Dilargachew Tegegn; Fasil Kenea Duguma; Melakebirehan dagnew

doi:10.19080/JOJPH.2019.05.555653

Short Communication

Assessment of Knowledge, Attitude, Practices and its determinant factors towards Acute Watery Diarrhea Disease among Military Personnel Living in Harar, Ethiopia, July 2018

**Dilargachew Tegegn, Fasil Kenea Duguma* and Melakebirehan dagnew**

Department of Public Health, Defense Health Science College, Addis Ababa, Ethiopia.

Submission: August 5, 2019; Published: August 26, 2019

*Corresponding author: Fasil Kenea Duguma, Department of Public Health, Defense Health Science College, Addis Ababa, Ethiopia JOJ Pub

How to cite this article:Dilargachew Tegegn, Fasil Kenea Duguma, Assessment of Knowledge, Attitude, Practices and its determinant factors towards Acute Watery Diarrhea Disease among Military Personnel Living in Harar, Ethiopia, July 2018. JOJ Pub Health. 2019; 5(1): 555653. DOI: 10.19080/JOJPH.2019.05.555653

Abstract

Acute watery diarrhea becomes a major health problem in most of developing countries like Ethiopia. Thus, it is important to identify the level of knowledge, attitude and practices in study area and identifying potential predictors for better intervention.

Objective: assessment of knowledge, attitude, practices, and its’ determinant factors towards acute watery diarrhea among military members in Harar, Ethiopia; 2018.

Methods: Household based cross-sectional study was conducted from February 8 to March 9/2018. The studies participant were 312 military members selected by systematic probability sampling technique and it was supported by qualitative data. Collected data were coded and entered in to epi-data version 3.1 and exported to SPSS version 21 for statistical analysis. Univariate, bivariate, and multivariable analysis was done through binary logistic regression. P-value less than 0.05 were used as statistically significant. Frequency, median and other statistics were calculated.

Results: About 49.7%, 96.4%, 56.7% respondents had good knowledge, attitudes, and practices score towards acute watery diarrhea. Result of multivariate logistic regression showed that age  30 years [AOR: 5.723; (95%CI: 1.586-14.062)], education 8 grades [AOR: 7.694; (95%CI: 2.185-27.096)], and respondents having poor knowledge [AOR: 19.076; (95%CI: 9.084-40.061)] were statistically significantly associated with poor practices on acute watery diarrhea prevention.

Conclusion: The respondents had better attitudes, but their practices and knowledge were not good enough to prevent the occurrence of an outbreak of acute watery diarrhea from its happening. Therefore, it need to improvement on the knowledge and practice gaps by providing regular and relevant information about the disease.

Keywords:Acute watery diarrhea; AWD; Knowledge; Attitude and Practice; Hygiene and Sanitation, public health Impact of Diarrhea; Awareness Toward Diarrhea

Abbreviations: AOR: Adjusted Odds Ratio; AWD: Acute Watery Diarrhea; CFR: Case Fatality Rate; CFSR: Cholera Fact Sheet Report; COR: Crude Odds Ratio; DUCHS: Defense University Collage of Health Science; DHMD: Defense Health Main Department; EPHEM: Ethiopian Public Health Emergency Management; FGD: Focus Group Discussion; KAP: Knowledge, Attitude, and Practices; OR: Odds Ratio; SEC: South East Command; SECHD: South East Command Health Department; SECRH: South East Command Referral Hospital; SPSS: Statistical Package for Social Science; USA: United States of America; WASH: Water Sanitation and Hygiene; WHO: World Health Organization

Introduction

Cholera synonymously called as acute watery diarrhea, is an acute enteric infection caused by exposure to the bacterium [1]. According to the WHO case definition, Person aged over 5 years with severe dehydration or death from acute watery diarrhea with or without vomiting. A case of cholera should be suspected when in an area where there is a cholera epidemic, a patient aged 2 years or more develops acute watery diarrhea, with or without vomiting [1,2]. Reports from the epidemic forms of cholera diar rhea, particularly in developing countries, show that toxigenic V cholerae with sero-group O1 or O139 is the main causative microorganism [3,4].

Reservoir of Etiologic Agent

Humans are the main reservoir of Vibrio cholerae. Asymptomatic carriers and patients carry huge quantities of vibrio in feces and in vomit; up to 100,000,000 bacteria can be found in 1 ml. of cholera liquid. Other potential reservoirs are water, fish, and aquatic plants. The infective dose depends upon individual susceptibility, but in general a 1,000,000 dose is needed to cause the illness [5].

Mode of Transmission

Cholera is transmitted by the fecal-oral route. A dose of more than one million organisms is usually needed to cause illness [5]. It is prevalent in places with inadequate water treatment, poor sanitation, and insufficient hygiene. Individual become infected with cholera from consuming food and water that are contaminated with the feces of an infected person. Person to person transmission has been documented [6].

Risk Factors

The people most at risk of contracting cholera are those who do not have access to potable water and adequate sanitation [6]. There were 1.3 billion people at risk for cholera in the 69 countries. The research article ‘updated Global Burden of Cholera Endemic countries’ report (June 4, 2015) indicated that the number of population at risk in Ethiopia was 68,804,272, moreover, estimated annual number of cases and estimated annual number of deaths was 275,221 and 10,458 respectively [7].

Mode of Prevention

Measures for the prevention of cholera mostly consist of providing clean water and proper sanitation to populations who do not yet have access to basic services. Health education and good food hygiene are equally important. Hand washing with soap after defecation and before handling food or eating, safe preparation, and conservation of food as well as after providing care to those with cholera is necessarily important to stop the spread of disease [7,8].

Magnitude of the Problem

The 2014 world health organization also described that; 190,549 cases were reported including 55% of cases were from Africa. Of 2,231 deaths reported worldwide 1,882(84.4%) occurred in Africa [9]. A descriptive study conducted in Nigeria also reviled that the case fatality rate of AWD epidemic in 2010 was 5.1%. This ranged in the state between 3.8% and 8.9% [10]. The WHO 2010 report suggests that around 90% of episodes of cholera had of mild to moderate severity and difficult to distinguish clinically from other causes of acute diarrhea [9].

According to the world health organization 2014 and 2016 Cholera and Hand washing fact sheet report, 80% of individuals infected with vibrio cholerae do not exhibit symptoms or exhibit mild symptom indistinguishable from other mild causes of diarrhea [6,7] However, about 20% of those who are infected develop AWD 10–20% of these individuals develop severe, watery diarrhea with vomiting.

If these patients are not treated promptly and adequately, the loss of such large amounts of fluid and salts (more than 10- 20 liters/day in severe forms) can lead to severe dehydration and death within hours. The case-fatality rate in untreated cases may reach 30– 50%. Treatment is straightforward (basically rehydration) [5,10]. The most severe cases in endemic settings occur in children or previously unexposed individuals, in epidemic settings the disease occurs in all age groups. This is also depending on other host and pathogens, as well as environmental factors [6].

Surveillance of Cholera in Ethiopia

In Ethiopia cholera is a mandatory notifiable disease. It is carried out at all level of health system. Suspected case at community level is any person 5 years and above with profuse watery diarrhea and vomiting (1). There is a disease surveillance system including cholera, established under military health service system. In addition, military health facilities are working in collaboration with zonal and regional health offices when there is a condition an epidemic of AWD is expected. But the reporting and response mechanism still weak it is because of the nature of the mission that military will perform. The WHO weekly epidemiological report on June 17/2016 reported that cholera remains a major public health problem in many parts of the world with 3-5 million cases reported per year and causing 100,000 – 120,000 deaths [8]. Cholera is endemic in Africa, Asia, and Central America [9]. Severe outbreak usually occurs in underdeveloped countries with inadequate sanitation, poor hygiene and limited access to safe water supply while in some countries, a seasonal relation for cholera epidemic has been observed [9].

In Ethiopia, there was an occurrence of AWD, which is the most common symptoms of “Cholera”, epidemic from July 2008 to June 2009, there were a total of 9,485 cases and 193 deaths (CFR was 2%) occurred in six regions including Addis Ababa. Afar Region took the country’s highest share of cases 2,988(31.5%) and deaths 99(51.25%) of AWD with a case fatality rate of 3.3% [11] According to a published document, on Ethiopian journal of health sciences, 2016, the major contributors for the occurrence of AWD outbreak in Ethiopia was climatic condition, Socio-demographic factors, insufficient WASH access, population density, poor awareness about the disease and way of life [12]. Epidemic of AWD is increasing in Ethiopia. It is related with expansion and rapid urbanization, this create migration of people to live in towns while environmental facilities are poor which is favorable for growth and transmission of vibrio cholera.

In 2016, there was AWD cases report in Harar town and the districts around it. Harari health bureau, besides making health facilities to be ready for farther action in early September 2017, they started to warn the community to undertake preventive measures proactively. This is because of that an epidemic of acute watery diarrhea triggered in vicinities of the regional state. It might be aggravated by the scarce availability of water, and poor management of wastes in the town that are experiencing currently. Being near to Somalia also makes the town at risk of AWD due to the fact that the presence of war and political instability in Somalia, and this typically permits to uncontrolled human traffic movement, contributes the occurrence of AWD epidemic.

There are 5 military camps in Harar town having 1,200 estimated military head of households. This community, as living in the town, shares everything, like market and water sources. Regardless of living in the camp, they are equally at risk of contracting AWD disease as civilian community unless they have full understanding about the disease and its transmission, prevention and control measures. In addition, if an epidemic occurs in the camp it could have a serious effect in terms of morbidity, mortality and productivity. And number of cases of AWD occurring will be much higher than that of the general population. This is because the risk factors for the occurrence of AWD such as inappropriate sanitation, inadequate water and food safety, and inappropriate waste disposal are present. The above environmental factors mentioned are present in most military settings in Harar. In order to improve risk factors that predispose the population to AWD it is useful to study level of KAP of military personnel living in camps.

Knowledge About Acute Watery Diarrhea

Study done in Bangladesh, 2013 showed that only 23% of respondents could correctly identify cholera as a watery diarrhea. Overall 54% of respondents had poor knowledge on cholera (AWD). Of less than 10% of respondents of the study knew that proper sanitation and health education are important preventive measures [13]. Study done by Goni Chamba. et al. in 2016 identified that 70% of the respondent knew a germ that caused cholera, while 18% of the respondents thought that cholera was caused by bad air. In addition, 45% of the respondents believed that cholera could be prevented through cleaning the house and toilet; while only 25% believed that it can be prevented by washing hands after toilet. Of the total 58% of the respondents knew that washing hands before serving food prevents cholera while only 42% knew that washing hands before serving food prevented cholera and believed that washing hands after serving food can also prevent cholera [14].

Another study conducted in a Long-Standing Refugee Camp, Thailand, identified that 218 (81%) of 270 respondents had heard about cholera. From 218 who had heard about cholera, 52% mentioned watery diarrhea as a symptom of cholera. Overall, 61% respondents knew two or more vehicles of cholera transmission and 62% knew two or more means of cholera prevention [15]. Study conducted by Sonja Merten et al. Democratic Republic of Congo, showed that ingestion of contaminated water and food was mentioned by 63% and 61% as main sources of cholera respectively. The most common perceived causes mentioned were unsafe water and food hygiene by 67% and 66% respectively. Health education 18% and the provision of clean water 15% were considered the most effective measures of cholera control [16].

Community based survey done on 405 households, in Haiti, 2011 identified the knowledge of common sign of cholera, and the two most common signs described as diarrhea were 89.1% and vomiting 83.4%. Regarding prevention of AWD, consumption of contaminated water and contaminated food were reported by 71.9% and 61.4% of the respondents respectively. The most common prevention method cited was hand washing 86%. In the study only 6.2% believed that drinking water from piped supply was safe and 94.1% reported washing their hands with soap [17]. The research done in Zambia, 2015 on 152 households to identify factors associated with cholera outbreak showed that 91.7% of respondent said they knew about cholera while 8.2% had no knowledge about cholera. Moreover about 88% and 88.2% of respondent identified watery diarrhea and vomiting as symptom of cholera respectively. And 90.7% reported drinking contaminated water as a medium for transmitting cholera while 84.2% mentioned that cholera is transmitted through eating contaminated food. The result of this study also showed that the number of people in the house and main source of drinking water were significantly associated (P < 0.008) to knowledge about cholera [18].

According to study done in Benin, of the total, 92.2% had good knowledge of cholera, 78.7% had moderate knowledge regarding health measure to prevent cholera. In this study the proportion of individuals with poor hygiene practices was higher in single (97.3%) than married (90.2%). There was strong relationship between the availability of latrines and hygiene practices (p<0.0001) [19].

Attitudes and Practices Towards AWD

Study done in Bangladesh showed that the respondent attitude and preventive practices were significantly correlated (r=0.061, p<0.001). The result showed 97% of the study participants had positive attitude towards cholera and 89% practiced food safety by having fresh food, avoiding rotten food and maintained good-hygiene. In this study two-third of the respondents used safe water for drinking and household purposes. Overall in this survey 61% followed good practices to prevent cholera [13]. Study done in Benin identified 92.5% of the respondent believed the effectiveness of hygiene measure to prevent cholera [19].

Recent study done in Thailand, in 2017 showed that only 19% households reported boiling or treating drinking water to make it safer and 12% reported doing so in the last 24 hours. For households that reported not boiling or treating their water, 89% reported that they believed that their “water source is safe and does not need treatment”. Moreover 49% of respondents reported washing hands on at least three types of occasions and 66% reported using soap to wash hands. And soap was observed at the place for hand washing in 84% households. Safe water containers, defined as covered water containers with spigots were observed in 73% of households [15]. Among the surveyed population in Kenya, 90% respondents stated that they washed their hands before and after eating. Washing hands after using the toilet (40%) or after cleaning babies when they defecate (26%). Moreover 42% of respondents in East Pokot stated that they had soap in the home compared with 97 (82%) of respondents in Turkana South. Most respondents stated they use soap to wash hands (67%), for laundry (76%), for cleaning utensils (70%), and for bathing (70%). In addition, 98% of respondents in East Pokot and 97% Turkana South use jerrycans for water storage in their home [20].

Behavioral change communication/health education has great impacts on the intended outcome especially for the prevention of epidemic prone diseases like AWD. This is evidenced by the study conducted in Haiti. This study reviled that the knowledge of respondents significantly rose from 48.1% to 63.8% during pre-campaign and post-campaign period respectively [21]. A matched case control study among 49 cases and 98 controls was done in Sierra Leone. In this study respondents were asked about ways of preventing cholera. Among those 79 (81%) stated washing hands, 66 (67%) drinking treated water and 38 (39%) eating properly heated food [22].

Another case-control study carried out in Uganda found 34% of case persons compared to 32% of control-persons obtained their drinking water from a river. However, 94% (46/49) of case-persons compared with 76% of control persons drank water that was neither treated nor boiled [23].

A case control study done in Afar region of Ethiopia using bivariate analysis showed that drinking untreated water, close contacts with patients, unhygienic latrine and not practicing hand washing were the possible risk factors for the outbreak [11]. Unmatched case control study done by Dickson Shey N, et al. showed 57.0% and 36.3% of respondents identified poor hygienic practices and lack of safe drinking water were the main perceived risk factors of cholera respectively. In addition, 80.0% of respondents indicated good hygienic practices as the main cholera preventive method [24].

Research method and Material

Study site

The study was conducted on military personnel living in Harar. Harar is one of the ancient towns in Ethiopia and is located in the east 526 KM away from Addis Ababa. There are five military camps namely “Mastenageja”, “Rasha and Cuba”, Musikegna and Shenkor”, Keladamba”, and “Omedela” which has 1,200 military head households. All camps are found in the town and located in different part. Municipal water supply is main source of water for all camps. Even though solid waste disposal system is linked with municipal office of the town, the pollution of solid waste were seen here and there in all camps.

The study site was selected because it’s the area where cholera epidemic occurring in the last consecutive years.

Study period

Study was conduct from February 08/2018 to March 09/2018.

a. Study Population

b. Quantitative Study

Target and source population was all military personnel those who were living in Harar military camps. And study participants were military personnel who were select from five military camps by using systematic sampling technique during data collection period.

Qualitative Study

FDG was conducted. Participants for FGD were selected among the female military wife from 5 camps in the same period.

Inclusion Criteria: All military household heads who were volunteers to participate in the study.

Military personals who were living at least 3 months and above in the camp.

Exclusion Criteria: Military families were not participated.

A person unable to interview because of illness or disability

Study Design: A cross sectional study design was used to conduct this study.

Study Variables

Independent variables

1. Socio-demographic characteristics such as age, sex, educational status, marital status, religion, family size, and number of less than 5 age children,

2. Environmental factors such as water sources and treatment, availability and utilization of latrine, household waste disposal, hand washing facility.

3. Personal factors such as boiling water for drinking, not eating uncooked vegetables, habit of hand washing.

Dependent variables

The dependent variables were knowledge, attitude and practice.

Measurement of Knowledge Attitude and Practice status of the respondents

To measure KAP of respondents on AWD a scoring system was used. Each correct response was scored as 1 while other responses such as incorrect or don’t know was scored 0.

Measurement of Knowledge

Since there were 11 items on knowledge section of the questionnaire the total score range was from 0 to 11. When the respondent got an aggregate knowledge score above median were assigned as good knowledge and then less than median was poor knowledge.

Measurement of Attitude

There were 12 statements in attitude section of the questionnaire giving a total score of 12 for the statements. The respondent was asked to indicate the extent of their agreement with the statements on whether they agreed or disagreed. A correct response was scored as 1 while a wrong response was scored as 0. Of the total score ranging from 0 to 12, a frequency distribution was carried out to find out a cut-off point for favorable and unfavorable attitude. When the respondent got an aggregate attitude score above median was assigned as favorable attitude and then less than median was unfavorable attitude.

Measurement of Practice

Since there were 10 items on practice section of the questionnaire the total score range was from 0 to 10. When the respondent got an aggregate knowledge score above median was assigned as good practice and then less than median was poor practice.

Operational Definition

Knowledge: it is information that a person is aware of what AWD is, its transmission and prevention. It will be measured based on the respondent correctly identify and respond to meaning, causes, sign and symptoms, and preventive measures of AWD.

Attitude: it is the perception of individuals regarding causative factors and preventive mechanism of AWD.

Practice: it is the overall behavior, habit or custom that a person does, follow up or carry out in his/her daily life in preventing AWD.

Cholera: it is an acute diarrheal infection caused by ingestion of food or water contaminated with the bacterium, Vibrio cholera.

Data Collection Instruments and Methods

Quantitative Study

Quantitative data was collected through face to face interview using a structured questionnaire which was adapted from a document designed to conduct surveys towards KAP of communities regarding diarrheal disease, cholera and cholera vaccines, water, sanitation, and hygiene [25]. Questionnaires were obtained data on socio- demographic characteristics; knowledge, attitudes, and practices regarding acute watery diarrheal disease. Observational check list was used for environmental assessment. Observation was made by interviewer for household characteristics, water storage containers and disposal system, presence of latrines, hand washing stations, and soap. All data were collected by trained nurses. The survey instrument was prepared in English translated into Amharic and finally translated back to English for consistency.

Qualitative Data

Qualitative Data was gathered by using FGD. FGD was conducted among the female military’s wife from 5 military camps in the same period. One FGD session have carried out, 2 participants were selected for the study. A group was comprised 10 participants. They were housewives of military and lived more than a year in the camp. Participants of FGD were not chosen for interview. Discussion was facilitated by principal investigator and the discussion of the participants were recorded by audio tape and manually written by other note taker after the consent of participants secured. The focus group discussion within the group was carried out until it reached the saturation level when no new information was conveyed. Discussion was focused on KAP regarding cholera.

Sampling Determination

n=1/(1-f)×((z α/2)^2 p(1-p))/d^2

Where: n – Required sample size.

d – Precision/ Margin of error = 5% (0.05)

f – Non-response rate (10%)

P – Estimated proportion 50% (0.5)

Zα – Confidence level at 95% (standard value 1.96)

n=1/(1-0.1)×((1.96)^2 0.5(1-0.5))/〖0.05〗^2 = 422.

The study population is finite and not more than 10,000. It was corrected and minimized to the appropriate number by using finite population correction factor (fpc) as follow.

fpc=n/(1+n/N) → fpc=422/(1+422/1.200) = 312

Sampling Technique

The study was done based on the military camps located in Harar town. There are 5 camps in the town. Proportionate sampling distribution technique was used to distribute samples in to five camps. Systematic sampling technique was used to select head of households to be enquired from every camp. As this study was intended to use systematic sampling technique to identify sampled military household head; every house in each camp were numbered by data collectors before data was collected. The head of households were selected every 4th house after random start.

Quality Assurance

To increase the reliability and accuracy, data collection tool was pretested on 5% of sample size on similar population living in military camps located in Addis Ababa. After it was pretested, the questionnaire was modified in order to measure response rate. Data collectors were trained, and data collection procedures were checked daily through supervision and frequent checking for its consistency on the same day by principal investigator. Coding and data cleaning was done properly. For qualitative study quality of information were assured through triangulation.

Data Analysis

Every questionnaire was checked for completeness, missed values and unlikely responses and then cleaned up manually on such indications just before leaving the study area. After that, the data was coded and entered in to Epi-data version 3.1. After the data was cleared, and then exported to SPSS version 21 for statistical analysis.

Descriptive statistics was applied in univariate analysis. Binary regression analysis was done to find out statistically significant association and strength of association between dependent and independent variables at p-value < 0.050 and OR with 95%CI. Those independent variables with p< 0.20 were fitted in to logistic model to determine potential predictors of KAP. The qualitative data were summarized and transcribed manually from the audiotape recorded. For detail analysis ground theory and content analysis approach were used to triangulate the quantitative results.

Ethical Consideration

Ethical clearance was obtained from DUCHS ethical review board to carry out the study. A formal letter was written to SEC. Firstly; the researcher was communicated with a person in charge of the office of SEC and got permission. After permission obtained from concerned body, written consent was secured from SEC. Informed verbal consent was obtained from each participant after the purpose of the study explained by the data collectors (Figures 1 & 2).

Results

Sociodemographic Characteristics

A total of 312 participants were interviewed with 100% response rate. In the 312 respondents, their age ranged from 21-52 years with a mean age of 38.3 (SD=6.71) years and the majority, 161(51.6%) were aged between 31 – 40 years old. Most of the respondent (89.9%) were male, married (88.8), and were between grades 9 – 12 (54.8%). Regarding educational status, more than half of them (54.8%) were from 9 to 12 grades complete. Nearly half of them were with in junior officers (47.8). Other characteristics are displayed in (Table 1).

The median knowledge score of respondents was 9 with IQR= 6(4-10). Almost half of the respondents (49.7%) had poor knowledge about acute watery diarrhea (AWD). Only 23.4% were correctly identifying watery diarrhea with or without vomiting as AWD. Eighty one percent of participants were recognizing poor or improper hand washing habits as one of important transmission route for AWD. Drinking contaminated water and eating rotten/ contaminated food were also mentioned as route of transmission by 76.9% and 67.0% respectively. Whereas, about 63.0% of the respondent were not have awareness of about correct hand washing procedure (Table 2). more than two third of respondent were NOT mentioned common water treatment methods like boiling and using chlorine-based treatment and only 32.1% knew eating unwashed fruits or vegetables may cause diarrheal diseases.

Attitudinal characteristics of the respondents towards AWD

The median attitude score of the respondent was 9 with IQR= 2(9 – 11). About 95 % (295) respondent had favorable attitude towards AWD (Table 3). All participants were believed that passing stool anywhere can causes AWD and washing both hand before eating could prevent the disease. Whereas, only 31.7% were believed water for domestic purpose needs treatment either boiling or chlorine-based solutions/tablets (Table 3)

Preventive practices towards AWD

The median preventive practice score of the respondent was 8 with IQR= 4(5 - 9. According to the definition of this study about forty four percent of participants’ scores below median and had poor practices in preventing diarrheal diseases in their houses and in the camp as well. Almost 93% (290) participants were implement water safety by having narrow mouthed separate water containers for drinking purpose and 63.1% treat water in their houses by either or used water treatment products. More than two third (67.9%) respondent practiced food hygiene and safety measures in their houses by avoiding rotten food/vegetables to eat and cooked food thoroughly before serving. Below one third of respondents was not always use soap when in need of washing hands (Figure 3).

Summary of Qualitative findings

All participants randomly selected were asked to participate in FGD complied. All were females housewives and aged between 30 and 41 years old. 10 participants were come from every military camp, two from each. All of females participated in FGD were heard about AWD from mass media and health extension workers who were visited their camp.

The qualitative analysis showed that respondents could describe AWD as one of the important diseases which deadly affect mans’ health. Most of the participant (8 of 10) in FGD stated that AWD could transmitted by insanitary handling of water and unhygienic food. The role of night soil and improper hand washing practices with transmission of AWD were well explained by four of the ten participants. They were also discussed on overall sanitation of the camps especially on solid waste management in relation with AWD. Every participant believed that they are at risk of AWD due to intermittent or interrupted water distribution which extremely affects sanitary utilization of inbuilt toilets. All participants believed on their vulnerability for the disease unless the problem of water supply and waste management system are solved.

Binary logistic regression analysis

Bivariate and multivariable analysis of factors affecting knowledge respondent regarding AWD.

Association of sociodemographic variables with knowledge on, attitudes, and practices towards acute watery diarrhea prevention were done through bivariate and multivariable logistic regression (Table 4). Bivariate and multivariable analysis of factors affecting knowledge regarding AWD.

Characteristics Knowledge (n = 312) Kn owl - edge (n = 312)

P.Kn p-value COR (95%CI) p-value AOR (95%CI)

To identify knowledge predictors both bivariate and multivariable analysis was done on different selected variables. The bivariate result showed that five variables were statistically significantly associated with knowledge level. After adjustment made participants with lower education was 11 times more likely to have poor knowledge compared to those with higher education (p<0.0001). Also, non officers and respondents with at least one under-five years old children significantly more likely than its respective indicators (Table 4).

Respondents with poor knowledge on AWD had significant differences in age categories. Participants in the age group 30 years and less (70.8%) were significantly more likely to have poor knowledge compared to those with more than 40years old (33%) [COR: 4.929(95%CI: 2.338-10.389)]. Households having three and lesser family member (56.2%) were significantly more likely to have poor knowledge about AWD than four and more persons (42%) [COR: 1.776; (95%CI: 1.132-2.785)]. Families without less than five years children significantly more likely to have poor knowledge compared to those who have at least one less than five years children in the house [AOR: 1.842; (95%CI: 1.110 – 3.057)]. Non-officers’ respondent (76.1%) significantly more likely to have poor knowledge than senior officers [AOR: 2.593; (95%CI: 1.169 – 5.750)]. Although, marital status, sex, water source/points and source of health education were not shown statistically any significant association with respondents’ poor knowledge level (Table 4).

Bivariate and multivariable analysis of factors affecting attitudes of respondent towards AWD

Concerning attitude predictors both bivariate and multivariable analysis was done on different covariates. After adjustment made only family size had statistical association to respondents’ attitude. Those respondents with family size three and bellow were three times more likely to have unfavorable attitude than those above three families [AOR=3.362(1.071 – 10.551)]. Other variables had no statistically significant association to attitude of respondents (Table 5). The above table showed that poor knowledge and unfavorable attitudes were significantly associated. Participants those with poor knowledge towards AWD are three times more likely to have unfavorable attitudes compared to those with good knowledge (Table 5). Respondents who currently have no less than five children are more likely to have unfavorable attitudes then those at least one [COR = 3.502; (95%CI: 1.116 – 10.990)].

Bivariate & multivariable analysis of factors affecting practices of respondent towards AWD

Both bivariate and multivariable analyses were done to find out predictors of practices which had statistically significant association. Most of predictors had statistically significant association with preventive practices towards AWD. After adjustment made four predictors were left with statistically significantly associated at AOR with 95%CI. Participants within age group of less than 30 and between 31 to 40 were significantly more likely to have poor practices to prevent them from AWD than those aged greater than forty (Table 6). In this study it was found that 85.7% of single (unmarried) respondents had poor knowledge about AWD and its prevention than married [COR: 8.973(95%CI: 3.031-26.567)] at a p-value <0.0001. Educational status (8 grades) of respondents was significantly associated with poor practices compared to those respondents with higher education [AOR: 7.694; (95%CI: 2.185-27.096)]. Presence or absence of less than 5 years children in a family were statistically significantly associated with knowledge, attitudes, and practices towards AWD [COR; 95%CI] (Table 6).

Observational based Result

All selected individual houses and their activities related to diarrheal diseases (AWD) preventive practices by the study participants were observed just after completing the questionnaires of quantitative part. Water safety, food hygiene practices, hand washing facility and presence of soap near to the point, presence of latrine and evidences of open defecation presence of garbage container were focused area included for observational assessment.

Based on the observational assessment, good handling of water observed in 92.9% of studied houses. These are explained by having separate water container with tight cover for only drinking purpose. Regarding water treatment more than half 161(51.6%) regularly practiced boiling and 49(15.7%) were used chlorine solution such as aqua-tablets and water guard. Whereas the rest of 102(32.7%) were not did anything to the water to treat, because they think it is safe. Out of the total (312) household observed 237(76%) had hand washing facility. From those who had hand washing facility soap was observed on 222(93.7%). Among the total respondent houses observed, improper waste handling were seen in 144(46.2%) explained by presence of rubbish and leftover foods in the kitchen. Regarding final waste disposal all camps were used municipal waste management system. During observation there were big metal containers in 5 camps. But it was not properly utilized. Wastes were seen outside the containers. This might be related with level of knowledge which was revealed through this study. Moreover, this problem might be aggravated by poor follow up from authorized body responsible to manage it (Table 7).

Predictors of good practices towards AWD

The logistic regression was performed to found effects of socio- demographic, knowledge, and attitude on practices towards AWD. As shown below in table 6, the result of logistic regression analysis of participants’ practices on AWD as the only outcome variable with different covariates such as socio-demographic variables, knowledge and attitudes towards prevention of AWD. Age in category, military rank, sex, education, marital status, family size, presence of less than five children, source of health information, knowledge, and attitudes were the variables those have p-value <0.20 with the outcome variables (practices) through Chi-square tests and bivariate logistic regression. Therefore, these variables were put in logistic regression analysis to fit the model with adjusted odds ratio at 95%CI. Backward likelihood ratio method was used.

Hosmer- lemeshow goodness of fit was undertaken. The output of “Hosmer-lemeshow goodness of fit” indicated p-value 0.473 which is more than 0.050; considering the rule of Hosmer-lemeshow test this model is adequately fitting the data. Result indicated that the 7th predictor model provided statistically significant improvement over the constant only model, X2(7,n=312)181.620, p<0.001. The ‘Nagelkerke R2” value is indicate that the model accounted for 59.1% of the total variance. The overall After all, four variables fit the model as potential independent predictors of poor practices such as age, level of knowledge, source of water, and educational status of respondents. Wald tests are shown that four predictors significantly predicted poor practices of AWD (Table 8).

Discussion

To the best of investigator’s knowledge, this was the first survey o KAP regarding AWD in Ethiopian Defense Force members. It was also the first evaluation of KAP in Harar military camps. The findings indicate that the gender and kind of sources of health message may not be an important issue regarding KAP of AWD disease.

The present study revealed that below half of participant (46%) had poor knowledge and poor practices (43.9%), while 94.6% exhibited favorable attitude by agreeing on the seriousness of AWD and needs a due attention on prevention practices. On the other hand, the result found that only 23.4% of respondent could identify AWD as watery diarrhea with vomiting, which was similar with study conducted in Bangladesh (23%) [13]. whereas in Thailand (52%), Haiti (81.9%), and Zambia (88%) respondent identified watery diarrhea as symptom of cholera (AWD) respectively [13, 15, 17, & 18]. In comparison, this study done in three countries, but the finding revealed as they had very low awareness of identifying acute watery diarrhea. This difference observed might be due to study design or difference in sample size. Positive/favorable attitude about AWD disease is a pillar to prevent cross infection. In line to this fact the result of this study revealed that about 95% had favorable attitude towards AWD. This high-level favorable attitude observed may be due to the repeated magnitude occurrence of AWD around Harar, the nearly districts of Oromia and Ethiopian Somali, the place where more people were severely affected since last year and back. However, the attitude level nearly similar with the finding of study in Benin and Bangladesh [13,19].

In addition, about 50% of respondent were under poor knowledge category, which is much greater compared to study found in Benin (7.2%) and Haiti (36.2%). Possible explanation for this much difference observed might be due to the weakness on health education program and limited health information dissemination activity for this community. Study done in Haiti revealed that the knowledge of respondents significantly rose from 48.1% to 63.8 % during and post cholera campaign period respectively [21]. The current study was measure level of preventive practices within study participants. According to the criteria, about 56% of respondent had good practices and 44% had poor practices regarding AWD and its prevention. Below one third (30.1%) of participants had separate water container with tight cover for drinking purpose. In the other two studies, it was observed that 73% and 98% of participants in Thailand and in Kenya had separate water container with tight cover. In comparison, the result of two studies were exceeded two to three times more than the current study. The result indicates how the current study participants were at risk of AWD outbreak. This is because poor water handling is one of the main causes for AWD outbreaks [1,6-8].

Hand washing is the single and most important means of preventing the spread of infection [7]. The result of this study showed that less than half of respondents (49%) had poor knowledge about the relationship between hand washing and preventing AWD. In about two-third of participants (67.9%) soaps were observed in a place where their usual place of hand washing. This result also 10-12% less that the result found in Kenya and Thailand respectively. In proper and regular hand washing, soaps play a big role at least, in removing microorganisms including pathogenies. Refusing to use soap, especially before eating and after toilet or contact toilet wares brings them to the risk of this disease [1,6-8].

This study found statistically significant association between outcome variables (KAP) and different factors. Most of the factors were exhibit association both knowledge and practices. While, only level of knowledge and presence of less than 5 years children were significantly associated with attitude of them. Knowledge of respondents was increased with increasing the age. The level of poor knowledge was significantly higher in respondents aged less than or equals to 30 years. Level of poor knowledge and poor practices were statistically significantly prevalent in relatively lower education, non-officers, and lower age. These are also significantly associated with family size and presence of less than 5 years children in the family. Having a child or being pregnant by itself increases utilization of health services than those who had not. Simultaneously they exposed for different health information and got opportunities from health facilities during follow up and vaccination programs.

Conclusion

Even though the respondents had better attitude towards acute watery diarrhea, the knowledge and practices in the study area were not satisfactory and good enough to prevent and to control AWD. The finding of this research indicated that 49.7% of respondents had poor knowledge towards AWD and 43.9% poorly practiced in their living area towards AWD prevention. Age less than thirty, education 8 grades, source of water, and poor level of knowledge independently associated towards poor level of practices. In general, most of respondents have lack of awareness about what exactly AWD means, its transmission and ways to prevent it.

Based on the findings of this study, the following points are recommended:

Continuous awareness creation and community mobilization activities towards AWD in militaries manifested. The target groups for such health education program should be those who are aged bellow 30, non-officers, to those who fetch water from outdoor sources. Most of respondent during interview and FGD participants explained they could not maintain good sanitation and hygiene practices to prevent AWD due to scarcity of water, poor waste and wastewater management program, while, these are key to successful on disease prevention. South east command and house management department should plan to maintain sustainable water supply in the camps. In line with this, they need to deal with Harar municipality regarding regular emptying of solid waste containers.