Effect of Health Education on KAP of Open defecation among inhabitants of Ojoo community, Ibadan...

The human practice of defecating in the fields, forests, bushes, bodies of water or any other open space, rather than using the designated sanitary facilities for waste disposal is referred to as Open defecation, which poses serious health and environmental challenges, and has continued to be a global public health concern (Gbadegesin, and Akintola, 2020). Open defecation is a main factor that spurs much contamination of the environment, water resources; and in turn increasing the risks of waterborne and water related diseases (Mukhtar, Yusuf and Asiya, 2023), such as cholera. The practice of open defecation aids in the transmission of microorganisms that cause diarrheoal diseases (Galan, Kim and Graham, 2013), with high vulnerability among children. Diarrhea, intestinal worms, polio, typhoid fever, hepatitis, trachoma, are some of the diseases challenging the health of Nigerians because of open defecation or poor sanitation practices, which has led to higher mortality and morbidity rates, therewith, about 70, 000 deaths are recorded every year in the country (Adeoye, 2015; Ufomba, Ubi A, Lilian, Oyalabu, Emurotus, Kwaskebe and Uwaoma, 2021). Therefore, open defecation is a challenge to the health development in Nigeria.

Open defecation is regarded as an unimproved method of sanitation and the least status on the sanitation ladder that affects everyone (Mukhtar, Yusuf and Asiya, 2023). From the global dimension, about 0.9 billion people are still into the act of open defecation. India accounts for 59 percent of the 1.1 billion people in the world who practice open defecation, leading to some serious negative effects on both their own health and the environment (WHO, 2021), and in sub-Saharan region of Africa about sixteen million citizens to two hundred and twenty million are perpetrating the act unabated (Ntaro, Owukuhaisa, Isunju, Mulogo and Ssempebwa, 2022). According to World Health Organization (WHO) and United Nations Children's Fund (UNICEF) Joint monitoring program (JMP) reports (2021), 494 million people practice open defecation (WHO, 2021).about 196 million are found in the sub-Saharan African region (Shivangi, 2021). This figure reaffirms the fact that open defecation intensifies the height of health related environmental challenges this part of African struggles with.In Nigeria, there are some reports showing that, 25% of the citizens are defecating in the open with variation among the various regions of the country (Onyemaechi, Akinyemi, Aribodor, Fajobi and Okoro, 2022). Other studies also showed that the majority of open defecation practices were taken place in rural areas of low-income countries (Galan, Kim and Graham, 2013). In rural communities, limited access to proper sanitation facilities, lack of awareness about the importance of sanitation, and economic constraints contribute to the persistence of open defecation practices (UNICEF, 2019). Some factors such as financial status of the household [(Abebe and Tucho, 2020), (Osumanu, Kosoe and Ategeeng, 2019)], household size and occupation (Osumanu, Kosoe and Ategeeng, 2019), and region (WHO&UNICEF, 2017) are associatied with open defecation. Furthermore, the Water Sanitation and Hygiene National Outcome Routine Mapping (WASHNORM) reports (2018), shows that 47 million Nigerians practice open defecation, and WASHNORM report (2021) shows, that 48 million people practice open defecation including 18 million children. This implies that, at least, one out of four Nigerians engage in open defecation. This development is a source of concern, since Nigeria has become number one open-defecation nation globally, taking a role previously held by India (Ismael, 2022).

The term 'Open defecation' is widely used in literatures on water, sanitation, and hygiene (WASH) problems in low-income countries. It is a principal threat to public health in many ways especially in rural settings. This is because it causes low sanitation which has led to higher mortality and morbidity rates among people Eradicating open defecation is the main aim of improving sanitation worldwide and it is an indicator used to measure progress towards the Sustainable Development Goal, which target highlights the elimination of open defecation as a means of improving the health, nutrition and productivity of developing countries’ populations such as Nigeria’s. Irrespective of availability of toilets, behavioral change efforts on human are needed to promote the use of sanitary facilities, and people should be educated and convinced on desisting from open defecation and using the sanitary facilities. The option of open defecation may be due to lack of access to toilets or cultural practices and these practices are common within countries where sanitation infrastructures are not available (Clasen et al., 2014). Therefore, open defecation is influenced by a number of reasons which include lack of space to build toilets, lack of income, seasonal factors, poverty, and educational level (Abubaka, 2018). Makhfudli et al. (2017) reported that proximity to water bodies and vegetation, behavior change communication, and community-provided subsidies significantly influence open defecation. Social Cognitive Theory (SCT) is applied to elucidate the social and observational influences on individuals' practices related to open defecation. SCT posits that learning occurs through observing others, and individuals are more likely to adopt behaviors when they perceive positive outcomes and have the self-efficacy to execute them (Bandura, 1986). Studies utilizing SCT have examined how social influences impact open defecation practices and how interventions can leverage observational learning to promote behavior change (Ojo, Ekpenyong and Osibanjo, 2018).

Open defecation is the act of passing excreta in exposed locations instead of in covered locations. This phenomenon does not just occur in the rural areas of Nigeria but also in the cities, and among the educated class in public tertiary institutions, business, and residential areas (Ismael, 2022). The UNICEF/WHO Monitoring Programme report (2015) shows that, some states in Nigeria fare well in combating open defection. States with the highest numbers of open defecation practices include Kwara, Plateau, and Ebonyi states, while states with the lowest numbers of open defecation practices were Abia, Akwa Ibom, and Zamfara states among others. Regrettably, policies and efforts to combat open defecation in Nigeria have failed, with only 14 out of 774 local government areas in the country being able to combat the problem of open defecation effectively. Previous findings show that Oyo state has the third highest prevalent rate of open defecation in Nigeria with about 54.0 percent after Plateau state with 56.2 percent and Ekiti state having 60.8 percent of open defecation practice respectively. The WHO/ UNICEF Joint Monitoring Programme (JMP) report (2015), for water supply and sanitation shows that, the ancient city of Ibadan, which is also the capital of Oyo state with a population of over 3.8 million is the hub of open defecation in the state. In Ibadan, this practice is almost perceived as a norm with more than half of the population indulging in it (UNICEF/WHO, 2015), compounded by the absence of a proper master-plan of the city, whuch has led to buildings being erected indiscriminately without accurate considerations for sanitary facilities, coupled with lack of water, poverty, and government’s inability to provide public toilets in schools and markets, and to monitor the duty of sanitary inspectors. Open defecation is a pervasive issue in many communities, including Ojoo in Akinyele Local Government, Ibadan, Oyo State. Based on a community health assessment conducted in 2021 (Smith, A., et al.), it was found that a significant percentage of the population in Ojoo practices open defecation due to a lack of adequate sanitation facilities. The absence of proper sanitary facilities and a reliable waste disposal system contributes to the prevalence of this unhygienic practice. This prevalence is exacerbated by factors such as rapid population growth, inadequate infrastructure development, and insufficient awareness about the health risks associated with open defecation. The communal nature of open defecation in Ojoo community further complicates efforts to address this issue, as it is often deeply rooted in cultural practices and community habits and attitudes. Such attitudes would have been learnt and acquired, since no one is born with attitude. Attitude can be created and sustained by cultural values of a particular environment, awareness level, socialization and selective exposure to information. The application to the health of an individual is based on the components of attitude (cognitive, affective and behavioural) and the type: negative or positive (Adio-Moses, 2007). If the attitude of individuals' is not favourable towards the practice of good sanitation, health education will be expected to change such attitudes. This is because health education initiatives can positively influence attitudes by raising awareness about the health risks associated with open defecation and promoting the benefits of improved sanitation practices. The theory of planned behaviour helps explore how individual attitudes toward open defecation, societal expectations, and perceived control over adopting improved sanitation practices influence behavioral intentions. The Theory of Planned Behaviour (Ajzen, 1991) is utilized to understand the role of attitudes, subjective norms, and perceived behavioral control in shaping intentions and behaviors related to open defecation (Fagbemi et al., 2019).

Knowledge is the result of knowing, and this occurs after people have sensed a certain object. Sensing occurs through the five human senses, namely the senses of sight hearing, smell, taste and touch, most of human knowledge is obtained through the eyes and ears. Someone’s knowledge will have an impact on someone’s actions or someone’s behavior, someone with good knowledge will act according to what he knows, and is more likely to have better behavior when compared to someone with poor knowledge, in this case stop behavior - Open defecation. Therefore, there is a need for efforts to increase public knowledge about the dangers of open defecation in the river, bushes or any other open spaces, by local health workers such as health education and counseling towards health empowerment [(Windy and Samino, 2016), (Alharbi, 2017)] Other than that, Sari (2021) stated that there is a relationship between knowledge and the incidence of open defecation. People who are less knowledgeable have a greater chance of preferring to defecate in any place so that they are easily infected with various diseases such as diarrheoa, typhoid, vomiting, dysentery, intestinal worms and itching compared to those with good knowledge. In line with Alfan (2021), Open defecation behaviour was found more in respondents with a low level of knowledge compared to respondents with a good level of knowledge. Based on Husna (2018), there is a relationship between knowledge and people’s habits of open defecation with the results of research in the field it is known that respondents’ knowledge about PHBs (Personal Hygiene Behaviours) and the benefits of latrines is still low, where some respondents still do not understand the benefits and objectives of defecating in latrines, so they use rivers and bushes to defecate. Besides, it is very difficult to change people’s habits that have been entrenched, especially open defecation behavior. In line with Muzaffar (2020), there is a significant relationship between knowledge and in achieving the target of stopping open defecation.

In addressing the prevalence of open defecation in Ojoo community, it is imperative to implement comprehensive interventions that will focus on community education to raise awareness about the health and environmental consequences of open defecation. Such intervention will require increasing the knowledge of Environmental Health Education, as human activities in the environment do not only bring benefits to man but has also resulted in many environmental problems such as pollution, waste generation and management; health education becomes imperative in these circumstances of man- made environmental problems, of which open defecation is one of them.

Environmental Health Education also called Environmental Education (EE), is a process in which individuals gain awareness of their environment and acquire knowledge, skills, values, experiences, and also the determination, which will enable them to act - individually and collectively - to solve present and future environmental problems (GDRC, 2023). In other words, environmental education is a process that allows individuals to explore environmental issues, engage in problem solving, and take action to improve the environment. As a result, individuals develop a deeper understanding of environmental issues and have the skills to make informed and responsible decisions. The Objectives of Environmental Education include promoting environmental awareness, encouraging environmentally responsible behavior, and developing an environmental ethic that promotes an understanding of the ecological interdependence of the social, political, and economic spheres. Environmental education is a process that allows individuals to explore environmental issues, engage in problem solving, and take action to improve the environment. As a result, individuals develop a deeper understanding of environmental issues and have the skills to make informed and responsible decisions. (United State Environmental Protection Agency (EPA) , 2023). Environmental education also strengthen the communities by promoting a sense of place and connection through community involvement. For instance, when an individual decide to learn more or take action to improve their environment, he/she reach out to community experts, donors, volunteers, and local facilities to help bring the community together to understand and address environmental issues impacting their neighborhood (Project Based Learning (PLB, 2023). Environmental Health Education is essential because it fosters an understanding of how individual decisions impact the environment, teaches individuals to lead sustainable lifestyles, and encourages them to become proactive stewards of the environment (Aspiring youths, 2023).

The major challenges faced by inhabitants of Ojoo community in pursue to end open defecation, is the lack of human resources base for sanitation. Although people living in slums constitute the highest percentage of those without the access to toilets, the whole communities suffer the effect of open defecation (Spears, 2014). The purpose of health education in this study is to improve individuals' knowledge, chances of success in changing attitude and practices towards good sanitation and proper hygienic practices, and provide the opportunity to make the right decision concerning health choices (Moronkola, 2003). Health education interventions to curb open defecation often draw from behavior change theories such as the Transtheoretical Model (Prochaska & DiClemente, 1983), which motivates people to try out new health behaviours by getting good knowledge of the behaviour to be adopted, assess the readiness of individuals to take on new healthier behaviours and weigh the health implications of open defecation (Sule, 2021). This theory guide the design and implementation of interventions, emphasizing stages of change and identifying factors influencing health behaviors.

Health education programs have been instrumental in raising awareness, disseminating information, and fostering community engagement to promote improved sanitation practices (Ahmed et al., 2020). Also, education about the environment raises awareness of issues, such as open defecation, impacting the environment upon which we all depend, as well as actions we can take to improve and sustain it. Therefore, it is paramount to empower individuals in the community on how to improve their environment health, which could come in form of an educational package, with attributes of sharing, caring and monitoring (Adio-Moses, 2007). The Health Belief Model (HBM) is employed to elucidate the factors influencing individuals' knowledge, attitudes, and practices regarding open defecation. HBM posits that perceived severity, susceptibility, benefits, and barriers play pivotal roles in shaping health-related behaviors (Rosenstock, 1974). Studies applying HBM have investigated how individuals perceive the risks associated with open defecation and how these perceptions influence their willingness to adopt improved sanitation practices (Smith et al., 2017).

Several studies and interventions have been carried out in Nigeria to address open defecation in the country, but the practice still remains. Knowledge, Attitude and Practice (KAP) study can be used to evaluate intervention success, a better understanding of common knowledge, beliefs, and behaviors, and set priorities (KAP Survey, 2014). Therefore, there is an increased need for improved sanitization systems in many parts of the world, particularly in Nigeria which occupies the first position in the practice of open defecation hierarchy and contributes to the global statistic of 2 billion people without proper sanitization. With gains made prior to 2019, Covid 19 and a fast-growing population in Nigeria have wiped out such gains in the aspect of tackling the issue of open defecation (Alade and Adedayo, 2021). An estimated 30 million people must be able to access improved sanitation services in Nigeria, before the fulfillment of the Sustainable Development Agenda 2030. This is to meet the nation’s target of reducing the number of people without access to improved sanitization, many states, including Oyo are expected to fall below this target due to urbanization, population growth, inefficient service provision and inadequate education on health, with Ojoo community falling short ranking in open defecation, there is a lot of work to be done. Assessing people's level of Knowledge, Attitude, and Practice (KAP) will give room for a better awareness program to the peoples studied, since KAP explores people's understanding, feeling, and action on a particular topic (Kaliyaperuma, 2004). Therefore, this study will assess the effect of Environmental Health Education on open defecation due to the KAP (Knowledge, Attitude and Practice) assessment carried out among inhabitants of Ojoo Community. The results of this study will provide important baseline information, which can improve on adequate hygiene and sanitation as critical determinants of health.

...adapted from an ongoing project thesis by Dada Opemipo Simileoluwa (Aka My Favourite Health Educator)

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