Socio-demographic characteristics
Two hundred ninety four respondents were interviewed and the response rate was 97.9%. The mean age of respondents was 35.83 ±8.74 years. In terms of marital status 30.3% (89) were married, 27.2% (80) were widowed, 26.9% (79) were divorced and the rest were single. Amhara was the dominant ethnic group with 98% (288), and the rest was Tigre.
About 43.9% (129) of the respondents were illiterate, 13.9% (41) can read and write and remaining 42.17% (124) attended formal education from elementary up to college or university level. Regarding the occupational status of the participants, daily labourers constitute the highest one 50.3% (148) followed by merchants 10.2% (30), commercial sex workers 9.2% (27), government employees 2.4% (7), without any job 20.4% (60) and others like farmers. The income distribution reveals that the poorest/lowest, second, third/middle, fourth and richest/highest quintile accounted for 18%, 13.9%, 34%, 18.4% and 15.6%, respectively.
The number of females in present study exceeds that of males, which may be due to higher proportion of females than males, like the national incidence for single point prevalence in Ethiopia with 1.8% to males and 2.8% females [
23]. About 4.1% (12), 5.6% (16), 3.4% (10), and 11.6% (34) of the clients required help during walking, eating, toilet use and cloth washing, respectively. Almost 7.8% 23) of the client had experienced diarrhoea for the past 24 hours which is comparatively lower than in Malawi and this difference might be due to the type of the container in use for water storage. Majority of the containers 90% (2580) was plastic and narrow neck and only 7% (21) used dipping for drawing water from the container while in Malawi 41.7% of container were plastic and 82.3% of respondents reported dipping a cup in the storage container of drinking water [
24,
25]. The slight difference might be due to hygienic and cultural practices between two countries. A similar study in Zambia and Malawi showed that PLWHA in HBC services account 27.5% and 43.3% diarrhoea for the past 24 hours [
24,
25].
Nationally, marital status was closely related to HIV prevalence, clients who were widowed, divorced, or separated had significantly higher rates than those who were married or living together [
10]. However, in the present study the proportionally HIV prevalence was more among married 30.3% (89) than the widowed ones 27.2% (80). The middle income quintile took the largest proportion 34% (100) in the study, while the national PLWHA income quintile lie in the highest income one [
10]. This may be due to the majority of the studied clients had no job and joined the OSSA and Mahibere-Hiwot Ethiopia to get support.
Water status of the clients
The majority of clients 71.8% (211) reported their drinking water source location as outside their yards in the neighbourhood, pipe water within their compound 5.8% (17), piped water in their own house 10.9% (32) and 9.2% (27) from public tap. Only a small number of clients i.e. 0.7% (2), 1% (30), and 0.7% (2) households get their water from protected well, spring and unprotected spring, respectively. Regarding the frequency of daily water fetching for the household of HIV clients, the majority of 44.9% (132) the households fetch water 2 times/day followed by 23.5% (69) in 3 times/day and 21.8% (64) of the household fetch once/day, and the rest 9.86% (29) households fetch their water > 4 times/day.
Assessment of size of the container for transporting water showed that majority of clients 70.7% (208) reported use of 16–20 L containers, while 5.4% (16), 10.9% (32), 6.1% (18) and 6.8% (20) of households used < 5 L, 5–10 L, 11–15 L and > 20 L containers, respectively. The 16–20 L transporting container size found in this study were similar with that in Malawi where majority of clients used 20 L containers for transporting drinking water [
24]. About 96.94% of the households stored their drinking water, out of which 90.2% (258) in plastic jerricans/containers, 10.8% (31) in traditional clay pots (
Insera), and remaining 1.7% (5) stored in metal containers. Majority of the clients 80.3% (236) practiced pouring method to withdraw water from the stored container, while 7.1% (21) practiced dipping and 12.6% (37) using both dipping and pouring methods. About 10.9% of the households treated their drinking water within 24 hours mostly through boiling 87.5% (28), chlorination (
Halazone tablets) 6.2% (2) and filtration (candle filter) 6.2% (2). In this study showed that treat their drinking water within 24 hours. The water treatment method through boiling was also in accordance with Indian, Malawian and Zambian studies which may be due to its less cost than other treatment methods [
14,
24,
25].
Assessment of discrimination by household members in water sources showed that 6.1% (18) of household members were discriminated in the water source use and out of them 4.4% (13) household members were forced to go far distance to fetch water to the family. In other research conducted in Ethiopia reported that one third of the respondents were discriminated in the water source and forced to go far distance to fetch water for their family [
26]. The present findings were also lower from Nigerian study where 29% of respondents reported discrimination at water point. The decrease in discrimination prevalence rate in present study might be due to improvement in knowledge and attitude towards HBC by their respective family members and caregivers [
11,
25]. In general water status served for the clients showed that 57.1% (168) of households have improved and 42.9% (126) of the households have unimproved water status. Poor water status among clients was more likely to be one of the cause for diarrhoea among PLWHA as WHO estimates that 85 − 90% of diarrheal illnesses in developing countries can be attributed to unsafe water [
26‐
28].
Bivarate and multivariate analysis was done between socio-demographic and predictor variables to the water status of PLWHA. The result revealed that income quintile, discrimination of family member and clients had no association in both analyzes. Whereas, educational status, forced to go far distance and need help with walking was associated in bivarate analysis and in multivariate analysis diarrhoea for the past 24 hours showed statistically significant association. Clients who have diarrhoea for the past 24 hours is 6 time more likely to be unimproved water status as compared to those who do not have diarrhoea for the past 24 hours (OR = 6.13 95% CI: 1.23, 30.57) (Table
1).
Table 1
Relationship between risk factors of water supply status among PLWHA on Home Based Care clients of Gondar City, 2009 (n = 294)
Educational status | Illiterate (can’t Read and write) | 58 | 71 | 1.0 | 1.0 |
| Read and write | 27 | 14 | 2.36 (1.13,4.91)* | 4.20 (0.92, 19.02) |
| Elementary | 17 | 34 | 0.61 (0.31,1.20) | 0.74 (0.19, 2.78) |
| Secondary | 19 | 39 | 0.59 (0.31,1.14) | 0.50 (0.17, 1.46) |
| Above grade12 | 5 | 10 | 0.61 (0.19,1.89) | 0.16 (0.01, 2.15) |
Income quintile | Lowest (poorest) | 15 | 38 | 0.47 (0.20,1.081) | 0.67 (0.137, 3.36) |
| Second (poor) | 11 | 30 | 0.43 (0.17,1.706) | 0.39 (0.057, 2.77) |
| Third (middle) | 52 | 48 | 1.29 (0.64,2.59) | 3.55 (0.96, 13.13) |
| Fourth (High) | 27 | 27 | 1.19 (0.54,2.61) | 2.99 (0.72, 12.42) |
| Fifth (Highest) | 21 | 25 | 1.0 | 1.0 |
Discrimination of family member in water source | Yes | 9 | 9 | 1.35 (0.52, 3.52) | 0.43 (0.06, 2.84) |
| No | 117 | 159 | 1.0 | 1.0 |
Discrimination of PLWHA in water source | Yes | 13 | 22 | 0.76 (.36, 1.58) | 1.61 (0.44, 5.86) |
| No | 113 | 146 | 1.0 | 1.0 |
Forced to go far distance to fetch water | Yes | 9 | 4 | 3.91 (1.13, 13.47)* | 3.84 (0.41, 35.27) |
| No | 42 | 73 | 1.0 | 1.0 |
Do you need help with walking | Yes | 1 | 11 | 0.11 (0.01, 0.89)* | 0.13 (0.01, 1.44) |
| No | 125 | 157 | 1.0 | 1.0 |
Diarrhea for the past 24 hour | Yes | 15 | 8 | 2.70 (1.10, 6.59)* | 6.13( 1.23, 30.57)* |
| No | 111 | 160 | 1.0 | 1.0 |
Sanitation status of the clients
More than half 57.8% (170) of the clients had latrine facility like traditional pit, VIP, pour flush latrines in 59.4% (101), 38.8% (66) and 1.8% (3) cases, respectively. About 63.5% (108) of the latrines were located inside the client’s yard, 15.8% (27) located outside the yard or shared private and 20.6% (35) of latrines are outside the yard and public shared.
Majority of 95.8% (163) the latrines did not have hand-washing facilities. Cultures of the society may affect the hand washing habit of the community, for example a Study in Myanmar showed that hand washing after toileting is influenced heavily by socio-cultural factors [
29]. The clients without any type of latrine facilities 74.2% (92) opt for open defecation in the nearby fields and vacant place, 12.9% (16) reported clay pots use and the rest 12.9% (12) clients burry their faeces in their in the yard. The study demonstrated that 4.8% (14) of the clients had forced discrimination in latrine area and 5.4% (16) of the clients had forced discrimination in the latrine area which forced them to go far distance. Even if there is an improvement in discrimination, still the problem exist in the country as it was reported in similar other study in Addis Ababa, Ethiopia [
19]. Another reason for not having any form of sanitation facility were economical 52.4% (65) and the rest 47.6% (59) had other reasons like lack of place, did not consider its importance and have no interest to construct. In general, sanitation status for the clients showed that 33% (97) of households have improved and 67% (197) of the households have unimproved sanitation status.
In the logistic regression analysis, sanitation status of clients is associated significantly with educational status and household latrine availability; clients who do not have latrine availability were 10 times more likely to have unimproved sanitation status as compared to those who do not have latrine availability (OR = 10.3 95% CI: 5.13, 21.03).
With increased educational status, the likelihood of having unimproved sanitation status decreased. Clients of elementary education are more than 59% less likely to be unimproved sanitation status as compared to illiterate clients (OR = 0.41 95% CI: 0.18, 0.94); Clients of secondary education are more than 71% less likely to be unimproved sanitation status as compared to illiterate clients (OR = 0.29 95% CI: 0.13, 0.63). Clients with > grade 12 are more than 74% less likely to be unimproved sanitation status as compared to illiterate clients (OR = 0.26 95% CI: 0.07, 0.94) (Table
2).
Table 2
Relationship between risk factors of, sanitation status among PLWHA on Home Based Care clients of Gondar City, 2009 (n = 294)
Educational status | Illiterate (can’t Read and write) | 98 | 31 | 1.0 | 1.0 |
| Read and write | 32 | 9 | 1.12 (0.48, 2.61) | 1.31 (0.52, 3.30) |
| Elementary | 29 | 22 | 0.41 (0.21, 0.82)* | 0.41 (0.18, 0.94)* |
| Secondary | 31 | 27 | 0.36 (0.18,0 .69)* | 0.29 (0.13, 0.63)* |
| Above grade12 | 7 | 8 | 0.27 (0.09,0 .82)* | 0.26 (0.07,0.94)* |
Income quintile | Lowest (poorest) | 32 | 21 | 0.73 (0.32, 1.68) | 1.05 (0.36, 3.01) |
| Second (poor) | 26 | 15 | 0.83 (0.34, 2.03) | 1.67 (0.56, 4.97) |
| Third (middle) | 68 | 32 | 1.02 (0.48, 2.16) | 1.88 (0.74, 4.77) |
| Fourth (High) | 40 | 14 | 1.38 (0.58, 3.28) | 1.73 (0.60, 4.97) |
| Fifth (Highest) | 31 | 15 | 1.0 | 1.0 |
Household latrine availability | Yes | 86 | 84 | 1.0 | 1.0 |
| No | 111 | 13 | 8.34 (4.36, 15.95)* | 10.39 (5.13, 21.03)* |
House hold members discriminate in the latrine | Yes | 11 | 3 | 1.85 (0.50, 6.80) | 4.18 (0.52, 33.28) |
| No | 186 | 94 | 1.0 | 1.0 |
Have you discriminated in the latrine | Yes | 11 | 5 | 1.08 (0.36, 3.22) | 0.30 (0.05, 1.62) |
| No | 186 | 92 | 1.0 | 1.0 |
Do you need help with walking | Yes | 10 | 2 | 2.54 (0.54, 11.82) | 1.57 (0.26, 9.49) |
| No | 187 | 95 | 1.0 | 1.0 |
Diarrhea for the past 24 hour | Yes | 14 | 9 | 0.74 (0.31, 1.79) | 0.61 (0.19, 1.87) |
| No | 183 | 88 | 1.0 | 1.0 |
A study in Bangladesh also investigated that educational status is highly significant to the presence of sanitation facilities i.e. household [
30]. Cultures of the society may affect the hand washing habit of the community, for example a Study in Myanmar showed that hand washing after toileting is influenced heavily by socio-cultural factors [
29]. This indicates that in the study area people may only consider the availability of latrine, but did not consider hand-washing facilities.
Hygienic practice of the clients
Only 8.2% (24) of the clients had hand washing place, from those who have a location for hand washing, 4.1% (12) households have hand washing devises like tap, basin, bucket, sink). About 58.8% (173) clients washed their hands with soap during the past 24 hours of a day. Only 21.7% and 8% clients in Malawi and Zambia, respectively using soap for washing hands after defecation, while 45% in Zambia and 58.8% (173) in the study area clients wash their hands with soap during the previous 24 hours, this difference may be due to people gave priority for other activities rather than for washing their hands after defecation [
24,
25]. About 39.1% (115) of the clients afford soap regularly for hygienic purpose while remaining could not. Out of those clients who did not afford soap, mostly 56.8% (167) because economical reasons but the rest have their own perceptions. In general 48.3% (142) of the households had good hygienic practice, while remaining 51.7% (152) had poor hygienic practice. Almost half of the clients 49.3% (145) had attended hygiene education in the past one year. The sources of information about water, sanitation and hygiene for the clients were, 51.0% (140) from voluntary home care givers, 43.4% (127) from health institutions and 5.5% (17) from public meetings.
The study showed that educational status is associated significantly with hygienic practice. Individuals of who can read and write are 2.4 times less likely to have poor hygienic practice than those illiterate clients (OR = 2.4 95% CI: 1.06, 5.41). This finding was similar with other researches in Myanmar and South Africa [
6,
29,
31]. Hand washing device availability is associated significantly with hygienic practice. Clients who do not have hand washing device is 8.7 times more likely to have poor hygienic practice compared to those who have hand washing device in the house (OR = 8.76 95% CI: 1.00,76.72). Economical reasons for the affordability of soap are associated significantly with hygienic practice (OR = 0.04 95% CI: 0.00, 0.42). There was no significant association between income quintile, frequency of bathing, presence of towel, attending hygiene education and diarrhoea for the past 24 hours (Table
3).
Table 3
Relationship between risk factors of Hygienic Practice among PLWHA on Home Based Care clients of Gondar City, 2009 (n = 294)
Educational status | Illiterate (can’t Read and write) | 64 | 65 | 1.0 | 1.0 |
| Read and write | 27 | 14 | 1.95 (0.94, 4.07) | 2.40 (1.06, 5.41)* |
| Elementary | 25 | 26 | 0.97 (0.51, 1.86) | 1.11 (0.54, 2.28) |
| Secondary | 28 | 30 | 0.94 (0.51, 1.76) | 1.11 (0.55, 2.22) |
| Above grade12 | 8 | 7 | 1.16 (0.39, 3.38) | 1.29 (0.41, 4.06) |
Income quintile | Lowest (poorest) | 26 | 27 | 1.14 (0.51, 2.53) | 1.39 (0.57, 3.38) |
| Second (poor) | 19 | 22 | 1.02 (0.44, 2.39) | 1.32 (0.52, 3.33) |
| Third (middle) | 54 | 46 | 1.39 (0.69, 2.81) | 1.64 (0.76, 3.50) |
| Fourth (High) | 32 | 22 | 1.73 (0.78, 3.83) | 2.39 (0.99, 5.76) |
| Fifth (Highest) | 21 | 25 | 1.0 | 1.0 |
Hand washing device availability | Yes | 1 | 11 | 1.0 | 1.0 |
| No | 151 | 131 | 12.67 (1.61, 99.52)* | 8.76 (1.00, 76.72)* |
How frequently do you wash your body | Every day | 8 | 7 | 1 | 1 |
| Twice a week | 45 | 44 | 0.89 (0.29, 2.67) | 1.31 (0.38, 4.54) |
| Once a week | 79 | 78 | 0.88 (0.30, 2.56) | 1.03 (0.31, 3.40) |
| once in a month | 16 | 10 | 1.40 (0.38, 5.06) | 1.62 (0.36, 7.14) |
| more than a month | 4 | 3 | 1.16 (0.19, 7.11) | 12.80 (0.81, 20.88) |
The reason that soap not affordable | Economical | 104 | 63 | 0.12 (.02, 0.54)* | 0.04 (0.00, 0.43)* |
| others | 8 | 4 | 1.0 | 1.0 |
The presence of towel in the HW place | Yes | 6 | 15 | 1.0 | 1.0 |
| No | 146 | 127 | 2.87 (1.08, 7.62)* | 2.26 (0.72, 7.09) |
Attending hygiene education | Yes | 73 | 72 | 0.89 (0.56, 1.42) | 1.23 (0.73, 2.07) |
| No | 79 | 70 | 1.0 | 1.0 |
Do you need help with walking | Yes | 3 | 9 | 0.29 (0.07, 1.12) | 0.23 (0.04, 1.14) |
| No | 149 | 133 | 1.0 | 1.0 |
Diarrhea for the past 24 hour | Yes | 15 | 8 | 1.83 (0.75, 4.46) | 1.62 (0.61, 4.26) |
| No | 137 | 134 | 1.0 | 1.0 |
Qualitative part
Twenty eight persons participated in in-depth interview from four categories such as HBC voluntary caregivers, community members, PLWHA those in HBC services and family caregivers. The participants were residents of Gondar city having age between 21–54 years with educational level ranged from illiterate to 12-grade complete. Important guiding questions were forwarded for all participants including some questions in the quantitative part that need further probing. All the participants of the in-depth interview know how water, sanitation, and hygienic practice are important for PLWHA. The findings was presented according to selected themes.
Economical problem was the major reason mentioned by majority of the respondents for insufficient amount of water availability in the household. All respondents believed that additional water is necessary for PLWHA other than the normal individual for different purpose like “taking.
Majority of the respondents expressed their “thanks for Anti retroviral Treatment (ART)” that people starts considering HIV diseases as a normal diseases with in previous 2 years. Due to this most of the time stigma and discrimination become minimized in their area, however, in some areas the problem exists,
“I have two children; my husband is passed two years before. Even if there is some progress to my health, I don’t have any job, due to my HIV status our neighbours forbid me to touch their water faucet, unable to transmit the diseases to their family, now I am forced to fetch water from the spring by travelling long distance from my house.”
(A 34 year-old married woman with two children)
In another case explained by a female living in one small living room, after her husband died from HIV before two years explained:
“One day, In the morning after I used the latrine, the owner of the household called me and told me that, I heard that your husband is dead by AIDS, you are also positive, so we should take the preventive measure, after this time you can’t share this toilet with us, because it needs additional water and the virus may evaporate and transmit with us. After that, now I am using public latrine by payment after travelling a long distance”
(29 years female clients with 5 children)
As found in quantitative study, majority of the respondents responded that economical reasons were the main contributor regarding latrines unavailability in the clients households. Discrimination and sickness were also the other causes. Majority of participants knew that how sanitation facilities are important for PLWHA for their waste disposal.
Most of the depth interview results were triangulated to the descriptive result showed that majority of clients were unable to have good hygiene practices in the household was due to economical reasons. Discrimination and sickness were also the cause to poor hygienic practices for few responds, while, based on the view of majority of respondents discrimination in the hygienic practices, and in general become minimized. Studies in other areas like in South Africa, Nigeria, and Kenya showed that economical reasons are the major reasons for poor hygienic practice for PLWHA in HBC services [
32‐
34]. In other studies in Democratic Republic of Congo, South Africa, Ethiopia and Nigeria showed that in addition to economical problems, the attitude of care givers, and their educational status were the core determinant factors towards the general hygiene status of the clients [
35‐
38]. The result obtained in this study was likely to be due to the low-income status of the subjects, which might not have afforded them the practice of good hygiene practice in the household in addition to other factors.
All participants know that how sanitation facilities are important for PLWHA. hygienic practices like, washing body, washing hands, washing clothes and shaving/cutting their hair were some of the activities that majority of respondents expressed, patients practiced on their daily activities. Almost all respondents express soap and water are the most important equipment that are important for keeping hygienic practices. The main reasons for not using soap by the clients were also assessed, majority of the qualitative study respondents agreed that it prevents communicable diseases by removing dirt and odour from the body. Most of the respondents expressed that economical issue was the major problem for clients to keep their hygienic activities. One woman at the age of 47 expressed that, one of her neighbour forbid her to washcloth equipments (tisht) after knowing her HIV status, “Your dirt may remain in the washcloth equipment and it may transmit to us thereby also transmitting the virus to us”.
In general majority of respondents agreed that after ART majority of patients are started to work, even if some patients are still in bed ridden, stigma and discrimination in the hygienic practices became minimized, compared to the previous years, but economical problem remain the burden for most of the patients still at this moment a 25 years old women said that “Everything concerning this illness is tied to money”.