NO3B UV
Spectrophotometric
screening method
2100
Spectrophotometer
UNICO 2100 series
Jenway
6 TC 9222B.E Standard
Total Coliform
membrane filter
procedure
WTC binder and
pipettes) and
inoculating wire
loop.
78532
TUTTLINGEN /
Germany
7 FC 9222D. Fecal
Coliform membrane
filter procedure
As needed for total
coliform test and
water
78532
TUTTLINGEN /
Germany
4.12.2 In Qualitative part
Data collected by conducting focus groups discussions which was analyzed as follow:
Data were taped recorded and transcribed.
The facilitator made notes of key points arising and verbatim quotes.
Manual thematic content analysis of transcripts and interview notes were applied.
Coding scheme and coding the data by relevant labels and categorization were
created.
58
4.13 Limitation of the Study
1. Having difficulty in obtaining more official, detailed and accurate information
about Al Shuka area from the municipality of Al Shuka, due to destruction of the
municipality building in the recent war 2014 on the Gaza Strip.
2. The researcher faced difficulties and constrains in access to participant of the pre-
test to fill with them the post-test because they lost their houses during the last
war and flit their houses to UNRWA shelters and stayed there after the war.
Accordingly, there was decrease in the number of participant from (208 in pre-test
to 158 in post test)
3. The control case samples were excluded from the study because of the war, that
Oxfam covered the whole area of Al Shuka with its intervention (water supply
and behavior change).
4. The questionnaires were filled with males households more than females in most
of participants. This was due to conservative culture of this area, in addition to the
high level of unemployment which led husbands to stay at homes. Husbands
insisted to fill the questionnaires instead of their wives which resulted in missing
of some accurate answers mainly about the level of personal hygiene before and
after cooking, benefit from Oxfam behavioral change intervention, water usage
and so on. Accordingly, the researcher conducted focus groups with 40 females
households to obtain deep answers and strength the study results.
59
CHAPTER FIVE
RESULTS AND DISCUSSION
This chapter presents the main study results based on the statistical analysis. A
comprehensive database has been developed for common water-borne diseases and socio-
demographic and environmental information for Al Shuka area- Rafah Governorate. The
study aimed mainly to identify the environmental determinants and socio demographic
factors of common water borne diseases among people of Al Shuka area- Rafah
Governorate, to recognize the common water borne diseases among people of Al Shuka
area, to detect the most age group affected by the identified common water borne
diseases, and finally to measure if there is difference in the waterborne diseases
prevalence among the people after water supply and total behaviour change intervention
by Oxfam- GB at Al Shuka area (Pre/Post-Test). Triangulation between the quantitative
and the qualitative results was conducted.
5.1 Demographic variables of the study population
The result in the table 5.1 shows that:
Distribution of the sample due to gender: Major of the whole sample study with
percent equal 85.6% are male, 14.4% of the sample are female.
Distribution of the sample due to job title: 52.9% of the whole sample are unemployed,
23.8% are employees, 10.2% are worker, 6.9% are housewives, while1.4% are
farmer,teacher4.2% and 0.6% are doctor.
Distribution of the sample due to monthly income: 63.4% of the whole sample their
monthly income 500 Nis and less, 17.5% their monthly income are between 500-1500
Nis, 14.4%their monthly income are between 1500-2500 Nis and only 4.7% their
monthly income are 2500 Nis and above.
Distribution of the sample due to breadwinner: Most of the sample with percent equal
85.3% their family breadwinner is the husband, while 14.7% their family breadwinner is
wife.
60
Distribution of the sample due to qualification: 26.6% of the sample are illiterate,
25.5% of the sampletheir qualification certificate are secondary, 24.1% are university and
above, 17.5% are prep, while only 6.4% are primary.
Table 5.1: Study samples characteristics
demographic
variables
Category
pre test
post test average
N % N %
Gender
male 182 87.5 127 83.0 85.6
female 26 12.5 26 17.0 14.4
Total 208 100.0 153 100.0 100.0
Job title
employees 62 29.8 24 15.7 23.8
unemployed 89 42.8 102 66.7 52.9
worker 36 17.3 1 .7 10.2
Farmer 5 2.4 0 0 1.4
Doctor 2 1.0 0 0 0.6
house wife 9 4.3 16 10.5 6.9
Teacher 5 2.4 10 6.5 4.2
Total 208 100.0 153 100.0 100.0
Monthly
income
500 Nis and less 110 52.9 119 77.8 63.4
500-1500 Nis 44 21.2 19 12.4 17.5
1500-2500 Nis 38 18.3 14 9.2 14.4
2500 Nis above 16 7.7 1 .7 4.7
Total 208 100.0 153 100.0 100.0
Breadwinner
Husband 180 86.5 121 83.4 85.3
Wife 28 13.5 24 16.6 14.7
Total 208 100.0 145 100.0 100.0
Qualification
Illiterate 27 13.0 69 45.1 26.6
Primary 21 10.1 2 1.3 6.4
Prep 52 25.0 11 7.2 17.5
Secondary 66 31.7 26 17.0 25.5
University and
above 42 20.2 45 29.4 24.1
Total 208 100.0 153 100.0 100.0
61
5.2 Results of knowledge and practice about general health (pre/post-test)
This section discusses the level of general health and personal hygiene among people of
Al Shuka area- Rafah governorate before and after Oxfam water supply and behavioral
change intervention. The obtained statistical results are shown in Table 5.2.
Table 5.2: The level of general health and personal hygiene among the study sample
at pre and post stages
Variables
Measurement Chi.
square % Pre-test
(N=208)
Post-test
(N=153)
When you
need to wash
your hands?
After using toilet 166 79.8% 153 99.3% 32.0** 19.0%
Before eating 186 89.4% 153 100% 282.2** 10.6%
Before food
preparation 58 27.9% 153 100% 50.8** 72.1%
Before children
feeding 20 9.6% 153 100% 15.5** 90.4%
After change the
diaper 17 8.2% 153 100% 13.1** 91.8%
After touching
animals 11 5.3% 153 100% 8.3** 94.7%
Other 23 11.1% 0 0.0% 18.0** -
*: significant at 0.05 **: significant at 0.01 \\: not significant
The obtained results of pre-test (before Oxfam project implementation) showed that
79.8% of the study participants said that they need to wash their hands after using toilet,
while after Oxfam intervention (post-test) the percentage was increased to 99.3%, with an
improvement percent of 14.9%. This improvement is statistically significant as shown in
Table (5.2) (Chi –square=32.0, p< 0.01). This shows that the Oxfam project have positive
effectiveness on the study sample area.
To confirm the effectiveness of the Oxfam project on the people of Al Shuka area the
focus groups were asked to identify when they need to wash their hands and what they
62
use to clean hands, They said that there was no concern with washing hands before the
implementation of Oxfam project while after implementing the project people in Al
Shuka area became more concern about washing hands before and after eating, after
toilet, after laundry, after cleaning home, before and after preparing food, washing
chicken and meat, after waking up, before and after feeding babies, after throwing
garbage, after changing dipper and after the children finish playing on roads and come
back home.
Public awareness programs can change the people behavior towards diseases reduction in
Al Shuka area. Many examples of successful efforts where public education has brought
about dramatic changes in human behavior include: potable water, hand washing, and
waterborne diseases (IFRC, 2011). Several studies confirmed the positive impacts of
awareness on the knowledge about the general health of people ( Aryal et al., 2012;
Unicef and PHG , 2010; EPA, 2002; Taleb, 2014; Unicef, 2011; Joshi and Amadi, 2013).
5.3 Results about water sources, uses and its quality at Al Shuka area
This section describes the status of water , water sources and cleanliness of water among
the study sample (target group) of Al Shuka area- Rafah governorate before and after
Oxfam project implementation. The obtained results are shown in Table 5.3.
63
Table 5.3: Status of water , water sources and how much clean it among the study of
Al Shuka at pre and post-test stages
Variables
Measurement Chi
square % Pre-test
(N=208)
Post-test
(N=153)
Source of
water for
usage
Buying 2 1.0% 0 0.0%
12.9** 9% Private wells 18 8.7% 1 0.7%
Municipal water 188 90.4% 152 99.3%
Do you think
that municipal
water is clean
and healthy for
domestic usage?
Yes 23 11.1% 148 96.7% 259.5** 88.6%
What is the
main usage
for this
water?
Personal Hygiene 198 95.2% 2 1.3% 314.4** 98.6%
Cooking 94 45.2% 0 0.0% 93.4** 100.0%
Drinking 12 5.8% 0 0.0% 9.1** 100.0%
Drinking
water source
Buying 206 99.0% 0 0.0%
361.2** Municipal water 2 1.0% 0 0.0%
Oxfam 0 0.0% 153 100.0%
Do you clean the mouth of water
hose before filling the tank? 53 25.5% 122 79.7% 103.9** %68.0
How do you
clean the
water tanker
host
By immersing it in
chlorine 3 5.7% 0 0.0%
25.08**
by immersing it in
water 42 79.2% 123 80.4%
Clean it with towel
then wash it 5 9.4% 0 0.0%
Other 3 5.7% 0 0.0%
During last
month how
many times
you have had
30.2** 15.93 One to two times 32 15.4% 33 21.6%
Three to four times 18 8.7% 1 0.7%
Five times and 17 8.2% 0 0.0%
64
to use the
municipal
water for
drinking
purposes?
above
Always 5 2.4% 0 0.0%
I don’t drink
municipal water at
all
136 65.4% 119 77.8%
Does the water tank is easily
reached by children? 121 58.2% 28 18.3% 57.6** 68.5
Do you clean
the water
tank?
Yes 202 97.1% 153 100.0%
56.1** 2.9 No 6 2.9% 0 0.0%
*: significant at 0.05 **: significant at 0.01 \\: not significant
Source of water: The obtained results from answered questionnaires showed that before
Oxfam intervention many people used the municipal water for different usage and
different purposes such as (cleaning, washing and personal hygiene) except drinking and
cocking found to be (90.4%) while some of them don’t use it at all because they believe
that the municipal water is very polluted. After the Oxfam intervention this percentage
has improved and found to be (99.3%) and then they start to use the municipal water for
different purposes except drinking, cocking and personal hygiene. The statistical results
showed some differences between both stages and these differences found to be
statistically significant (Chi–square=12.9, p< 0.01). Such changes prove that Oxfam
project had good and positive effects on the study sample people knowledge regarding
water sources in the study area.
Do you think that this water is clean and health: As indicated in Table 5.3 (n=23;
11.1%) only of the participants reported that the water they used during the pre-test stage
was clean and healthy, while after implementing the Oxfam project by distributing clean
water, most of the people reported that (n=148; 96.7%) the water they used was clean and
healthy. There were obvious differences between both stages with percentage of 88.6 %.
These differences were statistically significant as shown in Table 5.3 (Chi–square=259.5;
65
p< 0.01). Though, this change shows that Oxfam project had an essential effectiveness on
the study sample.
What is the main usage of this water: It can be seen from Table 5.3 that about (n=198;
95.2%) of the study sample used the municipal water for personal hygiene, while after
implementing Oxfam project only 1.3% used this water for the same purpose, hence,
these differences were found to be statistically significant (Chi–square=314.1, p< 0.01).
The results showed that about (n=94; 45.2%) from the study sample used water for
cooking purpose at the period of pre-test stage, while at the post-test stage no one of the
people used the municipal water for cooking as presented in Table 5.3 (0.0%). The
improvement in percentage was about 100. Such differences found to be statistically
significant (Chi –square=93.4, p< 0.01), this improvement proves that the people had a
good knowledge about the water quality after the implementation of Oxfam project and
used the distributed water by Oxfam for cooking and personal hygiene instead of
municipal water
Drinking water sources: It was indicated that before the implementation of Oxfam
project there was about (n=206; 99.0%) of the people used to buy the drinking water from
water tankers and (n=2; 1.0%) used water from municipal water distribution network,
while after the implementation of Oxfam project the only source for drinking water was
Oxfam (n=153; 100.0%). As shown in Table 5.3 these differences were statistically
significant (Chi–square=361.4, p< 0.01).
Cleaning the water hose mouth and using manners: It was indicated that at pre-test
stage there were about (n=53; 25.5%) of the people in the study sample used to clean the
water tanker hose mouth before filling their water tanks, while at post-test stage there
were about (n=122; 79.7%) used to clean the water tankers hose mouth. There was a big
change in the people behavior for cleaning the hose of water tankers with percentage
change to about 68.0%. These differences were found to be statistically significant as
shown in Table 5.3 (Chi–square=10.3.9; p< 0.01). As shown in Table 5.3 before
implementing the Oxfam project there were about (n=42; 79.2%) of the people in the
66
study sample used to clean the water hose mouth by immersing it in water, about (n=5;
9.4%) by towel, about (n=3; 5.7%) by immersing it in chlorine, and about (n=3; 5.7%)
by using other manner, while after implementing the project of Oxfam the only method
was by immersing the water hose mouth in water (n=123; 80.4%), though these
differences were found to be statistically significant (Chi–square=10.3, p< 0.01).
The question was asked to the study sample for how many times people have to use the
municipal water for drinking purpose. There were about (n=136; 65.4%) of the study
sample did not use (at all) the municipal water for drinking purpose at pre-test stage,
while about (n=119; 77.8%) was found at post-test stage. There were about (n=32;
15.4%) used to drink municipal water for one to two times at pre-test stage, while in the
post-test stage there were about (n=33; 21.6%) used to drink municipal water for the
same period. About (n=18; 8.7%) of the study sample used to drink municipal water for
three to four times at the pre-test stage, while it was found to be (n=1; 0.7%) at the post-
test stage. There were about (n=7; 8.2%) used to drink municipal water for five times and
above at pre-test stage, while it was found at the post-test stage that no one of the study
sample used municipal water for drinking purpose. The statistical analysis showed about
15.9% change, though these differences were found to be statistically significant (Chi–
square=30.2, p< 0.01).
Does the drinking water tank easily reached by children? it can be seen from Table
5.3 that at the pre-test stage there were about (n=121; 58.2%) of the study sample that
their drinking water tank was easily reached by children, while at the post-test stage there
were about (n=28; 18.3%) that their drinking water tank was easily reached by children.
The improvement percentage in results found to be about (68.5%), and the differences
was statistically significant (Chi–square=57.6, p< 0.01). This proved that the conducted
awareness program by Oxfam intervention had a good and success results on the study
sample population.
Do the people of study sample clean the drinking water tank? the obtained results
showed that at the pre-test stage there were about (n= 202; 97.1%) of the study sample
67
used to clean the drinking water tank, while at the post-test stage all people of study
sample (n=153;100.0%) used to clean the drinking water. The results showed
improvement percent of (2.9%), where these differences were found to be statistically
significant (Chi –square=56.1, p< 0.01). Hence, this improvement showed that Oxfam
project had good results on changing the behavior of the people at Al Shuka study area.
The focus groups were asked about the source and quality of water they used to utilize it
before and after the Oxfam project and they said that before the implementation of
Oxfam project there was no drinking water tanks and people only use small tanks which
was not enough for their daily use , accordingly they have to drink the municipal water
and the desalinated water which they used to use it for drinking purpose sometimes have
odor taste and from their point view the water was of bad quality and they observed the
incidence of some diseases such as parasites, diarrhea and some kind of skin diseases,
while after the implementation of Oxfam project, there was enough drinking water tanks,
continuously provided with sufficient desalinated water, therefore, they use it for
different purposes such as drinking, cooking and sometimes to wash hair, there was a
specialist usually used to test the water quality and add chlorine to sterilize the water, also
there was a guide girl used to inform the people about the quality of water if it’s
acceptable for drinking purpose or not. The implementation of Oxfam project had
improved the behavior of people in Al Shuka area particularly in washing hands, washing
drinking water tanks, washing the hose, and sterilizing water with chlorine. As reported
by the focus group it was observed that there was decline in water borne disease.
When the focus groups were asked about the main source of drinking water, they said
that before the implementation of Oxfam project they used to buy desalinated water in
small gallon from vendors due to their bad economic situation, while during the Oxfam
project they have been provided with desalinated water for 9 months which gave them
good chance to drink safe and clean water in addition to use it in their personal hygiene.
Also, they have been asked if they clean the hose nozzle or not, they said that before the
implementation of Oxfam project they didn’t use to clean the hose nozzle while after
implementing the project they used to clean the hose nozzle as they guided by the
68
specialist girl who used to teach them how to clean the water tanks and the hose nozzle.
They used to clean the water tanks and hose by chlorine and water.
Also, the groups were asked about how many times they had to drink from the municipal
water? They said that before the implementation of Oxfam program when the desalinated
water is finished, they used to stop drinking from the municipal water once or twice and
use it for cooking purposes, and sometimes they had to use it for five times or more
because they have no money to buy the desalinated water. However, after the
implementation of Oxfam project they used not to drink from the municipal water and
when water is finished from their water tanks they used to obtain some water from the
neighbors for drinking purpose. In addition, they said that the water tanks are away of
children hands to avoid any pollution by their dirty hands or wasting the water by leaving
the tap open.
Females’ households of focus groups were also asked about when the last time they had
cleaned the drinking water tanks, they said that before the implementation of Oxfam
project they were not caring about cleaning the tanks but after the implementation of the
project they used to clean the drinking water tanks every time before refilling the tanks.
The participants asserted that the specialist girl from Oxfam-GB awareness team taught
them practically how to clean the water tanks and the hose nozzle. The implementation of
Oxfam project had improved the behavior of people in Al Shuka area particularly in
washing hands, washing drinking water tanks, washing the hose. Also they have been
asked about how many times they used to boil the water before preparing the baby
feeding bottles, they said that before the implementation of Oxfam project they used to
boil the water before preparing it.
5.4 The result of common water borne and related diseases at Al Shuka area
This section presents the incidence of diarrhea and other diseases among the community
of Al Shuka area at Rafah governorate before and after the implementation of Oxfam
project. Table 5.4 presents data on people’ suffering from diarrhea last two weeks before
69
answering the questionnaire in both pre-test and post-test stages. Also it demonstrates the
main cause for diarrheal disease and if any member had suffered from other disease such
as skin, eye and stomach disturbance.
Table 5.4: Incidence of diarrhea and other water borne diseases among the study
sample of Al Shuka
Variables
Measurement
Chi square % Pre-test
(N=208)
Post-test
(N=153)
Did any one of your family members
have had diarrhea diseases last two
weeks?
72 34.6% 0 0.0% 66.1** 100%
Man 7 9.7% 0 0.0% - -
Woman 16 22.2% 0 0.0% - -
Child less than 5 years 49 68.1% 0 0.0% - -
Child more than 5 years 0 0.0% 0 0.0% - -
The main
cause for
diarrhea
Contaminated water 60 28.8% 0 0.0% 52.9** 100%
Contaminated food 95 45.7% 0 0.0% 94.8** 100%
Low house and
personal hygiene 20 9.6% 0 0.0% 15.5** 100%
Waste water 3 1.4% 0 0.0% 2.2// 100%
Dealing with animals \
animal wastes 1 0.5% 0 0.0% 0.73// 100%
Insects at home \
surrounding
environment
3 1.4% 0 0.0% 2.2// 100%
Other causes 77 37.0% 0 0.0% 71.9 100%
I don't know 15 7.2% 0 0.0% 11.5** 100%
Did any one of your family members
affected by other diseases during the
last two weeks?
94 45.2 1 0.7% 92.6** 98.8%
Dermal
diseases
no one 25 22% 0 0.0% - -
Man 12 10.5% 0 0.0% - -
Woman 43 37.7% 0 0.0% - -
Child less than 5 years 21 18.4% 0 0.0% - -
Child more than 5
years 13 11.4% 0 0.0% - -
Total 89 78% 0 0.0%
Eyes disease no one 49 43.0% 0 0.0% - -
Man 9 7.9% 0 0.0% - -
70
Woman 11 9.6% 0 0.0% - -
Child less than 5 years 22 19.3% 0 0.0% - -
Child more than 5
years 23 20.2% 0 0.0% - -
Total 65 57% 0 0.0%
*: significant at 0.05 **: significant at 0.01 \\: not significant
Did any one of the study sample family members have had diarrhea disease last two
weeks? It is clear from the above Table that there were about (n=72; 34.6%) of the study
sample have suffered from diarrhea during the last two weeks at pre-test stage.
Regarding infection according to age, there were about (n=49; 68.1%) children less than
5 years from the study sample who suffered from diarrheal disease during last two weeks
before Oxfam –GB intervention, then women with percentage of (n=16; 22.2%), and
about (n=7; 9.7%) of them were men and no one (n=0; 0.0%) of children more than 5
years were infected with diarrheal disease during last two weeks before Oxfam-Gb
intervention. While after the implementation of Oxfam project no one from the study
sample suffered from diarrhea during last two weeks. The improvement percentage was
about 100%, such differences were statistically significant as shown in Table 5.4 (Chi –
square=66.1, p< 0.01). This result indicates that the Oxfam project had a positive and
significant effectiveness on the study sample population.
The main cause for diarrheal disease: at pre-test stage it was found that about (n=95;
45.7%) of the study sample said and belief that the contaminated food is the main cause
of diarrhea which has infected their family members, while about (n=77; 37.0%) believed
that there are other reasons which may cause diarrhea and about (n=60; 28.8%)
convinced that contaminated water is the main cause of diarrhea, only (n=20; 9.6%)
verified that the cause is low house and personal hygiene conditions, while about (n=15;
7.2%) did not have any idea about the main cause of diarrhea disease, while after the
implementation of Oxfam project there was no any case suffered from infection of
diarrheal. The results revealed that the differences between pre-test and post-test were
statistically significant (p< 0.01), also there were about (n=3; 1.4%) said that the reason
might be due to wastewater pollution, and the same percentage (n=3; 1.4%) mentioned
71
that it is due to insects at home and the surrounding environment, while only one person
from the target group said that the cause of diarrhea is due to contact with animals or its
wastes, while after the implementation of Oxfam project there was no any case suffered
from diarrheal infection. Despite the differences were not statistically significant (p>
0.05), the obtained results show that the Oxfam program had an essential positive
effectiveness on the study sample population.
Did any one of the study family members have suffered from other diseases last two
weeks ?: There were about (n=94; 45.2%) of the study sample suffered from other
waterborne disease during last two weeks of the pre-test stage, while after the
implementation of Oxfam project only one person suffered from other disease during last
two weeks with improvement percentage of about 98.8%. The differences in the obtained
results are statistically significant (Chi–square=92.6; p< 0.01). This proves that the
Oxfam project had good and fruitful results on the health of the study sample population.
Referring to the other diseases in this study which include; dermal disease (Skin) and
eyes disease, however, the obtained statistical results were discussed as following:
Dermal disease: The statistical analysis result showed that out of (n=94; 45.2%) of the
study sample who suffered from other water borne diseases during last two weeks at the
pre-test stage, about (n=89; 78%) were infected with dermal diseases. Regarding
infection according to age group; there were about (n=43; 37.7%) women out of the study
sample who suffered from dermal diseases during last two weeks, then children less than
5 years with percentage of (n=21; 18.4%), and (n=13; 11.4%) were children more than 5
years age and about (n=12; 10.5%) were men, while (n=25; 21.9%) were not suffered
from dermal diseases. After conducting Oxfam-GB intervention there was no any case
suffered from dermal disease during last two weeks from the study sample population.
This results explained by women who stated during the focus groups discussion that they
were responsible about emptying cesspit and septic tanks at their houses by their hand
which resulted in direct contact with raw wastewater and infected them with pathogens.
72
Eye diseases: The obtained results from Table 5.4 showed that out of (n=94; 45.2%) of
the study sample who suffered from other disease during last two weeks at the pre-test
stage, there were about (n=65, 57%) of them were infected with eye diseases. According
to the age groups, the results demonstrated that, the most age groups who were infected
with eye diseases at pre-test were from children above 5 years with about (n=23; 20.2%),
then children less than 5 years (n=22; 19.3%), then women (n=11; 9.6) and finally men
(n=9; 7.9%), while (n=49; 43.0%) were not suffered from eye diseases. Although after
the implementation of Oxfam project there was no any case suffered from eyes disease
during last two weeks from the study sample period. Previous local studies concentrated
on the potential waterborne diseases caused by contaminated water in different areas of
the Gaza Strip, such as (Taleb, 2014) who found that Al-Buraj and Al-Nusirat area which
considered the closest area to source of contamination with wastewater in Wadi Gaza, got
the highest value in Dysentery infections among all Gaza Governorates. This revealed
that Wadi Gaza bad conditions can contribute in increasing the dysentery infections. The
analyses also show that Al-Nusirat and Wadi Gaza area got the highest value of Typhoid
infections in the middle area, Wadi Gaza and Al-Nusirat got the highest number of
Hepatitis A infections of the middle area that is very close Wadi Gaza.
Also, (Yassin et al., 2006) demonstrated that the contamination level of total and faecal
coliforms exceeded that of the World Health Organization (WHO) limit for water wells
and networks. Self-reported diseases among interviewees in Gaza City were associated
with source of drinking water, intermittent water supply, sewage flooding and age of
water, and wastewater networks. As well as, (Abu Amr and Yassin, 2008) pointed out
that diarrheal diseases were the most common self-reported diseases among the
interviewees in Khan Younis area in the south of the Gaza Strip. Another local study by
(Al Zarqa, 2010) identified the main four common water borne diseases in central and
northern governorates of the Gaza strip such as diarrhea bleeding, amobiases, Giardiases
and hepatitis A, in which resulted from utilizing bad quality of water. In the same
context, a study conducted by (Abu-Hejleh, 2004) investigated the relationship between
water quality and health among the people of Tubas district. With respect to water-related
73
diseases, diarrhea was the most common disease, particularly among students, followed
by eye and skin diseases.
The focus groups were asked if any person from their family suffered from diarrhea
before Oxfam-GB intervention. About (n=30; 75%) of them said that before the
implementation of Oxfam project there were large number of their family members
suffered from diarrhea mainly children less than 5 years but after the implementation of
the project the cases of diarrhea had been declined. While after three months of Oxfam-
GB intervention completion and stop water distribution among Al Shuka population;
some cases of the diarrhea infection has been observed including men, women, children
under 5 years and children above 5 years. The focus groups justified that the main causes
of diarrhea would be due to insufficient water for personal hygiene, and also because of
cold, intestine inflammation, contaminated food, hot weather, chemicals in watermelon,
insects and mosquito, rubbish, sewage, not washing hands and contamination with
sewage. They were also asked about the treatment process from diarrhea, their answers
were as following:
Home treatment like herbs, the water of boiling rice, starch and soft drinks
(7-up drink).
By going to hospital or private clinics (lots of children cases have been
sent to the nearby hospital for the treatment purpose suffered from drought
and diarrhea.
Buying medicine from the pharmacy without consulting the physician.
The focus groups were also asked about if anybody from their family suffered from any
other disease during the last month? they said that before the implementation of Oxfam
project there were a noticeably cases of several eyes and skin disease cases in the study
area but after the implementation of Oxfam project it was observed that there was a
decline in the number of cases suffered from infection especial skin disease, diarrhea and
eyes infection which spread in spring and July "Redness and inflammation". On the other
hand two months after the completion of Oxfam project there was a complain that several
74
cases observed with skin disease including children and women especially after the war
and during the presence of people in the shelters at UNRWA schools.
The results of the study questionnaires at the pre-test stage demonstrated the presence of
common water borne and water related diseases in Al Shuka area which include:
Diarrhea, Dermal, Colic, and Eyes diseases.. As compared with All data collected from
the records of Ministry of Health and the UNRWA (Relief Agency) about the trend of
waterborne diseases prevalence in the previous five years or more, it was observed that
more diseases registered in UNRWA are, acute bloody diarrhea, acute watery diarrhea <5
years, acute watery diarrhea> 5 years, viral hepatitis A and Typhoid. It was observed that
the prevalence of these diseases over the past five years is declined. For example, the
level of Acute bloody diarrhea incidence in 2012 was (0.30%), in 2013 was (0.21%),
while in the year 2014 was (0.03%) only (see annex-5). This shows that there is a
decrease in infection rates and this consistent with the same period of Oxfam intervention
at Al Shuka area by distribute desalinated water to the population and drinking water
tanks, as well as the conduction of several awareness program (for changing behavior of
the people positively towards improving their personal hygiene and surrounded
environment).
The incidence for the disease of acute watery diarrhea <5 years in 2012 found to be about
(3.24%), in 2013 was (1.53%) while in 2014 was (1.04%). Where the incidence for the
disease of acute watery diarrhea> 5 years in 2012 found to be about (1.92%) while in
2013 was (0.76%) and in 2014 was (0.59%). These results show decrease in infection
rates during the intervention period of Oxfam project. Records of the Ministry of Health
found that the percentage rate for the disease of acute bloody diarrhea in 2012 was about
(0.04%) and 2013 (0%) while in 2014 (0.04%), whereas for the disease of acute watery
diarrhea <3 years in 2012, 2013 and 2014 the ratio was (0%), and the disease of acute
watery diarrhea> 3 years over the years of 2012, 2013 and 2014 respectively (0.98%),
(0.84%), (1.54%). These results show decrease in infection rates during the intervention
period of Oxfam project (see annex-6).
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5.5 Results of awareness level about hygiene among people of Al Shuka area
This section presents the outcome of the hygiene awareness program among people of Al
Shuka area- Rafah governorate after the implementation of Oxfam project on the study
area. Results of the effects of hygiene awareness program among the study sample of Al
Shuka are presented in Table 5.5.
Table 5.5: Effects of hygiene awareness program among the study sample of Al
Shuka area
Variables Number %
Did you read or hear any
information or advices about
general hygiene
Yes 151 98.7
No 2 1.3
Total 153 100.0
Did you participate in any sessions
or benefited from home visits
Yes 139 90.8
No 14 9.2
Total 153 100.0
Source of general hygiene
information
Health centers 19 12.4
Home visits 127 83.0
Radio or television 6 3.9
Are home visits with the aim of
health awareness is appropriate and
have a benefit
Yes 153 100
There were about 98.7% of the study sample had information about the general hygiene
practices through reading, hearing from health educators or listening to education and
awareness programs in TV and Radio, while there were about 1.3% of the study sample
had no any information about general hygiene knowledge. There were about 90.8% of the
study sample had attended an educational program on the effects of general hygiene and
benefited from the health educators home visits, while there were about 9.2% of the study
sample had not attended such educational programs.
There were about 83.0% of the study sample source of general hygiene information were
from health educators home visits, about 12.4% were through health centers and about
3.9% were through health awareness programs broadcasting by Radio and Television. In
addition there were about 100% of the study sample said that the health educators home
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visits with the aim of health awareness is an appropriate strategy to educated the people
regarding general hygiene awareness.
The focus groups mentioned that they used to hear and read about the personal and public
hygiene by attending the awareness program which conducted by Oxfam teaching group
and also by home visits used to be conducted during the project activities. They said that
the personal and public hygiene information sources were Oxfam health promotion and
awareness team, television, schools, Oxfam guiding team visits to shelters schools. Also,
they said that the Oxfam guiding team visits were useful and the most important
information they gained are :
The process for cleaning the water tanks.
How to clean nozzle hose.
Personal hygiene and how to clean hands especially for children when posters
were distributed during the project activities and the people were asked to put
posters on the bathroom doors.
The children were asked to wash their hands and to be checked after washing their hands
for a period of one month and this was followed-up by the female Guides. The children
were taught not to touch suspicious objects, not to drink water directly from the tapes,
and households were asked to not expose water bottles and tanks to the sun radiation and
put soap inside bathrooms and toilets in addition to ask them to keep home clean.
By referring to the results of the observation sheet it was obvious that there is
improvement in the level of surrounding environment cleanliness than it was before the
intervention of Oxfam project in the area (cleanliness of the house, mother hygiene,
father hygiene, children hygiene and clean drinking water tank) and this shows the
effectiveness of the Oxfam project intervention in the area where the awareness program
played an important role to change the people behavior. The awareness program was
conducted by a group of health promoters whom educated the people about the
importance of personal hygiene, how to wash their hands, and how to clean the drinking
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water tank and its sterilization. Therefore the public awareness program has led to
positive results in the change of health and environmental behavior among the
population, and then reduction in the rate of diseases such as diarrhea and skin diseases.
5.6 Results of observation checklist
This section presenting the field visit observation results among the people of Al Shuka
area-Rafah governorate before and after Oxfam project implementation. Table 5.6
presents the response of the study population on various aspect of drinking water quality.
Table 5.6: Researcher observations sheet among the sample at pre and post test
Field visit findings
Measurements Chi
square % Pre-test
(N=208)
Post-test
(N=153)
Is the home clean 131 63.0% 152 99.3% 68.8** 37%
Is the mother clean 164 78.8% 151 98.7% 31.2** 20%
Is the father clean 123 59.1% 138 90.2% 42.4** 34%
Are children clean 128 61.5% 132 86.3% 26.7** 29%
Is the tank of drinking water
closed well 178 85.6% 151 98.7% 18.7** 13%
Is private drinking water tank
tap closed well 173 83.2% 152 99.3% 25.6** 16%
Is there stagnant water / algae
down drinking water tank 25 12.0% 3 2.0% 12.4** 0%
Is there a soap in the kitchen 155 74.5% 152 99.3% 42.7** 25%
Is there a soap in the
bathroom 164 78.8% 151 98.7% 31.2** 20%
Is there any bad smell in the
bathroom 88 42.3% 0 0.0% 85.5** 100%
Are there flies inside the
bathroom / kitchen 98 47.1% 10 6.5% 69.2** 86%
Are there animals in the house
or in the vicinity of the house 95 45.7% 32 20.9% 23.6** 54%
*: significant at 0.05 **: significant at 0.01 \\: not significant
It is clear from Table 5.6 that 63.0% of the study population houses were clean at pre-test
stage, while after the project implementation 99.3% of the study population houses were
clean. The improvement percentage was about 37.0%, and the differences was
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statistically significant (Chi–square=68.8, p< 0.01), therefore such result prove that the
Oxfam project had an essential effectiveness on the study population.
It was noticed that 78.8% of the study sample mothers were clean at pre-test, while after
the project implementation 98.7% of the study sample mothers were clean. The
improvement percentage was about 20.0%, such differences are statistically significant as
shown in Table 5.6 (Chi –square=31.2, p< 0.01), this result indicates that the Oxfam
project had positive effect on the study sample population. From Table 5.6 it was
observed that 59.1% of the study sample households were clean at pre-test stage, while
after the implementation of Oxfam project about 90.2% of the study sample households
found to be clean. The variation on percentage between both stages found to be 34.0%,
and these differences was statistically significant (Chi–square=42.2, p< 0.01). Such
results prove that the Oxfam project had significant improvement on the study sample.
During the field visit it was noticed that about 61.5% of the study sample children were
clean at pre-test stage, while after the Oxfam project implementation 86.3% of the study
sample children found to be clean. Dereferences on percentage between both stages found
to be 29.0%, and these differences was statistically significant (Chi –square=26.7, p<
0.01). Such results demonstrate that the Oxfam project had satisfactory effectiveness on
the study sample.
It can be seen from Table 5.6 that 85.6% of the study sample water tanks used for
drinking purpose were closed well at pre-test stage, while after the Oxfam project
implementation 98.7% of the study sample drinking water tanks were closed well. The
level of improvement between pre and post-test stages was (13.0%), and the differences
was statistically significant (Chi –square=18.7, p< 0.01). Therefore, these results prove
that the Oxfam project had good impact on the study sample.
During the field visit it was noticed that 83.2% of the study sample private drinking water
tank tap and cover was closed well at pre-test stage, while after the Oxfam project
implementation about 99.3% of the study sample private drinking water tank tap and
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cover found to be closed well. The differences in percentage between both stages found
to be 16.0%, and the differences was statistically significant as shown in Table 5.6 (Chi –
square=25.6, p< 0.01). This improvement demonstrates that, the Oxfam project had
positive effectiveness on the study sample.
It was observed that about 12.0% of the study sample found stagnant water/algae in the
bottom of their drinking water tanks at pre-test stage, while after the Oxfam project
implementation only 2.0% of the study sample found stagnant water/algae in the bottom
of their drinking water tanks. These differences are statistically significant (Chi –
square=12.4, p< 0.01), and prove that the Oxfam project had an essential effectiveness on
the study sample.
It was noticed that about 74.5% and 78.8 % of the study sample used to have soap in their
kitchen and bathroom respectively at pre-test stage, while after the Oxfam project
implementation about 99.3% and 98.7 of the study sample found to have a soap in their
kitchen and bathroom respectively. The differences in percentage between pre and post-
test stages found to be about 25 % and 20 % respectively, where these differences found
to be statistically significant (Chi –square=42.7, p< 0.01 and Chi-square=31.2, p<0.01) ,
this improvement demonstrate that the Oxfam project had an essential effectiveness on
the study sample.
During the field visit it was observed that about 42.3% of the study sample had a bad
smell in their bathroom at pre-test stage, while after the Oxfam project implementation it
was found that there is no bad smell in study sample bathrooms. The differences between
both stages found to be 57.7 %, and statistically these differences are significant (Chi –
square=85.5, p< 0.01). This change shows that the Oxfam project had a significant
improvement on the study sample population.
It can be seen from Table 5.6 that about 47.1% of the study sample had flies inside their
bathroom / kitchens at pre-test stage, while after the Oxfam project implementation only
6.5% of the study sample had flies inside their bathrooms/kitchens. The differences
between both stages found to be about 86.0%, and these differences statistically are
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significant (Chi –square=69.2, p< 0.01), hence, this change shows that the Oxfam project
had a good improvement on the study sample population.
During the field visit it was observed that 45.7% of the study sample had animals in their
homes or in the vicinity of their homes at pre-test stage, while after the Oxfam project
implementation about 20.0% of the study sample had animals in their homes or in its
vicinity. The differences between both stages found to be about 54.0%, and these
differences statistically are significant (Chi–square=23.6, p< 0.01), hence, this fluctuation
demonstrate that the Oxfam project had satisfactory effectiveness on the study sample
population.
5.7. Environmental and socio-demographic factors associated with common water
borne diseases at Al Shuka area
Determining the environmental and socio-demographic factors and determinants
associated with common water borne diseases among the people of Al Shuka area–Rafah
Governorate is helpful to identify the suitable intervention to improve the environmental
health situation at Al Shuka area. These factors are discussed in the following
subsections.
5.7.1. Environmental determinants and demographic variables on the prevalence of
diarrheal disease in the individuals of Al Shuka area
To identify the effect of the environmental factors and demographic factors such as (level
of income, type of occupation, education level) on the prevalence of diarrheal disease
among the individuals of Al Shuka area in Rafah, the logistic regression method was used
to build a statistical model to explain the most important factors that have a direct impact
on the spread of diarrheal disease, therefore, the obtained results are shown in Table
(5.7).
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Table5.7: The results of the gradual test method (Wald) to model logistic regression
(step wise) demographic variables and environmental variables on the prevalence of
diarrhea disease in the individuals of Al Shuka area in Rafah Governorate
Independent
variables
B S.E Wald Df Sig. Exp(B) 95% C.I for
EXP(B)
Lower Upper
There is stagnant /
algae below the
drinking water tank
1.44 0.43 11.05 1 0.001**
4.21 1.80 9.83
There is basin near
the bathroom/ inside
the bathroom
-0.66 0.33 4.03 1 0.045*
0.52 0.27 0.98
There is a bad smell
inside the bathroom
0.66 0.31 4.48 1 0.034*
1.93 1.05 3.56
The basin in the
bathroom is much
higher than the level
of children
-.075 0.32 5.51 1 0.019*
0.47 0.25 0.88
Constant -0.91 0.32 8.29 1 0.004**
0.40 - -
** P-value<0.001 * P-value<0.05 // P-value>0.05
It is clear from Table (5.7) that the relative importance of each of the independent
variables as specified in the logistic regression model to predict the variable of diarrhea
disease, where the statistical significance of some of the independent variables in this
model (P- value <0.01) and these variables are (stagnant water / algae below the drinking
water tank, there is a basin near the bathroom / inside the bathroom, there is a bad smell
inside the bathroom, the basin in the bathroom is much higher than the children's level)
and it was proved statistically that these independent variables are the best in terms of
differentiating between the infected and non-infected individuals with diarrhea. This was
selected for these variables according to the value of Wald Statistics, which refers to the
importance of the independent variables of the proposed model and the examination of
the independent variables coefficient if it was statistically significant and different from
zero or not. Also it shows the constant term difference in the equation for zero, which
means that it is statistically significant according to the value of Wald test (8.29, P-value
= 0.004 <0.01). As shown in the table it is clear that the standard error of the model
coefficients (S.E) had a standard error at least 2, which means that it can rely on these
factors in the interpretation of the results of classification also means that we do not face
any numerical problems.
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The results shown in Table (5.7) demonstrated that, wherever there is stagnant water and
algae below the drinking water tank used by the families of the study area that the
prevalence of diarrhea disease is increased of Al Shuka area in Rafah governorate and
vice versa. And also it was observed that there is a rise in the proportion of diarrhea as a
result of bad smells inside bathrooms and vice versa. The results also showed that the
more there are no basin near the bathroom or inside it, as well as whenever the basin in
the bathroom is much higher for children level; the more the prevalence of diarrhea
disease in Al Shuka area is increased and vice versa. From the other hands, it was noted
that there are some of the environmental variables do not have significant effect on the
increased incidence of diarrheal disease such as (clean home, clean mother, clean father,
clean children, drinking water tank closed well, there is hygienic sanitary facilities in the
kitchen, the level of hygiene in the health facilities, there is soap in the bathroom, there
are flies in the bathroom / kitchen, there are animals in the home or its surroundings).
These variables were not statistically significant, and this shows that they are not
influential variables on the high prevalence of diarrhea in the individuals of Al Shuka
area in Rafah governorate .
While the results of logistic regression analysis showed that the following demographic
variables (qualification, type of occupation, monthly income level) did not have a
significant effect on the spread of diarrhea disease in Al Shuka area located at Rafah
governorate.
5.7.2. Environmental and socio-demographic factors associated with other common
water borne diseases at Al Shuka area
To identify the most important environmental and socio-demographic factors that could
have an impact on the prevalence of other common water borne diseases among the
individuals of Al Shuka area in Rafah, logistic regression method was used to build a
statistical model for showing water borne diseases, the most important factors that have a
direct impact on the spread of disease. The obtained results from the statistical analysis
are illustrated in Table 5.8.
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Table5.8: Results of the gradual test method (Wald) to model logistic regression
(step wise) for demographic variables and environmental variables on the spread of
other diseases among individuals of Al Shuka area in Rafah Governorate
Independent
variables
B S.E Wald df Sig. Exp(B) 95% C.I for
EXP(B)
Lower Upper
Drinking water tank
closed properly
-1.03 0.53 3.83 1 0.05*
0.36 0.13 1.00
There is stagnant /
algae below the
drinking water tank
1.19 0.48 6.00 1 0.01**
3.28 1.27 8.48
There is basin near the
bathroom/ inside the
bathroom
-0.89 0.39 5.27 1 0.02*
0.41 0.19 0.88
The level of hygiene
in health facilities
0.78 0.22 13.17 1 0.001**
2.18 1.43 3.33
The basin in the
bathroom is much
higher than the level
of children
-.054 0.29 3.85 1 0.05*
0.58 0.33 1.04
There are flies inside
the bathroom / kitchen
1.91 0.34 31.03 1 0.001**
6.76 3.45 13.25
Constant -1.09 0.48 5.29 1 0.02*
0.34 - -
** P-value<0.001 * P-value<0.05 // P-value>0.05
It is clear from Table (5.8) that the relative importance of each of the independent
variables as specified in the logistic regression model to predict the variable of different
diseases, where the statistical significance of some of the independent variables in this
model (P- value <0.01) and these variables are (drinking water tank is closed properly,
there is stagnant / algae below drinking tank, there is a basin near the bathroom, the level
of hygiene in the health facilities, the basin in the bathroom is much higher than the
children's level, there are flies inside the bathroom), and it was proved statistically that
these independent variables are the best in terms of differentiating between the infected
and non-infected individuals with diarrhea. This was selected for these variables
according to the value of Wald Statistics, which refers to the importance of the
independent variables of the proposed model and the examination of the independent
variables coefficient if it was statistically significant and different from zero or not. As
shown in the table it is clear that the standard error of the model coefficients (S.E) had a
84
standard error at least 2, which means that it can rely on these factors in the interpretation
of the results of classification also means that we do not face any numerical problems.
It is clear from the demonstrated results that whenever the closure of drinking water tank
is proper, that there is less spread of diseases rate in Al Shuka area. It was also found that
wherever there is stagnant water/ algae in the bottom of drinking water tank that there is
a high rate of diseases in the individuals of Al Shuka area in Rafah and vice versa. In
addition it was noticed that if there is a basin near the bathroom or inside the bathroom,
that the spread of diseases rate is less among the individuals of Al Shuka area in Rafah
governorate and it was observed that the lower level of hygiene in the health facilities, the
greater prevalence of diseases in the individuals of the study samples of Al Shuka area in
Rafah governorate.
The obtained statistical results showed that the more the basin in the bathroom is much
higher for children level the greater the prevalence of diseases in Al Shuka area and vice
versa. It was also noticed that the more flies are found inside the bathroom, this led to a
high incidence of diseases among the individuals of Al Shuka area and vice versa.
While it appears that the following variables (clean home, clean mother, clean father,
clean children, there is sanitation facilities at home, there is soap in the bathroom, there is
a bad smell inside the bathroom, there are animals in the home or outside), statistically
are not significant, and this shows that they are not dominant variables on the high
prevalence of other diseases in the individuals of Al Shuka area in Rafah governorate.
While the results of logistic regression analysis showed that the following demographic
variables (qualification, type of occupation, level of monthly income) did not have a
significant effect on the spread of diseases in the area of Al Shuka in Rafah governorate.
5.8 Quality of water samples
A number of some water quality chemical and microbiological parameters were analysed
in cooperation with Oxfam before and after the implementation of Oxfam project at Al
Shuka area. The water quality parameters including: pH, EC, TDS, Total Coliform TC
85
and Faecal Coliform FC parameters. These are important parameters disturbing the water
quality and they are most likely found to be major influences being observed in the Gaza
Strip groundwater. In addition, water analyses during the Oxfam intervention were
conducted to ensure and confirm the improving results obtained by Oxfam intervention.
Since no chloride and nitrate analysis have been performed by Oxfam, the researcher
included these two additional analyses due to their importance to water quality. The
following subsection present the water quality analyses obtained results.
5.8.1 pH
The test of pH is one of the most common examination in water and great indicators of
water quality. According to World Health Organization (2003) the level of pH is
important to be measured and controlled as lower and higher values of pH may lead to
pipe corrosion and coating. As shown in Fig.5.1 the pH analytical data of water samples
(pre-test) were ranging between 5.16 and 7.88 where few water samples pH values were
below the acceptable WHO standards (6.5-8). For pre-test water samples the average
value of pH were found to be 6.
Fig.5.1: pH values for pre-test water samples collected from Al Shuka area
Fig.5.2 shows the distribution values of pH for the post-test of water samples. As shown
in the Figure the values of pH were ranging between 6.59 and 7.46 all the values were
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within the standard of WHO (6.5-8). For post-test water samples the average value of pH
were found to be 7.14. This result is matching with PWA (2014) last report which stated
that, “fortunately, the pH in Gaza aquifer is matching the WHO and PWA guideline
values”. According to produced GIS maps, and considering the accepted range of pH
from 6.5 to 8.5, the pH quality records are in good condition. This is due to the
intervention of Oxfam which adjusted the pH of drinking water to be within the WHO
standards. This should have a positive effects on the health of the people in Al Shuka
area. It's worth to mention that these results consistent with the results of MoH water
analysis at Al-Shuka area (from 2011-2015) ( Annex- 4.4, Annex- 4.5 ) .
Fig.5.2: pH values for post-test water samples collected from Al Shuka area
The World Health Organization (2010) recommends a pH value of 6.5 or higher for
drinking water to prevent corrosion. However, a pH above 8.0 would be detrimental in
the treatment and disinfection of drinking water with chlorine as reported by UNICEF
(2008). Though, pH values between 6.5 and 8.5 generally show good water quality and
this range is normal of most drainage basins of the world (UNEP/GEMS, 2007).
5.8.2 Electrical Conductivity (EC)
Conductivity in water is affected by the presence of chloride, nitrate, sulphate, and
phosphate anions (ions that carry a negative charge) or sodium, magnesium, calcium,
87
iron, and aluminium cations (ions that carry a positive charge). From Fig.5.3 it is clear
that about 89% of the EC values are found to be in the range of WHO (1500µS/cm) and
PS (1500µS/cm) standards while the remain (11%) of the readings were found to be
higher than the WHO and PS standards. The EC values of pre-test water samples were
ranging between 65 and 2970 μs/cm. The average value of EC was found to be 453
μS/cm.
Fig.5.3: EC values for pre-test water samples collected from Al Shuka area
From Fig.5.4 it is clear that about 99% of the EC values are found to be in the range of
WHO and PS standards while the remain (1%) of the values was found to be higher than
the WHO and PS standards. The EC values of post-test water samples were ranging
between 210 and 3320 μS/cm. The average value of EC was found to be 301 μS/cm.
88
Fig. 5.4: EC values for post-test water samples collected from Al Shuka area
It is clear from Figures 5.3 and 5.4 that the conductivity of drinking water was improved,
this is due to the intervention of Oxfam which reduced the EC of drinking water to be
within the WHO standards. This should have a positive effects on the health of the people
in Al-Shuka area. It's worth to mention that these results consistent with the results of
MoH water analysis at Al-Shuka area (from 2011-2015) ( Annex- 4.4, Annex- 4.5 ) .
5.8.3 Total dissolved solids (TDS)
It was reported that the high levels of TDS and chloride in the groundwater cause high
salinity in the water supply (Al-Jamal and Al-Yaqubi, 2000). Mostly, conductivity, TDS,
hardness, and the presence of ions like chloride, sodium, magnesium and calcium
indicates how much the quality of water is saline. Figs 5.5 and 5.6 show the distribution
of TDS concentrations among water samples collected from Al Shuka area before and
after Oxfam-GB intervention (pre-test and post-test sampling). Water containing TDS
less than 1000 mg/l could be considered to be “Fresh water” and good enough for
drinking purpose, as documented by (Shuval H. 2000).
89
Fig. 5.5: TDS values for pre-test water samples collected from Al Shuka area
As shown in Fig.5.5, it is clear that about 91% of the values are found to be in agreement
with WHO and PS standards (1000 mg/l) while the remaining (9%) were found to be
higher than the WHO and PS standards. The readings of TDS of pre-test water samples
were ranging between 33 and 1780 mg/l. The average value of TDS was found to be 252
mg/l.
Fig. 5.6: TDS values for post-test water samples collected from Al Shuka area
90
From Fig.5.6 it is clear that about 99% of the values of TDS are found to be in the range
of WHO and PS standards and the remaining (1%) was found to be higher than the WHO
and PS standards. The readings of TDS of post-test water samples were ranging between
105 and 2060 mg/l. The average value of TDS was found to be 156 mg/l. According to
World Health Organization the value of TDS for drinking water is 500 mg/l. Beyond this
range the water may cause several diseases which are not water borne but the cause of
disease is presence of excess salt (Gaurav, 2014). Therefore, the intervention of Oxfam
has improved the TDS of drinking water to be within the WHO standards. This should
have a positive effects on the health of Al Shuka area people. It's worth to mention that
these results consistent with the results of MoH water analysis at Al-Shuka area (from
2011-2015) ( Annex- 4.4, Annex- 4.5 ) .
5.8.4 Chloride CL-
The presence of chloride is well understood as one of the main causes for groundwater
salinity in the Gaza Strip, taking into account that levels of chloride concentrations found
in the Gaza groundwater are considerably higher than those permitted by WHO
(250mg/l) and PS (600mg/l) standards. As shown in Fig.5.7, almost all of the investigated
readings of water samples during this study are found to have low chloride
concentrations, ranging from 41mg/l to 117mg/l with an average of 60.4mg/l. The
Palestinian Authority (2014) status report stated that 24.6% of the groundwater wells in
the Gaza Strip have chloride concentration less than 250 while the remaining (75.4%)
exceeds the WHO chloride level.
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Fig.5.7: Chloride concentrations of water samples collected from Al Shuka area
Chloride concentrations in excess of about 250 mg/l can give rise to noticeable taste in
water, but the threshold depends upon the related cations. Users can, though, become
familiar to concentrations in excess of 250 mg/l. No health-based guideline value is
suggested for chloride in drinking water (WHO, 2005).
In compare to results obtained from MoH, it showed improvement in the quality of
drinking water distributed by Oxfam (Annex-4.4 , Annex 4.5) .
5.8.5 Nitrate (NO-3)
It was reported that the aggregate pollution of public and private drinking water wells by
nitrate is generally due to the wide use of fertilizers and waste (Khademikia et al. 2013).
The high levels of nitrates pollution, which are common occurrences in Gaza, are known
well as a health risk and they are measured to be the cause of blue babies disease
(Mogheir et al., 2013). In compare to results obtained from MoH, it showed improvement
in the quality of drinking water distributed by Oxfam (Annex-4.4 , Annex 4.5) .
Despite the fact almost 90% of the groundwater wells of the Gaza Strip have nitrate
concentrations two to eight times higher than the WHO guideline values (PWA, 2014),
but the nitrate average level over all collected water samples were found to be lower than
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permitted level by WHO (45mg/l) and PS (70mg/l) standards. The average value of
nitrate was found to be 22.16 mg/l. The range level of nitrate among all water samples
were ranging between 15mg/l and 32mg/l. The water samples analyses results of nitrate
concentrations are shown in Fig.5.8.
Fig.5.8: Nitrate concentrations of water samples collected from Al Shuka area
Environmental Protection Agency (EPA) has set a maximum contaminant level of 10
mg/l for nitrate (NO3-N) for drinking water. Nitrate levels above 10 mg/l may existing a
serious health concern for infants and pregnant or nursing women. Adults take more
nitrate exposure from food than from water. Infants, however, take the greatest exposure
from drinking water for the reason that most of their food is in watery form. This is
particularly exact for bottle-fed infants whose formula is re-formed with drinking water
with high nitrate concentrations. Nitrate can interfere with the aptitude of the blood to
carry oxygen to energetic tissues of the body in infants of six months old or younger. The
subsequent illness is called Methaemoglobinemia, or "blue baby syndrome". Pregnant
women may be less able to endure nitrate, and nitrate in the milk of nursing mothers may
affect infants directly. These persons should not consume water containing more than 10
mg/l nitrate directly, added to food products, or beverages (particularly in baby formula).
Some studies showed that nitrate may play a role in spontaneous miscarriages, thyroid
disorders, birth defects, and in the development of some cancers in adults. Recent human
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epidemiologic studies have shown that nitrate ingestion may be linked to gastric or
bladder cancer (Woolverton, 2015).
5.8.6 Total Coliform (TC)
According to WHO (2005) water is microbiologically contaminated due to the incidence
of undefined pathogens or because of high growth of total reasonable count or because of
existence of indicators bacteria at certain levels. Several bacteria are used as indicator to
measure the presence of bacterial contamination in drinking water. The microbiological
analysis of drinking water is generally conducted to evaluate hygienic quality of water. In
contaminated drinking water, the significant type of bacteria known is coliform bacteria.
The bacteriological water quality data in this study is analyzed for the evaluation purpose
to find out if there is contamination or not in drinking water before and after the
implementation of Oxfam project at Al Shuka area. The obtained results of
bacteriological data analysis are shown in Table 5.9 and discussed as below. Total
coliform bacteria are communal indicator in the environment and are mostly harmless. If
a laboratory test identifies only total coliform bacteria in drinking water, the source is
maybe environmental and fecal contamination is not likely. Though, if environmental
contamination can come into the system, pathogens might get in too. It is significant to
find out the source of contamination (El Tabish, 2014). Results showed that 48 water
samples out of 90 for the pre-test sampling period (53.3%) were contaminated with total
coliform. While about 17 water samples out of 90 for the post-test sampling period
(18.9%) were contaminated with total coliform. It's worth to mention that these results
consistent with the results of MoH water analysis at Al-Shuka area (from 2011-2015)
( Annex- 4.4, Annex- 4.5 ) .
5.8.7 Fecal Coliform (FC)
Fecal coliform bacteria are a smaller group of total coliform bacteria. They occur in the
intestines and feces of people and animals. The occurrence of fecal coliform in a drinking
94
water sample often indicates current fecal contamination. That means there is a greater
risk that pathogens are existing (El Tabish, 2014).
It is clear from Table 5.9 that only 2 water samples out of 90 for the pre-test sampling
period (2.2%) found to be contaminated with fecal coliform. While for the water samples
collected after the implementation of Oxfam program there was no contamination (0.0%)
with fecal coliform. This showed that the intervention of Oxfam has improved the
microbiological quality of drinking water in terms of fecal coliform contamination to be
within the WHO guidelines. This should have a positive effects on the health of Al Shuka
area in Rafah governorate. It's worth to mention that these results consistent with the
results of MoH water analysis at Al-Shuka area (from 2011-2015) (Annex-4.4, Annex-
4.5).
Table 5.9: Bacteriological contamination of collected water samples
Parameters/Source Water samples No. Contaminated samples No. Contamination %
Total Coliform
Pre-Test
Post-Test
90
90
48
17
53.3
18.9
Fecal Coliform
Pre-Test
Post-Test
90
90
2
0
2.2
0.0
95
CHAPTER 6
CONCLUSIONS AND RECOMMENDATIONS
The following conclusions are made based on the statistical analysis of the achieved
results from the study area questionnaires and experimental work which was conducted
during the study period.
6.1 Conclusions
The environmental determinants and socio demographic factors of common water borne
diseases among people of Al Shuka area- Rafah Governorate were identified. This main
objective is further divided into four objectives , the first objective is to identify the
common water borne diseases among people of Al Shuka area, the second objective is to
detect the most age group affected by the identified common water borne diseases, the
third objective is to identify the environmental determinants and socio demographic
factors associated with common water borne disease among individuals of Al Shuka area,
and the fourth objective is to measure if there is differences in the water borne diseases
prevalence among people after water supply and total behaviour change intervention by
Oxfam-GB at Al Shuka area (Pre-Post Test).
To achieve these objectives, the present study utilized quantitative and qualitative
measures by incorporating observations made regarding the personal hygiene and
environmental situation inside the participants' houses, as well as conducted focus groups
discussion with households (wives) and used Pre-Post Test oral administrative
questionnaire to determine the change in the level of common water borne diseases
prevalence among Al Shuka community after water supply and total behavioral change
after intervention by Oxfam-GB at Al Shuka area.
Based on the study results it is concluded that the most common water borne diseases in
the area of Al Shuka are including: diarrheal, dermal, and eye diseases. The results of
pre-test showed that, there were about (n=72; 34.6%) of the study sample (n=208) have
96
suffered from diarrhea, while after the intervention higher decline in the study sample
suffered from diarrhea. Also, about (n=94; 45.2%) of the study sample suffered from
other water borne diseases during of the pre-test stage with (n=89; 78%) of were infected
with dermal diseases, and about (n=65, 57%) of them were infected with eye diseases,
while after the implementation of Oxfam project only one person suffered from other
diseases .
Also, the results demonstrated that the most common age group who suffered from
diarrheal diseases among the infected people was children less than 5 years (n=49; 68%).
Regarding infection according to age group (n=43; 37.7%) of the study sample were
among women who suffered from dermal diseases. As well as, the most age groups who
were infected with eye diseases were from children above 5 years with about (n=23;
20.2%). Furthermore, water borne diseases found to be associated with environmental
factors and personal hygiene, such as (drinking water tank is closed properly, there is
stagnant /algae below drinking tank, there is a basin near/inside the bathroom, the level of
hygiene in the health facilities, the basin in the bathroom is much higher than the
children's level, there are flies inside the bathroom/kitchen, there is a bad smell inside the
bathroom). While the results of logistic regression analysis showed that there are some of
the environmental variables do not have significant effect on the increased incidence of
water borne diseases such as (clean home, clean mother, clean father, clean children,
there is hygienic sanitary facilities in the kitchen, there is soap in the bathroom, there are
animals in the home or its surroundings). Whereas the results of logistic regression
analysis showed that the following demographic variables (qualification, type of
occupation, level of monthly income) did not have a significant effect on the spread of
diseases in the area of Al Shuka-Rafah governorate.
Despite this positive improvement and decline in the incidence of these diseases at Al
Shuka area during and after the intervention of Oxfam-GB, the results of focus groups
which was conducted with females households three months after Oxfam intervention
ended and stop distributing desalinated water among Al Shuka community, revealed that
there was significant positive improvement the rate of diseases incidence at Al Shuka
area during the intervention of Oxfam. However, after the end of Oxfam project the
97
situation returned as it was before Oxfam intervention where people become suffering
again from access to sufficient clean drinking water, and they asserted that awareness
campaign about the importance of personal hygiene and cleaning the surrounding
environment are not enough, were the availability of safe and clean water to meet their
drinking and personal hygiene needs has a major impact in the decline of water borne
diseases.
6.2 Recommendations
Based on the findings of this study the following recommendations can be drawn:
1. Where poor Socioeconomic conditions reflect negative impact on the level of
waterborne diseases prevalence among Al Shuka community, hence further concern by
local and international organizations should be paid to improve the situation at Al-Shuka
area .
2. Al-Shuka area cannot continue depending on discontinuous water supply provided by
short term projects, where continuous safe and clean water supply should be ensured in
order to cover people needs and protect their health.
3. Establishing continuous public awareness campaigns and behavior change towards
improving the surrounded environment, personal hygiene, cleanliness and sanitary
programs should be ensured mainly in rural and vulnerable area of the Gaza Strip.
4. Periodic quality assessment of the water source should be conducted ensure that safe
drinking water which meets the WHO and Palestinian quality standards PS is available to
everyone.
5. Awareness programs related to water treatment, water quality and importance of flush
toilets should be carried out in Al Shuka area and the rural areas in the Gaza Strip to
improve the status of public health.
98
6. Further investigations and researches should be conducted on the rural and vulnerable
areas to identify the main determinant and factors associated with common water borne
diseases in these area, to draw suitable solutions and interventions.
99
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113
ANNEXES
114
ANNEX-1
Questionnaires and Observation Checklist
رفح -قة الشوكةدراسة حول أهم الامراض المتعلقة بالمياه و المنتشرة في منط
رقم الاستبانة ةـــــــيــصــخــــــات الشـــانـــــيــــــالب
الاسم رباعي 1 عنوان المنزل 2 المهنة 3 الدخل الشهري 4 إجمالي ذكور اناث عدد أفراد الأسرة 5A مجموع أفراد الأسرة B سنوات 5أقل من C سنة 15 سنوات الى 5الذين أعمارهم من D ( 16بالغين )سنة فما فوق الزوجة الزوج من هو رب الأسرة ؟ ) المعيل ( 6
للشخص الذي نقوم بمقابلته العلميالمؤهل 7 غير متعلم
متعلم . ثانوي3 ابتدائي. 1 .جامعي/ فما فوق4 . اعدادي 2
النظافة الشخصيةأسئلة الصحة العامة والسلوك المتعلق ب )يجب عدم ذكر الخيارات( متى تحتاج أن تغسل يديك ؟ 8A لا نعم بعد الخروج من الحمام B لا نعم قبل الأكل C لا نعم قبل اعداد الطعام أو الطهي D لا نعم قبل اطعام الأطفال E لا نعم بعد تغيير الحفاظ F لا نعم بعد لمس الحيوانات G حدد أخرى ,
9 ماذا تستخدم عادة في غسل اليدين؟ ) عدم ذكر أي
لــمـاذا؟ خيارات(
A الرماد B الرمل C أستعمل الماء فقط D مواد الجلي E الماء و الصابون F مادة أخرى
115
المستخدمة الــــــــميــــاهأسئلة تتعلق ب
يك؟) عدم ذكر ما هو مصدر مياه الاستعمال المنزلي لد 10 أي خيارات (
بلدية آبار تبرع شراء
هل تعتقد ان هذه المياه صحية وآمنة 11 لا نعم
لماذا
ما هي استخدامات هذه المياه؟ 12 الشرب الطبخ النظافة الشخصية المنزل نظافة
أخرى حدد:
بلدية عيةآبار زرا شراء أحصل على مياه الشرب من ) عدم ذكر أي خيارات ( 13من أوكسفام عبر القسائم
هل تقوم بغسل فوهة الخرطوم عند التعبئة؟ ) عدم ذكر 14 أي خيارات (
لا نعم
إذا كانت الإجابة نعم, كيف تقوم بذلك: 15A أنظف فوهة الانبوب بغمره في الكلور B اقوم بغمره بالماء C اقوم بمسحه بفوطة ومن ثم غسله D حدد أخرى ,
16 خلال الشهر الماضي كم مرة اضطررت لشرب مياه
البلدية عندما لم يتوفر لديك مياه صالحة للشرب
A دائما B مرة واحدة الى مرتين C ثلاث مرات الى أربعة D خمس مرات فما فوق E أنا لا أشرب مياه البلدية بالمطلق لا نعم للأطفال؟ هل خزان المياه في مكان سهل المنال 17
آخر مرة قمت فيها أو أحد أفراد أسرتك بتنظيف خزان 18 مياه الشرب كانت
A خلال الشهر الماضي B منذ مدة أكثر من شهر C انا لا أنظف خزان مياه الشرب مطلقا
19 خلال الثلاثين يوما الماضية كم مرة حاولت او جربت ان
بل تحضير الرضعة تغلى المياه ق
A ليس لدى اطفال لأفعل ذلك B مرة ولا C مرة الى مرتين D اكثر من ثلاث مرات E في جميع الحالات F اخرى , حدد
116
مراض المتعلقة بالمياه والنظافة الشخصيةالأل و اطفالأسئلة المتعلقة بصحة الأ
خلال الأسبوعين بالإسهالرتك هل أصيب أحد أفراد أس 20 لا نعم الماضيين؟
21 إذا كانت الاجابة نعم, كم عدد الأشخاص المصابين به
مع تحديد الفئة؟ في حال عدم وجود 0اكتب عدد المصابين أمام كل فئة ) ضع رقم
أي حالة(A رجل B بنت\امرأة C أطفال أقل من خمس سنوات ؟كم مرة أصيب ؟ حددي 22
23 في اعتقادك ما هو سبب الاسهال في عائلتك؟ ) عدم
( أمام الاجابات المذكورة ✔ضع علامة ) ذكر أي خيارات (
A مياه ملوثة B طعام ملوث C ضعف امكانيات النظافة الشخصية والمنزلية D مياه مجاري E مخلفات الحيوانات\التعامل مع الحيوانات F البيئة المحيطة\منزلحشرات في ال G أذكرها\أسباب أخرى H لا أعرف
ما هو الاجراء الذي قمت به لمعالجة الاسهال في آخر 24 مرة أصيب بها احد أفراد أسرتك )عدم ذكر أي خيارات(
A لم يتم اتخاذ اي اجراء B التوجه للطبيب أو مركز الرعاية الصحية أو مستشفى C مصاب ادوية بدون استشارة طبيةاعطاء ال D اعطاء محلول اشباع فقط E أخرى
25 خلال أمراض أخرىهل أصيب أحد أفراد أسرتك ب
لا نعم الأسبوعين الماضيين؟
اذا كانت الاجابة نعم حدد: نوع المرض
A أمراض جلدية 5طفل اقل من امرأة رجل
سنوات 5طفل أكبر من
سنوات
B (التهابات عيون ) (أمراض خاصة بالعيون/ حدد: رمد ( أخرى :
5طفل اقل من امرأة رجل سنوات
5طفل أكبر من سنوات
أسئلة تتعلق ببرامج التثقيف الصحي والزيارات المنزلية
26 خلال الأشهر الستة الماضية, هل حدث وأن رأيت أو
عن النظافة قرأت أو سمعت أية معلومات و نصائح العامة أو النظافة الشخصية من أي مصدر؟
لا نعم
لا نعمزيارات الاستفدت من أي أو جلسات شاركت في أي هل 27
117
ملاحظات أخرى للباحث/ة
لا نعم البيت نظيف 34 لا نعم م نظيفةالأ 35 لا نعم الأب نظيف 36 لا نعم الأولاد نظيفين 37 لا نعم خزان مياه الشرب مغلق بشكل جيد 38م صنبور المياه الخاص بخزان مياه الشرب محك 39
الإغلاق لا نعم
لا نعم يوجد مياه راكدة /طحالب أسفل خزان الشرب 40 لا نعم مطبخ( -يوجد مرافق صحية في المنزل )حمام 41 لا نعم يوجد مغسلة بالقرب من الحمام/ داخل الحمام 42 ممتاز جيد جدا جيد سيء مستوى النظافة في المرافق الصحية 43 لا نعم طبخيوجد صابون في الم 44 لا نعم يوجد صابون في الحمام 45 لا نعم يوجد رائحة كريهة داخل الحمام 46 لا نعم المغسلة في الحمام أعلى بكثير من مستوى الأطفال 47
الشخصية؟ بالنظافة المتعلقة المنزلية
ما هو مصدر المعلومات عن النظافة العامة أو النظافة 28 الشخصية؟
مراكز الصحة الزيارات المنزلية المثقفات الصحيات من خلال
الراديو أو التلفاز أخرى, حددي:
هل باعتقادك أن الزيارات المنزلية بهدف الثقثف الصحي 29 مناسبة ويتم الاستفادة منها؟
لا نعم
A ,؟الماذفي حال كانت الاجابة لا
B في حال كانت الاجابة نعم, ما هي أهم المعلومات التي تم ا؟الاستفادة منه
هل لديك أي توصيات؟ 30
أسئلة تتعلق بالمياه التي توزع من قبل مؤسسة أوكسفام
كم المدة التي تلقيتم فيها مياه محلاة من قبل مؤسسة أوكسفام من 31 بداية المشروع وحتى الآن؟
هل وجدتم اختلاف في المستوى الصحي من ناحية ) انتشار 32 الأمراض (؟
ف في المستوى الصحي من ناحية ) جودة المياه(؟هل وجدتم اختلا 33
118
لا نعم يوجد ذباب داخل الحمام/ المطبخ 48وضعها بجانب الحرق حاوية آلية التخلص من نفايات المنزل 49
المنزل امل البلديةع
لا نعم في المنزل أو في محيط المنزليوجد حيوانات 50 للباحث/ة ملاحظات أخرى 51
119
ANNEX-2
PERMISSIONS FROM RESPONSIBLE AUTHORITIES FOR
CONDUCTING EXPERMENTAL WORK
120
Annex 2.1: Permission Request from Al Azhar university to Oxfam-GB office in
Gaza for collecting data purpose
121
Annex 2.2: Permission Request from Al Azhar university to UNRWA public health
department Gaza for collecting data purpose
122
Annex 2.3: Permission Request from Al Azhar university to MoH public health
department Gaza for collecting data purpose
123
Annex 2.4: Pernission Request from Al Azhar University to MoH for
collecting data purpose
124
ANNEX-3
LABORATORY REPORT SHOWS WATER CHEMISTRY
ANALYSES GIVEN FROM MoH
125
ANNEX-4
WATER SAMPLES QUALITY DATA
Annex4.1: Water quality analytical results for pre-test samples (Oxfam-GB office)
Water
samples ph ec TDS color Turbidity FC TC streptococcus
sample 1 6.111 140 70 0 0 0 0 0
sample 2 6 270 135 0 0 0 0 0
sample 3 5.555 110 55 0 0 0 0 0
sample 4 6.202 160 80 0 0 0 TMC 0
sample 5 5.963 160 80 0 0 0 0 0
sample 6 5.438 185 93 0 0 0 0 0
sample 7 6.426 1530 840 0 0 0 0 0
sample 8 6.657 335 168 0 0 0 0 0
sample 9 6.42 357 180 0 0.5 0 TMC 0
sample 10 6.532 360 180 0 0.49 TMC TMC 0
sample 11 6.547 456 228 0 0.49 0 TMC 0
sample 12 5.312 85 43 0 0.45 0 0 0
sample 13 5.575 90 45 0 0 0 0 0
sample 14 6.141 208 105 0 0 0 0 0
sample 15 6.034 170 85 0 0 0 TMC 0
sample 16 6.975 2970 1780 0 0 0 0 0
sample 17 5.467 75 38 0 0 0 40 0
sample 18 6.155 207 105 0 0 0 40 0
sample 19 5.846 171 86 0 0 0 TMC 0
sample 20 6.344 166 83 0 0 0 20 0
sample 21 6.552 295 148 0 0 0 TMC 0
sample 22 5.874 155 78 0 0 0 32 0
sample 23 6.263 366 183 0 0 0 0 0
sample 24 5.316 85 43 0 0.48 0 TMC 0
sample 25 5.867 132 66 0 0.5 0 TMC TMC
sample 26 5.516 96 48 0 0.5 0 TMC 0
sample 27 5.913 167 84 0 0 0 TMC 0
sample 28 6.157 270 135 0 0.48 0 TMC 0
sample 29 5.522 358 180 0 0.5 0 TMC 0
sample 30 5.925 153 77 0 0 0 0 0
sample 31 6.385 315 158 0 0 0 0 0
sample 32 5.859 252 126 0 0 0 0 0
126
sample 33 6.111 205 103 0 0 0 0 0
sample 34 5.163 167 84 0 0 0 0 0
sample 35 6.009 155 78 0 0 0 0 0
sample 36 7.634 2570 1542 0 0 0 0 0
sample 37 6.356 275 138 0 0 0 0 0
sample 38 5.955 153 77 0 0 0 16 0
sample 39 6.052 160 80 0 0 0 TMC 0
sample 40 5.879 156 78 0 0 0 TMC 0
sample 41 6.094 180 90 0 0 0 0 0
sample 42 5.298 88 44 0 0.5 0 TMC 0
sample 43 6.297 297 150 0 0.48 0 TMC 0
sample 44 6.435 320 160 0 0 0 0 0
sample 45 6.129 155 78 0 0 0 0 0
sample 46 6.222 290 145 0 0.45 0 TMC 0
sample 47 5.81 140 70 0 0 0 TMC 0
sample 48 6.078 165 70 0 0 0 0 0
sample 49 7.861 2440 1465 0 0 0 TMC 0
sample 50 6.674 370 185 0 0 0 0 0
sample 51 6.024 322 160 0 0 0 0 0
sample 52 6.036 1605 883 0 0 0 0 0
sample 53 7.889 250 125 0 0 0 0 0
sample 54 6.17 193 97 0 0 0 30 20
sample 55 5.911 185 93 0 0.5 TMC TMC 0
sample 56 6.029 200 100 0 0.5 0 TMC 0
sample 57 5.908 170 85 0 0.48 0 TMC 0
sample 58 6.133 165 83 0 0 0 0 0
sample 59 7.661 2900 1740 0 0 0 0 0
sample 60 7.656 2020 1212 0 0 0 TMC 20
sample 61 5.71 145 73 0 0 0 TMC TMC
sample 62 5.967 170 85 0 0 0 0 0
sample 63 5.985 310 155 0 0 0 0 0
sample 64 5.458 72 36 0 0 0 0 0
sample 65 6.075 173 87 0 0 0 20 0
sample 66 6.197 175 88 0 0 0 36 0
sample 67 5.739 185 93 0 0.5 0 TMC TMC
sample 68 6.019 170 85 0 0 0 0 0
127
sample 69 5.879 65 33 0 0.49 0 TMC TMC
sample 70 6.134 173 87 0 0.48 0 TMC 0
sample 71 6.016 174 87 0 0.45 0 TMC TMC
sample 72 5.864 184 62 0 0.5 0 TMC 0
sample 73 6.064 185 93 0 0.48 0 TMC 0
sample 74 7.487 2300 1380 0 0 0 TMC 40
sample 75 6.352 327 164 0 0.5 0 TMC 0
sample 76 6.323 200 100 0 0.5 0 TMC TMC
sample 77 6.139 250 125 0 0.49 0 TMC TMC
sample 78 6.346 247 124 0 0.48 0 TMC 40
sample 79 6.542 340 170 0 0 0 0 0
sample 80 6.224 165 83 0 0 0 TMC TMC
sample 81 5.813 86 43 0 0 0 0 0
sample 82 7.362 2700 1620 0 0 0 0 0
sample 83 5.759 155 78 0 0 0 0 0
sample 84 6.189 413 206 0 0 0 0 0
sample 85 7.878 2960 1776 0 0 0 20 0
sample 86 5.83 155 78 0 0 0 0 0
sample 87 5.649 155 78 0 0 0 TMC TMC
sample 88 6.552 375 188 0 0 0 0 0
sample 90 6.002 180 90 0 0.5 0 TMC 0
128
Annex4.2: Water quality analytical results for post-test samples (Oxfam-GB office) Water
samples ph ec TDS color Turbidity FC TC streptococcus
sample 1 7.37 230 115 0 0 0 0 0
sample 2 7.03 230 115 0 0 0 0 0
sample 3 6.65 3320 2060 0 0 0 TMC 0
sample 4 7.294 235 118 0 0 0 0 0
sample 5 7.35 270 135 0 0 0 TMC 0
sample 6 7.23 240 120 0 0 0 0 0
sample 7 7.21 230 115 0 0 0 0 0
sample 8 7.09 240 120 0 0 0 0 0
sample 9 7.29 220 110 0 0 0 0 0
sample 10 7.18 230 115 0 0.34 0 TMC 0
sample 11 7.18 240 120 0 0 0 0 0
sample 12 7.35 235 118 0 0 0 TMC 0
sample 13 7.12 260 130 0 0 0 0 0
sample 14 7.23 350 175 0 0 0 0 0
sample 15 7.289 370 185 0 0 0 0 0
sample 16 7.39 250 125 0 0 0 0 0
sample 17 7.36 235 118 0 0 0 0 0
sample 18 7.254 250 125 0 0 0 0 0
sample 19 6.985 280 140 0 0 0 0 0
sample 20 7 220 110 0 0 0 0 0
sample 21 7.285 285 143 0 0 0 50 0
sample 22 7.192 220 110 0 0 0 0 0
sample 23 6.989 280 135 0 0 0 0 0
sample 24 7.32 230 115 0 0 0 0 0
sample 25 7.16 240 120 0 0.62 0 0 0
sample 26 7.16 310 155 0 0 0 TMC 0
sample 27 7.252 240 120 0 0 0 0 0
sample 28 6.975 230 115 0 0 0 0 0
sample 29 7.24 270 135 0 0 0 TMC 0
sample 30 7.35 235 118 0 0 0 TMC 0
sample 31 7.2 235 118 0 0 0 TMC 0
sample 32 7.26 330 165 0 0 0 0 0
sample 33 7.03 260 130 0 0 0 0 0
sample 34 7.258 220 110 0 0 0 0 0
sample 35 6.92 330 165 0 0 0 TMC 0
129
sample 36 7.17 215 108 0 0 0 0 0
sample 37 6.888 220 110 0 0 0 0 0
sample 38 6.708 225 113 0 0 0 0 0
sample 39 7.011 230 115 0 0 0 0 0
sample 40 7.31 225 113 0 0 0 0 0
sample 41 7.394 240 120 0 0 0 TMC 0
sample 42 7.35 240 120 0 0 0 0 0
sample 43 7.468 1150 630 0 0 0 0 0
sample 44 7.29 270 135 0 0 0 0 0
sample 45 7.369 230 115 0 0 0 0 0
sample 46 7.18 230 115 0 0 0 0 0
sample 47 6.93 300 150 0 0 0 TMC 0
sample 48 7.2 270 135 0 0 0 0 0
sample 49 6.78 225 113 0 0 0 0 0
sample 50 7.193 250 125 0 0 0 0 0
sample 51 7.01 250 125 0 0 0 0 0
sample 52 6.86 310 155 0 0 0 0 0
sample 53 7.23 250 125 0 0 0 0 0
sample 54 7.17 290 145 0 0 0 0 0
sample 55 6.96 325 163 0 0 0 0 0
sample 56 7.27 260 130 0 0 0 0 0
sample 57 7.143 295 148 0 0 0 20 0
sample 58 7.207 250 125 0 0 0 0 0
sample 59 7.06 230 115 0 0.17 0 0 0
sample 60 0
sample 61 0
sample 62 7.261 360 180 0 0 0 0 0
sample 63 6.966 220 110 0 0 0 0 0
sample 64 7.336 220 110 0 0 0 0 0
sample 65 7.33 245 123 0 0 0 60 0
sample 66 6.91 290 145 0 0 0 0 0
sample 67 7.157 280 140 0 0 0 0 0
sample 68 7.293 280 140 0 0 0 0 0
sample 69 7.349 215 108 0 0 0 0 0
sample 70 7.11 230 115 0 0 0 0 0
sample 71 7.17 250 125 0 0 0 0 0
130
sample 72 7.31 240 120 0 0 0 0 0
sample 73 7.12 250 125 0 0 0 70 0
sample 74 7.045 260 130 0 0 0 0 0
sample 75 7.263 350 175 0 0 0 0 0
sample 76 7.41 220 110 0 0 0 0 0
sample 77 7.403 230 115 0 0 0 0 0
sample 78 7.307 230 115 0 0 0 0 0
sample 79 7.18 230 115 0 0 0 0 0
sample 80 7.22 340 170 0 0 0 0 0
sample 81 6.871 210 105 0 0 0 0 0
sample 82 7.222 280 140 0 0 0 0 0
sample 83 6.926 320 160 0 0 0 TMC 0
sample 84 6.94 320 160 0 0 0 0 0
sample 85 7.23 250 125 0 0 0 TMC 0
sample 86 6.91 240 120 0 0 0 0 0
sample 87 6.595 215 108 0 0 0 0 0
sample 88 6.66 240 120 0 0 0 0 0
sample 89 6.852 230 115 0 0 0 0 0
sample 90 7.194 250 125 0 0 0 0 0
131
Annex-4.3: Water quality analytical results conducted during
Oxfam intervention (Sabha Health Lab–Gaza) Water samples Chloride (mg/l) Nitrate (mg/l)
Sample 1 72 26
Sample 2 58 23
Sample 3 64 26
Sample 4 41 21
Sample 5 70 26
Sample 6 60 27
Sample 7 60 27
Sample 8 70 28
Sample 9 78 32
Sample 10 52 17
Sample 11 54 23
Sample 12 68 29
Sample 13 117 20
Sample 14 64 16
Sample 15 51 15
Sample 16 54 15
Sample 17 62 18
Sample 18 56 16
Sample 19 56 16
Sample 20 56 16
Sample 21 56 16
Sample 22 54 16
Sample 23 66 17
Sample 24 66 16
Sample 25 54 16
Sample 26 58 16
Sample 27 58 16
Sample 28 58 25
Sample 29 54 27
Sample 30 52 25
Sample 31 52 26
Sample 32 51 22
Sample 33 49 21
Sample 34 70 22
Sample 35 62 24
Sample 36 56 23
Sample 37 49 23
Sample 38 52 22
Sample 39 49 23
Sample 40 62 25
Sample 41 52 24
132
Sample 42 52 22
Sample 43 74 27
Sample 44 58 27
Sample 45 58 25
Sample 46 68 31
Sample 47 86 24
Sample 48 84 26
133
Annex-4.4: Results of water analysis from Al-Shuka water wells (MoH) :
color Turbidity PH E.C TDS NO3 CL SO4 Alkakinity Hardness Ca Mg K Na المنطقة تاريخ اخذ العينة مصدر العينة
310 3.8 60 104 508 144 123 474 220 1469 2370 7.56 5> 5> رفح 04/18/2011 بئر الشوكة
230 3.1 78 108 589 168 132 460 293 1302 2100 8.07 5> 5> فحر 12/05/2011 بئر الشوكة
-بئر الشوكة الجمعية
280 3.4 56 77 425 174 180 425 153 1277 2060 7.65 5> 5> رفح 12/05/2011
430 4.3 71 98 537 153 237 639 189.4 1699 2740 7.89 5> 5> رفح 05/30/2012 بئر الشوكة
-بئر الشوكة الجمعية
280 3 75 98 554 153 102 485 220.1 1358 2190 7.89 5> 5> رفح 05/30/2012
430 4.4 80 104 589 142 242 646 184.8 1860 3000 7.83 5> 5> رفح 04/14/2014 بئر الشوكة
-بئر الشوكة الجمعية
280 3.1 81.8 111 614 138 93 511 219.7 1513 2440 7.94 5> 5> رفح 04/14/2014
443 4.6 88 114 602 156 263 658 195 1926 3210 7.9 5> 5> رفح 04/20/2015 الشوكة بئر
-بئر الشوكة الجمعية
292 4 91 128 631 148 123 521 2231 1527 2545 7.78 5> 5> رفح 04/20/2015
320 3.4 79 98 569 153 139 589 231.9 1705 2750 8.14 5> 5> رفح 06/24/2013 بئر الشوكة
-ئر الشوكة ب الجمعية
332 4.8 92 121 582 161 153 621 253.5 1474 2458 7.85 5> 5> رفح 06/24/2013
134
Anex-4.5: Results of water analysis from Al-Shuka water wells
(MoH) :
Parameter WHO
Standards
for drinking
water
Palestinian
Standards
for drinking
water
Average
pH Min: 7.56 6.5-8 6.5-8.5 7.86
Max: 8.14
TDS
mg/l
Min: 1277 1000 1000 1556
Max. 1926
EC
µs/cm
Min. 2060 1500 1500 2283
Max. 3210
Cl
mg/l
Min. 425 250 600 548
Max. 658
NO-3
mg/l
Min. 153 50 70 216
Max. 293
TC Min. < 10 <10 CFU/100
ml
<10 CFU/100
ml
TMC
Max. TMC
FC Min. 0 0 0 TMC
Max. TMC
*Hint: TMC: Too Many to Count CFU: Colony forming Units
135
ANNEX-5
INCIDENCE OF VARIOUS WATER-RELATED DISEASES IN AL-
SHUKA AREA (THE RECORDS FROM UNRWA)
Annex-5: Incidence of various water-related diseases in Al-Shuka area on a yearly
basis as obtained from the records of Department of Epidemiology, UNRWA
Acute
bloody
diarrhea
Acute watery
diarrhea <5
years
Acute watery
diarrhea >5
years
Viral
hepatitis A
Typhoid
Year
(2008)
Population
(10923)
Cases No.
Infection rate %
164
1.5%
435
3.98%
101
0.92%
4
0.04%
0
0
Year
(2009)
Population
(11294)
Cases No.
Infection rate %
122
1.08%
615
5.45%
284
2.51%
0
0
0
0
Year
(2010)
Population
(11680)
Cases No.
Infection rate %
186
1.59%
522
4.47%
172
1.47%
0
0
0
0
Year
(2011)
Population
(12108)
97
0.80%
460
3.80%
270
2.23%
8
0.07%
2
0.02%
136
Cases No.
Infection rate %
Year
(2012)
Population
(12552)
Cases No.
Infection rate %
38
0.30%
407
3.24%
241
1.92%
5
0.04%
0
0
Year
(2013)
Population
(13010)
Cases No.
Infection rate %
27
0.21%
199
1.53%
99
0.76%
11
0.08%
0
0
Year
(2014)
Population
(13840)
Cases No.
Infection rate %
4
0.03%
144
1.04%
82
0.59%
10
0.07%
0
0
137
ANNEX-6
INCIDENCE OF VARIOUS WATER-RELATED DISEASES IN AL-
SHUKA AREA (THE RECORDS From THE MINISTRY OF
HEALTH).
Annex-6: Incidence of various water-related diseases in Al-Shuka area on a yearly
basis as obtained from the records of Department of Epidemiology, Ministry of
Health.
Acute bloody
diarrhea
Acute watery
diarrhea <3 years
Acute watery
diarrhea >3 years
Year (2010)
Population (10923)
Cases No.
Infection rate %
22
0.19%
0
0
91
0.78%
Year (2011)
Population (11294)
Cases No.
Infection rate %
8
0.07%
0
0
122
1.01%
Year (2012)
Population (11680)
Cases No.
Infection rate %
5
0.04%
0
0
123
0.98%
Year (2013)
Population (12108)
Cases No.
Infection rate %
0
0
0
0
109
0.84%
Year (2014)
Population (12552)
Cases No.
Infection rate %
5
0.04%
0
0
213
1.54%