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).

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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).

75

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

77

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

86

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

93

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%